KPHC Full Outage – Saturday, September 23, 2023, 1:00 AM – 2:30 AM. Please use down time forms during this time.
Author: Viet Tran
Behavioral / Regulatory Barriers
- Requiring methadone for addiction
- Peritoneal dialysis
- Patients who present a threat to the safety and well-being of other patients
- IV/IM psychotherapeutics required in last 48 hours (except extended release)
- Physical restraints required/in use in last 48 hours
- No capacity and no decision-maker
- Hospice benefit elected
- Eating disorders (Primary diagnosis for current admission)
- Patients refusing all medications and care
- COVID-19+ isolation patients who are combative/not redirectable/wander
Medical / Nursing Behaviors
- CRE/CRO spectrum +
- Cardiac Rehabilitation required
- Ventilator-dependent
- Bi-pap to Trach Oxygen >7L/m or FIO2> 30%
- IV cardiac medications
- COVID-19+ isolation patients who also require isolation for another organism
Just a reminder that the kick off is coming 8/21/23
No new information since the presentation by James last month.
In brief:
Please use CHF orderset.
Please use CHF DC specific drop down menu in summary.
CHF DCI still not available as of today per region. Will update once it is available. Please use current .DCU with current drop down CHF instruction as appropriate.
Come have an amazing time in the sun with your colleagues and their family / pets! We will have tacos / quesadillas (grilled on site) along with an assortment of beverages (both alcoholic and non-alcoholic) and snacks! Lots of fun activities for the kids as well! We have reserved the picnic tables under the Pavilion. There is a big playground at this park catered to both young and older children.
When: Saturday September 16, 2023 from 1 – 5pm
Where: Jean Sweeney Open Space Park. 1100 Atlantic Ave, Alameda, CA 94501
Who: You + Immediate family + Pets
What to bring: Picnic Blankets, Sunscreen
Sponsored by : PHW & PICs
Departments: HBS, Cardiology, Urology, Infectious Disease, Interventional Radiology, Gastroenterology, Special Guests : Eric & Kapil
Questions?: Email Jeannie at hoa.n.tran@kp.org or text 510-203-2949
- Please use the ERM MMA order set (see photo below) that is embedded in our HBS admit order set. If it’s not ordered on admission, then you can still order it during the hospitalization using .ermmma
- Please avoid ordering norco or Percocet. If a patient is taking this chronically and you are continuing for admission, then please decouple and order oxycodone plus ATC Tylenol.
- Please educate patients on the importance of using ATC medications. You could mention that ATC Tylenol provides enough analgesia that the patient may not need opioids at all. Some of the outliers we are seeing have the correct orders, but because the patient refused the ATC medication, it was captured as an outlier.
Indications for Inpatient Echocardiograms
CVA/TIA
Per KP Stroke Clinical Practice Reference, “Echocardiography, both Transthoracic Echocardiogram (TTE) and Transesophageal Echocardiogram (TEE), is generally NOT recommended in the routine evaluation of TIA or stroke as the yield for finding a lesion which would alter therapy is very low
TTE (and TEE if TTE is unrevealing) should only be done for:
- Patients with cryptogenic stroke and history of previous cardiac problems / abnormal EKG.
- Young patients (age < 60) without other obvious etiology.”
Atrial Fibrillation/flutter
An echo is indicated for a new diagnosis of atrial fibrillation. This can be done as an outpatient unless there is a significant murmur or if the patient has new congestive heart failure.
If a prior echo exists, then repeating an echo is not necessary unless there is a new murmur or CHF.
Syncope
An inpatient echo should be done if there is a new murmur on exam. Otherwise, this can be done as an outpatient. If a prior echo exists without significant valvular disease (in the past 5 years), then a repeat echo is not needed.
CHF
Inpatient echocardiogram is indicated for patient with a new diagnosis of CHF. If the patient has had a prior echocardiogram documenting HFrEF, inpatient echocardiogram is not needed, and the patient should follow-up with his/her cardiologist. Patients with known HFpEF do not need repeated echocardiograms.
Endocarditis
Echocardiogram is indicated for bacteremia with a microbe known to be a common cause of endocarditis. Echocardiogram is not indicated for transient bacteremia with a pathogen not typically associated with endocarditis.
Insulin:
At first Lantus 0.3 units/kg x 1 (or start home dose insulin) and lispro 0.3 units /kg x 1
Then: Lispro 0.2 units/kg q4h.
Glucose monitored every 2 hours.
Protocol ends when sugars are less than 250. AG monitored to make sure it is decreasing. May still be elevated at the end of the protocol.
Fluids:
LR: 2 L then 500 mL/hr to complete total of 5 L.
D5-1/2NS with or without K: 150 mL/hr
Both fluids will run together. LR will stop when hits total of 5 L or when glucose is <250
D5 continues until 6 hours after last high dose lispro from protocol was given.
If the patient has CHF or renal failure, you will need to adjust these fluids. It is the same type of adjustment you would consider if they were on an insulin gtt.
Electrolyte Replacements:
We can use the K and Mg replacement protocols that the ICU uses. Also consider changing the D5 to including KCl.
End of protocol:
You will get a call from nursing staff that the patient’s glucose is less than 250. At this point, you will need to stop the insulin. Initiate sliding scale qAcHs. Discontinue everything in the protocol except the D5 gtt. If given lantus, start the patient’s long acting insulin 24 hours after lantus was given.
Of note, the AG may be still be elevated, so just because they are off the protocol doesn’t mean they can go home. You will need to follow this until the AG is less than 12.
Who is eligible:
Those with mild to moderate DKA which is defined as pH >=7.0 via ABG or VBG and bicarb >= 10. Someone who is alert or drowsy (not comatose).
Exclusion criteria:
Severe DKA (coma, pH < 7, bicarb < 10)
Anyone who needs ICU for any other reason.
Pregnancy
Patient weighing more than 133 kg (orderset has max 40 units per dose)
Can the patient go to CDA?
No, while the patients typically remain on protocol for 8 hours, it typically takes them just over 24 hours before they AG returns back to normal with patients typically staying another day before discharge. There is no significant time difference between SQ and IV insulin if you are wondering.