Unique Plan Description: ED Sickle Cell Disease
Plan Selection Display: ED Sickle Cell Disease
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2023-07-10 11:21:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-07-24 12:56:36
Available at all facilities: Yes

ED Sickle Cell Disease
Vital Signs
	Vital Signs
		T;N, frequency per assigned ESI
			Comment: VS are required per protocol while receiving narcotics to ensure safety
Diet
	NPO
		T;N
Laboratory
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Reticulocyte Count
		T;N, Stat, spec type = Blood
	Lipase Level
		T;N, Stat, spec type = Blood
	LDH
		T;N, Stat, spec type = Blood
	Bilirubin Total and Direct
		T;N, Stat, spec type = Blood
	D-Dimer - MH/WH/JE
		Stat, spec type = Blood
	D-Dimer Level - FH
		T;N, Stat, spec type = Blood
	ProBNP
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
	Lactate
		Stat, spec type = Blood
	Procalcitonin
		T;N, Stat, spec type = Blood
	Urinalysis
		T;N, Stat, Stat, spec type = Urine
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
Diagnostic Tests
	ECG in ED
		Stat
	Chest 1 View
		Stat, SOB
			Comment: At Bedside
	Chest 2 View
		Stat, SOB
	CT Head w/o Contrast for Stroke Alert
		Stat, CVA
	CTA Head and Neck for Stroke Alert
		Stat, CVA
	CTP Head for Stroke Alert
		Stat, CVA
	Venous Duplex Bil Upper or Lower
		Stat, Indication: Pain, Location Upper Bilateral
		Stat, Indication: Pain, Location Lower Bilateral
		Stat, Indication: Shortness of breath
	Venous Duplex Unilat Upper or Lower
		Stat, Indication: Pain, Location Left Upper
		Stat, Indication: Pain, Location Left Lower
		Stat, Indication: Pain, Location Right Upper
		Stat, Indication: Pain, Location Right Lower
		Stat, Indication: Shortness of breath
IV Solutions
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 999 ml/hr
			Comment: if patient not diabetic or hyperglycemic
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 500 ml/hr
			Comment: if patient not diabetic or hyperglycemic
	Sodium Chloride 0.9%
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 999 ml/hr
			Comment: only if pt dehydrated
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 500 ml/hr
			Comment: only if pt dehydrated
Medications
	albuterol CFC free 90mcg/inh inh aerosol
		2 puff, Aerosol, Inhalation, STAT
	albuterol-ipratropium 2.5 mg-0.5 mg/3 mL inhalation solution
		3 mL, Solution-Nebulization, NEBULIZED, Once, STAT
	albuterol 2.5 mg/3 mL (0.083%) inh soln
		3 mL, Solution-Nebulization, NEBULIZED, Once, STAT
	diphenhydrAMINE
		25 mg, Tab, By Mouth, Once, STAT
		50 mg, Tab, By Mouth, Once, STAT
	gabapentin
		300 mg, Capsule, By Mouth, Once, STAT
	hydroxyurea
		500 mg, Capsule, By Mouth, Once, STAT
			Comment: Pharmacy to dose starting at ~15mg/kg/day [max dose 35mg/kg/day], round to nearest capsule
	folic acid
		1 mg, Tab, By Mouth, Once, STAT
	loratadine
		10 mg, Tab, By Mouth, Once, STAT
	ondansetron
		4 mg, Injection, IV Push, Once, STAT
Mild Pain
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
		650 mg, Suppository, RECTALLY, Q6H, PRN see comment
			Comment: discomfort and/or pain-mild (pain rating 1-3) in opiate intolerant patient
	ibuprofen
		800 mg, Tab, By Mouth, Once, STAT
			Comment: pain rating 1-3
		600 mg, Tab, By Mouth, Once, STAT
			Comment: pain rating 1-3
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: pain rating 1-3
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: pain rating 1-3
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Once, STAT
			Comment: for pain rating 1-3 and if NPO
	morphine  IV
		2 mg, Syringe, IV Push, Once, STAT
			Comment: for pain rating 1-3 and if NPO
Moderate Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	acetaminophen-hydrocodone 325 mg-10 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 7.5 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Percocet 10 mg-325 mg oral tablet
		1 TAB, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	Roxicodone
		5 mg, Tab, By Mouth, Once, STAT
			Comment: For pain rating 4-6. If inadequate relief after 1 hour, may repeat dose if pain level moderate (pain rating 4-6) to severe (pain rating 7-10).  If repeat dose given, administer next dose at 4hr minimum unless otherwise prescribed.
	morphine  oral immediate release
		15 mg, Tab, By Mouth, Once, STAT
			Comment: Pain rating 4-6
	Dilaudid Injectable
		0.2 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		0.4 mg, Injection, IV Push, Once, STAT
			Comment:  For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	morphine  IV
		2 mg, Syringe, IV Push, Once, STAT
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
		4 mg, Syringe, IV Push, Once, STAT
			Comment: For pain rating 4-6; may give if NPO or for breakthrough pain if on oral analgesics
	ketorolac injectable
		15 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 4-6.
Severe Pain
	acetaminophen-hydrocodone 325 mg-5 mg oral tablet
		2 TAB, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	acetaminophen-hydrocodone 325 mg-7.5 mg oral tablet
		2 TAB, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	Percocet 5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	Percocet 7.5 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	Percocet 10 mg-325 mg oral tablet
		2 TAB, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	Roxicodone
		10 mg, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	morphine  oral immediate release
		30 mg, Tab, By Mouth, Once, STAT
			Comment: Pain rating 7-10
	Dilaudid Injectable
		0.4 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.5 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 7-10 if NPO or for breakthrough pain if on oral analgesics. Use 0.4mg if over age 70.
		0.6 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 7-10 if NPO
		0.8 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 7-10 if NPO
		1 mg, Injection, IV Push, Once, STAT
			Comment: For pain rating 7-10 if NPO
	morphine  IV
		4 mg, Syringe, IV Push, Once, STAT
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		6 mg, Syringe, IV Push, Once, STAT
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV Push, Once, STAT
		4 mg, Tablet-Disintegrating, By Mouth, Once, STAT
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (FH)
		12.5 mg, INT, IVPB, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
		25 mg, INT, IVPB, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Phenergan (JE)
		25 mg, Tab, By Mouth, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures
		25 mg, Suppository, RECTALLY, Once, STAT
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Once, STAT
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Once, STAT
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	ED Cardiac Telemetry Monitoring
		Continuous
	Oxygen Therapy, Nurse to Administer
		Via Nasal Cannula, O2 @ <95%, Titrate->Keep Sats>/= to >/= to 90%
	Continuous Pulse Oximetry by Nurse
		T;N
			Comment: Now
	Incentive Spirometry Subsequent
		
Consults/Follow-up
	Consult Hospitalist
		Reason for Referral: sickle cell crisis
	Consult Hematologist/Oncologist
		Reason for Referral: sickle cell crisis, Requested Time Frame Today

ED Blood Culture with Lactate
Laboratory
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	Lactate
		T;N, Stat, spec type = Blood
	.Blood Culture.
		T;N, Stat, spec type = Blood
	.Culture Blood
		T;N, Stat, spec type = Blood

ED Peripheral Lock Insert with Flush
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush, 4 hr
Patient Care
	Peripheral Lock-Insert
		T;N, Once

ED Antibiotics Community Acquired Pneumonia
Medications
Pain
	Tylenol
		650 mg, Tab, BY MOUTH, Q4H, PRN for temperature >  (see comment)
			Comment: 101.9
Non ICU
		First Line(NOTE)*
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Zithromax IVPB
		500 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
		Severe beta-lactam allergy alternative(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
Pneumonia-ICU
		First Line(NOTE)*
	Rocephin IVPB
		2,000 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Rocephin IVPB (FH)
		2,000 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Zithromax IVPB
		500 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
		Severe beta-lactam allergy alternative(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Azactam IVPB
		2,000 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
Pseudomonal Risk
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT, Infuse Over 30 min(s)
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT, Infuse Over 30 min(s)
		Quinolone alternative/allergy(NOTE)*
	Zosyn IVPB
		4.5 gm, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT, Infuse Over 30 min(s)
	Zosyn IVPB (FH)
		4.5 gm, INT, IVPB, Once, Indication: Pneumonia-Community acquired, Infuse Over 30 min(s)
	Zithromax IVPB
		500 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
		Beta Lactam Allergy(NOTE)*
	Levaquin IVPB
		750 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
	Azactam IVPB
		2,000 mg, INT, IVPB, Once, Indication: Pneumonia-Community acquired, STAT
MRSA Risk
		In addition to the antibiotics chosen above:(NOTE)*
	vancomycin - Pharmacy to Dose
		Pharmacy to Dose, IVPB, Once, Pneumonia-Community acquired, STAT
	Zyvox IVPB
		600 mg, Injection-Premix, IVPB, Once, Indication: Pneumonia-Community acquired, STAT

ED Blood Culture Set
Laboratory

	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
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*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase