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 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:

• Policy 307
• Policy 325M

• Observation/Short-Stay Medicine

Ward

• 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

• 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

• 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

• 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

References

Policy 307 Revised 7/2020