Subject: Standing Order for Diabetes Careexpandingaccess.wdfiles.com/local--files/start/Standing Orders Com… · provider performed exam, document in chart 5) Monofilament foot exam:

Pt. Reyes Community Health Center

Bolinas Community Health Center

Stinson Beach Community Health Center

Policy Procedure

Chapter: _______

Date to be reviewed/updated: ____________

DOO/MD/CFO Signature: ___________________

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 7th

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

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.




Policy Procedure

Chapter: _______



ED Signature:______________________________


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 50-75 years old who have either not had a colonoscopy

within 10 years or whose last FIT was >1 year previous.




Policy Procedure

Chapter: _______


DOO/MD/CFO Signature: __________________

ED Signature:______________________________


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.




Policy Procedure

Chapter: _______


DOO/MD/CFO Signature: _______________

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

www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/ excipient-

table-2.pdf. Do not give live attenuated influenza vaccine (LAIV; nasal

spray) to a person who has a history of either an anaphylactic or non-

anaphylactic 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

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 18–49 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 provider

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 www.immunize.org/vis.

4. Administer influenza vaccine as follows:

a. Give 0.5 mL of IIV to adults of all ages, or RIV to adults age 18–49 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 www.vaers.hhs.gov or (800) 822-7967.

VAERS report forms are available at www.vaers.hhs.gov.




Policy Procedure

Chapter: _______



ED Signature:__________________________


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)

g. immunosuppressive therapy (e.g., alkylating agents, antimetabolites, long-

term 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

www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-

table-2.pdf.

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 www.immunize.org/vis.

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:

http://www.immunize.org/vis

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 www.vaers.hhs.gov or by calling (800) 822-

7967. VAERS report forms are available at www.vaers.hhs.gov.

For standing orders for other vaccines, go to www.immunize.org/standing-orders

www.immunize.org/catg.d/p3075.pdf • Item #P3075 (8/12)

Technical content reviewed by the Centers for Disease Control and Prevention,.

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 •

www.immunize.org • www.vaccineinformation.org




Policy Procedure

Chapter: _______



ED Signature:__________________________


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

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

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 48-72 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 two-

step 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.

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 48-72 hours of placement




Policy Procedure

Chapter: _______



ED Signature:______________________________


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.

Documents

Subject: Standing Order for Diabetes Careexpandingaccess.wdfiles.com/local--files/start/Standing Orders Com… · provider performed exam, document in chart 5) Monofilament foot exam: