Care Of High Risk Patients & Provision Of High Risk Services

a) Emergency Patients

• Staffing
  ER Physicians, ER Nurses, EMTs
• Competency:
  Physicians: BLS, SCLS + other Life Support Courses,
  Nurses: BLS, ACLS + other Life Support Courses, EMT: BLS
• Process: Initial Triage, Emergency Room Assessment
• Document: Focus on ER Assessment, History & Physical Examination, Consents for procedures, medication, investigation requiring management & critical care
• Monitoring: Vital signs monitored during stay as required & prior to discharge as required
• Equipment: As per need — ECG; Defibrillator, Pulse Oximeter, Ventilator
• Evaluation: Compliance to relevant protocol, (e.g. door to needle, door to balloon, Sepsis, GI bleeding)

b) Code Blue

• Staffing: Code Blue Team: ER Doctor, Internal Medicine Doctor, Anesthesia, ICU Nurse, ECG Technician, Hospital Nursing Supervisor
• Competency: All staff— BLS & ACLS
• Process:  Start BLS algorithm — CPR, Call emergency extension number, Code Blue Team take over, Use Crash Cart, Defibrillator, O₂ as required.
• Document: Code Blue Sheet, Document the entire process in the Progress Notes
• Monitoring: Physiological Vital Parameters
• Equipment: Pulse Oximeter, ECG Monitor, Cardiac monitor/ Defibrillator; Crash Cart and Oxygen Cylinder as required
• Evaluation: Review of Code Blue cases thru CPR Committee, Review of Code Blue form completion.

c) Blood Transfusion

• Staffing: Physician, Staff Nurse, Lab Technician
• Competency: Nurse competency in IV Therapy + Blood Transfusion
• Process: Take Informed consent, Check blood, Check vital signs as baseline then 15 minutes. For the first hour then hourly till end and after 1 hour post blood transfusion
• Document: Informed Consent, Doctor’s Order Sheet, Progress Notes, Blood
• Transfusion Documentation form
• Monitoring: Monitor vital signs and transfusion reaction and report transfusion reaction (if any)
• Equipment: Blood Transfusion set, 18G Cannula
• Evaluation: CT Ratio, Blood Transfusion Reaction report

BLOOD TRANSFUSION REACTION

STOP TRANSFUSION! à call the Doctor on-duty and inform Blood Bank staff àStart IV Fluid (NS) àSend blood bag to Blood Bank for review àtake blood sample for other handàsend urine and blood sample for culture à complete Blood Transfusion Reaction form

d) Dialysis Patients

• Staffing: Nephrology physicians; dialysis nurses, biomedical dialysis technicians
• Competency: Trained and competent dialysis nurses, Physicians with granted privileges
• Process: Initial assessment/ Triaging
• Document:  Complete routine dialysis record, Physician Progress Notes (weekly), Nursing H & P (annually)
• Monitoring: Pre & post dialysis weight, AVF graft access, vital signs hourly basis
• Equipment: Hemodialysis machine; single use dialyzers
• Evaluation: Urea Reduction Rate (URR), Dialysis water testing biochemical for ARO, microbiology, endotoxin level

e) Restraints Patients

• Staffing: Physician and Nurses
• Competency: Nurses training in monitoring restraint Know type of restraints
• Process: Complete H&P; Document reason of restraint; use Physical Restraint Documentation form
• Document: Doctor’s Order every 24 hours; Patient & Family Education; record intake output, Nurse Monitoring documentation: 15 min for 1 hr., hourly thereafter
• Monitoring: Monitor (behavior, skin color, skin sensation, movement, nursing care), Fluid Intake & Output, Evaluate need of restraint within 24 hours, (Restraints every 2hrs & release for 1 hr.)
• Equipment: Specialized restraint types, when required
• Evaluation: Falls Risk Assessment

f) Comatose Patients

• Staffing: ICU Physician; Nurses
• Competency: Training in Critical Care; Competency Evaluation for all staff; ACLS trained
• Process: Admission & Discharge Criteria; Skin Bundles; Plan of Care; Pain Mgt. in comatose
• Document: Complete H&P; Document sedation agent
• Monitoring: ICU flow sheet component monitoring Pain; End of Life care; VAP Bundle
• Equipment: Central Monitor, Bed side Monitors, ECG monitor, Ventilator, Syringe and infusion pumps
• Evaluation: Pressure Ulcer, Falls Risk Patient Identification

g) Infectious Patient

Patient Care Structure for Infectious Patients in relation to: Staffing, Competency, Process, Documentation, Monitoring, Equipment & Evaluation — refer to Infection Control policies and procedures for proper reference and adherence.

h) Immuno-compromised Patients

Patients Care Structure for Infectious Patients in relation to: Staffing Competency, Process, Documentation, Monitoring, Equipment & Evaluation-refer to Infection Control policies & procedures for proper reference and adherence.

i) Pain Management

• Staffing: All healthcare providers
• Competency:
• Nurses with competency (epidural analgesia, patient controlled analgesia, pain management), doctors & Anesthetist with privileges
• Process: Use of Pain Assessment Form & Pain Tools
• Document: Completed H&P, pain & treatment documented in Doctors Progress
• Monitoring: Notes and Nurses Progress Notes, Use of Pain Assessment Flow Sheet
• Every 4 hours in acute care areas, Hourly in ICU or as per doctor’s order, Re-assess after 3o min. following any pharmacological or non pharmacological interventions and/ or as per standing order Outpatients are assessed at every encounter
• Equipment: Syringe pump, PCA pump (if needed)
• Evaluation: Pain Assessment Intervention & Re-assessment (AIR Cycle), Continuous Epidural Analgesia, Patient Controlled Analgesia