Download MedSurg Medication Policy

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Alert
It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see
Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and
the staff working on these units have received special training to deliver these medications. If a unit is not listed on the
Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference
Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris
IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV
pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see
extended text.
Step Down/Telemetry Units and Allowed Medications Reference Sheet
Caution - Read Carefully!
The units below are listed because they are Step-Down and/or Telemetry Units and their nursing staff have received
additional training and competencies to administer these medications. If a unit is not listed in the table below, the
medication cannot be administered on that unit. All ICUs may give medications listed in Reference Sheet.
Medication
CVCC/
GW MRCC/
NTCA SMCC PRECAUTIONS/
CVSS/GW Short GW Med
MONITORING
Tele
Stay Tele
Stepdown
Abciximab
(Reopro)
YES
YES
YES
NO
NO
INITIATE DOUBLE CHECK
PER P&P 40-04
Activase (tPa) NO
NO
NO
NO
NO
INITIATE DOUBLE CHECK NOT APPLICABLE TO
PER P&P 40-04
CATHFLO.
Adenosine
YES
YES
YES
YES
NO
Alcohol 10%
NO
NO
NO
NO
NO
Alprostadil
(Prostin VR)
NO
NO
NO
NO
NO
Amiodarone
YES
NO
YES
YES
YES
EXCEPTIONS
NOT APPLICABLE TO
CODE SITUATIONS.
REFER TO P&P 40-39.
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.
MONITOR FOR
EXTRAVASATION IF
NOT APPLICABLE TO
CODE SITUATIONS. REFER
USING PERIPHERAL
TO P&P 40-39.
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.
Atropine
YES
YES
YES
YES
YES
Bivalirudin
(Angiomax)
YES
YES
YES
NO
NO
Cisatracurium NO
(Nimbex)
NO
NO
NO
NO
NOT APPLICABLE TO
CODE SITUATIONS.
REFER TO P&P 40-39.
INITIATE DOUBLE CHECK
PER P&P 40-04
Medication
CVCC/
GW MRCC/
CVSS/GW Short GW Med
Tele
Stay Tele
Stepdown
NTCA SMCC Precautions/Monitoring Exceptions
Dexmedetomidine
(Precedex)
NO
NO
NO
NO
NO
Diltiazem
YES
YES
YES
YES
YES
Dobutamine YES
(rate >10
mcg/Kg/min)
NO
NO
NO
NO
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.
VASOPRESSOR ORDER
SET SHOULD BE USED
WITH INITIATION OF
VASOPRESSOR DRUGS
Dobutamine YES
(rate < or = 10
mcg/Kg/min
YES
YES
YES
YES
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.
VASOPRESSOR ORDER
SET SHOULD BE USED
WITH INITIATION OF
VASOPRESSOR DRUGS
SHOULD NOT BE
TITRATED ON FLOORS.
Dopamine
YES
(rate > 3
mcg/Kg/min)
NO
NO
NO
NO
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS
POSSIBLE.VASOPRESSOR
ORDER SET SHOULD BE
USED WITH INITIATION
OF VASOPRESSOR
DRUGS
Dopamine
YES
(rate < or = 3
mcg/Kg/min)
YES
YES
YES
YES
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.SHOULD
NOT BE TITRATED ON
FLOORS.
VASOPRESSOR ORDER
SET SHOULD BE USED
WITH INITIATION OF
VASOPRESSOR DRUGS
DOPAMINE MAY BE GIVEN
ON ANY UNIT IF THE DOSE
DOES NOT EXCEED 3
MCG/KG/MIN AND
TITRATION IS NOT
REQUIRED.
Medications
CVCC/
GW MRCC/GW NTCA SMCC Precautions/Monitoring Exceptions
CVSS/GW Short Med Tele
Tele
Stay
Stepdown
Epinephrine
NO
NO
NO
NO
NO
INITIATE DOUBLE CHECK NOT APPLICABLE TO CODE
PER HIGH RISK P&P 40- SITUATIONS.
04
REFER TO P&P 40-39
VASOPRESSOR ORDER
SET SHOULD BE USED
WITH INITIATION OF
VASOPRESSOR DRUGS.
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS POSSIBLE.
Epoprostenol NO
NO
NO
NO
NO
Eptifibatide
(Integrilin)
YES
YES
YES
NO
NO
Esmolol
(Brevibloc)
NO
NO
NO
NO
NO
Fentanyl
infusion
NO
NO
NO
NO
NO
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
NOT APPLICABLE TO PCAS
OR EPIDURALS.
FENTANYL INFUSIONS
MAY BE ADMINISTERED ON
OPCC (5100) AND GATEWAY
SURGICAL-ONCOLOGY.
NOT APPLICABLE TO
PROCEDURAL IVP FENTANYL
GIVEN FOR MODERATE
SEDATION. REFER TO
P&P 40-28 MEDICATION
ADMINISTRATION: SEDATION.
Hydromorphone
infusion
NO
Medication
CVCC/
GW MRCC/
NTCA SMCC Precautions/Monitoring Exceptions
CVSS/GW Short GW Med
Tele
Stay Tele
Stepdown
Ibutilide
(Corvert)
YES
NO
YES
YES
YES
Isoproterenol NO
NO
NO
NO
NO
Labetolol - IV NO
infusion
NO
NO
NO
NO
NO
NO
NO
NO
NOT APPLICABLE TO PCAS
OR EPIDURALS
HYDOMORPHONE INFUSIONS
MAY BE ADMINISTERED ON
OPCC (5100) AND GATEWAY
SURGICAL-ONCOLOGY.
Labetolol
YES
(Normodyne)
IVP
YES
YES
YES
YES
MAXIMUM TOTAL DOSE
300 MG
Lidocaine
YES
YES
YES
YES
YES
NOT APPLICABLE TO CODE
SITUATIONS. REFER TO
P&P 40-39
LORazepam
(Ativan)
infusion
NO
NO
NO
NO
NO
IVP DOSES OF ATIVAN
ARE OK
Metoprolol
(Lopressor)
IVP
YES
YES
YES
YES
YES
Midazolam
(Versed)
NO
NO
NO
NO
NO
VERSED IM MAY BE GIVEN
ON ANY UNIT IF BEING USED
AS A ONE TIME PRE-OP
MEDICATION AND THE DOSE
IS LESS THAN OR EQUAL TO 2
MG.
VERSED IVP MAY BE UTILIZED
FOR MODERATE SEDATION
ON ANY UNIT BY FOLLOWING
P&P 40-28 MEDICATION
ADMINISTRATION: SEDATION.
*Versed IV may be
administered as pre-op
medication in SDCC and
Holding Area
Medication
CVCC/
GW MRCC/
NTCA SMCC Precautions/Monitoring Exceptions
CVSS/GW Short GW Med
Tele
Stay Tele
Stepdown
Milrinone
(Primacor)
YES
YES
YES
YES
YES
Morphine
Infusion
NO
NO
NO
NO
NO
NOT APPLICABLE TO PCAS
OR EPIDURALS
MORPHINE INFUSIONS MAY
BE ADMINISTERED ON OPCC
(5100) AND GATEWAY
SURGICAL ONCOLOGY. IVP
DOSES FOR PAIN ARE OK
Nicardipine
(Cardene)
YES
NO
YES
NO
NO
Nitroglycerin
YES
NO
NO
NO
NO
Nitroprusside NO
(Nipride)
NO
NO
NO
NO
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
Norepinephrine
(Levophed)
NO
NO
NO
NO
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS
POSSIBLE.VASOPRESSOR
ORDER SET SHOULD BE
USED WITH INITIATION
OF VASOPRESSOR
DRUGS
NO
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
Medication
CVCC/
GW MRCC/
NTCA SMCC Precautions/Monitoring Exceptions
CVSS/
Short GW Med
GW Tele Stay Tele
Stepdown
Pancuronium NO
(Pavulon)
NO
NO
NO
NO
Pentobarbital NO
NO
NO
NO
NO
Phenylephrine NO
(Neosynephrine)
NO
NO
NO
NO
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
MONITOR FOR
EXTRAVASATION IF
USING PERIPHERAL
ACCESS. CENTRAL LINE
ACCESS MUST BE
CONSIDERED AS SOON
AS
POSSIBLE.VASOPRESSOR
ORDER SET SHOULD BE
USED WITH INITIATION
OF VASOPRESSOR
DRUGS
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
Procainamide YES
(Pronestyl)
NO
YES
YES
YES
Propranolol
(Inderal)
YES
NO
YES
YES
YES
Propofol
(Diprivan)
NO
NO
NO
NO
NO
NOT APPLICABLE TO CODE
SITUATIONS. REFER TO
P&P 40-39.
INFUSE VIA DEDICATED NOT APPLICABLE TO USE FOR
RSI PROCEDURES. REFER TO
LINE.
P&P 40-51.
CHANGE
TUBING/BOTTLE EVERY DIPRIVAN IVP MAY BE
UTILIZED BY CREDENTIALED
12 HOURS
PHYSICIANS FOR DEEP
SEDATION ON ANY UNIT BY
FOLLOWING P&P 40-28
MEDICATION
ADMINISTRATION: SEDATION.
DIPRIVAN INFUSIONS BY NOT
BE UTILIZED ON NONMECHANICALLY VENTILATED
PATIENTS UNLESS THE
PHYSICIAN IS PRESENT
DURING THE INFUSION.
Medication
CVCC/
GW MRCC/
NTCA SMCC Precautions/Monitoring Exceptions
CVSS/GW Short GW Med
Tele
Stay Tele
Stepdown
Rocuronium
(Zemuron)
NO
NO
NO
NO
NO
INITIATE DOUBLE CHECK NOT APPLICABLE TO USE FOR
PER HIGH RISK P&P 40- RSI PROCEDURES. REFER TO
04
P&P 40-51.
Sodium
Chloride 3%
YES
NO
YES
YES
YES
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
Succinylcholine NO
NO
NO
NO
NO
INITIATE DOUBLE CHECK NOT APPLICABLE TO CODE
PER HIGH RISK P&P 40- SITUATIONS. REFER TO P&P
04
40-39
Tirofiban
(Aggrastat)
YES
YES
YES
NO
NO
Vasopressin
NO
NO
NO
NO
NO
Vecuronium
(Norcuron)
NO
NO
NO
NO
NO
Verapamil
YES
NO
YES
YES
YES
INITIATE DOUBLE CHECK
PER HIGH RISK P&P 4004
NOT APPLICABLE TO CODE
SITUATIONS. REFER TO P&P
40-39
INITIATE DOUBLE CHECK NOT APPLICABLE TO USE FOR
PER HIGH RISK P&P 40- RSI PROCEDURES. REFER TO
04
P&P 40-51.
Alert
It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see
Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and
the staff working on these units have received special training to deliver these medications. If a unit is not listed on the
Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference
Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris
IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV
pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see
extended text.
ALERT
For more information regarding High Alert Medications at Deaconess Hospital, see Hospital P&P 40-04.
For information regarding Medication Disposal at Deaconess, see Hospital P&P 40-82.
For information regarding Dose Expressions and Unacceptable abbreviations at Deaconess, see Hospital P&P 40-48.
Step Down/Telemetry Units and Allowed Medications Reference Sheet are listed in the QUICK SHEET.
OVERVIEW
IV medications included in the Medication Safety System Guardrails Software are categorized into seven separate
medication profiles (Critical Care, Adult Telemetry, Med-Surg, Adult Oncology, Pediatrics less than 10 Kg, Pediatrics
greater than 10 Kg but less than 35 Kg, and Pediatrics greater than 35 Kg).
Typically, IV medications not listed in this policy may be given on any nursing unit according to existing skills and hospital
policies using appropriate written or computer drug references.
If a medication is not listed in this document or an existing hospital document when drug references indicate that special
precautions and monitoring should be taken, consult the Deaconess Pharmacist and/or Nursing Administration for
advice.
If advised by the Pharmacist or Nursing Administrator that special precautions are needed, Nursing Administration will
determine the specific location where the drug should be administered.
Administration guidelines for drug doses and rates can be altered by a physician's specific order or upon the
recommendation of the Deaconess Pharmacist; however, specific unit location for administration of medications cannot
be altered.
Nursing Service and Pharmacy will review these guidelines ANNUALLY.
SUPPLIES AND EQUIPMENT
Click here for a list of supplies and equipment.
MEDICATION GUIDELINES
Phenergan will be interchanged for other like medications unless given by anesthesia. If administering Phenergan, the
following criteria must be met:
Use central line if available.
DO NOT administer through hand veins - May require starting an appropriate IV site. If appropriate IV site unattainable,
may give promethazine (Phenergan) IM X 1, then contact phsician for further orders.
Dilute with minimum of 10 ml Normal Saline.
Run Normal Saline flush bag throughout administration if continuous IV fluids not infusing, or if IV fluids not compatible.
50 ml maximum dose of Normal Saline flush.
Instill through port furthest from the patient. Do not use syringe pumps.
Administer IV promethazine (Phenergan) slowly over 10-15 minutes. Observe patient continuously throughout
administration.
All Med Surg Units can infuse Dopamine at 3 mcg/kg/min or less using the following criteria:
Dopamine will be administered via the Alaris IV pump using the Medication Safety System Guardrails Software.
Bypassing the dose-checking componenent of the IV pump technology is prohibited to assure patient safety.
Low-dose Dopamine infusion will be ordered by the physician. Dopamine will not be titrated to maintain blood
pressure, but RN may tritrate to wean to off as follows: When the physician writes the order to discontinue Dopamine,
it is required that the dosage of Dopamine be decreased by 1 mcg/Kg/min per hour.
Vital signs should be taken with each dose change and 15 minutes after each dose change.
The physician's order will identify actual start dosage.
No other vasoactive or vasopressor infusions will be administered to the patient receiving low-dose Dopamine on the
Medical/Surgical units.
The Dopamine infusion will be infused at a lower port into a compatible primary IV line.
Patients requiring vasopressor infusions who do not meet these criteria will be transferred to the appropriate unit for
treatment (i.e. CVCC, NTCA, SMCC or ICU at Main campus. Medical Telemetry, Telemetry Stepdown or ICU at Gateway
campus).
The Registered Nurse will be responsible for hanging, monitoring, regulating and discontinuing the Dopamine infusion.
Dose calculations will be performed by a Registered Nurse and double-checked by a pharmacist and/or a Registered
Nurse every shift and documented. See Mosby Skill: Intravenous Infusion: Dose and Flow Rate Calculation.
Vital signs are monitored and documented every 15 minutes for the first hour. Then every four hours.
Check intake and output every shift.
Monitor IV site hourly for signs and symptoms of infiltration and check for blood return. Change IV for any questionable
sites, reddened areas, or if no blood return observed. If infiltration has occured, do not remove IV. Stop infusion
immediately and see treatment of Dopamine extravasation.
Document in EPIC: Condition of patient prior to infusion, blood pressure and pulse, weight, I&O, hourly IV site
monitoring and condition of site, response of patient to treatment.
Notify physician of any change in blood pressure and/or pulse.
IV push and infusion medication with specific high risks should be given on nursing units with trained staff and EKG
monitoring. Certain medications will be limited to the critical care units only to assure closer monitoring.
IV push and infusion medications with specific high risks may be given on a regular unit initially if the patient is attached
to a crash cart monitor and either the ordering physician OR an ACLS certified Registered Nurse is present at the
bedside. If the medication is to be continued, Nursing Administration will arrange for appropriate placement (that
includes EKG monitoring and appropriately trained personnel) of the patient.
Treatment of Extravasation:
Stop the flow of the IV immediately but DO NOT REMOVE the IV cannula.
Aspirate as much of the infiltrated drug as possible.
Attach a 5ml syringe to the IV cannula and aspirate gently.
After prepping skin with a Chloraprep, using TB syringe with 25 ga 5/8" needle to gently aspirate subcutaneously.
Dilute 5 mg of Regitine with 10-15 ml of normal saline and infuse through the retained IV cannula.
The Regitine and normal saline solution may also be instilled subcutaneously using a 25 ga 5/8 needle.
Remove the IV needle.
Maintain warm compresses to the affected area for a minimum of 4 hours.
Elevate the affected extremity.
Notify the physician.
Document in detail the occurrence of the infiltration and its treatment in EPIC.
Complete an incident report.
Check the site each shift. Document the status of the involved area until resolution occurs.
For the purposes of this skill, Critical Care profile units include:
Deaconess Main Campus
4800-Cardiovascular Surgical Trauma ICU, 2900-Cardiovascular ICU, 3900 Neuro/Medical ICU, ED-Emergency
Department, CVL-Cardiovascular Lab, Surgery, PACU
Deaconess Gateway Hospital
MS ICU, PICU, ED, Surgery, PACU, Neuro ICU
Heart Hospital
Heart Unit or Cath Lab
Nursing units with adult telemetry monitoring and training may give certain high-risk medications upon physician's order
without the physician being present. These units include:
Deaconess Main Hospital
2500/2600 Cardiovascular Care Center
Cardiovascular Short Stay
5500-5600-Medical Renal Care Center
3500-3600-Surgical Medical Care Center
3800 Neuro Transitional Care Center (NTCA)
Deaconess Gateway Hospital
General Medical Telemetry
Telemetry Stepdown
Heart Hospital
Short Stay Unit
Heart Floor
PROCEDURE
All initial drip rates are to be validated and documented by cosigning the initial titration graph that is attached to an EKG
monitor record.
The order set for vasopressors in EPIC should be used with any initiation of vasopressor drugs when the physician has
not included concentration, starting dosage, and maximum dosage. This includes extravasation management.
Narcotic infusions that are administered in a large volume (not PCA or Epidural) may be given in any critical care unit OR
the Oncology Pulmonary Care Center (OPCC-Unit 5100 OR GW Surgical Oncology).
Due to the high risk for medication errors associated with very high risk medications, as outlined by the Institute of Safe
Medication Practice and the CAPS, double signatures and validation of Orders prior to medication administration is
required at any location throughout the hospital for intravenous medications as noted in Policy and Procedure 4004 High Alert Medications.
This policy is NOT applicable for Emergency Resuscitation or Rapid Sequence Intubation. Refer to Policy and Procedure
40-39 Code Blue Process, Roles, and Responsibilites and P&P 40-28 Medication Administration-Sedation.
If a medication listed below is used during a procedure, refer to P&P 40-28 Medication Administration: Sedation
(Conscious Sedation Guidelines) for administration guidelines. Do not use the Medication Administration: Sedation
Policy as the guideline for administration of these medications if no procedure is being done.
ALL MEDICATIONS LISTED IN THE REFERENCE SHEET TABLE ARE APPLICABLE FOR CRITICAL AREAS (LISTED ABOVE UNDER
MEDICATION GUIDELINES). Use the REFERENCE SHEET to determine what other units may administer IVP and IV drip
medications.
EXCLUSIONS:
Chemotherapy drugs are considered hazardous agents. See P&P 40-34 Administration, Handling and Disposal of
Hazardous Drugs for administration guidelines and P&P 40-04 High Alert Medications.
Concentrated electrolytes are high-risk medications. Potassium chloride guidelines should be followed as outlined by
the Pharmacy Department.
Oral potassium replacement therapy is suggested as the first option.
Injectable potassium should never be admininistered IM, SC, IVP or in an undiluted form.
The routine use of lidocaine to decrease pain associated with potassium administration is not recommended, as the
appropriate rate of administration and dilution of potassium should lessen/eliminate pain associated with
administration. However, if lidocaine is thought to be necessary, the recommended dose should not exceed 20 mg/bag.
Patients should not recieve potassium at a rate >200mEq/24 hours.
Small Volume Potassium IV Supplementation (Max volume 500 ml)
Rate
Dilution
Central Line
Non Monitored
10
mEq/h
Remote
Monitored/Telemetry
20
mEq/h
Peripheral Line
10 mEq/h
If concentration equals or exceeds 0.15 mEq K+/ml, dilute to 20 mEq/ 100 ml or 4
mEq/ 250 ml
If concentration is less than 0.15 mEq K+/ml, dilute to 20 mEq/ 250 ml or
mEq/ 500 ml
*Doses exceeding 40 mEq should be administered in divided doses
Note: 1mmol KPhos = 1.46 mEqK+
For Large Volume IV Supplementation (greater than or equal to 500ml):
Rate
Dilution
Potassium
Potassium
Non-Monitored
10 mEq/h
60 mEq/L
Monitored
20 mEq/h
80 mEq/L
Peripheral Line
10 mEq/h
60 mEq/L
Central Line
Note: Concentrations and rates exceeding those listed above MUST be administered through a central line and the
patient MUST be on an EKG monitor.
Updated May 2016
Alert
It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see
Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and
the staff working on these units have received special training to deliver these medications. If a unit is not listed on the
40
Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference
Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris
IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV
pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see
extended text.
No supplies or equipment required.
Alert
It is the policy of the hospital that specific IV medications are given on specific units listed in the Reference Sheet-see
Quick Sheet or Extended Text. Units listed on the Reference Sheet are considered able to take Stepdown patients and
the staff working on these units have received special training to deliver these medications. If a unit is not listed on the
Reference Sheet, the medication cannot be administered on that unit. All of the medications listed in the Reference
Sheet may be given in the Intensive Care Units. All IV medications noted in this policy will be administered via the Alaris
IV pump using the Medication Safety System Guardrails Software. Bypassing the dose-checking component of the IV
pump technology is discouraged to assure patient safety. For more information specific to Deaconess Hospital, see
extended text.
S = Satisfactory | U = Unsatisfactory | NP = Not Performed
S
U
NP
Comments
Employee:____________________________ Signature:____________________________
Evaluator:____________________________ Signature:___________________________
Date:____ / ____ / _________
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