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201505147

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Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

ED - Protocols (11.0)

ED - Protocols (11.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department

11.0

POLICY & PROCEDURE





Effective Date:
November 14, 2014

 Administrative Manual
 Nursing Manual
 Other _______________

11.0
Revision Page 1 of
2

Emergency Department- Protocols




I. PURPOSE

To expedite patient care and facilitate throughput of patients by delegating responsibility to RN’s from ED
physicians to place initial care orders for the management of patient symptoms.

II. POLICY

Emergency Department (ED) nursing staff may implement chief complaint and/ or symptom driven ED
protocols immediately upon a patient’s arrival.

III. PROCEDURE

A. ED Protocols (Appendix A)
i. ED Immediate Orders- Adult applies to patients greater than 17 years of age.
ii. ED Immediate Orders- Pediatric applies to patients 17 years of age and younger.
iii. The ED RN initiates the immediate orders if documented symptoms or conditions are covered
in the order sets.
iv. The ED RN will follow specific ordering instructions that apply to the patient’s symptom/
condition being treated.
v. All orders within a protocol set, which are not single select, must be applied.
vi. Venous access will be ordered if needed to carry out orders to treat specific symptoms/
conditions.
vii. The ED RN signs the orders with the order mode ‘per protocol with co-signature’.
1. Orders may be acted upon before co-signature occurs.

B. Review of standing and immediate orders
i. ED Clinical Ops will review the ED Protocols annually and make any recommendations for
changes.
ii. Recommendations for changes will be shared with the ED physician group.
iii. Once approved, the recommendations will be forwarded to the ED Steering Committee.
iv. Any changes involving medications (including additions) will be taken to P&T Committee for
approval.
v. Approved changes will be sent to the Health Link (HL) Orders Team for build in HL.
vi. Changes will be implemented in HL.

D. Accessing Standing and Immediate Orders in HL
i. Open the patient’s chart.
ii. Click on “ED Navigator”.
iii. Click on the “Orders” tab at the top of the page.
iv. Search “Immediate”.
v. Select “Immediate Order Adult” or “Immediate Order Pediatric”.
vi. Click “Open order set”.
vii. Select chief complaint to access orders.


POLICY & PROCEDURE





Effective Date:
November 14, 2014

 Administrative Manual
 Nursing Manual
 Other _______________

11.0
Revision Page 2 of
2

Emergency Department- Protocols









IV. COORDINATION
Review by:
Director, Emergency Services
ED Clinical Operations Services
Vice Chair of Quality and Operations

V. SIGNED BY

Jeff Pothof, MD
Vice Chair of Quality and Operations
Department of Emergency Medicine


Tami Morin, MS, RN
Director
Emergency Services