Download Mgmt of Soft Tissue Infections Using IV Antibiotics Medical

1
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
Title: Management of Soft Tissue Infections Using IV Antibiotics
Manual: Patient Care Policies and Procedures
Type: Medical Directive
Section: Medical Directives
Additional Sections:
Developed by: Nurse Led Outreach Team RNEC
Original Effective Date: 2011
Approved by:
Date Revised:
Cross Reference:
Date Reviewed:
Key Words: Cellulitis, soft tissue infection, diabetic foot, infected wound
Appendix Attached:
Yes
No
Title:
Order and/or Delegated Procedure:
This medical directive for nurse practitioners on the Nurse Led Outreach Team governs:
1. Ordering of intravenous antibiotics used for the treatment of acute cellulitis and other soft tissue
infections in residents who are level II or higher, and who, in the clinical judgment of the healthcare
team would benefit from intravenous antibiotic therapy
Recipient Patients:
Appendix Attached:
Yes
No
Title:
Residents of nursing homes who have entered into Memorandums of Agreement with the York Central
Hospital Nurse Led Outreach program.
Appendix Attached:
Yes
No
Title:
Authorized Implementers:
RN’s and RN-EC’s in the Nurse Led Outreach Team, employed by York Central Hospital who possess the
knowledge, skill, judgment and demonstrated competency to implement this medical directive as outlined in
the Performance Readiness Plan.
Indications:
Appendix Attached:
Yes
No
Title:
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
2
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
1. When, after a thorough assessment of a change in a resident’s status, the RN-EC and/or MD
concludes that resident will not benefit from oral antibiotics, or oral antibiotic treatment has failed.
2. When assessment suggests that the resident is medically stable enough to be treated on an outpatient
basis with IV antibiotics.
Appendix Attached:
Yes
No
Title:
Contraindications:
This medical directive must not be implemented:
1. When the patient or Substitute Decision Maker (SDM) declines implementation of this Medical
Directive; and
2. Informed consent is not obtained.
3. When there is evidence of necrotizing fasciitis is present
4. When there is evidence of sepsis or septic shock
5. When patient has allergies to the medications listed in this directive
Consent:
Appendix Attached:
Yes
No
Title:
This medical directive cannot be instituted until the patient or SDM has provided informed consent for the
proposed investigation and treatment.
Obtaining and documenting informed consent includes the provision of information and the ability to answer
questions about:
 the implementation of this medical directive;
 the nature of the treatment;
 expected benefits of the treatment;
 material risks and adverse effects of the treatment;
 alternative courses of treatment; and
 likely consequences of not having the treatment (CNO, 2008, CPSO 2007).
The Resident or SDM must consent to care provided by RN(EC). If the resident or SDM does not wish to have
the RN(EC) participate in his/her care, the necessary workup will be provided by the most responsible physician.
While informed consent is the expectation, and this consent should be documented, a formal consent form does
not need to be signed.
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
3
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
Guidelines for Implementing the Order /
Appendix Attached:
Yes
No
Title:
Procedure:
The RN-EC or RN will complete the following prior to ordering IV antibiotics;
1. review the resident’s history including the history of present illness;
2. review current and past laboratory results;
3. conduct a focused physical examination based on results of history taking and laboratory review;
4. Discuss findings of examination and suggested course of action with MRP, and
5. write an order for IV antibiotics, based on clinical assessment and best practice guidelines.
6.
The RN-EC or RN will complete the upon ordering IV antibiotics:
 document the results of the history review, physical exam, assessment and plan of care;
 review the plan of care with the resident/SDM;
 Complete CCAC referral form, including medication orders, dose, route and length of treatment.
 Contact CCAC to establish services for the ongoing provision of IV antibiotics
 Review plan of care with registered nursing staff responsible for resident. Provide education as
needed.
 Initiate intravenous access in accordance with the policies and procedures of York Central Hospital
and the individual long-term care facility where the treatment is being initiated.
 If CCAC/home care agency is not willing to administer the first dose of antibiotic, the RN-EC or RN
is to arrange delivery of medication either through home care pharmacy or from hospital supplies,
and administer medication, as per hospital policy and procedure and best practice guidelines.


Documentation and Communication:
Appendix Attached:
Yes
No
Title:
1.
Orders are to be written legibly, ad include that the order is a result of implementation of a medical
directive. This order will include the full name of the directive, the name of the implementer and
their status.
6. Results of physical assessment are to be communicated to the care team, included the registered
staff and the most responsible physician. Documentation is to be done in accordance with the
policies of the LTC facility and the College of Nurses of Ontario.
7. the plan of care, based on the assessment, discussion with MRP and SDM, is documented and
communicated to the rest of the care team.
Review and Quality Monitoring
Appendix Attached:
Yes
No
Title:
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
4
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
Guidelines:
The RN(EC)’s in the Nurse Led Outreach Team will review the medical directives with the physician partner(s)
in the long-term care facilities on an annual basis. Changes / revisions/ editions must be taken to the appropriate
approving committees.
In addition the RN’s and/or RN(EC)s in these roles are expected to remain current in their specialty area in
regards to best practice guidelines for the management of soft tissue infections, and local antibiotic resistance
trends. This is outlined in the Performance Readiness Plan. In addition, registration with the College of Nurses
of Ontario requires the RN’s and RN(EC)s to participate in reflective practice, which includes Reflective Practice
and Practice Review annually.
Endorsing committees will include: Pharmacy, Nutrition and Therapeutics, Nursing Advisory Committee,
including the Chief Practice Officer. The Clinical Policy and Procedure Review and Approval Committee
will provide final review with the Medical Advisory Committee being the authorizing committee.
Administrative Approvals (as applicable): Appendix Attached:
PNT
NAC
Chief Practice Officer – York Central Hospital
Physician Partners – Long Term Care
Director of Nursing – Long Term Care
Chief of Staff.
Yes
No
Title:
Appendix Attached:
Approval Form
Yes
No
Title: Review and
Approving Physician(s)/Authorizer(s):
The medical directive shall be approved of by each physician partner at each participating long term care
home as well as the Medical Directors of each long term care facility.
References:
Appendix Attached:
Yes
No
Title:
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
5
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
College of Nurses of Ontario. (2008). Documentation. Retrieved October 13, 2010 from
http://www.com.org/Global/docs/prac/41001_documentation.pdf
College of Nurses of Ontario. (2009). Authorizing mechanisms. Retrieved January 11, 2010 from
http://www.cno.org/docs/prac/41075_AuthorizingMech.pdf
College of Nurses of Ontario. (2009). Consent. Retrieved January 11, 2010 from
http://www.cno.org/docs/policy/41020_consent.pdf
College of Nurses of Ontario. (2009). Directives. Retrieved January 11, 2010 from
http://www.cno.org/docs/prac/41019_MedicalDirectives.pdf
College of Nurses of Ontario (2009). Nurse Practitioners. Retrieved October 12, 2010 from
http://www.cno.org/Global/docs/prac/41038_StrdRnec.pdf
College of Physicians and Surgeons. (2004). Delegation of controlled acts. Retrieved January 12, 2010 from
http://www.cpso.on.ca/policies/policies/default.aspx?ID=1554
e-Laws. (1991). Regulated Health Professions Act (sections 28 & 29). Retrieved January 24, 2009 from
http://www.e-laws.gov.on.ca/html/statues/english/wlaws_statutes_91re.htm#BK25
Federation of Health Regulatory College of Ontario. (2007) An Inter-Professional guide on the use of orders,
directives and delegation for Regulated Health Professionals in Ontario. Retrieved January 24, 2009,
from http://mdguide.regulatedhealthprofessions.on.ca/why/default.asp
Clinical:
Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant
Staphylococcus aureus infections in adults and children.
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak
M, Talan DA, Chambers HF. Clin Infect Dis. 2011
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
6
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
APPENDIX A
MEDICATION
 Ancef (Cefazolin
Sodium)

Ceftriaxone
(Rocephin)

DOSAGE
500mg-1gm IV q6-8h
1gm IV Daily
Contraindications/Cautions
 Cephlosporin allergy
 Renal Dosing Required
 Use with caution in
patients on
anticoagulant therapy
(more frequent
monitoring of INR
required). in patients
with h/o C. diff colitis.
 Use with caution in
patients on
anticoagulant therapy
(more frequent
monitoring of INR
required).





Clindamycin
600-900mg IV q8h

Allergies to
cephlosporins.
Renal dosing not
required. Monitor INR
in patients with
advanced liver disease
Use with caution when
there is a history of C.
diff. or other risk
factors for C. diff
colitis.
Use with caution in
atopic individuals
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.
7
Point of Care Testing and Laboratory Tests by Long-term Care Outreach
Nurses.___________________________________________________________________________________
This medical directive is currently draft and has not been authorized.
A printed copy of this document may not reflect the current, electronic version on York Central Hospital’s Intranet. This material
has been prepared solely for the use at York Central Hospital. York Central Hospital accepts no responsibility for use of this
material by any person or organization not associated with York Central Hospital.
Discard after use.