Harbor:Right level of care: Difference between revisions
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* '''Continuous cardiac and pulse ox monitoring'''
* '''Continuous cardiac and pulse ox monitoring'''
* Stable patients  
* Stable patients  
* Nursing interventions '''q4 hrs''' (vitals, labs, POC testing)
** HR 40-130 (140 for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** Na 130-160
* Nursing ratio 1:4
* Nursing ratio 1:4
* Non-titrated IV meds:  Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin IVP only for hyperkalemia; labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV. Drips include non-titratable amiodarone, bumex, lasix, integrilllin, insulin. DKA patients requiring active drip titration will require a higher level of nursing intervention,
** Nursing interventions '''q4 hrs''' (vitals, labs, POC testing)
*Allows for HR 40-115 (120 if Afib), RR between 8 and 28, Sys BP 90-210  and MAP>65, up to 6L oxygen via NC, Na between 130 and 160 and nursing interventions
* Ok on Tele:
** 6L O2 via NC
*CPAP, BIPAP, chronic vent OK
*CPAP, BIPAP, chronic vent OK
*Excludes alcohol withdrawal patients on CIWA protocol which will require a 1:3 unit.
** Non-titrated IV meds:  Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin IVP only for hyperkalemia; labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV. Drips include non-titratable amiodarone, bumex, lasix, integrilllin, insulin.
*** DKA patients requiring active drip titration will require a higher level of nursing intervention
** ETOH withdrawal on PO meds only
** Femoral central line/Quinton per Policy 324


==PCU/SDU<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
==PCU/SDU<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==

Revision as of 09:44, 28 September 2020

These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgmentFile:1 - Right Level of Care Flowchart final 2018 tabloid view.pdf

Observation/Short-Stay Medicine

  • Goal of our observation/Short Stay is admission avoidance
  • If a brief additional stay in the ED will prevent admission, consider this option
  • All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs
  • (Previous: When boarding >5 obs patients in ED, admit DHS empaneled OBS-level patients)

Ward[1]

  • Unmonitored
  • Stable Patients
    • HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160
  • Nursing ratio 1:5
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
  • OK on ward
    • 4L O2 via NC
      • Chronic CPAP or Nasal BiPAP (with pulm attending approval)
    • Meds: Ativan IV q6, Bumex, CaCl, digoxin IV, Dilantin IV, Dilaudid IV, heparin IV, Lasix, potassium IVPB
    • ETOH withdrawal on PO meds only
    • NG tube, chest tube, peritoneal dialysis
    • Palliative/comfort care admissions, including vented comfort care patients

Telemetry[2]

  • 3W, 4W, 5E, 6W
  • Continuous cardiac and pulse ox monitoring
  • Stable patients
    • HR 40-130 (140 for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160
  • Nursing ratio 1:4
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
  • Ok on Tele:
    • 6L O2 via NC
  • CPAP, BIPAP, chronic vent OK
    • Non-titrated IV meds: Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin IVP only for hyperkalemia; labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV. Drips include non-titratable amiodarone, bumex, lasix, integrilllin, insulin.
      • DKA patients requiring active drip titration will require a higher level of nursing intervention
    • ETOH withdrawal on PO meds only
    • Femoral central line/Quinton per Policy 324

PCU/SDU[3]

  • 3W SDU, 4W/5E PCU
  • Continuous cardiac and pulse ox monitoring
  • Nursing interventions q2 hrs (vitals, suctioning, labs, POC testing)
  • Nursing ratio 1:3
  • Non-titrated IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt
  • Respiratory txs q2 hrs
  • BiPAP
  • Mechanical ventilation with FiO2<40% and infrequent ABG/vent adjustments
  • OK: subdural drains, special peritoneal dialysis, procedural sedation
  • NOT allowed: temp pacer, active chest pain, significant dysrhythmia or acute ischemic EKG changes, significant pulmonary edema

ICU[4]

  • 3W/5W/6W ICU, 3WCTU, 4WCCU
  • Actively managed ventilators
  • Nursing interventions q1 hr (vitals, labs, POC testing)
  • Nursing ratio 1:2 or 1:1 depending on instability
  • Actively titrated Drips: Cardene, Nipride, pentobarbital IV, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors

See Also

References

  1. ↑ Chappell 9/2020, Hospital Policies 307 & 325M
  2. ↑ Chappell 12/18, Hospital Policies 307 & 325M
  3. ↑ Chappell 12/18, Hospital Policies 307 & 325M
  4. ↑ Chappell 12/18, Hospital Policies 307 & 325M

Policy 307 Revised 7/2020

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