Vitals
Vital sign requirements for behavioral health patients without a medical issue
Every 12 hours and PRN
All patients regardless of chief complaint or triage acuity level will have this
Primary Assessment
Screen all patients 12 and above
Columbia Suicide Screening Risk
Every 15 minutes until stable, then hourly
ESI 2
ED Nurse to inpatient report
IPASS
Vital sign requirements for patients leaving the department
30 minutes
All patients will have at least one of these related to the body system of chief complaint
Use "Hospital Policy - Cosign NOT required"
Triage Protocols
Requires one resource
ESI 4
Professional, respectful communication that can help resolve interpersonal differences and improve clinical practice
Peer-to-peer review
Blood pressure, heart rate, respiratory rate, oxygen saturation, and temp
Full set of vitals
Documented within 1 hour of administration
Pain re-assessment
High risk situation
Every 5-15 minutes until stable, then every 1 hour and as needed
ESI 1
4.5 hours
TNK window max
Routine vitals for Med/Surge boarders
Every 4 hours and PRN
Requires physician notification
change in patient condition/critical values
LKW within 24 hours PTA
Stroke Alert
Every 2 hours and PRN
ESI 3
The process by which a nurse makes decisions based upon nursing knowledge, critical thinking, and clinical reasoning
Clinical Judgement
Every 2 hours and PRN
CABD
Primary assessment
Patients who are at risk for harming themselves or others
ESI 2
ESI 1 and 2
Completed by the ED Provider and/or ED RN at end of visit
Discharge Instructions