Unique Plan Description: Intensivist Rounds
Plan Selection Display: Intensivist Rounds
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2011-07-11 18:46:55
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-04-26 08:51:46
Available at all facilities: No

Intensivist Rounds
Admit/Discharge/Transfer
	Transfer to Critical Care (WH JE)
		
	Transfer to Med-Surg
		
Diet
	Advance Diet as Tolerated
		T;N
	NPO
		T;N, After Midnight
	Oral Supplement
		T;N
Laboratory
	Comprehensive Metabolic Panel
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Hemoglobin and Hematocrit
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	INR - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	hsCRP
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Sed Rate
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	ProBNP
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	TSH
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Thyroid Panel
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	UA (Culture if Positive)
		T+1;0400, Routine, Routine, spec type = Urine
		T;N, Stat, Stat, spec type = Urine
		T;N, Routine, Routine, spec type = Urine
	Blood Gases Arterial (ABG) - MH/WH/JE
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		Routine, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Magnesium Level
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Phosphorus
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Calcium Ionized
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
	Sputum Culture
		T+1;0400, Routine, spec type = Sputum
		T;N, Stat, spec type = Sputum
		T;N, Routine, spec type = Sputum
	Urinalysis
		T+1;0400, Routine, Routine, spec type = Urine
		T;N, Stat, Stat, spec type = Urine
		T;N, Routine, Routine, spec type = Urine
	UA (Culture if Positive)
		T+1;0400, Routine, Routine, spec type = Urine
		T;N, Stat, Stat, spec type = Urine
		T;N, Routine, Routine, spec type = Urine
	Lactate
		T+1;0400, Routine, spec type = Blood
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T+1;0001, Routine
		T;N, Routine
	Chest 2 View
		T+1;0001, Routine
		T;N, Routine
	CT Head w & w/o Contrast
		T;N, Routine
	CT Head w Contrast
		T;N, Routine
	MRI Brain w & w/o Contrast
		T;N, Routine
	MRI Brain w/o Contrast
		T;N, Routine
	Abd & Upright w Chest
		T;N, Routine
	ECG
		T;N, Routine
	Venous Duplex Bil Upper or Lower
		Indication: Pain, Location Upper Bilateral
		Indication: Pain, Location Lower Bilateral
	Venous Duplex Unilat Upper or Lower
		Indication: Pain, Location Left Upper
		Indication: Pain, Location Left Lower
		Indication: Pain, Location Right Upper
		Indication: Pain, Location Right Lower
	Echo w Doppler resting
		T;N, Routine
	TEE Transesophageal Echocardiogram
		T;N, Routine
IV Solutions
Medications
Patient Care
	Monitor Central Venous Pressure (CVP)
		T;N
	Foley Catheter
		T;N, Insert
	Discontinue Urinary Catheter
		T;N, Foley
	Enteral Tube
		T;N, Per Nasogastric Tube (NG), Insert, X Ray
	OG Tube
		T;N, OG, Insert
	Discontinue Enteral Tube
		T;N
	Discontinue OG Tube
		T;N
	Discontinue IV
		T;N
	IV-Decrease Rate
		T;N
	Discontinue Hospital Protocol
		T;N, Insulin Sliding Scale
		T;N, Heparin Protocol
		T;N, TPN
	Bladder Scan
		T;N
			Comment: Assess for Residual
	Glucose POC - RN
		T;N
Cardiac Telemetry Monitoring
	Cardiac Telemetry Monitoring
		T;N
			Comment: check with physician in 48 hours to see if telemetry can be discontinued.
	Discontinue Cardiac Telemetry Monitoring
		T;N
Therapies

	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	Consult Occupational Therapy, Evaluate and Treat
		T;N
	Consult Physical Therapy, Evaluate and Treat
		T;N
	Consult Speech Therapy (JE)
		
Consults/Follow-up
	Consult Physical Medicine (Rehab)
		
	Consult Social Work
		T;N
	Consult Wound Care
		
	Consult Diabetes Educator
		T;N
	Consult Anesthesiologist
		
	Consult Cardio-Thoracic Surgery
		
	Consult Cardiologist
		
	Consult Gastroenterologist
		
	Consult General Surgery
		
	Consult Head & Neck
		
	Consult Hematologist/Oncologist
		
	Consult Infectious Disease
		
	Consult Nephrologist
		
	Consult Neurologist
		
	Consult Neurosurgery
		
	Consult OB/GYN
		
	Consult Psychiatrist
		
	Consult Pulmonologist
		
	Consult Urology
		
	Consult Vascular Surgeon

Peripheral Lock - Access
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

Blood Culture Set
Laboratory
	.Blood Culture.
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, spec type = Blood
	.Blood Culture
		T;N, Stat, spec type = Blood
		T;N, Routine, spec type = Blood
		T+1;0400, Routine, spec type = Blood

Insulin Sliding Scale - NovoLOG
	Glucose POC - RN
		T;N, QIDACHS
		T;N, 15 minutes after carbohydrate source or medication administered
	Hemoglobin A1C
		T+1;0400, Routine, spec type = Blood
	Order Lab
		T;N
			Comment: Blood Glucose (POC) as needed for signs and symptoms of hypoglycemia for patients with diabetic medication orders or known diabetic.
Medications
	Standard Dose NovoLOG
		2 - 12 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale, Routine
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 2 units,200 - 249 = 4 units,250 - 299 = 6 units,300 - 349 = 8 units,350 - 399 = 10 units.Over 399 = 12 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings,TPN, etc). Enter as Q6H-SCH PRN
	High Dose NovoLOG
		5 - 30 units, Injection, SUBCUTANEOUS, QIDACHS, PRN, sliding scale
			Comment: << Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 5 units,200 - 249 = 10 units,250 - 299 = 15 units,300 - 349 = 20 units,350 - 399 = 25 units.Over 399 = 30 units, << Sliding Scale Comments >>Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order and POC glucose order to every 6hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).  Enter as Q6H-SCH  PRN
	glucose oral gel (JE)
		15 gm, Gel, By Mouth, Q15MIN, PRN, low blood sugar
			Comment: For blood glucose is 60-70mg/dL as an alternative to apple juice. Notify provider if given with corresponding POC glucose recheck value
	Dextrose 50%
		25 mL, Injection, IV PUSH, Q15MIN, PRN for low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN for low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Order Lab
		T;N, RN may change schedule of point of care glucose and sliding scale insulin order to every 6 hours if patient is NPO or not on oral diet (tube/enteral feedings, TPN, etc).. Enter POC order as Q6H-SCH, TIMED and medication order as Q6H-SCH PRN.
	Diabetic Snack
		T;N, Give snack (1 complex carb (15g), 1 protein snack (7g) ) anytime insulin is administered after the evening meal is complete and POC glucose is <150mg/dL.
	IV-Maintain
		T;N
			Comment: Patient should have IV site while on hypoglycemia protocol
	Hypoglycemia Treatment Parameters
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while in Hypoglycemia protocol.
		T;N, glucose <60 mg/dL treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel (MJE/MFH).  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

Adult TPN Protocol
Laboratory
		For critically ill adult patients, consider enteral nutrition when possible. Total Parenteral Nutrition (TPN) should be considered for patients who are unable to meet nutritional requirements with enteral nutrition and are expected to require it for great(NOTE)*
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, spec type = Blood
			Comment: (TPN Protocol)
	CBC with Diff
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Chromium Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Comprehensive Metabolic Panel
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Mon, spec type = Blood
			Comment: (TPN Protocol)
	Copper Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Magnesium Level
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Manganese Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Phosphorus
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+1;0400, Routine, Q24H, 5, Day(s), spec type = Blood
			Comment: (TPN Protocol)
		T+10;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
		If patient is on warfarin, select BOTH Protime orders below:(NOTE)*
	INR - MH/WH/JE
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
			Comment: (TPN Protocol)
		T;N, Stat, spec type = Therapeutic Blood
			Comment: (TPN Protocol)
	INR - MH/WH/JE
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Prothrombin Time (PT) - FH
		T+7;0400, spec type = Diagnostic Blood
			Comment: (TPN Protocol)
		T+7;0400, spec type = Therapeutic Blood
			Comment: (TPN Protocol)
	Selenium Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Triglycerides
		T;N, Routine, spec type = Blood
			Comment: (TPN Protocol)
		T+7;0400, Routine, Q7D-Lab, spec type = Blood
			Comment: (TPN Protocol)
	Zinc Level
		T+14;0400, Routine, Q14D-Lab, spec type = Blood
			Comment: (TPN Protocol)
Diagnostic Tests
	Indirect calorimetry
		T;N
			Comment: TPN Protocol.
IV Solutions
	TPN with Electrolytes - TPN Protocol
		1,800 mL, IV, T;2100, 75 ml/hr, 5 % Amino Acids, 15 % Dextrose, 40 mEq/L Sodium Chloride, 20 mEq/L Sodium Acetate, 15 mEq/L Potassium Chloride, 14 mMol/L Potassium Phosphat, 8 mEq/L Magnesium Sulfate, 4.8 mEq/L Calcium Gluconate, 10mL M W F mL/Bag MVI-Adu
			Comment: Infuse via central line only. TPN rate changes should occur with next bag unless specifically ordered by prescriber.
Patient Care
	Glucose POC - RN
		T;2100, Q6H
	Discontinue IV Fluids
		T;2100
			Comment: Upon TPN initiation (TPN Protocol)
	Central Line-Insert
		T;N
Consults/Follow-up
	Consult Dietitian
		T;N, Regarding: TPN, Dietitian Assess and Treat
			Comment: Pharmacy/Nutrition to order TPN solution, labs and make necessary adjustments.
	Pharmacy Consult - TPN
		T;N, Regarding: TPN | Pharmacy/nutrition to order TPN solution and monitor/adjust electrolytes. Add 100mg Thiamine IV Push daily for 7 days order if patient is at risk for refeeding syndrome. Discontinue Thiamine after 7 days.
			Comment: Pharmacy/nutrition to order TPN solution and monitor/adjust electrolytes. Add 100mg Thiamine IV Push daily x7 days order if patient is at risk for refeeding syndrome. Discontinue Thiamine after 7 days

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase