Download OBSERVATION UNIT DVT PATHWAY OUTLINE Exclusion Criteria

OBSERVATION UNIT
DVT PATHWAY OUTLINE
† Frick Hospital
† Latrobe Hospital
† Westmoreland Hospital
Exclusion Criteria: (Reason to admit as Inpatient to the hospital)
A. New documented Pulmonary Embolus (PE) or clinical suspicion for PE if unable to
get definitive test
B. Unstable vital signs: Hypotension/Tachycardia
C. New hypoxemia on room air or on usual home O2 (SaO2 ≤ 90%)
D. Contraindication to Low Molecular Weight Heparin (LMWH)
E. New unexplained anemia (Hgb < 10)
F. Heme-positive stool with any level of anemia
G. Active bleeding / high risk of bleeding
H. History of Heparin Induced Thrombocytopenia
I. Platelet count less than 75,000
J. Previous episodes of DVT > 2 or recurrent within last 3 months
K. Failed outpatient anticoagulant therapy
L. High risk for falls or trauma
M. Concomitant Unstable or exacerbated co-morbidity requiring admission
Observation Interventions:
A. Continuous Cardiac Monitoring
B. Monitor Vital Signs every 4 hours
C. Teach Patient/caregiver how to administer LMWH / Coumadin education
D. Arrange home health services
E. Further imaging as indicated
F. Physician to evaluate patient at admission, discharge and as needed.
Disposition Criteria:
A. HOME
1) Clinically stable (stable vital signs including O2 Saturation) and able to ambulate
2) No suspicion for PE
3) Anticoagulants initiated
4) Patient/caregiver demonstrate ability to manage care
B.
1)
2)
3)
ADMIT TO HOSPITAL
Patient becomes unstable or develops PE
Unable to ambulate due to pain and no support mechanism at home
Develops signs of bleeding
(This page not a part of the medical record.)
EXC 9600-032Ci (Rev.7/11)
OBSERVATION UNIT
DVT PATHWAY OUTLINE
† Frick Hospital
† Latrobe Hospital
† Westmoreland Hospital
PAGE 1 OF 4
… Place on Observation Unit for Observation Services due to (Reason): __________________
____________________________________________________________________________
Directed H&P Dictated:
… YES
… NO
PCP: ___________________________
ORDERS:
Nursing to do the following:
• Cardiac Monitor Æ Nurse Notifies Physician of any arrhythmias
• Nursing to check vitals with Pulse Oximetry and assess symptoms/pain level every 4 hours
• Activity: Up as tolerated unless contraindicated -- Off monitor for testing
• Thigh high TED stocking to leg with DVT
• Obtain accurate weight in Kg
• Allergies: _________________________________________________
_________________________________________________
• Reinforce observation status with patient including anticipated length of stay less than 23 hours
Choose all the following that apply:
Diet: [ ] Cardiac
[ ] Consistent Carbohydrate (CHHO/ADA)
[ ] IV Fluids
[ ] General
[ ] Other _____________
Type _____________ at ___________ml/hour
Physician Signature ______________________________ Date _______ Time _______
Verbal Order _____________________________________ Date _______ Time _______
EXC 9600-032Ci (Rev.7/11)
OBSERVATION UNIT
DVT PATHWAY OUTLINE
† Frick Hospital
† Latrobe Hospital
† Westmoreland Hospital
PAGE 2 OF 4
ORDERS (continued):
Medications:
• Physician to review Admission Medication Reconciliation Form (to see allergies and
continue/discontinue/clarify patient home medications and add any additional
medications needed for Observation DVT from the list below).
• Nursing will scan all orders to the pharmacy along with Admission Medication
Reconciliation Form.
… Lovenox 1mg/kg subcutaneously every 12 hours or
… every 24 hours (For GFR < 30)
… Coumadin _______ mg p.o. tonight
… Tylenol 650 mg p.o. every 6 hours p.r.n. for mild pain/fever
… Percocet … 1 tablet or … 2 tablets p.o. every 4 hours p.r.n. for moderate pain
… Vicodin … 1 tablet or … 2 tablets p.o. every 4 hours p.r.n. moderate pain
(Max. 8 per 24 hours)
… OTHERS: ________________________________________________________
______________________________________________________
______________________________________________________
Labs and studies:
… CBC, PT/INR, LFT’s if not done in ED
… Urine pregnancy test for menstruating women if not done in ED
… Daily PT / INR
… Initiate Lovenox and Coumadin education and assess patient / caregiver
willingness and readiness to administer Lovenox
… Case manager to assess for coverage of Lovenox and availability in pharmacy
… Home Health consult for Lovenox administration at home
… Lytes … Bun/ Cr
… CBC
… Tomorrow AM or … At ________________(Specify date and time needed)
… Spiral CT of chest with IV contrast to evaluate for PE
… V/Q scan to evaluate for PE
… Other ____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Physician Signature ______________________________ Date _______ Time _______
Verbal Order _____________________________________ Date _______ Time _______
EXC 9600-032Ci (Rev.7/11)
OBSERVATION UNIT
DVT PATHWAY OUTLINE
† Frick Hospital
† Latrobe Hospital
† Westmoreland Hospital
PAGE 3 OF 4
PROGRESS NOTES: (date, time and sign each entry)
Briefly document any interim patient encounters here.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Disposition (If admitted as “Inpatient”, document rationale):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DISCHARGE NOTE/ADDENDUM TO H & P DICTATED:
… YES … NO
Physician Signature _________________ Date _________ Time ______
EXC 9600-032Ci (Rev.7/11)
OBSERVATION UNIT
DVT PATHWAY OUTLINE
† Frick Hospital
† Latrobe Hospital
† Westmoreland Hospital
PAGE 4 OF 4
PHYSICIAN (Discharge):
• Review Discharge Medication Reconciliation Form.
• Prescriptions provided for: ________________________________
• Complete Patient Discharge Instructions.
• Discharge condition _________________________________
• Discharge to _______________________________________
DISCHARGE ORDERS (Check [√] when done and initial)
Nursing
… Smoking cessation packet given on admission, if patient is a current smoker or quit within
the past year.
RN ______
… DVT Education Folder given on admission.
RN ______
… Reinforce Lovenox/Coumadin Teaching
… N/A
RN ______
… Patient signs Discharge Instructions after review
RN_______
… Patient given, verbalizes understanding, and signs Medication
Reconciliation Home Instructions Form
RN_______
… Patient verbalizes understanding of recommended follow-up
RN_______
Case Management (CM)
To be done as close to start of care as possible:
… Reinforce observation status with patient including anticipated length of stay less than 23 hours
… Arrange Home Lovenox / Home Health or … N/A
… Assess for discharge needs
… Assess for transportation needs
At Discharge:
*CM Contact patient’s Primary Care Physician or covering physician to inform PCP the patient
was in Observation Unit for DVT.
CM______
*CM Complete the “Physician Notification” form and fax to PCP.
CM_______
*Nursing to do after hours
RN _______
Physician Signature __________________ Date _________ Time _____
RN Signature ________________________ Date ________ Time _____
CM Signature ________________________ Date ________ Time _____
EXC 9600-032Ci (Rev.7/11)