All Adult Medicine Providers
(includes all medical subspecialities)
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Note: open ALL links and attachments that are applicable to your area(s) of practice. |
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Acute Myocardial Infarction (AMI)
Review of CMS core measures for inpatients and outpatients presenting with AMI or cardiac related chest pain.
- AMI core measures (loaded 10/11)
Clinical practice: Diagnosis and evaluation for chest pain – adult observation patients
It is an expected clinical practice that all adult patients with unspecified chest pain that is low risk, atypical, or an unusual presentation for acute coronary syndrome (ACS) and does not require immediate inpatient hospitalization and/or intervention should be considered for placement in observation status to further evaluate their cardiac risk.
- Clinical practice: Diagnosis and evaluation for chest pain – adult observation patients (loaded 03/13)
Clinical practice: Heart failure exacerbation outpatient – adult
This recommended clinical practice states that all adult patients presenting in the Emergency Department (ED) with heart failure (HF) exacerbations will be assessed for acute conditions; and if they do not meet criteria for inpatient hospitalization, they should be considered for treatment in an outpatient/observation setting.
Pneumonia
Review of CMS core measures for inpatients with diagnosis of Pneumonia including measures for patients admitted thru the Emergency Department.
- Pneumonia core measures (loaded 10/11)
Reduce variation in pneumonia care practices and resource utilization
To improve length of stay, provide the safest care by reducing unecessary imaging, and reduce unnecessary delays in care of hospitalized pneumonia patients, this initiative has two parts:
(1) Increase the percent of pneumonia patients that are converted from IV to oral antibiotics by day 4 of their stay. An automatic conversion protocol is built into the established pneumonia related antibiotic order set available thru Cerner/CPOE
(2) Reduce the percent of pneumonia patients that receive a Chest CT as part of the routine work-up (Chest CT to be ordered only for underlying disease or if complications are present)
- Reducing variation in pneumonia care fact sheet (loaded 10/11)
Heart failure
Review of CMS core measures for inpatients with diagnosis of Heart Failure.
- Heart failure core measures (loaded 10/11)
Sepsis initiative
Establishes guidelines for early identification and treatment of sepsis in adult patients including Sepsis Outcomes (Mortality rate), diagnosis and treatment protocols (sepsis bundle compliance rate), timeliness of response to sepsis alert (rate), and formalized process for event investigation and documentation. Sepsis bundle includes measuring serum lactate, obtaining blood cultures prior to antibiotic administration, administering broad-spectrum antibiotic within 3 hrs of ED admission and within 1 hr of non-ED admission, giving fluid bolus in the event of hypotension and/or serum lactate> 4 mmol/L, and placing central line in event of persistent hypotension for further tx and assessment.
- Sepsis Simple Inpatient Flow (loaded 02/12)
- Severe Sepsis Clinical Practice (loaded 02/12)
Clinical practice: Central line management and prevention of Vascular Catheter Associated Infections (VCAI)
Establishes protocols for insertion and needs assessment for central lines including central line infection outcome (infection rate), insertion protocols (central line bundle compliance rate), timeliness of central line necessity check (daily check rate), and formalized process for event investigation and documentation. Central line insertion bundle includes hand hygiene, maximal barrier precautions upone insertion (gloves, hat, mask, gown, draps), chlorhexidine skin antisepsis, optimal catheter site selection (avoidance of femoral vein for access), and daily review of line necessity.
- Clinical Practice: Central Line Management and Prevention of Vascular Catheter Associated Infections (VCAI) (loaded 02/12)
Decrease readmission rate (AMI, HF, PN)
It is a Banner Health system initiative to decrease hospital readmission rates, specifically readmissions within 30 days of discharge, for acute myocardial infarction (AMI), pneumonia (PN), and heart failure (HF). Reduction in avoidable readmissions can be achieved through the efficiency and improvement in the transitions in care including assessment for readmission risk, consistent medication reconciliation process, consistent patient education, and assuring follow-up appointment with primary care provider within 7 days of discharge.
- Clinical practice: Readmission risk assessment - adult (loaded 02/12)
- Clinical practice: Hospital to principal care provider transition - adult (loaded 02/12)
Provision of appropriate end of life care (allowing natural death)
Provides framework for the provision of appropriate end of life care/withdrawal of life support in compliance with legal and ethical standards of care including guidance for the decision making process related to clinical choices including patient’s rights in the decision and the role of various individuals/providers in this decision making process.
- Provision of appropriate end of life care policy #12419 (loaded 07/12)
Clinical practice: Assessment and treatment of alcohol withdrawal syndrome - adult
Assessment and treatment of Alcohol Withdrawal Syndrome using symptom-triggered management based on the modified Severity Assessment Scale correlated with standardized treatment including benzodiazepine management and vitamin replacement.
Clinical practice: Diagnosis of diarrheal disease in clinical/ epidemiologic conditions
Outlines laboratory studies/evaluation of stools for diagnosing adult and pediatric diarrheal disease based on patient’s presenting condition and history.
- Clinical practice: Diagnosis of diarrheal disease in clinical/ epidemiologic conditions (loaded 02/12)
Clinical practice: Guidelines for the treatment of clostridium difficile associated diarrhea
Recommendations for treatment of mild to moderate disease with Metronidazole for first line therapy, relapse, and recurrent disease and to consider using vancomycin as initial therapy in severe disease.
- Clinical practice: Guidelines for the treatment of clostridium difficile associated diarrhea (loaded 02/12)
Clinical practice: Promoting appropriate use of PPIs (Proton Pump Inhibitors)
Outlines the indications for use of PPIs for adult patients in non-ICU settings and upon discharge.
Clinical practice: Hyperglycemic crisis in non-pregnant adults
Outlines standardized interventions to manage all non-pregnant adult patients diagnosed as presenting with Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS).
Clinical practice: Subcutaneous insulin usage for glycemic control in non-pregnant hospitalized adults
- Clinical practice: Subcutaneous insulin usage for glycemic control in non-pregnant hospitalized adults (loaded 07/12)
Clinical practice: Anesthesia administration
This clinical practice applies to all inpatients and outpatients in any setting for any purpose, by any route that receive anesthesia (including the use of short acting anesthetic agents for procedural sedation) in Banner Health facilities. All inpatients and outpatients within the Banner Health facilities receiving anesthesia will be administered anesthesia by appropriately credentialed providers based on evidenced based practice, or in its absence will practice within consensus guidelines to best serve the safety of Banner Health patients.
- Clinical Practice: Anesthesia Administration (loaded 02/12)
All cardiovascular surgery patients receiving IV insulin will be transitioned off the insulin drip to subcutaneous (sc) insulin doses sufficient to maintain blood glucose levels below 200 mg/dL and over 70 mg/dL on post-operative day 1 and 2 (defined as blood glucose closest to 0600).
Clinical practice: Appropriate use of inpatient PET scan - pediatric and adult
All patients requiring Positive Emission Tomography (PET) scans will be seen as outpatients rather than inpatients except in rare clinical circumstances, including patients with new diagnoses of lymphoma with symptoms or oncology patients too sick to leave the hospital, both needing staging for urgent inpatient treatment. Inpatient PET scanning should be used in rare clinical circumstances. Outpatient PET scan is appropriate for most patient scenarios.
Clinical practice: Acute Blood Loss Anemia Documentation (ABLA) in surgical patients
All surgical patients will be evaluated for acute post-operative blood loss anemia based on clinical indicators. Accurate documentation of the clinical indicators used, the results of this assessment describing the extent of the acute blood loss anemia (ABLA), and any therapeutic treatment provided will be recorded in the medical record. ABLA should only be documented when 1) blood loss of sufficient amount requires transfusion of blood products or 2) transfer to higher level of care (example – outpatient admitted after procedure or inpatient transferred to either a monitored bed or ICU). ICD code assignment of ABLA will occur if documented as such by provider.
Clinical practice: Early Warning System (EWS) to recognize deterioration on medical, surgical, and progressive care patients (Adult)
- Early Warning System (EWS) provider information (loaded 01/13)
- Clinical practice: Early Warning System (EWS) to recognize deterioration on medical, surgical, and progressive care patients (Adult) (loaded 03/12)
Clinical practice: Preventing postoperative pulmonary complications (ADULT)
Adult surgical patients will be screened to identify risk for developing post-operative pulmonary complications (PPCs). Patient specific interventions to reduce PPC risk will be applied. These include pre-operative pulmonary optimization, intraoperative surgical and anesthetic modalities, post-operative pulmonary intervention through the use of pain control, patient mobilization and lung expansion maneuvers.
Clinical Practice: Management of fragility hip fracture in adults
It is an expected clinical practice that all adults presenting with low energy hip fractures will be medically assessed and complex medical issues addressed to facilitate surgery within 24 hours for non-critical patients. This clinical practice describes a multidisciplinary approach to management of these patients starting in the Emergency Department through post-operative care.
Clinical practice: Epoetin clinical practice - adults
It is an expected clinical practice that adult patients will receive epoetin for appropriate indications (anemia of chronic kidney disease, zidovudine-induced anemia, chemotherapy-related anemia, myelodysplastic syndrome, and Jehovah’s Witnesses with anemia) using standardized dosing and monitoring to ensure the safe and effective use in a hospital setting.
- Clinical practice: Epoetin clinical practice - adults (loaded 04/13)
Additional items for gastroenterologists/others utilizing endoscopy procedure area
Clinical policy: Safe procedure policy – medical imaging and endoscopy
The purpose of this policy is to standardize safe practices to ensure correct patient, correct procedure, and the correct procedure site for procedures performed in Medical Imaging and Endoscopy including the process for conducting an interactive procedure time out just prior to the onset of procedure. This policy is consistent with Safe Surgery policy and Counts policy utilized in Surgery and Labor and Delivery areas.
Additional items for behavioral health providers
Clinical practice: Behavioral health medical clearance
Guidelines for medical clearance for patients requiring inpatient psychiatric care including guidelines for lab work, vital signs, and general medical care needs.
- Clinical practice: Behavioral health medical clearance (loaded 02/12)
Additional items for adult critical care medicine/intensivist
Clinical practice: Ventilator and sedation management – adult
Patients on the mechanical ventilator require awakening and breathing trials as early as possible to lead to extubation and avoid complications associated with ventilation. This clinical practice outlines a consistent process to address this.
Clinical practice: Acute respiratory distress syndrome – adult
All mechanically ventilated adult patients will be monitored for the presence and development of Acute Lung Injury (ALI) and the Acute Respiratory Distress Syndrome (ARDS). Identified patients will be treated with standardized approaches to mechanical ventilation that has been proven to reduce mortality including, but not limited to, use of low tidal volumes and adequate levels of PEEP.
Clinical practice: Inhaled nitrous oxide in patients with ARDS – adult
The purpose of this clinical practice is to standardize the use of iNO when it is chosen as a rescue therapy in patients with ARDS. iNO should only be considered after evidence-based strategies for ARDS management have failed and when trained and experienced practitioners believe that iNO can be of therapeutic benefit as a rescue therapy.
Clinical practice: ICU delirium identification, prevention and treatment – adult
Intensive care patients will have routine diagnostic screening and intervention to minimize the incidence and consequence of acute delirium. All caregivers should be aware of the range of delirium risk factors in the ICU. This clinical practice outlines use of validated diagnostic screening tool to be implemented as appropriate for ICU patients and preventative non-pharmacologic measures to be incorporated into the standard of care for all ICU patients. For patients with positive ICU Delirium screening, rapid and comprehensive protocol treatment will be utilized including management of sedations, analgesia, and delirium management therapies.
Clinical practice: Pooling of multiple respiratory specimens collected via bronchoscopy (single episode) for mycobacteria, fungi, legionella, pneumocyctis, as well as for quantitative bacterial culture for ventilator associated pneumonia
When multiple bronchoscopically obtained washings or bronchoalveolar lavage specimens (single episode) are sent on the same patient with requests for these tests, they will be pooled before processing for these organisms (with concentration where required)- rare exceptions will be made if clinically necessary.
Clinical practice: Hyperglycemic crisis in non-pregnant adults
Outlines standardized interventions to manage all non-pregnant adult patients diagnosed as presenting with Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS).
Clinical practice: ICU moderate-severe ETOH/substance withdrawal adult
Outlines expected clinical practice to address patients in an ICU setting with moderate to severe Alcohol Withdrawal Syndrome utilizing an aggressive withdrawal scale (physician should be at bedside prior to initiation).
Clinical practice: Prioritizing ED to critical care admissions – adult
Patients requiring immediate high intensity care in the Emergency Room will be prioritized for transfer to critical care locations. Those patients unable to be immediately transferred will receive critical care services to allow for high intensity management. This clinical practice outlines the high priority clinical indicators and types of interim management for critical care level services in the Emergency Department.
Clinical practice: Point of care chest ultrasonography - adult
This recommended Clinical Practice outlines the use of Point of Care (POC) Ultrasonography (US) for critically ill patients focusing on the chest for rapid assessment of the heart (“pump”) and volume (“tank”) related to shock and CHF. This rapid patient assessment will determine etiology of hemodynamic compromise, adequacy of fluid resuscitation and direct appropriate therapy.
Additional items for cardiologists
Clinical practice: Adult Implantable Automatic Cardio-Defibrillators (ICDs)
Outlines screening for eligibility criteria and exclusion criteria to assure evidence-based criteria are met prior to implementation of an ICD in an adult patient.
- Clinical practice: Adult Implantable Automatic Cardio-Defibrillators (ICDs) (loaded 10/11)
- Clinical practice: ICD - Summary of DOJ NCD false claims investigation (loaded 10/12)
Clinical policy: Invasive cardiovascular services: sponge, sharps and instrument counts
This Clinical Practice outlines the count procedure process to be performed in the invasive cardiovascular services procedure areas. This process is consistent with the system-wide counts policy utilized in the general operating rooms.
- Clinical policy: Invasive cardiovascular services: sponge, sharps and instrument counts (loaded 10/12)
Clinical policy: Safe procedure policy – cardiovascular services
The purpose of this policy is to standardize safe practices to ensure correct patient, correct procedure, and the correct procedure site for procedures performed in the Invasive Cardiovascular Labs including the process for conducting an interactive procedure time out just prior to the onset of procedure. This policy is consistent with Safe Surgery policy and Counts policy utilized in Surgery and Labor and Delivery areas.
Clinical practice: Dx and eval for syncope - adult
All adult patients presenting to the emergency department with syncope will be risk stratified based on their history and physical exam, electrocardiogram (ECG), blood pressure measurement, age and cardiac risk factors. Further testing to establish the etiology of the syncope will be based on the recommendations from the 2006 American Heart Association and the 2009 European Society of Cardiology.
- Clinical practice: Dx and eval for syncope - adult (loaded 07/12)
Clinical practice: Diagnosis and evaluation for chest pain – adult observation patients
It is an expected clinical practice that all adult patients with unspecified chest pain that is low risk, atypical, or an unusual presentation for acute coronary syndrome (ACS) and does not require immediate inpatient hospitalization and/or intervention should be considered for placement in observation status to further evaluate their cardiac risk.
- Clinical practice: Diagnosis and evaluation for chest pain – adult observation patients (loaded 03/13)
Clinical practice: Heart failure exacerbation outpatient – adult
This recommended clinical practice states that all adult patients presenting in the Emergency Department (ED) with heart failure (HF) exacerbations will be assessed for acute conditions; and if they do not meet criteria for inpatient hospitalization, they should be considered for treatment in an outpatient/observation setting.
Clinical practice: Administration of intravascular iodinated contrast media - adult
All adult patients (inpatient and ambulatory care) at Banner facilities receiving intravenous iodinated contrast will have contrast administered following a process that identifies risk for complications and ensures safety measures.
Additional items for neurologists
Clinical practice: ED treatment acute ischemic stroke - adult
All adult patients presenting to the ED with a possible acute ischemic stroke and consideration of IV thrombolysis will undergo emergent evaluation and treatment, including high acuity assignment in triage, a standard focused history, a standard focused neurological exam, expedited diagnostics including continuous cardiac monitoring and a stat brain CT without contrast, and prompt control of blood pressure. Includes guidelines for administration of thrombolytic therapy with intravenous tPA (Alteplase) to be administered within 60 minutes of patient arrival, or initial evaluation, to all ischemic stroke patients who meet established criteria within 4.5 hours of symptom onset, unless otherwise contraindicated.
Clinical practice: Initial evaluation and treatment of patients with hemorrhagic stroke
All adult patients with possible acute hemorrhagic stroke will undergo emergent evaluation and treatment, including a standard focused history and neurologic exam as well as diagnostic evaluations including continuous cardiac monitoring, stat brain CT without contrast, and prompt control of blood pressure.
