Mercy-Orders-DEM-ICH.txt Mercy Hospital of Pittsburgh DEM Intracranial Hemorrhage (ICH) Orders Change List The Owner of this Standing Order is Bruce MacLeod, M.D., Chair, DEM. Suggestions for changes should be emailed to both of Dr. MacLeod's Delegates for this Standing Order: Keith Conover, M.D. John Whiteford, M.D. Change List started 11/25/06 with version 2.0 dated 7/11/06. Most recent changes or proposed changes at top. See also Mercy-Orders-Template.txt and Mercy-Orders-Signature- Template.txt for additional notes of changes that apply to all orders. Proposed changes to version 2.1: - Based on discussion and vote at the DEM meeting 3/13/07, added a note to the ICH orders about "Decision made that patient not candidate for tPa or other anticoagulants if these orders used" purely for documentation reasons. - Added "Green is the Medical Records original copy. Please retain." at the bottom. - Made the wording a bit more clear by saying "Discuss with on-call interventional neurologist through the Transfer and Communications Center (TACC) dispatcher by radio or telephone at extension 5678 for possible alternate treatment options. If unable to reach interventional neurologist in reasonable time, or IF interventional neurologist and emergency physician BOTH agree systemic alteplase (tPA) is best option, give alteplase (ACTIVASE, tPA)." (additions CAPITALIZED) - changed a typo in the header that said "use after Brain Attack Orders if CT negative for bleed" to "positive for bleed" and a typo in the spelling of "ticlopidine"; changed "Vitamin K: 10 mg IV" to "Vitamin K 10 mg IV" - Suggested we add a place to document the time infusion started and finished, but this does not fit within the context of "physician orders to nurse" so added a notation to "record infusion start/stop time in nurses' notes." - will add urine tox screen: "urine tox screen for sympathomimetic drugs which is a standard part of the workup for a hemorrhage stroke especially in young patients. If a person is on one of these drugs it greatly increases the risk of arterial dissection during angiography in addition to being a possible reason for the hemorrhage." (John Baker) - Decided that, on the initial BAPET orders, we can do just a type and screen, and on the ICH or Thrombolytic orders, we can add FFP or type and cross as appropriate. - Added back the "Neurosurgical candidates only: consult anesthesia STAT to see patient in ED; triple lumen central line kit with extra drapes and ultrasound cover to bedside" that was on version 1.0 but left off of version 2.0 for unclear reasons. Changes prior to version 2.0 (7/11/06): - Changes made in platelet ordering flow to make more clear. "Page #1 of ICH rders: some confusion regarding how much platelet transfusion is needed if a patient is on coumadin+aspirin and also has a platlet count less than 100,000. Do you tranfuse 6+2 units? Verbage is somewhat confusing." (Kaveh Ilkhanipour) - fixed a dosing error in labetalol (mcg changed to mg) and moved the BP management to the Brain Attack orders. Changes prior to version 1.0 (7/31/05) - "Seems to me that, rather than a set of standing orders, what you had in the Word file was an optimistic outline of what should be done, but not in the form of standing orders. Telling a nurse to give a medication if she thinks the patient has uremic platelet dysfunction is not, according to the nurses with whom I spoke, an order they would be willing to accept. "So I tried to structure this as a sort of program flowchart in words and boxes, organized neatly. It is actually a lot different than the Word file. I had to take a lot of liberty with it."