Purple Book

RNPH Infection Control Guidelines and Practices: #


  1. COVID Pre-admission testing: For patients who are in an emergency department or inpatient medical setting and transferring to RNPH, one UCLA-approved negative COVID PCR test result is sufficient (e.g., there is no longer a specific window required for the test, such as the previous standard of <48 hours) but the test must be performed within that encounter/episode of For example, a patient admitted to RRMC 5 days ago with a negative COVID PCR upon admission, does not require a repeat test to transfer to RNPH.
  2. Direct to Unit Admission: For any patients being admitted to RNPH from outpatient settings (clinic, home, etc…), a pre-admission COVID test is strongly recommended, and a UCLA COVID PCR test must be performed immediately upon admission for those who have not had a prior pre-admission COVID test. This option is contingent upon the patient being able to comply with COVID testing expectations, and will be applied selectively on a case by case basis in conjunction with careful screening by NPH
  3. Masking: Per UCLA Health guidance, N95’s and eye protection remain “strongly encouraged” during patient encounters. Further, patients should continue to be encouraged to wear a hospital issued mask. Patients are permitted to unmask when outdoors on the RNPH deck space (regardless of their vaccination status). It is recommended that patients who are immunocompromised should continue to wear a mask when outdoors for added safety.
    1. Special considerations: Certain populations at RNPH may have particular difficulties complying with wearing masks (for example, children, or demented/agitated older adults). The interdisciplinary treatment team may need to consider the risk/benefit burden of mask-wearing on a case-by-case basis, weighing the theoretical protections (of the patient him/herself, of other patients, and of staff) against the specific or hypothetical negative consequences (increased facial touching, behavioral activation provoked by mask application, others).
  4. RNPH Visitor Policy: RNPH is permitting 2 healthy visitors per patient, each day, between 6-7 pm to 4W. Visitors must show proof of vaccination or proof of a negative test at the ground floor visitors desk prior to receiving a visitors pass, and they must wear a mask during their visit in the hospital.
    • If patients are in semiprivate rooms, one patient will have their visitor from during regular unit visiting hours, and the other patient will have their visiting time for the subsequent hour, to be arranged by unit staff.
  1. Court Hearings: PC and Riese hearings continue to take place via Webex. Log-in information is being sent every evening to Hospitalists and Nursing staff. Teams should discuss during rounds which patients have hearings, the time of the hearing, ensure that Webex info is shared, and ask nursing staff if they can accommodate the hearing with the iPAD and patient – otherwise be prepared to be present and on-site for the hearing.
  2. RNPH Team Rounding Protocols: Inpatient attendings are currently responsible for determining and modifying the team rounding format as Any change should be discussed and coordinated with the multiple disciplines involved in patient care and rounding on each unit / neighborhood.
    • After inpatient team rounds, all housestaff should remain on-pager and respond to patient care issues until 5pm per Each inpatient team can elect to coordinate their on-site housestaff/physician coverage after rounds, to allow members of the team to work more remotely. A minimum of 1 housestaff/physician per team should remain on-site to address any medical emergencies, and any issues that require in-person examination or interaction, including but not limited to seclusion/restraint/physical hold evaluation, med consents, court hearings, etc…
      • Housestaff are permitted to use scrubs at their own discretion
    • Other Reminders: Clinicians should continue excellent hand washing practices and practice physical distancing. Restraint evaluations must be completed in-person. RNPH primary teams should be sure to perform and document both a physical exam and cranial nerve exam within 24 hours of admission.
    • RNPH COVID Surge Plan – The surge plan has been updated to address all units and age populations (4E, 4N, 4W), and is accessible online through Policy Stat: https://uclahealth.policystat.com/policy/8122155/latest/