Unique Plan Description: Therapeutic Hypothermia (FH)
Plan Selection Display: Therapeutic Hypothermia (FH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2022-02-10 15:59:26
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-02-11 10:54:19
Available at all facilities: Yes

Phase-I-Initiation
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
			Comment: To critical care
Vital Signs
	Vital Signs
		Q15min, until stable, then per critical care unit routine.
		TEMP:Record core temp Q 15 minutes until 33-36 C is achieved, then Q 30 min. Do not cool to less than 33 C.
			Comment: HR: Monitor for hypothermia associated arrhythmia. Discontinue cooling and rewarm if significant dysrhythmia, hemodynamic instability or bleeding develops. BP: via arterial line Q 15 min. while cooling, then Q 30 min. once core temp is achieved..  MAP goal 70-100mmHg is preferred for optimal cerebral perfusion. BP may elevate during hypothermia due to peripheral vasoconstriction.  Monitor closely for hypotension during rewarming.
Laboratory
	CBC with Diff
		Stat, spec type = Blood
	Comprehensive Metabolic Panel
		Stat, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
	Lactate
		Stat, spec type = Blood
	Magnesium Level
		Stat, spec type = Blood
	Phosphorus
		Stat, spec type = Blood
	Ionized Calcium
		Stat, spec type = Blood
	Cortisol Level
		Stat, spec type = Blood
	D-Dimer Level - FH
		T;N, Stat, spec type = Blood
	hs Troponin I - FH
		Stat, spec type = Blood
	Myoglobin
		Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Pregnancy Test Urine
		Stat, Stat, spec type = Urine
			Comment: if applicable
	Triglycerides
		T+3;0400, Q7D-Lab, spec type = Blood
			Comment: while on propofol.  Discontinue order when propofol discontinued.
Diagnostic Tests
	Chest 1 View
		Hypothermia Post Arrest, Stat, Abnormal EKG
	CT Head w/o Contrast
		Stat, Loss of Consciousness
			Comment: If possible, a non contrasted Head CT should be obtained. Do NOT delay cooling for this.
	ECG in ED
		Stat, Indication: Post ACLS/Medical Emergency
IV Solutions
	Sodium Chloride 0.9%
		2,000 mL, IV, STAT, Bolus
			Comment: iced 4 C (39 F).  May use rapid infuser.  Located in Pharmacy medication fridge.
	Levophed 4mg/D5W 250mL Premix
		250 mL, IV, STAT, Increment Increase: 1 mcg/min, Increment Decrease: 1 mcg/min, Increment Freq: 3 min(s), Max Dose: 30 mcg/min
			Comment: **LEVOPHED** Concentration: 16mcg/mL .  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		4 mg, EVERY BAG, 8 mcg/min
	Levophed 4 mg/D5W 250 mL
		4 mg, EVERY BAG, 8 mcg/min
		250 mL, IV, STAT, Increment Increase: 1 mcg/min, Increment Decrease: 1 mcg/min, Increment Freq: 3 min(s), Max Dose: 30 mcg/min
			Comment: **LEVOPHED** Concentration: 16mcg/mL .  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		250 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, Maintain Parameter: SBP> Parameter Goal: 90, Increment Dose Increase: 5 mcg/min, Increment Dose Decrease: 5 mcg/min, Incremen
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
		50 mg, EVERY BAG, 5 mcg/min, T;N
	Diprivan 1000 mg/100 mL vial Premix IV
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS score OR BIS goal is not achieved. Change bottle and tubing q12hr.
		1,000 mg, EVERY BAG, 5 mcg/kg/min
		Do not replace potassium unless it is less than 3 mEq/L during cooling phase.(NOTE)*
Medications
	magnesium sulfate 4gm in 100mL water
		4 gm, 100 mL, IVPB, Once, 5 hr, 20 ml/hr
			Comment: unless dialysis dependent patient
	fentaNYL
		50 mcg, Injection, IV Push, Once, STAT, 4 hr
			Comment: Suggest 25 to 50 mcg.
	morphine  IV
		4 mg, Syringe, IV PUSH, Once, STAT, 4 hr
	Versed (FH)
		2 mg, Injection, IV Push, Q15MIN, PRN for see comment
			Comment: while on ventilator support.
		4 mg, Injection, IV Push, Q15MIN, PRN for see comment
			Comment: while on ventilator support.
	rocuronium
		0.6 mg/kg, Injection, IV Push, Once, T;N
			Comment: Bolus
Patient Care
	Cold Therapy
		Ice bag
			Comment: Continuously, immediately apply ice packs to axilla & groin.
	Foley Catheter
		Foley, Insert, Once
			Comment: use urometer
	GI Tube
		NG | OG, Once
			Comment: Insert
	Vital Signs/Hemodynamic Monitoring
		T;N, Place bladder temp probe
	Passive Convective Cooling
		T;N, Passive Convective Cooling: expose patient, dampen skin, cooling fan, cooling body wraps or blankets set to 33 C, (91.4 F). Reduce temperature in patient room, ice packs applied to axilla/groin/torso/neck/limbs.
	Notify MD
		T;N+120, Upon admission to critical care for orders to initiate Therapeutic Hypothermia Phase II (Cooling/Maintenance)
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: Acute Cardiac Arrest
	Consult Pulmonologist
		Reason for Referral: Therapeutic Hypothermia

Phase-II-Cooling
Vital Signs
	Vital Signs
		Cooling: every 15 minutes (including MAP) while cooling then every 30-60 minutes once patient reaches target core temperature.
			Comment: MAP goal 70-100mmHg is preferred for optimal cerebral perfusion.
		Cooling: Maintain hypothermia for 24 hours once target temperature of 33 C (91.4F) has been achieved.
			Comment: Monitor core temp continuously using rectal or urinary catheter probe.
Diet
	NPO
		
Laboratory
	CBC with Diff
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	Comprehensive Metabolic Panel
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	Blood Gases Arterial (ABG) - FH
		T;N+240, Timed, Q6H, 24, hr, spec type = Blood
	Lactate
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	Magnesium Level
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
			Comment: Goal Mg level > 3 mg/dl.
	Phosphorus
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	Ionized Calcium
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	Glucose POC - RN
		T;N, Q1H
			Comment: Goal range: < 180, must be drawn out of line, not fingerstick, during cooling phase. Initiate Therapeutic Hypothermia Insulin Drip during cooling phase if blood sugar >180. After 24 hours, when glucose is in target range (140-180) for 4 hours, cancel q1h glucose order and enter order for q2h
	CK
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
	hs Troponin I - FH
		T;N+240, Timed, Q6H 24 hr, spec type = Blood
Diagnostic Tests
	Echo w Doppler resting
		Stat
			Comment: Hypothermia protocol; If ongoing hypotension with cardiac etiology, ongoing arrhythmia, indeterminate EKG, Additional ECHO may be needed in 24 hours.
		T;N+1440, Routine
			Comment: Indication; Medical Therapy Therapeutic Hypothermia protocol
	ECG
		T;N+320, Timed, Indication: Myocardial Infarction (Acute)
			Comment: NURSING MUST PAGE EKG WITH TIMES FOR EKG to be done
		T;N+800, Timed, Indication: Myocardial Infarction (Acute)
			Comment: NURSING MUST PAGE EKG WITH TIMES FOR EKG to be done
		T+1;0001, Routine, Indication: Myocardial Infarction (Acute), DAILY, 4, Dose(s)/Time(s)
		T;N, Routine, Indication: Myocardial Infarction (Acute)
			Comment: dysrythmia or morphology change on cardiac monitor, PRN
	Chest 1 View
		T+1;0001, Routine, Myocardial Infarct, DAILY
			Comment: while intubated
IV Solutions
		Do not replace potassium unless it is less than 3 mEq/L during cooling phase.(NOTE)*
	rocuronium 250 mg/25 mL
		250 mg, EVERY BAG, 4 mcg/kg/min
		25 mL, IV, Routine, Start: T;N, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 12 mcg/kg/min
			Comment: Use ideal body weight for dosing.  Comment: Determine supramaximal TOF setting before giving rocuronium,  Rate: begin at 4 mcg/kg/min and titrate to keep at 2 twitches with TOF.  Range:  4 to 12 mcg/kg/min, up to 16 mcg/kg/min.  NMB Infusion adjustments: 0 twitches= hold NMB for 30 minutes, reassess TOF, and adjust NMB.  If TOF remains at 0, notify physician.  1 twitch= decrease NMB infusion by 50%.  2 twitches (GOAL) = maintain current infusion rate.  3 twitches= increase infusion rate by 10%.  4 twitches= increase infusion rate by 25%.Retest TOF 10-15 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 to 4 hours after a clinically stable and satisfactory level of blockade is achieved.
	Diprivan 1000 mg/100 mL vial Premix IV
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS score OR BIS goal is not achieved. Change bottle and tubing q12hr.
		1,000 mg, EVERY BAG, 5 mcg/kg/min
Medications
	rocuronium
		0.6 mg/kg, Injection, IV Push, Once, T;N
	calcium gluconate IVPB
		1 gm, Injection-Premix, IVPB, Q6H, PRN for see comment, 100 ml/hr, duration: 24 hr
			Comment: for ionized calcium <1
	busPIRone
		30 mg, Tab, ORAL GASTRIC, Q8H, STAT, 3 Dose(s)/Time(s)
	aspirin
		300 mg, Suppository, RECTALLY, DAILY
			Comment: change to NG or PO when able
Patient Care
	Passive Convective Cooling
		T;N
			Comment: Passive Convective Cooling: expose patient, dampen skin, cooling fan, cooling body wraps or blankets set to 33 C, (91.4 F). Reduce temperature in patient room as appropriate.  Ice packs applied to axilla/groin/torso/neck/limbs.
		T;N, Arterial line placement by MD as soon as possible
		T;N, Wrap hands & feet in dry towels to minimize shivering.
	Notify MD
		T;N, Cooling: MAP <65 despite use of vasopressors. If patient has recurring arrhythmias, discontinue active cooling.  Urine output >300ml/hr or <30ml for two consecutive hours. Monitor core temp with rectal probe continuously.
		T;N, During Cooling phase: If temp >35 C (95F) during maintenance phase despite implementation of all ordered interventions.
		T;N, During cooling phase if phosphate <2. If serum magnesium <1.8, for shivering unresponsive to treatment.
		T;N+1440, When patient has been at target temperature of 33 C (91.4F) for 24 hours for orders to initiate Therapeutic Hypothermia Phase III (rewarming) orders.
	Glucose Management
		T;N, titrate to keep glucose < 140 if on IV Insulin infusion.
Therapies
	Respiratory Consult-Assess and Treat

Phase-III-Warming
Vital Signs
	Vital Signs
		Target temp: 36.1-37.5 C (96.9-99.5 F)
			Comment: Rewarm using machine/wraps and increase temperature 0.25C/hour (0.5F/hour) to a target temperature of 37 C (98.6F). Maintain the machine at 37 C (98.6F) for 48 hours once target temperature has been achieved. Do not allow hyperthermia > (37.5C/99.5F) in the first 48 hours after cooling phase. After 48 hours discontinue machine and protocol.
Laboratory
	CBC with Diff
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
	Comprehensive Metabolic Panel
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
	Lactate
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
	Magnesium Level
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
			Comment: Goal Mg level > 3 mg/dl.
	Phosphorus
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
	Ionized Calcium
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
	hs Troponin I - FH
		T;N+360, Timed, Q12H 24 hr, spec type = Blood
Diagnostic Tests
	Echo w Doppler resting
		Stat
			Comment: Hypothermia protocol; If ongoing hypotension with cardiac etiology, ongoing arrhythmia, indeterminate EKG, Additional ECHO may be needed in 24 hours.
		T;N+1440, Routine, Indication: Cardiac arrest
	ECG
		T;N+320, Timed, Indication: Myocardial Infarction (Acute)
			Comment: NURSING MUST PAGE EKG WITH TIMES FOR EKG to be done
		T;N+800, Timed, Indication: Myocardial Infarction (Acute)
			Comment: NURSING MUST PAGE EKG WITH TIMES FOR EKG to be done
		T+1;0001, Routine, Indication: Myocardial Infarction (Acute), DAILY, 4, Dose(s)/Time(s)
		T;N, Routine, Indication: Myocardial Infarction (Acute)
			Comment: dysrythmia or morphology change on cardiac monitor, PRN
	Chest 1 View
		T+1;0001, Routine, Myocardial Infarct, DAILY
			Comment: while intubated
IV Solutions
		Do not replace potassium unless it is less than 3 mEq/L during cooling phase.(NOTE)*
	rocuronium 250 mg/25 mL
		250 mg, EVERY BAG, 4 mcg/kg/min
		25 mL, IV, Routine, Start: T;N, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 12 mcg/kg/min
			Comment: Use ideal body weight for dosing.  Comment: Determine supramaximal TOF setting before giving rocuronium,  Rate: begin at 4 mcg/kg/min and titrate to keep at 2 twitches with TOF.  Range:  4 to 12 mcg/kg/min, up to 16 mcg/kg/min.  NMB Infusion adjustments: 0 twitches= hold NMB for 30 minutes, reassess TOF, and adjust NMB.  If TOF remains at 0, notify physician.  1 twitch= decrease NMB infusion by 50%.  2 twitches (GOAL) = maintain current infusion rate.  3 twitches= increase infusion rate by 10%.  4 twitches= increase infusion rate by 25%.Retest TOF 10-15 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 to 4 hours after a clinically stable and satisfactory level of blockade is achieved.
	Diprivan 1000 mg/100 mL vial Premix IV
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS score OR BIS goal is not achieved. Change bottle and tubing q12hr.
		1,000 mg, EVERY BAG, 5 mcg/kg/min
Medications
	acetaminophen 160 mg/5 mL oral liquid
		1,000 mg, Elixir, ORAL GASTRIC, Once, STAT
		650 mg, Elixir, ORAL GASTRIC, Q6H, T;N+360, duration: 8 Dose(s)/Time(s)
			Comment: through 48 hour rewarming
	potassium chloride IVPB (FH)
		40 mEq, INT, IVPB, Once, PRN for see comment, duration: 24 hr
			Comment: Once normothermia achieved if K+ <3.5 and if no evidence of CKD/AKI. If given, repeat K+ level in 1 hour. Notify provider if recheck <3.5.
	aspirin
		300 mg, Suppository, RECTALLY, DAILY
			Comment: change to NG or PO when able
Patient Care
	Notify MD
		T;N+2880, During rewarming re: removal of femoral venous and/or arterial lines when patient has been 36.1 C (96.9F) for 48 hours.
	Vital Signs/Hemodynamic Monitoring
		RW: Once temperature >/= 36.1 (96.9F), discontinue neuromuscular blocking agents first, then wean sedation and analgesic infusions.
Consults/Follow-up
	Consult Social Work
		T+1;9600, Evaluation
			Comment: post therapeutic hypothermia cardiac arrest.
	Consult Occupational Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat
			Comment: Indication for Referral: Evaluate & Treat. Therapeutic Hypothermia
	Consult Physical Therapy, Evaluate and Treat
		T+1;0600, Reason to See: Evaluate and Treat, WB: Full Weight Bearing
			Comment: Indication for Referral: Evaluate & Treat. Therapeutic Hypothermia

Blood Culture Set
Laboratory
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	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		Timed, spec type = Blood
		T+1;0400, Routine, spec type = Blood

Therapeutic Hypothermia Insulin Drip
IV Solutions
	insulin regular 100 units/NS 100 mL Premix
		100 units, EVERY BAG, 2 units/hr
		100 mL, IV, Routine, Total Volume = 100
			Comment: Concentration:1 unit/mL, Initial Rate: 2 mL/hr = 2 units/hr, continuous if glucose greater than 180.   Titrate infusion to target glucose of 140-180.  If glucose is:   1) Less than 100 discontinue infusion, continue blood glucose monitoring and follow Insulin IV infusion hypoglycemia treatment parameters if necessary; restart drip at 1/2 previous rate when glucose >140.  2) 100-139, decrease infusion by 1 unit/hr. 3) 140-180, no change.  4.) 180-219, and glucose is greater than or equal to the previous glucose, increase infusion by 1 unit/hour.  5.) 180-219, and glucose is less than the previous glucose, maintain the same rate.  6.) Greater than 220, increase infusion by 2 units/hour.   Initiate insulin drip during cooling phase if BS >180 or as otherwise directed.  Obtain glucose POC-RN q1hr starting with initiation of drip. Discontinue Regular Insulin Infusion 24 hours after rewarming completed.  Contact MD if rate >10 unit/hr.  If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes.  If enteral and/or parenteral nutrition support is stopped or held, decrease infusion to 0.5 unit/hour and notify physician.
	insulin regular 100 units/NS 100 mL IV
		100 units, EVERY BAG, 2 units/hr
		100 mL, IV, Routine, Total Volume = 100
			Comment: Concentration:1 unit/mL, Initial Rate: 2 mL/hr = 2 units/hr, continuous if glucose greater than 180.   Titrate infusion to target glucose of 140-180.  If glucose is:   1) Less than 100 discontinue infusion, continue blood glucose monitoring and follow Insulin IV infusion hypoglycemia treatment parameters if necessary; restart drip at 1/2 previous rate when glucose >140.  2) 100-139, decrease infusion by 1 unit/hr. 3) 140-180, no change.  4.) 180-219, and glucose is greater than or equal to the previous glucose, increase infusion by 1 unit/hour.  5.) 180-219, and glucose is less than the previous glucose, maintain the same rate.  6.) Greater than 220, increase infusion by 2 units/hour.   Initiate insulin drip during cooling phase if BS >180 or as otherwise directed.  Obtain glucose POC-RN q1hr starting with initiation of drip. Discontinue Regular Insulin Infusion 24 hours after rewarming completed.  Contact MD if rate >10 unit/hr.  If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes.  If enteral and/or parenteral nutrition support is stopped or held, decrease infusion to 0.5 unit/hour and notify physician.
Medications
	Dextrose 50%
		25 mL, Injection, IV Push, Q15MIN, PRN, see comment
			Comment: If glucose <60mg/dL. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Glucose Level
		Q1H, spec type = Blood
			Comment: Goal range: < 180, must be drawn out of line, not fingerstick, during cooling phase. Start during cooling phase if blood sugar >180. After 24 hours, when glucose is in target range (140-180) for 4 hours, cancel q1h glucose order and enter order for q2h.
	Notify MD
		T;N, if glucose POC >200mg/dL for 2 consecutive checks
	Discontinue
		T;N, insulin drip protocol 24 hrs after patient has been rewarmed and begin Insulin Sliding Scale Novolog Level 1
	Notify MD
		T;N, for instructions if dietary change: abrupt change in oral intake, change to NPO status, tube feedings are held or discontinued, TPN held or discontinued.  (caloric intake necessary to prevent hypoglycemia)
		T;N, If insulin requirements > 10units/hr for further instruction
	Hypoglycemia Treatment Parameters
		T;N
			Comment: Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Blood glucose <40mg/dl (critical value), treat with Dextrose 50%, 25 mL, then immediately notify physician.  Repeat glucose in 15 minutes. Blood glucose 40-55 mg/dL give Dextrose 50% 25 mL. Repeat glucose 15 min after treatment. Notify physician after follow-up value is obtained. Blood glucose 56-70 mg/dL administer 4 oz apple juice.  If patient NPO or unable to tolerate oral intake, give Dextrose 50%, 25ml.  Repeat glucose in 15 minutes after treatment.  If repeat glucose 55-70, repeat apple juice or Dextrose. Obtain another glucose, Give 1 complex carb (15g) and 1 protein snack (7g) or patient meal if patient able to take orals any time hypoglycemia is treated.
		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 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.  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL 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