Harbor:Right level of care: Difference between revisions
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''These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment''[[:File:1 - Right Level of Care Flowchart final 2018 tabloid view.pdf]]
''These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment''
* '''An admitting attending can always write an order to override below criteria'''
** '''Use corrected Na''' - the admitting team can write a '''communication order: "Ok for ward with Na 128 per Dr. X" ''' (Dr. Stein 5/2024)


==[[Harbor:Observation placement|Observation]]<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
*Right Level of Care Flowchart:
* Goal of our observation/Short Stay is admission avoidance
* All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs


==Ward<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
*[https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/307-Admissions,%20Discharge%20Criteria%20for%20the%20Adult%20Wards,%20Telemetry,%20Progressive%20Care%20Units.pdf Policy 307]
*[https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/325M-Guidelines%20for%20Intravenous%20Medication%20Administration.pdf Policy 325M]
 
* [[Harbor:Observation placement|Observation/Short-Stay Medicine]]
 
==Ward<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
* Unmonitored
* Unmonitored
* Stable Patients
* Stable Patients
* Nursing interventions q4 hrs (vitals, labs, POC testing)
** HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** Na 130-160 (corrected Na)
* Nursing ratio 1:5
* Nursing ratio 1:5
* Chronic CPAP or Nasal BiPAP (with pulm fellow approval)
** Nursing interventions q4 hrs (vitals, labs, POC testing)
* Palliative/comfort care admissions, including vented comfort care patients
* OK on ward
* OK on ward:  NG tube, chest tube, peritoneal dialysis
** 4L O2 via NC
* Meds: Ativan IV q6, Bumex, CaCl, digoxin IV, Dilantin IV, Dilaudid IV, heparin IV, Lasix, potassium IVPB  
*** Chronic CPAP or Nasal BiPAP (with pulm attending approval)
* FUTURE POSSIBILITY (currently 1 per day when boarding >5 obs patients):  DHS empaneled OBS-level patients
** 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 (ambulatory patient)
** Palliative/comfort care admissions, including vented comfort care patients


==Telemetry<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
==Telemetry<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
* 3W, 4W, 5E, 6W
* 3W, 4W, 5E, 6W
* 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 (corrected Na)
* 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:
*CPAP, BIPAP, chronic vent OK
** 6L O2 via NC
*Excludes alcohol withdrawal patients on CIWA protocol which will require a 1:3 unit.
*** 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<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
==PCU/SDU<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
* 3W SDU, 4W/5E PCU
* 3W SDU, 4W/5E PCU
* Continuous cardiac and pulse ox monitoring
* Continuous cardiac and pulse ox monitoring
* Nursing interventions '''q2 hrs''' (vitals, suctioning, labs, POC testing)
* Acceptable Vitals & Labs:
** HR 40-140 (160 for A-fib), RR 8-34, SBP 90-220, Sp02>75%
** Na 120-165 (corrected Na)
* Nursing ratio 1:3
* Nursing ratio 1:3
* ''Non-titrated'' IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt  
** Nursing interventions '''q2 hrs''' (vitals, suctioning, labs, POC testing)
* Respiratory txs q2 hrs
* Ok on PCU/SDU:
* BiPAP
** O2 via NRB or HFNC
* Mechanical ventilation with FiO2<40% and infrequent ABG/vent adjustments
*** Respiratory treatments q2 hrs
* OK:  subdural drains, special peritoneal dialysis, procedural sedation
** Meds: ''Non-titrated'' IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt, dopamine, dobutamine
* '''NOT allowed''':  temp pacer, ''active chest pain'', significant dysrhythmia or acute ''ischemic EKG changes'', significant pulmonary edema
** ETOH withdrawal requiring IV medications per CIWA protocol
** Peritoneal dialysis patients with cycler
** Subdural drains, procedural sedation
*** '''NOT allowed''':  temporary pacer, ''active chest pain'', significant dysrhythmia or acute ''ischemic EKG changes'', significant pulmonary edema


==ICU<ref>Chappell 12/18, Hospital Policies 307 & 325M</ref>==
==ICU<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
* 3W/5W/6W ICU, 3WCTU, 4WCCU
* 3W/5W/6W ICU, 3WCTU, 4WCCU
* Nursing ratio 1:2 or 1:1 depending on instability
** Nursing interventions '''q1 hr''' (vitals, labs, POC testing)
* Actively managed ventilators
* Actively managed ventilators
* Nursing interventions '''q1 hr''' (vitals, labs, POC testing)
** Frequent ABG monitoring
* Nursing ratio 1:2 or 1:1 depending on instability
* Actively titrated Drips: Cardene, nitroprusside, pentobarbital, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
* Actively titrated Drips: Cardene, Nipride, pentobarbital IV, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
** Na <120 (corrected Na)


==See Also==
==See Also==
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==References==
==References==
<references/>
<references/>
Policy 307 Revised 7/2020


[[Category:Admin]]
[[Category:Admin]]

Latest revision as of 13:51, 1 June 2024

These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment

  • An admitting attending can always write an order to override below criteria
    • Use corrected Na - the admitting team can write a communication order: "Ok for ward with Na 128 per Dr. X" (Dr. Stein 5/2024)
  • Right Level of Care Flowchart:

Ward[1]

  • Unmonitored
  • Stable Patients
    • HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160 (corrected Na)
  • 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 (ambulatory patient)
    • 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 (corrected Na)
  • 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
  • Acceptable Vitals & Labs:
    • HR 40-140 (160 for A-fib), RR 8-34, SBP 90-220, Sp02>75%
    • Na 120-165 (corrected Na)
  • Nursing ratio 1:3
    • Nursing interventions q2 hrs (vitals, suctioning, labs, POC testing)
  • Ok on PCU/SDU:
    • O2 via NRB or HFNC
      • Respiratory treatments q2 hrs
    • Meds: Non-titrated IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt, dopamine, dobutamine
    • ETOH withdrawal requiring IV medications per CIWA protocol
    • Peritoneal dialysis patients with cycler
    • Subdural drains, procedural sedation
      • NOT allowed: temporary pacer, active chest pain, significant dysrhythmia or acute ischemic EKG changes, significant pulmonary edema

ICU[4]

  • 3W/5W/6W ICU, 3WCTU, 4WCCU
  • Nursing ratio 1:2 or 1:1 depending on instability
    • Nursing interventions q1 hr (vitals, labs, POC testing)
  • Actively managed ventilators
    • Frequent ABG monitoring
  • Actively titrated Drips: Cardene, nitroprusside, pentobarbital, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
    • Na <120 (corrected Na)

See Also

References

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

Policy 307 Revised 7/2020

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