Q1HR (DEF)* Q2HR Intra-Abdominal Pressure Notify Provider if greater than 15mmHg, Q4HR Activity Activity Bedrest, Constant Indicator (DEF)* Bedrest

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1 Unique Plan Description: ICU General Admission Adult Plan Selection Display: ICU General Admission Adult PlanType: Medical Version: 28 Begin Effective Date: 4/13/ :46 End Effective Date: Current Available at all facilities ICU General Admission Adult Admit/Transfer/Discharge Admit Type Assign to Utilization Review assessment protocol Admit Patient Inpt Cardiology (DEF)* Inpt GI Surgery Inpt Internal Med I (Red) Inpt Internal Med II (Orange) Inpt Internal Med III (Green) Inpt Nephrology (Yellow) Inpt Neurology Inpt Neurosurgery Inpt Pulmonary Med Inpt Surgery CT Inpt Surgery Oncology Inpt Surgery Transplant Inpt Surgery Trauma Inpt Surgery Urology Inpt Surgery Vascular Transfer Patient Condition Patient Condition Critical (DEF)* Serious Fair Good Code status other than full code requires a separate physician order.(note)* Code Status Full Code Vital Signs/Monitoring Vital Signs Basic Vital Signs, Q1HR (DEF)* Basic Vital Signs, Q1HR, PA Catheter results Q4HR, Call HO with results Basic Vital Signs, Q2HR Basic Vital Signs, Q2HR, PA Catheter results Q4HR, Call HO with results Vital Signs ICP Monitoring, Q1HR Delirium Assessment Q12HR Notify Provider Vital Signs SBP> 180, SBP< 90, HR> 130, HR< 60, MAP< 65, O2 Sat< 95%, RR> 24, T> 38.5, T< 35, UOP< 30ml/ hr, ICP> 15 Use these vital sign parameters for patients with head trauma or diabetes insipidus(note)* Notify Provider Vital Signs SBP> 180, SBP< 90, HR> 130, HR< 60, MAP< 65, O2 Sat< 95%, RR> 24, T> 38.5, T< 35, UOP> 200 ml/hr for 2 hrs, UOP< 30ml/hr, ICP> 15 Notify Provider Hemodynamic Measures CPP< 60 Neurological Checks Q1HR (DEF)* Q2HR Measurements Weight, On Arrival, ONCE Daily Weight Weight, QNIGHT Intake and Output-Strict

2 Q1HR (DEF)* Q2HR Intra-Abdominal Pressure Notify Provider if greater than 15mmHg, Q4HR Activity Activity Bedrest, Constant Indicator (DEF)* Bedrest with Logrolling, Constant Indicator Up to Bedside Commode, Constant Indicator Bed Position Elevate HOB, 30 Degrees, Constant Indicator Traction Bucks Traction (DEF)* Cervical Traction Overhead Arm Traction Pelvic Traction Tibia Pin Traction Nursing Hygiene Activity Oral Care, Q4HR, For ventilated patients Obtain Equipment Arterial Line set-up to bedside with pressure bag, ONCE Urinary Catheter Insertion Indwelling Catheter, Bedside Drain (DEF)* Condom Catheter, Bedside Drain Drain/Tube Insertion Nasogastric/Orogastric Tube, Low Continuous Suction, Constant Indicator (DEF)* Nasogastric/Orogastric Tube, Low Intermittent Suction, Constant Indicator Drain/Tube Insertion EVD, Bedside Drain, Set at 15. Record output Q1HR, Constant Indicator Drain/Tube Insertion Jackson-Pratt, Bulb Drain, Record output Q4HR, Constant Indicator Feeding Tube Insertion Nasogastric Tube, Feeding, Once Feeding Tube is inserted and prior to using, order XR Chest 1 View Frontal to confirm placement., ONCE Feeding Tube Maintenance Nasogastric Tube, Feeding, Check placement, Q4HR Chest Tube/Blake Drain Insertion Water-Seal 20 cm Suction, Record output Q4HR Dressing Change Chest, Change Chest Tube dressing daily with like dressing, Every Day Isolation Precautions Standard Precautions (DEF)* Standard Precautions Contact Precautions Standard Precautions Droplet Precautions Standard Precautions Contact Precautions Droplet Precautions Standard Precautions Airborne Precautions Standard Precautions Neutropenic Precautions Pin Care Q8HR Fecal Management System without Medication Administration Adult/Pediatric Subphase(SUB)* Fecal Management System with Medication Administration Adult/Pediatric Subphase(SUB)* Wound Care General Adult/Pediatric Subphase(SUB)* Please check the appropriate Quality Measure order if the patient's condition qualifies for one of the these quality measures.(note)* Pneumonia Quality Measures AMI Quality Measures Heart Failure Quality Measures SCIP Quality Measures Diet If dietary fluid volume restriction is needed, place under the line item of "Dietary Fluid Restricted" in the individual diet order.(note)* NPO Except Medications, sips of water for meds (DEF)* Including Medications

3 May Have Ice Chips Clear Liquid Diet Dysphagia Puree (Level 1) Dysphagia Mechanically Altered (Level 2) Regular Diet Renal Diet Adult Diabetic Diet, 1800 kcal (DEF)*, 2000 kcal, 2200 kcal Low Fat/Low Cholesterol Diet Low Sodium Diet Gastrectomy Diet Advance Diet as Tolerated Advance To Regular Diet, As Tolerated, per Guidelines (DEF)* Advance To Dysphagia Puree (Level 1), As Tolerated, per Guidelines Advance To Full Liquid Diet, As Tolerated, per Guidelines Advance To Dysphagia Mechanically Altered (Level 2), As Tolerated, per Guidelines Advance To Low Fat/Low Cholesterol Diet, As Tolerated, per Guidelines Advance To Adult Diabetic Diet, 1800 kcal, As Tolerated, per Guidelines Advance To Adult Diabetic Diet, 2000 kcal, As Tolerated, per Guidelines Advance To Adult Diabetic Diet, 2200 kcal, As Tolerated, per Guidelines If selecting Tube Feeding order, please complete either the Enteral Nutrition Initiation Adult Subphase or the Parenteral Nutrition Initiation Adult Subphase to order the specific feeding details.(note)* Bolus ADULT Tube Feeding Continuous ADULT Tube Feeding Enteral Nutrition Initiation Adult Subphase(SUB)* Parenteral Nutrition Initiation Adult Subphase(SUB)* Continuous Infusions Hyperalimentation orders will continue to be ordered using paper order form.(note)* NS BOLUS F 500 ml,, Injection, PRN, PRN Other (see comment) Comments: For arterial line with flush solution to pressure bag NS BOLUS F 1,000 ml,, Injection, ONCALL, x 1 dose(s) (DEF)* Comments: infuse over 1 hour as a bolus 1,000 ml,, Injection, ONCALL, x 2 dose(s) Comments: infuse over 1 hour as a bolus 1,000 ml,, Injection, ONCALL, x 3 dose(s) Comments: infuse over 1 hour as a bolus NS F 1,000 ml, 125 ml/hr,, Injection (DEF)* 1,000 ml, 75 ml/hr,, Injection 1,000 ml, 50 ml/hr,, Injection 1/2NS F 1,000 ml, 125 ml/hr,, Injection (DEF)* 1,000 ml, 75 ml/hr,, Injection 1,000 ml, 50 ml/hr,, Injection D5-1/2NS F 1000 ml, 50 ml/hr,, Injection D5-1/2NS-KCl 20mEq/L 1000mL F 1000 ml, 50 ml/hr,, Injection LR F 1000 ml, 50 ml/hr,, Injection amiodarone 1.8 mg/ml in D5W 250 ml Drip (mg/min) (S)* D5W Drip - INET

4 Comments: Infuse at 1 mg/min x 6 hours then change rate to 0.5 mg/min x 18 hours;conc: 1.8 mg/ml; Total Volume = 250 ml amiodarone ADDITE - INET 450 mg, 1.8, mg/min diltiazem 1 mg/ml in NS 125 ml Drip (mg/hr) (S)*, 5 mg/hr = Titration Increment, 15 min = Titration Interval Comments: Titrate to maintain sinus rhythm.hold for HR below.hold for SBP below.*conc: 1 mg/ml* diltiazem ADDITE - INET 125 mg, 5, mg/hr DOPamine 1600 mcg/ml in D5W 250mL PREMIX Drip(mcg/kg/min) (S)* premix product INET parameters, 2 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP above.*conc: 1600 mcg/ml* DOPamine INET premix 400 mg/250 ml 400 mg, 2, mcg/kg/min DOBUTamine 2 mg/ml in D5W 250 ml PREMIX Drip (mcg/kg/min) (S)* premix product INET parameters, 2.5 mcg/kg/min = Titration Increment, 10 min = Titration Interval Comments: Titrate to goal MAP of.titrate to cardiac output goal of.*conc: 2 mg/ml* DOBUTamine INET premix 500 mg/250 ml 500 mg, 2.5, mcg/kg/min epinephrine 20 mcg/ml in NS 250 ml Drip (mcg/kg/min) (S)*, 0.02 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP above.*conc: 20 mcg/ml* epinephrine ADDITE (concentration=1mg/ml) - INET 5 mg, 0.01, mcg/kg/min eptifibatide 0.75 mg/ml PREMIX Drip (mcg/kg/min) (S)* premix product Comments: start at 2 mcg/kg/min (MAX rate = 15 mg/hr (20 ml/hr); if CrCl < 50 ml/ min, reduce rate to 1 mcg/kg/min (MAX rate = 7.5 mg/hr (10 ml/hr); Conc: 0.75 mg/ml ***CONTRAINDICATED FOR USE IN DIALYSIS PATIENTS*** eptifibatide INET premix 75 mg/100 ml 75 mg, 2, mcg/kg/min tirofiban 50 mcg/ml in NS 250 ml PREMIX Drip (mcg/kg/min) (S)* premix product, x 18 hour(s) Comments: maintenance infusion 0.15 mcg/kg/min x 18hrs.If CrCl =< 60 ml/min, reduce maintenance rate by 50%*Conc: 50 mcg/ml*pharmacy: Max dosing weight = 153 kg;max maintenance rate for CrCl > 60mL/min = 1,350 mcg/hr (27 ml/hr)max maintenance rate for CrCl =< 60mL/min = 675 mcg/hr (13.5 ml/hr) tirofiban INET premix 12.5 mg/250 ml 12.5 mg, 0.15, mcg/kg/min insulin regular 1 unit/ml in NS 100 ml Drip (unit/kg/hr) (S)* NS Drip - INET Comments: Titrate per ICU insulin infusion protocol; Conc: 1 unit/ml; Total Volume = 100 ml insulin regular ADDITE - INET 100 unit, 0.1, unit/kg/hr labetalol 2 mg/ml in NS 100 ml Drip (mg/min) (S)*, 0.5 mg/min = Titration Increment, 15 min = Titration Interval Comments: Titrate to maintain MAP below.and/or SBP below.hold for SBP less than.hold for HR less than.*conc: 2 mg/ml* labetalol ADDITE - INET 200 mg, 0.5, mg/min lidocaine 4 mg/ml in D5W 500 ml PREMIX Drip (mg/min) (S)* premix product Comments: Physician only to titrate.notify physician for arrhythmias.*conc: 4 mg/ml*

5 lidocaine INET premix 2 gm/500 ml 2,000 mg, 1, mg/min milrinone 200 mcg/ml in NS 100 ml Drip (mcg/kg/min) (S)*, mcg/kg/min = Titration Increment, 10 min = Titration Interval Comments: Titrate to maintain MAP and/or SBP above.titrate to goal cardiac output of.*conc: 200 mcg/ml* milrinone ADDITE - INET 20 mg, 0.25, mcg/kg/min nitroglycerin 200 mcg/ml D5W 250mL PREMIX Drip(mcg/kg/min (S)* premix product INET parameters, 0.25 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP below.hold for SBP less than.titrate to relief of chest pain.*conc: 200 mcg/ml* nitroglycerin INET premix 50 mg/250 ml 50 mg, 0.25, mcg/kg/min nitroprusside 200 mcg/ml in NS 250 ml Drip (mcg/kg/min) (S)*, 0.5 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP below.hold for SBP less than.*conc: 200 mcg/ml* nitroprusside ADDITE - INET 50 mg, 0.3, mcg/kg/min norepinephrine 64 mcg/ml in NS 250 ml Drip (mcg/kg/min) (S)*, 0.02 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP of.*conc: 64 mcg/ml* norepinephrine ADDITE - INET 16 mg, 0.01, mcg/kg/min phenylephrine 160 mcg/ml in NS 250 ml Drip (mcg/kg/min) (S)*, 0.1 mcg/kg/min = Titration Increment, 2 min = Titration Interval Comments: Titrate to goal MAP of.*conc: 160 mcg/ml* phenylephrine ADDITE - INET 40 mg, 0.1, mcg/kg/min vasopressin 1 unit/ml in NS 100 ml Drip (unit/hr) (S)* NS Drip - INET Comments: For non-sepsis indications and organ donation: Starting dose of 1 unit/hr - titrated to a MAP goal of For sepsis: Dose of unit/hr - fixed dose, do NOT titrateconc: 1 unit/ml; Total Volume = 100 ml vasopressin ADDITE - INET 100 unit, unit/hr Heparin Drip Weight-Based (Cardiac/Stroke) Adult Protocol Subphase(SUB)* Heparin Drip Weight-Based (VTE) Adult Protocol Subphase(SUB)* Critical Care Sedation Orders Adult Subphase(SUB)* Critical Care Paralysis Adult Subphase(SUB)* Controlled Substance Infusion Adult Subphase(SUB)* Medications Order Community-Acquired Pneumonia Powerplan for patients with suspected community-acquired pneumonia(note)* Use the Epidural Adult or the Patient Controlled Analgesia PCA Adult/Pediatric PowerPlan if these analgesia types are in use or need to be ordered.(note)* Alcohol Withdrawal (LOW Dose) Prophylaxis Adult Subphase(SUB)* Alcohol Withdrawal (HIGH Dose) Prophylaxis Adult Subphase(SUB)* Stress Ulcer Prophylaxis Adult Subphase(SUB)* Venous Thromboembolism Prophylaxis Adult Subphase(SUB)* Initiate ICU MAGNESIUM Replacement Protocol 1 EA,, PRN, PRN Other (see comment) Comments: ELECTROLYTE REPLACEMENT PROTOCOL Initiate ICU POTASSIUM Replacement Protocol 1 EA,, PRN, PRN Other (see comment) Comments: ELECTROLYTE REPLACEMENT PROTOCOL albuterol-ipratropium CFC free 100 mcg-20 mcg/inh inhalation aerosol 1 puff, INH, Q6HR

6 Comments: 1 puff=100mcg albuterol / 20mcg ipratropiummax 6 puffs/24hr (**NOTE NEW FORMULATION** Brand = Combivent RESPIMAT) albuterol-ipratropium 3-0.5mg jet neb RT treatment-duoneb 3 ml, jet neb, Soln, Q4HR albuterol jet neb RT treatment 2.5 mg, jet neb, Soln, Q4HR eptifibatide (mcg/kg) 180 mcg/kg,, Injection, ONCE Comments: Max dose = 22.6 mg tirofiban BOLUS (mcg/kg) 25 mcg/kg,, Injection, ONCE, Over 5 minute Comments: Loading dose 25 mcg/kg over 5 minutes; discard remainder; Note: Loading dose does NOT have to be renally adjusted. *Conc: 50 mcg/ml* PHARMACY: Max dosing weight = 153 kg; Max bolus dose = 3,750 mcg (75 ml) fentanyl 25 mcg,, Injection, Q4HR, PRN, x 10 day(s), Hard Stop midazolam 2 mg,, Injection, Q4HR, PRN Agitation, x 10 day(s), Hard Stop Cefoxitin for Post-Op Antibiotic Prophylaxis in GI Surgery Patients(NOTE)* cefoxitin 2 gm, PB, Injection Powder, Q8HR, x 2 dose(s), Hard Stop Laboratory Conditional Lab Instructions Protocol Labs, Order and obtain lab specimens per protocols, Constant Indicator MRSA PCR - use to screen for MRSA on patients admitted to the ICU. Do not use this test to monitor patients with known MRSA.(NOTE)* MRSA PCR Nasal, Urgent collect, ONCE Comments: Collection method is Nasal Swab only. Prealbumin Blood, MTH LAB Albumin Blood, MTH LAB Capillary Blood Glucose ONCE CBC with Diff, Nurse collect ABG w/meas Sat Comprehensive Metabolic Panel, Nurse collect Phosphorus Inorganic Magnesium Level, Nurse collect Lactic Acid Lactic Acid Blood, Timed Study collect, Q6HR INTERVAL 4 time(s) Comments: For suspected sepsis. Run test as Urgent test. Prothrombin Time Comments: Includes INR APTT Urinalysis Urine, Urgent collect, ONCE Urine Pregnancy Qualitative Urine, Urgent collect, ONCE Capillary Blood Glucose Q4HR (DEF)* AC and HS CBC without Diff Blood, Timed Study collect, Q8HR INTERVAL 3 time(s), Nurse collect (DEF)* Blood, Timed Study collect, Q6HR INTERVAL 4 time(s)

7 Blood, Timed Study collect, Q4HR INTERVAL 6 time(s) ABG w/meas Sat Blood, Timed Study collect, Q8HR INTERVAL 3 time(s) (DEF)* Blood, Timed Study collect, Q6HR INTERVAL 4 time(s) Blood, Timed Study collect, Q4HR INTERVAL 6 time(s) Basic Metabolic Panel Blood, Timed Study collect, Q8HR INTERVAL 3 time(s) (DEF)* Blood, Timed Study collect, Q6HR INTERVAL 4 time(s) Blood, Timed Study collect, Q4HR INTERVAL 6 time(s) Comprehensive Metabolic Panel Phosphorus Inorganic Magnesium Level Prothrombin Time Comments: Includes INR APTT ABG w/meas Sat Whole Blood Calcium Ionized Comments: Collect with Blood Gas specimen in same syringe Troponin I Quant Blood, Timed Study collect, Q6HR INTERVAL 3 time(s) CK Total Blood, Timed Study collect, Q6HR INTERVAL 3 time(s) Blood Culture Site 1 Blood Venipuncture, Urgent collect, ONCE (DEF)* Blood from Intravascular Line, Urgent collect, ONCE Blood Culture Site 2 Blood Venipuncture, Urgent collect, ONCE (DEF)* Blood from Intravascular Line, Urgent collect, ONCE Respiratory Culture + Gram Sputum, Urgent collect, ONCE Urine Culture Urine, Urgent collect, ONCE (DEF)* Urine Catheterized, Urgent collect, ONCE Urine Clean Catch Midstream, Urgent collect, ONCE MRSA Surveillance Cultures - Do not use these orders for nasal screens for MRSA. May use for non-nasal screening or for monitoring known MRSA(NOTE)* MRSA Surveillance Culture Site 1 Axilla Swab, Urgent collect, ONCE (DEF)* Groin Swab, Urgent collect, ONCE Rectal Swab, Urgent collect, ONCE Nasal Swab, Urgent collect, ONCE MRSA Surveillance Culture Site 2 Rectal Swab, Urgent collect, ONCE (DEF)* Groin Swab, Urgent collect, ONCE Rectal Swab, Urgent collect, ONCE Nasal Swab, Urgent collect, ONCE MRSA Surveillance Culture Site 3 Axilla Swab, Urgent collect, ONCE (DEF)* Groin Swab, Urgent collect, ONCE Rectal Swab, Urgent collect, ONCE Nasal Swab, Urgent collect, ONCE MRSA Surveillance Culture Site 4 Axilla Swab, Urgent collect, ONCE (DEF)* Groin Swab, Urgent collect, ONCE Rectal Swab, Urgent collect, ONCE Nasal Swab, Urgent collect, ONCE B-Natriuretic Peptide

8 Respiratory Oxygen Therapy Nasal Cannula, Keep SPO2 greater/equal 90%, Improve Oxygenation (DEF)* Nasal Cannula, 2 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, 4 L/min, Keep SPO2 greater/equal 90%, Improve Oxygenation Nasal Cannula, Keep SPO2 greater/equal 92%, Improve Oxygenation Oxygen Therapy Aerosol Face Mask, 28% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation (DEF)* Aerosol Face Mask, 40% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation Trach Collar, 28% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation Trach Collar, 40% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation Venti Face Mask, 28% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation Venti Face Mask, 40% FiO2, Keep SPO2 greater/equal 90%, Improve Oxygenation Oxygen Therapy T-Tube, 40% FiO2, Keep SPO2 greater/equal 90% (DEF)* T-Tube, 35% FiO2, Keep SPO2 greater/equal 90% Enter specific Ventilator settings for order completion(note)* Ventilator Settings Ventilator Settings General/Surgical Ventilator Protocol (DEF)* Obstructive Ventilator Protocol Restrictive Ventilator Protocol Ventilator Mechanics Weaning Parameters Rehab PT/OT/ST/AUD PT Adult Eval and Treat OT Adult Eval and Treat Radiology/Imaging XR Chest 1 View Frontal XR Chest 2 Views Diagnostic Tests All diagnostic tests must be ordered on paper diagnostic order forms.(note)* Consults/Ancillary Services All medical service consults remain on paper consult form.(note)* Consult to Food and Nutrition Consult Respiratory Therapy Other(NOTE)* *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention S - This component is an Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase