Download Laboratory Test and Diagnostic Procedures Medical Directive

ED Outreach Services MEDICAL DIRECTIVES
Hôpital régional de Sudbury Regional Hospital
ISSUED BY:
AUTHORIZED BY:
ISSUE DATE:
CATEGORY:
ED Patient Care Team
Emergency & Medical Program Council
SUBJECT:
Laboratory Test and Diagnostic Procedures
REVISION DATE:
PAGE: 1 of 15
Medical Directives
ED Outreach Services Medical Directive - Laboratory Test and Diagnostic Procedures
Title:
Laboratory Test and Diagnostic
Procedures Directive
Activation Date:
Sponsoring/Contact
Person(s)
(name, position, contact particulars):
Orders:
Directive
Number:
EDOS01
Review due by:
Dr. Chris Bourdon, Interim Chief of Staff
Dr. Andrew Caruso, Interim Emergency Department Medical Director
Dr. Andre Roch, Physician Lead, Extendicare and TCU
Mary Beth Gibbons, RN - Clinical Leader – ED Outreach
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Orders for laboratory test and diagnostic procedures as identified on the appended order tables:
Page 2 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
1. Laboratory Test Order Table
a) Routine Blood Work
CBCD (Hct, Hgb), Electrolytes (Na, K, Cl),
Total CO2, Glucose, Urea, Creatinine, Calcium
b) Cardiac Marker
(Troponin I)
c) Venous Blood Gases
(pH, PCO2, PO2, TCO2, HCO3,
Base Excess, sO2)
d) Serum Coagulopathy
(INR)
e) Blood Cultures X 2
f) Urine for R&M/C&S
g) Sputum C&S
h) Wound Care Swab C&S
15
2. Diagnostic Procedures Order Table
a) 12 Lead ECG
b) Glucometer - Capillary Blood
Glucose
c) Peak Flows (pre/post)
Recipient Patients:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Any patient presenting to the ED Outreach Services (within the HRSRH or Long Term Care facilities with who
the HRSRH has a Memorandum of Understanding) who meets the conditions identified in this directive.
Patients having received lab testing and diagnostic procedures administered under this directive will have their
results made available to the attending LTC Physician, and/or MRP.
ED Outreach Nurse will make available and forward the record of administered tests and procedures to the
attending physician for disposition.
Authorized Implementers:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Page 3 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
15
All ED Outreach Nurses and designated staff who have successfully completed the relevant ED Outreach
Services Medical Directive orientation program as described in Review & Quality Monitoring Guidelines.
Medical directive certification is to be completed every 2 years. The ED Outreach Nurse - Team Lead will
maintain a list of authorized implementers as part of the Medical Directive record.
All physicians involved in the ED Outreach Services will review the medical directives yearly and upon any new
directives added to the program. The ED Outreach Nurse - Team Lead and/or ED Medical Director will
make available to all new physicians to the ED Outreach Services a medical directive package which will be
signed prior to program involvement.
Indications:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
 Lab tests and diagnostic procedures will be administered for the period beginning from when a patient is
assessed by the ED Outreach Nurse to first contact with the attending LTC physician, unless the attending
LTC physician explicitly orders implementation of the directive beyond that period.
 Prior to implementation of any directive, a patient assessment is completed by the ED Outreach Nurse in
accordance with standards of practice and any applicable Hôpital régional de Sudbury Regional Hospital
(HRSRH) policy. Allergies and sensitivities must be documented.
 Specific indications are identified in the appended Order Tables.
Definitions for indications used in the table:
1. Anaphylaxis – as manifested by one or more of the following signs:

Uticaria (rash, hives)

Swelling of lips, tongue, throat

Dysphagia

Shortness of breath, wheezing
2. Cellulitis – as manifested by one or more of the following signs:

Inflammation (hot to touch)

Redness

Fever – Temperature greater than/equal to 38°C
 Mild/moderate pain
3. Dehydration – as manifested by one or more of the following signs:

Loss of appetite/decreased fluid intake

Nausea/vomiting

Diarrhea
 Fever – Temperature greater than/equal to 38°C
4. Falls – as manifested by one or more of the following signs:
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures

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Mild/Moderate pain and/or discomfort to extremity and/or acute back pain (compression #)
 Mild/Moderate swelling of extremity
5. Fever – as manifested by one or more of the following signs:

Fever – Temperature greater than/equal to 38°C

Loss of appetite/decreased fluid intake

Nausea/vomiting

Dizziness
 Decreased urine output
6. Foley Catheter Difficulties – as manifested by one or more of the following signs:

Hematuria

Increased sediment in foley drainage bag

Possible blocked or kinked foley catheter
 Mild/Moderate abdominal pain and/or discomfort
7. Lacerations – as manifested by one or more of the following signs:

Controlled bleeding

Wounds not involving the face or ears
 Minor skin tears
8. Respiratory Tract Infections – as manifested by one or more of the following signs:

Mild/moderate shortness of breath

Cough

Fever – Temperature greater than/equal to 38°C

Pleuritic Pain

Mild/moderate crackles or bronchial breath sounds

Mild/moderate SOB

Known asthmatic or mild COPD

Audible wheezes
9. Syncope – as manifested by one or more of the following signs:

Pale

Diaphoretic

Hypotensive
 Brief LOC
10. Urinary Tract Infections – as manifested by one or more of the following signs:

Hematuria

Difficulty voiding

Dysuria

Mild abdominal pain
Page 5 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures

15
Fever – Temperature greater than/equal to 38°C
 Lethargy / Altered LOC
11. Weakness/Dizziness - as manifested by one or more of the following signs:

Brief LOC

Pale

Diaphoretic

Generalized feeling of unwell
See appended Order Tables.
Consent:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Staff implementing the directive will obtain consent in accordance with the Health Care Consent Act and any
relevant HRSRH policies and procedures.
Guidelines for Implementing the Order
/ Procedure:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Tables
Blood specimens for diagnostic studies may be collected by:
1. Venipuncture,
2. Saline Lock, or
3. Accessing established Vascular Access Device (not including hemodialysis lines) if central line
certification is completed.
For specific guidelines, see appended Order Tables.
Page 6 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
Documentation and Communication:
15
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Implementing staff will document the:

Specific lab test and diagnostic procedure order in the order section of the patient record, noting the
medical directive name and number and signing off the order with implementer’s name and signature as
per the attending LTC physician (when attending LTC physician known). Ensure any requisition
contains this information.

Indications, implementation and patient response in accordance with HRSRH record-keeping policies ED Outreach Services Flow Chart, and Medical Directive Form (EDOS01)
Note: Clear and timely notification, communication and documentation between the nurse and the physician
are critical to safe, proper use of a medical directive.
Review and Quality Monitoring
Guidelines:
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Staff identifying any untoward or unintended outcomes arising from implementation of orders under this
directive, or any issues identified with it will report these to LTC Physician as soon as possible for appropriate
disposition.
This does not include untoward or unintended outcomes or issues that are possible clinical sequelae regardless
of whether a directive or direct order is used.
Certification process

LTC MD - yearly

ED MD renewal – yearly

ED Outreach Nurse recertification – every 2 years which will consist of a written test and/or successful
completion of certification exam and/or maintenance of competence process
Administrative Approvals:

ED Patient Care Team

Emergency/Medical Program Council

Professional Practice Council

Professional Advisory Committee

Medical Advisory Committee
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
Approving Physician(s)/Authorizer(s):
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
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CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
15
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
References
Appendix Attached:
Yes
No
Title: Laboratory Test and Diagnostic Procedures Order Table
List any references here, as below, attach appendix, or list references in Performance Readiness Assessment
form
(Module 1).
Fitchett, D., Goodman, S., Langer, A. (2001). New Advances in the management of acute coronary syndrome.
[electronic version]. CMAJ, 164(9)
Fenton,D. (2005 January 5). Acute Coronary Syndrome, retrieved July 25, 2005 from
http:/www.emedicine.com/emerg/topic31.htm
Newberry, L. (Ed.). (1998). /Sheehy’s Emergency Nursing. Principles and Practice/. 4^th Ed. .Mosby: Toronto.
Electrocardiogram in Acute Myocardial Infarction new England Journal Med. 2003: 348: 933-940
Guidelines 2006 for cardiopulmonary and Emergency Cardiovascular care: American Heart Association
Tintinelli,j.E Kelen,GD and Stapczynski, J.S Emergency medicine: A Comprehensive Study Guide, 6th Edition
2004.
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
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Administrative Approvals for Use of Medical Directives – EDOS01, EDOS02, EDOS03, EDOS04
ED/Patient Care Team
Name of Patient Care Team
Mrs. Diane Baigrie
Name of Chairperson
__________________________________________
Signature
Date
____ June 7, 2010
____
Date
_____June 7, 2010_________
Dr. Andrew Caruso
Name of Medical Advisor
__________________________________________
Signature
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
Page 9 of
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Emergency/Medical Program Council
Name of Program Council
Vanda Cooper
Name of Administrative Director
__________________________________________
Signature
Date
__________________________
Date
__________________________
Date
__ June 7, 2010___________
Date
__________________________
Date
__________________________
Dr. Andrew Caruso
Name of Medical Director
__________________________________________
Signature
Nursing Professional Practice Council
Name of Professional Council
Grace St. Jean
Name of Chairperson
__________________________________________
Signature
Professional Advisory Committee
Mary Townend
Name of Chairperson
__________________________________________
Signature
Medical Advisory Committee
Dr. Chris Bourdon
Name of Chairperson
__________________________________________
Signature
Page 10 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
15
Appendix
ED Outreach Services - Laboratory Test and Diagnostic Procedures Directive (EDOS01)
Title and Number of
Directive:
Laboratory Test and Diagnostic Procedures Directive (EDOS01)
1. Anaphylaxis
2. Cellulitis
3. Dehydration
4. Falls
5. Fever
6. Foley Catheter Difficulties
7. Lacerations
8.
Respiratory Tract Infections
9. Shortness of Breath
10. Syncope
11. Urinary Tract Infections
12. Weakness & Dizziness
Page 11 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
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1. Laboratory Test Order Table
ED/LTC Laboratory Test and Diagnostic Procedures Directive (EDOS01)
Orders
Indications/Contraindications
Care Map Guidelines
Laboratory Test
a) Routine Blood Work
CBCD (Hct,Hgb), Electrolytes
(Na, K, Cl), Total CO2,
Glucose, Urea, Creatinine,
Calcium
b) Cardiac Marker
(Troponin I)
Signs and symptoms including one or more of the following:

Cellulitis

SOB, weakness, dizziness, looks unwell

Dehydration

Neurologic condition (alteration in neurologic status,
decreased LOC, confusion, suspected stroke)

Falls

Syncope

Fever

Dehydration

Respiratory Tract Infections

Mild to Moderate abdominal pain

Shortness of Breath

Signs and symptoms of infection - fever or hypothermia with
tachypnea and tachycardia

Syncope

Urinary Tract Infections

Chronic, diagnosed disease(s) with change in status or
exacerbation in condition

Weakness & Dizziness
Signs and symptoms of one or more of the following

Falls

SOB

Syncope

Weakness/dizziness

Weakness & Dizziness

Looks unwell
Page 12 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
Orders
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Indications/Contraindications
Care Map Guidelines
Laboratory Test
c) Venous Blood Gases
(pH, PCO2, PO2, TCO2,
HCO3, Base Excess, sO2)
Signs and symptoms of one or more of the following
d) Serum Coagulopathy
(INR)
Signs and symptoms including one or more of the following:
e) Blood Cultures X 2

Shortness of Breath

Falls
 Mild to moderate shortness of breath
 Chronic, diagnosed disease(s) with change in status or
exacerbation in condition

Current warfarin use

Syncope

Possible pulmonary embolus (SOB, tachycardia, hypoxia, risk
factors such as recent surgery, immobility)

Weakness & Dizziness

Possible stroke/TIA (weakness, numbness, trouble speaking,
vision problems, headache, dizziness)

Actual or potential hemodynamic instability
Patients with actual or suspected infection (localized or generalized)
with temperature greater than/equal to 38°C or less than/equal to
36°C who presents with any of the following signs and symptoms:
Collection standard: 2 sets of cultures
10 minutes apart


Tachypnea greater than 20 RPM
Cellulitis


Tachycardia HR greater than 90 BPM
Dehydration


Altered LOC
Fever


Urinary Tract Infections
Inmmunocompromised patients

Patients with indwelling vascular access devices
Page 13 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
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Indications/Contraindications
Orders
Care Map Guidelines
Laboratory Test
f) Urinalysis
Urine for R&M/C&S
g) Sputum
Sputum for C&S
h) Wound Care
Wound swab for C&S
Signs and symptoms including one or more of the following
 Dehydration

Hematuria
 Falls

Difficulty voiding
 Fever

Dysuria
 Foley catheter difficulties

Mild abdominal discomfort
 Urinary Tract Infections
 Fever – temperature greater than/equal to 38°C
NOTE: Foul-smelling urine is NOT to be used as a clinical criteria
for ordering urinalysis or C&S. Use as a teaching point in LTC
Homes to prevent over-diagnosis of UTI and subsequent antibiotic
resistance.
Signs and symptoms including one or more of the following

Fever – temperature greater than/equal to 38°C

Productive cough
 Shortness of breath
Signs and symptoms including one or more of the following

Inflammation – hot to touch

Redness

Fever – temperature greater than/equal to 38°C

Weeping wound
 Weakness & Dizziness
 Fever
 Respiratory Tract Infection
 Cellulitis
Page 14 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
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2. Diagnostic Procedures Order Table
ED/LTC Laboratory Test and Diagnostic Procedures Directive (EDOS01)
Orders
Indications/Contraindications
Care Map Guidelines
Diagnostic Procedures
a) 12 Lead ECG
b) Glucometer - Capillary
Blood Glucose
Signs and symptoms of, or including one or more of the following:
 Falls

Respiratory pathology
 Lacerations

Cardiac pathology
 Respiratory Tract Infections

Metabolic imbalance
 Shortness of Breath

Possible adverse reaction to medications or drugs
 Syncope

Weakness or lightheadedness
 Weakness & Dizziness

Change in neurological status – acute confusion
To determine baseline glucose status in patients with a diagnosis of
diabetes mellitus and for signs and symptoms suggestive of
hypoglycemia or hyperglycemia, including one or more of the
following:
 Cellulitis
 Dehydration
 Falls

Altered LOC
 Fever

Confusion, agitation, behavioural changes
 Respiratory Tract Infections

Recent or active seizure
 Shortness of Breath

Syncopal event
 Syncope

Listless, lethargic, fatigued
 Urinary Tract Infections
 Weakness & Dizziness
Page 15 of
CATEGORY:
Medical Directives
SUBJECT:
Laboratory Test and Diagnostic Procedures
15
2. Diagnostic Procedures Order Table
ED/LTC Laboratory Test and Diagnostic Procedures Directive (EDOS01)
Orders
Indications/Contraindications
Care Map Guidelines
Diagnostic Procedures
c) Peak Flows (pre/post)

Mild/Moderate Shortness of Breath

Audible wheezing
 Shortness of Breath