Protocols in the ED

Veetach

We will be switching from Codonix to Meditech in the next year- many of our staff are used to Meditech for order entry, magic office email, etc. The nurses on the medsurg floor and telem use it now and we in the ED hear a lot of complaining about it trickle down to us. Do you find it user-friendly for the ED? Does it have capabilitis for integrating with your cardiac monitoring system to auto. download rhythm strips, download VS trends without hand entering? THat would be a step up for us- just in those aspects of charting alone

Anne

Veetach

We will be switching from Codonix to Meditech in the next year- many of our staff are used to Meditech for order entry, magic office email, etc. The nurses on the medsurg floor and telem use it now and we in the ED hear a lot of complaining about it trickle down to us. Do you find it user-friendly for the ED? Does it have capabilitis for integrating with your cardiac monitoring system to auto. download rhythm strips, download VS trends without hand entering? THat would be a step up for us- just in those aspects of charting alone

Anne

Our hospital has been live on Meditech for 3 years (this includes nursing documentation on all floors except for ED and CCU/ICU) our CCU/ICU just went live with nursing documentation last month, and we have been working on the EDM module since July 14. We are now working on Phase II of our implementation, we will go live with Nursing doc(in the ED) in June of 2005 and shortly thereafter, physician documentation, RX writing and discharge packets will be implemented.

It is a very thorough system, we just bought new spacelab monitors and they are compatible with Meditech. In fact, you can document at the bedside directly from your spacelab monitor. Sorry for droning on and on about this, but its pretty exciting for us. I hope you a good transition!

We are finally going to use medtech. We have been setup for 2 yrs but do to so much staff leaving and coming we have been on hold.. starting next week we will start bedside quick registration. We will slowly do all documenting at the bedside..

We are finally going to use medtech. We have been setup for 2 yrs but do to so much staff leaving and coming we have been on hold.. starting next week we will start bedside quick registration. We will slowly do all documenting at the bedside..

Do you guys have a tracker? If you all want to commiserate and compare notes about Meditech, email me:

[email protected]

good luck!

We use TEV in our facility. It has plans to integrate with meditech. (we use meditech for order entry & lab results. We started out on paper for about awhile. We went live(paperless) about 10 months ago. In general, I think the majority like it. We also use protocols at triage. The MD's met as a group to decide on them. Some like them othes don't. It does seem to increase pt. satisfaction. Helps out with wait time. results are usually back before MD sees pt.

It was frightening at first for most of the staff, a period of adjustment.

Does anyone out there work for a Magnet Facility? How has that changed your environment?

Our ER uses "wellsoft" we all thought we would hate it. It is a tracking system and a documentation program and includes many other things we use that are changed and adapted to the hospital by the hospital. We all nearly die wheit goes out for an up-date. I am sure there are some problems but it will do just about anything. I am not sure how to tell you how to contact the people but they are so nice. I hope this is what you needed and I will try and get contact info if you want it. Gayle

Veetach, what computer system will you be using? We started using Amelior last month in the ER and it was a disaster. We all hated it, it finally crashed one night and has been gone several weeks now, and we are so happy! Just wondering if you know of a "good" computer system.

We have guideline we use very ofter for major trauma, chest pain and sob. They are basic and help tremendously when there is a crucn(more often than not)I can send these if it would help. Gayle

This topic has probably already been discussed, and for those of you who have been members here for a long time, I apologize for repeating the topic. I am wondering though, how many of you are allowed to practice using protocols in the ED?

I am talking about chest pain or respiratory or abdominal pain protocols, etc. Our hospital is going to start using them in the spring, with the go live of a new computer program.

I am wondering how many of you already do this.

We have guideline we use very ofter for major trauma, chest pain and sob. They are basic and help tremendously when there is a crucn(more often than not)I can send these if it would help. Gayle

I would be really interested in any protocols that anyone would be willing to share with me. I work in a rural hospital er and just this week started making protocols. Thanks

[email protected]

COULD YOU SEND ME A COPY OF YOUR PROTOCOLS?

This topic has probably already been discussed, and for those of you who have been members here for a long time, I apologize for repeating the topic. I am wondering though, how many of you are allowed to practice using protocols in the ED?

I am talking about chest pain or respiratory or abdominal pain protocols, etc. Our hospital is going to start using them in the spring, with the go live of a new computer program.

I am wondering how many of you already do this.

COULD YOU SEND ME A COPY OF YOUR PROTOCOLS? THANKS

We have begun the process of implementing smoe protocols in our ED just recently. Will be using chest pain r/o MI, Angina, Pneumonia and a couple of others within the next 6 weeks. We have computerized charting, but not orderentry -- so we are trying to figure out how to document our progress on the protocol ( pathway-like) without double charting. ER docs love the idea, the ER nurses -- are open to giving it a try. Our gen Docs.... don't even like suggestions, so am interested in seeing how they react when theses protocols are instituted on their units!!

Please send me a copy of your medical directives. thanks.

We have advanced medical directives in place for COPD carepath, chest pain, migraine's, etc...and a bunch more. I can scan them and email if your interested. Awhile back, I had snail mailed a copy to someone on line and it would be costly. Let me know what your specifically interested in.

Sarah

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

GENERAL ABDOMINAL PAIN

I.V - Hold blood. If severe Nausea/Vomiting Tell M.D.

RUQ Pain(Gallstones) or Severe General Upper Abdominal Pain - CMP, Amylase, CBC

Lower Quadrant Pain(suspect Possible Pregnancy, Ectopic, UTI, Atypical Appendicitis) - MP, CBC *ADD HCG and U/A (midstream or mini - cath as appropriate)*

RLQ Pain (Appendicitis) -U/A (midstream/mini-cath as appropriate) and CBC, MP

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

GI Cocktail Orders

Unless ordered differently a GI cocktail consists of:

10 ml of Viscous Lidocaine

10 ml of Donnatal

30 ml of Maalox/Mylanta

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

POSSIBLE HIP FRACTURE

IV

Chest X-Ray

X-Ray affected leg

Labs - BMP, CBC

EKG (if over 50)

Foley Catheter

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

LACERATION

Set up room, suture set and prep-tray

Evaluate laceration - If nerve or flexion/extension problems, STOP, refer evaluation to physician- NO problems - move on

Tetorifice if needed - Td. 0.5 cc IM

Follow policy 10.R28 for prepping laceration

May use topical to wounds

X-ray as indicated for injury

IV lock PRN

Prepping Laceration (from policy 10R.28)

Prep tray - 1 section NS & 1 section 1 part betadine/9parts NS

Anesthetic:

1% Xylocaine with adrenalin (epinephrine) except on fingers, toes, member & nose

0.25% Bupivacaine Hydorchloride(Marcaine) on fingers, toes, member & nose

1% Xylocaine without epinephrine on dog bites

May add 1cc on Sodium Bicarb to 9cc Xyolacaine (not marcaine) to decrease sting

Maximum dose - 7ml/kg Xylocaine with Adrenalin

- 2mg/kg Marcaine

Inject anesthetic inside wound margin slowly injecting one end first then down one edge to the other end of wound & back to 2nd edge

Assess for anesthesia & repeat injection if any area not anesthetized

Shave excess hair if needed (except eyebrows)

Consult MD before shaving beards or mustaches

Place dry sterile gauze pad into wound to protect from solutions

Use betadine sol'n to clean skin around wound to include: 1) all of hand if wound involves hand

2) area large enough to avoid suture contamination, 3) may use lanolin based solvent in very dirty areas except wound bed, 4) may use toothbrush to scrub (except wound bed)

Remove soaked drapes & replace with sterile ones

When suture completed, clean wound with NS & apply antibacterial ointment (Polysporin if pt not allergic)

Apply Adaptic & dry sterile dressing

Splint in position if wound over joint

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

ALTERED LEVEL OF CONSCIOUSNESS/WEAKNESS

Foley catheter or mini-catheter PRN

IV Saline Lock

CBC, CMP, Blood Glucose

U/A

EKG

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

CONGESTIVE HEART FAILURE

IV (Saline Lock)

EKG

Portable Chest X-Ray

Foley catheter as needed

Respiratory Treatment

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

FLANK PAIN

I.V. - Hold Blood,

Mid-stream Urinalysis *(Mini-cath preferred if patient cannot follow detailed prep instructions)*

High Fever (Pyelonephritis) - Temp > 100 CBC, MP

Tylenol

Child Bearing Age - *ADD HCG* (Ectopic, PID)

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

ISOLATED EXTREMITY INJURY

Immobilize joints above and below injury

Apply ice to affected area

Elevate Extremity

Remove rings on injured extremity

If obvious fracture assessed as Type 2 or 3, consider IV Lock

ISOLATED EXTREMITY INJURYX-Ray Extremity if swelling, bruising, deformity or PRN

CXR (undress waist up)

Clavicle (undress waist up)

Elbow 4 v

Forearm 2 v

Hand 3 v (include fingers)

Humerus 2 v(undress waist up)

Shoulder 3 v(undress waist up)

Wrist 3 v

***Physician consult for C-Spine, L-Spine or infants***

Ankle 3 v

Ankle 2 v/Foot 3 v

Femur 2 v (undress waist down)

Foot 3 v (include toes) 2 v

Knee 4 v (undress waist down)

Knee/Patella 3 v (undress waist down)

Lower Leg 2 v (undress waist down)

Oscalcis (Heel) 2 v

Pelvis with Lateral Hip

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

lady partsL BLEEDING

CBC & HCG (Unless fetal heart tones present)

Consider sending to Labor & Delivery if meets criteria per policy. No guidelines need implementation if sending to L&D

*RH Status* (if known pregnancy & pt. doesn't know blood type- consider ordering old chart if previous delivery at Salem Hospital)

NPO

Consider minicath

IF Acute: In E.D. (unstable vital signs)

Type & screen

I.V Lock

Prep for Pelvic

EMERGENCY DEPARTMENTGUIDELINES/PROTOCLS CHEST PAIN

Monitor, Pulse Oximeter

O2 - @ liters or titrate

I.V. - Lock - Draw all labs

CBC, MP, CPK, Troponin

PT/PTT if on Coumadin

EKG

Portable CXR or 2 view Chest X-Ray depending on stability

Nitroglycerin SL Q 5 min. x3, maintain SBP>100

If Acute Suspicious Chest Pain Get M.D.

ASA Chewable 81 mg - 4 tabs

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLSSHORTNESS OF BREATH

Wheeze/Tightness - Albuterol 0.5cc in 2cc NS (if needed Type back)

Asthma/Wheezing/Young Healthy - if Fever & Pleuritic Pain add CXR

Monitor, Pulse Oximeter

Suspect CHF if Severe Distress(RA sats

I.V. Lock

Consider cardiac source (Draw blood & order tests if strong suspicion)

EKG; CXR

CBC; MP; CPK; Trop

Nitro SL Q 5 min X3 - maintain SBP>100

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

SORE THROAT (WITHOUT AIRWAY COMPRIMISE)

RAPID STREP(order if pt. has 2 out of 3 - fever, exudate, lymphadenopathy)

ACTIVE VOMITING (SEE ABD. Pain)

Start I.V.

Draw Labs

Phenergan 12.5 mg I.V or

Phenergan 25 mg I.M.

Phenergan Supp. Pediatric Dose 1 mg/kg

Type back & consider Abd. Pain Guidelines

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

ADULT FEVER

Tylenol 1 gm. P.O.

PEDIATRIC FEVER

Weight Based Tylenol 15 mg/kg OR

Motrin 10 mg/kg

NO MOTRIN UNDER 6 MONTHS AGE

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

PAIN

Protocol may be used in the following circumstances:

Patient 14 years or older

Complaints of Pain greater that 3 out of 10 on a 10 point pain measurement scale

Has not taken pain medication within past 2 hours preceding arrival to ED

Is unlikely to be NPO for tests on arrival to ED

Has NO KNOWN ALLERGIES to selected analgesia to be given

IF ALL CRITERIA MET ONE OF FOLLOWING MAY BE GIVEN:

IBUPROFEN 600 MG P.O OR TYLENOL 1000 MG P.O

EMERGENCY DEPARTMENT GUIDELINES/PROTOCOLS

PSYCHIATRIC PATIENTS

Call Social Services when on site otherwise call PCC on arrival to triage

U/A if Elderly

UDS

ETOH if visibly intoxicated. Draw and hold other tubes

If any pill ingestion known or suspected order Tylenol and ASA levels

Appropriate drug levels if on meds - ie. Depekote

EMERGENCY DEPARTMENT PAIN MANAGEMENT GUIDELINES/PROTOCOLS FOR TITRATED IV NARCOTICS

Pain Goal for each patient: Pain rated at or less that 5 on scale and/or patient reports pain tolerable

Protocol may be used in the following circumstances:

Patient has been assessed by physician & physician has ordered analgesia

Patient at least 16 years or older

Has NO KNOWN ALLERGIES to selected analgesia to be given

Morphine 2-4 mg IV every 5 minutes to maximum dose of 10 mg

Dilaudid 0.5 - 1 mg every 15 minutes to maximum dose of 2 mg

Demerol 12.5 mg every 15 minutes to maximum dose of 50 mg

IF PATIENT PAIN NOT CONTROLLED WITH MEDICATION AS GIVEN IN PROTOCOL, CHECK WITH PHYSICIAN ABOUT ADDITIONAL MEDICATIONS OR DOSAGES

Pediatric DKA Policy

Initial Approach

Do CBG - if "High" do STAT serum Glucose

LABS: Electrolytes, BUN, CBC, Venous pH, Urine for glucose & acetate

IV - 10cc/kg of NS over 30 - 60 min

NPO

After initial assessment, treatment based on degree of Acidosis

For moderate (pH 7.5-7.25) to severe (pH

DO NOT GIVE INSULIN OR BICARB BOLUS INITIALLY

REFER TO POLICY AS SOON AS PT. DIAGNOSED

Pediatric DKA: Mild Acidosis (pH > 7.25) See Policy

Begin IV maintenance & replacement with NS (maximum 125 cc/hr - see policy for calculations)

Begin insulin drip 0.08 - 0.1 units/kg/hr if pt in ED for 2 hours

Add K+ 3mEq/kg/24 hr within 2 hrs of admission to ED or when insulin has been started

Labs: Hourly blood glucose. Venous pH or CO2 electrolytes at 2 hours & 4 hours

If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving

Pediatric DKA: Moderate Acidosis ( pH7.15-7.25) See Policy

Give bolus of 10 cc/kg of NS. This may be repeated

Use NS for maintenance and replacement fluids (see policy for chart)

Begin insulin at 0.1 mg/kg/hr if the pt. is in ED for 2 hours

Add K+ at 3 - 5 mEq/kg/24 hrs. within 2 hrs of admission to ED

Blood glucose every hour, venous pH or CO2 electrolytes at 2 and 4 hours

If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving

Pediatric DKA: Severe Acidosis(pH See Policy

Bolus NS at 20cc/kg. Do not give more unless there is evidence of shock

Continue NS at rate of 1 ½ maintenance (see chart)

Monitor vital signs continuously

Arrange PICU bed as soon as possible

Begin insulin drip at 0.1 units/kg/hr within 2 hrs of admit to ED

Add K+ at 3-5 mEq/kg/24hr within 2 hrs or when insulin has been started

Obtain bedside glucose every 30 min (meter may only read high)

Blood glucose every hour, venous pH or CO2 electrolytes at 2 and 4 hours

If blood sugar below 350mg/dl and pt. is being given insulin, add 10% dextrose to the IV solution. Maintain blood sugar between 250 and 300 mg/dl while acidosis is resolving

Pediatric DKA Policy:Fluid and Insulin Dosing Chart

Trauma Team- Modified Trauma Activation

Isolated penetrating injury above base of skull

Isolated amputation above wrist or ankle

Death of same care occupant

Ejection of patient from enclosed vehicle

Extrication time > 20 min

EMT requests trauma team evaluation for high energy transfer situations or presence of co-morbid factors

Hangings*

Drownings (unwitnessed or suspect spinal cord injury)*

Pulseless extremity with traumatic injury*

Pedestrian vs. auto (especially if age>65 or on Coumadin)*

Trauma Team-Full Activation

Systolic BP

Respiratory difficulty with rate 29

GCS 10 or less

Penetrating injury mid thigh to base of skull

Flail Chest

Two or more fractures of the femur or humerus

Paralysis

EMT suspects life threatening injuries

Amiodarone (Cordarone)

Rapid Infusion: Mix 150 mg in D5W 50 ml over 10 min.

Slow Infusion: Mix 900 mg in 500 ml NS

360mg/6 hr(1mg/min)= 33.3ml/hr then

540mg/18hr (0.5mg/min)=16.6 ml/hr

Dobutamine Dosing Chart 500mg/250ml(2,000 mcg/ml)

Dopamine(Inotropin) 400mg in 250ml

Integrilin (Eptifabatide)

We have advanced medical directives in place for COPD carepath, chest pain, migraine's, etc...and a bunch more. I can scan them and email if your interested. Awhile back, I had snail mailed a copy to someone on line and it would be costly. Let me know what your specifically interested in.

Sarah