Triage protocols. what does your ER use?

We have a 5-level triage system with guidlines on how to determine acuity. Some of it's a bit subjective.

Usually a tech will take vitals before the pt sees the nurse. The nurse takes the history and determines the triage level. If a pt is having chest pain the tech will do an ekg in triage and have a doc read it. If a patient is really bad, they get their ekg, their line and labs done, O2, and rolled into the ed on a stretcher.

Coming in by ambulance does not guarantee a bed immediately. The charge nurse listens to EMS report and does an eyeball assessment. If the patient is stable, they go to triage and have to register there and wait like everybody else. The pt also has to worry about getting their own ride home.

We are a level 4 trauma center and rather rural. We only have a 3 level trauma center-emergent, urgent and non-emergent. I can't remember all the criteral but here are some. Emergent- cardiac arrest-anaphylactic shock-seizure-hemmorhage-and iminent(sp) childbirth, head injury, chestpain susMI. Urgent- fever >102.5, abd pain, SOB w sat >90, susp fx small bone, lacs w bleeding contained, poss miscarriage. Non-emergent- cough, fever

Try this site for further info.

http://www.kingstonbasehospital.ca/Downloads/Paramedic%20downloads/PCP%20Downloads/The%20Canadian%20Triage%20and%20Acuity%20Scale.pdf

Hi In may place we have to levels of centers Urgency and Emergency In Urgency ceter they are mading a triage and they will make a disidion about further transfer, actually in Emergency center we are treating onlly trauma patient as we cold them Hot-casess ( accidents, Cardiac arrest, Hemoragia, anafillactic shock chest pain susp. IM, angina pectoris and so on, For the non emergency casses old cold casses they will treat at Urgency

I work in a 26 bed ER - 11 ER beds, 10 fast-track/clinic beds and 5 hold beds. We use Canadian Triage Assessment system (5 levels) for determining urgency and frequency of re-evaluation. We have really nice posters in triage with common complaints and their level of acuity.

Ambulance patients are placed in a bed, if there is an empty one. Rarely are ambulance patients sent to waiting room and triage unless there are no empty beds, with no hope in sight for one clearing. That was common practice in our old ER - nurses said "don't reward the frequent fliers who abuse the ambulance system by making them think ambulance = automatic bed", but I noticed that this punitive system didn't slow them down - just made them (and us) adversaries...

Hope this helps!

We use the Emergency Severity Index (ESI) 5-level system, and have for about a year-and-a-half. Prior to that, we had a three-level (Emergent/Urgent/Non-urgent) system. The ESI system has been pretty well-received, and seems to have removed a certain degree of ambiguity inherent to the three-level system.

Ambulance patients are triaged at the garage door; usually we get a brief report prior to their arrival via an alpha-numeric pager text message. Coming by ambulance does not guarantee a bed (at least when I'm triaging) unless the patient's condition warrants it. I'm more than willing to help someone into a wheelchair and place them in the lobby to wait their turn if they took the ambulance in for UTI symptoms (which does happen).

We also have a Fast Track area in our ED during certain hours for triage level 4 or level 5 patients.

We are a level 1 trauma center...we do the 5 level ESI. We do no procedures in triage...it defeats the purpose I feel...Triage is "to sort" not "to treat"...the very most we will do is give a cup for urine and dip a urine, or an accucheck...all ekg's iv's are done in the back, if you need o2...you go to the back...ties up triage nurse too much to get all involved in that...our charge nurse brings people back to the back...rarely does the triage nurse leave the desk...of course unless a GSW walks in, in that case, we take them right back with security help....If we are especially concerned about a patient, we call the charge nurse phone and make them aware of our concerns...Our policy is to try and get everyone to the back asap. Even if it means in the hallway. In the ER I used to work at, we did the 3 level system and we had more broad protocols...where we ordered xrys, labs, ekgs, and such from triage, bogged us down and when we did a study, we actually found that it was no more efficient than basic triage and working them up in the back...and it actually slowed the flow of the ER down because of the time it took for the triage nurse to get the orders and Ivs and what-not done...

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)

iF YOU HAVE EMERGENCY ROOM PROTOCOLS/STANDING ORDERS/GUIDELINES........PLEASE SEND ME A COPY. THANKS.

Hi all,

This is my first time posting here. I am trying to do some research about Triage protocols and different ways of doing things. Any info you guys can give me would be appreciated.

I'd like to know how you determine levels of urgency, who handles ambulance arrivals, does coming by ambulance guarantee a bed or do you triage and sent nonurgent ambulance patients to the lobby?

Thanks,

lifsavER67

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)

iF YOU HAVE EMERGENCY ROOM PROTOCOLS/STANDING ORDERS/GUIDELINES........PLEASE SEND ME A COPY. THANKS.

Wow. I wasn't the one who asked for the list but thanks for taking the time to post that. Pretty impressive first post Susie.

Welcome to allnurses Susie and lifsaver67 ! :balloons:

Z

thanks for your responses everyone! i'd welcome any input that anyone else has as well. right now we are trying to revamp our protocols and i am just looking for ideas!

CTAS 1 - life threatening, VSA

CTAS 2 - emergent , should be seen by MD with in 15 mins. of arrival to ER; ex: chest pain

CTAS 3 - can safely wait 1/2 hr. prior to MD to see; ex: fever

CTAS 4 - can safely wait 1 hr. prior to MD to see; ex: sprained ankle

CTAS 5 - can safely wait 2 hr. prior to MD to see; ex: presecription renewal

We follow these guidelines. I have additional information on CTAS if you are interested. Let me know.

Sarah

Going to the lake today.....

Similiar to mommatrauma- we use the ESI ratings. We apply LET at triage, Tetracaine eye complaints, Motrin PRN, xray injured extremities. We also splint/ice etc. -(this is for the minor acute fast track crowd) .

Others include clean catch UA (unless full bladder needed for pelvic US) for abd pains.

If there are long waits for available beds- we have done quickie ECGs, benadryl PO, ASA- but these orders are all obtained by the triage nurse from the doc/(NP or PA for MACU) after the pt was assessed by the triage nurse. This is why it is rucial that the triage nurse be one of the most experienced/trained staff person-- many times you rely on a gut instinct- especially if you have MANY waiting that normally you would take back sooner if beds were available. I have applied nasal O2 at triiage if pt's sats were 91-92 but otherwise not ACUTELY ill- (pneumonias, early CHF's, etc.)

We also recheck waiting room patients every 15 minutes for change in condition-we keep a triage/waiting room log for this. Every hour we recheck VS as well.

Intervening for pain control is becoming a JCAHO hot item- that's why we have standing protocols fromMACU for the use Motrin or if something else is needed we call and get order for Percocet-- but make sure these people aren't walking out on you if you go that route--some sort of release/sig needs to be signed by the patient prior to getting the med (I'm working with Risk on that one--also featured in the recent JEN issue)

A lot to develop- good luck

Anne