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Archive for the ‘Policy’ Category

Central Line Policy

Written by phil

November 29th, 2012 at 7:50 pm

Elmhurst DNR Forms

Folks,

HHC has significantly simplified the DNR/DNI process (I know, I can’t believe it either).

Here is the deal:

Pt is making his or her own decisions and wants to be DNR and/or DNI:
Have pt sign a pink DNR form and if he or she wants DNI, a refusal of treat form
this is unchanged

For everything else, including proxy, surrogate, DNR, DNI, withdrawal of care you just need to use one form
It is in the cardiac room form rack or here:
http://ehced.org/forms/
You need to identify the family member who is the proxy or surrogate on the form, but he or she doesn’t need to sign (huge win for pall care).

Email me if you have any questions

Scott

Written by phil

July 8th, 2012 at 2:50 pm

Posted in Elmhurst,Policy

ED Policy / Protocol online reorganization

We’ve been reorganizing how the ED’s policies and protocols are
presented online, for your use on shift.

This reorganization was an outgrowth of the big ED policies review, in
anticipation of the Joint Commission visit. ED policies were
cross-referenced with hospital policies, and in many cases revised.
This effort was led by Suzanne Young-Mercer, Keri Gardner, and Kevin
Baumlin, with contributions from many of you in the department. I
thought it was a good opportunity to categorize the policies online.

The old way — an alphabetical list — was not easy to use or browse.
The policy about who gets sent to L&D was under “I” for Initial Care
of Pregnant Patients. The protocol for managing Animal Bites was under
“A”, but the protocol for Monkey Bites was under “M” (and yes, we have
a monkey bite protocol).

Policies and protocols are now organized by category. All medical
protocols are together, and we have some sub-sections for protocols
for at-risk populations as well as diversion, EMS and disaster
policies. The policies surrounding admissions and dispositions are
together, as are policies involving consults and interactions of other
departments.

These policies can be really helpful to you, on shift:

— When the MICU is full, who is “responsible” for calling other ICUs
about admission? It’s the MICU fellow – clearly stated in policy 34.5,
ICU Consults and Admissions.

— When Vascular Surgery is giving you trouble about seeing a diabetic
foot ulcer, refer to policy 34.8, Admission of Patients with DM and
Foot Ulceration or Infection. They are supposed to be consulted on ALL
ED DM patients with infections/ulcers of foot or leg, and all
admissions should go to them unless comorbidities supersede.

— If you want to know your responsibilities and resources for
domestic violence patients, check policy 26.3, Domestic Violence.

— Plenty of guidance on transfers, what constitutes crowding or
diversion status, what you can say to patients over the telephone,
what should be reported to the police, to the CDC, etc.

— if you ever need inspiration, we also have a vision statement and
mission statement, under Administration (at the very bottom of the
page).

You can keyword search, as always, by pressing Control-F, though it
will take some familiarity with the policies to search well (“OR”
works but “Surgery” doesn’t…)

Accessing the policies from inside Epic: Click on “My Dashboards” then
click on ED Policy Manual in the middle column.

From the web: http://www.mssm.edu/departments-and-institutes/emergency-medicine/about-us/manual
(there are links to this from mssmEM.com and SinaiEM.org)

If you have suggestions for moving, renaming or clarifying some of
these policies and protocols, please let me know!

Thanks,
Nick

Written by reuben

May 20th, 2012 at 5:20 am

Posted in Epic,Policy

Foot Ulcer Policy

Written by phil

December 14th, 2011 at 3:38 pm

Consult Policy / Medical Board Rules&Regs

Written by phil

June 15th, 2011 at 7:51 pm

Posted in Consults,Policy

Peds ED to Clinic Diversion Flow & Policy

1. Patient presents to the front desk staff at greet desk.
2. BA ascertains name and DOB of patient and checks to see if they have previously been to PEDS Clinic.
3. Once BA identifies patient as PEDS clinic patient they will indicate in Reason for Visit Field: PC (PEDS Clinic)/reason for visit.
4. Triage nurse quick triages patient in IBEX to assess acuity of patient (emergent vs. non-emergent) and then calls Attending/Fellow to validate assessment.
5. Attending/Fellow assesses patient as well, validates decision and suggests to patient/parent that they can go to PEDS Clinic as walk-in patient.  If parent agrees, attending writes note in IBEX and dispositions patient as “sent to clinic”.  If parent disagrees, they are sent to the ED waiting area to wait as triaged.
6. BA will then: 1) identify patient under “sent to clinic” disposition, 2) discharge patient from IBEX, and 3) cancel patient visit from Cerner.






Introduction:

The following describes the process by which The Mount Sinai Hospital’s Emergency Department will handle non-emergent pediatric patients during the hours of 8:30am -3:30pm Monday – Friday and 10am – 2:30pm on Saturdays.

Policy:

All patients that present to the Mount Sinai Emergency Department will receive a medical screening exam to determine level of acuity by a health care provider.   In the event the exam indicates that the visit is non-emergent, then the ED staff will refer the patient to the Pediatric Clinic if they are an established Pediatric Clinic patient in the past 12 months and participate in an insurance plan accepted by the Pediatric Clinic.

Procedure:

When a patient presents to the Mount Sinai Emergency Department, the ED-BA located at the Greet Desk will validate the patient’s name and date of birth.  During the look-up of the patient in the Cerner ADT system (between the hours of 8:30am to 3:30pm  Monday –Friday and 10am-2:30pm Saturday) the ED-BA will determine if the patient is an established patient in the Pediatric Clinic (seen within the past 12 months and participates in an insurance plan accepted by the Pediatric Clinic).  If the ED-BA determines that the pediatric patient has met the criteria as a Pediatric Clinic patient then the ED- BA will process the patient in the ADT system (Cerner) as a “Quick Registration.”  The Quick Registration will include the national patient identifiers (Name & DOB), referring source, PC (PEDS Clinic)/the reason for visit along with the onset date.

Once the patient’s Quick Registration has been completed with required data elements, then the patient’s information will be sent from the ADT system to the Emergency department’s electronic medical record system (IBEX).  The patient’s information will be viewed in the triage nurse’s queue and the patient will be called for triage.

The triage nurse will expedite all pediatric patients with the PC designation in the reason for visit field.    Once the triage nurse has assessed the acuity level of the pediatric patient (emergent vs. non-emergent), he/she will call the Attending/Fellow to validate the assessment.

Once the Attending/Fellow assesses the patient and validates the decision that the patient is non-emergent patient, the Attending/Fellow will suggest to the patient/parent that they can go to the PEDS Clinic as a walk-in patient.  If parent agrees, the Attending/Fellow will write a note in IBEX and disposition the patient as “sent to clinic”. If parent disagrees, they are sent to the ED waiting area to wait as triaged.

The BA will then: 1) identify the patient under “sent to clinic” disposition, 2) discharge the patient from IBEX, and 3) cancel the patient visit from Cerner.

Written by reuben

October 14th, 2010 at 11:02 pm

Posted in Peds,Policy

ED Central Line Policy

All central lines placed in the emergency department on patients who are not arrested or nearly arrested must meet these criteria:

1. The key portions of the procedure, which include initial cannulation of the vein and confirmation of venous placement, must be performed with an attending present.

2. The appearance of dark and non-pulsatile blood flowing from a freshly-inserted needle or catheter is insufficiently accurate to reliably distinguish arterial from venous placement. All central lines must be confirmed by ONE of the following methods prior to vessel dilation. This applies to standard triple-lumen and 8.5 Fr (introducer/Cordis) catheters.

a. Formal pressure transduction to confirm a non-arterial waveform.

b. Manometry using extension tubing. 8.5 Fr catheter kits come with sterile extension tubing in the set; triple lumen catheter kits do not. The sheath housing the guidewire can easily be used for this purpose. Patients with low arterial pressure or high venous pressure can generate misleading results.

c. Analysis of blood oxygen content using a blood gas drawn from the line. Results can be compared against a known arterial sample if ambiguous (e.g. in a hypoxic patient).

d. Anatomic ultrasound confirmation of the wire in a vein. Images or clips saved should demonstrate the wire in a collapsible vein juxtaposed to a non-collapsible artery; please save or print and scan images or clips.

e. Functional ultrasound confirmation by seeing normal saline rapidly injected through the catheter pass through the right heart. This is called the bubble test. Please save or print and scan images or clips.

If any single confirmation technique is inconclusive, use another confirmation technique.

These confirmation techniques do not replace the post-insertion chest xray, which evaluates for depth and complications of central line placement. The CXR is poor at distinguishing arterial from venous placement.

All central lines must be documented with the appropriate MD Procedures template, within which the steps for appropriate placement and confirmation are listed.

Contact me with any questions concerns.

reuben

Hospital Central Venous Catheterization Safety Policy

The Bubble Test

Written by reuben

October 8th, 2010 at 3:39 am

Pediatric ED to Clinic Diversion Process

Introduction:
The following describes the process by which The Mount Sinai Hospital’s Emergency Department will handle non-emergent pediatric patients during the hours of 8:30am -3:30pm Monday – Friday and 10am – 2:30pm on Saturdays.
Policy:
All patients that present to the Mount Sinai Emergency Department will receive a medical screening exam to determine level of acuity by a health care provider.   In the event the exam indicates that the visit is non-emergent, then the ED staff will refer the patient to the Pediatric Clinic if they are an established Pediatric Clinic patient in the past 12 months and participate in an insurance plan accepted by the Pediatric Clinic.
Procedure:
When a patient presents to the Mount Sinai Emergency Department, the ED-BA located at the Greet Desk will validate the patient’s name and date of birth.  During the look-up of the patient in the Cerner ADT system (between the hours of 8:30am to 3:30pm  Monday –Friday and 10am-2:30pm Saturday) the ED-BA will determine if the patient is an established patient in the Pediatric Clinic (seen within the past 12 months and participates in an insurance plan accepted by the Pediatric Clinic).  If the ED-BA determines that the pediatric patient has met the criteria as a Pediatric Clinic patient then the ED- BA will process the patient in the ADT system (Cerner) as a “Quick Registration.”  The Quick Registration will include the national patient identifiers (Name & DOB), referring source, PC (PEDS Clinic)/the reason for visit along with the onset date.
Once the patient’s Quick Registration has been completed with required data elements, then the patient’s information will be sent from the ADT system to the Emergency department’s electronic medical record system (IBEX).  The patient’s information will be viewed in the triage nurse’s queue and the patient will be called for triage.
The triage nurse will expedite all pediatric patients with the PC designation in the reason for visit field.    Once the triage nurse has assessed the acuity level of the pediatric patient (emergent vs. non-emergent), he/she will call the Attending/Fellow to validate the assessment.
Once the Attending/Fellow assesses the patient and validates the decision that the patient is non-emergent patient, the Attending/Fellow will suggest to the patient/parent that they can go to the PEDS Clinic as a walk-in patient.  If parent agrees, the Attending/Fellow will write a note in IBEX and disposition the patient as “sent to clinic”.  If parent disagrees, they are sent to the ED waiting area to wait as triaged.
The BA will then: 1) identify the patient under “sent to clinic” disposition, 2) discharge the patient from IBEX, and 3) cancel the patient visit from Cerner.

The official MS Word Document is available here.

Introduction:

The following describes the process by which The Mount Sinai Hospital’s Emergency Department will handle non-emergent pediatric patients during the hours of 8:30am -3:30pm Monday – Friday and 10am – 2:30pm on Saturdays.

Policy:

All patients that present to the Mount Sinai Emergency Department will receive a medical screening exam to determine level of acuity by a health care provider.   In the event the exam indicates that the visit is non-emergent, then the ED staff will refer the patient to the Pediatric Clinic if they are an established Pediatric Clinic patient in the past 12 months and participate in an insurance plan accepted by the Pediatric Clinic.

Procedure:

When a patient presents to the Mount Sinai Emergency Department, the ED-BA located at the Greet Desk will validate the patient’s name and date of birth.  During the look-up of the patient in the Cerner ADT system (between the hours of 8:30am to 3:30pm  Monday –Friday and 10am-2:30pm Saturday) the ED-BA will determine if the patient is an established patient in the Pediatric Clinic (seen within the past 12 months and participates in an insurance plan accepted by the Pediatric Clinic).  If the ED-BA determines that the pediatric patient has met the criteria as a Pediatric Clinic patient then the ED- BA will process the patient in the ADT system (Cerner) as a “Quick Registration.”  The Quick Registration will include the national patient identifiers (Name & DOB), referring source, PC (PEDS Clinic)/the reason for visit along with the onset date.

Once the patient’s Quick Registration has been completed with required data elements, then the patient’s information will be sent from the ADT system to the Emergency department’s electronic medical record system (IBEX).  The patient’s information will be viewed in the triage nurse’s queue and the patient will be called for triage.

The triage nurse will expedite all pediatric patients with the PC designation in the reason for visit field.    Once the triage nurse has assessed the acuity level of the pediatric patient (emergent vs. non-emergent), he/she will call the Attending/Fellow to validate the assessment.

Once the Attending/Fellow assesses the patient and validates the decision that the patient is non-emergent patient, the Attending/Fellow will suggest to the patient/parent that they can go to the PEDS Clinic as a walk-in patient.  If parent agrees, the Attending/Fellow will write a note in IBEX and disposition the patient as “sent to clinic”.  If parent disagrees, they are sent to the ED waiting area to wait as triaged.

The BA will then: 1) identify the patient under “sent to clinic” disposition, 2) discharge the patient from IBEX, and 3) cancel the patient visit from Cerner.

Written by reuben

May 25th, 2010 at 5:25 am

Posted in Peds,Policy

MSSM Central Venous Catheterization Safety Policy

Ultrasonic guidance is now required per Medical Board policy for placement of all non-emergency central venous catheters in the internal jugular vein.  Attendings must be present at all critical events during central venous catheterization.  Chest radiography is insufficient to determine if a central venous catheter is in the venous circulation.  We must also measure pressure through the catheter (by manometry or pressure transducer), perform a blood gas analysis, or certain other methods.  Please read the policy in detail.  It is in effect immediately, and failure to comply is a serious matter.  Thank you for your efforts to increase patient safety.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY
This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.
All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.
Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.
The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.
A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.
Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.
For all central venous lines, the techniques to be used for confirmation of venous placement include:
Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;
Determination of the of the intravascular pressure using sterile tubing as a venous manometer;
Analysis of the PO2 of a blood specimen drawn from the needle/catheter;
Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or
Using a contrast study to opacify the venous structures.
For Insertion of Large-Bore Catheters and Introducers
To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.
In the event that no confirmatory test is conclusive, then the catheter must be removed.
The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.
Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.
The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.
NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:
No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.
The following issues must be considered in interpreting these tests:
The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.
Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.
Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.
Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY

This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.

All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.

Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.

The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.

A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.

Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.

For all central venous lines, the techniques to be used for confirmation of venous placement include:

Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;

Determination of the of the intravascular pressure using sterile tubing as a venous manometer;

Analysis of the PO2 of a blood specimen drawn from the needle/catheter;

Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or

Using a contrast study to opacify the venous structures.

For Insertion of Large-Bore Catheters and Introducers

To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.

In the event that no confirmatory test is conclusive, then the catheter must be removed.

The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.

Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.

The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.

NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:

No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.

The following issues must be considered in interpreting these tests:

The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.

Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.

Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.

Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

Written by reuben

March 12th, 2010 at 5:00 pm