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/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)

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
- Meds: 4L O2 via NC, 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
- Chronic CPAP or Nasal BiPAP (with pulm attending approval)
- Palliative/comfort care admissions, including vented comfort care patients

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.

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

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

Policy 307 Revised 7/2020

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