clinician quality/operation patient care services

of 2

LBH Hospital PowerPlan Committee Agenda/Minutes

Videoconference Call (**NEW** +1 973 854 6173 Meeting ID: 111 567 4074 Please use *6 to mute/unmute)

Clinician Quality/Operation Patient Care Services Informatics✓ Dr. Kenneth Lee (Co-Chair) Christine Sullivan Mary Zell ✓ Kenny McHugh (Co-Chair)

Dr. Jonathan Thierman Jacqueline Adams Min Kwon Leslie WelfieldDr. Oluwasayo Akinyosoye Amanda ShroutDr. Diana Molavi Janice Marlett

Amelia DayucosBrooke AdamsCarole Louis

Dr. Sam Smith Nancy BrownRon Mendoza Kristine Feller

Dr. Ian Loper Dr. Kiran Kuna Kristen Parsons Patricia Kokoski Steve GoyetteDr. Jed Rosen Stacey Fisher-Hill Lisa UrieKimberly Bown Judy Waltz

Action/Plan *I.

1

ab

2

3

Tara Baynes4

Soumil Sheth

Changes approved by Dr. Makadia 9/9/20. Note - per Tara, this is the only plan that should be used for HF, so the "ED Adult: Heart Failure" and "Observation Heart Failure" should both be inactivated.

ED Adult: Asthma Exacerbation( Cherwell # 571518 / PP # 351 )

Wednesday September 23, 2020

Heart Failure Admission (Inpatient or Observation)( Cherwell # 496654 / PP # 385 )

The Living Legacy Foundation, In-House Coordinator, is requesting changes to the organ donor powerplan. Herein, changes include addition of multiple medications and changes to Labs and Radiology orders.Ricky Amoateng

Dr. Soriano

( Cherwell # 537469 / PP # 323 )

PEDS Stroke ED PPs

Organ Donor PP

https://meeting.windstream.com/j/1115674074

Check marks indicate the presence of the Invited Participants/Guests Agenda Topic

( Cherwell # 521592 / PP # 302/303 )

InvitedLBH/Sinai

Dr. Charles AlbrechtPharm/Lab/Rad/Nutrition

(0-21 years WITH Sickle Cell)PEDS Stroke ED PPs request

NW

Carrol

Guest

Request Details / Meeting NotesReview New Requests: (PP= PowerPlan)

(29 days to 17 years old withOUT sickle cell)

Please see attached powerplan draft

page 1 of 48

of 2

5

Sullivan, Christineabcde

6

7

II.III. Next Meeting: 10/28/2020 Wednesday 3-4 pm by Videoconference/Call ONLY * Request Status Update can be followed online by clicking on this hyperlink

FYI - NONE

Kate Ledbetter

Scott Penfil, MD/Brian Broomell

( Cherwell # 561933/ PP # 344)

All Vital Signs orders are to be pre-checked. Replaces all previous vital sign orders. Note start and stop times. Vital Signs, begin T, N, Q1 hour X 4 hours (stop in 240 minutes).Vital Signs, begin T, N+240, Q2 hours X 8 hours (stop in 720 minutes).Vital Signs, begin T, N+720, Q4 hours for duration of PCA.

Neonatal Admission (CH)

( Cherwell # 584883 / PP # 357)

Ampicillin dosing for neonates has changed in NeoFax, so we are updating our Power Plan to match current recommendations:PMA > 32 weeks - < 35 weeks 50 mg/kg Q12HPMA > 35 weeks 50 mg/kg Q8HMeningitis 100 mg/kg Q8H

Replaces vital signs orders for the following PowerPlans( Cherwell # 567007/ PP # 349)

PICU MIS-CThis powerplan (See attached word Document) addresses the care of pediatric patients suffering severe illness from COVID-19 infection.

PCA Peripheral Adult

PCA Peripheral Peds/PICUPeds Ortho Post Op with PCA PowerPlan

PCA Ortho Postop Powerplan

PCA Peripheral HIGH CONCENTRATION Adult

page 2 of 48

9.23.2020 PowerPlan Request Item #1a P 1 of 2

Printed on: 08/24/20 13:24 Page 1 of 2 Domain: B244

Unique Plan Description: ED Peds Stroke (0-21 years WITH Sickle Cell) Plan Selection Display: ED Peds Stroke (0-21 years WITH Sickle Cell) PlanType: Medical Version: 1 Begin Effective Date: 08/10/2020 08/10/20 12:42 End Effective Date: Current Available at: SHB ED Peds Stroke (0-21 years WITH Sickle Cell) Admit/Diagnosis

For pediatric patients 0-21 years old presenting to ED with stroke symptoms AND has sickle cell disease:(NOTE)*

Vital Signs Cardio-Respiratory Monitoring

T;N Pulse Oximetry Continuous

T;N Vital Signs

T;N, Q1H, HR, RR, BP Temperature

T;N, q2h Notify Provider for VS's of:

T;N, Temp > 37 degrees C Activity Bedrest

T;N, at all times (DEF)* T;N, at all times, HOB flat, neck midline for ischemic stroke T;N, at all times, HOB up 30-45 degrees for venous thrombosis

Diet NPO

T;N, No exceptions Patient Care Orders Blood Glucose Monitoring POC

T;N, Stat, Notify MD if glucose < 60 or > 150 mg/dl Miscellaneous Nursing Order (NON-Medication)

T;N, PSA to page pediatric hematologist on call STAT Respiratory Therapy Oxygen Therapy Protocol

T;N, Maintain O2 sat > 95% IV Solutions sodium chloride 0.9% (Bolus)

20 ml/kg, IV, ONCE, Inj, infuse over 60 min(s), 10 mL/kg for neonates Comments: 10 ml/kg for neonates

Sodium Chloride 0.9% 1,000 ml, IV, ml/hr

D5NS 1,000 ml, IV, ml/hr

Medications acetaminophen (pediatrics)

20 mg/kg, rectal, ONCE, Supp, round to divisible dose (half or whole supp) of 120mg, 325mg or 650mg ; Do not exceed adult dosing

Comments: For T>38Cround to divisible dose (half or whole supp) of 120mg, 325mg or 650mg ; Do not exceed adult dosing

cefTRIAxone (pediatrics) 75 mg/kg, IV, ONCE, STAT, Therapeutic rationale= T>/= 38 C, Inj Syringe

Comments: max = 2000mg

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Printed on: 08/24/20 13:24 Page 2 of 2 Domain: B244

lorazepam (pediatrics) 0.1 mg/kg, IV, ONCE, Inj

Comments: max = 4mg lorazepam

1 mg, IV, ONCE, Inj (DEF)* 2 mg, IV, ONCE, Inj

fosphenytoin (pediatrics) 15 mg/kg, IV, ONCE, Inj Syringe, loading dose, mg/kg = mg PE/kg, goal range = 10-20 mcg/ml

Comments: max = 1500mg PE levETIRAcetam (pediatrics)

20 mg/kg, IV, ONCE, Inj Comments: max dose = 4500mg

Laboratory CBC with Auto Diff STAT (ED)(SUB)* Retic Count

ST collect Venous Bld, T;N Comprehensive Metabolic Panel

ST collect Venous Bld, T;N EPOC POC

T;N, Stat, EPOC All Tests INR / PT

ST collect Venous Bld, T;N PTT

ST collect Venous Bld, T;N Blood Culture

T;N, Blood, ST, peripheral Type and Screen STAT (ED)(SUB)* ***Cross Match Order***(NOTE)* _Red Blood Cells

T;N, ST Diagnostic Tests EKG.

T;N, Stat *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 phasetextControl

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9.23.2020 PowerPlan Request Item #1b P 1 of 3

Unique Plan Description: ED Peds Stroke (29 days to 17 years old withOUT sickle cell) Plan Selection Display: ED Peds Stroke (29 days to 17 years old withOUT sickle cell) PlanType: Medical Version: 1 Begin Effective Date: 08/10/2020 08/10/20 10:15 End Effective Date: Current Available at: SHB ED Peds Stroke (29 days to 17 years old withOUT sickle cell) Admit/Diagnosis

For pediatric patients 29 days to 17 years old presenting to ED with stroke symptoms AND does not have sickle cell disease:(NOTE)*

Pager page pediatric neurologist on call STAT

Vital Signs Vital Signs with Pulse Oximetry

T;N, Continuous Vital Signs

T;N, Q1H, HR, RR, & BP Temperature

T;N, q2h, Notify MD if temp > 37 C Activity Bedrest

T;N, complete | at all times, Continuous Bedrest

T;N, complete | at all times, Continuous, HOB flat, neck midline for ischemic stroke Bedrest

T;N, at all times | complete, Continuous, HOB up 30-45 degrees for venous thrombosis or ICH

Diet NPO

T;N, NPO except for medications Respiratory Therapy Oxygen

T;N, Maintain Sp02 > 95, Continuous IV Solutions sodium chloride 0.9% (Bolus)

20 ml/kg, IV, ONCE, Inj, infuse over 60 min(s), 10 mL/kg for neonates Comments: 10 mL/kg for neonates

Sodium Chloride 0.9% 1,000 ml, IV, ml/hr

D5NS 1,000 ml, IV, ml/hr

Medications acetaminophen (pediatrics)

20 mg/kg, rectal, ONCE, Supp, round to divisible dose (half or whole supp) of 120mg, 325mg or 650mg ; Do not exceed adult dosing

Comments: For T>38Cround to divisible dose (half or whole supp) of 120mg, 325mg or 650mg ; Do not exceed adult dosing

lorazepam (pediatrics) 0.1 mg/kg, IV, ONCE, Inj

Comments: max = 4mg lorazepam

page 5 of 48


1 mg, IV, ONCE, Inj (DEF)* 2 mg, IV, ONCE, Inj

fosphenytoin (pediatrics) 15 mg/kg, IV, ONCE, Inj Syringe, loading dose, mg/kg = mg PE/kg, goal range = 10-20 mcg/ml

Comments: max = 1500mg PE levETIRAcetam (pediatrics)

20 mg/kg, IV, ONCE, Inj Comments: max = 4500mg

aspirin 5 mg/kg, PO, ONCE, Chewable Tab

Comments: round to nearest 81mg tablet or half tab, max = 324mggive only if head CT is negative for ICH or suspicious for ischemic stroke

Laboratory CBC

ST collect Venous Bld, T;N, MUST ORDER CBC WITH THIS Auto Differential

ST collect Venous Bld, T;N CMP

ST collect Venous Bld, T;N EPOC POC

T;N, Stat, EPOC All Tests INR / PT

ST collect Venous Bld, T;N PTT

ST collect Venous Bld, T;N Fingersticks POC

T;N, Stat, notify MD if glucose < 60 or > 150 mg/dL Diagnostic Tests

MRI is the preferred imaging study. Consider sedation. If MRI studies cannot be done within 30-60 minutes, order head CT without IV contrast.(NOTE)*

EKG POC T;N, Stat

EKG. T;N, Stat

MRA-Carotids W Contrast T;N Stat, Transport Mode: STRETCHER

MRA-Head/Brain WO Contrast T;N Stat, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg

MRI-Head/Brain WOW Contrast T;N Stat, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg

MRV-Head/Brain WOW Contrast T;N Stat, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg

CT-Head/Brain WO IV Contrast T;N Stat, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg

*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

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Rx - This component is a prescription SUB - This component is a sub phasetextControl

page 7 of 48

9.23.2020 PowerPlan Request Item #2 P 1 of 7

Printed on: 08/26/20 09:25

Unique Plan Description: Brain Dead Organ Donor Plan Selection Display: Brain Dead Organ Donor Plan Synonyms: Brain Dead PlanType: Medical Version: 4 Begin Effective Date: 06/25/2020 06/25/20 12:25 End Effective Date: Current Available at: Carroll Hospital Lev Spec Hosp NWH SHB Brain Dead Organ Donor Admit/Diagnosis Transfer Care to Living Legacy Foundation

T;N Diagnosis

T;N, Brain Death; organ donor Vital Signs Vital Signs

T;N, for 5 day(s), Q1H and record - Including blood pressure, temperature, heart rate, SaO2, and Notify on site Coordinator if SBP < 90; MAP < 65

Central Venous Pressure Monitoring T;N, q1h for 5 day(s)

Patient Care Orders Turn and Position

T;N, Q2H for 5 day(s) I&O Strict

T;N, for 5 day(s), Q1H Total & Record Trendelenberg Reverse

T;N, for 5 day(s), at 30 degrees if BP Tolerates Miscellaneous Nursing Order (NON-Medication)

T;N, Fill Living Legacy Foundation blood tubes for serologies Miscellaneous Nursing Order (NON-Medication)

T;N, Discontinue all previous medications with the exception of GI Prophylaxis and Vasoactives and Antibiotics

Miscellaneous Nursing Order (NON-Medication) T;N, Maintain MAP of 65 or greater. Notify Living Legacy Foundation Coordinator if MAP less than 65

or greater than 85 Transfuse Red Cells

T;N Transfuse Thawed Plasma

T;N Saline Lock IV with Routine Flushes per Protocol

T;N, Nurse to place protocol flush orders Central Line Care & Flushes

***Arterial and Central Line Care & Flushes***(NOTE)* Central Line Bundle, Adult(SUB)* Arterial Line Insert & Maintain (Adult)(SUB)* Respiratory Therapy Suction

T;N, for 5 day(s), PRN Chest Physiotherapy

T;N, Q4H, 5, day(s)

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Printed on: 08/26/20 09:25

Chest PT (by Nursing) T;N, Q4H, 5, day(s)

ABG Draw T;N, ST, PRN

IV Solutions sodium chloride 0.9% (Bolus)

ml, IV, Inj, Duration = 5 day(s) Dextrose 5% in Water

1,000 ml, IV, Duration = 5 day(s), ml/hr Dextrose 5% with 0.45% NaCl

1,000 ml, IV, Duration = 5 day(s), ml/hr Sodium Chloride 0.9%

1,000 ml, IV, Duration = 5 day(s), ml/hr Sodium Chloride 0.45%

1,000 ml, IV, Duration = 5 day(s), ml/hr Dextrose 5% with 0.9% NaCl

1,000 ml, IV, Duration = 5 day(s), ml/hr D5W & sodium bicarbonate 150 meq (IVS)* Dextrose 5% in Water

1,000 ml, IV, Duration = 5 day(s), ml/hr, Start T;N sodium bicarbonate

150 mEq Medications SoluMedrol

2 gm, IV, ONCE, Inj, Duration = 5 day(s) (DEF)* 1 gm, IV, Q12HV, Inj, Duration = 5 day(s)

levothyroxine 20 mcg, IV, ONCE, Inj, Duration = 5 day(s), bolus dose

labetalol 20 mg, IV, Q15 mins, PRN, Other, see comments, Inj, Duration = 5 day(s)

furosemide 40 mg, IV, Q4H, PRN, Other, see comments, Inj, Duration = 5 day(s)

Comments: at the direction of Living legacy clinical coordinator hydrALAzine

20 mg, IV, Q1H, PRN, Other, see comments, Inj, Duration = 5 day(s) ICU Electrolyte Replacement Nursing Protocol(SUB)* ICU Electrolyte Replacement Protocols (NW)(SUB)* CCU - Electrolyte Replacement NURSING Protocol (CH)(SUB)*

Hyperkalemia--For K> 5.8mmol/L(NOTE)* Dextrose 50%

50 ml, IV, ONCE, STAT, Inj Comments: Hyperkalemia--For K> 5.8mmol/L

sodium bicarbonate 50 mEq, IV, ONCE, STAT, Inj

Comments: Hyperkalemia--For K> 5.8mmol/L insulin regular

15 units, IV, ONCE, STAT, Inj Comments: Hyperkalemia--For K> 5.8mmol/LDispose unused drug in black container

Glucose Management Dextrose 50%

50 ml, IV, as directed, PRN, Other, see comments, Inj, Duration = 5 day(s), if glucose <= 75mg/dL Dextrose 10%

250 ml, IV, as directed, PRN, Other, see comments, Inj, Duration = 5 day(s)

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Comments: infuse over 15 minutes if glucose <= 75mg/dL insulin aspart, sliding scale

sliding scale, IV, as directed, PRN, Other, see comments, Inj, Duration = 5 day(s) Comments: if glucose remains > = 250 mg/dL after removing all dextrose from IVF, start sliding scale; 250-300 give 5 units, 301-350 give 10 units, 351-400 give 15 units, 401-450 give 20 units, if > 451 order insulin drip at 0.1 units/kg/hrDispose unused drug in black container

insulin drip standard (IVS)* Sodium Chloride 0.9%

250 ml, IV, Duration = 5 day(s), Start T;N Comments: Dispose unused drug in black container

insulin regular (for standard drip) 250 units, unit/hour

**insulin drip (CH) (regular) standard** (IVS)* Sodium Chloride 0.9%

100 ml, IV, Duration = 5 day(s), Start T;N insulin regular

100 units, unit/hour Antibiotics Ancef

1 gm, IV, Q8H, Inj Unasyn

1.5 gm, IV, Q6H, Inj Comments: for CrCl >/= 30 mL/min

clindamycin 600 mg, IV, ON CALL, Therapeutic rationale= If PCN allergy, Inj

Zosyn, Adult(SUB)* Piperacillin-Tazo (Zosyn) IV - Adult (CH)(SUB)* levoFLOXacin, Adult(SUB)* Vancomycin IV(SUB)* Vancomycin - IV - Pharmacy to Dose (CH)(SUB)* Vasoactive Agents DOPamine drip standard (Critical Care Only) (IVS)* premix diluent (titrate)

250 ml, IV, Start T;N, Titrate By = 2.5 mcg/kg/min, Titrate Frequency (min)= 5, Maximum Dose = 50 mcg/kg/min

Comments: Adjust titration dose according to patient response DOPamine infusion 400 mg/ 250 mL

400 mg, 0.5, mcg/kg/min DOBUTamine drip standard (Critical Care Only) (IVS)* premix diluent (titrate)

250 ml, IV, Start T;N, Goal = Living Legacy will titrate, Titrate By = 0.5 mcg/kg/min, Titrate Frequency (min)= 5, Maximum Dose = 2.5 mcg/kg/min

Comments: Adjust titration dose according to patient response, under the direction of the clinical coordinator

DOBUTamine infusion 500 mg/250 mL 500 mg, 0.5, mcg/kg/min

nitroglycerin drip standard (Critical Care Only) (IVS)* premix diluent (titrate)

250 ml, IV, Start T;N, standard concentration, Titrate By = 5 mcg/min, Titrate Frequency (min)= 5, Maximum Dose = 200 mcg/min

Comments: Adjust titration dose according to patient response, dispose unused drug in black container

nitroglycerin infusion 50 mg/250mL 50 mg, mcg/min

nitroprusside drip standard (IVS)*

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Printed on: 08/26/20 09:25

Dextrose 5% in Water (titrate) 250 ml, IV, Titrate By = 0.5 mcg/kg/min, Titrate Frequency (min)= 5, Maximum Dose = 10

mcg/kg/min Comments: Adjust the drip as needed based on patient condition

nitroprusside 50 mg, mcg/kg/min

norepinephrine drip standard (IVS)* Dextrose 5% in Water (titrate)


Comments: Adjust titration dose according to patient response norepinephrine

4 mg, mcg/min Norepinephrine drip 8/500 standard CH (IVS)* premix diluent (titrate)

500 ml, IV, Start T;N, Titrate By = 2 mcg/min, Titrate Frequency (min)= 5, Maximum Dose = 50 mcg/min

Norepinephrine infusion 8 mg/500ml 8 mg, mcg/min

phenylephrine drip standard (IVS)* Dextrose 5% in Water (titrate)


Comments: Adjust titration dose according to patient response phenylephrine

100 mg, mcg/min EPINEPHrine drip standard (IVS)* Dextrose 5% in Water (titrate)


Comments: Adjust titration dose according to patient response EPINEPHrine

4 mg, mcg/min vasopressin drip standard (for Organ Donor Management) (IVS)* Dextrose 5% in Water (titrate)

100 ml, IV, Start T;N, Goal = Living Legacy will titrrate, Titrate By = 0.04 unit/min, Titrate Frequency (min)= 5, Maximum Dose = 1 unit/min

Comments: Adjust titration dose according to patient response vasopressin

60 units, 0.04, unit/min levothyroxine drip standard (IVS)* Sodium Chloride 0.9%

200 ml, IV, Start T;N levothyroxine IV

200 mcg, 10, mcg/hour niCARDipine drip standard (Carroll) (IVS)* premix diluent (titrate)

200 ml, IV, Start T;N, Titrate By = 2.5 mg/hour, Titrate Frequency (min)= 5, Maximum Dose = 15 mg/hour

niCARDipine infusion 20mg/200ml 20 mg, 5, mg/hour

niCARDipine drip standard (NS)(Critical Care Only) (IVS)* sodium chloride 0.9% (titrate)

250 ml, IV, Start T;N, Titrate By = 2.5 mg/hour, Titrate Frequency (min)= 5, Maximum Dose = 15 mg/hour

niCARDipine

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Printed on: 08/26/20 09:25

25 mg, 5, mg/hour Miscellaneous PRN Medications Hespan

500 ml, IV, ONCE, NOW, Inj, ml/hr Comments: May repeat as needed to max 20ml/kg in 24hrs under the direction of clinical coordinator

albumin human 5% intravenous solution 25 gm, IV, as directed, PRN, Other, see comments, Inj

Comments: under direction of clinical coordinator albumin human 25% intravenous solution

25 gm, IV, as directed, PRN, Other, see comments, Inj Comments: under direction of clinical coordinator

phytonadione 10 mg, IV, ONCE, PRN, Other, see comments, Inj

Laboratory Blood Bank ABO/Rh

ST collect Venous Bld, T;N, *Must also order Antibody Screen-Gel, 5 day(s) Antibody Screen-Gel

ST collect Venous Bld, T;N, *Must also order ABO/Rh, 5 day(s) Request Plasma

T;N, ST Request Red Blood Cells

T;N, ST Hematology CBC

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Auto Differential

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Chemistry Panels BMP

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) CMP

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Hepatic Function Panel

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s), if Liver Donor Chemistry Osmolality, Serum

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Troponin I, Plasma

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Troponin T

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) CPK

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s), if Heart Donor Magnesium level

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s), if Heart Donor Phosphorus level

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Protein

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Amylase level

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s), if Pancreas Donor

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Printed on: 08/26/20 09:25

Lipase level Timed Study collect Venous Bld, T;N, q6hr, 5 day(s), if Pancreas Donor

Total Bilirubin Timed Study collect Venous Bld, T;N, q6hr, 5 day(s)

Calcium Ionized Level Timed Study collect Venous Bld, T;N, q6hr, 5 day(s)

Lactate (Single - NOT for Suspected Sepsis) Timed Study collect Venous Bld, T;N, q6hr, 5 day(s)

GGT Timed Study collect Venous Bld, T;N, q6hr, 5 day(s)

LDH Timed Study collect Venous Bld, T;N, q6hr, 5 day(s)

Coagulation PT/ INR

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) PTT

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Fibrinogen Activity

Timed Study collect Venous Bld, T;N, q6hr, 5 day(s) Urine Studies Osmolality, Urine

T;N, Urine, RT collect, *re-order and collect q6h ***Urinalysis with Micro with reflex to culture NOW***(NOTE)*

UA Micro ST collect Urine, T;N

Urinalysis w/Reflex to Urine Culture ST collect Urine, T;N

***Urinalysis with Micro with reflex to culture Every Morning***(NOTE)* UA Micro

RT collect Urine, T;N, q6am Urinalysis w/Reflex to Urine Culture

RT collect Urine, T;N, q6am Microbiology Blood Cultures x 2(SUB)* Blood Culture

T;N, Blood, RT, Peripheral (Recommended), x2, 15 minutes apart Blood Culture

T;N, Blood, RT, Peripheral (Recommended), x2, 15 minutes apart Culture / Sputum w/ Gram Stain

T;N, ST, With clean Ballard Urine Culture

T;N, Urine Catheter, ST Diagnostic Tests Echo Transesophageal with Probe TEE (CH)(SUB)* Echo Transesophageal (TEE) PowerPlan(SUB)* X-Rays XR-Chest Portable

T;N Routine, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: r/o infiltrates XR Chest 1V (Ambulatory)

T;N Bronchoscopy w Image

If Lung Donor EKG

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Printed on: 08/26/20 09:25

EKG POC T;N, Routine, QDay for 5 day(s)

EKG POC T;N, Routine, PRN

EKG. T;N, Routine, QDay for 5 day(s)

EKG. T;N, Routine, PRN

EKG T;N, Routine, QDay for 5 day(s), eval for organ donation

EKG T;N, Routine, PRN

Cardiac Echocardiogram

T;N Routine, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: eval LV function CP-Echocardiogram

T;N Routine, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: eval LV function Echo Complete TTE (CH)

T;N Consults Cardiovascular Procedure

T;N, Cardiac Cath Procedure, Right Cardiovascular Procedure

T;N, Cardiac Cath Procedure, Left Cardiovascular Procedure

T;N, Cardiac Cath Procedure, Bilat *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 phasetextControl

page 14 of 48


Unique Plan Description: Heart Failure Admission (Inpatient or Observation) Plan Selection Display: Heart Failure Admission (Inpatient or Observation) Plan Synonyms: CHF Admission (Inpatient or Observation) PlanType: Medical Version: 1 Begin Effective Date: 03/07/2017 03/07/17 08:10 End Effective Date: Current Available at: Carroll Hospital NWH SHB Heart Failure Admission (Inpatient or Observation) Admit/Diagnosis Admit

T;N Admit to

T;N, Inpatient Admit to Inpatient:

T;N Admit to Inpatient (CH)

T;N, Medicine, Medical/Surgery Diagnosis

T;N, Heart Failure Admitting Physician.

T;N Attending Physician.

T;N Consulting Physician

T;N Code Status Code Status

T;N (DEF)* T;N, PLEASE COMPLETE MOLST / DNR ORDER FORM, Consider AICD Deactivation

Patient Alerts Notify MD if

Notify MD for urinary output <1000mL in 2 hours (or <500mL if cre >2.5) after IV diuretics


T;N, Q8H (DEF)* T;N, Q4H

Notify Provider for VS's of: T;N, Temp > 38.0 C, HR> 120, HR< 50, SBP> 180, SBP< 90, RR> 24, RR< 8, 02 Sat< 92%

Telemetry/Cardiac Monitoring PowerPlans(SUB)* Pulse Ox (Pt Care)

T;N, Check ambulatory RA pulse ox prior to discharge. Notify MD if <89% Activity

Consider early PT/OT consult to avoid excessive length of stay (consult found in consult section below)(NOTE)*

OOB T;N, as tolerated

Bedrest

page 15 of 48


T;N Diet NPO

T;N (DEF)* T;N, NPO except for medications T;N, After Midnight

Restricted Diet T;N, Diabetic-CHO per Meal: Carbohydrate Controlled Diet (4CHO/meal), 2g Sodium (DEF)* T;N, 2g Sodium

Patient Care Orders Reminder: Communicate net negative goals to nursing.(NOTE)*

Intake and Output T;N, STRICT

Weight T;N, QDay, Standing as tolerated

TED Stockings (Pt Care) T;N, Apply compression stockings/ace bandages to LE (unless skin breakdown or suspecrted acute DVT)

If patient meets criteria for sepsis draw blood listed in the Sepsis Protocol Lab Orders PowerPlan T;N

VTE Prophylaxis Medical VTE Prophylaxis(SUB)* Respiratory Therapy Oxygen Therapy Protocol

T;N Oxygen (NW)(LSH)(CH)

T;N, Routine, via Nasal Cannula Cough and Deep Breathe

T;N BIPAP

T;N Medications Loop Diuretics

For patients who have been on loop diuretic therapy as an outpatient, the total daily dose should be changed to an oral furosemide equivalent and administered IV at 1-2.5 times the total daily dose (ie 40mg po lasix = 1mg po Bumex = 20mg torsemide)(NOTE)*

furosemide 40 mg, IV, ONCE, STAT, Inj (DEF)* 80 mg, IV, ONCE, STAT, Inj

furosemide 40 mg, IV, QDay, Inj (DEF)* 40 mg, IV, BID, Inj 80 mg, IV, QDay, Inj 80 mg, IV, BID, Inj

bumetanide 1 mg, IV, ONCE, STAT, Inj (DEF)* 1 mg, IV, BID, Inj 1 mg, IV, QDay, Inj 2 mg, IV, BID, Inj 2 mg, IV, QDay, Inj

AngiotensinReceptorNeprilysinInhibitor

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Reminder: ACC/AHA guidelines recommend RAS-inhibition with ACE inhibitors or ARBs or ARNI in conjunction with evidence-based beta-blockers to reduce morbidity and mortality in patients with chronic HFrEF to reduce morbidity and mortality, unless contraindicated. Patients with chronic HFrEF NYHA class II or III who tolerate ACE inhibitors or ARBs can be switched to an ARNI to further reduce morbidity and mortality. Can consider in hemodynamically stable patients with SBP>100. Do not use with ACE inhibitor or ARB. Do not use in patients with documented allergy to ACE inhibitor or ARB or history of angioedema.(NOTE)*

Entresto 24 mg-26 mg oral tablet 1 tab(s), PO, BID, Tab, Recommended starting dose for patient's with eGFR < 30 mL/min/1.73m2, moderate hepatic impairment, ACE-I/ARB naive or previously taking low-doses of these agents

Comments: Hold for SBP < 90 or DBP < 60Ensure patients switching from an ACE-I undergo a 36hr washout period prior to starting Entresto to avoid increased risk of angioedema

Entresto 49 mg-51 mg oral tablet 1 tab(s), PO, BID, Tab


Entresto 97 mg-103 mg oral tablet 1 tab(s), PO, BID, Tab


Angiotensin Receptor Blockers candesartan

4 mg, PO, QDay, Tab (DEF)* 8 mg, PO, QDay, Tab 16 mg, PO, QDay, Tab 32 mg, PO, QDay, Tab

valsartan 40 mg, PO, QDay, Tab (DEF)* 80 mg, PO, QDay, Tab 160 mg, PO, QDay, Tab 320 mg, PO, QDay, Tab

losartan 25 mg, PO, QDay, Tab (DEF)* 50 mg, PO, QDay, Tab 100 mg, PO, QDay, Tab

Angiotensin-Converting Enzyme Inhibitors Reminder: All patients with asymptomatic or symptomatic left ventricular dysfunction should be started on an ACE Inhibitor(NOTE)*

lisinopril 5 mg, PO, QDay, Tab (DEF)* 10 mg, PO, QDay, Tab 20 mg, PO, QDay, Tab 40 mg, PO, QDay, Tab

Beta Blockers Do not order metoprolol tartrate. Metoprolol succinate dose is equivalent to total daily dose of metoprolol tartrate.(NOTE)*

carvedilol 3.125 mg, PO, Q12H, Tab (DEF)* 6.25 mg, PO, Q12H, Tab

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12.5 mg, PO, Q12H, Tab 25 mg, PO, Q12H, Tab

metoprolol extended release 12.5 mg, PO, QDay, ER Tab (DEF)* 25 mg, PO, QDay, ER Tab 50 mg, PO, QDay, ER Tab 100 mg, PO, QDay, ER Tab 200 mg, PO, QDay, ER Tab

Aldosterone Antagonists Reminder: ACC/AHA guidelines recommended the use of low doses of spironolactone (12.5 to 25 mg/day) in patients with recent or recurrent NYHA class II-IV heart failure, an ejection fraction < 35%, a serum creatinine less than 2.5 mg/dL, and a serum potassium less than 5 meq/L.(NOTE)*

spironolactone 12.5 mg, PO, QDay, Tab (DEF)* 25 mg, PO, QDay, Tab

Nitrates Reminder: ACC/AHA guidelines recommend the use of hydralazine with nitrates in patients who self-identify as African American with NYHA class III-IV HFrEF receiving optimal therapy with ACE-inhibitors and beta-blockers, unless contraindicated. The combination of hydralazine/isosorbide dinitrate can also be used to reduce morbidity or mortality in patients with symptomatic HFrEF who cannot be given an ACE-inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency unless contraindicated(NOTE)*

BiDil(SUB)* Stool Softeners/Laxatives docusate

100 mg, PO, BID, PRN, constipation, Capsule Senokot

2 tab(s), PO, Qbedtime, PRN, constipation, Tab bisacodyl

10 mg, rectal, QDay, PRN, constipation, Supp Miscellaneous acetaminophen

650 mg, PO, Q4H, PRN, Tab Comments: do NOT exceed TOTAL acetaminophen daily dose of 4 grams/24 hours

guaifenesin 200 mg, PO, Q4H, PRN, cough, Liq

Mylanta 30 ml, PO, Q6H, PRN, dyspepsia, Susp

Laboratory Chemistry ProBNP

Venous Bld, T;N, if not done in ED Magnesium level

Venous Bld, T;N, if not done in ED Magnesium level

Venous Bld, T+1;N Troponin I, Plasma

Timed Study | Venous Bld, T;N, q4hr, 12 hr TSH Third Generation

Venous Bld, T;N TSH Third Generation

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Venous Bld, T+1;N BMP

Venous Bld, T;N, if not done in ED BMP

Venous Bld, T;N, daily CMP

Venous Bld, T;N, if not done in ED Note: Lipid Panel includes Total Cholesterol, HDL, Triglycerides, and Calculated LDL. LDL Direct will be added by reflex when triglycerides are > 400.(NOTE)*

Lipid Panel ($,1d) RT | Venous Bld, T;N

Lipid Panel ($,1d) RT | Venous Bld, T+1;N

Hematology CBC

Venous Bld, T;N, if not done in ED CBC

RT | Venous Bld, T+1;N PT ($,1d)

Venous Bld, T;N, if not done in ED PTT

Venous Bld, T;N, if not done in ED PTT

RT | Venous Bld, T+1;N Diagnostic Tests EKG

T;N, Routine EKG POC

T;N EKG.

T;N Order Echo only if no record of LV function assessment in Cerner or noted in outpatient records within 90 days or if sudden change in patient's condition or if indicated for other reasons(NOTE)*

CP-Echocardiogram/Cardiac Doppler T;N Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg

Echocardiogram (TTE) PowerPlan(SUB)* Echo Complete TTE (CH)

T;N, Congestive heart failure, unspecified, Referred to Provider (Name): XR-Chest 2V

T;N, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg, Reason: Heart failure XR Chest 2V (Ambulatory) Consults Heart Failure Navigator

T;N Refer to Cardiac Rehab Phase II Program

T;N Consult Care Solutions (Disease Management)

T;N, CHF Heart Failure Transitional Care

T;N Cardiology - Sinai Heart Failure Clinic - Referral

T;N, Karen Stewart; Barbara Klimuszka Cardiology - Northwest Heart Failure Clinic - Referral

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T;N, Rebecca Aiken; Barbara Klimuszka Care Mgmt Med Surg Inpt Consult

T;N Care Management Consult (NW)

T;N Consult-Nutrition

T;N, if first time HF patient OT Consult / Evaluate and Treat-Acute Hosp

T;N, Dx: Heart failure PT Consult / Evaluate and Treat-Acute Hosp

T;N, Dx: Heart failure Physical Therapy Eval & Treat-Acute Hosp

T;N Pastoral Care Consult

T;N Home Health Care

T;N Consult - Cardiology

T;N Consult - Cardiology (SHB)

T;N Reminder: consider palliative care consult if patient has had more than 3 admissions, advanced HF, multi organ dysfunction, or an end stage condition.(NOTE)*

Consult-Palliative Care T;N

Consult - Chronic Disease Management T;N

Other Patient Education-Heart Failure

T;N, QDay Patient Educator Consult

T;N, CHF Patient Education-Smoking Cessation

T;N *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 phasetextControl

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9.23.2020 PowerPlan Request Item #4 P 1 of 3 Unique Plan Description: ED Adult: Asthma Exacerbation Plan Selection Display: ED Adult: Asthma Exacerbation PlanType: Medical Version: 1 Begin Effective Date: 08/21/2020 08/21/20 14:22 End Effective Date: Current Available at: Carroll Hospital NWH SHB ED Adult: Asthma Exacerbation Vital Signs

BEST PRACTICE: Maintain MAP > 65 mmHg +/- SBP > 90 mmHg, urine output >/= 0.5 ml/kg/hr(NOTE)*

Vital Signs per Acuity Pulse Ox (Pt Care)

T;N, with Vital Signs Notify Provider for VS's of:

T;N, Temp > 38, HR> 120, HR< 50, SBP> 180, SBP< 90, RR> 24, RR< 8, 02 Sat< 92 Patient Care Orders Saline Lock IV with Routine Flushes per Protocol

T;N Respiratory Therapy Oxygen Therapy Protocol

T;N Oxygen (NW)(LSH)(CH)

T;N, Stat, Continuous Peak Flows

T;N, Before and After each treatment ABG Draw

T;N, ST EPOC POC

T;N, Stat, EPOC Blood Gases Medications Bronchodilators

Albuterol Continuous neb(NOTE)* albuterol neb 2.5mg

2 neb, inhaled, ONCE, STAT, Neb, Duration = 1 hr (DEF)* Comments: 2 nebs = 5 mg, dose to be delivered over 1 hour at 5 mg/hr

4 neb, inhaled, ONCE, STAT, Neb, Duration = 1 hr Comments: 4 nebs = 10 mg, dose to be delivered over 1 hour at 10 mg/hr

6 neb, inhaled, ONCE, STAT, Neb, Duration = 1 hr Comments: 6 nebs = 15 mg, dose to be delivered over 1 hour at15 mg/hr

8 neb, inhaled, ONCE, STAT, Neb, Duration = 1 hr Comments: 8 nebs = 20 mg, dose to be delivered over 1 hour at 20 mg/hr

Other Bronchodilators(NOTE)* albuterol-ipratropium inhalation solution

3 ml, inhaled, ONCE, STAT, Neb (DEF)* Comments: Max 6 doses in 24 hour period

3 ml, inhaled, ONCE, PRN, shortness of breath/wheezing, Neb Comments: Max 6 doses in 24 hour period

albuterol neb 2.5mg 1 neb, Neb, inhaled, ONCE, STAT (DEF)*

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1 neb, inhaled, ONCE, PRN, shortness of breath/wheezing, Neb albuterol MDI

2 puff(s), inhaled, ONCE, STAT, Oral Inhaler (DEF)* Comments: Seal unused drug in ziplock bag, return to pharmacy

2 puff(s), inhaled, ONCE, PRN, shortness of breath/wheezing, Oral Inhaler Comments: Seal unused drug in ziplock bag, return to pharmacy

racemic EPINEPHrine 2.25% neb 1 neb, Neb, inhaled, ONCE, STAT

EpiPen 0.3 mg, IM, ONCE, STAT, Inj

EPINEPHrine (anaphylaxis) 0.3 mg, IM, ONCE, STAT, Inj

Corticosteroids methylPREDNISolone

40 mg, IV, ONCE, Start T;N, STAT, Inj (DEF)* 60 mg, IV, ONCE, Start T;N, STAT, Inj

dexameTHASONE 8 mg, IV, ONCE, STAT, Inj

predNISone 60 mg, PO, ONCE, STAT, Tab

Miscellaneous magnesium sulfate

2 gm, IV, ONCE, STAT, Inj, infuse over 20 min(s) Comments: infuse over 20 min

Laboratory ED Addon Lab

T;N, Stat Chemistry BMP

ST | Venous Bld, T;N CMP

ST | Venous Bld, T;N Hematology

***All CBC's drawn in the Carroll ED will be placed with an Auto Differential***(NOTE)* CBC

ST | Venous Bld, T;N Diagnostic Tests EKG

T;N, Stat EKG.

T;N, Stat EKG POC

T;N, Stat XR-Chest 2V

T;N Stat, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg, Reason: Respiratory Distress/ Failure

XR-Chest Portable T;N Stat, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: Respiratory Distress/ Failure

Other Patient Education-Smoking Cessation

T;N Patient Teaching (NW)

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T;N, Instruct on: Asthma, Use of Inhalers Patient Education

T;N, Instruct on: Asthma, Use of Inhalers *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 phasetextControl

page 23 of 48


Unique Plan Description: Ortho Post Op, Adult with PCA POWERPLAN Plan Selection Display: Ortho Post Op, Adult with PCA POWERPLAN PlanType: Medical Version: 2 Begin Effective Date: 12/18/2014 12/18/14 13:39 End Effective Date: Current Available at: NWH SHB Ortho Post Op, Adult with PCA POWERPLAN Admit/Diagnosis Admit

T;N Admit to

T;N, Inpatient, 3CD - Surgical/Orthopedic Admit to Inpatient (CH)

T;N Diagnosis

T;N Procedure (Patient Care)

T;N Admitting Physician.


T;N Consulting Physician

T;N Resident/PA/NP

T;N Code Status Resuscitation Status

T;N, Full Resuscitation (DEF)* T;N, Do Not Resuscitate, Sinai and Carroll Only: PLEASE COMPLETE THE DNR / MOLST ORDER FORM

Patient Alerts Hip Precautions

T;N No Pillows under OP Knee

T;N, if post-op TKA or ACL Vital Signs Vital Signs with Pulse Oximetry

T;N, Q1H for 4 hr Vital Signs with Pulse Oximetry

T;N+240, Q2H for 8 hr Vital Signs with Pulse Oximetry

T;N+720, Q4H, until pump is discontinued, then Q8h Vital Signs with Pulse Oximetry

T;N, Q8H Notify Provider for VS's of:

T;N, Temp > 38.5, HR> 120, HR< 50, SBP> 180, SBP< 90, RR> 24, RR< 10, 02 Sat< 90, Sedation Level > 4 Pain Score > 5

Neurovascular Checks T;N, Right Upper Extremity, Q4H, x 24 hrs...then Q8H (DEF)* T;N, Right Lower Extremity, Q4H, x 24 hrs...then Q8H T;N, Left Upper Extremity, Q4H, x 24 hrs...then Q8H T;N, Left Lower Extremity, Q4H, x 24 hrs...then Q8H

Neurovascular Checks T;N, Right Upper Extremity, Q8H (DEF)* T;N, Right Lower Extremity, Q8H T;N, Left Upper Extremity, Q8H

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T;N, Left Lower Extremity, Q8H Any increase in PCA basal rate or administration of a bolus dose must return to most frequent monitoring schedule(NOTE)*

Activity OOB

T;N, in AM, POD#1 (DEF)* T;N, ad lib T;N, as tolerated, ambulate in hall

Bedrest T;N

Flat in Bed T;N, May log roll (DEF)* T;N, No log roll T;N, When brace is off

Weight Bearing Status T;N, LE: Weight Bearing as Tolerated, With Assistive Device (DEF)* T;N, LE: No Weight Bearing., Left, with assistive device T;N, LE: No Weight Bearing., Right, with assistive device T;N, LE: Partial Weight Bearing, Left, with assistive device T;N, LE: Partial Weight Bearing, Right, with assistive device T;N, LE: Touch Toe Weight Bearing, Left, with assistive device T;N, LE: Touch Toe Weight Bearing, Right, with assistive device T;N, LE: 50%, Left, with assistive device T;N, LE: 50%, Right, with assistive device

Elevate T;N, Head of Bed

Bedside Commode (Nursing) T;N, 3 in 1

Diet Dietitian to Manage Medical Nutrition Therapy

T;N NPO

T;N, NPO except for medications (DEF)* T;N, No exceptions T;N, NPO except for ice chips

Restricted Diet T;N, House Menu, Clear Liquid, When bowel sounds present. (DEF)* T;N, Room Service

Regular Diet T;N, Room Service

Regular Diet T;N, Room Service

Restricted Diet T;N, Room Service (DEF)* T;N, House Menu, Clear Liquid

Patient Care Orders Surgical VTE Prophylaxis(SUB)* Intake and Output

T;N, Q8H Weight

T;N, QDay Drain Maintenance

T;N, Drain type: Hemovac, empty and record amount q4h, for 8, Hr(s) Drain Maintenance

T;N+480, Drain type: Hemovac, empty and record amount q8h, for 16, Hr(s) Drain Maintenance

T;N+720, Drain type: Hemovac, empty and record amount q12h Reinfusion Drain Per Policy (Ortho)

T;N Foley Catheter Maintenance

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T;N, Discontinue orders: Remove per nursing protocol Straight Catheterize

T;N, If no void in next 8 hrs, and notify H.O. Incentive Spirometry (Pt Care)

T;N Ice Packs

T;N, Continuous, to surgical/injury site (DEF)* T;N, Intermittent, to surgical/ injury site

Elevate T;N, Affected Extremity on two pillows (DEF)* T;N, Foot of Bed, Bilateral Lower Extremities, above level of heart

Pillows T;N, place one pillow under elbow

Dressing Change / Wound Care T;N, Dry sterile dressing, QDay, After first dressing change by surgery. May also change prn. (DEF)* T;N, Dry sterile dressing, QDay, Ortho/Neuro service to change first dressing

Saline Lock IV with Routine Flushes per Protocol T;N

Central Line Care & Flushes Central Line Bundle, Adult(SUB)* Equipment Consult Orthopedic Technician

T;N, Routine, Trapeze (DEF)* T;N, Routine, CPM Machine

Trapeze T;N, Safety checks every shift.

Abduction Pillow T;N, Not Applicable

Knee Immobilizer T;N, Left, At All Times (DEF)* T;N, Right, At All Times T;N, When Out of Bed T;N, When In Bed

CPM 0 Degrees - T;N, Increase by 10 degrees twice a day; maximum goal =

Cervical Collar. T;N

Elastic Back Support T;N, Not Applicable

Wrist Splint T;N

Ankle Brace Honeycomb T;N

Ankle Brace Training T;N

Arm Sling T;N

Arm Elevator T;N

Bledsoe Knee Brace (Post-Op) T;N

Bledsoe Boot High Top T;N

Bledsoe Elbow Brace T;N

IV Solutions Lactated Ringers

1,000 ml, IV, ml/hr Dextrose 5% with 0.45% NaCl

page 26 of 48


1,000 ml, IV, ml/hr Dextrose 5% with 0.9% NaCl

1,000 ml, IV, ml/hr Sodium Chloride 0.45%

1,000 ml, IV, ml/hr Sodium Chloride 0.9%

1,000 ml, IV, ml/hr Dextrose 5% & 0.45% NaCl 1000ml & KCL 20 meq (IVS)* Premix Diluent D5&0.45NaCl

1,000 ml, Inj, IV Dextrose 5% w/ 0.45%NaCl and KCl 20mEq/L

20 mEq, Every Bag Dextrose 5% & 0.45% NaCl 1000ml & KCl 40meq (IVS)* Premix Diluent D5&0.45NaCl


40 mEq, Every Bag Sodium chloride 0.9% 1000ml & KCl 20 meq (IVS)* Sodium Chloride 0.9%

1,000 ml, IV, ml/hr potassium chloride

20 mEq Medications PCA, Peripheral Adult(SUB)* PCA, Peripheral Adult (NW)(SUB)* Antibiotics ceFAZolin

2 gm, IV, Q8HV, Indication = Surgical site infection prophylaxis, duration = 2 dose(s), Inj If penicillin allergic (select ONE) :(NOTE)*

clindamycin 600 mg, IV, Q8HV, Indication = Surgical site infection prophylaxis, duration = 2 dose(s), Inj

vancomycin 1 gm, IV, ONCE, Indication = Surgical site infection prophylaxis

Analgesics: Non-Opioids acetaminophen

650 mg, PO, Q4H, PRN, pain mild (pain score 1-3), Tab Comments: do NOT exceed TOTAL acetaminophen daily dose of 4 grams/24 hours

acetaminophen 650 mg, PO, Q4H, PRN, pain moderate-severe (pain score 4-10), Tab

Comments: for adjunctive pain therapy, do NOT exceed TOTAL acetaminophen daily dose of 4 grams/24 hours

acetaminophen 650 mg, PO, Q4H, PRN, temperature greater than 38.5 C, Tab

Comments: do NOT exceed TOTAL acetaminophen daily dose of 4 grams/24 hours ** Discontinue other NSAIDS **(NOTE)* Celecoxib, Ibuprofen or Ketorolac MUST be approved by surgeon:(NOTE)*

celecoxib 200 mg, PO, BID, Capsule (DEF)* 200 mg, PO, QDay, Capsule, for age > 65 yo or CrCl 30-50 ml/min

ibuprofen 400 mg, PO, Q6H, PRN, pain mild (pain score 1-3), Tab

ketorolac 15 mg, IV, Q6H, PRN, pain mild (pain score 1-3), Inj, Duration = 5 day(s)

Comments: if patient is NPO or cannot tolerate PO Analgesics: Opioids

Opioid Analgesics - to begin AFTER PCA discontinued(NOTE)* Moderate Pain (pain score 4-6):(NOTE)* Oral Opioids(NOTE)*

oxyCODONE immediate release 5 mg, PO, Q4H, PRN, pain moderate (pain score 4-6), Tab

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Comments: to begin AFTER PCA is discontinued, when patient can tolerate PO morphine

15 mg, PO, Q3H, PRN, pain moderate (pain score 4-6), Tab Comments: to begin AFTER PCA is discontinued, when patient can tolerate PO

IV Opioids(NOTE)* morphine

1 mg, IV, Q2H, PRN, pain moderate (pain score 4-6), Inj Comments: to begin AFTER PCA is discontinued, if patient is NPO or cannot tolerate PO

HYDROmorphone 0.5 mg, IV, Q4H, PRN, pain moderate (pain score 4-6), Inj

Comments: to begin AFTER PCA is discontinued, if patient is NPO or cannot tolerate PO Severe Pain (pain score 7-10):(NOTE)* Oral Opioids(NOTE)*

oxyCODONE immediate release 10 mg, PO, Q4H, PRN, pain severe (pain score 7-10), Tab

Comments: to begin AFTER PCA is discontinued, when patient can tolerate PO morphine

30 mg, PO, Q3H, PRN, pain severe (pain score 7-10), Tab Comments: to begin AFTER PCA is discontinued, when patient can tolerate PO

IV Opioids(NOTE)* morphine

2 mg, IV, Q2H, PRN, pain severe (pain score 7-10), Inj Comments: to begin AFTER PCA is discontinued, if patient is NPO or cannot tolerate PO

HYDROmorphone 1 mg, IV, Q4H, PRN, pain severe (pain score 7-10), Inj

Comments: to begin AFTER PCA is discontinued, if patient is NPO or cannot tolerate PO Anticoagulants warfarin

mg, PO, QDay, Tab, Duration = 1 dose(s) Comments: Seal empty packaging and unused drug in ziplock bag. Discard in BLACK container.

Pharmacy Dosing Service - Warfarin T;N, QDay

REMINDER: Change start date/time on enoxaparin to at least 12- 24 hours post-op.(NOTE)* enoxaparin

40 mg, subQ, QDay, Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal (DEF)*

Comments: Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal 30 mg, subQ, QDay, Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal, for CrCl 10-29 ml/min

Comments: Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal 30 mg, subQ, BID, Inj, Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal

Comments: Do Not Initiate until at least 12-24 hours post-op or after Epidural/Spinal Postoperative Beta-Blocker(SUB)* Muscle Relaxants cyclobenzaprine

10 mg, PO, TID, Tab Antiemetics metoclopramide

10 mg, IV, Q6H, Inj, Duration = 24 hr Dietary Supplements ferrous sulfate

325 mg, PO, TIDwithMeals, Tab Tums

500 mg, PO, TIDwithMeals, Chewable Tab Miscellaneous PRN Medications Maalox

30 ml, PO, Q6H, PRN, indigestion, Susp Milk of Magnesia

30 ml, PO, Qbedtime, PRN, constipation, Susp

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Chloraseptic Spray 1 spray(s), PO, as directed, PRN, sore throat, Oral Spray

Comments: Dispose unused drug in black container Cepacol Sore Throat

1 lozenge(s), PO, as directed, PRN, sore throat, Lozenge zolpidem

5 mg, PO, Qbedtime, PRN, sleep/insomnia, Tab Laboratory POC Testing Blood Glucose Monitoring POC

T;N Chemistry BMP

RT | Venous Bld, T+1;0400 (DEF)* RT | Venous Bld, T+1;0400, daily, 3 day(s) RT | Venous Bld, T+1;0400, daily

Notify T;N, HO of results of BMP POD#1

Coagulation PT ($,1d)

RT | Venous Bld, T+1;0400 (DEF)* RT | Venous Bld, T+1;0400, daily

PTT RT | Venous Bld, T+1;0400

Hematology CBC

RT | Venous Bld, T+1;0400, daily, 3 day(s) (DEF)* RT | Venous Bld, T+1;0400

Notify HO for T;N, Hct<25%

Diagnostic Tests EKG POC

T;N, Stat EKG.

T;N, Stat Imaging Notify RIAO Tech

T;N XR-Pelvis

T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Left Total Hip Replacement (DEF)* T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Right Total Hip Replacement

XR-Pelvis T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Right Total Hip Replacement

XR-Knee 2V Left T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Left TKR

XR-Knee 2V Right T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Right TKR

XR-Shoulder 1V Left T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Left Shoulder Replacement

XR-Shoulder 1V Right T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Right Shoulder Replacement

XR-Shoulder 2V Left T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Left Shoulder Replacement

XR-Shoulder 2V Right

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T;N ASAP, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg, Reason: s/p Right Shoulder Replacement

Consults Care Mgmt Med Surg Inpt Consult OT Consult / Evaluate and Treat-Acute Hosp

T;N, Dx: orthopedic surgery, For: ADL Retraining PT Consult / Evaluate and Treat-Acute Hosp

T;N, Dx: orthopedic surgery, For: Ambulation/Gait Training, Ambulate w/Assistive Device WOC Nurse Consult

T;N Nutrition Consult

T;N Pastoral Care Consult

T;N Psychiatry Consult

T;N, If STAT call 25123 Rehab MD Consult / Ortho

T;N Speech Consult / Evaluate and Treat-Acute Hosp

T;N Care Management Consult (NW)

T;N Occupational Therapy Eval & Treat-Acute Hosp

T;N, Dx: orthopedic surgery, For: ADL Retraining Physical Therapy Eval & Treat-Acute Hosp

T;N, Dx: orthopedic surgery, For: Ambulation/Gait Training, Ambulate w/Assistive Device Subacute Evaluation (NW)

T;N Certified Wound Nurse Consult (NW)

T;N Anesthesia to evaluate patient for nerve block to prevent post op pain (CH)

T;N Other Patient Education

T;N, Instruct on: Post-OP Patient Education-Smoking Cessation

T;N Patient Education (NW)

T;N, Instruct on: Post-OP *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 phasetextControl

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Unique Plan Description: PCA, Peripheral Adult Plan Selection Display: PCA, Peripheral Adult PlanType: Medical Version: 5 Begin Effective Date: 11/21/2019 11/21/19 11:17 End Effective Date: Current Available at: Lev Spec Hosp SHB PCA, Peripheral Adult Patient Alerts PCA Emergency Response

T;N Stop PCA

T;N, If Respiratory Rate is less than 10, SPO2<95%, EtCO2>50, or Patient is obtunded/unarousable, or POSS>=3

Give Narcan per order T;N, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>=3

Page Respiratory Therapy T;N, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>=3

Notify MD if Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>=3, T;N

Oxygen Therapy T;N, Non Rebreather Mask, 100 percent, PRN, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>=3


T;N Vital Signs with Pulse Oximetry




T;N, Q8H End Tidal CO2 Monitoring - continuous

T;N, should be maintained < 50 and >20 Patient Care Orders Miscellaneous Nursing Order (NON-Medication)

T;N, Monitor and record BP, pulse, RR, pulse ox and EtCo2 Q1H X 4, Q2H X 8, then Q4H until PCA pump discontinued

Miscellaneous Nursing Order (NON-Medication) T;N, Any increase in basal rate, increased level of sedation, or respiratory depression must return to most frequent monitoring schedule

Notify T;N, Notify Provider for Respiratory Rate<10, SPO2<95%, POSS>=3 EtCO2>50 and <20

Respiratory Therapy Oxygen

T;N, set up at bedside Medications PCA

All breakthrough pain control while on PCA must be administed by PCA bolus versus a PRN opioid dose; narcotic medications may, however, be ordered to be given on a regularly scheduled round-the-clock basis to be administered orally or intravenously, but NOT on a PRN or as needed basis.(NOTE)* Please refer to Reference Text Information above for guidance on initial dosing recommendations per Pain Management PCA Policy and Procedure.(NOTE)* Basal rates are NOT recommended for opioid naive patients(NOTE)*

morphine 5mg/ml PCA syringe (IVS)* morphine 5mg/ml PCA

page 31 of 48


mg, mg, mg/hour, mg/hour, IV, Start T;N HYDROmorphone 1mg/ml PCA syringe (IVS)* hydromorphone 1mg/ml PCA

mg, mg, mg/hour, mg/hour, IV fentanyl 10mcg/ml PCA syringe (IVS)* fentanyl 10mcg/ml PCA

mcg, mcg, mcg/hour, mcg/hour, IV, Start T;N Sodium Chloride 0.9%

1,000 ml, IV, KVO while PCA is in place, ml/hr Emergency Response naloxone

0.1 mg, IV, as directed, PRN, Other, see comments, Inj, give STAT and repeat every 2 minutes x4 doses for RR < 8, patient unarousable or obtunded

Comments: repeat every 2 minutes x4 doses for RR < 8, patient unarousable or obtunded Bowel Management Senokot

2 tab(s), PO, BID, Tab docusate

100 mg, PO, BID, Capsule *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 phasetextControl

page 32 of 48

9.23.2020 PowerPlan Request Item #5c P 1 of 2

Unique Plan Description: PCA Peripheral HIGH CONCENTRATION Adult Plan Selection Display: PCA Peripheral HIGH CONCENTRATION Adult PlanType: Medical Version: 3 Begin Effective Date: 10/17/2017 10/17/17 08:45 End Effective Date: Current Available at: SHB PCA Peripheral HIGH CONCENTRATION Adult Patient Alerts PCA Emergency Response

T;N Stop PCA

T;N, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>3 Give Narcan per order

T;N, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>3 Page Respiratory Therapy

T;N, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>3 Notify MD if

Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>3, T;N Oxygen Therapy

T;N, Non Rebreather Mask, 100 percent, PRN, If Respiratory Rate is less than 8, or Patient is obtunded/unarousable, or POSS>3






T;N, Q8H End Tidal CO2 Monitoring - continuous

T;N, should be maintained <50 and >20 Patient Care Orders Miscellaneous Nursing Order (NON-Medication)

T;N, Monitor and record BP, pulse, RR, pulse ox and ETCo2 Q1H X 4, Q2H X 8, then Q4H until PCA pump discontinued;

Miscellaneous Nursing Order (NON-Medication) T;N, Any increase in basal rate or administration of a bolus dose must return to most frequent monitoring schedule

PCA Emergency Response T;N

Notify T;N, Notify Provider for Respiratory Rate<10, SPO2<90%, Sedation Level >4, Pain Score>5 cannot be maintained, ETCO2>50 and <20

Respiratory Therapy Oxygen Therapy Protocol

T;N, set up at bedside Medications PCA

All breakthrough pain control while on PCA must be administed by PCA bolus versus a PRN opioid dose; narcotic medications may, however, be ordered to be given on a regularly scheduled round-the-clock basis to be administered orally or intravenously, but NOT on a PRN or as needed basis.(NOTE)*

page 33 of 48

9.23.2020 PowerPlan Request Item #5c P 2 of 2

High concentration PCA therapy is restricted to chronic pain patients with documented opioid tolerance and dose requirements. High concentration PCA solutions may only be ordered by Anesthesia, Pain Specialists, Oncology, and Hematology Attendings, or other Medical Provider guided by a Pain Consultant.(NOTE)* The IV pumps used to deliver doses of PCA solutions have minimun volume requirements; please note the following when ordering high concentration PCA solutions: HYDROMORPHONE (10mg: 1mL):- Total hourly PCA dose should be equal to or greater than 6mg/hr. IF A BASAL IS INCLUDED, the basal rate MUST BE greater than 1mg/hr.MORPHINE (12.5mg: 1mL): - Total hourly PCA dose should be equal to or greater than 50mg/hr. IF A BASAL IS INCLUDED, the basal rate MUST BE greater than 1.2mg/hr.FENTANYL (50 mcg: 1mL):- The total hourly PCA dose should be equal to or greater than 150mcg/hr. IF A BASAL IS INCLUDED, the basal rate MUST BE greater than 5mcg/hr(NOTE)*

morphine 12.5mg/ml PCA syringe (IVS)* morphine 12.5mg/ml PCA (RED PUMP) HYDROmorphone 10mg/ml PCA syringe (IVS)* hydromorphone 10mg/ml PCA (RED PUMP) fentanyl 50mcg/ml PCA syringe (IVS)* fentanyl 50mcg/ml PCA (RED PUMP) Sodium Chloride 0.9%

1,000 ml, IV, KVO while PCA is in place, ml/hr Emergency Response naloxone

0.1 mg, IV, as directed, PRN, Other, see comments, Inj, give STAT and repeat every 2 minutes x4 doses for RR < 8, patient unarousable or obtunded

Comments: repeat every 2 minutes x4 doses for RR < 8, patient unarousable or obtunded Bowel Management Senokot

2 tab(s), PO, BID, Tab docusate

100 mg, PO, BID, Capsule *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 phasetextControl

page 34 of 48

9.23.2020 PowerPlan Request Item #5d P 1 of 2 Unique Plan Description: PCA, Peripheral Peds/PICU Plan Selection Display: PCA, Peripheral Peds/PICU PlanType: Medical Version: 6 Begin Effective Date: 08/11/2020 08/11/20 16:52 End Effective Date: Current Available at: Peds Hem/Onc SHB PCA, Peripheral Peds/PICU Patient Alerts Stop PCA

T;N, If Respiratory Rate is <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), or Patient is obtunded/unarousable, or POSS>=3

Give Narcan per order T;N, If Respiratory Rate is <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), or Patient is obtunded/unarousable, or POSS>=3

Page Respiratory Therapy T;N, If Respiratory Rate is <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), or Patient is obtunded/unarousable, or POSS>=3

Oxygen Therapy T;N, Non Rebreather Mask, 100 percent, PRN, If Respiratory Rate is <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), or Patient is obtunded/unarousable, or POSS>=3

Notify MD if If Respiratory Rate is <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), or Patient is obtunded/unarousable, or POSS>=3, T;N





T;N+960, Q4H for 8 hr, until pump is discontinued, then Q8h Vital Signs with Pulse Oximetry

T;N, Q8H End Tidal CO2 Monitoring - continuous Patient Care Orders Cardio-Respiratory Monitoring

T;N, For PCA basal rate. Miscellaneous Nursing Order (NON-Medication)

T;N, Any increase in basal rate, increased level of sedation, or respiratory depression must return to most frequent monitoring schedule

Miscellaneous Nursing Order (NON-Medication) T;N, Monitor and record BP, pulse, RR, pulse ox and EtCo2 Q1H X 4, Q2H X 8, then Q4H until PCA pump discontinued

Notify Notify Provider for Respiratory Rate <10 /min (15 yrs & older) or <12/min (8-14 years old) or <14/min (2-8 years old), <18/min (1-2 years old), SPO2<95%, POSS>3, Pain Score>5 cannot be maintained, EtCO2>50 and <20

Respiratory Therapy Oxygen

T;N, setup at bedside IV Solutions Sodium Chloride 0.9%

1,000 ml, IV, KVO

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9.23.2020 PowerPlan Request Item #5d P 2 of 2

Comments: Begin if primary IV fluid discontinued for IV PCA without basal rate; while on PCA

Medications PCA

All breakthrough pain control while on PCA must be administed by PCA bolus versus a PRN opioid dose; narcotic medications may, however, be ordered to be given on a regularly scheduled round-the-clock basis to be administered orally or intravenously, but NOT on a PRN or as needed basis.(NOTE)* Please refer to Reference Text Information above for guidance on initial dosing recommendations per Pain Management PCA Policy and Procedure(NOTE)* Basal rates are NOT recommended for opioid naive patients(NOTE)*


mg, mg, mg/hour, mg/hour, IV, Start T;N HYDROmorphone 1mg/ml PCA syringe (IVS)* hydromorphone 1mg/ml PCA

mg, mg, mg/hour, mg/hour, IV fentanyl 10mcg/ml PCA syringe (IVS)* fentanyl 10mcg/ml PCA

mcg, mcg, mcg/hour, mcg/hour, IV, Start T;N Caregiver PCA

All breakthrough pain control while on PCA must be administed by PCA bolus versus a PRN opioid dose; narcotic medications may, however, be ordered to be given on a regularly scheduled round-the-clock basis to be administered orally or intravenously, but NOT on a PRN or as needed basis.(NOTE)* Please refer to Reference Text Information above for guidance on initial dosing recommendations per Pain Management PCA Policy and Procedure(NOTE)* Basal rates are NOT recommended for opioid naive patients(NOTE)*


mg, mg, mg/hour, mg/hour, IV, Start T;N Comments: Caregiver PCA

HYDROmorphone 1mg/ml PCA syringe (IVS)* hydromorphone 1mg/ml PCA

mg, mg, mg/hour, mg/hour, IV, Start T;N Comments: Caregiver PCA

fentanyl 10mcg/ml PCA syringe (IVS)* fentanyl 10mcg/ml PCA

mcg, mcg, mcg/hour, mcg/hour, IV, Start T;N Comments: Caregiver PCA

Emergency Response naloxone

0.1 mg, IV, as directed, PRN, Other, see comments, Inj Comments: if respiratory rate < 12 /minute for 8-14 years old, < 14/minute for 2-8 year old, < 18/minute for 1-2 year old or if POSS <or = 3, May Repeat dose every 1-2 minutes based on patient assessment for a total of 4 doses.

Bowel Management senna

2.5 ml, PO, BID, Liq, for ages 2-5 years old (DEF)* 5 ml, PO, BID, Liq, for ages 6-12 years old 10 ml, PO, BID, Liq, for ages > 12 years old

senna 2 tab(s), PO, BID, Tab, adult dose

*Report Legend:

page 36 of 48

9.23.2020 PowerPlan Request Item #5e P 1 of 5

Unique Plan Description: Peds Ortho Post Op, with PCA Powerplan Plan Selection Display: Peds Ortho Post Op, with PCA Powerplan PlanType: Medical Version: 2 Begin Effective Date: 05/28/2019 05/28/19 09:34 End Effective Date: Current Available at: SHB Peds Ortho Post Op, with PCA Powerplan Admit/Diagnosis Admit

T;N Start Observation

T;N, Pediatrics Non-Telemetry, Semi Private, None Diagnosis

T;N Procedure (Patient Care)

T;N Admitting Physician.


T;N Code Status Code Status

T;N, Full Resuscitation (DEF)* T;N, Do Not Resuscitate, Refer to paper DNR form.

Patient Alerts Isolation

T;N Vital Signs Vital Signs with Pulse Oximetry





T;N Neuro Checks

T;N, Q4H for 24 hr Neuro Checks

T+1;N, Q8H Activity Activity as Tolerated

T;N Bedrest

T;N, Bathroom Privileges, strict bedrest (DEF)* T;N, supine without log roll T;N, supine with log roll

OOB T;N, to chair, POD #1 (DEF)* T;N, ambulate in hall, POD #1

Weight Bearing Status T;N, LE: Weight Bearing as Tolerated, Left (DEF)* T;N, LE: Weight Bearing as Tolerated, Right T;N, LE: Partial Weight Bearing, Left

page 37 of 48


T;N, LE: Partial Weight Bearing, Right T;N, LE: Touch Toe Weight Bearing, Left T;N, LE: Touch Toe Weight Bearing, Right T;N, LE: No Weight Bearing., Left T;N, LE: No Weight Bearing., Right

Elevate T;N, Head of Bed

Flat in Bed T;N, when brace is off

Diet Dietitian to Manage Medical Nutrition Therapy

T;N NPO

T;N, No exceptions (DEF)* T;N, NPO except for medications T;N, NPO except for medications

Restricted Diet T;N, Room Service, Pediatric

Restricted Diet T;N, Room Service, Pediatric

Breast Milk T;N

Tube Feedings Enteral Feedings(SUB)* Patient Care Orders Intake and Output

T;N, Q12H Intake and Output Strict

T;N, Q12H Cardio-Respiratory Monitoring

T;N Drain Maintenance

T;N, Drain type: Hemovac, empty and record amount q12h (DEF)* T;N, Drain type: JP, empty and record amount q12h

Elevate T;N, Left Upper Extremity on one pillow, under elbow (DEF)* T;N, Right Upper Extremity on one pillow, under elbow

Dressing Change / Wound Care T;N, to the Other, Dry Sterile Dressing, QDay, PRN, to operative site; first dressing change to be performed by surgery

Pin Care T+1;N, to the Arm, Other, After 24 hours; routine pin care. (DEF)* T+2;N, to the Arm | Leg, Other, After 24 hours; routine pin care.

Ice Packs T;N, to affected extremity

Urinary Catheter Maintenance T;N, To straight drainage, Discontinue orders: Remove per nursing protocol (DEF)* T;N, To straight drainage, Discontinue orders: When epidural is out, discontinue 1 hour after epidural removed T;N, To straight drainage, discontinue when patient is ambulatory

Straight Catheterize T;N, If no void in next, and notify H.O.

VTE Prophylaxis TEDs (Pt Care)

T;N, Bilateral Lower Extremities (DEF)* T;N, Left Lower Extremity T;N, Right Lower Extremity

Foot Pumps

page 38 of 48


T;N, Both (DEF)* T;N, Left T;N, Right

SCDs (Pt Care) T;N, Bilateral Lower Extremities (DEF)* T;N, Left Lower Extremity T;N, Right Lower Extremity

Equipment Consult Orthopedic Technician

T;N, Routine, peds post-op Trapeze

T;N, perform safety checks every shift CPM 0 Degrees -

T;N, BID Elastic Back Support

T;N MAFO

T;N AFO

T;N, Routine Respiratory Therapy Oxygen Therapy

T;N, Maintain Sp02 > 94, Wean to Room Air, Discontinue oxygen on POD#1 if saturation is greater than 94% on room air.

Cough and Deep Breathe T;N, encourage

Incentive Spirometry (Pt Care) T;N, q1h, while awake

Bronchial Hygiene T;N

Suction T;N

IV Solutions Dextrose 5% & 0.45% NaCl 1000ml & KCL 20 meq (IVS)* Premix Diluent D5&0.45NaCl


20 mEq, Every Bag Lactated Ringers

1,000 ml, IV, ml/hr Heparin Lock with Routine Flushes

T;N Central Line Care with Routine Flushes per Protocol

T;N Medications Surgical Site Infection Prophylaxis, Peds Post Op(SUB)* PCA, Peripheral Peds/PICU(SUB)* Antacids Maalox

5 ml, PO, QID, PRN, indigestion, Susp, For children < 2 years old (DEF)* 15 ml, PO, QID, PRN, indigestion, Susp, For children 2-12 years old 30 ml, PO, QID, PRN, indigestion, Susp, For children > 12 years old

Antiemetics ondansetron (pediatrics)

0.1 mg/kg, IV, Q8H, PRN, nausea/vomiting, Inj, x 2 doses Comments: x 2 doses

ondansetron 4 mg, Inj, IV, Q8H, PRN, nausea/vomiting, x 2 doses

page 39 of 48


Comments: x 2 doses, adult dose Bowel Management docusate (pediatrics)

2.5 mg/kg, Liq, PO, BID, PRN, constipation docusate

100 mg, Capsule, PO, BID, PRN, constipation Comments: adult dose

Fleet Enema 1 enema, rectal, PRN, constipation, if no BM

Dietary Supplements MVI with minerals

1 tab(s), Tab, PO, QDay Comments: adult dose

Centrum Jr 1 tab(s), Chewable Tab, PO, QDay

ferrous sulfate (pediatrics) 2 mg/kg, Liq, PO, BID

ferrous sulfate 325 mg, Tab, PO, TIDwithMeals

Comments: adult dose GI Prophylaxis famotidine (pediatrics)

0.4 mg/kg, IV, BID, Inj Syringe famotidine

20 mg, Inj, IV, BID (DEF)* Comments: adult dose

20 mg, IV, QDay, Inj, for CrCl < 50 ml/min Comments: adult dose

Laboratory Hematology CBC

RT collect Venous Bld, T+1;0400, daily, 3 day(s) (DEF)* RT collect Venous Bld, T+1;0400

Auto Differential RT collect Venous Bld, T+1;0400, MUST ORDER CBC WITH THIS, daily, 3 day(s)

Chemistry BMP

RT collect Venous Bld, T+1;0400 POC Testing Guaiac Stools POC

T;N, Routine, guaiac all stools; notify provider if positive Urine Dipstick POC

T;N, Routine, q void (DEF)* T;N, Routine, q4h T;N, Routine, q8h

Diagnostic Tests EKG POC

T;N, Stat EKG.

T;N, Stat Imaging Notify RIAO Tech

T;N XR-Chest 2V

T+1;0500 Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg XR-Chest Portable

T+1;0500 Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg Consults

page 40 of 48


Care Mgmt RIAO Peds Consult T;N

Care Mgmt Peds Inpt Consult T;N

Child Life Specialist Consult T;N, Routine

Nutrition Consult T;N

OT Consult / Evaluate and Treat-Acute Hosp T;N

PT Consult / Evaluate and Treat-Acute Hosp T;N

Rehab MD Consult / General Rehab T;N, For: General Rehab Consult

Inpatient Psyc Consult Peds T;N

Other Patient Teaching

T;N, Instruct on: Post-OP, active ankle exercises Patient Education-Smoking Cessation

T;N *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 phasetextControl

page 41 of 48

9.23.2020 PowerPlan Request Item #6 P 1 of 4 Unique Plan Description: PICU MIS-C Plan Selection Display: PICU MIS-C PlanType: Medical Version: 1 Begin Effective Date: 08/11/2020 08/11/20 09:41 End Effective Date: Current Available at: SHB PICU MIS-C Admit/Diagnosis Admit

T;N, PICU Start Observation

T;N, Pediatrics Diagnosis

T;N, MIS-C Admitting Physician.


T;N Transfer to:

T;N, PICU Code Status Resuscitation Status

T;N Vital Signs Vital Signs

T;N, per PICU monitoring Neuro Checks


T;N Cardio-Respiratory Monitoring

T;N Pulse Oximetry Continuous

T;N, pulse ox, continuous Activity Bedrest

T;N (DEF)* T;N, Bathroom Privileges

Elevate T;N, Head of Bed (DEF)* T;N, Head of Bed 30 degrees

Activity as Tolerated T;N

OOB T;N, to chair (DEF)* T;N, ambulate in room, with assistance T;N, as tolerated

Diet NPO

T;N, No exceptions (DEF)* T;N, NPO except for medications

page 42 of 48


T;N, NPO except for ice chips Restricted Diet

T;N Patient Care Orders IV Start / Restart

T;N Intake and Output Strict

T;N Provide Educational Material Central Venous Pressure Monitoring

T;N Weight

T;N, QDay Respiratory Therapy Oxygen Therapy

T;N Cough and Deep Breathe

T;N Suction

T;N Ventilator Settings

T;N Medications acetaminophen (pediatrics)

10 mg/kg, PO, Q6H, Routine, PRN, Liq (DEF)* Comments: Max Dose 650 mg

15 mg/kg, PO, Q6H, Routine, PRN, Liq Comments: Max Dose 650 mg

diphenhyDRAMINE (pediatrics) 1 mg/kg, IV, Q6H, Routine, PRN, itching, Inj (DEF)*

Comments: Max Dose 50 mg 1 mg/kg, PO, Q6H, Routine, PRN, itching, Inj

Comments: Max Dose 50 mg famotidine (pediatrics)

0.5 mg/kg, IV, Q12H, Routine, Inj Syringe Comments: Max Dose 20 mg

cefTRIAxone (pediatrics) 75 mg/kg, IV, Q24HV, Routine, Indication = Bacteremia, Inj Syringe

Comments: Max Dose 2000 mg clindamycin (pediatrics)

13 mg/kg, IV, Q8H, Routine, Indication = Other, Inj Syringe Comments: Max Dose 900 mg; suspected Toxic Shock Syndrome

PEDS: Kawasaki Medications(SUB)* Laboratory Blood Culture

T;N, Blood, ST CBC

ST collect Venous Bld, T;N, ONCE Auto Differential

ST collect Venous Bld, T;N, ONCE CBC

RT collect Venous Bld, T+1;0400, 3 day(s) Auto Differential

page 43 of 48


RT collect Venous Bld, T+1;0400, 3 day(s) CMP

ST collect Venous Bld, T;N, ONCE CMP

RT collect Venous Bld, T+1;0400, 3 day(s) Magnesium level

ST collect Venous Bld, T;N, ONCE Magnesium level

RT collect Venous Bld, T+1;0400, 3 day(s) Phosphorus level

ST collect Venous Bld, T;N, ONCE Phosphorus level

RT collect Venous Bld, T;0400, 3 day(s) BMP

ST collect Venous Bld, T;N, ONCE BMP

RT collect Venous Bld, T+1;1600, 3 day(s) Troponin I, Plasma

ST collect Venous Bld, T;N, ONCE Troponin I, Plasma

RT collect Venous Bld, T+1;0400, 3 day(s) Lipase level

ST collect Venous Bld, T;N, ONCE Lipase level

RT collect Venous Bld, T+1;0400, 3 day(s) ProBNP

ST collect Venous Bld, T;N, ONCE ProBNP

RT collect Venous Bld, T+1;0400, 3 day(s) Lactate (Initial Sepsis) Reflex

ST collect, T;N, ONCE Triglycerides

ST collect Venous Bld, T;N, ONCE Triglycerides

RT collect Venous Bld, T+1;0400, 3 day(s) EPOC POC

T;N, Routine, EPOC Blood Gases, ONCE Procalcitonin

ST collect Venous Bld, T;N, ONCE Procalcitonin

RT collect Venous Bld, T+1;0400, 3 day(s) CRP

ST collect Venous Bld, T;N, ONCE CRP

RT collect Venous Bld, T+1;0400, 3 day(s) DDIMER

ST collect Venous Bld, T;N, ONCE DDIMER

RT collect Venous Bld, T+1;0400, 3 day(s) Urinalysis w/ microscopic(SUB)* Urine Culture Pediatric

T;N, ST Stool Culture

page 44 of 48


T;N, ST Peds RVAP

RT collect Nasopharyngeal Swab, T;N, ONCE Fibrinogen Activity

RT collect Venous Bld, T;N, daily, 3 day(s) INR / PT

ST collect Venous Bld, T;N, ONCE INR / PT

RT collect Venous Bld, T;N, q12hr, 3 day(s) PTT

ST collect Venous Bld, T;N, ONCE PTT

RT collect Venous Bld, T;N, q12hr, 3 day(s) Ferritin

ST collect Venous Bld, T;N, ONCE Ferritin

RT collect Venous Bld, T+1;0400, 3 day(s) Coronavirus (COVID-19), NAA

Nasopharyngeal Swab, RT collect, T;N COVID-19 IgG

Venous Bld, RT collect, T;N EBVPAN

Venous Bld, RT collect, T;N CMV Abs IgG/IgM ($$,3d)

Venous Bld, RT collect, T;N Diagnostic Tests Echocardiogram

T;N, Stat - MUST Call Department Echocardiogram

T;N, Routine, for 3 days EKG.

T;N, Routine XR-Chest 2V

T;N Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg XR-Abdomen KUB

T;N Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg US-Abdomen Limited

T;N Routine, Transport Mode: STRETCHER, No-Pt <350 lb./159 kg, Reason: if abdominal pain or persistent emesis

Consults Consult - Infectious Disease (SHB)

T;N, Priority: Routine Consult - Hematology/Oncology (SHB)

T;N Consult - Cardiology (SHB)

T;N Consult Child Life Specialist

T;N *Report Legend:

page 45 of 48

9.23.2020 PowerPlan Request Item #7 P 1 of 3 Unique Plan Description: Neonatal Admission (CH) Plan Selection Display: Neonatal Admission (CH) Plan Synonyms: SCN - Neonatal Admission (CH) PlanType: Medical Version: 1 Begin Effective Date: 04/12/2018 04/12/18 08:47 End Effective Date: Current Available at: Carroll Hospital Neonatal Admission (CH) Admit/Diagnosis

***Note: This is the correct PowerPlan for Couplet Care Babies***(NOTE)* Admit as Neonate (CH)

T;N Diagnosis

T;N Condition

T;N, Stable Code Status Resuscitation Status

T;N, Full Resuscitation, No Information (Default to Full Code) (DEF)* T;N, Do Not Resuscitate, PLEASE COMPLETE PAPER DNR ORDER FORM

Activity Neonatal Activity (CH)

T;N, Open Crib (DEF)* T;N, ICC T;N, Isolette T;N, Other

Diet NPO

T;N, Other Breast Milk

T;N, at least every 2-3 hours Breast Milk

T;N, w/supplementation; at least q2-3H, if feeds poor or < 10min = full supp feed. If feeds fair or 10-20min = half supp. feed. If feeds well and >20min then no supp needed.

Breast Milk Supplementation (CH) T;N

Infant Formula Feeding (CH) T;N

Infant Bolus Feeding (CH) T;N

Patient Care Orders Vital Signs Neonatal

T;N, Q1HX4, then Q2H until stable and then Q4H; obtain BP on admission and then qshift Cardio-Respiratory Monitoring

T;N Obtain Medication Clinical Weight

T;N, QDay Pulse Oximetry Continuous

T;N Blood Glucose Monitoring POC

T;N, Q2HX2, then Q4HX4, then Q8H Intake and Output

T;N, as directed Intake and Output Strict

T;N, as directed Keep Umbilical Cord Clean and Moist

T;N Newborn Metabolic Screening

page 46 of 48


T;N, on admission and per protocol Congenital Heart Defect Screen at 24-48 hours Car Seat Testing if <37 Weeks

T;N, or if less than 5 lbs Respiratory Therapy Oxygen (NW)(LSH)(CH)

T;N, Routine ABG Draw

T;N, ST Venous BG

T;N, ST | ST IV Solutions Dextrose 10% in Water

250 ml, IV, ml/hr Medications erythromycin ophthalmic 0.5% ointment

1 appl, eye(each), ONCE, Ophth Oint Comments: in each conjunctival sac

phytonadione (pediatrics) 1 mg, IM, ONCE, Inj

hepatitis B pediatric vaccine 0.5 ml, IM, At discharge, Start T+1;N, Inj, to be given after the first 24 hours, at or above 2000 gms or at discharge (whichever comes first)

Comments: to be given after the first 24 hours, at or above 2000 gms or at discharge (whichever comes first)

NACL09NEB3 nare(each), Q1H, PRN, congestion

poractant alfa (pediatrics) 2.5 ml/kg, ETTube, ONCE, Inh Sol

PMA greater than 32 weeks and less than 35 weeks:(NOTE)* ampicillin (pediatrics)

50 mg/kg, IV, Q12H, Indication = Bacteremia, Inj Syringe gentamicin (pediatrics)

4.5 mg/kg, IV, Q36H, Indication = Bacteremia, Suspected Organism = Empiric, Inj Syringe PMA greater than or equal to 35 weeks:(NOTE)*

ampicillin (pediatrics) 50 mg/kg, IV, Q8HV, Indication = Bacteremia, Inj Syringe

gentamicin (pediatrics) 4 mg/kg, IV, Q24HV, Indication = Bacteremia, Suspected Organism = Empiric, Inj Syringe

Meningitis Dosing(NOTE)* ampicillin (pediatrics)

100 mg/kg, IV, Q8HV, Indication = Meningitis / CNS Infection, Suspected Organism = Empiric, Inj

ampicillin (pediatrics) 100 mg/kg, IV, Q12HV, site of infection = R/O serious bacterial infection-Peds, Suspected Organism = Empiric, Inj

PMA greater than 32 weeks and less than 35 weeks:(NOTE)* gentamicin (pediatrics)

4.5 mg/kg, IV, Q36H, site of infection = R/O serious bacterial infection-Peds, Suspected Organism = Empiric, Inj Syringe

PMA greater than or equal to 35 weeks:(NOTE)* gentamicin (pediatrics)

4 mg/kg, IV, Q24HV, site of infection = R/O serious bacterial infection-Peds, Suspected Organism = Empiric, Inj Syringe

poractant alfa (pediatrics) 2.5 ml/kg, ETTube, ONCE, Inh Sol

Laboratory Blood Gas, Cord Arterial

T;N, ST ST, Cord Blood Art CBC

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RT | Venous Bld, T+1;0600 Auto Differential

RT | Venous Bld, T+1;0600, MUST ORDER CBC WITH THIS Manual Differential

Venous Bld, RT collect, T+1;0600, MUST ORDER CBC WITH THIS Culture / Blood

T;N, Blood, ST, on admission CSF Lab Orders(SUB)* BMP

ST | Venous Bld, T;N CRP

ST | Venous Bld, T;N Bilirubin Total/Direct

ST | Venous Bld, T;N Cord Blood for O Mom

ST | Cord Blood, T;N Newborn Meconium (CH)(SUB)* Cord Blood Rh Neg Mom.

ST | Cord Blood, T;N Urine Studies Urinalysis (non-catheter) w/ Micro, w/ Reflex Culture PowerPlan(SUB)* Drugs of Abuse Panel

T;N, Urine, ST collect Diagnostic Tests XR-Chest 2V

T;N Stat, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg Comments: pediatric

XR-Clavicle Left T;N Stat, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg

Comments: pediatric XR-Clavicle Right


Echo Complete TTE (CH) T;N, Referred to Provider (Name):

US-Renal Retroperitoneal T;N Stat, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg

Comments: pediatric US-Spinal Cord and Contents


US-Pediatric Hip Dysplasia T;N Stat, Transport Mode: PORTABLE, No-Pt <350 lb./159 kg

Comments: pediatric EKG.

T;N, Stat Consults Nutrition Consult

T;N Speech Consult / Evaluate and Treat-Acute Hosp

T;N, For: Other, Tolerate PO/GI standpnt: Yes, Mental health appropriat: Yes, Took PO prior to admiss: Yes, Symptom not esoph nature: Yes, difficulty feeding

Care Mgmt Peds Inpt Consult Home Health Care

T;N, Skilled Nursing Care Comments: Home Visit for Baby

*Report Legend:

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clinician quality/operation patient care services

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