Section 9: Clinic Rotation Responsibilities

9.1 Time Requirements

Most clinic rotations are scheduled in four-hour increments, but some may be scheduled for as long as six hours. Care is taken to schedule clinic rotations around required academic courses. Students will need to spend additional time researching patient cases, responding to patient inquiries, and following up with patients outside of the assigned time in clinic.

ND Student Clinic Expectations

  • Hydrotherapy technicians can expect to fulfill clinic rotation requirements in approximately four hours per week.
  • Secondaries can expect to fulfill clinic rotation requirements in approximately 8 – 12 hours per week.
  • Primaries can expect to fulfill clinic rotation requirements in approximately 15 – 20 hours per week.
  • Other clinic-related activities such as preceptorship, community education, outreach, grand rounds and case reports are not included in these estimates, and should be added to the hourly commitments listed above.

CCM Student Clinic Expectations

  • Observers can expect to work in the clinic approximately four (4) hours per week.
  • Clinical mentoring students can expect to work in the clinic approximately 4-5 hours per week per rotation.
  • Pre-internship students can expect to work in the clinic approximately four (4) hours per week per rotation.
  • DSOM and MSOM interns can expect to work in the clinic approximately 5-6 hours per week per rotation, for a total of between 2-4 rotations per quarter. MAc interns can expect to work in the clinic approximately 5-6 hours per week per rotation, for a total of between 1-3 rotations per quarter.

9.2 Clinic Preview and Review

Students report to assigned clinic shifts prior to the shift start time by gathering in a conferencing area where patient assignments for the shift are given. In preparation for the shift, the attending physician, resident or practitioner conducts a case preview session in which cases for the day are briefly discussed. Once case preview is completed, students begin their patient visits under the direct supervision of the clinical faculty member to whom they are assigned.

The clinical supervisor oversees all student clinical activity while the student is on shift, and although the intern has responsibility for patient care, authorization from the clinical supervisor is always necessary before the student proceeds with exams, treatment plans or other integral components of patient care. At the conclusion of each four-hour clinic shift, a case review session is held, during which clinical supervisors and students discuss the day’s cases.

Students’ prompt arrival at clinic shifts is imperative. Tardiness will result in the loss of clinic hours (see Section 6.6 Tardiness).

9.3 Student Scope of Authority

Students are authorized to participate in clinical activities, including care and treatment for patients in NUNM Health Centers and NUNM community clinics, including but not limited to, taking patient’s history, performing physical exams, and participating in diagnostic and therapeutic aspects of patient care, which is directed and supervised at all times by an attending physician or practitioner.

9.4 Time Management on Clinic Rotations

In order to best serve patients during their appointments, it is the responsibility of students and clinical supervisors to be on time with patient appointments. Proper time management reinforces the development of good practice-building skills. It is especially important to be on time with the last appointment of the day to ensure proper and timely clinic-closing procedures.

The clinical supervisor will decide how much and how long the case discussion should occur in front of the patient, and how much should be in the privacy of the clinic conference room. The clinical supervisor ensures that case discussion with each student is as timely as possible, so that the patient is not left unattended for more than 10 minutes.

No patient should wait for any service related to their visit for more than 10 minutes, with the exception of waiting for an herbal formula to be filled.

9.5 Maintaining Safety in the Clinic Setting

In the event of an emergency, accident or security issue, students are required to contact their clinical supervisor or clinic administrator immediately. The appropriate code as noted in the Acute Care Emergency Manual should be initiated as soon as possible.

NUNM Emergency Contact Numbers

  • 911 for police, fire or medical emergency
  • After-Hours Security Pager – 503.830.3613
  • Exposure Control Officer – 503. 380.7694
  • Facilities and Safety Supervisor – 503.552.2014
  • Evening/Weekend Security Guard – 503.830.3613
  • First Response Security: after-hours alarm response and security service – 866.686.1886
  • After-Hours Physician On-Call pager – 971.266.9344

Please refer to the “NUNM Acute Care Emergency Manual” book for specific emergency response procedures.

For the safety of all clinic community members, it is vitally important that each student be familiar with the potential health risks of clinical medicine and the proper protocols for lessening those risks.

Any procedure that involves breaking the skin creates an opportunity for exposure to infection. Appropriate precautions must be used whenever there is a potential for exposure to blood, other bodily fluids (e.g., saliva, mucus, weeping lesions) or body tissues.

Due to a possible risk of exposure to body fluids, students, faculty and staff must adhere to the following guidelines in all clinical treatment areas (treatment rooms, laboratory areas and medicinary):

  • No food or beverages are to be present
  • Avoid having to insert contact lenses, apply makeup, brush teeth or do any other personal procedure that unnecessarily exposes mucus membranes to potential infection
  • Clinical treatment areas must be equipped with appropriate sharps containers and biohazard containers
  • Areas must be fully stocked with gloves and other personal protective equipment at all times
  • Closed-toe shoes must be worn at all times by clinicians while seeing patients
  • Hand-washing facilities are available either in the room or an immediately adjacent room

Hand-washing is the most important single procedure for preventing infection in a healthcare setting. Hands should be washed according to current standards for medical providers:

  • Before and after each patient
  • After contact with blood or body fluids, or obvious environmental contaminants
  • At the end of a treatment or procedure
  • After maintaining personal hygiene

All students should be aware and conscientious when performing any and all clinical procedures —from inserting acupuncture needles or performing an exam, to cleaning and disinfecting the treatment room afterwards. Special care must be taken to avoid accidents. In the event of an accident, the clinical supervisor must be contacted immediately and the blood borne pathogen exposure protocol should be initiated. The protocol is as follows: use the online incident reporting system to record the exposure and the individual involved. Contact the CMO (contact information is available in the online incident reporting system and in the hardcopy needle stick packets). Follow the instructions in the hardcopy needle stick packet, available in every clinical conference room. Needle stick packets are also found behind the clinic front desk and in the clinic hallway near the acupuncture supply cabinets. Needle stick packets can also be found online through the “Exposure and Incident Forms” link at the bottom of every page of the nunm.edu website.

Each health center is equipped with first aid kits, an AED (defibrillator), body fluid spills kit, biohazard bags and containers, and fire extinguishers. The clinics also house OSHA manuals and MSDS manuals for reference. Personal protective equipment (PPE) is provided by the clinic for laboratory, minor surgery and other procedures where the potential for exposure is high.

Specific CCM Safety Needs

NUNM classical Chinese medicine safety protocols are based on, and wholly consistent with, the information in the most recent “Clean Needle Technique for Acupuncturists” manual. Please refer to the most recent CNT manual for current information and instruction about the following: care of instruments, pain or trauma upon insertion, pain after insertion, positioning the patient, skin disinfection, depth of needle insertion, safety and electrical stimulation, and moxibustion.

Acupuncture Needle Protocols

Some of the most common clinical tasks facing CCM students are the insertion and removal of acupuncture needles. Handling needles may be hazardous; students should work with them slowly, carefully and cautiously.

Insertion of acupuncture needles:

  • Care must be taken to avoid contamination when removing needles from the sterile packaging.
  • Needles must not be touched by the bare finger during insertion.
  • All opened needles, whether or not they have been used, must be discarded in the sharps container as they are no longer sterile. For this reason, needle packages should be opened only at the time of use.
  • Gloves, finger cots and cotton balls should always be available to prevent exposure of the hand that places pressure on the insertion site.

Disposal of used acupuncture needles:

  • Disposable needles must immediately be discarded in sharps containers.
  • Needles should not be gathered in small bunches as they are removed; they should be dropped individually into the sharps container directly after they are removed. Alternatively, they may be transported to the sharps container in a kidney basin or other impervious container.
  • Used needles should be handled as little as possible in order to minimize the possibility of an accidental needle stick.

Use of moxibustion:

  • Patients must be thoroughly counseled regarding the procedure, risks and alternatives, and be given time to ask questions prior to the use of moxibustion.
  • Extreme care must be taken when lighting and using moxa in the clinic.
  • Treatment doors must remain closed during and after moxa treatment.
  • Fireproof bowls are provided and must be used when lighting and transporting moxa.
  • Moxa sticks and matches must be extinguished and disposed of properly.
  • Failure to follow appropriate safety guidelines may result in disciplinary action.

9.6 Maintaining Cleaning Standards in the Treatment Room

After each and every patient visit, the students and clinician(s) who treated the patient are responsible for cleaning the treatment room in accordance with the following protocols. These are institutional protocols that have been set to meet federal and state safety regulations.

General Cleaning

Treatment rooms should be left clean, tidy and ready for the next patient and clinician.

  • Used exam table paper should be removed. Table paper is thrown in the garbage if it has not been contaminated with body fluids. If it has been contaminated with body fluids, it must be discarded in the biohazard container in the treatment room.
  • Used linens are removed in accordance with the following instructions:
    • Linens such as towels and sheets that have not been exposed to body fluids are to be placed in a green laundry bag. These bags are located in the linen storage areas on each floor of the clinic.
    • Linens that have come into contact with body fluids or open wounds must be sealed in a biohazard bag and placed into the regular laundry sack for proper processing.
      • Students are advised to use good judgment in these scenarios. Linens that are saturated with a patient’s body fluid require this process. Linens with a small drop of blood do not. The faculty supervisor should be consulted if there is any question.
      • Biohazard bags are stocked in each patient treatment room.
    • When the green linens bags become full, it is the students’ responsibility to transfer the bags from their stations throughout the clinic to the large, green rolling bins in the general storage area on the first floor.
    • Be certain that any garbage in the room ends up in the garbage bin, not the biohazard container.
    • Be certain that all biohazard waste ends up in the biohazard container.
    • Tidy up counter areas, shelving units and cabinets in treatment rooms by returning medical supplies to their original spot.
    • Return shared clinic equipment to appropriate storage location, so that the next person can find it.
    • Clean surfaces by wiping them with Caviwipes.

Instruments

  • All disposable instruments and materials that have come into contact with body fluids must be properly disposed of in the appropriate biohazard container.
  • All non-disposable instruments that need to be cleaned and sterilized for reuse must be placed in the Cidex bucket to be cleaned and autoclaved by the clinic staff.
    • The Cidex bucket is located on the counter in the clinic operations hallway.

Gloves

Gloves must be worn any time there is a reasonable possibility of hand contact with blood, body fluids or broken skin (exposed tissue). Gloves that have been contaminated with body fluids should be immediately removed and placed in the biohazard can located in the treatment room.

  • Care should be taken to avoid touching anything in the treatment room with the gloves.
  • When students need assistance with depositing the gloves in the biohazard can they should ask a fellow student, faculty member or clinic staff for assistance in the treatment room. They should not leave the treatment room with the gloves.
  • Contaminated gloves are not to be worn outside of the treatment room under any circumstances.

Use of Caviwipes as Disinfectant

Caviwipes are the disinfectant used to clean and decontaminate treatment rooms and common areas throughout NUNM Health Centers. Students are required to disinfect treatment rooms and surfaces that may have been exposed to contamination. This should include the following times:

  • At the beginning of every clinic rotation
  • At the end of every clinic rotation
  • Any time there is visible body fluid contamination

The following application procedures must be followed completely in order to ensure proper, effective disinfecting; and meet OSHA standards:

  • Every surface that may have been exposed to or come into contact with body fluids, including sneezes and coughs, must be disinfected.
  • When body fluid contamination is visible, disposable gloves should be worn for the clean-up process. If body fluid contamination is not visible on a surface, it is not necessary to wear gloves while disinfecting.
  • When body fluid contamination is visible, that surface should be cleaned with Caviwipes first.
  • When an NUNM-approved tuberculocidal disinfectant is not available, a chlorine bleach solution should be used to disinfect as follows:
    • The solution should be 10% chlorine bleach and 90% cold water
    • The solution must be fresh (i.e., made within the past 24 hours)
    • All surfaces should be sprayed with chlorine bleach solution and left wet for five minutes
  • All treatment room doorknobs should be treated with Caviwipes at the end of every clinic rotation.
  • If there has been any potential for exposure, clipboards used in the treatment room should also be cleaned with Caviwipes.

Pediatric Area Cleaning

In recognition of the more sensitive nature of our pediatric patients, a hydrogen peroxide antimicrobial disinfectant is used instead of Caviwipes to clean the surfaces in the pediatric-designated clinical areas.

Body Fluid Spills

Each clinic is equipped with a kit to be used for cleanup of major body fluid spills. The faculty supervisor or a clinic employee can be consulted for information about its location. If further instructions are necessary, an MSDS book is available at NUNM Health Centers.

Burnt Materials (Moxa)

Stainless steel bowls must be used to hold and extinguish burning materials in the treatment room. Moxa extinguishers should be used for moxa sticks whenever available. Give burnt materials sufficient time to cool thoroughly in the stainless steel bowl before being emptied into the trash.

Cups (for Chinese medicine cupping treatments) Students are to place cups into the Cidex bucket on the counter in the pass-through hallway for cleaning by the clinic operations coordinator.

9.7 End of Clinic Shift Checklist

  1. Survey each exam room
    1. All supply levels should be checked and any urgent needs should be reported to the clinic director or clinic operations coordinator.
    2. Full sharps containers should be taken to the biohazard bin and replaced with an empty container.
    3. The room should be left clean for its next use.
  2. Laundry
    1. All dirty laundry must be placed into laundry bags.
    2. Full bags must be tied off and placed into the large laundry bins.
    3. Clean, unused linens should be put back on the designated linen shelves.
  3. Medical equipment
    1. Medical equipment should be unplugged when not in use.
    2. After use, the equipment should be put back into its proper storage place.
  4. Patient transactions
    1. Clinical supervisors must assign diagnostic and CPT codes, and electronically sign and close charts.
    2. All patient payment transactions must be completed 15 minutes before the end of shift.
    3. Clinical supervisors will be available to the students throughout the patient check-out process.
  5. Patient charts
    1. Clinical supervisors will review and sign electronic charts.
    2. Charts must be completed within 24 hours of the patient visit.
  6. Clinic conference rooms
    1. At the end of the shift, students should ensure that the clinic conference rooms are picked up.
      1. Confidential materials are put in a shredding bin.
      2. Books are returned to bookshelves.
  • Loose papers are picked up.
  1. All appropriate materials are recycled.
  2. Any confidential patient information that is not being returned to the chart is placed in a locked shredding box.
  3. Food containers, plates, silverware, etc., are put away or thrown out.
  1. Lost and found
    1. Any personal items left in the clinic will be held in lost and found for one month and then donated or discarded.