Provider Orientation & Resources  

All Adult Medicine Providers
(includes all medical subspecialities)

 

Note: open ALL links and attachments that are applicable to your area(s) of practice.

Learn more about:

Acute Myocardial Infarction (AMI)
Review of CMS core measures for inpatients and outpatients presenting with AMI or cardiac related chest pain.


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: 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.


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)


Heart failure
Review of CMS core measures for inpatients with diagnosis of Heart Failure.


Clinical Practice: Sepsis And perFusion Evaluation (SAFE) for High Risk Patients-Adult
It is an expected clinical practice that all adult patients who meet criteria for an S.A.F.E. (Sepsis And perFusion Evaluation) Alert will be considered high risk for mortality and will be evaluated for severe sepsis and perfusion status.  When an SAFE alert fires on a patient, a SAFE Alert Review form will be attached and can be used to document evidence of active infection, assessment for other causes of hypoperfusion, and orders for lactic acid and NS bolus.  Patients will be reevaluated for targeted interventions as well as current diagnosis and treatment options.


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 SAFE 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 hours of ED admission and within 1 hour 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.


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: Prevention of Catheter-associated Urinary Tract Infections
It is an expected clinical practice that all adult and pediatric patients requiring an indwelling urinary catheter will receive appropriate Catheter-associated urinary tract infection prevention (CAUTI) strategies.


Decrease readmission rate (AMI, HF, PN, COPD, THA/TKA and all cause)
It is a Banner Health system initiative to decrease hospital readmission rates, specifically readmissions within 30 days of discharge, for a composite measure of patients with AMI, HF, PN, COPD and Total Hip Arthroplasty/Total Knee Arthroplasty and for readmissions for any cause. 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, notification of primary care providers and assuring follow-up appointment with primary care provider within 7 days of discharge. Cerner will have an mPage that will identify patients at risk for readmission.


Clinical Practice: Delirium Identification, Prevention and Treatment  
It is an expected clinical practice that all adult Intensive Care, Medical-Surgical, Progressive care, and Emergency Department (ED) patients will have routine screening and interventions, such as medication management, orientation to the environment, early mobility, and promotion of sleep/rest cycles, to minimize the incidence, duration and negative consequences of delirium.  This clinical practice has been defined but not yet fully implemented.


Clincial Practice: 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.


Clinical Practice: Comfort care bundle for actively dying adult patients
It is an expected clinical practice that all hospitalized adult patients identified by their providers as having entered the actively dying phase will have the comfort care bundle initiated.  The bundle includes affirmation and documentation of CPR status, the decision maker, and goals of care as well as use of the comfort care order set and interdisciplinary referral as appropriate. This clinical practice has been defined but not yet fully implemented.


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: 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: Appropriate use of fecal transplants for relapsing clostridium difficile infection in adults
As a recommended clinical practice, adult patients presenting with relapsing or refractory Clostrdium difficile infections, who have failed medical therapy, may be considered for fecal transplant to restore normal bowel flora. This clinical practice outlines patient selection criteria, donor selection criteria, and communicable disease screening requirements in order to ensure patient safety. 


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
All non-critically ill inpatients with hyperglycemia will be managed with scheduled subcutaneous insulin to improve glycemic control as defined by a reduction in hyperglycemia (BG > 180 mg/dL) and hypoglycemia (BG <70 mg/dL).


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 Policy: Procedural sedation for therapeutic/diagnostic procedure
This clinical policy applies to both Adult and Pediatric Patients and defines the circumstances under which procedural sedation may be administered and define responsibilities and parameters for the management of the patient requiring procedural sedation for pre-intra-post, short-term diagnostic, or therapeutic procedures including monitoring requirements.  This clinical policy has been defined but not yet fully implemented.


Clinical practice: Quantitative and qualitative exhaled carbon dioxide measurements during procedural sedation pediatric and adult patients 
It is an expected clinical practice that all inpatients and outpatients of any age and clinical setting receiving anesthesia (moderate, deep, general and regional ((with sedation)) will, in addition to standard monitors, have the ventilation evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide.  This clinical practice has been defined but not yet fully implemented.


Clinical Practice:  Management of Known Difficult Airway – Adult and Pediatrics (Excludes Neonatal)
It is an expected clinical practice that patients having a known difficult airway will receive care specific to the identified airway type that includes an electronic alert, coordination of care and airway management.  The patient will receive information and documentation related to their difficult airway and the need for notification of providers during future care.  The clinical practice design includes the creation of system-wide standards for the identification of patients with known difficult airways, EMR alerts and notifications across clinical modalities, preparation and approaches for intubation and extubation  including standardized airway carts and supplies, and the continuation of patient care planning outside the acute episode.


Clinical practice: Insulin drip transition post cardiac surgery - adult
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: Use of medication for the reversal of anticoagulation - adult
It is an expected clinical practice that all adult patients presenting to a Banner facility (inpatient and emergency room department) in need of anticoagulation reversal to prevent or minimize negative outcomes (e.g., bleeding events) will be assessed to determine the most appropriate reversal strategy. This will include selection of the most appropriate medication/reversal agent based on the patient’s anticoagulation therapy.


Clinical Practice: Transitioning post-operative cardiac surgery patients - Adult
It is an expected clinical practice that all adult post-operative cardiac surgical patients will receive a follow up phone call within 48 hours after discharge, be scheduled for physician follow up appointments with cardiologist, cardiothoracic surgeon, and/or primary care physician before discharge and will receive automatic referral and authorization to cardiac rehabilitation to prepare for transition to the next level of care incorporating individual outpatient resources.


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: Blood transfusion – adult
It is an expected clinical practice that all adult patients who are hemodynamically stable will not routinely receive packed red blood cells when the hemoglobin level is above 7.0 grams/deciliter. While the 7 g/dl red cell transfusion threshold for hemodynamically stable patients serves as a guideline for the majority of patients, there may be clinical circumstances that necessitate red cell transfusion at hgb levels higher than 7 g/dl.  Examples may include patients with signs or symptoms of anemic hypoxia and/or organ ischemia, patients with ongoing blood loss, and patients at risk of complications due to inadequate oxygenation. This clinical practice also outlines pre-operative and perioperative assessment and management regarding potential blood transfusion.


Clinical Practice: Use of Cytomegalovirus (CMV) Seronegative Blood Products (Adult and Pediatric)
It is an expected clinical practice that patients requiring red blood cell transfusions who are allogeneic stem cell transplant recipients in whom both the donor and recipient are CMV negative; or fetuses receiving intrauterine transfusion; or neonates who have received an intrauterine transfusion will receive CMV Seronegative Blood Products.


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)
Adult patients in Medical Surgical and Progressive Care units will have routine Early Warning System (EWS) screening and interventions based on changes in blood pressure, heart rate, respiratory rate, temperature, pulse oximetry, and level of consciousness using an evidence-based EWS screening tool administered on admission, at change of shift, and with changes in patient condition.  An EWS score will be calculated and interventions based on the score may include increased vital sign frequency, strict intake and output, notification of rapid response team, notification of charge nurse and physician, and possible transfer to higher level of care, resulting in a decrease in mortality, hospital length of stay, and code blue calls.


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: Management of Uncomplicated Deep Vein Thrombosis (Adult)
It is an expected clinical practice that all adult patients presenting to the Emergency Department with uncomplicated Deep Vein thrombosis (DVT) not requiring admission for other reasons will be discharged with anticoagulation and outpatient follow-up.  The management of Deep Vein Thrombosis (DVT) varies among providers.  With the use of low molecular weight heparin and oral Xa inhibitors it has been shown that patients can be safely and effectively be discharged home without increased risk for complications.  With this in mind, following a more structured and consistent approach to the management of patients with uncomplicated DVTs can lead to the safe discharge of this patient population reducing avoidable admissions.  This clinical practice has been defined but not yet fully implemented.


Clinical practice: Preoperative testing for elective surgeries - adults
It is an expected clinical practice that all elective surgery adult patients will receive preoperative testing based only on clinical indication. Avoid routine tests unless testing for specific indications or purpose.


Clinical Practice: Management of asymptomatic pyuria and bacteriuria – adult
It is an expected clinical practice that adult patients with no symptoms of urinary tract infection (UTI) should not be screened for UTI with urinalysis or culture, including patients with indwelling foley or supra pubic catheter.  In the event that an asymptomatic patient is screened, a finding of pyuria and/or growth of bacteria or fungi should not lead to treatment with antibiotics based on IDSA (Infectious Disease Society of America) guidelines of 2005.  Exceptions are asymptomatic patients who are pregnant or are undergoing urologic surgery for which screening and antibiotic treatment may be indicated.

There are conflicting recommendations from expert specialty organizations regarding the treatment of asymptomatic bacteriuria in patients undergoing elective joint replacement surgery.  Therefore, physicians should weigh the risk of infection in these patients vs. the risk of antibiotic use on a case by case basis.


Clinical Practice: Gynecologic Oncology Referrals (Adult) Language
It is an expected clinical practice that all adult gynecological oncology patients with confirmed or suspected gynecologic malignancies will be referred to a gynecological oncologist or a physician trained in gynecological surgical procedures to perform debulking and/or staging.


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: Management of hyponatremia in non-pregnant adults
It is an expected clinical practice that all non-pregnant adult patients presenting with hyponatremia will undergo correction based on chronicity, volume status and severity. A treatment algorithm will be used to manage all levels of hyponatremia including, when indicated, 3% saline. Expected monitoring practices will be a part of the treatment algorithm to ensure safe and appropriate adjustments to care based on patient response. This clinical practice has been defined but not yet fully implemented.


Clinical Practice: Inpatient Management of Neurogenic Bladder - Adults 
It is an expected clinical practice that all adult patients identified with neurogenic bladder caused by central or peripheral nervous dysfunction will be managed using an interdisciplinary approach designed to minimize complications and improve urinary dysfunction outcomes. This clinical practice outlines a systematic care plan/program to be utilized. This clinical practice has been defined by not yet fully implemented.


Clinical Practice:  Inpatient Management of Neurogenic Bowel - Adults
It is an expected clinical practice that all adult patients identified with neurogenic bowel caused by centralized or peripheral nervous dysfunction will be management using an interdisciplinary approach designed to minimized complications and improve bowel dysfunction outcomes. This clinic practice outlines a systematic care plan/program to be utilized. This clinical practice has been defined but not yet fully implemented.


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.

Clinical Practice: Anesthesia care for adult endoscopy
It is an expected clinical practice that all adult patients undergoing endoscopy procedures will be evaluated by the performing providers to determine the need for involvement of an anesthesia provider based on procedure type and qualifying medical condition(s). If deemed necessary, then a qualified Anesthesia provider will be consulted to evaluate the patient and provide the anesthesia care service. Applicable documentation to support medical necessity and request for consult will be completed.


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.


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: 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:  Therapeutic Hypothermia in Cardiac Arrest Patients - Adult
It is an expected clinical practice that all cardiac arrest patients who have return of spontaneous circulation (ROSC) but remain comatose will have therapeutic hypothermia initiated and completed over 24 hours to improve mortality and neurological outcomes.  This clinical practice has been defined but not yet fully implemented.

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.

Clinical practice: Daily chlorhexidine gluconate (CHG) for patient hygiene
It is an expected clinical practice that all adult inpatients in a critical care unit will receive daily chlorhexidine gluconate (CHG) hygiene, except where contraindicated or excluded. All patients having surgery will receive a CHG bath pre-operatively. This clinical practice has been defined but not yet fully implemented.

Clinical Practice: ICU Palliative Care Bundle - Adult 
It is an expected clinical practice that all adult patients in the ICU with a length of stay greater than or equal to 1 day will have affirmation and documentation of resuscitation status and medical decision maker in their record, and on days 3 to 5 of the ICU stay, an interdisciplinary family meeting regarding goals will be held with initiation of interdisciplinary referrals as needed, all elements of the ICU Palliative Care Bundle.    This clinical practice has been defined but not yet fully implemented.


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 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: 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: Coronary artery angiography and/or percutaneous transluminal angioplasty medical necessity
It is an expected clinical practice that all patients presenting with angina, angina equivalent symptoms, acute coronary syndrome or moderate to high risk patients with or without symptoms and positive functional testing may be considered for Coronary Artery Angiography and/or Percutaneous Transluminal Angioplasty (PTA) based on established medical necessity guidelines.  Identification of the medical necessity for the procedure, signature, date, and time will be established prior to procedure and documented in the Medical Record prior to procedures or medical interventions.

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: 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: 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: Initial evaluation and treatment of patients presenting with Acute Ischemic Stroke or Transient Ischemic Attack, including the use of Thrombolytics
It is an expected clinical practice that all adult patients presenting to the ED with acute neurologic symptoms consistent with stroke will undergo emergent evaluation and treament, including high acuity assignment in triage, a standard focused history, a standard focus 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 patienets who met established criteria within 4.5 hours of symptom onset, unless otherwise contraindicted.  It also outlines evaluation and mangament of patients presenting with Transient Ischemic Attacks (TIA) including guidelines for patient disposition.


Clinical practice: Initial evaluation and treatment of patients with hemorrhagic stroke - Adult
It is an expected clinical practice that 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.


Clinical Practice:  Evaluation, Management and Treatment of Adult Patients Presenting with Mild Traumatic Brain Injury
It is an expected clinical practice that all patients over the age of 18 with Mild Traumatic Brain Injury (TBI) will undergo and complete neurologic evaluation, which includes a comprehensive concussion history, review of systems, mini-mental status exam, cranial nerve exam, motor and sensory exam and postural stability exam.  Management and treatment of mild TBI is to occur until there is resolution of symptoms and deficits.  This clinical practice has been defined but not yet fully implemented.


Additional items for medical oncologists

Clinical Practice: Positron Emission Tomography (PET) Scans in the surveillance of Asymptomatic Patients with Lymphoma
It is an expected clinical practice that All adult patients with aggressive lymphoma who have achieved a complete response will not receive routine surveillance positron emission tomography (PET) scans unless clinically indicated, due to the risk for false positives.


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