Harbor:Right level of care

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

  • Right Level of Care Flowchart:

Observation/Short-Stay Medicine
  • Goal of our observation/Short Stay is admission avoidance
  • 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
  • (Previous: When boarding >5 obs patients in ED, admit DHS empaneled OBS-level patients)

Ward[1]
  • Unmonitored
  • Stable Patients
    • HR 40-115 (120 max for A-fib), RR 8-28, SBP 90-210, SpO2>88%
    • Na 130-160
  • 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
  • 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
  • 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

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

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