Download RRT Medical Directives (LHSC)

Medical Directives
Critical Care Outreach Team - Adult
Effective Date: November 2006
Date for Review/Revision: November 2008
Critical Care Outreach Teams (CCOT) are part of the Critical Care Strategy of the
Ministry of Health and Long Term Care. The goal is to improve patient safety and access
to critical care resources. LHSC is one of 26 institutions across the province to receive
funding to implement CCOTs
CCOT is comprised of specially trained critical care practitioners. They are critical care
intensivist lead nurse-based teams. CCOT team members work collaboratively with
hospital ward staff to identify, assess and respond to the needs of seriously ill patients
prior to the development of progressive and irreversible deterioration. These teams apply
the principals of acute medicine and resuscitation across the hospital, and bring specialist
knowledge and skills from the intensive care unit directly to the bedside on a 24/7 basis.
There are 5 core functions performed by the CCOT:
1) Early identification and facilitation of resuscitation of hospital in-patients at risk
of deterioration.
2) Prophylactic interventions, such as follow-up of patients recently discharged from
the ICU to prevent readmission, and rounds on high-dependency units
3) Knowledge dissemination to promote:
a. Acute care education, specifically the recognition and resuscitation of the
acutely ill adult patient, to nurses, physicians, students and other
healthcare professionals.
b. The concept of CCOT’s, their use and effectiveness in improving patient
safety.
c. A culture of patient safety and responsiveness.
4) Assistance with decisions regarding appropriateness of care and end-of-life
decision-making.
5) Guidance with appropriate disposition of patients and utilization of critical care
resources.
The CCOT is comprised of an ICU Intensivist, ICU Registered Nurse and Registered
Respiratory Therapist. All of the Registered Nurses have a minimum of 3 years ICU
experience and will attend a 2-day course specifically designed for the CCOT responders
provided by the Canadian Resuscitation Institute. All team members will be provided
with ongoing education by the site-leads.
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These directives will apply to all CCOT RN/RRTs who have received the specific
training for this role.
These medical directives have been derived from the existing “LHSC Respiratory
Therapy Advanced Care Medical Directives” with the addition of a “Universal Directive”
and “Electrolyte Disturbance Directive”.
USE OF PROTOCOLS
These protocols are not intended to be all encompassing of the complex medical
situations that may be encountered. Since patients do not always fit into a “cook book”
approach, these protocols are not a substitute for good clinical judgment. Providers
should utilize the resource of the designated LHSC Physician (LHSC MD) for situations
that fall outside of these protocols but who may benefit from advanced skills or
medications. The intended use of these protocols are to provide advanced care as required
until care can be transferred to an LHSC physician.
As guidelines, the CCOT RN/RRT should contact the LHSC MD promptly for:
 Critical or distressed patients that may benefit from advanced treatments that
do not fit into the protocols.
 Patients who do not stabilize after protocol treatment and further advanced
treatment is indicated.
 Specific situations that have been outlined in the protocols.
 Any time the CCOT RN/RRT assesses need to call LHSC physician of record
for advice or consultation.
Refusal of Treatment
When a patient refuses to give consent for assessment or management, the CCOT
RN/RRT should ensure that the patient has capacity and ensure the refusal is informed. If
the patient does not have capacity, is a danger to himself or others, or is suspected to be
suffering from a life-threatening condition, then the CCOT RN/RRT should seek help in
ensuring the patient receives appropriate care. The options open to the CCOT RN/RRT
include contacting the physician of record for the patient, contacting LHSC MD. Refer to
LHSC Policy “Patient Rights and Responsibilities” Policy Number PCC049.
Remember that consent is a process and not just a signature. If the CCOT RN/RRT has
any concerns regarding the patient’s capacity or refusal, the LHSC physician of record
may be contacted for advice.
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Universal Directive
Environmental Scan
Upon arrival of the Critical Care Outreach Team (CCOT) the RN/RRT will assess the
environment to ensure personal/team safety. If safety is in question the responding team
members will first ensure appropriate assistance (i.e. Security, Fire Department) are in
place.
Once safety is established the responding CCOT members will perform an initial-Primary
Assessment. The patient will be assessed for:
1. Patent Airway
2. Adequate Breathing
3. Presence of Circulation
If immediate/emergent interventions are required the RN/RRT will call a pre-arrest or
code blue if necessary
When the Critical Care Outreach Team (CCOT) is called the RN/RRT are covered to
initiate any or all of the following Secondary Assessment Procedures/ Treatments/
Interventions:
 Vital signs, including Oxygen saturation.
 Place on continuous cardiac monitoring.
 Supplemental Oxygen administration to maintain SpO2 >92% or if known
or suspected COPD with CO2 retention maintain SpO2 88-92%.
 Obtain intravenous access. Start IV line with 0.9% Normal Saline solution
set to 30cc/hour.
 Obtain a blood glucose measurement via glucose meter
 May draw any or all of the following blood work: electrolytes,
BUN/Creatinine, CBC, INR/PTT and capillary blood gases.
 May order and obtain a Chest x-ray.
 May order and obtain a 12 lead ECG.
 The RN/RRT will obtain a brief medical history including:
a. History of present illness
b. List of medications and allergies
c. Past medical and surgical history
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Shortness of Breath/Respiratory Distress Protocol
When the following conditions exist, the CCOT RN/RRT may administer Salbutamol and
Ipratropium according to the following protocol and algorithm. Salbutamol and
Ipratropium will be administered via MDI with spacer or through a nebulizer (volume
between 2.5-5.0 ml) as indicated below.
Indications:
Patient must have bronchospasm or wheezing or the absence of wheezes (due to severe
lack of air movement).
Contraindications and Risks:

Any known allergy to medications
Procedures/treatments/interventions:
1. Vital signs including O2 saturation
2. Supplemental O2 administration to maintain Spo2 > 92% or if known or suspected
COPD with CO2 retention maintain SpO2 88-92%
3. Spirometry (if available)
4. Salbutamol (Ventolin) 6 puffs metered dose inhaler (MDI) (600 mcg) with
aerochamber/spacer device & Ipratropium (Atrovent) 6 puffs metered dose
inhaler (MDI) (120 mcg) with aerochamber/spacer device
OR
Salbutamol (Ventolin) 5mg & Ipratropium (Atrovent) 500 mcg/2 ml
nebulized for a total minimum volume of 3 cc
5. If reassessment reveals that the patient has not significantly improved following
completion of the initial dose repeat Salbutamol (Ventolin) 6 puffs metered
dose inhaler (MDI) (600 mcg) with aerochamber/spacer device OR Salbutamol
(Ventolin) 5mg /2 ml nebulized Q15 min x2.
6. At the end of the protocol, if the patient is not improving, the CCOT RN/RRT
should contact the LHSC MD, and if every attempt to contact the LHSC physician
of record has failed, the protocol may be repeated while continuing to try to
contact the LHSC physician of record
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Intravenous Access & Fluid Administration Protocol
Indications
Actual or potential need for:
 Intravenous medication administration OR
 Intravenous fluid therapy
Procedure
1. Intravenous access will be by saline lock or IV line with 0.9% normal saline (NS)
set to Keep Vein Open (KVO) unless otherwise specified below. KVO rate is 3060 ml/hour.
2. When the patient is suspected to be acutely hypotensive/ hypovolemic without
crackles on chest auscultation, and has a systolic BP<90 the CCOT RN/RRT may
give an IV fluid bolus.
Repeat vitals and perform a chest auscultation after every 250 mL. Return to
TKVO when SBP is >90 or chest auscultation reveals crackles or other signs
of congestive heart failure.
3. If signs of congestive heart failure (crackles) AND the patient does not clinically
improve AND BP remains <90 start Dopamine at 5mcg/kg/min. Titrate to
systolic BP of 90 mmHg.
Note:




If starting an IV, the CCOT RN/RRT will make attempts in the following order of
site preference:
Peripheral upper extremity maximum of 2 attempts (preference to a distal site).
If the patient is unconscious or in an arrest situation and needs IV medications or
fluid bolus, CCOT RN/RRT may attempt lower extremities.
When administering IV fluid resuscitation, the CCOT RN/RRT must carefully
observe for signs of fluid overload (e.g.: crackles on chest auscultation).
.
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Electrolyte Disturbance Directive
When the following indications exists the CCOT RN/RRT may treat the following
electrolyte disturbances according to the following protocol:
Indications:
Acute or potential need for electrolyte replacement if serum phosphate <0.8 mmol/L
Acute or potential need for electrolyte replacement if serum K+  3.5 mmol L
Acute or Potential need for electrolyte reduction if serum K+  7.0 mmol/L
Acute or potential need for electrolyte replacement if serum Mg++ < 0.7 mmol/L
Contraindications:
 Renal insufficiency with Creatinine >200 mmol/L
 Severe oliguria (< 30 ml/h) or anuria
 Chronic renal failure
Notify MD


if K+ 2.9 mmol/L initiate appropriate electrolyte replacement and notify
MD
If contraindication exist and electrolyte orders can not be carried out
Procedures/ Treatments/ Interventions
Phosphate Replacement:
 If serum phosphate is <0.8 mmol/L AND K+  3.5 mmol/ L
Give 30mmol phosphate ( as Potassium) in 100 ml IV solution over 2 hours.
***Do not give additional K+ replacement, as this will provide 44 mmol of K+

If serum phosphate is <0.8 mmol/L AND if K+ > 3.5 mmol/L
Give 30mmol Phosphate (as Sodium) in 100 ml IV solution over 2 hours.

Patient Tolerating Enteral feeds
Give phosphate effervescent tablet 1000mg per NG/po x 1 dose instead of IV
Potassium Replacement:
 If K+  3.2 mmol/L
Give 40 mmol KCL in 100ml IV solution over 1 hour OR 40 mmol per NG/po x 1
dose (do not use enteric coated oral tablets)
If central line not in situ, administer IV in two doses.

If K+ > 3.2 and  3.5 mmol/L
Give 20 mmol KCL in 100 ml IV solution over 1 hour OR 20 mmol per NG/po x
1 dose (do not use enteric coated oral tablets)
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Potassium Reduction:
If K+>7.0
1. Calcium Gluconate, 10ml of a 10% solution IV over 2 minutes (Do not
administer to patients with hypercalcemia or if digoxin toxicity is suspected)
2. 1 amp - 50 mL D5W
3. 5 units of Regular (Toronto) Insulin
4. 1 mEq/kg Sodium Bicarbonate (up to 100 mEq through a slow IV push)
Magnesium Replacement:
 If serum Mg++ < 0.7 mmol/L OR ionized Mg++ < 0.53 mmol/L (novastat) give 2
gms magnesium sulfate in 100 ml IV solution over 1 hour
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Suspected Cardiac Ischemia Chest Pain Protocol
When the following indications and conditions exist, the CCOT RN/RRT can administer
Nitroglycerin 0.4 mg spray SL, and ASA two (2) 80 mg chewable tablets according to
the following protocol. Nitroglycerin administration will not exceed three doses and
ASA will not exceed 160 mg.
Indications
An alert patient experiencing chest pain consistent with that caused by cardiac ischemia
OR experiencing his or her typical Angina/MI pain.
Conditions
Patient is > 40 kg.
To receive Nitroglycerin
The patient must:
 be  40 Kg.
 be alert and responsive
 NOT have taken a prescription erectile dysfunction medication i.e. Sidenafil
Citrate (Viagra), Vadenafil HCI (Levitra), Tadalafil (Cialis) etc. within the past 48
hours
 Have a Systolic BP that is  90 mmHg. and a heart rate that is  60 bpm. and 
160 bpm.
To receive ASA
The patient must:
 be  40 Kg.
 be alert and responsive
 NOT have an allergy to ASA or other NSAID
 NOT have current active bleeding (GI or other disorders)
 have NO evidence of CVA or head injury within 24 hours
 have a history of previous use of ASA with no adverse reaction if a known
asthmatic
Procedure
1. Administer 100% O2 and document vital signs.
2. Initiate continuous cardiac monitoring and pulse oximetry (if available).
3. Place the patient in a sitting or semi-supine position.
4. Administer ASA 160 mg (2 x 80 mg) for the patient to chew and swallow.
5. 12 ECG
a. Right side ECG if inferior injury pattern is noted to assess for Right
Ventricular involvement.
6. Initiate IV NS TKO.
7. Administer nitroglycerin (0.4 mg spray) Q 5 minutes prn for chest pain, to a
maximum of three doses only if;
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a. 12 lead does not show signs of Right Ventricular involvement.
b. Systolic BP is ≥ 90 mmHg and the heart rate is ≥ 60 bpm and ≤ 160 bpm.
Note: If the patient has self-administered Nitro, the CCOT RN/RRT may still give
Nitro to a maximum of three doses
8. Assess vitals after each dose. Discontinue Nitroglycerin if systolic BP drops by
1/3 of the initial systolic blood pressure.
9. Should the patient’s vital signs fall outside of the designated parameters listed
above at any time, Nitroglycerin will be discontinued.
10. Follow the IV fluid administration protocol (if indicated).
Note::
 If the patient's chest pain fully resolves and then recurs, it is treated as a new
episode of chest pain and the NTG protocol is repeated, but not the ASA.
 Patients may be reluctant or refuse to take ASA. In such cases, respect the
patient’s wishes and notify the receiving hospital staff on arrival.
 Administer ASA even if the patient has already taken their normal dose prior to
your arrival or even if the chest pain has resolved. This will ensure that the
appropriate medication and dose was given and documented by a Health Care
provider.
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Altered Level of Consciousness (LOC) – Suspected Hypoglycemia Protocol
When the following conditions exist, a CCOT RN/RRT can administer Dextrose
intravenously (IV) or Glucagon subcutaneously (SC) or intramuscularly (IM) according
to the following protocol. A maximum of two doses will be administered.
Indications
Patient who exhibits any of the following serious symptoms: agitation decreased
LOA/LOC, syncope, confusion, seizure or symptoms of stroke.
Conditions
Patient who has a blood glucose reading of < 4 mmol.
Contraindications
Glucagon is contraindicated in the following:
 Allergy to Glucagon
 History of pheochromocytoma (rare adrenal gland tumor), if known.
Procedure
1. Administer 100% 02, manage airway and assist ventilations as required.
2. Initiate cardiac monitoring and pulse oximetry (if available).
3. Perform blood glucometry to confirm a reading of 4 mmol/l or less.
4. Establish IV access NS TKVO (if possible).
5. Administer 25 grams of 50% Dextrose ( 50 mL)
6. If IV access is unobtainable or delayed, administer 1 mg SC/IM Glucagon.
7. If the patient responds to Dextrose or Glucagon, the patient may receive oral
glucose or other simple carbohydrate (providing the patient is awake and able to
protect their airway).
8. If no clinical improvement is observed, the CCOT RN/RRT may repeat the
glucometry.
9. If the patient still meets the requirements for treatment the CCOT RN/RRT may
repeat a second dose of Dextrose after 10 minutes or administer a second dose of
glucagon after 20 minutes. The patient may receive a maximum of two doses of
glucagon including any Glucagon administered prior to the CCOT RN/RRT’s
arrival.
Note:
 A CCOT RN/RRT may perform blood glucometry on a patient with signs or
symptoms that may be related to a glucose problem (hypo- or hyper-glycemia)
 If only mild signs and symptoms are exhibited, and the patient does not meet the
above indications, treatment (including oral glucose) will not be initiated
 If glucometry indicates the patient’s reading is > 25 mmol/l, consider that these
patients may be significantly dehydrated.. Physician will be notified.
.
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Seizure Protocol
When the following conditions exist, a CCOT RN/RRT may administer diazepam or
midazolam according to the following protocol to a maximum of two doses.
Indications
Patient who is unresponsive and
Currently experiencing a generalized motor seizure.
Procedure
1. Administer 100% O2, manage airway and ventilate as indicated.
2. Initiate continuous cardiac monitoring and pulse oximetry (if available).
3. Perform blood glucometry. If blood glucose is  4 mmol/l, treat as for
hypoglycemia protocol before proceeding with this protocol.
4. Establish IV line.
5. Administer Diazepam 5 mg IV over 1 minute
6. If after 2 attempts or 3 minutes, IV access has not been secured, administer
Midazolam 0.2 mg/kg intramuscularly (IM) or intranasal (IN) to a maximum
single dose of 10 mg.
7. If the seizure stops during the administration of the drug, terminate the
administration.
8. If after another 2 minutes, the seizure continues or recurs, repeat administration of
Diazepam over a 1-minute period to a maximum of two doses by protocol. If the
seizure stops during the administration of the drug, terminate the administration.
9. Monitor respiratory status
10. Contact LHSC physician of record if other intervention/management is required
including treatment of focal seizures.
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Clinical References
Ontario- Ministry of Health Long Term Care Critical Care Strategy
www.health.gov.on.ca/english/providers/program/critical_care/critical_care_mn.html
Ontario Critical Care Steering Committee Final Report 2005
References – Practice
College of Nurses of Ontario (2000) “ When, Why and How to use Medical Directives”
Zettle, R. “ Delegation of Controlled Acts and the Use of Medical Directives”
by permission from law firm Borden, Ladner, Gervais LLP - 2003
Zettle R, “Drafting a Medical Directive - Some Useful Tips and Pitfalls to Avoid”
by permission from law firm Borden, Ladner, Gervais LLP – 2003
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Approval
The Critical Care physicians, as attending physicians, endorse the medical directives as
specified above for all RN/RT members of the CCOT
_____________________________
Date__________________
Dr. F. Rutledge, Critical Care Medicine
_______________________________________
Dr. R. Butler Site Chief ICU UH Anaesthesia
Date___________________
………………………………………………………………………………………
_____________________________
Date_________________
J. Kojlak, Director, Critical Care
_____________________________
Date__________________
J. Walker, Co-Lead UH
_____________________________
Date__________________
J. Gole Co-Lead VH
_____________________________
Date__________________
C. Shavalier, Professional Practice
………………………………………………………………………………………………………………………….
MAC Authority
__________________________________
Dr. I. Herrick
Date: ________________
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