We will assist; I will ask Anne Pedersen and Mike Olszewski to provide guidelines for ICU admission criteria here at Hamot.

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1 Wednesday, February 8, 205 :52 PM Pam Bray, RN Olszewski, Michael; Pedersen, Anne RE: Assistance Pam, We will assist; I will ask Anne Pedersen and Mike Olszewski to provide guidelines for ICU admission criteria here at Hamot. Thanks, Jim CNO, VP Patient Care Services Office Cell Pam Bray, RN [mailto:pbray@kanehospital.org] Wednesday, February 8, 205 :46 PM Assistance Jim, I just met with Gary about staffing, challenges of lower inpatient census, etc and voiced that although I do not want to close our ICU, it seems like it might be the best option in a fiscal sense. As a first step, I will obtain the census for last year for ICU and look at the patient diagnosis to see if all definitely met True ICU criteria. Second I am going to review our ICU admission criteria to see what revisions may be possible. Physicians last reviewed in March of 203, when they did the Criteria deemed Appropriate for Internal Medicine Consults policy (see both attached). I need your assistance in helping to determine what criteria you would utilize to determine what patients we could care for on M/S and what would definitely need transferred. I would be considering a change in BiPaP, CHF, DKA, electrolyte imbalance, etc as ones we might be able to keep as M/S staus. As always thanks for your help.. Pam Bray, RN, DON Director of In-Patient Services Kane Community Hospital-An Affiliate of 4372 Rt 6 Kane, PA Fax pbray@kanehospital.org "Our mission is to serve our patients and their families, our communities, and one another."

2 Wednesday, February 8, 205 :53 PM Pam Bray, RN Dickson, Corinne RE: Question Pam, I ll ask Corinne to set up a conference call and we can discuss these issues. Thanks, Jim CNO, VP Patient Care Services Office Cell Pam Bray, RN [mailto:pbray@kanehospital.org] Monday, February 6, 205 :06 AM Question Jim, As it is budget time, the reassessment of staffing levels is again on the table. Although there are certainly differences between the patient care acuity and processes here and those at your facility (with you having the availability of residents, volunteers for escorting patient to testing and upon discharge, RT and pharmacy around the clock, etc to name a few) I am requesting your thoughts on the patient to nurse ratios that you would be utilizing for our ACU (Acute Care Unit) that includes M/S and ICU patients. Our ICU as we discussed before would be comparable to your step down unit and there are probably ICU patients 50% or less of the time. We also serve as the unit caring for SPU patients after 2:30pm (some discharged that evening, some staying overnight) and frequent blood transfusions for SPU patients. Our current system is based on 8 HPPD and broken out as follows: 45% on day shift; 35% on evenings and 20 % on nights. Staffing is RNs, with a telemetry nurse (who also transcribes orders, answers phone, etc) on each shift. Currently the only shift that has a PCA is day shift and they are normally the one sent home as census decreases, unless no ICU patient and low patient acuity permits that one sent home being an RN. Next years budget will be based on 9 patients (IP and obs). That would mean 3 staff on first and second shift and two on third. One of the staff on each shift would be a telemetry nurse who is an LPN. This year we have been having the 45% (4 staff) on days, the 35% (3-4 staff depending on acuity) on evenings and then having 2 or 3 staff on nights (instead of the suggested.8 staff) depending on patients acuity/icu patients. So I would appreciate any input you could provide in this arena..thanks and stay warm Pam Bray, RN, DON Director of In-Patient Services Kane Community Hospital-An Affiliate of 4372 Rt 6 Kane, PA Fax pbray@kanehospital.org

3 Monday, February 23, 205 2: PM Rhodes, John Gary Fiorenzo, Jim RE: Kane ICU Thanks Gary; let me know what I can do to help. CNO VP Patient Care Services Office Cell Rhodes, John Gary Monday, February 23, 205 :43 AM Fiorenzo, Jim Kane ICU, what we intend to do is to revise our Acute Care Unit admission criteria to essentially run a 'step-down' unit vs. an ICU. And, that is the verbiage we are going to use. We are not going out there and 'closing our ICU'. I am hearing that Elk Regional is going to do that and prefer to wait until they actually do that. At the beginning of FY '6, I will physically close the ICU unit and move SPU to that space. I have to discuss with physicians before we say or do anything with this. Mark is working on the financial impact, it will be minimal and relate primarily to staffing ratios, plus our ability to hire and retain 'ICU' nurses. I expect it will have some impact on CMI, we have to look at that as well. Gary John Gary Rhodes, FACHE Vice President CEO Kane Community Hospital Interim CEO Brooks Memorial Hospital, Dunkirk, N.Y. N.Y Pa Cell

4 February 20, 205 Friday February 205 SuMo TuWe Th Fr Sa March 205 SuMo TuWe Th Fr Sa Friday Daily Task List Arrange By: Due Date 7 am Environmental Safety Rounds Ground PT, Audiology+++ Hammer, Brian Magnet Meeting Jim's Office Dickson, Corinne Call Mahan; Jim's Office ; Struchen, Sara Jim / Anne (Monthly); Jim's Office; Dickson, Corinne 00 Ethics Committee Meeting CR_HAM_Med_Staff (Service Account) Stewart, Lindie 2 pm 00 Notes 2 00 Call - Kane Staffing Levels and ICU Decision; Jim to Call Pam ; Dickso 3 00 CNO Rounding /28/205 2:58 PM

5 UPMC HAMOT HOSPITAL INTERMEDIATE UNIT CAPABILITTIES 204 Observations and Monitoring 4-MRIU 6-IU 8- Neuro Medications 4-MRIU 6-IU 8- Neuro Devices 4-MRIU 6-IU 8- Neuro Nurse: Patient Ratio 3: 3:* 4: Bolus Meds Tracheostomy Yes Yes Yes Highest vital signs frequency q 4h q2h q2h IV Metoprolol boluses Yes Yes No Translaryngeal endotracheal tubes No No No Highest neuro check frequency q h q4h q2h IV Labetalol boluses Yes Yes Yes Temporary TV pacer No Yes No Highest pulse check frequency q4h q4h q2h IV Hydralazine boluses Yes Yes Yes Surgical pacer wires/pacer No Yes No Highest Urine output frequency q4h q4h q2h Mannitol boluses No No No External ventricular drain No No Yes Continuous EKG monitoring (hardwire) Yes Yes Yes IV Opiate boluses Yes Yes No Lumbar drain Yes Yes Yes Continuous EKG monitoring (telemetry) Yes Yes Yes Arterial line No No No Continuous pulse oximetry (hardwire) Yes Yes Yes Infusions 4-MRIU 6-IU 8- Neuro Central line Yes Yes Yes Continuous pulse oximetry (telemetry) Yes Yes Yes Amiodarone Yes Yes Yes Temporary dialysis catheter Yes Yes Yes Respiratory Pleth Monitoring Yes Yes No Argatroban No Yes Yes Introducers (> 8F) Yes Yes No Capnography/capnometry PCA PCA PCA Diltiazem Yes Yes Yes Chest tubes Yes Yes Yes Central venous pressure No No No Dobutamine Yes* Yes Yes Mediastinal tubes No Yes No Invasive blood pressure No No No Glycoprotein IIb/IIIa antagonists No Blank No Ventricular assist device Yes No No ICP monitoring No No No Heparin Yes Yes Yes Continuous EEG monitoring Yes No No** Insulin Yes Yes Yes Ketamine No No No * Day shift only Lasix Yes Yes Yes ** Future Milrinone Yes Yes Yes Nerve blocks (Lidocaine or Bupivacaine) Yes Yes Yes Interventions 4-MRIU 6-IU 8- Neuro Nicardipine Yes No Yes Mechanical ventilation with Endo tube No No No PCA opiates Yes Yes Yes Mechanical ventilation with tracheostomy Yes Yes No Sodium bicarbonate Yes Yes Yes Non-invasive ventilation Yes Yes Yes Nighttime CPAP/BiPap (OSA patients) Yes Yes Yes * No titration High Flow Oxygen therapy (> 6L) Yes Yes Yes High Flow Nasal O2 (Optiflow System) Yes Yes Yes Face Mask O2 > 40% Yes Yes No NRB Mask (0-5L/min) Yes No Yes