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Management of STAT Medications for Inpatient Units (6.1.7)

Management of STAT Medications for Inpatient Units (6.1.7) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.7


UW HEALTH CLINICAL POLICY 1
Policy Title: Management of STAT Medications for Inpatient Units
Policy Number: 6.1.7
Category: UW Health
Type: Inpatient
Effective Date: November 15, 2016

I. PURPOSE

To standardize the process for communicating and handling STAT medication orders to ensure the best
possible outcome for the patient.

To clearly outline roles and responsibilities to ensure a consistent response from all disciplines in critical
situations.

II. SCOPE

This policy pertains to UW Health inpatient units when STAT medication orders exist. For potentially life-
threatening situations or when patients are unresponsive, staff should have a low threshold to call a Code
Blue and refer to procedures outlined in UW Health clinical policy #5.1.2, Cardiopulmonary Resuscitation
Response Team. Calling a Code Blue allows for an immediate response by an interdisciplinary team and
ensures availability of necessary medications and supplies.

III. DEFINITIONS

A. “Code Blue”: An emergency code circumstance called at UW Health for unresponsive people and others
with potentially life-threatening situations.
B. ”STAT” medication: A medication with a rapid onset of action that is needed for a potentially life threatening
condition, emergency situation, or when a patient is experiencing acute pain, agitation or severe discomfort.
i. The types of medications that would most often be processed as STAT include:
a. Intravenous antihypertensives or antiarrhythmics
b. Intravenous vasopressor medications for treatment of hypotension
c. Parenteral antipsychotics/sedatives for management of acute behavioral episodes,
psychotic episodes or sedation for ventilated patients
d. Parenteral anticonvulsants for acute management of seizures
e. Hemostatics for the treatment of acute bleeding
f. Racemic epinephrine
g. Medications for treatment or prevention of anaphylaxis
h. Parenteral or oral analgesics for the treatment of acute pain, including migraine
headaches
i. Intravenous fluids and electrolytes to treat serious electrolyte imbalance, dehydration,
hypotension
j. Antidotes for treatment of medication or chemical toxicity
k. Agents needed to acutely reverse other medication effects
l. Thrombolytics except for catheter clearance
m. High-dose glucocorticoid steroids for spinal cord injuries or meningitis
n. Anti-infectives for the treatment of febrile neutropenia and serious infections such as
meningitis and sepsis
o. Anti-infectives, insulin and other premedication in anticipation of emergent
surgeries/procedures
p. Aspirin for patients suffering an acute MI or stroke
q. Nitroglycerin (all routes) for treatment of chest pain or myocardial ischemia
r. Antiemetics for treatment of nausea and vomiting
s. Insulin for treatment of hyperglycemia or hyperkalemia
t. Glucose and glucagon for treatment of hypoglycemia
u. Mannitol or hypertonic saline for treatment of increased intracranial pressure
v. Bronchodilators for acute shortness of breath or bronchospasm
w. Anticoagulants for new venous thromboembolism diagnosis
x. Anxiolytics, sedatives and opioids for acute air hunger or anxiety in palliative care patients
C. Turn around time: The amount of time required from order entry or verbal communication of the order to
medication administration to the patient.



UW HEALTH CLINICAL POLICY 2
Policy Title: Management of STAT Medications for Inpatient Units
Policy Number: 6.1.7

D. SECURE tube: A special function of the pneumatic tube delivery system that requires the person receiving
the tube to enter a security code (e.g., 3333) in order to release the tube from the tube station. The tube
station will beep after the tube arrives at the tube station until the security code is entered.

IV. POLICY ELEMENTS

A. STAT medication turn around time should be less than 30 minutes with the expectation that medications will
be procured and administered to the patient as soon as safely possible.
B. Assigning the status of “STAT” to a medication is intended to ensure the responsiveness of the system when
these medications are needed.
C. Effective and frequent communication between providers is essential in situations when STAT medications
are needed.
D. All medication orders, excluding Code Blue events, must be entered into the electronic medical record and
include documentation of administration.
E. In emergency situations, healthcare providers should optimize medication administration response time by
using medications readily available on the patient care units (e.g., crash carts, automated dispensing
cabinets, pharmacist locked drawers, floor stock, etc.).

V. PROCEDURE

A. The ordering provider enters a STAT medication order into the electronic medical record and flags it as
“STAT.” The ordering provider should contact the patient’s nurse or respiratory therapist to communicate the
need for STAT medication administration.
B. In some circumstances, verbal orders are necessary and appropriate for communicating STAT medication
needs. In such circumstances, it is expected that providers comply with requirements for safe verbal order
processing as outlined in UWHC policy #8.16, Patient Care Orders.
C. When learning of a STAT medication need, the pharmacist immediately addresses the STAT medication
need and reviews the order for clinical appropriateness.
D. If procured from central pharmacy, central pharmacy staff will prepare medication immediately, label as
STAT, and tube medication to patient care location. The SECURE tube function will be used where
available. If medication cannot be sent via pneumatic tube system, medication will be delivered to the
patient’s nurse, nurse care team leader, unit pharmacist, or health unit coordinator with instructions
regarding the STAT nature of administration.
E. The medication is administered to the patient as soon as safely possible and the administration is
documented in the electronic medical record.

VI. COORDINATION

Author: Director, Pharmacy
Senior Management Sponsor: VP, Quality and Patient Safety
Reviewers: Director, Medical Nursing
Approval committees: Medication Safety Committee; Pharmacy and Therapeutics Committee; UW Health
Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: October 17, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee



UW HEALTH CLINICAL POLICY 3
Policy Title: Management of STAT Medications for Inpatient Units
Policy Number: 6.1.7


VIII. REFERENCES

UWHC policy #7.36, Emergency Response Teams
UWHC policy #8.33, High Alert Medication Administration
UW Health clinical policy #5.1.2, Cardiopulmonary Resuscitation Response Team
UWHC policy #8.16, Patient Care Orders
Nursing Patient Care departmental policy #10.19AP, Medication Administration Using Barcode Scanning
Technology (Adult and Pediatric)
The Center for Medicare and Medicaid Services, Interpretive Guidelines §§482.23(c) and (c)(1)

IX. REVIEW DETAILS

Version: Revision
Next Revision Due: November 2019
Formerly Known as: Hospital Administrative policy #7.08