Harbor:Right level of care: Difference between revisions

No edit summary
No edit summary
 
(5 intermediate revisions by the same user not shown)
Line 1: Line 1:
''These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment''
''These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment''
* '''An admitting attending can always write an order to override below criteria'''
** '''Use corrected Na''' - the admitting team can write a '''communication order: "Ok for ward with Na 128 per Dr. X" ''' (Dr. Stein 5/2024)


*Right Level of Care Flowchart:
*Right Level of Care Flowchart:
 
*Policy 307:  https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/307-Admissions,%20Discharge%20Criteria%20for%20the%20Adult%20Wards,%20Telemetry,%20Progressive%20Care%20Units.pdf
*Policy 325M:  https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/325M-Guidelines%20for%20Intravenous%20Medication%20Administration.pdf


==[[Harbor:Observation placement|Observation/Short-Stay Medicine]]==
*[https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/307-Admissions,%20Discharge%20Criteria%20for%20the%20Adult%20Wards,%20Telemetry,%20Progressive%20Care%20Units.pdf Policy 307]
* Goal of our observation/Short Stay is admission avoidance
*[https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Harbor-UCLA%20Medical%20Center%20Policies%20and%20Procedures/325M-Guidelines%20for%20Intravenous%20Medication%20Administration.pdf Policy 325M]
* Consider a brief additional stay in the ED if it will prevent an admission
 
* All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs
* [[Harbor:Observation placement|Observation/Short-Stay Medicine]]
* (Previous:  When boarding >5 obs patients in ED, admit DHS empaneled OBS-level patients)


==Ward<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
==Ward<ref>Chappell 9/2020, Hospital Policies 307 & 325M</ref>==
Line 16: Line 14:
* Stable Patients
* Stable Patients
** HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** Na 130-160
** Na 130-160 (corrected Na)
* Nursing ratio 1:5
* Nursing ratio 1:5
** Nursing interventions q4 hrs (vitals, labs, POC testing)
** Nursing interventions q4 hrs (vitals, labs, POC testing)
Line 32: Line 30:
* Stable patients  
* Stable patients  
** HR 40-130 (140 for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** HR 40-130 (140 for A-fib), RR 8-28, SBP 90-210, SpO2>88%
** Na 130-160
** Na 130-160 (corrected Na)
* Nursing ratio 1:4
* Nursing ratio 1:4
** Nursing interventions '''q4 hrs''' (vitals, labs, POC testing)
** Nursing interventions '''q4 hrs''' (vitals, labs, POC testing)
Line 48: Line 46:
* Acceptable Vitals & Labs:
* Acceptable Vitals & Labs:
** HR 40-140 (160 for A-fib), RR 8-34, SBP 90-220, Sp02>75%
** HR 40-140 (160 for A-fib), RR 8-34, SBP 90-220, Sp02>75%
** Na 120-165
** Na 120-165 (corrected Na)
* Nursing ratio 1:3
* Nursing ratio 1:3
** Nursing interventions '''q2 hrs''' (vitals, suctioning, labs, POC testing)
** Nursing interventions '''q2 hrs''' (vitals, suctioning, labs, POC testing)
Line 67: Line 65:
** Frequent ABG monitoring
** Frequent ABG monitoring
* Actively titrated Drips: Cardene, nitroprusside, pentobarbital, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
* Actively titrated Drips: Cardene, nitroprusside, pentobarbital, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
** Na <120 (corrected Na)


==See Also==
==See Also==

Latest revision as of 13:51, 1 June 2024

These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment

  • An admitting attending can always write an order to override below criteria
    • Use corrected Na - the admitting team can write a communication order: "Ok for ward with Na 128 per Dr. X" (Dr. Stein 5/2024)
  • Right Level of Care Flowchart:

Ward[1]

  • Unmonitored
  • Stable Patients
    • HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160 (corrected Na)
  • Nursing ratio 1:5
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
  • OK on ward
    • 4L O2 via NC
      • Chronic CPAP or Nasal BiPAP (with pulm attending approval)
    • Meds: Ativan IV q6, Bumex, CaCl, digoxin IV, Dilantin IV, Dilaudid IV, heparin IV, Lasix, potassium IVPB
    • ETOH withdrawal on PO meds only
    • NG tube, chest tube, peritoneal dialysis (ambulatory patient)
    • Palliative/comfort care admissions, including vented comfort care patients

Telemetry[2]

  • 3W, 4W, 5E, 6W
  • Continuous cardiac and pulse ox monitoring
  • Stable patients
    • HR 40-130 (140 for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160 (corrected Na)
  • Nursing ratio 1:4
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
  • Ok on Tele:
    • 6L O2 via NC
      • CPAP, BIPAP, chronic vent OK
    • Non-titrated IV meds: Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin IVP only for hyperkalemia; labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV. Drips include non-titratable amiodarone, bumex, lasix, integrilllin, insulin.
      • DKA patients requiring active drip titration will require a higher level of nursing intervention
    • ETOH withdrawal on PO meds only
    • Femoral central line/Quinton per Policy 324

PCU/SDU[3]

  • 3W SDU, 4W/5E PCU
  • Continuous cardiac and pulse ox monitoring
  • Acceptable Vitals & Labs:
    • HR 40-140 (160 for A-fib), RR 8-34, SBP 90-220, Sp02>75%
    • Na 120-165 (corrected Na)
  • Nursing ratio 1:3
    • Nursing interventions q2 hrs (vitals, suctioning, labs, POC testing)
  • Ok on PCU/SDU:
    • O2 via NRB or HFNC
      • Respiratory treatments q2 hrs
    • Meds: Non-titrated IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt, dopamine, dobutamine
    • ETOH withdrawal requiring IV medications per CIWA protocol
    • Peritoneal dialysis patients with cycler
    • Subdural drains, procedural sedation
      • NOT allowed: temporary pacer, active chest pain, significant dysrhythmia or acute ischemic EKG changes, significant pulmonary edema

ICU[4]

  • 3W/5W/6W ICU, 3WCTU, 4WCCU
  • Nursing ratio 1:2 or 1:1 depending on instability
    • Nursing interventions q1 hr (vitals, labs, POC testing)
  • Actively managed ventilators
    • Frequent ABG monitoring
  • Actively titrated Drips: Cardene, nitroprusside, pentobarbital, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors
    • Na <120 (corrected Na)

See Also

References

  1. ↑ Chappell 9/2020, Hospital Policies 307 & 325M
  2. ↑ Chappell 9/2020, Hospital Policies 307 & 325M
  3. ↑ Chappell 9/2020, Hospital Policies 307 & 325M
  4. ↑ Chappell 9/2020, Hospital Policies 307 & 325M

Policy 307 Revised 7/2020

Retrieved from "https://www.wikem.org/w/index.php?title=Harbor:Right_level_of_care&oldid=373771"