Physician Orders ADULT

Physician Orders ADULT attach patient label here Order Set: ED Non-STEMI Unstable Angina Orders Height: cm Weight: kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Admission/Transfer/Discharge Patient Status Initial Inpatient Bed Type: Med Surg Critical Care Stepdown Obstetrics Other Patient Status Initial Outpatient Outpatient Status/Service: OP-Ambulatory OP-Diagnostic Procedure OP-Observation Services NOTE to MD: Initial status inpatient --- For a condition/dx with severity of illness or co-morbid conditions indicating a hospital stay greater than 24 hours is required. Initial Status Outpatient Ambulatory surgery Outpatient surgery/procedure with discharge anticipated after a routine or, in some cases, extended recovery. Routine recovery after outpatient surgery is estimated at 6-8 hours. Extended routine recovery may be required for a patient to stay longer (could be overnight) to recover from anticipated sequela of surgery including effects of anesthesia, nausea, pain. For unanticipated sequela of surgery or a complicated post operative course, the patient may require a status change to inpatient. Please consult with a case manager before making this choice of status change. Examples: Initial status outpatient is generally selected for patients undergoing PCI, diagnostic caths, EP studies, ablations, pacemaker implantations, other routine surgeries. Initial status Outpatient -Observation Services Short term treatment, assessment and reassessment - estimate discharge within 24 hours In some cases (for Medicare patients), this can be extended to 48 hours. Observation Services can also be utilized when it is unclear (without additional assessment) whether the patient will require an inpatient stay. Notify physician once T;N, of room number on arrival to unit Primary Diagnosis: Secondary Diagnosis: Vital Signs Vital Signs T;N, q2h(std), based on patient condition Activity Bedrest w/brp T;N Food/Nutrition NPO Start at: T;N Patient Care Old Chart to Floor T;N Intermittent Needle Therapy T;N,q4day Insert/Site (INT Insert/Site Care) Intermittent Needle Therapy T;N,Stat,q4day,secondary site Insert/Site (INT Insert/Site Care) O2 Sat Spot Check-NSG T;N O2 Sat Monitoring NSG T;N Telemetry (Cardiac Monitoring) T;N, Stat Whole Blood Glucose Nsg (Bedside T;N Glucose Nsg) ED Non-STEMI Unstable Angina-20530-QM-0808-013112 (Fayette 0412) Page 1 of 3

Physician Orders ADULT attach patient label here Order Set: ED Non-STEMI Unstable Angina Orders Nasal Cannula (O2-BNC) Respiratory Care T;N Routine, 2 L/min, Special Instructions: Titrate O2 to keep O2 sat greater than or equal to 92% ISTAT Blood Gases (RT Collect) T;N Stat once (ABG- RT Collect) Continuous Infusions Sodium Chloride 0.9% 500 ml, IV, STAT, ( 1 dose ), 1,000 ml/hr Sodium Chloride 0.45% 1,000 ml,iv,stat,t;n,75 ml/hr Medications Radiocontrast Nephropathy Prophylaxis (RCN) Protocol (see order set below) VTE Prophylaxis (MEDICAL) Orders attached NOTE: If aspirin not ordered/given, must document reason not given and/or contraindications. Contraindication-Aspirin T;N Aspirin allergy Intracranial bleed GI bleed Preadmission oral anticoagulation therapy Aspirin sensitivity Blood disorder Gastritis Peptic Ulcer Disease Risk of bleeding aspirin 324 mg,chew tab,po,once,stat,t;n aspirin 300 mg,supp,pr,once,prn Other, specify in Comment,STAT,T;N NOTE: Select below to document Beta Blocker contraindication Contraindication-Beta Blocker T;N Beta-Blocker Blocker contraindicated Symptomatic bradycardia Symptomatic hypotension Moderate/severe LV dysfunction Shock/impaired perfusion PR interval greater than 0.24 seconds on EKG Second or third degree heart block without pacemaker Active asthma/reactive airway disease Other: metoprolol 5 mg, Injection, IV Push, q5min, STAT, ( 3 dose ) metoprolol 25 mg,tab,po,once,stat,t;n simvastatin 40 mg,tab,po,once,stat,t;n atorvastatin 80 mg, Tab, PO, once, STAT NOTE: Hold Nitroglycerin if SBP less than 100mmHg. nitroglycerin 0.4 mg, Tab, SL, q5min, PRN Chest Pain, STAT nitroglycerin (nitroglycerin 50 50 mg / 250 ml, IV, STAT, Titrate mg/d5w infusion) morphine 2 mg,injection,iv Push,q5min,PRN Chest Pain,STAT,T;N,( 3 dose ) Heparin Non-VTE Protocol Orders ondansetron 4 mg,injection,iv Push,once,STAT,T;N ondansetron 4 mg, Injection, IV Push, q6h, PRN Nausea/Vomiting, STAT clopidogrel 600 mg,tab,po,once,stat,t;n clopidogrel 75 mg,tab,po,once,stat,t;n ED Non-STEMI Unstable Angina-20530-QM-0808-013112 (Fayette 0412) Page 2 of 3

Physician Orders ADULT attach patient label here Order Set: ED Non-STEMI Unstable Angina Orders Medications continued Glycoprotein IIb/IIIa Dosing Protocol (see order set below) acetaminophen 650 mg, Tab, PO, q4h, PRN Headache, STAT NOTE: If magnesium level is less than 2.1mEq/mL, order Magnesium Sulfate below: magnesium sulfate 2 g,injection,iv Piggyback,Routine,T;N,( infuse over 2 hr ) famotidine 20 mg,injection,iv Push,once,STAT,T;N Laboratory Lipid Profile T;N, STAT, once, Type: Blood, Nurse Collect CBC T;N, STAT, once, Type: Blood, Nurse Collect Comprehensive Metabolic Panel T;N, STAT, once, Type: Blood, Nurse Collect (CMP) Chem 8 Profile POC T;N, Stat Prothrombin Time (PT/INR) T;N, STAT, once, Type: Blood, Nurse Collect Partial Thromboplastin Time (PTT) T;N, STAT, once, Type: Blood, Nurse Collect Magnesium Level T;N, STAT, once, Type: Blood, Nurse Collect Brain Natriuretic Peptide (BNP) BNP by Triage POC T;N, Stat D-Dimer Quantitative Urine Drug Screen Triage STAT, T;N, once, Type: Urine, Nurse Collect Drug Screen Stat Urine ED Only T;N, STAT, once, Type: Urine, Nurse Collect Drug Screen Stat Urine T;N, STAT, once, Type: Urine, Nurse Collect Drug Abuse Screen Urine STAT, T;N, once, Type: Urine, Nurse Collect NOTE: If possiblitiy of pregnancy, and not previously done in past 72 hours, order appropriate pregnancy Pregnancy Screen Serum T;N, STAT, once, Type: Blood, Nurse Collect Pregnancy Screen Urine T;N, STAT, once, Type: Urine, Nurse Collect Pregnancy Screen Urine Point of T;N, Stat, once Care Diagnostic Tests Electrocardiogram (EKG) Start at: T;N, Priority: Stat, Frequency: once Electrocardiogram (EKG) Start at: T;N, Priority: Stat Chest 1VW Frontal T;N, Reason for Exam: Chest Pain, Stat, Portable Chest 2VW Frontal & Lat T;N, Reason for Exam: Chest Pain, Stat, Stretcher CT Thorax W Cont T;N, Reason for Exam: Chest Pain, Stat, Stretcher CT Thorax W Cont T;N, Reason for Exam: Pulmonary Embolism, Stat, Stretcher CT Thorax W Cont T;N, Reason for Exam: Aneurysm, Stat, Stretcher CT Thorax & Abdomen W/Cont Orders (CT Chest & Abdomen W/Cont Orders) Consults/Notifications Physician Consult T;N, Consult: interventional cardiologist Physician Consult T;N, Consult: cardiologist Physician Consult T;N, Consult: Primary Care Physician Notify Physician-Continuing T;N, Notify: physician, recurrent chest pain;new or sustained arrhythmias; systolic BP less than 90 mmhg or greater than 180mmHg; excessive bruising,bleeding, or hematoma; syncope/pre-syncope;headache or mental status changes; heart rate less than 45bpm or greater than 120bpm. ED Non-STEMI Unstable Angina-20530-QM-0808-013112 (Fayette 0412) Page 3 of 3

attach patient label here Physician Orders Care Set: Radiocontrast Nephropathy Prophylaxis (RCN) Protocol [X or R] = will be ordered unless marked out. Medication allergy(s): Latex allergy Other: Primary Diagnosis: Secondary Diagnosis: RCN Protocol Standard Orders NOTE: Risk factors: Diabetes, Heart Failure, Age greater than 75 years, SCr greater than 1.5 mg/dl or Estimated GFR less than 60 ml/min RCN Protocol Standard Pre Procedure Orders Dextrose 5% in Water 1,000 ml + sodium bicarbonate (additive) 150mEq/1,000mL, IV, routine, T;N, (1 hr), 3mL/kg/hr, Comment: Infuse at 3mL/kg/hr over 1 hour prior to procedure 150 meq Sodium Chloride 0.9% 1,000mL, IV, routine, T;N, (12 hr), 1mL/kg/hr, Comment: Infuse at 1mL/kg/hr prior to procedure Sodium Chloride 0.45% 1,000mL, IV, routine, T;N, (12 hr), 1mL/kg/hr, Comment: Infuse at 1mL/kg/hr prior to procedure Dextrose 5% in Water 1,000 ml + sodium bicarbonate (additive) 150 meq RCN Protocol Standard Post Procedure Orders 150mEq/1,000mL, IV, routine, T;N, (6 hr), 1mL/kg/hr; Comment: Infuse at 1mL/kg/hr Sodium Chloride 0.9% 1,000mL,IV, routine, T;N, (12 hr), 1mL/kg/hr; Comment: Infuse at 1mL/kg/hr Sodium Chloride 0.45% 1,000mL,IV, routine, T;N, (12 hr), 1mL/kg/hr; Comment: Infuse at 1mL/kg/hr 23017-QM-ver2-PT-RCN Prophy Protocol-Ver3 011912 Page 1 of 1

Physician Orders- ADULT Physician Orders-ADULT VTE Medical Prophylaxis Orders Attached patient label here Height: cm Weight: kg Allergies: Medication allergy(s): Latex allergy Other: NOTE: Medical Risk Factor Assessment, Bleeding Risk Factor Assessment and Mechanical Device (SCD) Contraindication Assessment criteria is listed below VTE orders. VTE ORDERS If Bleeding Risk is Present, place SCD order below: Sequential Compression Device Apply T;N, Apply To: Lower Extremities, Comment: Bleeding Risks Present If NO Bleeding Risk Present, place ONE Heparin or Enoxaparin order below and place both CBC orders: heparin 5,000 units,injection, subcutaneous, q12h, Routine, T;N, Comment: Pharmacist may adjust administration times after first dose. heparin 5,000 units,injection, subcutaneous, q8h, Routine, T;N, Comment: Pharmacist may adjust administration times after first dose. OR enoxaparin 40 mg, Injection, Subcutaneous, Qday, Routine, T;N, If CrCl less than 30 ml/min, pharmacy to adjust dose to 30mg SQ Qday. Pharmacist may adjust administration times after first dose. AND BOTH CBCs: CBC w/o Diff Routine Routine,T;N, once, Type: Blood, CBC w/o Diff Time Study Routine,T+2;0400,, QODay, Type: Blood Do Not Administer VTE Prophylaxis: Contraindication-VTE Prophylaxis T;N, Reason: Patient has bleeding risk for anticoagulants, and SCDs are contraindicated. Consider early ambulation. MEDICAL RISK FACTOR ASSESSMENT: This is a partial list of medical risk factors. Clinicians are advised to consider other risk factors or conditions that may predispose patients to DVT/PE. Check all that may apply: Prolonged immobilization, paralysis, or bed rest ordered ICU patient Sepsis diagnosis or Active Infection Active inflammatory bowel disease Cancer and/or presence of malignancy Heart Failure Respiratory Disease (COPD or Pneumonia) Ischemic Stroke (non-hemorrhagic) Prior history of VTE or Pulmonary Embolism Age greater than 45 Morbid Obesity (BMI greater than 35) Central Line or PICC Line Current treatment with estrogens (Oral contraceptives; Hormone Replacement Therapy) Hereditary clotting disorder Pregnancy with diagnosed clotting disorder or Antiphospholipid Syndrom diagnosis Nephrotic Syndrome No medical risk factors exist VTE MEDICAL PROPHYLAXIS-22225-QM- 1008 Ver 4 032911 Page 1 of 2

Physician Orders- ADULT Physician Orders-ADULT VTE Medical Prophylaxis Orders Attached patient label here BLEEDING RISK FACTOR ASSESSMENT: This is a partial list of bleeding risk factors. Clinicians are advised to consider other risk factors or conditions that may predispose patients to DVT/PE. Check all that may apply: Patient already receiving anticoagulation therapy with warfarin, heparin, fondaparinux, enoxaparin or other anticoagulation therapy Active bleeding INR greater than 1.5 and patient NOT on warfarin therapy INR greater than 2 and patient ON warfarin therapy Transplant patients with platelet count less than 100,000 Platelet count less than 50,000 (applies to patients with no history of transplant procedures) Solid organ transplant during this episode of care OR within 30 days of admission Documented bleeding or Coagulopathy disorder Hemorrhagic Stroke within 6 weeks of admission Severe Uncontrolled Hypertension Recent Intraocular or Intracranial surgery Vascular Access or Biopsy sites inaccessible to hemostatic control Recent Spinal Surgery Epidural or Spinal Catheter Pregnancy, Possible Pregnancy or Postpartum (to include up to 6 weeks post partum) Heparin Induced Thrombocytopenia (HIT) Heparin allergy or pork allergy No Bleeding Risk Factors exists MECHANICAL DEVICE (SCD) CONTRAINDICATION ASSESSMENT Known or suspected deep vein thrombosis or pulmonary embolism Acute stages of inflammatory phlebitis process Disruptions in lower extremity skin integrity ( surgical incision, recent skin graft, dermatitis, etc. ) Arterial occlusion Instances where increased venous or lymphatic return is undesirable Massive lower extremity edema Unable to place device VTE MEDICAL PROPHYLAXIS-22225-QM- Ver 4 032911 Page 2 of 2

attach patient label here Physician Orders ADULT Order Set: Glycoprotein Iib/IIIa Dosing Protocol Orders Height: cm Weight: kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Glycoprotein Iib/IIIa Dosing Protocol T;N Or (Glycoprotein Iib/IIIa Dosing Protocol Orders Initiate) NOTE: Select either Reopro OR Integrilin orders from below: NOTE: If platelet count < 100,000, abciximab (ReoPro) is contraindicated and will not be given ReoPro Dose Orders NOTE: If platelet count < 100,000, abciximab (ReoPro) is contraindicated and will not be given ReoPro - Glycoprotein IIb/IIIa Orders abciximab 0.25 mg/kg, Injection, IV Push, once, Routine, Comment: Administer over 2-3 minutes abciximab infusion 7.2 mg / 250 ml, IV, Routine, ( 12 hr ), 0.125 mcg/kg/min, Comment: Maximum rate= 10mcg/min Integrilin ACS Dose Orders NOTE: If patient is on dialysis, eptifibatide (Integrillin) is contraindicated and won't be given: Integrilin ACS Dose Orders NOTE: Choose bolus and infusion orders from below: eptifibatide (eptifibatide bolus) 180 mcg/kg, Injection, IV Push, once, Routine, (1 Dose), Comment: Administer over 1 minute. eptifibatide (eptifibatide infusion (75 75 mg / 100 ml, IV, Routine, ( 24 hr ), 2 mcg/kg/min NOTE:If calculated CrCl less than 50 ml/min (based on actual weight), place order below: eptifibatide (eptifibatide infusion (75 75 mg / 100 ml, IV, Routine, ( 24 hr ), 1 mcg/kg/min Integrilin Cath Lab Dose Orders Integrilin Cath Lab Dose Orders eptifibatide (eptifibatide bolus) 180 mcg/kg, Injection, IV Push, q10min, Routine, ( 2 dose ) eptifibatide (eptifibatide infusion (75 75 mg / 100 ml, IV, Routine, ( 24 hr ), 2 mcg/kg/min NOTE: If calculated CrCl less than 50 ml/min (based on actual weight), place order below: eptifibatide (eptifibatide infusion (75 75 mg / 100 ml, IV, Routine, ( 24 hr ), 1 mcg/kg/min PT Glycoprotein Iib-IIIa Dosing Protocol-23006- QM1208 Ver4 110411 Page 1 of 1