Unique Plan Description: Gen Adm Chest Pain ACS Intermediate Risk Heart Score 4-6
Plan Selection Display: Gen Adm Chest Pain ACS Intermediate Risk Heart Score 4-6
PlanType: Medical                                 
Version: 3          
Begin Effective Date: 2024-01-23 12:34:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-01-23 12:34:00
Available at all facilities: Yes

Gen Adm Chest Pain ACS Intermediate Risk Heart Sco
Admit/Discharge/Transfer
		 HEART Score 4-6: Use this order set for intermediate risk for Adverse Cardiac Event, admit to Chest Pain Unit (CPU)(NOTE)*
	Admit to Observation Status
		T;N
	Discharge Conditional
		Conditions to be met: Patient's lab work and ECG are negative and no continuing S/S of ACS, T;N
Vital Signs
	Vital Signs
		Per protocol
		T;N, Q1H x 4, then Q4H
Activity
	Bedrest with Bathroom Privileges
		
	Activity-As Tolerated
		T;N, If patient denies chest pain, SOB or asymptomatic SBP >90
Diet
	NPO
		T;N
Laboratory
	Lipid Panel
		T+1;0400, Routine, spec type = Blood
Diagnostic Tests
	ECG
		T;N+360, Timed, Indication: ACS Rule Out
			Comment: to be done 6 hours after initial EKG
	Echo Stress
		T;N, Routine
	Discharge Diagnostics
		T;N, Stress Echo to be completed within 72 hr of discharge.
IV Solutions
Medications
	aspirin
		325 mg, Tablet-Chew, By Mouth, Once, T;N
			Comment: If not given in ED
		81 mg, Tablet-Chew, By Mouth, DAILY, T+1;0900
	Ambien
		5 mg, Tab, By Mouth, QHS, PRN, insomnia
	Nitrostat
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, PRN, chest pain
			Comment: may repeat three times.
	Tylenol
		650 mg, Tab, By Mouth, Q6H, PRN, discomfort
		650 mg, Suppository, RECTALLY, Q6H, PRN, discomfort
	ibuprofen
		600 mg, Tab, By Mouth, Q6H, PRN, pain-mild
	ketorolac injectable
		30 mg, Injection, IV Push, Q6H, PRN, pain-moderate
			Comment: Do not give if systolic blood pressure is < 90mm Hg or if serum creatinine is greater than 1.5mg/dL (or creatinine clearance < 50ml/min).
	morphine  IV
		2 mg, Syringe, IV Push, Q1H, PRN, pain-moderate
			Comment: Call if chest pain not relieved
	Xanax
		0.25 mg, Tab, By Mouth, Q6H, PRN, anxiety
	Pepcid
		20 mg, Tab, By Mouth, BID
	ondansetron
		4 mg, Injection, IV Push, Q6H, PRN for nausea and/or vomiting
	Narcan
		0.4 mg, Injection, IV Push, Q5MIN, PRN, see comment
			Comment: If patient has received opiate agents in the past 24 hours and/or if patient becomes somnolent with minimal or no response to stimuli or respiratory rate is 8 or less per minute.  RN may administer naloxone prior to contacting MD.  Notify MD immediately upon administration of naloxone.
Patient Care
	Resuscitation Status
		Full Code
		No Code
	Cardiac Telemetry Monitoring
		Telemetry Indications: ACS/Arrhythmia/QTc
	Notify MD
		T;N, STAT of chest pain or chest pain equivalent, ST segment changes, unstable vital signs, arrhythmias
	Notify MD of Lab results
		T;N, STAT if troponin elevated.
	Order ECG
		T;N, STAT PRN Chest Pain or Chest Pain Equivalent
	Patient Education
		T;N, Krames discharge instructions for non cardiac pain
		T;N, Provide patient with hospitalist brochure.
	Notify MD
		T;N, if HR <60 or >120, SBP <90 or >180, DBP >100, SPO2 <90%
Therapies
	Oxygen Therapy, Nurse to Administer
		Via Nasal Cannula, Continuous, Titrate->Keep Sats>/= to 91%
	Pulse Oximetry Spot Check by nurse
		Q1H, 4, Dose(s)/Time(s)
		T;N+240, Q4H
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: Chest Pain
	Consult Cardiac Rehab: Inpatient
		T;N, Indications MI
			Comment: chest pain
	Consult Cardiac Rehab: Outpatient
		T;N, Indications MI
			Comment: chest pain

Peripheral Lock - Access
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

VTE Prophylaxis
Medications
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T;N+480
			Comment: (CrCl>30) Start 8 hours after admission. Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
		40 mg, Syringe, SUBCUTANEOUS, DAILY, T+1;0900
			Comment: (CrCl>30) Pharmacy to adjust dose based on pt weight. VTE Prophylaxis
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N
			Comment: VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T;N+480
			Comment: Start 8 hours after admission. VTE Prophylaxis
		5,000 units, Injection, SUBCUTANEOUS, Q8H-Sch, T+1;0600
			Comment: VTE Prophylaxis
Patient Care
		Sequential Compression Device and Anti Embolism Device orders will not suppress the VTE Advisor(NOTE)*
	Sequential Compression Device
		T;N, Apply, Once
	Anti Embolism Stockings
		T;N, Apply, Once
			Comment: knee high
	VTE Prophylaxis Contraindication
		High Risk of Bleeding
		Procedure Planned
		ASA order meets prophylaxis requirement
		If patient is low risk or further evaluation needed, complete advisor:(NOTE)*
	VTE Advisor
		Medical

hs Troponin T - MH/WH/JE
Laboratory
	hs Troponin T - MH/WH/JE
		Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

hs Troponin I - FH (Stat and 2hr and 6hr)
	hs Troponin I - FH
		T;N, Stat, spec type = Blood
		T;N+120, Timed, spec type = Blood
		T;N+360, Timed, spec type = Blood

Insulin Sliding Scale - NovoLOG
	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*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