PVHD - Palo Verde Hospital

PVHD BOARD OF DIRECTORS

a

PALO VERDE HOSPITAL

MANUAL: SURGICAL SERVICES

Effective Date:

07/10 Number: SS-2002

Reviewed:

Revised:

AUTHOR Tara Barth, RN

TITLE: Temperature and Humidity in the Operating Rooms Page 1 of 1

Section I: Purpose

Provide environment temperature and humidity recording/documentation guidelines for the Surgical Services Department.

Section II: Who may Perform / Responsible

Registered Nurses, Licensed Vocational Nurses

Section III: Policy

The temperature of the Operating Rooms shall be maintained between 68 degrees F and 73 degrees F. The humidity of the Operating Rooms shall be maintained between 35% and 60%. Surgical Services Nursing staff shall monitor the temperature and humidity in each operating room before the start of scheduled surgery cases. Temperature and humidity will be recorded in the temperature/humidity log appropriately. Surgical Services staff will contact the Plant Operations department if the temperature and/or humidity are out of range and cannot be controlled by actions made by the surgical services staff. The Plant Operations Department will ensure that the temperature is calibrated correctly. Any actions made will be documented by the Surgical Services Nursing staff and the result of the action will documented at a later time on the temperature/humidity log.

Forms:

Temperature/Humidity Log


b

PALO VERDE HOSPITAL

MANUAL: HOSPITAL WIDE CLINICAL Effective

Date: 12/04 Number:

Reviewed: 06/06

Revised: 05/08, 6/10

AUTHOR: Tara Barth, R.N.

TITLE: UNIVERSAL PROTOCOL FOR PREVENTION OF WRONG SITE, WRONG PROCEDURE, WRONG PERSON SURGERY

Page 1 of 4

Section I: Purpose

To establish guidelines for the prevention of Wrong Site, Wrong Procedure, Wrong Person Surgical and/or invasive procedures in all clinical areas where operative and/or invasive procedures are performed.

Section II: Person whom may perform/responsible

Physicians, Licensed Independent Practitioners, Allied Health Professionals, Registered Nurses, Respiratory Therapists, Radiological Technologists

Section III: Policy It is the policy Palo Verde Hospital that all patients will remain free from injury as a result of Wrong site, Wrong Procedure, Wrong Person procedures.

Section IV: Procedure

1. Verification of the correct person, procedure, and site and side should occurs:

a. With the patient involved, awake and aware, if possible. b. At the time of admission or entry into Palo Verde Hospital. c. At the time the surgery/procedure is scheduled. d. Anytime the responsibility for care of the patient is handed off to

another caregiver. e. Before the patient leaves the preoperative area or enters the

procedure/surgical room. 2. Verify the patients identity

a. Prior to commencement of any operative and/or invasive procedures, the patient’s identity must be confirmed utilizing the patient’s name and date of birth.

b. Name and date of birth must be confirmed with verbal responses from the patient and with the patient’s identification band.

b. In the event the patient is a minor, incompetent, sedated, has a language barrier, or is a trauma/emergency and the communication process is impeded, the patient’s legal guardian, family member, health care proxy, or interpreter should may respond to patient

PALO VERDE HOSPITAL

UNIVERSAL PROTOCOL FOR PREVENTION OF WRONG SITE, WRONG PROCEDURE, WRONG PERSON SURGERY Page 2 of 4

identifier questions. 3. Verify the procedure to be performed.

a. Prior to the commencement of any operative and/or invasive procedure, the procedure to be performed must be confirmed.

b. This process begins with scheduling the procedure. Scheduling information must include: Patient’s full name, date of birth, unabbreviated procedure to be performed including differentiation of laterality, and the physician name.

c. Prior to the procedure, a pre-procedure verification checklist is completed to match the items that are to be available in the procedure area to the patient. This checklist is to include as appropriate to the procedure, at least the following:

A completed and timely history and physical or update

A signed procedure consent form completed

Nursing assessment, and preanesthesia assessment completed

Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed

Any required blood products, implants, devices, and/or special equipment for the procedure

d. When confirming the correct procedure, personnel should verify the patient responses using the scheduled procedure, consent, history & physical and available x-rays.

4. Mark the Correct Site and Side a. Prior to entry into the surgical suite and prior to the start of any

operative and/or invasive procedures, regardless of where the procedure is performed, the person performing the procedure marks the correct operative site and side as appropriate.

b. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.

c. For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intraoperative imaging techniques may be used for locating and marking the exact vertebral level.

d. The site marking involves the patient whenever possible. Marking is performed with the patient awake and aware whenever possible.

e. The site is marked using an indelible marker and be visible after the skin prep and draping.

f. Only the word YES, is used to mark the correct site and side. g. The mark is placed on the patient so that it is visible after the patient

has been prepped and draped. h. In the event the patient is a minor, incompetent, sedated, has a

language barrier, or is a trauma/emergency and the communication process is impeded, the patient’s legal guardian, family

PALO VERDE HOSPITAL


member/significant other, health care proxy, or interpreter participates in site and side marking when possible.

i. Should a patient refuse site marking, the procedure will not commence. the person performing the procedure is notified and reviews the rationale for site marking with the patient. If the patient continues to refuse site marking, an alternate method is used.

j. For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum) the person performing the procedure will be responsible for applying an orange band on the patient placing it on the correct patient arm of the intended side of the procedure. The band will contain the patient name, date of birth and the procedure including the correct site and side. Note: Examples of other situations that involve using the above alternative processes include:

Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice.

Teeth

Premature infants, for whom the mark may cause a permanent tattoo.

k. The following procedures are exempt from site marking:

Single organ cases

Interventional cases for which there is no predetermined insertion site.

Teeth –However, operative teeth are marked on the patients dental x-rays.

Premature infants in which marking may cause tattooing. 5. Time-Out

a. A “Time-Out” is conducted immediately prior to the start of any operative and/or invasive procedure by a designated member of the team and involves the immediate members of the procedure team including the individual performing the procedure, the anesthesia provider, the circulating nurse, the scrub tech and other active participants who will be participating in the procedure from the beginning as appropriate to the location of the procedure.

b. When two or more procedures are being performed on the same patient, and the person performing the procedure changes, a time out is to be performed before each procedure is initiated.

c. The time- out includes the verification of at least the following:

The correct patient

The correct procedure

The correct surgical side and site

Availability of the appropriate implants and special equipment needed

d. Documentation of the correct patient, procedure, site, and implants is

PALO VERDE HOSPITAL


placed in the Pre-Operative Nursing Assessment/Report. Peri-Operative Record by the clinical person responsible for conducting the time out. the care of the patient

e. The “Time Out” section requires signature, date and time documented.

6. Universal Protocol Process for Non-OR settings included bed side Procedures: a. Site marking must be done for any procedure that involves laterality,

multiple structures or levels (even if the procedure takes place outside

the OR) b. The confirmation of the patient’s ID, the procedure, side and site will be

documented will be documented on the informed consent or other approved form available on every Unit:

c. Verification, site marking, and “time out” procedures should be as consistent as possible are consistent throughout the hospital, including the OR and other locations where invasive procedures are done.

EXCEPTION: Cases in which the person performing the procedure is in continuous attendance with the patient from the time of decision to do the procedure may be exempted from the site marking requirement. The requirement for a “time out” for final verification still applies.

References:

The Joint Commission National Patient Safety Goals The Joint Commission Universal Protocol Guidelines

Attachments:

Time out Stamp

Forms:

Pre-surgical Procedure Checklist, Peri-operative Record, Consent Form


C

PALO VERDE HOSPITAL

MANUAL: Hospital Wide Chapter 1: Leadership, Section 2: Medical Records/Information Management

Effective Date:

04/01/08 Number: CLS

Reviewed: 06/10

Revised: 06/10


TITLE: Informed Consent for Surgical and/or Invasive Procedures and Informed Consent for the Administration of Anesthesia

Page 1 of 2

Section I: Purpose

To provide guidelines for obtaining and verifying informed consent.

Section II: Person whom may perform/responsible

Medical Staff, Licensed Independent Practitioners, Licensed Nursing, Approved Translators.

Section III: Policy Informed consent is obtained by the Physician and/or Licensed Independent Practitioner.


Informed Consent must be obtained for, but is not limited to the following procedures:

o Any procedure requiring the administration of moderate sedation or

anesthesia o All surgical and/or invasive procedures o Central line placement o Chest tube insertion o Blood administration o Radiographic procedures with IV contrast o Barium enema o Lumbar puncture o Paracentesis o Tracheostomy o Administration of thrombolytics o Ring removal (jewelry)

The physician must sign the Informed Consent form, prior to the start of any operative and/or invasive procedures thereby certifying that the risks benefits and alternatives have been discussed with the patient.

If general, neuraxial, or MAC anesthesia is to be given, the Informed Consent form is to be signed, thereby certifying that the risks, benefits and alternatives

PALO VERDE HOSPITAL

MANUAL: Hospital Wide Chapter 1: Leadership, Section 2: Medical Records/Information Management

Effective Date:

04/01/08 Number: CLS

Reviewed: 06/10

Revised: 06/10


TITLE: Informed Consent for Surgical and/or Invasive Procedures and Informed Consent for the Administration of Anesthesia

Page 2 of 2

have been discussed with the patient.

The nurse caring for the patient should verify the informed consent process by observing the physician’s signature.

Cases performed using moderate sedation and/or local anesthesia where there is no anesthetist present do not need an Anesthesia Consent.

The witness to the patient’s signature must sign the consent thereby verifying that the patient did sign the consent.

For Spanish speaking persons, Spanish Informed Consent forms are to be completed utilizing the same procedures.

The translator for the patient must sign the consent.

The Informed Consent form shall be considered valid until the patient revokes the consent, or is discharged prior to the procedure.

In emergency situations, where there the patient is unable to give informed consent, and there is no health care proxy immediately available, the physician and or licensed independent practitioner may give consent for the patient. There must be two separate physician’s documentation in the medical record documenting the emergent need to proceed without consent.

For patients insured by Medical undergoing sterilization procedures the State of California Consent Form PM 330 must be completed at least 30 days prior to the procedure and be no more than 180 days old.

References:

CMS Conditions of Participation: Surgical Services Section 485.639 CAMCAH Standard RI.2.40

Forms

Palo Verde Hospital Consent Form

California Code of Regulations Title 22 Section 70707.1


d

PALO VERDE HOSPITAL

MANUAL: Surgical Services

Effective Date:

06/10 Number: SS-8074

Reviewed:

Revised:


TITLE: Cardiopulmonary Resuscitation in the Operating Room Page 1 of 3

Section I: Purpose To provide guidelines for Cardiopulmonary Resuscitation in the Operating Room.

Section II: Who may Perform/Responsible

All Surgical Staff

Section III: Policy

All nursing staff will be currently BCLS/ACLS certified and will attend CPR recertification workshop every two (2) years.

Nursing staff currently certified in BCLS/ACLS may initiate CPR when appropriate.

Emergency crash cart, supplies and defibrillator must be checked every shift for completeness and function.

A cardiopulmonary resuscitation report must be completed by the nurse and physician following each arrest.

Supplies: Emergency Crash Cart

Section VI: Procedure

From 7:30 AM to 3:00 PM Monday through Friday, the operating room code will be activated by verbally calling code blue. The hospital Code Blue Team will not be utilized. CRNA, RN, CST will be in room. Anesthesiologist, supervisor, surgeon, medical consult and all available Surgical Services RNs will respond.

During PMs, nights, holidays and weekends, staff will activate emergency alarm system in operating room. On a normal telephone, dial operator and request "Code Blue," state adult or pediatric and operating room number.

Start time elapse clock located in operating room and record time of

arrest. Emergency crash cart is brought into operating room immediately by

assisting staff or scrub tech.

PALO VERDE HOSPITAL

Title: Cardiopulmonary Resuscitation in the Operating Room Policy Number: SS-8074 Page 2 of 3

When responding code team arrives, staff not involved with actual resuscitation measures are to be directed away from the scene.

The Nursing Supervisor will ascertain which physician will be giving orders

during resuscitation efforts. In most circumstances it will be the anesthesiologist or surgeon and only those orders will be followed.

Prepare and administer medications, as ordered by physician in charge.

Other drugs requested and not in the crash cart drawer may be obtained

from the anesthesia cart. Connect patient to cardiac monitor if not already done. Then turn EKG to

“Lead II”. Run tracing continuously throughout the arrest.

ACLS protocol will be followed, per physician order.

Section VII: Documentation

Throughout cardiopulmonary resuscitation measures, an assigned nurse will document:

Medications being administered, with dosage and time

Defibrillation, with amount of watts discharged

Other procedures being performed (i.e., intubation, arterial blood gases,

cutdown) Patient's response (i.e., state of consciousness, respiration, pulse, blood

pressure, skin color)

Record on Nurses’ Notes:

Patient's condition and/or activities prior to arrest Time of arrest

Patient reaction to all measures given

Heart action, if any, including samples of tracings

Nurse's signature

PALO VERDE HOSPITAL

Title: Cardiopulmonary Resuscitation in the Operating Room Policy Number: SS-8074 Page 3 of 3

Cardiopulmonary Resuscitation Report:

Cardiopulmonary Resuscitation Report form is to be filled out by the RN and physician, immediately following an arrest. Report will be distributed as follows:

Original in patient’s medical record One (1) copy sent to Quality/Risk One (1) copy to Pharmacy. At the same time, request a new drug

tray

References:

Forms:


e

PALO VERDE HOSPITAL

MANUAL: Surgical Services

Effective Date:

06/10 Number: SS-9019

Reviewed:

Revised:


TITLE: Do Not Resuscitate, or Allow Natural Death Orders Page 1 of 7

Section I: Scope Patients designated "Do Not Resuscitate, or Allow Natural Death Orders" in the physician's orders for the purpose of floor care and ICU care, who subsequently present for care in the operating room.

Section II: Purpose

A patient's right to accept or refuse medical treatments is fundamental, particularly when faced with a terminal illness. The aim of this policy statement is to preserve and make known this right as it pertains to the patient in the operating room.

It must be stated, however, that interventions which are part of routine anesthetic management to maintain function under anesthesia may be considered to be resuscitation measures in other settings like the patient care unit or the ICU.

Furthermore it should be noted that when cardiac arrest occurs during anesthesia, if promptly recognized, and deemed reversible, resuscitation is usually successful.

The treatment of cardiac arrest in the perioperative period carries with it a more favorable prognosis than the treatment of cardiac arrest in other settings. Therefore resuscitation efforts in the operating room may help patients to achieve their original treatment objectives.

Many, if not most patients, when presented with these facts, may therefore elect to suspend Do Not Resuscitate, or Allow Natural Death orders during the perioperative period.

This policy, however, makes allowances for those patients who wish to continue their Do Not Resuscitate status or Allow Natural Death orders into the operating room.

PALO VERDE HOSPITAL

Title: Do Not Resuscitate, or Allow Natural Death Orders Policy Number: SS-9019 Page 2 of 7

Section III: Definitions (per AORN):

Allow Natural Death:

A physician directive that promotes discussions with the patient/family about end-of-life decisions in a way that guide the patient/family in the direction of what action to take versus what action not to take.

Do Not Resuscitate:

A specific physician’s order mandating that cardiopulmonary resuscitation should not be performed.

Perioperative Period:

For the purpose of this policy, discussion of the term "perioperative period" will refer to the time when an anesthesiologist accepts responsibility for the patient's care until responsibility is relinquished back to another service or practitioner. This period is usually pre-op holding, the OR, the PACU and the immediate post-op ICU period.

Section IV: Policy Statement:

Recognizing that most cardiac arrests in the operating room occur as a consequence of surgical or anesthetic interventions and, recognizing that when such cardiac arrests are noted promptly and deemed reversible, that resuscitative efforts are usually successful and, recognizing that the resuscitation from cardiac arrest occurring in the operating room or in the perioperative period carries with it a more favorable prognosis than resuscitation from cardiac arrests in other settings and, recognizing that such resuscitative efforts may in fact facilitate the achievement of the objectives for which the patient has elected surgery, it is therefore the general policy of the operating room that all patients are to be granted the benefit of resuscitative efforts in the event of a cardiac arrest regardless of the underlying disease and circumstances.

The Department of Anesthesia fully realizes that, in the case of terminally ill patients, it is easier to withhold the initiation of long-term therapies than to discontinue such therapies once initiated. However, it is the nature of surgery and anesthesia that events occur very rapidly and an individual patient's condition, being in a constant state of flux, does not always permit a practitioner the luxury of assessing whether a particular treatment initiated in the operating room will be a short-term intervention or evolve into a long-term therapy. Such assessments of particular modes of therapy can only be made over the course of the ensuing postoperative days, after a particular patient's response to those

PALO VERDE HOSPITAL


interventions can be evaluated. It will therefore be the general policy of the Department of Anesthesia in all cases, other than the exceptions provided for herein, to institute resuscitative measures in those requiring them under the assumption that these therapies are short-term by the nature of operating room arrests.

The Department of Anesthesia recognizes that, despite careful explanation of the facts and principles outlined above, some patients may insist on the continuation of their Do Not Resuscitate status or Allow Natural Death orders into the operative setting. In the spirit of emphasizing patient rights in structuring the medical treatment plan it is therefore also recognized that exceptions to the above-stated policy may occur. Such exceptions will allow for the continuation of a patient's Do Not Resuscitate status or Allow Natural Death orders into the operating room, after fulfilling certain requirements pertaining to definitions, explanation, agreements and documentation.

Section V: Definition of Cardiac Arrest:

For the purpose of this policy statement, cardiac arrest shall be defined by the occurrence of one or more of the following:

Asystole

Ventricular fibrillation

Sustained ventricular tachycardia without perfusion

Electromechanical dissociation

The defining point for cardiac arrest is the need to use closed cardiac

compression to maintain circulation or the need to employ DC countershock.

Maintenance of physiologic function under anesthesia is to be clearly distinguished from resuscitation measures. Interventions to support anesthesia may include the following:

Drugs to maintain a stable blood pressure Drugs to maintain a stable cardiac rhythm

Drugs used in the support of airway maintenance

Drugs used to support spontaneous ventilation

PALO VERDE HOSPITAL


Drugs used to maintain an adequate cardiac output Drugs used to treat adverse affects of anesthetic agents or other agents

used in the support of anesthesia Assisted or controlled positive pressure ventilation, whether by mask or by

endotracheal tube Endotracheal intubation

Section VI: Management of Cardiac Arrest:

When the patient (designated Do Not Resuscitate status or Allow Natural Death orders in the perioperative setting) develops cardiac arrest, closed cardiac compression and DC countershock may not be employed, except to treat arrests which occur as a direct result of the anesthesia or the surgery.

Endotracheal Intubation:

While it is realized that there may be the unusual situation of all

parties involved agreeing on resuscitative measures short of endotracheal intubation, it is the policy that endotracheal intubation be considered a modality of support under anesthesia and that an anesthesiologist should be loathe to relinquish the option to use this adjunct should the circumstances warrant. Patients reluctant to agree to the possibility of endotracheal intubation in the operating room for fear of prolonged ventilatory support postoperatively should address the issue of "time limited therapeutic interventions" and extubation with the involved practitioners, especially their primary care physician.

To reiterate, endotracheal intubation is a routine supportive

measure included in the rendering of anesthesia and does not, in the operating room, constitute a resuscitative measure.

Multidisciplinary approach to patient discussion - shared responsibility:

Patients who agree to the suspension of their Do Not Resuscitate

status or Allow Natural Death orders during the operative period do not necessarily require further extensive explanations from their physician/anesthesiologist, as this will be the usual policy, unless otherwise stated.

PALO VERDE HOSPITAL


Patients requesting explanations or the institution of a protocol involving anything but the total suspension of Do Not Resuscitate status or Allow Natural Death orders shall have a preoperative discussion with the involved surgeon, the primary care physician and the anesthesiologist who will administer care in the operating room. This discussion shall cover the following:

The patient's ultimate therapeutic objectives

A clear description of specific potential arrest situations in the operating room

Potential outcomes with resuscitation

Potential outcomes without resuscitation

A clear explanation of the distinction between anesthesia supportive measures and resuscitation measures

A clear discussion of those measures which the patient does and does not agree to and under what circumstances

The specifics of this discussion shall be documented in the medical record progress notes section by the anesthesiologist with supporting documentation notes from the surgeon, primary care physician and other relevant practitioners

It is the responsibility of the patient's primary care physician to initiate a discussion of this subject

It is the responsibility of the anesthesiologist to further explain in detail the operating room Do Not Resuscitate, or Allow Natural Death Orders policy

It is the responsibility of the healthcare team (i.e., internist, surgeon and anesthesiologist) to clearly communicate with each other the proposed treatment plan, as concerns Do Not Resuscitate status or Allow Natural Death orders in the operative setting, and to document in the progress notes that this multidisciplinary discussion has transpired

The patient has the right to change his/her decision at any time

PALO VERDE HOSPITAL


Individualized Patient Plan:

In the case of any patient who has been designated Do Not Resuscitate status or Allow Natural Death orders at anytime preoperatively, it must be clearly stated at the end of the anesthesiologist's preoperative note that the patient falls into one of two categories:

Patient has agreed to suspension of Do Not Resuscitate status or Allow Natural Death orders (all resuscitative measures will be employed in the operating room and PACU).

Patient wishes Do Not Resuscitate status or Allow Natural Death orders continued into the perioperative setting and into the operating room. In this case there must be a clear discussion of the intervention to be withheld in the operating room and under what circumstances specifically they are to be withheld.

A member of the multidisciplinary team (i.e., anesthesiologist,

surgeon and internist) must designate in the physician's orders, preoperatively, that the patient is either "Suspend Do Not Resuscitate, or Allow Natural Death Orders for Anesthesia" or Continue Do Not Resuscitate, or Allow Natural Death Orders for Anesthesia".

If the patient has decided to suspend the Do Not Resuscitate

status or Allow Natural Death orders intraoperatively, a member of the multidisciplinary team (i.e., anesthesiologist, surgeon, internist) must designate in the Physicians’ Orders when the Do Not Resuscitate, or Allow Natural Death order is to be reinstated.

The OR nurses preoperative checklist should note the presence or

absence of "OR-Do Not Resuscitate, or Allow Natural Death Orders Discussion in Progress Notes" and "OR-Do Not Resuscitate, or Allow Natural Death Orders Written".

The patient has the right to change his/her decision at any time.

If the patient changes his/her decision during the intraoperative period, a specific timeframe shall be established for reinstating the pre-existing Do No Resuscitate order.

PALO VERDE HOSPITAL


An anesthesiologist may withdraw from a Do Not Resuscitate, or Allow Natural Death Orders case anytime prior to the induction of anesthesia, if the shared plan is ethically, morally or emotionally unacceptable to that individual practitioner.

An anesthesiologist who elects to withdraw from a Do Not

Resuscitate status or Allow Natural Death orders case must assist the patient and surgeon in their search for another anesthesiologist, from within the department who is amenable to the Do Not Resuscitate, or Allow Natural Death Orders plan.

If the second anesthesiologist finds the proposed Do Not

Resuscitate, or Allow Natural Death Orders plan objectionable, the case must then be referred to the Department of Anesthesia Chairperson.

Cases of Do Not Resuscitate status or Allow Natural Death orders

disputes, which remain unresolved by the Department of Anesthesia Chairperson, must then be referred to the Chairperson of Surgery, then the Chief of Staff.

This policy applies to any case undertaken by an anesthesiologist at any

anesthetizing site in the hospital including those outside the Operating Room (i.e., ICU, Patient Care Unit, Endoscopy Suite, Imaging Services Suite).

References:

Association of periOperative Registered Nurses (AORN) Position Statement “Perioperative Care of Patients with Do Not Resuscitate or Allow Natural Death Orders”, Revision March 2009.


f

PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

07/96 Number: 11.06

Reviewed: 09/04, 1/05, 07/07, 03/10

Revised: 06/99, 08/01, 02/08, 03/10

AUTHOR David Hoel

TITLE: OVERRIDING DRUGS FROM AUTOMATIC DISPENSING MACHINE (PYXIS) AFTER HOURS

Page 1 of 2

Section I: Purpose To define the use of the override function in the automated dispensing machine (Pyxis), to obtain after-hour medications, and identify the best practices associated with its us.

Section II: Who may Perform/Responsible Director of Pharmacy Nursing

Section III: Policy Override medications are medications that can be accessed by nursing staff before the review of an order by the pharmacist. The purpose is to allow for quick administration of medications in emergency and stat situations that occur when pharmacy is closed.

Section VI: Procedure Prior to removing medication from Pyxis, the nurse must perform a first dose mini profile. The pyxis console contains a program for drug information (Lexi-Comp drug information service), allowing the nurse to review all pertinent information on the drug prior to removing it. Patient safety should be considered in all decisions involving override medications. The nurse is to review the order and address the following:

1. Appropriateness of the drug and indication of patient. 2. Check for drug allergies, sensitivities. 3. Duplication of medications and therapies. 4. Contraindications of drug. 5. Drug, dose, frequency, and route of administration. 6. Potential drug and food interactions. 7. Variation from approved override medications.

REMOVING DRUGS FROM PYXIS MED STATION/ AFTER HOURS

PALO VERDE HOSPITAL

DISPENCING, OBTAINGING DRUGS FROM AFTER-HOUR STOCKS 11.06 Page 2 of 2

1. Choice of Drugs:

Items shall be chosen with safety in mind, limiting wherever possible, quantities, dosage forms, and container sizes that might endanger patients. Override medications will be from a list of emergency and non-emergency items that have a strong safety profile approved by the P & T committee (see attached list). Medications removed using the override function will be analyzed by a pharmacist and audited on a regular basis.

2. Prepackaged Drugs:

Drugs that have been prepackaged (by the manufacturer or the pharmacy) shall be removed when needed. If drugs are not prepackaged, the person making the withdrawal shall take the entire bulk container (eg: liquids)

3. Maintenance of Drug Levels: Pharmacy personnel shall maintain this stock at pre-established levels

4. Amount of Drugs to Remove:

Only amounts of drugs sufficient for immediate therapeutic needs may be removed from these stocks. The amount removed may extend beyond a single dose, but should not exceed the amount to last until drugs are available from the pharmacy.

Attachments: Approved override medication list.


g

PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

07/96 Number: 6.04

Reviewed: 06/99, 08/01, 08/04, 01/05, 09/06, 02/08, 03/10

Revised: 09/06, 02/08

AUTHOR David Hoel

TITLE: INVESTIGATIONAL DRUGS, ASSURING CONTINUITY OF CARE ESTABLISHED

Page 1 of 1

Section I: Purpose Administration of a patient's personal supply of an investigational drug or a drug in clinical trial may be continued provided the administration of the drug is deemed in the best interest of the patient.


Pharmacist, Physician

Section III: Policy

The facility shall consider the need to assure continuity of care of patients admitted to the facility who are participating in investigational drug studies or clinical trials.

Section VI: Procedure The physician responsible for the patient shall verify that the administration of the drug was properly initiated (informed consent, applicable state and federal laws, etc.) prior to admission to this facility. The Pharmacist will identify the medication, before it can be used as a patient’s own medication. OBLIGATION TO OBTAIN INFORMATION ON THE DRUG The pharmacy shall provide all available information: approved protocols, adverse reactions, drug interactions, dosage form, route of administration, strength, actions, uses, side effects, and symptoms of toxicities of the drug to the attending practitioner, nursing station, pharmacy and those who dispense and administer the drug. SECURITY OF THE DRUG

PALO VERDE HOSPITAL

INVESTIGATIONAL DRUGS, ASSURING CONTINUITY OF CARE ESTABLISHED 6.04 Page 2 of 2

The pharmacy shall ensure that supplies of the investigational drug are securely stored in the pharmacy and at the patient care area.


h

PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

07/96 Number: 9.05

Reviewed: 06/99, 08/01, 01/05, 07/07, 01/08, 03/10

Revised: 09/06, 01/08

AUTHOR David Hoel

TITLE: REFRIGERATION AND FREEZING Page 1 of 2

Section I: Purpose Definition of Refrigeration and Freezing Drug Storage

Section II: Who may Perform/Responsible Any Pharmacy Personnel

Section III: Policy Biological and thermo-labile drugs that require refrigeration or freezing shall be stored in a refrigerator or freezer that is capable of maintaining the necessary temperature.

Section VI: Procedure LONG-TERM REGRIGERATION Drugs requiring refrigeration for long-term storage, but stored at room temperature for short periods (e.g., insulin, succinylcholine, and ergotamine tartrate), shall be dated when removed from refrigeration and destroyed when the recommended room temperature expiration date is reached. REFRIGERATOR AND FREEZER TEMPERATURE MONITORING Refrigerator and freezer temperatures in patient care areas shall be monitored and recorded at leastevery 24 hours. Refrigerator and freezer temperatures in the pharmacy shall be monitored and recorded each day that the pharmacy is open. Refrigerators and freezes that store Vaccines will be monitored every 12 hours. If temperatures deviate from the acceptable range, an adjustment shall be made. Refrigerators and freezers will not maintain the acceptable range will be repaired or replaced.

Any deviation from the temperature above must be corrected immediately. Attempt

PALO VERDE HOSPITAL

REFRIGERATION AND FREEZING 9.05 Page 2 of 2

to bring the temperature back to the acceptable range by adjusting the thermostat. If there is no thermostat or the thermostat cannot be located, contact the Maintenance Department for assistance. Thirty minutes after adjusting the thermostat, check the temperature to see if it is back in the acceptable range or is getting closer to the acceptable range. If the temperature has not changed, contact Maintenance to determine the problem. If the refrigerator/freezer contains medications, contact the Pharmacist to determine if the medication needs to be moved to another refrigerator/freezer or destroyed. Document the temperatures, your initials, the discrepancy, and all corrective action taken in the appropriate space. (see attachment)

References: Merck Manual

Forms: Refrigerator/Freezer Temperature Log


i

PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

07/96 Number: 10.09

Reviewed: 11/04, 01/05, 09/06, 02/08, 03/10

Revised: 09/06, 02/08

AUTHOR Richard Simpson

TITLE: RANGE ORDERS Page 1 of 2

Section I: Purpose Definition of Range Orders

Section II: Who may Perform/Responsible Pharmacist

Section III: Policy Range orders for medications are acceptable when they contain parameters whether pain scales, or specific parameters.

Section VI: Procedure Range orders are those in which the dose or dosing interval varies over a prescribed range depending on the situation or the patient’s status. RANGE ORDERS FOR ANALGESICS The hospital’s pain scale uses a 1-10 range:

1. Score 1-3 is considered mild pain 2. Score 4-6 is considered moderate pain 3. Score 7 or greater is considered severe pain

Generally, most patients do best if pain is eliminated or reduced to a mild level. Unless otherwise stated, the goal of pain management is a score or less than 4. Orders for range doses for analgesics should reference the hospital pain scale. Examples include:

1. Morphine 2 mg IV every 4 hours for pain scale of 4-6 2. Morphine 4 mg IV every 4 hours for pain scale greater than 6

OR 1. Tylenol #3 1 tablet PO every 4 hours for pain scale of 4-6 2. Tylenol #3 2 tablets PO every 4 hours for pain scale greater than 6

PALO VERDE HOSPITAL

RANGE ORDERS 10.09 Page 2 of 2

RANGE ORDERS FOR MEDICATIONS OTHER THAN ANALGESICS Range orders for non-analgesics are acceptable. Such orders must contain an objective parameter with which to measure. If no objective parameters are written, orders will be started with the smallest dose at the longest interval. If symptomatic relief is not obtained, then the next dose can be increased

References: The Joint Commission (TJC)


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PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

07/96 Number: 9.06

Reviewed: 06/99, 08/01, 01/05, 09/06, 01/08, 03/10

Revised: 03/10

AUTHOR David Hoel

TITLE: INSPECTIONS, MEDICATION AREAS Page 1 of 2

Section I: Purpose Inspection of Drug storage Areas

Section II: Who may Perform/Responsible Any pharmacy Personnel

Section III: Policy The Director of Pharmacy or qualified designee shall conduct inspections of all medication areas (e.g., nursing care units and other areas where drugs are dispensed, administered, or

stored) no less than every 30 days.

Section VI: Procedure AREAS TO INSPECT Inspections shall include the main pharmacy, all nursing care units, drug storage units, emergency boxes and emergency carts, and all other areas of the facility where drugs are dispensed, administered, and stored (including drugs in areas that do not obtain their stocks from the pharmacy). DOCUMENTATION OF THE INSPECTIONS Inspections shall be documented and inspection records shall be retained by the pharmacy. RESOLUTION OF DEFICIENCIES OR PROBLEMS Corrective action shall be taken to resolve deficiencies. Immediate action will be taken when possible. WHAT TO INSPECT As appropriate, inspections shall verify:

1. Drugs for external use, and orally are stored separately from injectable drugs. 2. Drugs requiring special storage conditions to assure stability are so stored.

PALO VERDE HOSPITAL

INSPECTIONS, MEDICATION AREAS 9.06ge 2 of 2

3. Biological and other thermo-labile drugs are stored in a refrigerator (or a separate compartment within a refrigerator) that is capable of maintaining the necessary temperature.

4. Biological and other thermo-labile drugs that require freezing are stored in a freezer (or a separate freezer compartment within a refrigerator) that is capable of maintaining the necessary temperature.

5. All drugs are stored in accordance with current standards (e.g., USP) to maintain their integrity, stability, and effectiveness.

6. Outdated and otherwise unusable drugs are identified, removed from stock, and stored to prevent their distribution and administration.

7. Distribution and administration of controlled drugs are adequately documented in accordance with law by the pharmacy, nursing service, and other involved services and personnel.

8. Emergency drugs, as approved by the medical staff, are sealed and intact and in adequate and proper supply within the pharmacy and in designated areas. 9. The metric system is in use for measuring drugs. 10. All references and information supplied by the pharmacy are displayed or available.

INSPECTIONS OF REFRIGERANTS AND FREEZERS Refrigerator and freezers will be inspected at least monthly. WHAT TO INSPECT Refrigerator and freezer inspections shall include:

1. Expired and unusable drugs (e.g., unlabeled or mislabeled drugs) 2. Discontinued drugs 3. Cleanliness 4. Organization 5. Presence of a thermometer 6. Food storage 7. Infection control hazards 8. Safety hazards 9.

RECORDS A record of refrigerator and freezer inspections shall be maintained. This record shall verify that all drugs requiring refrigeration or freezing are properly stored and that the refrigerator and freezer temperatures are within the acceptable range.

References: United States Pharmacopeia (USP)

Forms: Inspection Form


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PALO VERDE HOSPITAL

MANUAL: PHARMACY

Effective Date:

12/04 Number: 11.02A

Reviewed: 01/05, 09/06, 03/10

Revised: 09/06

AUTHOR Richard Simpson

TITLE: MEDICATION ORDERS/PRE-PRINTED ORDER SETS

Page 1 of 2

Section I: Purpose Defining Medication orders processing and Pre-printed order sets.

Section II: Who may Perform/Responsible Pharmacist

Section III: Policy Medication orders shall, except when the Pharmacy is closed, be processed and dispensed only after being reviewed and checked by a Pharmacist.

Section VI: Procedure All direct copies of physicians’ orders shall be transcribed by means of entering in them into the computer by the Pharmacist. If the orders are entered by a Pharmacy Technician, they are checked by a Pharmacist: Pharmacist shall check for:

1. Completeness of the drug order 2. Correctness of the drug order 3. Drug allergies 4. Drug incompatibilities 5. Appropriate dosage, route, frequency, and indications

Any questions or clarifications regarding the physician drug order shall be directed to the physician by the Pharmacist.

1. Physicians shall be contacted by verbal or written communications 2. Written communication shall be placed in the front of the chart and a copy placed in

the patient’s profile card. 3. Verbal orders shall be written in the patient’s chart if any drug orders are changed. 4. Verbal orders are processed in accordance wit the policy on Verbal and Telephone

Orders.

PALO VERDE HOSPITAL

MEDICATION ORDERS 11.02A Page 2 of 2

Drugs shall be dispensed only after review of the product and/or the physician order by the Pharmacist.

1. The amount dispensed shall be dictated by the distribution system for the particular area in which the patient is located.

a Unit dose system: maximum 72 hour supply for each patient cassette b Automated dispensing Machine (PYXIS) , each dose taken separately.

Pre-Printed Order sets: 1. Standing orders for drugs may be used for specified patients, when authorized by a

licensed prescriber. A copy of the standing orders shall be dated and signed by the prescriber. A copy of the standing orders shall be dated and signed by the prescriber and included in the patient’s medical record. The standing orders shall”

a. Specify the circumstances under which the drug is to be administered.

b. Specify the types of medical conditions of patients for whom the standing orders are intended.

c. Be initially approved by the pharmacy and therapeutics committee, and be reviewed at least annually by that committee.

d. Be specific to the drug, dosage, route and frequency of administration Section V: References The Joint Commission (TJC) Title 22


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PALO VERDE HOSPITAL

MANUAL: PHARMACY Effective

Date: 07/96 Number: 10.05

Reviewed: 06/99,08/01 09/04,01/05 09/06,02/08, 03/10

Revised: 09/06,02/08

AUTHOR: Richard Simpson

TITLE: ORDERS, AUTOMATIC STOP Page 1 of 2

Section I: Purpose Definition of Automatic Soft Stop on Designated Drug orders


Pharmacist

Section III: Policy There shall be an automatic cancellation (“soft stop”) on orders of specified toxic and dangerous drugs as established by the medical staff. The medical staff shall establish reasonable time limits for the specified drugs.


EXCEPTIONS TO THE AUTOMATIC ORDER POLICY The following are exceptions to the automatic policy:

1. Number of doses to be administered is ordered 2. Length of time the drug is to administered is ordered 3. The drug is reordered

CANCELLATION OF DRUG ORDERS Drug orders shall NOT be cancelled or temporarily stopped until the prescriber (or other authorized practitioner):

1. Has been contacted (within normal working hours) 2. Is aware of the impending expiration of the order and 3. Has had an opportunity to direct that the administration of the drug is to be stopped,

continued, or altered. MONITORING FOR COMPLIANCE The pharmacy shall monitor automatic stop order compliance when transcribing new orders to patient profiles and while auditing patient drug supplies. NOTIFYING PRACTITIONERS OR IMPENDING EXPIRATION Pharmacy shall notify the practitioner responsible for the patient before the impending expiration of an order (24 hours when possible). Pharmacy shall place in chart a list of orders with an impending expiration.

PALO VERDE HOSPITAL

MANUAL: PHARMACY Effective

Date: 07/96 Number: 10.05

Reviewed: 06/99,08/01 09/04,01/05 09/06,02/08, 03/10

Revised: 09/06,02/08

AUTHOR: Richard Simpson

TITLE: ORDERS, AUTOMATIC STOP Page 2 of 2

REINSTATEMENT OF ORDERS THAT HAVE BEEN CANCELLED OR TEMPORARILY STOPPED Orders that have been cancelled or temporarily stopped may be reinstated by a written or verbal order by the practitioners responsible for the patient.

Forms:

Automatic Stop Orders

Drug Time Frame

Antibiotics 7days

Narcotics 4 days

Hypnotics 4 days

Sedatives 4 days

Tranquilizers 4 days

Anticoagulants 72 hours

Corticosteroids 30 days

Routine Medications 30 days

Oxytocics 2 days


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PALO VERDE HOSPITAL

MANUAL: L&D, Postpartum, and Newborn Nursery and Respiratory Therapy

Effective Date:

10/01/2003 Number:

Reviewed: 07/2004

Revised: 06/2010

AUTHOR

TITLE: Oxygen Therapy for the Newborn Page 1 of 3

PURPOSE (Standard of Care): OB RN’s, in conjunction with Respiratory Therapists, will correct cyanosis and hypoxemia and avoid possible sequelae through use of supplemental oxygen. .

POLICY: A physician order is required to administer oxygen or to discontinue oxygen therapy. Supplemental oxygen will be administered to infants in the nursery as needed to correct cyanosis and hypoxemia prior to getting a physician order.

EQUIPMENT:

Oxyhood Flow Meter O2 Analyzer Humidifier Pulse oxymeter with probe

PROCEDURE (Standard of Practice)

A. Assessment of Need

Because there are known hazards associated with the administration of oxygen to infants, it will be administered only to those infants demonstrating signs/symptoms of oxygen need. These include:

Low pO2

SaO2 consistently below 90

Cyanosis

Respiratory distress (i.e. tachypnea, retractions, grunting, nasal flaring)

Apnea

Tachycardia

Bradycardia

PALO VERDE HOSPITAL

Title: Oxygen Therapy for the Newborn Policy Number: Page 2 of 3

B. Oxygen Administration

1. Emergency a. When it is determined that an infant is in need of oxygen, therapy may be

started by an RN b. .Initially, oxygen in high concentrations may be delivered by a face mask

or endotracheal tube. c. The physician is notified immediately of the infant condition and the need

for O2.

2. Continued Use a. When the immediate crisis has stabilized, oxygen will be warmed and

humidified for administration. This is generally accomplished through the use of an oxyhood.

b. An oxygen analyzer is used in conjunction with the oxyhood to measure the amount of FiO2 being delivered to the neonate. This is placed under the hood and near the infant’s face.

c. In addition, an inline thermometer will be used. The temperature of the humidified, warmed air will be maintained at 36 – 37 degrees C.

3. Infant Monitoring

a. Oxygen Saturation b. An oxygen saturation monitor will be used on all infants requiring O2 use.

The saturation monitor allows for continuous monitoring of oxygen therapy and decreases the number of times blood gases must be drawn.

c. Oximeter probe is placed on the lateral foot or hand with the sensor lights placed directly over one another. It is secured in place with tape or a Velcro strap.

d. Care will be given to avoid restricting circulation to the part of the body distal to the sensor.

e. The sensor site will be changed approximately every 8 hours to avoid pressure sores, etc. at the site of application.

f. Exposure of the sensor to direct, high intensity light will be avoided as it is one of the most common causes of abnormal SaO2 values.

g. Oxygen Needs 1. An hourly measurement and recording of the concentration of

oxygen being delivered to the infant will be made. 2. Blood gases will be drawn and recorded according to physician

order so that values may be correlated with the infant’s condition and SaO2.

PALO VERDE HOSPITAL

Title: Oxygen Therapy for the Newborn Policy Number: Page 3 of 3

REFERENCES: Karlsen, K. (2006). The S.T.A.B.L.E. program. Post-resuscitation/pre-transport stabilization care of sick infants: Guidelines for neonatal healthcare providers. (5

th ed.).

Park City, UT: The S.T.A.B.L.E. Program. Kattwinkel, J. (Ed.). (2006). Textbook of neonatal resuscitation (5

th ed.). Elk

Grove, IL: American Academy of Pediatrics and American Heart Association. Simpson, K. R., & Creehan, P. A. (2008). Perinatal nursing. (3

rd ed.).

Philadelphia, PA: Lippincott, Williams, & Wilkins.


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PALO VERDE HOSPITAL

MANUAL: PERINATAL

Effective Date: 08/03 Revised/Reviewed: 07/04, 06/06

Number:

Title: Patient Transport Identification and Transport Guidelines Maternal/Fetal Neonatal

Page 1 of 3

Procedure: Patient Transport Identification and Transport Guidelines

Maternal/Fetal Neonatal\

PURPOSE: To assist in identifying meternal/fetal and neonatal conditions of those patients requiring a higher level of care and/or continuing care not possible at this hospital – higher level of care. GUIDELINES:

1. Maternal and Fetal Indications for Transport

PTL/PROM/Bleeding/IUGRO/Oligohydramnios at estimated GA <36 weeks

Mutlifetal gestation, twins < 36 weeks estimated GA

Multifetal gestation triplets or more, any gestation

Significant maternal conditions – for example diabetis (poorly controlled/vascular involvement) renal disease, sepsis, cardiac disease, liver disease, disseminated intravascular coagulation, mothers medical condition may warrant referral to higher level of care irrespective of gestational age of fetus.

Hypertensive disorders

Maternal Trauma and surgical complications

Polyhydramnios (AFI>25)

Hydrops Fetalis, any cause

Eryhtrobalstosis requiring intrauterine transfusion

Congenital anomaly requiring special newborn care 2. Neonatal Indications for Transport

BW < 2000 grams

Gavage feeding > Two days

Oxygen > 3 – 4 hours

RDS / Acidosis > Two hours

Pulmonary hypertension

Meconium aspiration

Hypoglycemia unresolved

Infant of diabetic mother, symptomatic

Infant of substance abusing mother, symptomatic

Shcok

Perinatal asphyxia

PALO VERDE HOSPITAL

MANUAL: PERINATAL


Number:


Page 2 of 3



Parenteral nutrition, peripheral

Hemolytic disease

Inborn metabolic errors

Surgery 3. Other Considerations

Obstetric patients may be considered for transfer when adequate qualified staff and / or labor beds are not available

An initial assessment will be completed by the registered nurse

Physician will evaluate patient prior to transfer to rule out impending delivery. If impending delivery is ruled out the physician will obtain an accepting physician for the patient

The physician caring for the infant requiring a higher level of care will consult with a neonatal specialist to determine infant care needs prior to and during transfer and for the mode of transfer most appropriate.

4. Guidelines for Maternal Transport:

a. stable vital signs b. Reassuring external fetal monitoring

When a patient’s condition is beyond the scope of the physician’s privileges, it becomes their responsibility to obtain the appropriate consultation and/or transfer the patient to another facility

Transport should be considered when the resources immediately available for higher risk intra-partum and or neonatal care are not adequate to deal with the patient’s actual or anticipated condition

Intitial stabilization steps will begin in the labor and delivery or nursery care areas. The decision to transport, and the location of the transport will be the decision of the attending physician

No patient will be transferred to another hospital for whatever reason will have transfer consent and other pertinent forms filled out prior to departure.

The receiving institution shall approve the transfer in advance, and this will be documented on the transfer communications log, and the inter-hospital transfer form.

PALO VERDE HOSPITAL

MANUAL: PERINATAL


Number:


Page 3 of 3



GUIDELINES:

Coordinate with the attending physician as to where the mother/infant is to be transported. Notify hospital receiving mother/infant to coordinate transportation.

a. In most cases the receiving hospital will send their transport team

or ground transport for transport of infants b. If a helicopter is landing, notify the ER clerk, so that the helipad

lights can be turned on c. In most cases mothers will be transported by ground ambulance or

air transport by either ALS or BLS as determined by the physician COMPLETE DOCUMENTATION:

a. Physician Certification b. Interhospital Transfer Form c. Hospital Transfer Communication Log d. All Sections on forms should be completed e. Make copy of all X-Ray films f. Make copy of infant’s and mothers chart


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PALO VERDE HOSPITAL

MANUAL: PERINATAL


Number: IV 5.2

Title: Isolation of the Newborn

Page 1 of 1

POLICY Infants delivered by a mother suspected with communicable/infectious disease(s) are isolated from other neonates of the nursery as ordered by the physician. GUIDELINES 1. Obtain supplies to last that shift including formula and nipples. 2. Wash hands, don appropriate personal protective equipment before caring for infant.

3. Place infant’s individual supplies into the crib drawer.

4. If infant’s condition allows the infant to be with the mother, the crib may be taken to her

room.

5. Follow routine procedures for the disposal of linen and trash.

6. Remove gown and gloves, wash hands before leaving room and wash hands again in the anteroom.

7. Collect cultures, administer antibiotics and carry out any other special procedures as ordered by the physician.

8. Observe all infants for early symptoms of infection.

9. An infant with diarrhea will be separated from other infants

10. An infant with lesions will be separated from other infants.


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PALO VERDE HOSPITAL

MANUAL: L&D, Postpartum, and Newborn Nursery

Effective Date:

06/2010 Number:

Reviewed:

Revised:

AUTHOR Fran Killian MSN RN, Interim Manager, OB/Nursery

TITLE: Care of the Premature or LBW Neonate Page 1 of 1

PURPOSE (Standard of Care): The care of premature and/or low birth weight babies will be focused on stabilization after resuscitation in preparation for transfer to a higher level of care.

POLICY: Premature and LBW infants will be stabilized under a radiant warmer in the newborn nursery with attention to the following:

1. Airway - Monitor and Re-Assess

Vital signs – T, HR, Respiratory rate and effort, including how much oxygen is provided and resulting oxygen saturation, and B/P

Signs of well-being – Skin perfusion, strength of the pulses, neurologic status and urine output.

2. Temperature – Normal response to cold stress in term infants is

vasoconstriction. It is possible that premature infants experience the effects of hypothermia sooner than term infants. A normal core (rectal) temperature is between 36.5 and 37.5

oC (97.7 and 99.5

oF).

3. Hypoglycemia – Infants who are premature, LBW and/or stressed are at a

greater risk for hypoglycemia. Establish IV access and administer D10W (without electrolytes) at a rate of 80 mL/kg/day.

4. Shock – shock is “inadequate vital organ perfusion and oxygen delivery”. Three types of shock → hypovolemic, cardiogenic, septic.

5. Laboratory Work – signs of neonatal sepsis may range from subtle and non-specific to unmistakably apparent. Causes of sepsis may include PROM, premature labor, chorioamnionitis, recent maternal infection, maternal UTI, or ROM longer than 18 hours)

REFERENCES: Karlsen, K. (2006). The S.T.A.B.L.E. program: Pre-transport/post-resuscitation stabilization care of sick infants: Guidelines for neonatal healthcare providers. (5th ed.). Salt Lake City, UT: S.T.A.B.L.E., Inc.

Kattwinkel, J. (Ed.). Textbook of neonatal resuscitation. (5

th ed.). American

Academy of Pediatrics and American Heart Association.


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PALO VERDE HOSPITAL


Effective Date:

06/23/2010 Number:

Reviewed:

Revised:


TITLE: Assignment of Patients during High Census Times

(Overflow) Page 1 of 1

POLICY: Obstetrical patients will be assigned to Med/Surg/Tele beds during a time of high OB census. The OB charge nurse will work with the MST charge nurse to make room assignments. Every effort will be made to assign the OB patients to rooms that are close to each other. The OB nurses will be responsible for the obstetrical patients unless other arrangements are made. The obstetrical patients assigned to MST beds will be strongly encouraged to keep their room door closed and keep the baby’s bassinet on the side of the bed away from the room door. As soon as postpartum beds are available, the OB patients will be moved from the MST unit to the postpartum beds.


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PALO VERDE HOSPITAL


Effective Date:

Number:

Reviewed:

Revised: 06/2010


TITLE: Medical Screening Exam - Obstetrical Page 1 of 5

PURPOSE (Standard of Care) All pregnant patients admitted to the OB Department of Palo Verde Hospital for evaluation of a potential emergency condition will receive an OB medical screening examination for evaluation of labor and fetal well-being.

POLICY:

Patients presenting to the labor and delivery area for care will receive a medical screening exam and assessment regardless of the patient’s ability to pay for this service.

The medical staff by-laws will reflect authority to delegate a medical screening exam

to be conducted by labor and delivery registered nurses (RNs) who have successfully completed the competency.

Review of all transferred patient charts for EMTALA (Emergency medical Treatment and Labor Act) compliance documentation is completed by the Quality Management Department and forwarded to the Quality Committee.

This policy and procedure will be reviewed semi-annually by the OB Medical Director

and the OB Nurse Manager and recommended as is/or with changes to administration, the MEC and the Board.

A face-to-face patient evaluation by the physician will be conducted under the following circumstances.

a. Emergent conditions requiring prompt medical intervention after the initial stabilizing care has been started.

b. Acute decompensation of the patient and/or fetus c. Problems that are not resolving as anticipated. d. History, physical or lab findings inconsistent with the clinical picture. e. Upon request of the patient or the nurse.

The Registered Nurse who has successfully completed the requirements, may perform a medical screening exam in Labor and Delivery. A. Qualifications

1. Arizona State Registered Nurse Licensure. 2. Evidence of AWHONN (Association of Women’s Health, Obstetric, and

Neonatal Nurses) Intermediate Electronic Fetal Monitoring Course. 3. Neonatal Resuscitation Certification 4. Successful completion of the hospital and Labor & Delivery Department

orientation programs and competencies.

PALO VERDE HOSPITAL

Title: Medical Screening Exam - Obstetrical Policy Number: Page 2 of 5

5. At least one year Labor and Delivery experience. 6. EMTALA training.

B. Initial Evaluation and Competency

1. Upon completion of requirements, initial competency of each RN is verified by the OB Medical Director.

2. The Obstetrics Department Manager or designee, who is deemed competent to perform Medical Screening Examination, will then observe competency of qualified Labor and Delivery Registered Nurses at least three times initially and then annually thereafter.

3. Copies of the completed competencies will be placed in a designated area of the Privileges Manual kept at the Labor & Delivery Nurses’ station.

C. Continued competency validation will include the following:

1. Three medical records will be reviewed for competency and appropriate documentation at 6-month and 12-month intervals by the Obstetrics Department Manager or designee. If the Obstetrics Department Manager is not the reviewer, the monitoring activities must be conducted by a peer review system and not by the caregiver.

2. Staff requiring additional competency validation, as identified by the Obstetrics Department Manager or designee, will be reevaluated at appropriate intervals until acceptable skill level is achieved and sustained.

D. Obstetrical Emergency Conditions may include but are not limited to:

Maternal Fetal

Headaches Vomiting Visual disturbances Epigastric pain Proteinuria 2+ or greater Edema face/ extremities 2+ B/P 140/90 or greater Severe pain not related to contractions Frank vaginal bleeding Temperature > 102

o

Pulse <50 or > 120 bpm Respiratory rate < 12 or > 26. Exacerbation of chronic medical conditions (i.e. Diabetes mellitus, asthma, hypertension) Duration of previous labor < 3 hours

No fetal heart tones Non-reassuring FHR (fetal heart rate)

pattern, including baseline <110 or > 160 bpm. Decreased or absent variability, or non-reactive non-stress test that continues after interventions are performed.

Decreased fetal movement accompanied by non-reactive non-stress test or positive contraction stress test.

Malpresentation Prolapsed cord

PALO VERDE HOSPITAL


PROCEDURE: (Standard of Practice)

A. The perinatal screening exam will include the following: 1. A review of the prenatal record (if available), identification of risk factors,

pregnancy status, medical history, allergies and current medical problems or symptoms.

2. Calculation of the EDC (expected date of confinement) using the gestation wheel, prenatal data, and ultrasound reports if available.

3. Patient vital signs (positional). 4. Fetal monitoring for interpretation of fetal heart rate, baseline variability and

the presence or absence of periodic changes (gestational age may preclude this portion of the exam).

5. Uterine monitoring in the presence of contractions. 6. Abdominal palpation for the presence of contractions and fetal position. 7. Assessment of any vaginal bleeding or bloody show. 8. Determination of status of membranes, intact or ruptured. 9. Nitrazine paper may be used.

10. Vaginal examination for assessment of the following: (done only if indicated)

Dilatation

Effacement

Station

Fetal presentation. 11. Assessment of other patient complaints or symptoms, including pain,

decreased fetal movement, headache, epigastric pain, blurred vision, and excessive thirst.

B. The minimal time to assess the patient receiving the MSE (medical screening

exam) is one hour; and, when applicable, continual electronic fetal monitoring (EFM) is required for a one-hour minimum time. The MSE is conducted concurrently with the OB assessment. Therefore, the “Obstetrical Medical Screening Exam” form as well as Form #0129/6560 – “Obstetric Assessment & Evaluation” will be completed.

1. Upon initial scoring for the MSE, the physician will be notified of any positive findings in Part A for further orders and to promote timely intervention. This area of the tool identifies conditions that will require a physician evaluation prior to patient discharge. If there are no positive findings in Part A, Proceed to Part B.

2. Part B of the screening tool scores each positive finding to assist the RN in identifying medical conditions that individually or in combination require physician evaluation. A score of 3 or more requires notification of the physician to promote timely intervention for the patient’s medical condition and a physician evaluation is required prior to patient discharge.

PALO VERDE HOSPITAL


3. Part C of the screening tool scores each positive finding to further determine the need for continuing medical treatment or for discharge. This section of the MSE includes 1-hour monitoring and a complete assessment. At any time that the patient’s condition changes to a more urgent or emergent situation, the physician is to be notified immediately of the change.

C. The primary physician or designee will be notified of the patient’s arrival and the

initial assessment findings by the Registered Nurse. The report will contain the following items

1. Patient name 2. Age 3. Gravidity/Parity 4. All information gathered in the medical screening exam.

D. Patient disposition 1. If maternal and fetal status is stable and true labor can be excluded, the

physician may elect to discharge the patient via direct verbal or telephone order to the Registered Nurse.

2. The Registered Nurse will provide the patient with written discharge instructions on “Antepartum Discharge Instructions”, Form #6120/6557, as per the physician and also any additional education required.

3. The patient will sign the discharge instruction sheet to acknowledge receipt and understanding of their instructions.

4. The RN will follow established transfer policy/procedures in the event that the physician determines that the patient requires a higher level of care.

E. Documentation: The Registered Nurse will: 1. Record the information obtained from the medical screening examination on

the appropriate form. (Form #0129/6560 – “Obstetric Assessment & Evaluation”). Place the yellow copy in labeled folder in the prenatal records file if the patient is discharged undelivered.

2. Record all physician orders. 3. Complete the discharge instructions on the “Obstetrical Observation

Discharge Instructions” form (#10800) if the patient is discharged. 4. Complete the “Antepartum Discharge Instructions”, Form #6120/6557.

Place the yellow copy of this form with the yellow copy of the Obstetric Assessment and Evaluation summary in the appropriate folder in the prenatal files.

5. The RN will complete the Emtala form (Certificate of Transfer – 2 pages, and the Transfer Communication Log when the physician has made arrangements to transfer the patient a physician in a facility with a higher level of care. The physician should sign the form.

6. All original forms will become a part of the patient’s permanent medical record and will be placed, in order, in the H.I.M. (Health Information Management) box.

PALO VERDE HOSPITAL


REFERENCES: American Academy of Pediatrics, & The American College of Obstetricians and Gynecologists. (2007). Guidelines for perinatal care, (6

th ed.). Author.

Examination and Treatment for Emergency Medical Conditions and Women in Labor. Title

42> Chapter 7> Subchapter XVIII> Part E> § 1395dd. (Emtala.com). Simpson, K. R., & Creehan, P. A. (2008). Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Perinatal nursing, (3

rd ed.). Philadelphia: Lippincott-

Raven.


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PALO VERDE HOSPITAL

MANUAL: Intensive Care Unit

Effective Date:

06/06 Number: 1.3

Reviewed: 03/10

Revised: 063/10

AUTHOR

TITLE: Admission Assessment and Reassessment -ICU Page 1 of 9

Section I: Purpose:

To facilitate documentation of pertinent patient care information concerning the condition and the care given by nursing personnel. To facilitate the identification of changes in the patient’s condition which shall be reported to the attending/consulting Physician

Section II: Who may Perform/ Responsible: Licensed RN shall complete an assessment every shift and reassessment every 4 hours and PRN as the patient condition warrants

Section III: Policy: All patients in ICU will have admission assessment initiated within 15 minutes of admission and completed within 41 hour. A RN shall complete an assessment of each patient at least every 12 hours.


A. Entries in the the nursing documentation system/chart are used to document patient care data.

B. The 24 Hour Flow Sheet is primarily used for tracking vital signs, hemodynamic monitoring, intake and output, EKG strips, Medication Allergies, Invasive lines dilution/concentration of IVF/gtt, Physician Contact, Weights, Ventilation settings, Interventions.

C. Computerized entries are primarily used for documenting assessments or evaluations of specific systems or processes.

D.C. The information below is a summary of both types of entries.

Formatted: Tab stops: 0.5", Left

PALO VERDE HOSPITAL

Title: Admission Assessment and Reassessment -ICU Policy Number: 1.3 Page 2 of 9

E.D. 24 Hour Flow Sheet

1. The 24 hours ICU flow sheet shall be initiated every 24 hours commencing at 0700.

2. All entries to the flow sheet shall be legibly initialed and/or signed.

3. Initials must have a corresponding signature and title on the flowsheet.

4. Only Hospital approved abbreviations and those noted on the flowsheet may be used.

F.E. Heading

1. It shall be the responsibility of the 1845-0715 Telemetry Tech to prepare the patient data flowsheet for the day.

2. STAMP the form with the addressograph plate Add the patient data sticker where indicated and hand write patient’s name, medical record, and date where indicated prior to use of the flowsheet.

3. The correct date must be entered at the top of the sheet which includes date and time of admission and daily dates corresponding with the 24 hour period in which patient care is provided.

G.F. Vital signs

1. Routine vital signs (TEMP, HR, BP, RR, SA02) shall be recorded a minimum of every 5 hours unless otherwise ordered. If vital signs are required more often than every fifteen minutes a separate flow sheet should be used.

2. Stable patients, Temperature recorded Q 4 hours.

3. Vital signs will be recorded every 30-60 minutes when infusing vasoactive medications. HR, BP, or the appropriate parameters will be recorded every 15-30 minutes when titrating vasoactive medications.

4. MAP, Pulse Oximetry, Cardiac Rhythm will be documented Q 1 hour, and PRN as ordered.

5. When administering blood and/or blood product vital signs will be done and documented as per PVHMHD’s Blood Transfusion Policy and Procedure.

6. Vital signs on new admissions to the ICU will be done every 15 min. x 4, every 30 min. x 2 then every hour, unless otherwise ordered by a physician to be done at more frequent intervals.

7. Post op vital signs of patients new to the ICU will be done every 15 min. x 4, and every 30 min. x 2. If stable, record vital signs every hour.

8. Use symbols as stated on Hemodynamics flowsheet for pulse and BP.

H.G. Invasive Lines

1. All I.V. sites and invasive lines (TripleLumen, PA catheters, A-lines, Quinton catheters) shall be checked, and date of insertion documented.



PALO VERDE HOSPITAL


2. Dilution/Concentration of all IVF and/or gtts shall be documented.

3. All IV and/or invasive line sites/appearance and length of insertion shall be documented a minimum of every 4 hours.

I.H. Physician Contact

1. Time and name of physician contacted (telephone/visits) will be documented.

2. When applicable, a narrative note describing the nurse/physician discussion regarding the patient’s plan of care shall be computer documented in the charting under Physician contact.

J.I. Invasive / Hemodynamic Monitoring

1. Leveling and zeroing of monitoring equipment (Hemodynamic response) will be performed and recorded Q 12 hours and PRN.

2. HOB will be documented Q 4 hours when recording Hemodynamic profiles.

3. CVP will be documented Q 1-2 hours, or PRN as ordered.

4. If the arterial line is used to determine Hemodynamic status then cuff correlation blood pressure and arterial line digital readings will be compared and recorded Q 6 hours and PRN.

K.J. Ventilation

1. The mode of oxygen administration and FiO2 shall be documented Q 4 hours.

2. If the patient is on a ventilator, the following parameters are to be documented Q 4 hours and PRN when making changes: FiO2 ; vent mode/rate; TV/PIP; PEEP/PS.

3. When obtaining arterial blood gases and/or other labs, values should be documented in the appropriate box and time slots.

L.K. Intake and Output Summary

1. The summary of Intake & Output for the 24 hour period should be reflected on heading page (24 hour totals include pre-admission I and O from OR, PACU, ED, Med/Surg).

2. The patient’s admission weight, yesterday’s weight, and today’s weight will be documented in the box provided. Also, if applicable, post dialysis weight will be documented.

3. Fluid intake and output is summarized per shift. A cumulative total for all shifts is done by the Nightshift Nurse at 06:00 a.m. The following is the appropriate times for summary:

0600 am by night shift (1900-0730) 1800 pm by day shift (0700-1930)






PALO VERDE HOSPITAL


4. Intake should include all I.V.s, PO, and NG Tube feedings. Separate spaces are provided for PO/NGT intake, each type of I.V. fluid and/or each type of blood products.

5. Separate spaces for output are designated. This is to include urinary output, NG Tube drainage, stools, and other drainage, i.e. chest tube, Jackson-Pratt, etc., are to be documented in spaces provided.

6. Net input and output is to be identified each shift and the cumulative fluid balance documented every 24 hours. A space is provided at the front of the flow sheet for the previous days net fluid balance.

7. The 24-hour total is recorded at the right column of the summary box.

M.L. EKG Strips

1. EKG strips will be obtained on every single ICU/CCU patient Q 4 hours. 2. Each EKG strip shall include: lead, time, rate, rhythm, P wave, P-R Interval,

QRS Interval, T waves, ectopics, and interpretation.

3. The license nurse caring for the patient is responsible for identification and documentation of EKG strips.

4. Rhythm changes and patient response shall be called to the patients physician by the primary nurse.

ADMISSION ASSESSMENT DOCUMENTATION

A. The admitting nurse uses the nursing documentation system/chart admission

assessment forms. The following assessment criteria is docuemented:

1. History of chief complaint

a. Specific information must be written / documented .

2. Medical History: Medication Allergy History. If direct admission the medication reconciliation for is completed.

3. Med Allergies/ Home Meds:

a. All allergies are listed

b. Medications taken routinely at home are listed with dosage and frequency

c. Disposition of any meds brought to the hospital is noted.

4. Admission History- TB screening, smoking assessment, pneumonia screening.

a. Notation is made regarding the arrival of the patient and those accompanying the patient.

5. Valuables/Clothing



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PALO VERDE HOSPITAL


a. Disposition and description of all valuables (such as jewelry) is noted

b. Disposition of clothing or other personal items is noted.

6. Orientation

a. Orientation to the unit includes information such as use of the call light, location of the bathroom, visitors, and etc.

b. The nurse notes if the patient or other is the one informed.

c. The nurse notes if the patient is at risk for falls. If classified as fall risk, then a fall sign will be hung above the bed.

7. Neurological Assessment

a. Normal neurological assessment indicates: Patient is alert and oriented to person, place, and time. Behavior is appropriate t situation. Pupils equal and reactive to light. Active ROM of all extremities with symmetry of strength. No parasthesia.

b. If abnormal neuro criteria, the nurse documents in the nursing documentation sytem.chart.

8. Cardio Assessment

a. Normal cardiovascular assessment indicates: Pulse regular. Capillary refill is <3 sec. peripheral pulses are palpable. NO edema. No calf tenderness.

b. If abnormal CV criteria the nurse documents in the nursing documentation system/chart.

9. Respiratory Assessment

a. Normal respiratory assessment indicates: Resp 10-20/min. Nail beds pink. Breath sounds clear, regular and unlabored. No cough.

b. If abnormal resp criteria, the nurse documents in the nursing documentation sytem.chart.

10. Perfusion/Sensation Assessment.

a. Normal skin assessment indicates: Skin intact, warm and dry. Color normal for patient. Mucous membranes moist.

b. Normal sensation indicates: Normal sensations to extremity.

c. If abnormal skin or sensation criteria, the nurse documents in the nursing documentation sytem.chart.

11. Functional Assessment

a. Normal musculo assessment indicates: Absence of joint swelling and tenderness. Normal ROM of all joints. No muscle weakness. Gait steady and even. No deformities. Patient is ambulatory.

b. If abnormal functional criteria, the nurse documents in the nursing documentation sytem.chart.

12. Vision/Hearing/Speech/Oral Assessment

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a. Normal vision indicates no visual disturbances.

b. Normal hearing indicates no hearing disturbance.

c. Normal speech indicates nor speech impairment noted.

d. If abnormal vision, hearing, speech, or oral criteria, the nurse documents in the nursing documentation sytem.chart.

13. Pain Assessment

a. The initial assessment is done to gather information related to current pain as well as a history pain and/or its control prior to admission

b. Additional information is added if more specifics are needed for the initial assessment.

14. GU/GI Assessment

a. Normal GU assessment indicates: Patient voiding without discomfort or difficulty. Bladder not distended after voiding. Urine clear and yellow. Continent of urine.

b. Normal GI assessment indicates: Abdomen is soft, non-tender, with positive BS in all quadrants. NO complaints of nausea, vomiting, diarrhea or constipation. Appetite is good and weight is WNL

c. Normal GYN assessment indicates: uncomplicated GYN history and physiology

d. If abnormal criteria present, the nurse the nurse documents in the nursing documentation sytem.chart.

15. Nutritional Assessment

a. No high risk factors indicates nor recent loss/gain of weight, fluid intake noted to be adequate, no special diet required, does not need assistance to eat. Good appetite.

b. Dietary consult is indicated if any of the screen's abnormal criteria is met.

c. RN to have health unit coordinator enter order for dietary consult if indicated.

16. Nutritional Assessment II. This screen is designed to add any information related to nutritional deficits, but not necessarily requiring a full nutritional assessment, such as food likes and dislikes or special food needs related to culture.

17. Psychological Assessment

a. Normal psychological assessment indicates: Characteristics of appearance, behavior and verbalizations appropriate to situation. Alert and oriented to person, place, and time. Memory intact. Affect appropriate. NO mood swings noted. Patient denies ETOH use. Patient denies substance use.

b. If abnormal criteria present, the nurse documents in the nursing documentation sytem.chart.

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PALO VERDE HOSPITAL


18. Psychosocial /Spiritual

a. Normal psychosocial/spiritual assessment indicates: Patient appears calm

b. If abnormal criteria present, the nurse documents in the nursing documentation.

19. Education Assessment

a. No barriers to learning: Patient exhibits no barriers to learning at this time.

b. Preferred methods of learning are indicated, if language other than English spoken it is indicated, and who the teaching is done with is indicated.

c. If abnormal criteria present, the nurse documents in the nursing documentation chart

d. Mark all areas specific to type of teaching given and required added information for discharge teaching.

20. Discharge Planning Assessment

a. Uncomplicated discharge plan indicates: No evidence of noncompliance with medical treatment in the past. No history of drug abuse, physical abuse or neglect. No prolonged stressors, confusion or disorientation reported. Adequate living arrangements

b. If abnormal criteria present, the nurse documents in the nursing documentationchart.

B. Immediately after the admission the admitting nurse proceeds with the development

of the patient’s Plan of care. and may add comments as free text in the nursing chart.

INTERVENTIONS

A. Document the time when a procedure/ treatment was provided. Additional charting

as free text will be documented as needed.

B. Monitor alarms will be checked at least Q shift.

C. Range of motion shall be documented PRN.

D. Activity (positioning, amb., up in chair) shall be documented at a minimum of every 2 hours.

E. Deep breathing and Cough shall be documented at a minimum of every 2 hours.

F. Incentive spirometry shall be documented PRN.

G. Suction shall be documented PRN.

H. ETT placement check at least Q 4 hours.




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I. Dressing check (c) and dressing change () shall be documented PRN.

J. Site Check

1. If a mainline with no drips, shall be documented every 2 hours.

2. If the I.V. is a cardiovascular drip, it shall be checked every hour. Example Dopamine, Nipride, NTG, Dobutamine, Neosynephrine.

K. Infusion Check

1. If a mainline, shall be documented every 2 hours.

2. If the I.V. is a drip, it shall be checked every hour. L. Bath and linen shall be Δ PRN.

M. Oral care shall be done at a minimum of BID, and checked PRN. (Patients with ETT shall have oral care at least Q 4 hours.)

N. Gastric Residual and tube placement checked every 4 hours PRN and documented.

O. Restraints type shall be documented and checked as per restraints policy and procedure.

P. Medication allergies shall be documented at all times on the MAR, the Kardex , the care plan and thes in computer and flow sheet.

Medication Profile

A. The Intensive Care Unit uses PYXIS and an electronic written medication profile.

B. Medication/Route/Frequency shall be documented at all times in the medication profile.

Patient Assessment/Reassessment

A. Nursing assessment and reassessment shall be documented corresponding to

patient care given from 0700 to 1900 and 1900 to 0700 respectively.

B. Patient system reassessment will be done and documented Q 2-4 hours, or more frequently as patients condition warrants.

C. Nursing Charting every 2 hours and PRN Documentation.

D. Significant abnormal findings and/or acute changes will be described/documented in the nurses notes.

Care Plan

A. Nursing Care Plans will be initiated on admission and revised / reviewed every

24 hours. .


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PALO VERDE HOSPITAL


B. The purpose of the care plan is to plan care and to anticipate, recognize, and prevent real and potential problems encountered by the patients.

C. Each Nurse involved in the patient care will be responsible for identifying the nursing problems of the patient and appropriate plan of care and intervention.

D. The Nursing Care Plan will provide a means of communication among nurses involved in the care of a particular patient. If during transfer to another area of the Hospital some identified problems are not met, these will be marked ongoing and endorsed to the receiving Nurse.

E. Recognition and attention will be given to the psychosocial needs of patients and their families. The patient, family, or significant other will be involved in the plan of care.

F. The Nursing Care Plan will be made part of the permanent record.

G. The identified problems/needs should be based on nursing needs of the patient. A list of approved nursing diagnosis will be made available in the Unit.

H. Care plans and outcome goals will be evaluated Q 12 hours and entered in nursing documentation system/chart.

I. Date and time of resolution of the problem will be indicated and initial by the Nurse assuming the care of the patient during the resolution of the problem.


v

PALO VERDE HOSPITAL


Effective Date:

06/06 Number: 1.4

Reviewed: 03/10

Revised: 063/10

AUTHOR

TITLE: Propofol (Diprivan) Sedation Guidelines in ICU Page 1 of 3

Section I: Purpose:

To ensure safe practice in the administration of Ppropofol (Diprivan) as an agent for sedation in the ICU. Propofol injection is an intravenous sedative hypnotic agent for the use in the induction and maintenance of anesthesia or conscious sedation. Intravenous infusion of Ppropofol produces effects within 30 seconds of initiation and typically dissipates within 10 to 20 minutes after infusion is discontinued.

Section II: Who may Perform/ Responsible: Applies to all ICU licensed nursing personnel trained in the administration of IV Conscious Sedation

Section III: Policy: The patient must be intubated and mechanically ventilated. There must be a written order by the physician for Ppropofol to be administered. The Ppropofol infusion will be administered by ICU nursing personnel only. Propofol may be administered only as a sedative agent byR.N.s nursing personnel. (For induction of anesthesia, only an anesthesiologist may administer.)


DOSAGE/ADMINISTRATION:

A. Prior to Administration: 1. The Physician’s order must identify the patient, drug and titration guidelines.

The default level of sedation will be 3 on the Ramsey Scale unless the physician orders otherwise. prescribed level of sedation using the see modified Ramsey Score outlined on the following page.

2. The nurse must verify patient allergies, sensitivities or contraindications to the agent. Any patient with such contraindications must be reported to the physician before the drug will be initiated.

3. Obtain baseline neuro status, EGG, vital signs including the heart rate, blood pressure, respiratory rate and central filling pressure (CVP, PA), if a PA catheter present.

4. Assure mechanical ventilation is adequate. Monitor SaO2 (O2 Saturation) hourly and notify physician with any changes in baseline.

5. Pharmacy will prepare for the administration using strict Aseptic technique


PALO VERDE HOSPITAL

Title: Propofol (Diprivan) Sedation Guidelines in ICU Policy Number: 1.4 Page 2 of 3

under laminar flow hood. This is only in the case when having to dilute the Ppropofol concentration by transferring in-to a D5W glass bottle. In most instances, nursing personnel will be using the premixed 500mg/50ml infusion vial that requires no mixing. May use fat emulsion vented tubing for administering Ppropofol via infusion pump per central line access. Central line is desirable but not required. Do not use if there is evidence of emulsion separation, discoloration of particulate matter.

6. Do not filter Ppropofol with less than 5 micron filter. B. Dosage:

1. Initiate Ppropofol infusion at 5mcg/Kg/min after an awake baseline has been obtained.

2. Increase Ppropofol infusion at 5mcg/Kg/min increments every 5 to 10 minutes until prescribed level of sedation (usually level 3) is achieved. Allow 5 to 10 minutes to pass before each titration to allow for maximal sedative and hemodynamic effect. Document vital signs every time propofol is titrated.

Modified Ramsey Sedation Scale a. Level 1: Patient anxious, irritated, or restless b. Level 2: Patient cooperative, oriented and tranquil c. Level 3: Patient responds to commands only d. Level 4: Asleep, brisk response to loud auditory stimulus e. Level 5: Asleep, sluggish responses to loud auditory stimulus f. Level 6: Asleep, no responses to loud auditory stimulus, sluggish

response to light glabellar tap, responds to noxious stimulus.

g. Level 7: No response to light glabellar tap, no response to firm nail pressure or other noxious stimuli, Pharmacologically paralyzed and receiving Neuromuscular blocking agent.

g. 3. Most patients will require 5 to 3075 mcg/Kg/min (0.3 – 4.5mg/Kg/hr) or higher

for adequate sedation. There is no maximum dosage for Ppropofol is 50 mcg/Kg/min..

4. Propofol emulsion is a single use product with no antimicrobial preservative. It can support the rapid growth of microorganisms. Strict aseptic procedures, including wiping the vial stopper with Isopropyl alcohol swabs prior to spiking the vial are essential.

5. Change IV tubing and discard any unusual Ppropofol every 12 hours. This applies only to the pre-mixed infusion vial that requires no mixing. When Ppropofol is transferred to a syringe or D5W glass bottle, you must discard any unused Ppropofol after 6 hours; the line should be flushed or discarded. All tubing on Ppropofol containers must be dated, timed, and initialed.

6. Change IV dressing every 24 hours using strict aseptic technique. Observe for signs of microbial contamination such as fever, sepsis, etc…


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PALO VERDE HOSPITAL

Title: Propofol (Diprivan) Sedation Guidelines in ICU Policy Number: 1.4 Page 3 of 3

C. Monitoring parameters:

1. Once maintenance dose is achieved, monitor signs every hour. IF significant hypotension occurs, decrease infusion rate by 50% and notify the physician.

2. Every 24 hours, decrease Ppropofol infusion by 5 to 10mcg/Kg/min every 5 minutes until patient reaches light level of sedation (level 2). Patient should be cooperative, oriented and tranquil. If there is any change in baseline neuro status, notify physician for evaluation. Once evaluated, titrate back to prescribed level of sedation by increasing drip rate by 5-10 mcg/Kg/min at 5-10 min intervals.

3. Weaning of propofol should be done slowly and with caution. Decrease dose 5-10 mcg/Kg/min in 5-10 minute intervals and monitor for return to baseline neuro status. Patients awakened too rapidly may become agitated, anxious, and/or resist ventilator as an appropriate response to the sudden influx or stimuli occurring during the transition from deep sedation to clear-headed level of consciousness.

NOTE: A PARALYTIC AGENT IS OFTEN USED IN CONJUCTION WITH DIPRIVAN DISCONINUE PARALYTIC AGENT AND CONFIRM RECOVERY FROM NEUROMUSCULAR BLOCKAGE WITH A NERVE STIMULATOR PRIOR TO INITIATING WEANING PROCESS.

D. Warnings: 1. Propofol does not contain analgesic or amnesic properties. Consider adding

benzodiazepine or narcotic analgesic in patients receiving neuromuscular blocker.

2. Propofol is contraindicated in patients known to be sensitive to the agent or any of its components (soybean, egg phosphatide, and glycerol).

3. Propofol is contraindicated for the use in pediatrics, pregnant or nursing mothers and patients who are not intubated.

4. Propofol is not recommended for the use in patients with hyperlipidemia, hypotension, hypovolemia, increased intracranial pressure or impariedimpaired cerebral circulation, history of epilepsy or seizures, or unstable hemodynamics. Caution should be used in these types of patients. If used in these types of patients, dosage levels should be reduced.

5. Propofol dose requirements may be reduced in patients receiving concomitant opiates or combination of opiates and sedatives. These agents may potentiate the sedative and hypotension effects of Ppropofol.

6. Propofol should not be co-administered through the same IV line with blood or plasma because compatibility has not been established.

7. Hypotension occurred in 26% of ICU patients. Infusion induction with volumetric pump is required. Avoiding bolus and initiating sedation with a slowly titrated infusion can reduce this effect.

8. Green or cloudy urine can occur after long infusions.




w

PALO VERDE HOSPITAL


Effective Date:

06/06 Number: 1.1

Reviewed: 03/10

Revised:

AUTHOR

TITLE: Admission and Discharge Criteria ICU Page 1 of 3

Section I: Purpose: Admission to the Unit is based on the level of medical supervision and nursing care required. To identify the appropriateness of admission, continued stay and discharge of patients in the ICU setting. Admissions will be held on a bed available basis upon request of the attending Physician. Level I being highest to priority. Level II being second highest priority and Level III being third priority.

Section II: Who may Perform/ Responsible:

Section III: Policy:


ADMISSION CRITERIA ICU patients should have potentially life-threatening conditions that cannot be cared for adequately without close and intensive surveillance. Priority admission will be determined by level of classification. Level I being the highest priority.

LEVEL I admissions include: Post-successful cardiopulmonary resuscitation; Acute onset of chest pain with evidence of MI by EKG, hypotension, (SBP< 90), or post-concurrent thrombolytic therapy; Cardiogenic shock; Pulmonary edema; Ventricular tachyarrythmias requiring frequent cardioversion/ defibrillation; Brady arrhythmias with hypotension (SBP < 90); Cardiac tamponade with hypotension (SBP < 90); Patient with transvenous pacemaker; Acute respiratory distress requiring continuous intervention/nursing observation/intubation;

PALO VERDE HOSPITAL

Title: Admission and Discharge Criteria ICU Policy Number: 1.1 Page 2 of 3

Shock of any cause with accompanying hypotension (SBP < 90); Hypertensive crisis requiring continuous drug infusion IV or invasive monitoring; GI Bleed with hematocrit < 25, hemoglobin < 8, and/or active bleeding; Massive trauma with multiple system involvement; Neuro-comprised patient (with ICP catheter); Multiple trauma or severe single system injury; Any post-op surgical patent requiring mechanical ventilation longer than standard recovery period; Severe neurological disorders with potential for rapid deterioration in neuro status; Patients who suffered untoward surgical events; and Severe CHF. Endocrive emergencies such as, severe Diabetic Keto Acidosis requiring Insulin infusion, adrenal insufficiently with hemodynamic instablity.

LEVEL II admissions include: Critically ill patients who have potential immediate risk of requiring Level I care. Prolonged ischemic chest pain/unstable angina without evidence of acute MI by EKG; Uncontrolled hypertension not requiring continuous IV drug infusion or invasive monitoring; Patient requiring hemodialysis having evidence of life-threatening arrhythmias or hypotension during previous dialysis runs; Neuro-compromised patient not requiring ICP catheter; Post-surgical patient with pre-existing conditions which create a higher than normal risk ; and Major abdominal surgery. Unstable electrolytes:

130 < Na + > 155

3.0 < K+ > 6.0

60 < Glucose > 500

LEVEL III admissions include: Critically ill patients with chronic illness with or without superimposed acute illness who, because of limited physiologic reserve, are less likely to survive or be benefited greatly from intensive care. Care may be limited to be supportive and comfort measures. Their need may be for more intensive care delivery rather than acute medical care.

DISCHARGE CRITERIA The following discharge criteria must be met for the discharge of patients from ICU/CCU:

PALO VERDE HOSPITAL

Title: Admission and Discharge Criteria ICU Policy Number: 1.1 Page 3 of 3

Discharge Criteria for LEVEL I, II, and III Patients: Absence of ischemic pain for 24 hours; Absence of life-threatening arrhythmias for 24 hours; Resolving CHF; Stable hemodynamic status; Absence of pulmonary artery line, femoral/radial arterial lines, transvenous pacemaker; Respiratory status stable for 12 hours without mechanical assistance; Blood pressure without systolic or diastolic variation of more than 30mm Hg for 12 hours without IV drug agents; Hemoglobin/hematocrit improved or unchanged for 24 hours; BUN and/or creatinine improved or unchanged for 24 hours; Neuro vital signs improved or unchanged for 12 hours; Absence of ICP line; and Psychiatric clearance or Physician statement stating that patient is no longer suicidal.

SPECIFIC GUIDELINES FOR ADMISSION AND DISCHARGE OF ICU/CCU

PATIENTS Admission to the ICU requires a written physician order for Intensive Care. A physician who desires ICU care for his/her patient must have ICU admitting privileges at the Hospital or contact an appropriate physician to accept the patient for ICU admission. In case of conflict regarding admission or discharge criteria, the ICU Medical Director will decide which patients should be given priority. The ICU Medical Director will make final triage decisions related to patients who need to be transferred out of the unit when beds are needed. Patients will not be transferred out of ICU with indwelling invasive monitoring catheters, i.e. arterial, PA, LA, ICP, or patients on mechanical ventilation and/or transvenous pacemaker, or patient receiving continuous infusion of vasoactive drugs. Patients in the end stages of a terminal illness, no code patients, and post-operative patients recovering during p.m. and night shifts may be admitted to the ICU if rooms are available. Every attempt no to discharged patients home from ICU will be made – cases of patients going home form ICU will be reviewed by the ICU manager. The attending physician shall be contacted for clearance of transfer or discharges.


x

PALO VERDE HOSPITAL


Effective Date:

06/06 Number: 1.9

Reviewed: 03/10

Revised: 063/10

AUTHOR

TITLE: Introduction to the ICU Page 1 of 3

DEFINITION

A. The Intensive Care Unit is a specially equipped and staffed unit designed to provide close observation, continuous treatment, and nursing care to patients needing intensive or cardiac care.

PURPOSE

A. To concentrate in a service area where those patients who are critically or seriously ill will benefit from highly skilled and constant nursing observation, assessment, and appropriate intervention. Those intensive needs that require ICU admission are addressed in the “ICU Admission and Discharge Criteria” policy.

B. To provide frequent observation of vital signs, measurement recording of fluid intake and output, close and skilled observation for signs of pain, shock, hemorrhage, respiratory difficulty, increased intracranial pressure, vascular collapse, and other critical conditions.

C. The scope of services provided in ICU includes invasive and noninvasive hemodynamic/cardiac/neurological monitoring.

D. To reduce the high mortality associated with cardiac disease by: 1. Early detection and treatment of cardiac arrhythmias, shock, and failure; and 2. Increasing the incidence of successful cardiac resuscitation.

E. To provide an area for special procedures such as cardioversion, insertion of intravascular catheters, pacemakers, etc.

F. Cardiac invasive procedures do not include angiography/angioplasty. G. All patients are evaluated by a physician to determine the type and extent of care to

be provided to the patient. In the event that the patient requires care that the ICU is unable to provide the require care, the physician shall make the necessary arrangements for transfer. Transfer to an outside facility is addressed in the “Transfer Policy”.

OBJECTIVES

A. The staff objective is to give the highest standard of professional care to all patients regardless of their social, economic, and religious status, to meet the emotional support to families of critically ill patients.

B. The nurse to patient ratio shall not exceed 1:2 as mandated by Title 22; in the event there is a deficiency in the number of staff to care for the patients, all attempts shall be made to replace the deficiency with a qualified staff member. . In some instances the patient’s acuity may require 1:1 nursing care, a guideline is provided below to assist the staff in making this decision. Once a patient is designated as 1:1 the immediate supervisor will be notified immediately to assist with staffing

PALO VERDE HOSPITAL

Title: Introduction to the ICU Policy Number: 1.9 Page 2 of 3

reassignments. 1. Patients on a continuous infusion of a paralytic

2. Patients that require continuous monitoring and adjusting of modalities every 15 minutes

3. Patients on multiple vasoactive infusions being actively titrated

4. Multiple or time consuming procedures in and out of the department 5. Grieving families, dysfunctional family situation, or severe behavioral

dysfunction

*NOTE: The above list is meant to be a guideline and is not all inclusive.

B. C. Personnel assigned to the Unit will function closely and cooperatively with the Medical

Staff, Administration, and all Hospital department divisions. D. The staff attempts to serve a vital need in the community by preserving health and

hopefully reducing morbidity and mortality.

PHILOSOPHY

A. The Palo Verde Hospital District Nursing Department is guided by a philosophy organized upon the belief that:

A.

1. Individualize plan of care by qualified personnel must be given without discrimination due to race, color, religion, or economic status; we have the responsibility to serve as patient advocates and implement the Patient’s Bill of Rights;

2. We, The Intensive Care Team, believe that we have the responsibility to contribute to the continuity of patient care by collaborating with other health care disciplines in the performance of their functions.

3. The retention of the patient’s self-respect, dignity, and rights as a citizen are to be respected and held as a nursing priority;

4. We, The Intensive Care Team, must meet the cultural and language needs of the patient;

5. Patient teaching is the primary tool the interdisciplinary team have with which they may prevent illness and enhance patient normalization, self-sufficiency, and wellness;

6. The Critical Care Team, is committed to community service with a special emphasis on underserved areas and groups;

7. Nurses are retained by a fulfilling job experience enhanced by positive feedback, and professional growth through continuing education.

8. The Nursing Department is committed to indigenous leadership and the utilization of internal career ladders.

STANDARDS OF PRACTICE

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PALO VERDE HOSPITAL

Title: Introduction to the ICU Policy Number: 1.9 Page 3 of 3

A. The American Association of Critical-Care Nurses (AACN) Core Curriculum is used as reference for the development of standards and policies in the ICU as well as information submitted by the ICU personnel to allow for formulation of polices appropriate to the resources and needs of the facility.


y

______Date________Time_________________M.D. Signature T.O. _____________________________RN

PALO VERDE HOSPITAL Patient ID

PRE-PRINTED DRIP ORDERS

Drip Standardized Titration Orders Optional Physician Orders (must fill in all blanks)

□ Amiodarone Drip

Clinical response goal:

□ For VT Bolus with 300mg in 20 ml of D5W over 3-5 min. □ After bolus infuse at 1 mg/min for 6 hours then reduce dose to 0.5mg/min for 18 hours then consult physician for additional dosage.

Bolus ______mg in _____ml over _____min. After bolus infuse at _________mg/min for ________hours then reduce dose to _______mg/min for _____hours. Consult physician for additional dosage orders.

□ Cardizem Drip


□ Bolus 0.25 mg/Kg IVP over 2 minutes then start continuous infusion at 5mg/hr and titrate by 5mg/hr every 15 minutes until clinical response is achieved. Maximum dose: 15mg/hr. If clinical

response not achieved, call MD for further orders.

Bolus ________over __________ then start continuous

infusion at _________and titrate by___________ every 15 minutes until clinical response is achieved. Maximum dose: 15mg/hr. If clinical response not

achieved, call MD for further orders.

□ Dobutamine Drip


□ Start at 2.5 mcg/kg/minute. Titrate by 2.5 mcg/kg/minute every 10 minutes until clinical response is achieved. Maximum dose: 20

mcg/kg/minute. If clinical response not achieved, call MD for further orders.

Start at ___ mcg/kg/minute. Titrate by ___ mcg/kg/minute every ___ minutes until clinical response achieved. Maximum dose: ___ mcg/kg/minute. If clinical response not achieved, call MD for further orders.

□ Dopamine Drip


□ Start at 5 mcg/kg/minute. Titrate by 2.5 mcg/kg/minutes every 5 minutes until

clinical response achieved. Maximum dose: 20 mcg/kg/minute. If clinical response

not achieved, call MD for further orders.

Start at ___ mcg/kg/minute. Titrate by ___ mcg/kg/minutes every ___ minutes until clinical response achieved. Maximum dose: ___ mcg/kg/minute. If clinical response not achieved, call MD for further orders.

□ Lidocaine Drip


□ Start at 1 mg/minute. Titrate by 1 mg/minute every 15 minutes until clinical response achieved. Maximum dose 240 mg/hour. If

clinical response not achieved, call MD for further orders.

Start at ___ mg/minute. Titrate by ___ mg/minute every ___ minutes until clinical response achieved. Maximum dose ___ mg/hour. If clinical response not achieved, call MD for further orders.

□ Nitroglycerin Drip


□ Start at 3 mcg/minute. Titrate by 5 mcg/minutes every 5 minutes until clinical response achieved. Maximum dose 200 mcg/minute. If


Start at ___ mcg/minute. Titrate by ___ mcg/minutes every ___ minutes until clinical response achieved. Maximum dose ___ mcg/minute. If clinical response not achieved, call MD for further orders.

□ Norepinephrine Drip


□ Start at 1 mcg/minute. Titrate 1 mcg/minute every 15 minutes until clinical response achieved. Maximum dose 12 mcg/minute. If


Start at ___ mcg/minute. Titrate ___ mcg/minute every ___ minutes until clinical response achieved. Maximum dose ___ mcg/minute. If clinical response not achieved, call MD for further orders.

□ Propofol Drip

Clinical response goal sedation level: 3

Other:______

□ Start at 5 mcg/kg/minute. Titrate by 5 mcg/kg/minute every 5 minutes until clinical response achieved. Maximum dose 50 mcg/kg/minute. If


Start at ___ mcg/kg/minute. Titrate by ___ mcg/kg/minute every ____minutes until clinical response achieved. Maximum dose _______ mcg/kg/minute. If clinical response not achieved, call MD for further orders.

□ Versed Drip


□ Start at 0.4 mg/Kg/hr Titrate by 0.2 mg/kg/hr every 5 min. until clinical

response achieved. Maximum dose 0.35 mg/kg/hr. . If clinical response not achieved, call MD for further orders. Consider change to another medication in 48 hours based on physician evaluation and order.

Start at__________mg/kg/hr. Titrate by__________every _________ until clinical response achieved. Maximum dose _______mg/kg/hr. If clinical response not achieved, call MD for further orders. Consider change to another medication in 48 hours based on physician evaluation and order.

PVHD - Palo Verde Hospital

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