ems protocol

POLICY and PROCEDURE

TITLE: Emergency Department Standing Orders Number: 11914 Version: 11914.6 Type: Patient Care Author: Effective Date: 6/12/2013 Original Date: 1/1/2010 Approval Date: 5/23/2013 Deactivation Date: Facility: System Population (Define): All Employees and Patients Replaces: Approved by: ED Clinical Consensus Group; BH System Practice Oversight Team; Care Management Operations Council

May not be current policy once printed 1 Print Date: 7/30/2013

TITLE: Emergency Department Standing Orders I. Purpose/Expected Outcome:

A. To provide a pathway of timely, coordinated care for patients with specific symptoms, determined through assessment by an RN that correspond to a specific standing order delegated by a medical provider to reduce delays in medical treatment and care.

B. To provide a set of Standing Orders that the Hospital Emergency Department Registered Nurse (RN) can initiate to address urgent/emergent medical condition(s) of patients presenting to the Emergency Department.

C. To provide direction to the Hospital Emergency Department Registered Nurse (RN) to address injuries and/or medical problems ranging from critical and life threatening to minor and self limiting and establishing a layer of safety for patients presenting to the Emergency Department while determining appropriate treatment in a timely manner.

II. Definitions:

A. Standing Order (SO): an order approved by the applicable Medical Executive Committee that may be executed prior to an individual provider order. Standing Orders are limited to a subset of orders in regards to a patient condition or circumstance that are necessary for timely and efficient care.

III. Policy:

A. Prior to implementation at a facility, these Emergency Department (ED) Standing Orders must be approved by the applicable Medical Executive Committee who may choose to utilize any or all of these Standing Orders. These Standing Order sets are not intended to replace more detailed department specific clinically based emergency response order sets such as Code Blue protocols.

B. The ED Registered Nurse (RN) will initiate orders off the Standing Order sets if the patient assessment findings warrant the Standing Order intervention within their scope of competency and within the resources of the applicable Emergency Department. 1. These Standing Order sets are complaint specific and were developed to be within the critical

thinking skill set of a bedside emergency department RN. 2. The RN may not alter the content of any Standing Order. 3. A Standing Order set(s) does not need to be implemented in its entirety. The RN should

implement applicable section(s) of the Standing Order set based on patient assessment and established criteria.

4. More than one Standing Order set may be used for a patient as appropriate per patient need and RN assessment. For example: A patient presenting with a laceration may require both the

Policy Title: Emergency Department Standing Orders

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Standing Order for Tetanus and an order for radiologic testing depending on patient’s presentation.

C. The RN will consult with an on-duty ED physician/provider if clarification is needed in initiating a Standing Order(s).

D. The RN is accountable and responsible for the delegation of any intervention in the Standing Order set.

E. The RN must document assessment findings, interventions, and outcomes per this policy. F. Emergency Department Standing Orders must be entered into the patient’s medical record and

authenticated by the responsible provider for the patient according to the facility/department specific order authentication process.

IV. Procedure/Interventions:

A. Patient presents to the ED with specific symptoms that align with a current ED Standing Order set B. RN assessment confirms symptom(s) or condition that warrants initiation of Standing Order set C. RN initiates corresponding SO and consults with medical provider if additional clarification is

needed D. Standing Order Sets:

1. Applicable to all adult/pediatric patients experiencing the following conditions: a. SO ED - Abdominal pain b. SO ED - Chest Pain Adult c. SO ED – Diarrhea d. SO ED – Dyspnea e. SO ED – Dysuria f. SO ED - Eye Problems g. SO ED – Fever h. SO ED - Flank Pain i. SO ED - GI Bleeding j. SO ED – Hemoptysis k. SO ED – Laceration l. SO ED - Medical Imaging m. SO ED - Musculoskeletal Pain n. SO ED - Nausea & Vomiting o. SO ED - Seizure p. SO ED –Shortness of Breath q. SO ED – Syncope r. SO ED –Vaginal Bleeding

B. See Appendix A for details on associated orders specific to the outlined conditions.

V. Procedural Documentation:

A. N/A VI. Additional Information:

A. Centers for Medicare & Medicaid Services, Conditions of Participation Section 482.23 (c) (2) “The use of standing orders must be documented as an order in the patient’s medical record and authenticated by the practitioner responsible for the care of the patient, as the regulations at 42 CFR §482.23(c) (2) and §482.24(c) (1) require, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances. We would expect to see that the standing


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order had been entered into the order entry section of the patient's medical record as soon as possible after implementation of the order (much like a verbal order would be entered), with authentication by the patient's physician”

VII. References:

Centers for Medicare & Medicaid Services, Conditions of Participation Section 482.23 (c) (2)

VIII. Other Related Policies/Procedures: A. Provider Hospital Orders-Standing Orders Development and Approval Policy B. Nursing Assessment Policy C. Medication Administration Policy D. Nursing Standards of Practice guidelines

IX. Keywords and Keyword Phrases:

A. Standing Orders- Emergency Department B. Standing Orders C. ED D. Emergency Department E. Nursing Assessment F. Medication Administration

X. Appendix:

A. Appendix A: Emergency Department Standing Orders.


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Appendix A: -------------------------------------------------------------------------------------------------------------------------------------

Table 1 Emergency Department Standing Orders

SO ED ABDOMINAL PAIN Nursing Saline Lock IV DIET NPO (except medications) NPO (including medications) Laboratory CBC w/Diff [cs] UR UA. CMP POC for nursing (urine dipstick) Epigastric or RUQ Pain Add: Lipase Serum With Jaundice and/or on Warfarin Add: PT(includes INR) If Female of Menstruating Age and No Hysterectomy Add: UR HCG Qual POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Qual Serum HCG Quant, Serum Possible Cardiac Component or Upper Abdominal Pain > 40 years old, Add: Troponin I Assay POC Troponin DIAGNOSTIC TESTING EKG

SO ED Chest Pain Adult NURSING Suspect Cardiac Origin: Saline Lock IV (Antecubital) Cardiac Monitoring RSP Oximeter Continuous RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N LABORATORY CBC w/Diff [cs] CMP


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Troponin I Assay POC Troponin If on Warfarin Add: PT(includes INR) DIAGNOSTIC TESTING EKG MEDICAL IMAGING Chest Single View Adult Portable Chest PA + Lat MEDICATIONS Aspirin initial 324 mg. PO chew tab

SO ED Diarrhea Nursing Saline Lock IV LABORATORY Elderly Patients with Orthostatic Changes, or Any Patient with Suspected Volume Deficit: CBC w/Diff [cs] CMP Nurse Communication: Collect & save stool specimen if possible UR UA POC for nursing (urine dipstick POC Nursing) Urine Culture (UR Culture Urine) if indicated

SO ED Dyspnea NURSING RNs may use their clinical judgment to initiate an SVN (small volume nebulizer) based on signs and symptoms including: -Dyspnea and/or wheezing - Oxygen saturation <90% For patients ages 1 year- 17 years old, RNs may initiate the ED Pediatric Asthma protocol based on an Asthma Respiratory Severity Score (RSS) as applicable For patients ages 0- 24 months old, RNs may initiate the Pediatric Bronchiolitis protocol as applicable including performing a Bronchiolitis Respiratory Severity Score (BRS) Call / request Respiratory to respond RSP Oximeter Continuous

RSP Suction- age appropriate suction bulb or BBG nasal aspirator (Reserve deep suction for airway obstruction causing significant respiratory compromise)

RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N (or blow by for infants) RSP SVN - Albuterol 2.5 mg SVN, Soln, 1 x ONLY Shortness of Breath or wheezing

RSP Peak Flow Measurement 2 times- Perform Peak Expiratory Flow Rate (PEFR) before and after treatment if able (Exception infants and small children)

For patients under 11 years old presenting with sudden onset loud barking cough, Pediatric trained RNs may initiate the following (available only at Certified Pediatric Emergency Departments) Mild: Barky Cough MEDICATION Dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x only


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Moderate/Severe: Barky Cough with active stridor, retractions at rest, retractions with severe respiratory distress, hypoxia, or cyanosis If child is under 6 months of age: RSP SVN-Racemic epinephrine 0.3ml of 2.25% solution diluted in 3mL NS SVN, 1x ONLY If child is 6 months of age or older: RSP SVN-Racemic epinephrine 0.5mL of 2.25% solution diluted in 3 mL NS SVN, 1x ONLY If child is no longer moderate/severe: Medication dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x ONLY dexamethasone (Decadron) 0.6mg/kg IM, not to exceed 10 mg, 1 x ONLY. For use only if patient vomits oral dose. Document patient assessment and notify provider as soon as possible after treatment has begun Repeated SVNs are given only after the provider has been consulted or per ED Pediatric Asthma protocol SO ED Dysuria LABORATORY UR UA Urine Culture (UR Culture Urine) if indicated POC for nursing (urine dipstick POC Nursing) If Female of Menstruating Age and No Hysterectomy Add: HCG Urine Qual POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Quant, Serum HCG Qual Serum

SO ED Eye Problems MEDICATIONS FOR SEVERE PAIN DUE TO POSSIBLE CORNEAL ABRASION OR FOREIGN BODY CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation. tetracaine ophthalmic 1 drop, 1x ONLY proparacaine ophthalmic 1 drop, 1 x ONLY NURSING Visual Acuity Evaluation CHEMICAL SPLASH TO THE EYE(s) Check pH, but do not delay irrigation CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation, if not contraindicated: tetracaine ophthalmic 1 drop, 1x ONLY proparacaine ophthalmic 1 drop, 1x ONLY S-Sol Irrigation Sodium Chloride 1L (S-Solution Irrign NaCl 0.9 1L), use ocular irrigation set NURSING Visual Acuity Evaluation

SO ED Fever Nursing Saline Lock IV LABORATORY


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Toxic appearance: CBC w/Diff [cs] CMP Lactic Acid Blood Culturex2 UR UA POC for nursing (urine dipstick POC Nursing) Nurse Communication: urinalysis – clean catch or catheter MEDICATION Consider Acetaminophen when: 1. the child's temperature is 38.0 C or higher 2. The child was under dosed according to weight guidelines 3. Or the last dose was vomited regardless of the time it was given. Consider Ibuprofen when Acetaminophen was given within the last 4 hours and if the child’s temperature to 38.0 C or greater. 14 years and younger: 15mg/kg Acetaminophen PO or rectal For children age 6 months to 14 years: 10mg/kg Ibuprofen PO If Neonatal Fever:

IV Saline Lock Straight Catheter Insert NEO UR UA catheterize UR Culture - catheterize Blood Culture x 1 Draw red top to hold Lidocaine 4% cream (LMX /Ela-max)- apply up to 5 gm to lumbar spine area

SO ED Flank Pain NURSING Saline Lock IV LABORATORY Basic Labs: CBC w/Diff [cs] Comprehensive Metabolic Panel UR UA Urine Culture (UR Culture Urine) if indicated POC for nursing (urine dipstick POC Nursing) If Female of Menstruating Age and No Hysterectomy Add: HCG Urine Qual POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Quant, Serum HCG Qual Serum

SO ED GI Bleeding Nursing Saline Lock IV LABORATORY Apply Blood Band ID to all specimens CBC w/Diff [cs]


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Comprehensive Metabolic Panel PT(includes INR) Hold Clot If Patient on Heparin or Hemophiliac Add: PTT (APTT) If Hemodynamically Unstable, add: Type and Screen If Chest Pain, see SO ED Chest Pain SO ED Hemoptysis Nursing Mask Medical Imaging Chest X-ray PA/Lat

SO ED Laceration MEDICATION If last tetanus immunization greater than 5 years or unknown, and no history of adverse reaction to tetanus (IF CHILD IS UNDER 10 YEARS OF AGE, CONTACT PROVIDER)

diphtheria/pertussis, acel/tetanus adult (diphtheria/pertussis/tetanus) 0.5mL IM 1X ONLY For topical anesthetic use at laceration site (DO NOT USE for fingers, toes, nose, or ears) LET topical anesthetic solution- apply up to 3 mL to an open wound for 20-30 minutes For patients under 18 years old presenting with pain associated with minor closed head injury and/or laceration (available only at Certified Pediatric Emergency Departments) Consider Acetaminophen for pain: If the child was not already given acetaminophen Consider Ibuprofen for pain when child is over 6-months-of-age AND Acetaminophen was given within the last 4 hours or the child is allergic to acetaminophen Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY

SO ED Medical Imaging PRIOR TO ORDERING 1. Nurse may order one site (all views) for x-rays. Consult with physician if more than one site (all views) needs to be ordered, unless special instructions are noted in “WHAT TO ORDER” 2. Question patient for possible pregnancy 3. Examine injured area and initiate ice, immobilization and elevation 4. Request analgesia ASAP as needed 5. Always palpate joints above and below injury to assess for other injuries INDICATIONS: 1. Injury confined to extremities 2. Presence of deformity, instability, crepitus, point tenderness, ecchymosis, swelling or pain


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3. Patient request which meets above criteria 4. History significant for probable fracture PROVIDER CONSULTATION NEEDED: 1. Any time multiple sites may need to be taken 2. Any doubts the nurse has on which films to order, i.e. unable to localize injury 3. All patients possibly pregnant 4. Any associated injury to head, neck or trunk 5. Any evidence of neurovascular compromise WHAT TO ORDER "Heard a pop", inversion or eversion ankle injury; swelling at malleoli. Palpate fifth metatarsal and if pain present, order a foot x-ray also. Ankle film does not visualize the metatarsals well. Ankle 3 Or More Views Lt Ankle 3 Or More Views Rt Post traumatic pain if associated with decrease or loss of supination, pronation, flexion or extension. ** In a child of 5 years or less with unexplained loss of arm function and no apparent soft tissue swelling, a radial head subluxation must be considered and x-rays should not be obtained prior to physician evaluation. Elbow 3 Or More Views Lt Elbow 3 Or More Views Rt If swelling or pain on top of foot. Foot 3 Or More Views Lt Foot 3 Or More Views Rt Clear hand injury distal to wrist Hand 3 Or More Views Lt Hand 3 Or More Views Rt Order special calcaneal films if fracture suspected Calcaneus [Heel] Lt Calcaneus [Heel] Rt 1. Inability to stand or walk with localized knee pain 2. Post traumatic joint effusion 3. A fall or blow to the kneepatellar area with subsequent inability to flex or extend the knee fully. If pain over patellar area, add order for sunrise (patellar) view Knee 3 View Lt Knee 3 View Rt Tenderness above the shoulder or on top of the shoulder; may or may not have swelling/deformity. Shoulder 2 Or More Views Lt Shoulder 2 Or More Views Rt 1. Fall on an outstretched hand with swelling and tenderness to the wrist 2. If snuffbox tenderness, a comment of "navicular view" in the order comments. Wrist 3 Or More Views Lt Wrist 3 Or More Views Rt Post traumatic pain in hip area if associated with rotated and shortened leg Hip 2 Or More Views Lt Hip 2 Or More Views Rt Pelvis 1 or more views Post traumatic pain in thigh area with swelling or pain to thigh area Femur 2 Or More Views Lt Femur 2 Or More Views Rt


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SO ED Musculoskeletal Pain Nurse Communication: Provider comfort measures i.e. Ice, pillow, elevation and consult MD for pain medication MEDICATION For patients under 18 years old presenting with pain associated with minor closed head injury and/or musculoskeletal injury (available only at Certified Pediatric Emergency Departments) Consider Ibuprofen for pain when child is over 6-months-of-age: 1. If the child was not already given ibuprofen Consider acetaminophen for pain if: 1. Ibuprofen was given within the last 6 hours, 2. the child is allergic to ibuprofen, 3. The child is under 6-months-of age Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY

SO ED Nausea and Vomiting Nursing Saline Lock IV

For pediatric patients greater than 6 months old, may start Oral Rehydration Therapy (ORT) per protocol as applicable

LABORATORY UR UA POC for nursing (urine dipstick POC Nursing) CMP CBC w/Diff [cs] If Female of Menstruating Age and No Hysterectomy Add: UR HCG Qual Quick Qualitative Urine Pregnancy (HCGKITU) POC for nursing (urine HCG POC Nursing) HCG Qual Serum HCG Quant, Serum MEDICATIONS 2 mg for weight from 8 to 16 kg 4 mg for weight >16 kg Ondansetron (Zofran®) ________ mg PO DIS (Disintegrating) Tablet or liquid now

If Abdominal pain follow SO ED Abdominal pain careset

SO ED Seizure Nursing Saline Lock IV Nurse Communication, place seizure pads around patient. LABORATORY Glucose Point-of-Care (Finger-Stick Glucose) With Prior Seizure History and On One Of These Medications Add: Carbamazepine (Tegretol) Level Dilantin Level


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Valproic Acid (Depakane) Level Phenobarbitol Level If Fever or Obtunded Add: Blood Culturex2 UR UA POC for nursing (urine dipstick POC Nursing) Urine Culture (UR Culture Urine) if indicated CBC w/Diff [cs] Comprehensive Metabolic Panel If Female of Menstruating Age and No Hysterectomy Add: UR HCG Qual POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Qual Serum HCG Quant, Serum

SO ED Shortness of Breath Does Not Apply to Uncomplicated Asthma in a Young Patient, see SO ED Dyspnea NURSING Saline Lock IV RSP Oximeter Continuous RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N LABORATORY CBC w/Diff [cs] CMP If Cardiac Origin Add: BNP Troponin I Assay POC Troponin DIAGNOSTIC TESTING EKG MEDICAL IMAGING Chest Single View Adult Portable Chest PA + Lat

SO ED Syncope NURSING Notify Physician if Hemodynamically unstable Orthostatic vitals Saline Lock IV LABORATORY Draw Extra Tubes for Possible Cardiac Enzymes, PT, INR, PTT, Toxicology Studies, Type and Screen CBC w/Diff [cs] CMP UR UA POC for nursing (urine dipstick POC Nursing) If Female of Menstruating Age and No Hysterectomy Add: Urine HCG Qual


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POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Qual Serum HCG Quant, Serum Apply Blood Band ID to Specimens DIAGNOSTIC TESTING EKG

SO ED Vaginal Bleeding LABORATORY UR UA POC for nursing (urine dipstick POC Nursing) CBC w/Diff [cs] If Female of Menstruating Age and No Hysterectomy Add: UR HCG Qual POC for nursing (urine HCG POC Nursing) Quick Qualitative Urine Pregnancy (HCGKITU) HCG Qual Serum If Patient Reports a Positive Pregnancy Test or has a Positive Pregnancy Test Add: Rh Only HCG Quant, Serum If on Warfarin Add: PT(includes INR)

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