Harbor:Right level of care: Difference between revisions

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===RIGHT LEVEL of CARE===
''These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment''
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]]
* '''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)


* Observation
*Right Level of Care Flowchart:
** Goal of our observation unit is admission avoidance
** All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs


* Ward
*[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]
** Unmonitored
*[https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/325M-Guidelines%20for%20Intravenous%20Medication%20Administration.pdf Policy 325M]
** Stable Patients
 
* [[Harbor:Observation placement|Observation/Short-Stay Medicine]]
 
==Ward<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
* 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)
** Nursing interventions q4 hrs (vitals, labs, POC testing)
** Chronic CPAP or Nasal BiPAP (with pulm fellow approval)
* 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
** Palliative/comfort care admissions, including vented comfort care patients
** OK on ward:  NG tube, chest tube, peritoneal dialysis
** Meds:  Ativan IV q6, Bumex, CaCl, digoxin IV, Dilantin IV, Dilaudid IV, heparin IV,  Lasix, potassium IVPB
** FUTURE POSSIBILITY (currently 1 per day when boarding >5 obs patients):  DHS empaneled OBS-level patients


*Telemetry
==Telemetry<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
** Continuous cardiac and pulse ox monitoring
* 3W, 4W, 5E, 6W
** Stable patients – same level of nursing care as ward
* '''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)
** Nursing interventions '''q4 hrs''' (vitals, labs, POC testing)
** Non-titrated IV meds:  Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin gtt (IVP only for hyperkalemia; DKA patients require a higher level of nursing intervention), labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV  
* 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
==PCU/SDU<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
** Continuous cardiac and pulse ox monitoring
* 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)
** Nursing interventions '''q2 hrs''' (vitals, suctioning, labs, POC testing)
** ''Non-titrated'' IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt  
* Ok on PCU/SDU:
** Respiratory txs q2 hrs
** O2 via NRB or HFNC
** BiPAP
*** Respiratory treatments q2 hrs
** Mechanical ventilation with FiO2<40% and infrequent ABG/vent adjustments
** Meds: ''Non-titrated'' IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt, dopamine, dobutamine
** OK:  subdural drains, special peritoneal dialysis, procedural sedation
** ETOH withdrawal requiring IV medications per CIWA protocol
** '''NOT allowed''':  temp pacer, ''active chest pain'', significant dysrhythmia or acute ''ischemic EKG changes'', significant pulmonary edema
** 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 9/2020, Hospital Policies 307 & 325M</ref>==
* 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==
*[[Harbor:Main]]


*ICU
==References==
** Actively managed ventilators
<references/>
** Nursing interventions '''q1 hr''' (vitals, labs, POC testing)
Policy 307 Revised 7/2020
** Actively titrated Drips: Cardene, Nipride, pentobarbital IV, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors


Chappell 12/18, Hospital Policies 307 & 325M
[[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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