Harbor: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 judgmentFile:1 - Right Level of Care Flowchart final 2018 tabloid view.pdf

Observation

• 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

• Unmonitored
• Stable Patients
• Nursing interventions q4 hrs (vitals, labs, POC testing)
• Nursing ratio 1:5
• Chronic CPAP or Nasal BiPAP (with pulm fellow approval)
• 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

• 3W, 4W, 5E, 6W
• Continuous cardiac and pulse ox monitoring
• Stable patients
• Nursing interventions q4 hrs (vitals, labs, POC testing)
• 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,
• 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
• CPAP, BIPAP, chronic vent OK
• Excludes alcohol withdrawal patients on CIWA protocol which will require a 1:3 unit.

PCU/SDU

• 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

• 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

• Harbor:Main