Subject: Standing Order for Diabetes Care

Transcription

1 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Standing Order for Diabetes Care Purpose: As of 2011, diabetes affects 8% of the U.S. population. Diabetes is the 7 th leading cause of death in the United States. Uncontrolled diabetes can damage many parts of the body including the heart, blood vessels, eyes, kidneys, and nerves. Although diabetes does not have a cure, it can be controlled. Keeping sugar, cholesterol and blood pressure levels at or below the recommended goals and getting routine lab tests and procedures at recommended intervals can prevent complications from diabetes Procedure: Under this standing order, medical assistants and RNs with proper training may provide diabetes panel management for patients who fit these criteria. 1) This protocol applies to all patients with a diagnosis of type 1 or type 2 diabetes who come into the clinic for any appointment. 2) At every visit, check and document in the medical record: a. weight and BMI b. blood pressure c. smoking status (if a smoker, give smoking cessation resources) 3) At every visit, review the chart and identify whether patient is due for the following routine lab tests. If due, complete lab requisition and do test today if possible: a. Hemoglobin A1c: i. If most recent A1c result is above 7, repeat A1c every 3 months. ii. If most recent A1c result is at or below 7, repeat A1c every 6 months b. Serum Creatinine: Repeat every 12 months. c. Fasting Lipid Panel: Repeat every 12 months

2 d. Urine Microalbumin Test: Repeat every 12 months 4) At every visit, identify whether patient is due for the following routine procedures: a. Retinal eye exam: Repeat every 12 months i. Alert patient they are due for their annual exam ii. Refer patient to optometrist or ophthalmologist iii. If patient says they had an exam in the past 12 months, ask which provider performed exam, document in chart 5) Monofilament foot exam: Repeat every 12 months a. Trained medical assistants may perform monofilament at visit when due b. Document results of monofilament in chart and notify provider of abnormal findings c. Visual Foot inspection: Repeat at every visit to identify cracks and sores d. Request patient to remove shoes and socks at every visit. 6) Identify whether patient requires immunizations a. Flu: repeat once a year b. Pneumococcal: i. If no previous immunization, administer one dose of PPSV23 ii. If patient is 65 and older AND previous dose of pneumococcal vaccine was administered more than 5 years ago, revaccinate once with PPSV23 c. Td/Tdap: i. If previous Td but no previous Tdap, administer one dose Tdap immediately ii. If previous Td or Tdap is more than 10 years ago, revaccinate with Td 7) Provide basic patient education as needed a. Deliver education based on the patient s baseline knowledge level. b. Include information on disease and medication 8) Offer self management support and goal setting at each visit a. Create an action plan with patient b. Document verbal or written action plan in chart or electronic medical record c. Ask patient about action plan progress at next visit or establish follow up date 9) Offer referral to the following as needed: a. Smoking cessation b. Nutrition c. Exercise group d. Blood pressure group e. Pharmacist f. Behavioral Health 10) Refer to community resources 11) Document the visit and procedures taken in patient chart or electronic medical record.

3 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Standing orders protocol for fecal occult blood (FIT) testing Purpose: To reduce morbidity and mortality from colon cancer through routine screening based on national guidelines. Protocol: Under these standing orders, MAs/RNs may order a FIT for eligible patients. Eligible patients are those between years old who have either not had a colonoscopy within 10 years or whose last FIT was >1 year previous.

4 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Standing orders protocol for HbA1c testing Purpose: To reduce morbidity and mortality from diabetes through comprehensive management based on ADA guidelines Protocol: Under these standing orders, MAs/RNs may test the HbA1c of eligible patients. Eligible patients are those with a documented diagnosis of diabetes (type 1 or type 2) on their Problem List whose last HbA1c was at least 3 months prior.

5 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Standing orders for administering Influenza vaccination to adults Purpose: To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention s Advisory Committee on Immunization Practices. Procedure: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may vaccinate patients who meet any of the criteria below. 1. Identify adults with no history of influenza vaccination for the current influenza season. 2. Screen all patients for contraindications and precautions to influenza vaccine: a. Contraindications: a serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its components. For a list of vaccine components, go to excipienttable-2.pdf. Do not give live attenuated influenza vaccine (LAIV; nasal spray) to a person who has a history of either an anaphylactic or nonanaphylactic hypersensitivity to eggs, who is pregnant, who is age 50 years or older, or who has chronic pulmonary (including asthma), cardiovascular (excluding hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic (including diabetes) disorders; immunosuppression, including that caused by medications or HIV. b. Precautions: moderate or severe acute illness with or without fever; history of Guillain Barré syndrome within 6 weeks of a previous influenza

6 vaccination; for LAIV only, close contact with an immunosuppressed person when the person requires protective isolation, receipt of influenza antivirals (e.g., amantadine, rimantadine, zanamivir, or oselta- mivir) within the previous 48 hours or possibility of use within 14 days after vaccination. c. Other considerations: an egg-free recombinant hemagglutin influenza vaccine (RIV) may be used for people ages years with egg allergies of any severity. People who experience onset of hives only after ingesting eggs may also receive inactivated influenza vaccine (IIV) with the following additional safety measures: 1) administration by a healthcare pro- vider familiar with the potential manifestations of egg allergy and 2) observation for 30 minutes after receipt of the vaccine for signs of a reaction. 3. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient s medical record or office log, the publication date of the VIS and the date it was given to the patient. Pro- vide non-english speaking patients with a copy of the VIS in their native language, if available and preferred; these can be found at 4. Administer influenza vaccine as follows: a. Give 0.5 ml of IIV to adults of all ages, or RIV to adults age years, intramuscularly (22 25g, 1 1½" needle) in the deltoid muscle. (Note: A e" needle may be used for adults weighing less than 130 lbs [<60 kg] for injection in the deltoid muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90 degree angle.) b. For healthy adults younger than age 50 years, give 0.2 ml of intranasal LAIV; 0.1 ml is sprayed into each nostril while the patient is in an upright position. c. For adults age 18 through 64 years, give 0.1 ml IIV-ID intradermally by inserting the needle of the microinjection system at a 90 degree angle in the deltoid muscle. d. For adults age 65 years and older, give 0.5 ml of high-dose IIV-IM intramuscularly (22 25g, 1 1½" needle) in the deltoid muscle. 5. Document each patient s vaccine administration information and follow up in the following places: a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. If vaccine was not given, record the reasons(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 7. Report all adverse reactions to influenza vaccine to the federal Vaccine Adverse Event Reporting System (VAERS) at or (800) VAERS report forms are available at

7 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center ED Signature: Date Board approved: Policy Procedure Date Reviewed: Subject: Standing Orders for Administering Pneumococcal (PPSV23 and PCV13) Vaccine to Adults Purpose: To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention s Advisory Committee on Immunization Practices. Procedure: Under these standing orders, eligible nurses and other healthcare professionals (e.g., pharmacists), where allowed by state law, may vaccinate adults who meet any of the criteria below. 1. Identify adults in need of vaccination with pneumococcal polysaccharide vaccine (PPSV23) based on the following criteria: a. Age 65 years or older with no or unknown history of prior receipt of PPSV b. Age 64 years or younger with no or unknown history of prior receipt of PPSV and any of the following conditions: i. cigarette smoker ii. chronic cardiovascular disease (e.g., congestive heart failure, cardiomyopathies) iii. chronic pulmonary disease (e.g., chronic obstructive pulmonary disease, emphysema, asthma) c. diabetes mellitus, alcoholism or chronic liver disease (cirrhosis), d. candidate for or recipient of cochlear implant; cerebrospinal fluid leak e. functional or anatomic asplenia (e.g., sickle cell disease, splenectomy) f. immunocompromising condition (e.g., HIV infection, congenital immunodeficiency, hematologic and solid tumors)

8 g. immunosuppressive therapy (e.g., alkylating agents, antimetabolites, longterm systemic corticosteroids, radiation therapy) h. organ or bone marrow transplantation; chronic renal failure or nephrotic syndrome 2. Identify adults in need of an additional dose of PPSV23 if 5 or more years have elapsed since the previous dose of PPSV and the patient meets one of the following criteria: a. Age 65 years or older and received prior PPSV vaccination before age 65 years b. Age 64 years or younger and at highest risk for serious pneumococcal infection or likely to have a rapid decline in pneumococcal antibody levels (i.e., categories 1.vi.-ix. above) 3. Identify adults age 19 years and older in need of vaccination with pneumococcal conjugate vaccine (PCV13) who are at highest risk for serious pneumococcal infection or likely to have a rapid decline in pneumococcal antibody levels (i.e., categories 1.v. 1.ix. above). 4. Screen all patients for contraindications and precautions to pneumococcal vaccine: a. Contraindication: a history of a serious reaction (e.g., anaphylaxis) after a previous dose of pneumococcal vaccine (PPSV or PCV) or to a vaccine component. For a list of vaccine components, go to b. Precaution: moderate or severe acute illness with or without fever c. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Although not required by federal law, it is prudent to document in the patient s medical record or office log, the publication date of the VIS and the date it was given to the patient. Provide non-english speaking patients with a copy of the VIS in their native language, if available; these can be found at 6. Administer vaccine as follows: a. For adults identified in 1. and 2. above, administer 0.5 ml PPSV23 vaccine either intramuscularly (22 25g, 1 1½" needle) in the deltoid muscle or subcutaneously (23 25g, 5/8" needle) in the posterolateral fat of the upper arm. b. For adults identified in 3. above, administer 0.5 ml PCV13 intramuscularly (22 25g, 1 1½" needle) in the deltoid muscle. For adults previously vaccinated with PPSV, give PCV13 at least 12 months following PPSV. If not previously vaccinated with PPSV, give PCV13 first, followed by PPSV23 in 8 weeks. c. (Note: A 5/8" needle may be used for IM injection for patients who weigh less than 130 lbs [<60kg] for injection in the deltoid muscle, only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.) 7. Document each patient s vaccine administration information and follow up in the following places:

9 a. Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. If vaccine was not given, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). b. Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 8. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 9. Report all adverse reactions to PPSV23 and PCV13 to the federal Vaccine Adverse Event Reporting System (VAERS) at or by calling (800) VAERS report forms are available at For standing orders for other vaccines, go to Item #P3075 (8/12) Technical content reviewed by the Centers for Disease Control and Prevention,. Immunization Action Coalition 1573 Selby Ave. St. Paul, MN (651)

10 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Protocol for Tuberculin Skin Testing Purpose: To provide a nursing procedure for Tuberculin Skin Testing. Procedure: The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice. The skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be rescheduled for another skin test. The reaction should be measured in millimeters of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis). TST Reactions Interpreted Skin test interpretation depends on two factors: 1) Measurement in millimeters of the induration 2) Person's risk of being infected with TB and of progression to disease if infected Classification of the Tuberculin Skin Test Reaction An induration of 5 or more millimeters is considered positive in: 1) HIV-infected persons

11 2) A recent contact of a person with TB disease 3) Persons with fibrotic changes on chest radiograph consistent with prior TB 4) Patients with organ transplants 5) Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1month or longer, taking TNP-a antagonists) An induration of 10 or more millimeters is considered positive in any person, including persons with no known risk factors for TB Note: The CDC recommends using a 15 mm cutoff for low risk reactors. However, in California, this cutoff is not recognized because California is a high incidence state and the prevalence of nontuberculous mycobacterial infections is lower than in other regions of the United States. False Positive Reactions Some persons may react to the TST even though they are not infected with M. tuberculosis. The causes of these false-positive reactions may include, but are not limited to, the following: Infection with nontuberculosis mycobacteria Previous BCG vaccination Incorrect method of TST administration Incorrect interpretation of reaction Incorrect bottle of antigen used False-Negative Reactions Some persons may not react to the TST even though they are infected with M. tuberculosis. The reasons for these false-negative reactions may include, but are not limited to, the following: Cutaneous energy (energy is the inability to react to skin tests because of a weakened immune system) Recent TB infection (within 8-10 weeks of exposure) Very old TB infection (many years) Very young age (less than 6 months old) Recent live-virus vaccination (e.g., measles and smallpox) Overwhelming TB disease Some viral illnesses (e.g., measles and chicken pox) incorrect method of TST administration Incorrect interpretation of reaction Who Can Receive a TST

12 Most persons can receive a TST. TST is contraindicated only for persons who have had a severe reaction (e.g., necrosis, blistering, anaphylactic shock, or ulcerations) to a previous TST. It is not contraindicated for any other persons, including infants, children, pregnant women, persons who are HIV-infected, or persons who have been vaccinated with BCG. How Often Can TSTs Be Repeated In general, there is no risk associated with repeated tuberculin skin test placements. If a person does not return within hours for a tuberculin skin test reading, a second test can be placed as soon as possible. There is no contraindication to repeating the TST, unless a previous TST was associated with a severe reaction. What is a Boosted Reaction In some persons who are infected with M. tuberculosis, the ability to react to tuberculin may wane over time. When given a TST years after infection, these persons may have a false-negative reaction. However, the TST may stimulate the immune system, causing a positive, or boosted reaction to subsequent tests. Giving a second TST after an initial negative TST reaction is called two-step testing. Two-Step Testing Conducted Two-step testing is useful for the initial skin testing of adults who are going to be retested periodically, such as health care workers or nursing home residents. This twostep approach can reduce the likelihood that a boosted reaction to a subsequent TST will be misinterpreted as a recent infection. TSTs & Persons Receiving Vaccinations Vaccination with live viruses may interfere with TST reactions. For persons scheduled to receive a TST, testing should be done as follows: Either on the same day as vaccination with live-virus vaccine or 4-6 weeks after the administration of the live-virus vaccine At least one month after smallpox vaccination ADMINISTRATION OF MANTOUX TUBERCULIN SKIN TEST Prior to administer test, provider needs to identify patient and review complete form checking for exposure to tuberculosis or a previously positive PPD test. 1) Wash hands and don disposable gloves 2) Cleanse injection site with alcohol and allow to dry 3) Wipe diaphragm of the vial stopper with alcohol 4) Solution is administered in a Tuberculin syringe fitted with a short 1/2" 26 or 27 gauge needle. 5) A new needle must be used with every patient 6) Draw 0.1ml of antigen into Tuberculin syringe 7) Hold syringe upright and tap lightly to rid any air bubbles S.

13 8) Push plunger of syringe until there is 0.1ml of antigen for injection 9) Immobilize patient's arm (left forearm is desired) on firm surface 10) Pull skin taut before inserting needle 11) Place bevel of needle upward so that the needle is parallel to skin to ensure accurate intradermal puncture by needle 12) Insert and puncture needle just below the skin 13) Inject antigen 14) A 6-10mm diameter white induration (bleb) should appear. The induration will quickly absorb. No dressing is required at injection site. 15) In the event that antigen was delivered subcutaneously (i.e. no bleb will form) or if a significant part of the dose leaks from the injection site, the test should be repeated immediately at another site at least 5cm (2 inches) away. 16) Remove gloves and wash hands 17) Remind patient to return for reading of test results in hours of placement

14 Chapter: Date to be reviewed/updated: DOO/MD/CFO Signature: Pt. Reyes Community Health Center Bolinas Community Health Center Stinson Beach Community Health Center Policy Procedure ED Signature: Date Board approved: Date Reviewed: Subject: Standing orders protocol for scheduling pap tests and/or requesting last pap test records Purpose: To reduce morbidity and mortality from cervical cancer through routine screening based on national guidelines. Protocol: Under these standing orders, MA/RN asks patient when last pap done. If over 3 years previous, schedule WWE or offer pap test today if appropriate. If pap test done within 3 years elsewhere, complete medical record release to obtain most recent pap test result at that time.