Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol

Transcription

1 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol ACETAMINOPHEN FOR PAIN, DISCOMFORT AND/OR FEVER PROTOCOL APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for those patients who present with pain or discomfort related to fever (temperature >38.0 C). INCLUSION CRITERIA Fever with pain or discomfort EXCLUSION CRITERIA Allergy to acetaminophen Infants <3months of age (these patients must be CTAS 2 and seen expeditiously) Liver disease Pediatric patient with 15mg/kg acetaminophen in last 4 hours or 60mg/kg in past 24hrs Elderly (>70yrs of age) patient with acetaminophen total >3g in 24hrs Adult patient with acetaminophen total >4g in 24hrs Note Fever is a normal adaptive immunologic response to infection. Routine treatment of fever does not reduce the duration of infection. Fever outside of critical illness should only be treated in the presence of pain and/or discomfort. Acetaminophen crosses the placenta and is considered safe for short-term use in pregnancy. Acetaminophen passes into breast milk but is not likely to have adverse effect on breast feeding infants. A maximum single does of acetaminophen for a person <17yrs of age is 15mg/kg to a maximum of 1000mg. The maximum 24hr dose is 60mg/kg in 24hrs to a maximum of 4 grams.

2 A maximum single does of acetaminophen for a person >17yrs of age is 1000mg. The maximum 24hr dose is 4g in 24hrs for an adult or 3g in 24hrs for the elderly (>70yrs of age). PROTOCOL 1. Complete full set of vital signs T/P/R/BP & SpO2. Perform and document an assessment including past medical history, history of presenting illness and perform a physical examination. Use Fast Track or 4 Page Nursing Notes based on anticipated patient destination. 2. Record weight in all patients <17 yrs of age 3. Complete pain assessment including pain scale (0-10) and PQRST like assessment 4. Screen for exclusion criteria. 5. Initial Administration of Acetaminophen: <17 years of age give 15mg/kg acetaminophen to a maximum of 975mg. All pediatric medications must undergo independent double-checking of dosage. > 17 years of age give 975mg of acetaminophen 6. Documentation: Chart medication given in the Nurses Notes. On the physician order sheet (The Red), indicate the medication has been given according to the Acetaminophen Protocol. 7. Re-assess patient including a full set of vital signs as above in approximately 1 hour of receiving medication. Document patient response to medication and reassess pain/discomfort. 8. This protocol may be repeated every 4 hours PRN while the patient is waiting for initial physician assessment. 9. As usual, inform the charge RN and/or ED physician of any patients of particular concern PERMITTED TO PERFORM PROTOCOL Registered Nurse

3 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol LOWER ABDOMINAL/FLANK PAIN PROTOCOL: ADULT PATIENT >17YRS OF AGE APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON ESTABLISHED 2000 UPDATED 2014 PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for adults who present with uncomplicated lower abdominal pain and/or flank pain. PERMITTED TO PERFORM PROTOCOL Registered Nurse INCLUSION CRITERIA Age greater than or equal to 17 years Abdominal pain below the umbilicus or pain isolated to the flank(s) EXCLUSION CRITERIA Trauma Diffuse or ill-defined abdominal pain Note If a patient presents with tachycardia, hypotension and/or obvious distress, notify an Emergency Physician immediately Consider reference to the Suspected Sepsis Protocol if the patient has a likely source of infection and 2 or more SIRS criteria (Temp >38 or < 36; HR >90; RR>20)

4 PROTOCOL 1. The patient must have a complete assessment including past medical history, history of presenting illness, physical examination, and a full set of vital signs performed and documented. 2. Advise all patients and family members of NPO status. 3. Start an IV. Infuse normal saline to run at 30 ml/hr or saline lock the IV. 4. Labs: Draw and send a CBCD, NA, K, CL, C02, CRE, URE, GLUCR. If on coumadin send INR & PTT. DO NOT send coagulation studies routinely. If possible, draw and send to the lab additional tubes (i.e. chemistry and coagulation studies) for tests that may be required as add-ons. If protocol is initiated at triage, the Triage Team Lead is responsible for reporting abnormal results to an ED physician. If blood is drawn from triage, ensure accuracy of the patient s primary phone number. 5. Send UA. Do not routinely send a urine culture. Provide urine filter and patient instructions if flank pain is suggestive of nephrolithiasis/kidney stone. 6. Send a urine PREG if female and <45yrs of age. 7. Documentation: Chart blood work, diagnostics and interventions performed on the Nurses Notes. On the physician order sheet, indicate that bloodwork has been sent and the Lower Abdominal Pain Protocol has been initiated. 8. The clinician drawing and sending the bloodwork is responsible for reporting abnormal results to the ED physician. If a critical lab result is returned prior to the patient being seen by a physician, notify an Emergency Physician immediately.

5 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol SUSPECTED FRACTURED HIP PROTOCOL: ADULT PATIENT >65YRS OF AGE APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON ESTABLISHED 2000 UPDATED 2014 PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide registered nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for adults who present with a suspected fractured hip. Patients with femur fractures, open fractures, displaced fractures, significant mechanisms of injury or hemodynamic instability and polytrauma are not appropriate for this protocol. PERMITTED TO PERFORM PROTOCOL Registered Nurse INCLUSION CRITERIA Adult greater than or equal to 65 years of age with a shortened and rotated lower extremity, typically after fall from standing. EXCLUSION CRITERIA Polytrauma Significant mechanism of injury (MVC, fall from >2m etc.) Hypotension Note Does this patient require spine immobilization? If yes, apply cervical collar, initiate neutral spine position and log rolling. Inform ED Physician and Charge Nurse of same.

6 PROTOCOL 1. Upon transfer from EMS stretcher to ED stretcher, place patient on a slider board. 2. Patient must be completely undressed. Perform and document a complete assessment including past medical history, history of presenting illness, physical examination, a full set of vital signs and focused neurovascular assessment of the involved extremity including circulation, sensation, motor and temperature (CSMT). 3. Inform emergency physician immediately of any hypotensive patients with suspected hip fracture. (Systolic BP <90mmHg or <110mmHg with history of hypertension). 4. Keep patient NPO. 5. If patient is likely to require analgesia to facilitate transfer to x-ray, obtain an order for analgesia. With physician approval, fentanyl for initial analgesia if pain scale greater than or equal to 4/10 and systolic BP >90mmHg, then give 0.5mcg/kg IV to a single maximum dose of 50mcg. May repeat dose Q5min prn until pain <4/10 to a maximum of 100mcg. As always, monitor for adverse drug reaction. 6. Send to x-ray with a requisition for: XR Hip (left or right) and Pelvis. Write in the name of the physician covering your side of the department (A or B). If a fracture is observed x- ray should perform a chest x-ray at the same time. 7. Remove patient from slider board as quickly as possible. If fracture is confirmed: 8. Start an intravenous infusion at 30mL/hr or saline lock. In the frail elderly or patients with a history of cardiovascular disease do not hang a bag of saline larger than 500mL. 9. Labs: Obtain the following blood work: CBCD, NA, K, CL, C02, CRE, URE, GLUCR, INR & PTT, ALBUMIN, CA, MG, TSH, B12 and a Type & Screen. The nurse sending the bloodwork is responsible for reporting abnormal results to an ED physician. 10. Insert a foley catheter and attach to an urometer bag. 11. Perform an ECG. All ECGs should be shown to an ED physician and initialled as reviewed. 12. Obtain Fractured Hip Pre-Operative Order (Edmonton Zone Only) Form 09904(Rev ). Obtain Consent to Treatment Plan or Procedure Form 09741; Emergency Department (Pre-Op) Check List Form PP80; and Anesthesia Record CH Document all blood work, diagnostics and interventions on the Nursing Notes. Document blood work on the physician order sheet and write Fractured Hip Protocol on same. The clinician drawing and sending the bloodwork is responsible for reporting abnormal results to the ED physician.

7 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol SUSPECTED ISCHEMIC CHEST PAIN PROTOCOL: ADULT PATIENT >35YRS OF AGE APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON ESTABLISHED 2000 UPDATED 2014 PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for those patients who present with suspected ischemic cardiac chest pain and risk factors (including but not limited to): Known ischemic heart disease Positive family/genetic history Tobacco use Hypercholesterolemia Diabetes PERMITTED TO PERFORM PROTOCOL Registered Nurse INCLUSION CRITERIA Age >35 Chest pain, pressure or discomfort Arm, shoulder, jaw, epigastric and/or intra-scapular pain Shortness of breath Diaphoresis Nausea EXCLUSION CRITERIA Palliative patients (C1 and C2 Goals of Care designations) Patients with non-specific weakness, fatigue, dizziness, or ill-defined symptoms

8 PROTOCOL 1. ECG (12 lead +/- 15 lead). Any ECG should be shown to an ED physician and initialled as reviewed. a) Perform a 12-lead ECG within ten minutes of arrival and whenever a change in chest pain occurs. b) If there is ST segment elevation in leads II, III, and AVF (inferior leads) obtain a 15 lead ECG to identify a right ventricular and/or posterior ST elevation MI (STEMI). c) If patient is having ongoing chest pain during initial assessment, repeat ECG Q15 mins x 2 (for 3 ECG's total). 2. Perform and document a complete assessment including past medical history, history of presenting illness, a full set of vital signs and perform a physical examination. 3. Give ASA (acetylsalicylic acid) 160 mg to chew. Hold if allergy or of dose has been given by EMS or already take by patient. Give ASA even if patient has taken own 81mg EC ASA. 4. Oxygen therapy: a) Oxygen should NOT routinely be given in the absence of hypoxia. b) Maintain an oxygen saturation of equal to or greater than 94%. c) If patient is a known CO2 retainer an oxygen saturation of 92% may be reasonable and may not require oxygen therapy. A physician s order for oxygen therapy is required in this population. 5. Apply cardiac monitor leads, monitor the patient in lead II. Interpret the rhythm and note it in the Nurse s Notes to refer back to if the patient has a change in rhythm. Set heart rate limits above and below the patient s rhythm by 20bpm (narrow limits). Set NIBP to cycle Q15 minutes minimum for the first four readings/60 minutes. 6. Start an IV. If possible, do not use the right forearm or right wrist for IV access (allowing right radial approach for percutaneous coronary intervention). Infuse Normal Saline at 30 ml/hr. Avoid potential for fluid overload by either hanging a 250mL bag of Normal Saline or use an IV pump to control the rate. Consider the use of a 3-way extension set. 7. Labs: Draw and send CBC-D, NA, K, CL, CO2, GLUCR, CRE, URE, INR/PTT, CK, TROP, CA, MG. If blood is drawn from triage, ensure accuracy of the patient s primary phone number. 8. Documentation: Chart blood work, diagnostics and interventions performed in the nurses notes. On the physician order sheet (The Red), indicate that CCU bloodwork has been sent, ASA given (if applicable) and Cardiac Chest Pain Protocol has been initiated. 9. The clinician drawing and sending the bloodwork is responsible for reporting abnormal results to the ED physician. If a critical lab result is returned prior to the patient being seen by a physician, notify an Emergency Physician immediately.

9 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol UPPER ABDOMINAL PAIN PROTOCOL: ADULT PATIENT >17YRS OF AGE APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON ESTABLISHED 2000 UPDATED 2014 PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for adults who present with uncomplicated upper abdominal pain. PERMITTED TO PERFORM PROTOCOL Registered Nurse INCLUSION CRITERIA Age greater than or equal to 17 years of age Abdominal pain above the umbilicus or diffuse/generalized abdominal pain EXCLUSION CRITERIA Trauma Recent GI surgery Pain isolated to the groin, lower quadrants, or flanks Note If a patient presents with tachycardia, hypotension and/or obvious distress, notify an Emergency Physician immediately. Consider that abdominal pain may be caused by myocardial infarction. In patients with significant cardiac risk factors who present with upper abdominal pain at triage, especially those with diabetes, perform the Expedited 12 Lead ECG at Triage Protocol for the desirability of a cardiac work-up as outlined in the Suspected Cardiac Ischemic Chest Pain Protocol.

10 PROTOCOL 1. The patient must have a complete assessment including past medical history, history of presenting illness, physical examination, and a full set of vital signs performed and documented. 2. Advise all patients and family members of NPO status. 3. If the patient has upper abdominal pain and is >35 yrs of age, perform an ECG. If the patient is younger than 35 yrs of age an ECG may be performed at the nurse s discretion. Any ECG should be shown to an ED physician and initialled as reviewed. 4. Start an IV. Infuse normal saline to run at 30 ml/hr or saline lock the IV. 5. Labs: Draw and send CBCD, NA, K, CL, C02, CRE, URE, GLUCR and liver panel (ALT, AST, ALKPHOS, TBIL and LPS). If known to be coumadin, send INR & PTT. Do not send coagulation studies routinely. If possible draw and send, to the lab, additional tubes (i.e. chemistry and coagulation studies) for tests that may be required. If blood is drawn from triage, ensure accuracy of the patient s primary phone number. 6. Send UA if pain is generalized, or patient is febrile, or if patient complains of frequency or dysuria. Do NOT send UA for isolated upper abdominal pain in the absence of other symptoms. 7. Send urine pregnancy for all female patients under 45 yrs of age if sending a UA. Otherwise send serum HCG if female <45yrs and urine sample not immediately available. 8. Documentation: Chart blood work, diagnostics and interventions performed in the Nurses Notes. On the physician order sheet, indicate that bloodwork has been sent and the Upper Abdominal Pain Protocol has been initiated. 9. The clinician drawing and sending the bloodwork is responsible for reporting abnormal results to the ED physician. If a critical lab result is returned prior to the patient being seen by a physician, notify an Emergency Physician immediately. At triage, the Triage Team Lead is responsible for reviewing reported results.

11 Royal Alexandra Hospital Emergency Department Nurse Initiated Protocol VAGINAL BLEEDING DURING PREGNANCY PROTOCOL APPROVING AUTHORITY EMERGENCY MEDICINE SITE CHIEF: DR COLIN PETERSON EXECUTIVE DIRECTOR EMERGENCY: CAROL MANSON MCLEOD PATIENT CARE MANAGER: LISA SORENSON ESTABLISHED 2000 UPDATED 2014 PROTOCOL AUTHORS DR KEIR PETERSON DR RICKY ZHANG MATTHEW DOUMA RN ALI DRAKE RN NEXT REVIEW: TRIAL VERSION VERSION: 2 PAGE 1 OF 2 PURPOSE Nurse initiated Emergency Department Protocols are designed to provide nurses working in the RAH-ED with medical authorization to initiate specific diagnostics, therapeutics and interventions for patients, prior to initial physician assessment. This protocol is intended for those patients who are pregnant (clinically apparent or with previously documented positive pregnancy test) and experiencing vaginal bleeding. PERMITTED TO PERFORM PROTOCOL Registered Nurse INCLUSION CRITERIA Pregnant female with vaginal bleeding EXCLUSION CRITERIA Significant hemorrhage +/- signs of hypovolemic shock

12 PROTOCOL 1. Perform and document a complete assessment including past medical history, history of presenting illness, perform a focused physical examination and a full set of vital signs. The patient must have a complete assessment including past medical history, history of presenting illness, physical examination, and a full set of vital signs performed and documented. 2. Labs: Draw and send blood for CBC-D, HCG & ANEV. Insertion of an IV is at the clinician s discretion. If blood is drawn from triage, ensure accuracy of the patient s primary phone number. 3. Keep track of vaginal output in number of saturated pads. 4. Documentation: Chart blood work, diagnostics and interventions performed in the Nurses Notes. On the physician order sheet, indicate that bloodwork has been sent and the Vaginal Bleeding During Pregnancy Protocol has been initiated. 5. The clinician drawing and sending the bloodwork is responsible for reporting abnormal results to the ED physician. If a critical lab result is returned prior to the patient being seen by a physician, notify an Emergency Physician immediately.