Clinical Guidelines - Chapter X - www.myfhcc.net

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Clinical Guidelines - Chapter X - www.myfhcc.net

  1. 1. Chapter X. Family Health Care Clinic, Inc. Care Guidelines
  2. 2. Healthcare Management Guidelines Ambulatory Care Guidelines Section A: Introduction to Ambulatory Care Management The purpose of ambulatory care management is the same as the purpose of management of other healthcare ser- vices. The purpose is to balance aggregate patient care quality, safety and cost objectives. Patient care quality is , defined by (1) the patient's health status, that is, the outcome of the care and (2) the patient's perception of the physician/patient relationship and the physician's efficiency in delivering the care. The health status outcome is measurable andcan be evaluated on a retrospective basis.The patient’s perceptions can be surveyed retrospectively, but will most likely be favorable if the health static outcome is favorable and care was delivered decisively and efficiently. Delivery efficiency will also determine, to a large-extent, the cost of the care. The delivery of medical care is not an exact science. It is likely that several different methods or courses of treatment can be identified that will lead to a favorablehealthstatusoutcome.Theoptimalcourseof treatmentis thetreatmentthatconsumestheleasthealthcare resources while leading to a favorable health status outcome. Minimizing the cost of care by improving delivery efficiency is beneficial to all payers and me patient. Healthcare providers may temporarily benefit from delivery inefficiency under fee-for-service reimbursement. However, providers win ultimately benefit from improved delivery efficiency because their capacity to deliver care increases with improved efficiency. Increasingly, payors are using efficiency measures to guide their healthcare-buying decisions. This volume of the Guidelines provides ambulatory care management information that can guide healthcare providers, health plans and payors in healthcare delivery andbuying decisions, so they can progress towards an optimally efficient objective. A major flaw in many utilization management programs is that the program is put in the position of reacting to what might happen rather than proactively planning what should happen. "What should happen" is an explicit clinical standard for the high-quality, safe, efficient care of routine uncomplicated cases. The majority of cases are routine and uncomplicated and the appropriate standards for care can be readily defined. Once riffling thisstandard should be applied to all cases, with temporary deviation from the standard as needed to handle any complications. This volume of the HMGs presents a collection of ambulatory care standards we have developed. Our combined experience includes direct patient care, patient care management, and assessment andconsultation for managed care systems. These standards are regularly used by M&R healthcare consultants in healthcare management reviews and actuarial evaluations. Clinical conformity to these standards in the treatment of r0utine, uncomplicated cases win produce individual outcomes which will likely lead to efficient, aggregate outcomes. Significant deviation from these standards in the treatment of routine, uncomplicated cases will likely produce unsatisfactory outcomes. In using these standards, managed care plans,plan sponsors andhealthcare providers shouldscrutinize the standardsand make modifications that are appropriate for the specific healthcare delivery system involved. Application of the standards to any individual patient should not be done without the evaluation by a qualified medical professional of the standards' appropriateness to the specific circumstances involved.
  3. 3. HealthcareManagementGuidelines Section B: Primary Care Management Guidelines 1. INTRODUCTION This sectionpresentsPrimaryCare Management Guidelines as currentlydefinedby M&R. Modification of these guidelinesmaybe requiredto meet the objectives of the managed care plan, the plan sponsor or the healthcare provider involved. A primary care physicianina managed care plan is usuallyresponsible for all servicesrequiredby the patient except when precipitous emergencycircumstances preclude the primary physician's role.The primary physician's services are personal,andhis responsibilitycontinuous.The scope of the responsibilityis comprehensive (i.e., all required services,including preventive services). The primary care physicianshouldprovide those services whichcanbe provided appropriately within his or her drills andobtain consultationwhenadditional knowledge or skills are required.Consultationincludes advice receivedfrom a telephone discussionwitha specialistandthe referral ofapatient to a specialistfor services.Whencare by one or more specialists is required,the responsibilityof the primary care physician is to coordinate all services,notonly his or her own, but alsoall services by all specialists. ' <>■ ? * " ■•••« •' The skillsandinterestsofphysicians withresponsibilityfor primary care are variable. While the following protocols indicate typical primaryphysicianperformance,itmustbe understoodthat undiagnosedor intrac- table problems, inwhich the patient's optimal healthstatus has notbeen achieved or restored,shouldhave considerationby another physician.The other physicianis usuallyinanon-primary care specialty,although some primary care groups will have consultationby a secondprimary care physicianintheir groupifthat secondphysicianhas special interest,knowledge or skill. The variabilityinprimary care-physicians'skills encompasses bothprocedural and cognitive services.Within the framework of the newer evaluation and management services,we can understand the variability in physicians' cognitive services.Table 1 defines primary care more preciselyand indicates a new category of service,cognitive care. It alsoindicates the types of professionals who may provide different categories of services. Those primary care physicians who achieve optimal healthstatus for their patients by decision-making of moderate and highcomplexity, as well as appropriate use of diagnostic technologyand the performance of some therapeutic procedures,are more valuable man those who do not One rationale for the designationofa primary care physicianis the avoidance of the expense of multiple physicians addressing multiple problems when one physicianmight address them all infewer visits without duplication of diagnostic technology.The following protocols assume that primary care physicians will provide successful cognitive care for most patients. CurrentProcedural Terminology (CPT) uses examples of decision-making complexitylinkedto specialistswhenthe care shouldbe done by primary care physicians. Those primary care physicians,whodo not perform diagnostic or therapeutic procedures,or particularly,do not provide successfulcognitive care for common problems, are less valuable than those who do. Excessive specialistreferralsare usuallyseenwhenprimary care physicians are gynecologists or subspecialtyinternists. The former over-refer for most specialties andthe latter over-refer for dermatological,gynecological and musculoskeletaldiagnoses.Manymanaged care plans do not routinelyapprove suchphysicians tobe primary care physicians unlesstheydemonstrate comprehensive services andsuccessful cognitive care.Our experience here shows thatme bestprimary care physicians oftenare General Practice/FamilyPractice,InternalMedicine or General Pediatric physicians. Many managed care plans and groups provide training incertainspecialties for primarycare physicians who have not been able to provide successfulcognitive care as oftenas colleagues.The following protocols can be considereda syllabus for suchtraining.
  4. 4. HealthcareManagementGuidelines L. OTOLARYNGOLOGY Primary care physicianshould: 1. Treat tonsillitis and streptococcal infections including scarlet fever, thoroughly. He or she should be able to perform and read throat cultures andstreptococcus screens inthe office. 2. Refer for consideration far tonsillectomy if there have been three documented episodes within four months or six documented episodes within one year despite adequate antibiotic treatment. Alsorefer if there is tonsillar obstructionor recurrentperitonsillar abscess. 3. Evaluate and treat other oropharyngeal infections suchas stomatitis,herpangina, or herpes simplex. 4. Treat acute otitis media with op to three different ten-day courses ofantibiotics ifitis unresolved.Treat persistenteffusionfor up to three months ifunresolved. Treat recurrentotitis media, that is three episodes within sixmonths,with continuous low-dose prophylactic antibiotics far three tosixmonths.Refer ifacute otitis media continues toxic for 48 hours despite treatment because of considerationfor tympanocentesis.Refer for persistentinfectionafter three courses of antibiotics,for persistenteffusion lasting greater manthree months despite continuedantibiotic treatmentand for failure ofprophylaxis. Refer if there is persistenthearingloss or delayedspeechand articulationinchildrenunder the age of three.Evaluate with tympanograms or audiograms.Refer ifthere is persistentretractionoftympanic membranes. Obtain lateral nasopharyngeal x-rays as appropriate. 5. Treat acute and chrome sinusitiswithup to two courses ofantibiotics for upto 20 days.Refer if infection is not responsive in72 hours or persistentafter 20 days. 6. Treat allergic orvasomotor rhinitis aggressively with antihistamines, decongestants,nasal sprays or steroids as necessary. Refer if nasal obstruction is evident despite three months of treatment 7. Remove ear wax with hydrogen peroxide, irrigation,or curettement. 8. Treat nasal polyps with antihistamines,decongestants andnasal sprays andrefer ifthe polyps are symptomatic and unresponsive. 9. Diagnose and treatacute parotitis and acute salivaryglandinfections with antibiotics. 10. Refer for: a) parotid masses, b) acute or persistenthearingloss notattributable to fluidor wax, c) hoarsenesswhichpersistsgreater thanthree weeks, d) hemoptysis.
  5. 5. HealthcareManagementGuidelines N. PULMONARY Primarycare physicianshould: 1. Diagnose and treat asthma, acute bronchitis and pneumonia. 2. Diagnose andtreatchronic bronchitis andchronic obstructive pulmonarydisease withperiodic antibiotics,inhaledor oral bronchodilators and/or steroids.Obtainthe results ofpeak-flowrates, pulmonary function,arterial blood gas andtheophylline levels as appropriate. Refer patients for respiratoryfailure or poor response to their regimen. 3. Manage home aerosol medications and oxygen as needed. - 4. Work up possible tuberculosis or fungus infections withskintests,sputumtests andserological tests. 5. Order chestx-rays,special views (e.g.,decubitus views)and CT scans as appropriate. 6. Refer for percutaneous lung biopsies,pleura!biopsies,"or supraclavicular node biopsies. 7. Refer for pleura!effusionsnotdue;to heartfailure or acute pneumonia.Refer for unresolvedpneumonia, hemoptysis, long masses,interstitial disease,sarcoidosis,tuberculosis,or unusual infections.
  6. 6. Healthcare Management Guidelines F. GENERAL SURGERY Primary care physician should: 1. Evaluate and follow small breast lumps in teenagers. 2. Order screening mammography according to an approved schedule. One such schedule could be for a baseline mammogram between the ages of 35 and 40, mammogram every two to four years between the ages of 40 and 50 and mammogram annually over the age of 50. In patients under 50 more frequent screening could be appropriate in high risk patients including those with previous breast cancer, family history of breast cancer in first degree female relatives, or fibrocystic disease. 3. Aspirate cysts, being sure to have careful pathological examination on bloody fluid. 4. Refer persistent cysts, lumps or suspicious mammograms. Undiagnosed masses must have excisional biopsy. 5. Refer hernias after determining risk status. Define whether incisional hernias are medically necessary or cosmetic. 6. Diagnose gallbladder disease and refer to a surgeon if significantly symptomatic. Refer to a surgeon qualified for laparoscopic cholecystectomy unless mat procedure is clearly contraindicated. 7. Refer extrahepatic bile duct obstruction unless gastroenterologist will do ERCP.
  7. 7. HealthcareManagementGuidelines D. ENDOCRINOLOGY Primary care physician should: 1. Manage most diabetics, including Type 1 and Type 2 patients, including patient education, supervision of home testing, medication management, regular examinations and yearly retinal examinations and renal function testing. Contract education programs may be advantageous if available. 2. Manage diabetic ketoacidosis. 3. Obtain consultation for a) Coma not rapidly reversible by glucose, b) Instability in an established management program, c) Complications including retinopathy and nephropathy. 4. Diagnose and treat thyroid disorders. Refer for radioiodine therapy if considered appropriate. Refer for exophthalmos if moderately severe or symptomatic. 5. Manage thyroid nodulesby appropriate testing, scans andultrasound. Refer for fine needle aspiration biopsy if indicated. 6. Refer suspected disorders of calcium metabolism, adrenal, gonadal, or pituitary dysfunction after appropriate testing has been obtained with the advice of the intended endocrine consultant 7. Refer growth retardation only when it is clearly established as non-familial. 8. Identify and treat significant hyperlipidemia. Screening should consist of a baseline total cholesterol, repeated fasting if elevated. If die repeat is soil elevated, determination of triglycerides and HDL may be appropriate. Treat with diet andexercise asappropriate. Treat with medication if diet hasnot achieved or made substantial progress toward goal within six months. Refer if the patient had not responded to diet and medication, including two different medications, within one year.
  8. 8. Healthcare Management Guidelines 7. If trained,the primary care physicianmay do biopsies ofsuspicious lesions for cancer,or others suchas actinic keratoses. 8. Diagnose andtreatcommon hair and nail problems and dermal injuries. a) Examples of common hair problems include: fungal infections,ingrownhairs,virilizing causesof hirsutism,or alopecia as a resultofscarringor endocrine effects. b) Examples of common nail problems include:trauma, disturbances associatedwithother dermatoses or systemic illness,bacterial or fungal infections and ingrown nails. c) Examples of dermal injuries include:minor burns, lacerations andtreatmentof bites andstings. 9. Explain to patients mat the removal of certainlemons is usuallyconsideredcosmetic bycarriers andmay not be covered. These lesions would include: liver spots,spider veins, wrinkles,skintags,cysts,lipomas and flatasymptomatic warts, non-inflamed papillomas, male-pattern baldness,tattoos, hereditary hypertrichosis and non-changing pigmented lesions withthe exception of dysplastic nevi, basal cell nevus syndrome and nevo-cellular nevi.
  9. 9. HealthcareManagementGuidelines C. DERMATOLOGY Primary care physician should: 1. Treat acne with: a) Topical medications including: i. Astringents ii. Antibiotics iii. Retin-A iv. Moisturizing agents onoccasion b) Oral broad-spectrum antibiotics, and c) Accutane for cystic acne ifthe physician is familiar with treatment schedules andside effects. Avoid in women of childbearing potential. d) Use at leastthree modalities over athree-month period. Consider consultationor referralif,after threemonths,the problemhas not been resolvedor improve- ment has ceased,or for severe cystic acne. 2. Treat recurrentacne. 3. Treat painful or disabling warts with topical suspensions,electrocautery,or liquidnitrogen.Refer ifthe above treatment has been unsuccessfulinsymptomatic or functionallyimpairedpatients. 4. Diagnose common rashes andtreat them with appropriate protocols. Included would be: a) Contact dermatitis, b) Dermatophytoas, c) Herpes genitalis, d) Herpes2oster, e) Pediculosis, f) Pityriasis rosea, h) Psoriasis, i) Scabies, j) Seborrheic dermatitis, k) Tinea versicolor. 5. Identify suspiciousmoles.Ifa suspicious lesionsuggests the possibilityofmelanoma, refer the patient to a dermatologist trainedinwide excisional surgeryor a plastic surgeon. 6. Refer basal or squamous cell carcinomas todermatologists exceptthose onthe eyelids or face which may be referredtoa facial plastic surgeon.
  10. 10. Healthcare Management Guidelines B. CARDIOLOGY Primary care physician should: 1. Evaluate chest pain, murmurs and palpitations, and recognize significant heart disease by history, examination, electrocardiogram, echocardiogram and stresstesting including stress electrocardiogram, echocardiogram or nuclear scan. 2. Evaluate and treat coronary risk factors including smoking, hyperlipidemia, diabetes andhypertension. 3. Treat hypertension, congestive heart failure, stable angina and non life-threatening arrhythmias. 4. Treat angina medically with nitrates, beta-blockers, calcium channel blockers and other medication as appropriate. Evaluate non-invasively those who may need catheterization. 5. Determine whether syncope is cardiac, i.e.: valvular or arrhythmic, by history, examination, electrocardiogram, ambulatory monitoring and echocardiogram. 6. Diagnose and hospitalize patients with acute myocardial infarctions. Manage their inpatient course, discharge and follow-up care. Obtain consultation for candidates for thrombolysis, stress testing, catheterization, angioplasty, or surgery and for patients with life-threatening arrhythmias, or hemodynamic complications requiring invasive monitoring. 7. Consult for: a) unstable angina post-MI, b) post-subendocardial MI with or without angina, c) angina despite maximal medical therapy with maximally touted doses of nitrates, beta-blockers and calcium channel blockers, d) intractable heart failure andarrhythmias, e) pericardial effusion, f) congenital or valvular disease. Consult only for diagnosis, non-invasive studies and to define appropriate follow-up.
  11. 11. Healthcare Management Guidelines E. GASTROENTEROLOGY Primarycare physicianshould: 1. Diagnose lower abdominal pain by history,exarninatioiuCBCurinalysis,stool for blood. Sigmoidoscopy shouldbe performed if the stool is positive for blood or there is an alteredbowel habit Referral tosurgeryfor suspectedappendicitis or to gynecologyfor suspectedpelvic disorder would be appropriate. 2. Diagnose andtreatacute diarrhea: a) Bloody-stool culture,ova and parasites,sigmoidoscopy. Treat infectious diarrheaif identified. b) Non-bloody—supportive, but stool neutrophils and culture, ova and parasites if the patient is febrile or the symptoms last72 to 96 hours. Treat infectious diairheaifidentified. 3. Treat protracted vomiting with outpatient rectal or parentcxal medications. Diagnose obstruction or need for parenteral fluids by examination, x-ray and laboratory. Consider consultationifobstructiondiag nosed. 4. For stools positive for blood on diet free of redmeat, primary care physicianshouldhave a barium enema (air contrast)performedanddo flexible sigmoidoscopy.Refer ifpolyps or other abnormalities are found, or if no diagnosis has been established by the examinations. 5. Diagnose andtreatheartburn,upper abdominal pain, hiatal herniaandacidpeptic disease. 6. Diagnose and treatfunctional bowel syndrome by history,esaimnaticii,laboratory,including sigmoidoscopy,bariumenema,lactose tolerance,advice,symptomatic treatment.Refer for chronic bleeding, weightloss,or major psychopathology. 7. Diagnose andtreatjaundice by history,examination,laboratay, including hepatitis serology,ultrasound and scanifobstructionwithout gallstones.Refer ifundiagnosedhepatocellular disease or ifjaundice is complicatedby fever,or intractable ascites.Refer extrahepatic bile ductobstruction. S. Diagnose andtreat ascites byhistory,examination,laboratory, paracentesis (ifqualified),dietand diuretics.Refer ifperitoneal fluidis anexudate, cbylous,or intractable, or iffever persists. 9. Diagnose and treat symptomatic, bleeding or prolapsed hemorrhoids. Treatment may include diet, suppositories,srtzbaths.Thrombosedexternal hemorrhoids shouldbe treatedby the primary care physician with local minor surgery. If severely symptomatic hemorrhoids are refractory to treatment, the patient may be referredfor additional nonsurgical treatment.
  12. 12. 10. Manage inflammatory bowel disease with antibiotics, steroids andsupportive care, with intermittent consultation if control is not well maintained, or for colonoscopy. 11. . Perform screening flexible sigmoidoscopy according to a recommended schedule. One such schedule could be for a baseline examination after age 50 and for every five years thereafter. More frequent re- examinations would be indicated far high risk patients or those in whom a stool for occult blood test has been positive.
  13. 13. Healthcare Management Guidelines G. GYNECOLOGY Primary care physician should: 1. Perform routine pelvic examinations and Papanicolaou smears. These examinations should be carried out on some regular schedule. A typical schedule could be at the age of 18 or the onset of sexual activity and should be repeated at one to three year intervals depending on risk. High risk status would include those with early onset of sexual intercourse and those with multiple partners. If a previous Pap smear has been abnormal it may be indicated that it be repeated at more frequent intervals man annually. On the other hand if a previously abnormal Pap smear has been normal for three consecutive examinations, the frequency of testing can be according to the baseline-schedule. 2. Perform laboratory testing for sexually transmitted disease for those patients with symptoms or multiple sexual partners. 3. Diagnose and treat vaginitis and sexually transmitted diseases. 4. Evaluate lower abdominal pain to distinguish gynecological from gastrointestinal causes. This should include a thorough gynecological history including menstrual and sexual histories as well as symptoms. Complete pelvic examination, pregnancy testing, other laboratory studies including CBC, urinalysis, smears, cultures and ultrasound should be done. Consultation should be sought if ectopic pregnancy is present or an uncertain-clinical diagnosis would benefit from another opinion or laparoscopy. 5. Diagnose vaginal bleeding by history, examination, pregnancy test, CBC and other laboratory tests. Many instances can be managed satisfactorily with hormones. If hormonal control is inadequate, the primary care physician may perform a dilatation and curettage or endometrial sample if he or she is trained to do so; if not me patient should be referred for those diagnostic services. Higher risk pad over 35 or with menometrorrhagia should be referred. 6. Diagnose and treat endometriosis with hormone therapy. If the diagnosis is uncertain, consultation may be sought andmaintenance treatment provided by the primary care physician. Ifsymptoms are refractory to drug treatment, referral for laparoscopy would be appropriate. 7. Manage premenstrual syndrome with the use of hormones, non-steroidal anti-inflammatory drugs, diuretics and other symptomatic treatment. 8. For breast diseases see General Surgery.
  14. 14. Healthcare Management Guidelines P. UROLOGY/NEPHROLOGY Primarycare physician should: 1. Diagnose andtreatinitial andrecurrenturinarytractinfections,including followupexaminations for clearing.Ifinfectionsate persistentor recurrent,the physicianshouldadminister prolongedsuppressive therapy. If infections are persistentor recurrentthe primarycare physicianshouldlook:for anatomical reasons by IVP and voiding cystourethrogram. 2. Provide long termchemoprophylaxis ifthere have been as many as three separate infections withina twelve-month period. 3. Diagnose andtreaturethritis. 4. Explain hematospermia and follow for possible recurrences. 5. Evaluate hernaturiaand refer ifit is unexplainedor due to a mass. 6. Evaluate incontinence and refer ifobstructive lesions require treatment. 7. Diagnose andtreatepididymitis and prostatitis. 8. Differentiate scrotal or peritesticular masses from testicular masses. Refer if the mass is testicular or does 9. Evaluate prostatism andprostaticnodules including IVP, voiding cystourethrogram, rectal ultrasound, acidphosphatase, prostate specific antigen.Referifthe prostate is suspicious for malignancyor if obstructive symptoms lead the patient to choose surgical treatment. 10. Manage urinarystonesonanoutpatient basis unless oral pain control andhydration are impossible. Provide expectant care for small (4 mm or less)distal stones butrefer ifthose do not pass ina week. Refer for larger or proximal stones for considerationofremoval, stenting,or lithotripsy. 11. Evaluate male factor infertilityandimpotence and treat readilycorrectable factors suchas inhibitory drugs.If organic impotence or male factor infertilityis suspectedandnot readilycorrectable,the patient shouldbe referredwith an explanation of the applicable plan benefits. 12. Evaluate renal failurebylaboratory tests,ultrasoundandscans.Treatrenal failureby eliminating aggravating factors anddietaryadvice. Refer for acute renal failure,obstructive uropathy, 50% reduction increatinineclearance,or nephrotic syndrome. 13. Refer for circumcisionifthere have been recurrentbalanitis or foreskinproblems.
  15. 15. Healthcare Management Guidelines A. LOW BACK PAIN 1. Without neurological deficit a) Briefbed rest,rest,exercises,analgesics,muscle relaxants,physical measures,e.g.,heat, massage, tractionfor up to eightweeks onoutpatientbasis.Ifchiropractic manipulations are effective within several manipulations, more extensive treatment may be avoided. b) Spinal x-ray if the patient is known to have: 1) malignancy, 2) fever, 3) trauma. c) MRI if symptoms persistdespite eighth weeks of conservative management. d) Persistentsymptoms despite negative imaging should have consultation with neurologist or neurosurgeon. e) Herniated or bulging disc,or spinal stenosis withpersistentdisabling symptoms,proceed to: 1) percutaneous disc ablation/aspiration, or 2) diskectomy, laminotpmy, laminectomy. 2. With progressive neurological deficit a) MRI, and b) EMG - Neuroconsult, c) Therapeutic procedure for anatomical lesion. 3. With stable neurological deficit a) Rest,conservative treatment as la) above, and b) EMG - Neuroconsult,and c) MRL d) If satisfactorysymptomatic reliefwithineightweeks,nofurther measures except strengthening exercisesandinstructioninbody mechanics. e) If unsatisfactorysymptomatic status andanatomical lesion,proceedtotherapeutic procedure.
  16. 16. Healthcare Management Guidelines G. EMERGENCY ROOM AND URGENT CARE CENTER VISITS SectionB.4 of this Chapter shows,in Table 4,an allocationof physicianservices,projecting emergencyroom and urgentcare center (ER/UCC) use at 169 visits per 1,000 members. While mat table shows only die physician costs,and assumes that the treating physician would be paid on a fee-for-service basis,die same utilizationrate would apply to die facilities andtheir charges. Many payers and medical managers findthat emergencyrooms,are usedinappropriately,for conditions and serviceswhichcouldbe provided indie office or inan urgentcare center.Inappropriate use of die emergency room is often attended by disproportionate charges for these less seriouslyillpatients,who may be treated defensivelyby providers unfamiliar with them. Existing approaches to control emergencyroom costs include: 1. Substantial copayments by patients, 2. Retrospective denials of coverage stating that the level of service was not medically necessary,or 3. A requirementfor primarycare physicianauthorization,which,onoccasion,is grantedretrospectively and/or inappropriately. Contract language defining emergencies is oftenimprecise. Another approach is tostipulate by contract,thatcertaindiagnoses are appropriate for office or urgentcare level treatmentand reimbursement.Examples of suchconditions are: • Allergic reactionswithout dyspnea • Animal bites whichdo not require suturing • Asthma responding to single inhalation or parental treatment • Back pain without recentacute trauma or recent neurologicalcomplaints or findings • Bronchitis • Checks andrechecksofbums, casts,testresults,or wounds • Colds or coldsores • Conjunctivitis without the presence of a contact lens,aforeignbody or trauma • Cough • Dermatitis,itching,rash • Diarrheawithout bleeding or dehydration, inolder childrenor adults • Dressing change • Extremity injurywithout deformity or hemorrhage • Flu symptoms • Foley catheter replacement • Genital discharge or pain without abdominal pain • Headache unlessofsudden onset, unprecedentedseverity,or associatedwith fever or recenttrauma • Human bites without tissue disruption • Ingrown toenails • Insect bites with symptoms which are only local • Lacerations which do not involve nerves or tendons, do not require suturing,or are over 24 hours old
  17. 17. Healthcare Management Guidelines • Localizedinfections • Medication administrationor refills • Musculoskeletal pains notassociatedwith recenttrauma • Needle sticksor puncture wounds • Otitis mediaunless associatedwith a temperature over 104°or ear drainage * Paronychia • Sinusitis • Sore throat • Stye • Subungual hematoma • Suture removal • Toothache without facial swelling or lymphadenopathy • Urinary burning, frequency, Notwithstanding the above, the emergencyroom is the appropriate level of service for the following condi tions: • Abnormal or unstable vital signs • Abnormal motor, sensory,,<wtendon functions ofrecentonset • Eye pain or redness inthe presence of contact lenses,foreignbody, or trauma • Inability to be transferredintoawheelchair for transport • Laceration of eyelids,vermillionborder of the hp or other complex facial lacerations • Nose bleeding unable to be controlledby conservative measures • Psychiatric lossofcontrol,intoxication, significantconfusionor disorientation,or ifmere is ahigh probability of a needfor security • Vaginal bleeding or pain in pregnancy or inany woman with a late or missedperiod
  18. 18. PrenatalCare The Primary Care Provider Recommended Guidelines: I. Medically access and stabilize high risk conditions including: A. Diabetes in Pregnancy B. Hyperemesis gravidarum C. Pregnancy-induced hypertension D. Preterm labor D. Rh status E. History of sexual abuse F. AIDS II. Completed required laboratory tests, including CBC, hematocrit, and urine analysis III. Assess adaptation to pregnancy, including family and work role changes. Provide support as needed. IV. Assess fetal growth and development V. Educate patient, family, and caregiver about: A. Nutritional factors which promotea healthy outcome, B. Importance of avoiding tobacco, alcohol, and other drugs, C. How to establish and maintain good oral hygiene, D. Recommended physicalactivity and exercise, E. Maintaining good postureand body mechanics, F. Rest and relaxation, G. Sexual activity, H. Benefits and techniques of breast feeding, I. Postnatalcare requirements including: 1. Pain management 2. Wound care 3. Frequency of follow-up visits 4. Decisions about birth control VI. Establish a birth plan with patient and family preparation, including: A. Measures known to enhance the progress of labor, including: 1. Upright positions, 2. Frequent position changes and ambulation 3. Relaxation techniques and hydrotherapy B. Trial of labor after previous cesarean section C. Pain Management D. Family preparation and involvement E. Cultural and religious requirements related to care of mother, infant, and placenta VII. Assess home safety, needs, and capabilities VIII. Hospital Care A. Labor and Delivery B. Monitor daily progress 1. Assess progress of labor 2. Assess maternal and fetal status 3. Pain management 4. Adherence to elements of birth pal, as possible C. Facilitate thecontinued availability of caregiver support during labor and delivery D. Ensure adequate process for obtaining informed consent E. Ensure that prophylacticantibiotics are given F. Assess psychosocialfactors including anxiety. Provide psychosocialsupport and referral as needed. G. Post Delivery 1. Monitor daily progress 2. Assess and stabilize the infant 3. Assess and stabilize the mother, including: a. Recovery from anesthesia b. Pain management
  19. 19. c. Leg exercises and ambulation d. Wound care e. GI function f. Amount of lochia g. Breast care 4. Provide for home care if needed
  20. 20. Vaginal Delivery The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds II. Encourage the use of contraceptives III. Educate thepatient about contraceptiveoptions. IV. If patient requires induced abortion, preferably schedule prior to 20 weeks gestation, educate the patient about A. Anticipatory grieving. B. Risk for infection. C. Pain D. Community resources, including Planned Parenthood. E. Other forms of contraception. V. Prenatal care A. Medically assess and stabilize high risk conditions, including: 1. Diabetes in pregnancy. See also Diabetes in Pregnancy. 2. Hyperemesis gravidarum. See also Hyperemesis Gravidarum. 3. Pregnancy induced hypertension 4. Rh status. 5. Preterm labor 6. History of sexual abuse. 7. Substance abuse. 8. AIDS B. Complete required laboratory tests, including CBC, hematocrit, and urine analysis. C. Assess adaptation to pregnancy, including family and work role changes. Provide support as needed D. Assess fetal growth and development E. Educate patient, family, and caregiver about: 1. Nutritional factors which promotea healthy outcome. 2. Importance of avoiding tobacco, alcohol, and other drugs. 3. How to establish and maintain good oral hygiene. 4. Continuation of physicalactivity and exercise 5. Maintenance of good postureand body mechanics. 6. Rest and relaxation. 7. Sexual activity. 8. Breastfeeding. 9. Postnatalcare requirements, including frequency of visits and decisions about birth control F. Establish a birth plan with patient participation, including: 7. Birth setting, including environmental modifications. 8. Birthing position. 9. Decision about episiotomy. 10. Use of electronic fetal monitoring 11. Pain management. 12. Family preparation and involvement. 13. Cultural and religious requirements related to the care of the mother, infant, and placenta G. Assess home safety, needs, and capabilities V. Hospital - Labor and delivery N. Monitor progress: 1. Maternaland fetal status, as well as progress of labor. 2. Pain management 3. Psychosocial factors, including anxiety. Provide psychosocialsupport and referral as needed 4. Nutrient and fluid intake 5. Adherence to elements of birth plan. 6. Facilitate theavailability of caregiver support duringlabor
  21. 21. 7. Postbirth 8. Monitor daily progress: a. Assess and stabilize the infant. b. Assess and stabilize the mother. VIII. Coordinate development of treatment goals and plans with multiple caregivers, including obstetrician, pediatrician, and primary care provider IX. Facilitate transition to next level of care. X. Ensure timely referral to appropriatecommunity resources and applications for publicfunding XL. OptimalRecovery Course A. Day 1: Uncomplicated delivery. Parental or oral medication. Diet as tolerated. DiscontinueIV. Ambulatory. B. Day 2: Afebrile. Uterus is firm. No significant bleeding or medical problems. Ambulatory. Oralmedication. Discharge AM or PM 24 hours post delivery XII. Goal Length of Stay: 1 day postpartum Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. XIII Extended stay beyond goal length of stay may be needed for: A. Complications of procedure - forceps or vacuum-assisted delivery, breech delivery, and third or fourth degree vaginal lacerations may occur; anticipate pain management and attention to maintaining bowel function. Expect brief stay extension. B. Care for comorbidities - patients with comorbidities, including prematureruptureof membranes, preeclampsia, diabetes mellitus, gestational diabetes, and chorioamnionitis, may require continued inpatient care. Expect brief stay extension C. Severe complications (e.g., uterine rupture, massive hemorrhage) may require surgery and further inpatient care. Expect moderate stay extension 14. Refer to Home healthcare for patients who require assessment and management of care, including: A. Assistancewith lactation. B. Pain management C. Wound management D. Maternaland infant status. E. Bowel and bladder function. F. Complications, including endometritis
  22. 22. CesareanSection I. The Primary Care Provider will coordinate care and anticipate needs. II. Encourage measures to reduce risk for cesarean birth, including: A. Using home environment for early or latent labor. B. Labor techniques that enhance progress. C. Nonpharmacologic measures to reduce pain and discomfort and enhance relaxation. D. Smoking cessation. E. Appropriateweight gain for patient's height and prepregnancy weight. F. Vaginal birth after cesarean. G. Assess fear of childbirth and coping abilities during third trimester. H. Provide support and referral as needed. I. Useactive labor management when epidural anesthesiais used for pain management in nulliparous women, including: 1. Education about the effect of epidurals and components of active labor management. 2. Useof oxytocin. 3. Amniotomy when diagnosis of labor is established. 4. Support for laboring woman. III. Avoid routine induction for spontaneous ruptureof membranes at term or post-termpregnancy. IV. Consider individual circumstances when risk for cesarean is present, including: A. Breech presentation. B. Twin gestation. C. Genital herpes. D. Failure to progress. E. Gestational age greater than 30. F. Maternalheight less than 62 inches. G. Gestationalweight gain greater than themedian for one's body mass index. H. Fundal height measured at term. I. Maternalhypertension. J. History of pelvicfracture. V. Prenatal care A. Medically assess and stabilize high risk conditions, including: 1. Diabetes in pregnancy. 2. Hyperemesis gravidarum. 3. Pregnancy-induced hypertension. 4. Pretermlabor. 5. Rh status. 6. History of sexual abuse. 7. Substance abuse. 8. AIDS B. Complete required laboratory tests, including CBC, hematocrit, and urine analysis. C. Assess adaptation to pregnancy, including family and work role changes. Provide support as needed. D. Assess fetal growth and development E. Educate patient, family, and caregiver about: 1. Nutritional factors which promotea healthy outcome. 2. Importance of avoiding tobacco, alcohol, and other drugs. 3. How to establish and maintain good oral hygiene. 4. Recommended physicalactivity and exercise. 5. Maintaining good postureand body mechanics. 6. Rest and relaxation. 7. Sexual activity. 8. Benefits and techniques of breastfeeding. 9. Postnatalcare requirements, including a. Pain management.
  23. 23. b. Wound care. c. Frequency of follow-up visits. d. Incisions about birth control. e. Establish a birth plan with patient and family participation, including: (1) Measures known to enhance the progress of labor, including: (a) Upright positions. (b) Frequent position changes and ambulation. (c) Relaxation techniques and hydrotherapy. (2) Trial of labor after previous cesarean section. (3) Pain management. (4) Family preparation and involvement. (5) Cultural and religious requirements related to the care of themother, infant, and placenta. f. Assess home safety, needs, and capabilities. VI. Hospitalcare - Labor and delivery A. Monitor daily progress: 1. Assess progress of labor. 2. Assess maternal and fetal status. 3. Pain management. 4. In elective Cesarean section, intrathecal morphine may result in less pain and less IV morphine consumption. 5. Adherence to elements of birth plan, as possible. B. Facilitate thecontinued availability of caregiver support during labor and delivery. C. Ensure adequate process for obtaining informed consent. D. Ensure that prophylacticantibiotics are given. E. Assess psychosocialfactors, including anxiety. Provide psychosocialsupport and referral as needed. F. Post delivery G. Monitor daily progress: 1. Assess and stabilize the infant. 2. Assess and stabilize the mother, including: a. Recovery from anesthesia. b. Pain management. Avoid meperidine, as it is associated with more neonatal neurobehavioral depression than morphine. c. Leg exercises and ambulation. d. Wound care. e. GI function. 3. Postpartumcare, including: a. Amount of lochia. b. Breast care, including lactation support. H. Facilitate decision about discharge destination. Most patients aredischarged home with home healthcare if needed. I. Coordinate development of treatment goals and plans with multiple health care professionals. J. Facilitate transition to next level of care. K. Ensure timely referral to appropriatecommunity resources and applications for public funding. L. Ensure that follow-up appointment is made. VII. Clinical Indications for Procedure - Procedure indications include (any one of the following): A. Dystocia(failure to progress, cephalopelvic disproportion) B. Malpresentation with failure or refusal of version
  24. 24. C. Fetal distress D. Placenta previa E. Placental abruption F. Severe preeclampsia G. Unable to undergo vaginal delivery due to comorbidities (e.g., cardiomyopathy) H. Previous uterine rupture I. Previous cesarean section with (any one of the following): 1. Refused trial of labor 2. Known vertical uterine scar 3. HIV or active genital herpes simplex infection 4. Multiplegestation - selected cases 5. Polyhydramnios/fetalanomaly 6. Obstructivepelvic tumors 7. Prior abdominal cervical cerclage - selected cases 8. Prior vaginal colporrhaphy - selected cases J. OptimalRecovery Course 1. Day 1: Operatingroom for surgical delivery, possibly after trialof labor. Parenteral fluid and medication. Possible patient controlled analgesia (PCA). 2. Day 2: Clear liquids to advanced diet as tolerated. Discontinue PCA. Discontinue IV and urethral if not done previously. Parenteral or oral medication. Ambulatory. Flatus present. 3. Day 3: Afebrile. Ambulatory. No significant vaginal bleeding. Oral medication. Usualdiet. Discharge. 4. Goal Length of Stay: 2 days postpartum 5. Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than thegoal) when it is appropriate for their clinical status and care needs. K. Extended stay beyond goal length of stay may be needed for: 1. Complications of procedure - (e.g., bowel, ureter, or bladder injury) anticipaterepair, possibly reoperation. Expect brief to moderate stay extension. 2. Care for comorbidities - patients with complex comorbidities (e.g., diabetes requiring insulin, chronic hypertension, cardiac or renal disease) may require continued inpatient care. Expect brief stay extension. VIII. Home healthcare may be suitable for patients who require: A. Assistancewith managing lactation. B. Skilled assessment of wound, pain management, or complications. C. Further psychosocialassessment and referral. D. Provide skilled assessment with an emphasis on: 1. Care of infant. 2. Wound management. 3. Pain management.. 4. Manage complications, including: a. Endometritis b. Wound infection.. c. Wound dehiscence. d. Excessive bleeding. e. Educate patient, family, and caregiver about: (1) Pain management. (2) Expected amount and color of lochia. (3) Breastfeeding. (4) Breast care, including care of breasts during engorgement. (5) Care of the infant (6) Importance of postpartumfollow-up visits for both mother and infant. (7) Nutritional requirements.
  25. 25. Hyperemesis Gravidarum The Primary Care Provider Recommended Guidelines: I. Coordinate care and anticipateneeds by early detection of risk factors include pregnant women who: A. Are <20 years of age. F. Are obese. G. Are nonsmokers. H. Have multifetal or molar pregnancies. I. Are hyperthyroid. V. Educate patient, family, and caregiver about underlying pathologies, including: A. High levels of estrogen or human chorionic gonadotropin. B. Vitamin B deficiencies. C. Increased sensitivity to circulating sex steroid hormones D. High stress levels. E. Psychological factors, including conflicting feelings about the pregnancy III. Medically assess and stabilize comorbid medical conditions, including: D. Hyperthyroidism. E. Liver dysfunction. IV. Assess: A. Vital signs. B. History of nausea and vomiting. C. Other symptoms such as diarrhea, indigestion, abdominal pain or distortion. D. Precipitating factors related to the onset of symptoms. E. Prepregnancy weight, and documented gain or loss F. Tissueturgor for evidence of dehydration G. Electrolyteimbalances. H. Thyroid function. I. Anxiety related to stateof health and pregnancy outcome J. Monitor ketonuria V. Prenatal - Educate patient, family, and caregiver, about: A. Management plan, including medications and IVs. B. Methods of eating that may decreased nausea and vomiting, including frequent, small, low-fat meals. C. Herbal teas, such as chamomile or raspberry leaf, that may decrease nausea. VI. When hospitalized, monitor daily progress: G. Enteral or parenteral nutrition. H. Intake and output I. Patient's responseto interventions, including: 1. Antiemetic medication 2. Fluid and electrolytereplacement. 3. Nutritional support. D. Advance diet from oral fluids to bland foods, including crackers and toast. E. Promote adequate rest. F. Assess psychosocialfactors, including: 4. Risk for anxiety and depression. 5. Ability to work. 6. Changes in lifestyleand social roles. 7. Provide psychosocialsupport and referral as needed. VII. Facilitate decision about home or recovery facility care. VIII. Coordinate development of treatment goals and plans with multiple caregivers
  26. 26. IX. Facilitate transition to next level of care. X. Ensure timely referral to appropriatecommunity resources and applications for public funding. XI. Ensure that follow-up appointment is made and transportation is available. XII. Inpatient Admission - Admission may be indicated for (any one of the following) A. Moderateto severe dehydration manifested by (any one of thefollowing): 1. Postural hypotension 2. Marked electrolyte abnormalities 3. Increased hematocrit 4. Increased BUN to creatinine ratio B. Inability to tolerate oral medication and nutrition C. Unacceptable antiemetic side effects (e.g., hypotension, extrapyramidalreactions) D. Concern for abdominal pathology (e.g., fatty liver of pregnancy, pancreatitis) XIII. OptimalRecovery Course A. Day 1: Admit patient for dehydration, suspected abdominal pathology or other indications. Urinalysis, CBC, chemistry panel. Possible ultrasound or x-rays. Bed rest with bathroom privileges. Parenteral fluid, thiamine and other vitamins, electrolyte correction as needed. Parenteral or rectal anti-emetics. Liquid diet as tolerated. Discharge planning. Possible discharge. B. Day 2: Patient is no longer dehydrated. Electrolytes are normal. Theabdomen is benign. Other causes of emesis excluded. Liquid or solid diet. Discharge C. Goal Length of Stay: Ambulatory to 1 day Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. XIV. Extended stay beyond goal length of stay may be needed for: A. Severe malnutrition - may necessitate that totalparenteral nutrition (TPN) be initiated. Monitor liver function, electrolytes, lipids, and short-termmarkers of nutritionalstatus, such as pre-albumin. Transfer to home healthcare once access line is in place and TPN established. Expect brief stay extension. B. Hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome - continue to monitor coagulation profile, liver function, platelets, mental status, and hydration status. Expect moderateto prolonged stay extension. C. Hydatidiformmole - continue to monitor HCG level and hydration status;discharge to home with close follow-up when further treatment plan established and stable. Expect brief stay extension. D. Wernicke's encephalopathy or other CNS complication - continue IV thiamine, steroids, and anticoagulants, as well as supportivecare. Transfer to recovery facility for rehabilitation when stable. Expect brief stay extension. E. Fetal compromise - continue to monitor fetal heart tones, movement, and growth. Expect brief to moderate stay extension.
  27. 27. Pregnancy-InducedHypertension The Primary Care Provider Recommended Guidelines: I. Coordinate Care and Anticipate Needs = Risk Factors A. Family history of hypertension or vascular disease. B. Pregnancies occurring under the age of 17 or over the age of 35. C. Multiplegestation. D. Primigravida E. Diabetes F. Hydrops fetalis. G. Hydatiformmole. H. Renal infections. I. Elevated alpha protein at 15 to 20 weeks gestation. II. Care in office or rapid treatment site A. Hypertensivedisorders are themost common medical complications of pregnancy B. Pregnancy induced hypertension is elevated blood pressurewithout proteinuria. The presence of proteinuria is indicative of pre-eclampsia which can occur in conjunction with pregnancy-induced hypertension C. Prenatal 1. Medically assess and stabilize preexisting blood pressureor renal disease: 2. Assess blood pressure 3. Obtain urinalysis for proteinu ria. 4. Obtain blood sample for blood urea nitrogen, creatinine, uric acid, platelets and hemoglobin. 5. Assess edema. 6. Assess reflexes. 7. Assess fetalmovement. 8. Assess fundal height. 9. Obtain ultrasound as needed. III. Educate patient, family, and caregiver about: A.. Underlying pathologies and management plan B. How to recognize signs and symptoms of complications, and when to report to health care professional, including: 1. Blood pressureelevation >30 systolicor > 15 diastolic from baseline. 2. Decreased fetal movement. 3. Planned prenatalcare. 4. Assess home safety, needs, and capabilities IV. Care in hospital A. Monitor daily progress: 1. Blood pressure. 2. Weight 3. Proteinuria 4. Intake and output 5. Cerebral or visual disturbances. 6. Signs and symptoms of edema, including pulmonary edema. 7. Nail beds, observing for cyanosis. 8. Fetal movement. B. Assess psychosocialfactors, including: 1. Anxiety and depression. 2. Changes in lifestyle. 3. Changes in social roles. C. Coordinate development of treatment goals and plans with multiple caregivers, including obstetrician, neonatologist, home health nurse, and child care provider D. Facilitate transition to next level of care ensuring that all needed equipment is available. E. Communicate patient status to primary care provider. F. Ensure timely referral to appropriatecommunity resources and applications for public funding. G. Ensure that follow-up appointment is made and transportation is available.
  28. 28. V. Home healthcare may be suitable for patients who require skilled assessment and management of care, including: A. If beyond 20 weeks gestation. B. To minimize out-of-home appointments for patients on strict bedrest. C. Blood pressure. D. Weight E. Proteinuria F. Intake and output. G. Cerebral or visual disturbances H. Signs and symptoms of edema, including pulmonary edema. I. Nail beds, observing for cyanosis. J. Fundal height. K. Fetal movement. L. Patient is safe at home, with adequate caregiver available as needed VI. Educate patient, family, and caregiver about care requirements. VII. Clinical Indications for Inpatient Admission A. Uncontrolled hypertension (systolic>=160 mmHg or diastolic >=110 mm Hg) with (any one of the following): 1. Proteinuria > 100 mg/L on urine dipstick or > 1 g/24 hours 2. Rapid increase in serum creatinine to > 1.2 mg/dL 3. Platelet count <100,000/mm3 4. Evidence of microangiopathic hemolytic anemia with increased lactate dehydrogenase 5. Elevated hepatic enzymes (alanine aminotransferase or aspartateaminotransferase) 6. Epigastric pain 7. Significant edema 8. Evidence of acute and progressing target organ disease (any one of the following): a. Hypertensiveencephalopathy b. Cerebral infarction c. Intracerebral hemorrhage d. Myocardialischemia, myocardial infarction e. Acute pulmonary edema f. Aortic dissection g. Seizures h. Acute renal insufficiency i. Papilledema j. Evidence of fetal compromise (any one of the following): (1) Abnormal fetal heart tones (2) Abnormal contraction stress test (3) Abnormal biophysicalprofile B. OptimalRecovery Course 1. Day 1: Admit patient for blood pressureout-of-control, hypertensive symptoms, or failure to respond to outpatient antihypertensives. Bed rest. Frequent vitalsigns. Urinalysis, CBC, platelet count, chemistry panel (including creatinine and transaminases). Oral or parenteral antihypertensives. Establish gestational age. Fetal monitoring. Discharge planning 2. Day 2: Blood pressurenormal or adequately controlled. Laboratory values normal or resolved to near normal. Up ad lib. Oral medication. Discharge C. Goal Length of Stay: Ambulatory to 1 day Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. D. Extended stay beyond goal length of stay may be needed for:
  29. 29. 1. Preeclampsia/Eclampsia - development of these findings may require continued use of parenteral agents, possibledelivery. Expect brief to moderate stay extension; prolonged stay may benecessary if delivery cannot be accomplished 2. Ongoing fetal compromise - detection of abnormalities on fetal monitoring may require continued hospitalobservation. Expect brief to moderate stay extension 3. Other hypertension-associated conditions in pregnancy (e.g., hemolysis, low platelets) - may require ongoing inpatient care. Expect moderate to prolonged stay extension. 4. Uncontrolled hypertension or target organ damage (e.g., cerebral infarction). VIII. Home Care A. Restriction of activity B. Home blood pressuremonitoring C. Discourage use of alcohol and tobacco D. Pharmacologic treatment for diastolic blood pressuregreater than 100 mm Hg
  30. 30. PretermLabor, Threatened The primary Care Provider Recommended Guidelines: I. Be aware that thecurrent 11 % rateof pretermbirth has not changed significantly in thepast 20 years despiteincreased rate of interventions, including bed rest, hydration, and enhanced prenatal care II. Educate pregnant women that risk factors are present in 50% of women with preterm labor: Risk factors include: A. Demographic risks: 1. African-American. 2. Below 17 or above 24 years of age 3. Lower socioeconomic status 4. Unmarried 5. Lower level of education. B. Medical risks predating current pregnancy 1. History of previous preterm birth 2. Multipleabortions, spontaneous or elective. 3. Uterine anomalies 4. Low pregnancy weight for height. 5. Parity (0 or >4) 6. Diabetes 7. Hypertension C. Medical risks in current pregnancy 1. Multiplegestation. 2. Infection, including: bacterial vaginosis and urinary tract infection 3. Incompetent cervix 4. Short interval between pregnancies 5. Bleeding in first trimester 6. Placenta previa or abruptio placentae 7. Fetal anomalies 8. Premature ruptureof membranes D. Behavioral and environmental risks: 1. Diethylstilbestrolexposure 2. Smoking 3. Poor nutrition 4. Alcohol or other substance use, especially cocaine 5. Late or lack of prenatalcare. 6. High stress III. Prenatal in Office Site D. Medically assess and stabilize comorbid medical conditions, including diabetes and hypertension E. Identify women at risk for pretermlabor and tailor interventions to specific needs and resource availability. Most interventions designed to prevent preterm birth do not work F. Interventions may include 1. Tocolyticagents, including g. Beta agonists, e.g., ritodrine and terbutaline h. Prostaglandin inhibitors, e.g., indomethacin. i. Calcium channel blockers, e.g., nifedipine. j. Oxytocin antagonists k. Magnesium sulfate 2. Special programs targeted to high-risk conditions, including drug use 3. Relaxation therapy 4. Antibiotic treatment of urinary tract infections and bacterial vaginosis
  31. 31. IV. Educate patient, family, and caregiver about: A. How to recognize signs and symptoms of pretermlabor. B. How to recognize signs and symptoms of pretermlabor. C. How to recognize signs and symptoms of complications, and when to report to health care professional IV. If hospitalized, monitor daily progress: A. Ensure that patients with prematureruptureof themembranes who test positivefor group B Streptococcus receive antibiotic therapy B. Assess psychosocialfactors, including: C. Fear for outcome, anxiety and depression. 1. Changes in lifestyle 2. Changes in social roles. 3. Provide support and referral, as needed. A. Corticosteroid therapy may promotefetal maturation B. Facilitate decision about home care. Home healthcare may be suitable for patients with cervical dilatation of 3 cm or less, and fewer than 4 to 6 contractions per hour C. Coordinate development of treatment goals and plans with multiple caregivers D. Facilitate transition to next level of care E. Regularly communicate with professional staff, patient, family, and caregiver F. Regularly communicate with professional staff, patient, family, and caregiver G. Ensure that follow-up appointment is made H. HospitalAdmission may be indicated for (any one of the following) 1. Preterm ruptureof membranes 2. IV tocolytics (beta-adrenergic agonists) required 3. Administration of IV magnesium as a tocolytic 4. Suspected amnionitis 5. Significant vaginal bleeding 6. Maternalinfection (e.g., pyelonephritis, pneumonia) 7. Severe maternal disease trigger or comorbidity including: a. Uncontrolled diabetes b. Diabetic ketoacidosis c. Severe dehydration d. Preeclampsia e. Severe hypertension 8. Delivery 9. Fetal demise 10. Condition requiring premature delivery (preeclampsia or presumed fetal growth restriction) L. Day 1 Admit patient with significant contractions before term. Bed rest. Parenteral hydration, parenteral tocolytictherapy, and corticosteroids[A1 (if indicated for fetal maturation). Eliminate infectious or other medical causes. Usual diet. Discharge planning. Possible discharge, if contractions cease and parenteral medication not in use. Day 2: Contractions ceased. Activity as tolerated. Discharge. Goal Length of Stay: Ambulatory to 1 day M. Extended stay beyond goal length of stay may be needed for: 1. Significant infection - anticipateparenteralantibiotics, observation until contractions ceased; transition to home healthcare for continued parenteral antibiotics. Expect brief stay extension. 2. Continued uterine contractions - anticipate continued parenteral tocolytics;for progression to delivery expect brief stay extension;if contractions controlled, continued IV tocolytics may or may not be necessary. Expect brief to prolonged stay extension. 3. Fetal demise - anticipate progression to delivery and possibleinduction of delivery (near term); if
  32. 32. contractions cease and delivery not elected, anticipate discharge while awaiting spontaneous delivery. Possible brief stay extension. 4. Continued vaginal bleeding - anticipaterapid evaluation of placentaprevia or abruption, may require surgical control, delivery, or both. Expect brief to moderate stay extension. 5. Other condition (e.g., severe maternal disease, prematuredelivery) requiring continued inpatient care. Expect brief to moderate stay extension. V. Alternatives to hospitalization VI. B. Outpatient care in labor and delivery unit 1. Observation, fetal and maternal monitoring 2. Tocolytictrial 3. Discharge if contractions ceased C. Home care 1. Decreased activity 2. Possible parenteral hydration 3. Possible tocolytictherapy 4. Corticosteroids[A] (if indicated for fetalmaturation)
  33. 33. IMMUNIZATIONS Recommended childhood and adolescent immunization schedule- The guideline recommendations and format were approved by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics. Primary Care Provider should: 1. Ensurethat therecommended childhood and adolescent immunization schedule is current with changes in manufacturers' vaccine formulations Recommend to the parent or guardian that thefollowing Immunization Schedule be followed: A. Hepatitis B Vaccine The schedule indicates a change in the recommendation for the minimum age for the last dose in the hepatitis B vaccination schedule. The last dose in the vaccination series should not be administered beforeage 24 weeks (updatingthepreviousrecommendation notto administer the last dose before age 6 months). The final doses in theHib and PCV series should be given at age >12 months Influenza Vaccine - Healthy children aged 6 to 23 months are encouraged to receive influenza vaccine when feasible during influenza season. Children in this age group are at substantially increased risk for influenza- related hospitalizations. TheAdvisory Committeeon Immunization Practices (ACIP) has indicated further that beginning in fall 2004, children aged 6 to 23 months will be recommended to receive annual influenza vaccine. ProvideVaccine Information Statements to parentsor guardian - TheNational Childhood Vaccine Injury Act requires that all health-care providers give parents or patients copies of Vaccine Information Statements before administering each dose of the vaccines listed in the schedule. Advise parents or guardian of recommended immunization schedule as listed below: Range of recommended ages *Catch-up vaccination Preadolescent assessment Vaccine Birth 1 mo 2 mo 4 mo 6 mo 12 mo 15 mo 18 mo 24 mo 4—6y rs 11-12 13-18 y rs yrs Hepatitis B 2 Hep B#l only if mother HBsAg (-) *HepB series HepB#2 HepB#3 DTaP DTaP DTaP DTaP DTaP Td •Td Haemophilus influenza ty pe b4 Hib Hib Hib4 Hib Inactivated Polio IPV IPV IPV IPV Measles, Mumps, MMR#1 MMR#2 *MMR#2 Rubella5 Varicella 6 Varicella ♦Varicella Pneumococcal 7 PCV PCV PCV >CV Indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2003, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Hepatitis B vaccine (HepB): All infants should receive the first dose of HepB vaccine soon after birth and before hospital discharge; the first dose also may be given by age 2 months if the infant’s mother is HBsAg-negative. Only monovalent HepB vaccine can be used for the birth dose. Monovalent or combination vaccine containing HepB may be used to complete the series; 4 doses of vaccine may be administered when a birth dose is given. The second dose should be given at least 4 weeks after the first dose except for combination vaccines, which cannot be administered before age 6 weeks. Thethird doseshould be given at least 16 weeks after the first dose and at least 8 weeks after thesecond dose. Thelast dosein thevaccination series (third or fourth dose) should not be administered before age 24 weeks. Infants born to HBsAg-positive mothers should receive HepB vaccine and 0.5 mL hepatitis B immune globulin (HBIG) within 12 hours of birth at separatesites.Theseconddoseis recommended at age 1 —2 months. The last dose in the 2. B. C. 3. 4.
  34. 34. 9. vaccination series should not beadministered beforeage 24 weeks. Theseinfants should betested for HBsAg and anti-HBs at age 9—15 months. Infants born to mothers whoseHBsAg status is unknown should receive the first dose of the HepB vaccine series within 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the mother’s HBsAgstatus;if theHBsAgtestis positive, theinfant should receive HBIG as soon as possible (no later than age 1 week). The second dose is recommended at age 1—2 months. The last dose in the vaccination series should not be administered before age 24 weeks. Diphtheriaand tetanustoxoids and acellular pertussis vaccine(DTaP):Thefourth doseof DTaP may be administered at age 12 months provided that 6 months have elapsed since the third dose and the child is unlikely to return at age 15—18 months. Thefinaldosein theseries should begiven at age >4 years. Tetanusand diphtheriatoxoids (Td) is recommended at age 11—12 years if at least 5 years have elapsed since the last dose of tetanus and diphtheria toxoid-containing vaccine. Subsequent routine Td boosters are recommended every 10 years. Haemophilus influenza type b (Hib) conjugate vaccine: Three Hib conjugate vaccines are licensed for infant use. If PRP- OMP (PedvaxHIB®* or ComVax®8 [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination products should not be used for primary vaccination in infants at ages 2,4, or 6 months but can be used as boosters after any Hib vaccine. The final dose in the series should be given at age >12 months. Varicella vaccine (VAR): Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., thosewho lack a reliable history of chickenpox). Susceptible persons aged >13 years should receive 2 doses given at least 4 weeks apart. Influenza vaccine: Influenza vaccine is recommended annually for children aged 6 months with certain risk factors (including but not limited to asthma, cardiac disease, sickle cell disease, HIV, and diabetes), and household members of persons in groups at high risk and can be administered to all others wishing to obtain immunity. In addition, healthy children aged 6—23 months areencouraged to receive influenza vaccine if feasible because children in this age group are at substantially increased risk for influenza-related hospitalizations. Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if 6—35 months or 0.5 mL if >3 years). Children aged <8 years who are receiving influenza vaccine for the first time should receive 2 doses (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV). TABLE. Catch-up immunization schedule for children and adolescents who start late or who are >1 month behind Catch-up schedule for children aged 4 months 6 years Dose 1 (minimum age) Minimum interval betweendoses Dose1 to dose 2 Dose2 to dose 3 Dose3 to dose 4 Dose4 to dose 5 DTaP (6 wk) 4wk 4wk 6 mo 6 mo' IPV (6 wk) 4 wk 4 wk 4wk2 HepB 3 (birth) 4 wk 8 wk (and 16 wk after 1st dose) M M R(12mo) 4wk4 VAR (12 mo) Hib5 (6 wk) 4 wk:if 1st dosegiven at age <12 mo8 wk (as final dose): if 1st dosegiven at age 12—14 moNo further doses needed: if 1st dosegiven at age >15 mo 4 wk6 :if current age<12 mo8 wk (as finaldose)6: if current age >12 mo and 2nd code given at age <15 moNo further doses needed: if previous dose given at age >15mo 8 wk (as final dose): this dose only necessary for children aged 12 mo—5 y who received 3 doses before age 12 mo PCV7 (6 wk) 4 wk: if 1st dose given at age <12 mo and current age <24 mo8 wk (as final dose): if 1st dosegiven at age > 12 mo or current age 24-59 moNo further doses needed: for healthy children if 1st dosegiven at age >24 mo 4 wk: if current age <12 mo8 wk (as final dose): if current age >12 moNo furtherdoses needed: for healthy children if previous dose given at age >24mo 8 wk (as final dose): this dose only necessary for children aged 12 mo—5 y who received 3 doses before age 12 mo
  35. 35. Catch-up schedule for children aged 7-18 years Minimum interval betweendoses Dose 1 todose 2 Dose 2 to dose 3 Dose 3 to booster dose Td:4wk Td: 6 mo Td8: 6 mo: if 1st dose given at age <12 mo and current age <11 v5 v: if 1st dosegiven at age >12 mo and 3rd dose given at age <7 v and current age >11 y10y: if 3rd dose given at age >7 y IPV»: 4 wk IPV9 :4 wk IPV2,9 HepB:4wk Hep B:8wk(and l6 wk after 1st dose) VAR10:4wk Note: A vaccine series does not require restarting, regardless of thetime that has elapsed between doses. 10. Inactivated polio vaccine (IPV): For children who received an all-IPV or all-oral poliovirus (OPV) series, a fourth doseis not necessary if third dosewas given at age >4 years. If both OPVand IPVweregiven as part of aseries, a totalof 4 doses should be given, regardless of thechild’s current age. 11. Hepatitis B vaccine (HepB):All children and adolescents who have not been vaccinated against hepatitis B should begin thehepatitis B vaccination series during any visit. Providers should make special efforts to immunize children who were born in, or whose parents were born in, areas of the world where hepatitis B virus infection is moderately or highly endemic. 12. Haemophilus influenzaetypeb (Hib) conjugatevaccine:Vaccine generally is not recommended for children aged >5 years. 13. Hib:If current age is <12 months and thefirst 2 doses werePRP-OMP(PedvaxHIB®® or ComVax®® [Merck]), thethird (and final) dose should be given at age 12—15 months and at least 8 weeks after the second dose. 14. Reporting Adverse Reactions Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance on completing a VAERS form is available at www.vaers.org or at telephone, 800-822-7967. Diseasereporting. Suspected cases of vaccine-preventablediseases should be reported to stateor local health departments. Additionalinformation about vaccines, including precautions and contraindications for vaccination and vaccine shortages, is available at www.cdc.gov/nip or at theNationalImmunization information hotline, telephone 800-232-2522 (English) or 800-232-0233 (Spanish)
  36. 36. Appendectomy, Uncomplicated The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds II. Be aware that: A. Delay in patient's presentation for treatment leads to a higher risk of perforation B. Younger patients (<5 years) are more likely to present with perforated appendix C. The signs and symptoms of appendicitis in children may include: 1. Abdominal pain, initially dull, is often referred to the periumbilical area. The pain may become sharper over a few areas and localize in theright lower quadrant. 2. A history of pain migrating to theright lower quadrant may be difficult to document in young children because they cannot offer such detail in thehistory. However, if it can be documented, appendicitis is quite likely. 3. Right lower quadrant pain is present in 80% of patients with appendicitis. 4. Anorexia, nausea, and vomiting are often present. 5. Pain on movement, guarding, or pain with walking may be present. Patients with peritoneal inflammation may walk slowly, bent over, or limp. A positivepsoas sign, i.e., stretching the psoas muscle with right hip hyperextension while thepatient is lying on theleft side, indicates overlying peritoneal inflammation. 6. Most patientswith acuteappendicitis havelow-grade fever. A high fever (>38.5degrees C) in appendicitis suggests perforation. 7. White blood count and urinalysis are of little value because they are neither sensitivenor specificto appendicitis. Appendicitis can causepyuriawhen the inflamed appendixis adjacent to the ureter or bladder. III. Preoperative A. Antibiotics, administered preoperatively, may reduce postoperativewound infections. B. Open surgery is more common than laparoscopy. However, in patients without ruptured appendix, laparoscopic surgery offers advantages, including: 1. Fewer infections. 2. Decreased postoperativeanalgesia. 3. Faster recovery. 4. In obese patients or in young female patients, theentireperitonealcavity can be explored to rule out other causes of pain. IV. Hospital- Postoperative A. Monitor daily progress: 1. Assess abdomen daily with inspection, auscultation, percussion, and palpation. Notechanges in theseobservations. 2. Assess for changes in blood pressure, temperature, and heart ratethat would indicate sepsis, dehydration, or hemorrhage. 3. Look for changes in pattern of pain or other symptoms, such as nausea and vomiting. 4. Assess surgical wound for signs of infection. Administer pain medication either IM or with PCA. 5. Length of stay is shortened for patients who receive intermittent administration of narcotics, rather than PCA or continuous infusion. B. Facilitate decision about home or recovery facility care. C. Coordinate development of treatment goals and plans with multiple caregivers. D. Facilitate transition to next level of care. E. Regularly communicate with professional staff, patient, family, and caregiver. F. Ensure timely referral to appropriatecommunity resources and applications for public funding. G. Ensure that follow-up appointment is made. H. Assess home safety, needs, and capabilities. I. Clinical Indications for Procedure: 1. Suspected acute appendicitis
  37. 37. J. OptimalRecovery Course 1. Day 1: Operating room. Parenteral fluid, medication, and antibiotics. Ambulatory. 2. Day 2: Afebrile. Flatus present. Liquid diet and if tolerated, discontinueIV. Oral medication. Discharge. 3. Goal Length of Stay: 1 day postoperative 4. Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than thegoal) when it is appropriate for their clinical status and care needs. K. Extended stay beyond goal length of stay may be needed for: 1. Prolonged fever - may require longer observation on parenteral antibiotics. Expect brief stay extension. V. Home healthcare may be suitable for patients who require skilled assessment and management of care, with emphasis on: A. Gastrointestinalsymptoms. B. Wound and skin care.. C. Management of comorbidities or complications. D. Administration of fluids. E. Ongoing education about: G. 1. How to care for wound and skin. 2. Signs and symptoms of complications to report to the health care professional. 3. How to advance diet. ******************************************************************************************************
  38. 38. Apnea, Apparent Life-Threatening Event(near SIDS) The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds A. Monitor infants at risk with apnea monitor B. Educate family and caregiver of newborn infants about signs and symptoms of apnea, interventions, and emergency care II. Be aware that: A. Clinical definition of apnea includes: 1. The cessation of respiration lasting longer than 20 seconds 2. It is a sleep-dependent state, with the frequency increasing during active REM sleep III. Distinguish periodic breathing from prolonged apneic pauses. The latter may be associated with serious illnesses A. A careful history and physicalare important, as apnea may have a number of causes, including: 1. Apneain newborn infants may be due to hypoglycemia, meningitis, drugs, hemorrhage, seizures, shock, sepsis, anemia, pneumonia, hyaline membrane disease, persistent pulmonary hypertension, or muscle weakness. 2. A common cause of apnea in children is adenotonsillar hypertrophy 3. Children with small, triangular chins, retroposition of themandible, steep mandibular plane, high hard palate, long oval face, or long soft palateare at high risk for breathing disorders during sleep. B. Clinical manifestations in children include: 1. Loud snoring, often continuous. 2. Difficulty breathing. 3. Marked paradoxical chest and abdominal motion. 4. Retractions during sleep. 5. Daytimesleepiness and performance deficits, such as learning or behavioral problems, due to lack of sleep C. Monitor infants at risk with apnea monitors D. Gentle cutaneous stimulation is often adequate for infants having mild and intermittent episodes. E. Infants having prolonged and recurrent apnea require immediate bag and mask ventilation F. Use oxygen to treat hypoxia G. CPAP is effective therapy for mixed or obstructiveapneas. For children with adenotonsillar hypertrophy, adenotonsillectomy is effective treatment. IV. Educate thefamily and caregiver about: A. Correct use of theapnea monitor, and the importanceof adherence to theprocedures for operation and maintenance. B. Appropriatesleepingposition, and how to maintain upper airway patency during sleep. C. How to administer oxygen, if indicated. D. Home sleep study. E. How to performCPR. F. Signs of theophyllinetoxicity. G. How to access rapid emergency care for prolonged and recurrent apnea. V. Hospitalization may be required for diagnosis of suspected apnea, or prolonged and recurrent apnea. A. Monitor daily progress. B. Regularly communicate with patient, family, and caregiver. C. Ensure funding and access to apnea monitor and oxygen equipment. D. Ensure that a plan for follow-up care is developed with the family and caregiver E. Educate family and caregiver prior to discharge about:
  39. 39. 1. Correct use of theapnea monitor if prescribed, and theimportance of adherence to the procedures for operation and maintenance. 2. Appropriatesleepingposition, and how to maintain upper airway patency duringsleep. How to administer oxygen, if indicated. How to perform CPR. 3. Signs of theophyllinetoxicity. 4. How to access rapid emergency care for prolonged and recurrent apnea. F. OptimalRecovery Course 1. 1 .Day 1: Admitted to monitored bed for observation of possiblereflux and monitoring of cardiorespiratory status (obtain through history fromfamily). CBC with differential electrolytes, possibleblood, urine, and cerebrospinal fluid cultures; consider parenteral antibiotics. RSV culture and ELISA (enzyme-linked immunoadsorbent assay) if appropriateseason. Possiblechest x-ray, electroencephalogram, electrocardiogram, reflux evaluation, toxicology screen, and brain imaging. Consider evaluation for shaken baby syndrome; possiblesocial service consult. 2. Day 2: Pediatric sleep study. Thepatient has not had apneic episodes lasting over 15 seconds or requiring stimulation, nor have other concerning events occurred. Cultures and other evaluation negative to date. CPR training in progress. 3. Day 3: Cultures and other evaluation negative. Taking normal nourishment. CPR training completed. The patient has not had episodes lasting over 15 seconds or requiring stimulation, nor have other concerning events occurred. Home apnea monitor arranged and education on use done (if used). Discharge 4. Goal Length of Stay: 2 days. Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriatefor their clinical status and care needs. G. Extended stay beyond goal length of stay may be needed for: 1. Continued apneic episodes in hospital - variable stay extension. 2. Initiation of medications (theophylline, caffeine, anti-reflux regimen) - expect brief stay extension prior to discharge on apnea monitor VI. Home healthcare may be required for skilled assessment of the patient, and reinforcement of family and caregiver education A. Assess home safety, needs, and capabilities B. Ensure that apneamonitor is available in the home, and family and caregiver understand theimportance of using the monitor appropriately. C. Assess psychosocialfactors, including: 1. Family and caregiver anxiety. 2. Need for referrals to counseling or psychosocialsupportfor child's behavioral and learning difficulties. 3. Educate family and caregiver about: a. Correct use of theapnea monitor, and the importanceof adherence to theprocedures for operation and maintenance. b. Appropriatesleepingposition, and how to maintain upper airway patency during sleep c. How to administer oxygen, if indicated.. d. How to performCPR. e. Signs of theophyllinetoxicity. f. How to access rapid emergency care for prolonged and recurrent apnea.
  40. 40. Apnea, Neonatal(TermInfants) The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds A. Monitor infants at risk with apnea monitor. B. Educate family and caregiver of newborn infants about signs and symptoms of apnea, interventions, and emergency care. II. Be aware that: A. Clinical definition of apnea includes: 1. The cessation of respiration lasting longer than 20 seconds 2. It is a sleep-dependent state, with the frequency increasing during active REM sleep 3. Distinguish periodicbreathing from prolonged apneic pauses. Thelatter may be associated with serious illnesses. B. A careful history and physicalare important. Apneamay be due to hypoglycemia, meningitis, drugs, hemorrhage, seizures, shock, sepsis, anemia, pneumonia, hyaline membrane disease, persistent pulmonary hypertension, or muscle weakness. C. Monitor infants at risk with apnea monitors. D. Gentle cutaneous stimulation is often adequate for infants having mild and intermittent episodes. E. Infants having prolonged and recurrent apnea require immediate bag and mask ventilation F. Use oxygen to treat hypoxia.. G. CPAP is an effective therapy for mixed or obstructive apneas. III. Educate thefamily and caregiver about: A. Correct use of theapnea monitor, and the importanceof adherence to theprocedures for operation and maintenance. B. Appropriatesleepingposition, and how to maintain upper airway patency during sleep. C. How to administer oxygen, if indicated How to performCPR. D. Signs of theophyllinetoxicity. E. How to access rapid emergency care for prolonged and recurrent apnea. IV. Hospitalization may be required for prolonged and recurrent apnea, and diagnoses of related conditions. A. Monitor daily progress. B. Regularly communicate with family, and caregiver. C. Ensure funding and access to apnea monitor and oxygen equipment. D. Ensure that a plan for follow-up care, including emergency management, is developed with thefamily and caregiver. E. Educate family and caregiver prior to discharge about: 1. Correct use of theapnea monitor, and the importanceof adherence to theprocedures for operation and maintenance. 2. Appropriatesleepingposition and how to maintain upper airway patency during sleep. 3. How to administer oxygen, if indicated. 4. How to performCPR. 5. Signs of theophyllinetoxicity. 6. How to access rapid emergency care for prolonged and recurrent apnea. V. OptimalRecovery Course A. Day 1: Admitted to special care nursery/Level II nursery. Open warmer or isolette. Cardiorespiratory monitoring and pulseoximetry. History and physicalexamination. CBC, electrolytes, glucose, calcium. Consider chest x-ray, possible ultrasound of head, and urine drug screen. Blood and cerebrospinal fluid culture. Begin IV fluid therapy and withhold feedings until stable. Oxygen and/or mechanical ventilation as needed. Begin parenteral antibiotics. Discuss care with parents. B. Day 2: Continuecare in Level II nursery. Continuecardiac and respiratory monitoring. If stable, begin oral feedings and wean parenteral fluids. Continue parenteral antibiotics. If apnea persists, consider electroencephalogram, electrocardiogram, sleep study, and evaluation of upper airway. Parenteral theophylline. Continue discussions with parents.
  41. 41. C. Day 3: Continue care in Level II nursery. Continue cardiac and respiratory monitoring. Advance to full feedings. Blood and CSF cultures negative. Discontinue parenteral antibiotics. Determine need for pharmacologic support. Possibledischarge if no intervention needed and any parent training or follow-up arrangements completed. D. Day 4-5: Theinfant has not had any apneaor bradycardia in thepast 72 to 96 hours. CPR training completed. Home apnea monitor arranged, if indicated. Parents instructed in use of monitor and in administration of theophyllineif indicated. Follow-up care arranged. Discharge from Level II. E. Goal Length of Stay: 3 to 4 days. Note:Goallength of stay assumes optimalrecovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriatefor their clinical status and care needs. F. Extended stay beyond goal length of stay may be needed for: 1. Continued apnea - variable stay extension depending on apnea history or etiologies identified VI. Home Healthcare may be required for skilled assessment of thepatient, and reinforcement of family and caregiver education. A. Assess home safety, needs, and capabilities. B. Ensure that apneamonitor is available in the home, and family and caregiver understand theimportance of using the monitor appropriately. C. Provide referrals to community, psychosocial, and financial support. D. Assess psychosocialfactors, including: 1. Family and caregiver fear and anxiety about the child's future 2. Need for referrals to counseling or support for patient and family A. Educate family and caregiver about: 1. Home sleep study. 2. Correct use of theapnea monitor, and the importanceof adherence to theprocedures for operation and maintenance. 3. Appropriatesleepingposition, and how to maintain upper airway patency during sleep. 4. Medication 5. How to administer oxygen, if indicated. 6. How to performCPR. 7. Signs of theophyllinetoxicity. 8. How to access rapid emergency care for prolonged and recurrent apnea
  42. 42. Asphyxia, Neonatal, Mild The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds II. Be aware that: H. A. Perinatal asphyxiaoccurs in approximately 30% of infants at 28 weeks gestation, and in 2% to 3% of term infants B. Prevent prematurebirth through comprehensive prenatal care, especially for high-risk pregnancies. III. Anticipatewhich infants are at risk of needing resuscitation. A. Take a careful preliminary assessment, and full ante- and intrapartum history. IV. Hospital - Primary goals of treatment include: A. Eliminate theunderlying condition. B. Protect the child from ongoing injury. C. Effects of severe asphyxiation typically appear at 2 to 3 days of life. D. Monitor daily progress: 1. Distinguish mildly from severely affected infants: a. Level of consciousness. b. Mildly affected infants present with irritability and hyperalertness. c. Severely affected infants are either comatose or progress to an unresponsivestate. d. Respiratory and heart rates. e. Periodic respirations and apnea may necessitate intubation. f. Brain stem function. g. Pupillary reactivity is slow to respond or completely absent. h. Poor suck and swallow reflex may be evident, even with mildly affected infants. i. Motor assessment. j. Mildly affected infants are more hypertonic. k. Severely affected infants are hypotonicand lack spontaneous movements. 1. Evidence of multisysteminvolvement, including cardiovascular, pulmonary, renal, GI, hematologic, metabolic, and CNS. m. Temperaturefluctuations, n. Initiatenasogastric feedings if theinfant is unable to suck and swallow appropriately, or protect theairway. 2. Assess follow-up needs, including: a. Apneamonitor. b. Gastrostomy tube. c. If potentialis favorable, physicaltherapy and early intervention programs. d. Prior to discharge, coordinate direct contact with thepediatrician and other specialists who will continue thecare of the patient. e. Possiblereferral to social worker may be beneficial to assist in management of issues related to grief and loss. 3. Assess psychosocialfactors, including: a. If mildly affected, assess the effect on the family relative to long-term prognosis. b. Refer to community sources of information, support, and counseling, as needed. c. Ensure family and caregiver understanding of thenature of the infant's injuries, and the long-term prediction of prognosis. d. Address end-of-life issues and refer to appropriateservices, such as hospice, for severely affected infants. 4. Educate family and caregiver about: a. Potential life-threatening complications, such as aspiration or apnea. b. How to use an apnea monitor, if indicated.
  43. 43. c. How to manage nutritionalsupport, includingplacement of thefeeding tube, if necessary. d. How to monitor, record, and intervene in temperaturefluctuations. e. How to recognize and manage seizure activity. f. Resuscitation and emergency measures. 5. Assess home safety, needs, and capabilities. 6. Regularly communicate with professional staff, patient, family, and caregiver. 7. Coordinate multiple caregivers and sources of funding. E. Clinical Indications for Admission 1. To level II nursery] for 5 minute Apgar score <=6 and (any one of the following) a. Acidosis (cord pH <=7.1 or base deficit of >= 12 mmol/L) b. Jitteriness, hyper-alert state, irritability (mild) c. Lethargy, poor tone (moderate) d. Bradycardia or tachycardia (defined by 5th and 95th percentiles) Oxygen requirement e. Hematuria or elevated creatinine 2. To level III nursery for more severe findings suggestive of severe asphyxia F. OptimalRecovery Course 1. Day 1: Admit term neonate to Level II nursery. Open warmer or isolette. Cardiac and respiratory monitoring, pulseoximetry. History and physicalexamination. CBC with differential and platelet count, electrolytes, glucose, arterial blood gases. Chest x-ray and electrocardiogram. Normal or impaired alertness, tone, and neurologic exam. Possible blood and CSF cultures. Possible antibiotics. Begin IV fluids and withhold feedings. Normal renal function. Monitor daily weight and intake/output of fluids. Discuss care with parents. 2. Day 2: Continuecare in Level II nursery. Open crib. Cardiac and respiratory monitoring. Begin oral feedings and decrease IV fluids. Respiratory status stable. Possibleantibiotics. Normal neurologic examination and normal renal function. Discuss progress with parents. 3. Day 3: Temperatureand vital signs stable. Oral feedings tolerated. Cultures negative at 48 to 72 hours, antibiotics discontinued. Discharge from Level II unit. 4. Goal Length of Stay: 2 days 5. Note: Goal length of stay assumes optimal recovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than thegoal) when it is appropriate for their clinical status and care needs. H. Extended stay beyond goal length of stay may be needed for: 1. Signs of hypoxic-ischemic encephalopathy - variable stay extension. 2. Most common in first day but may present up to 3 days after delivery 3. Seizures 4. Abnormal EEG 5. Continued oxygen requirement 6. Renal abnormalities 7. Feeding intolerance V. Home Healthcare A. May continueto require skilled assessment and management of: 1. Respiratory status. 2. Nutritional status. 3. Feeding difficulties, including sucking and swallowing. 4. Sleeping patterns. 5. Neurologic status. 6. Cardiovascular status. B. Refer as needed if signs and symptoms of multisystemdamage appear after discharge. C. Assess psychosocialfactors, including: 1. Grief and loss issues for family of compromised infant. 2. Bonding of parents or caregiver with infant. 3. Issues related to fear and anxiety about the infant's future. D. Refer for counseling and support, as needed.
  44. 44. E. Educate family and caregiver about: 1. Potential life-threatening complications, such as aspiration or apnea. 2. How to use an apnea monitor, if indicated. 3. How to manage nutritionalsupport, includingplacement of a feeding tube, if necessary. 4. How to monitor, record, and intervene in temperaturefluctuations. 5. How to recognize and manage seizure activity. 6. Resuscitation and emergency measures.
  45. 45. Aspirationof Foreign Body The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeed II. Be aware of: A. Risk factors for aspiration of foreign bodies include: 1. Age 6 months to 3 years. 2. Children with pre-existing pulmonary conditions that may obscurethe emergency natureof the aspiration. 3. Disabled children, particularly neurologic impairment, or other sources of poor oral-motor skills. B. To prevent the most common causes of aspiration: 1. Maintain adult supervision of young children while eating. 2. Keep dangerous foods away from children who are too young to chew and swallow carefully. 3. Most commonly aspirated foods include nuts, popcorn, hot dogs, and bread. 4. Discourage children from running with food or other objects in mouth. 5. Children may bite plasticcup edges and aspiratethe fragments. 6. Small items such as beads, button boxes, and coins should not be given to young children as toys. 7. Keep safety pins closed and away from children. 8. Discourage older children from placing school supplies, such as pen caps and paper clips, in their mouths. 9. Balloons are an underestimated source of danger, and parents and caregivers should superviseplay with balloons. 10. Children with older siblings may have access to toys with smallparts that arenot age-appropriate for babies or toddlers. C. Widespread community education, which targets parents and caregivers about: 1. The importance of keeping all small objects away from babies and small children. 2. How to manage feeding problems. 3. How to recognize signs of aspiration. 4. How to performemergency measures. III. Educate thefamily and caregiver about: A. The importance of keeping all small objects away from babies and small children. B. How to manage feeding problems. C. How to recognize signs of aspiration. D. How to performemergency measures. IV. Perform emergency measures as needed, if in first contact with child. V. For long-standing, undetected foreign body: A. History may include an immediate episodeof choking, gagging, and paroxysmalcoughing, often immediately followed by chronic wheezing. B. Physical examination may reveal: 1. Tracheal shift. 2. Decreased breath sounds on the side of the obstruction. 3. Delayed air entry or exit on the obstructed side, detectable with a two-headed stethoscope. 4. Impending respiratory arrest or severe distress. 5. Stridor 6. Aphonia C. Signs of a foreign body that is long-standing, but undetected, may include: 1. Occasional cough or slight wheezing.
  46. 46. 2. Recurrent lobar pneumonia or intractable "asthma", often with bilateral wheezing and many episodes of status asthmaticus. 3. Fever 4. Hemoptysis D. Perform or refer for treatment, involving endoscopy and removal of theforeign body with bronchoscope under direct visualization, as soon as possible. E. Complications may include secondary infection. F. Coordinate decision about the need for home healthcare services. G. Most patientscan be managed through telephonefollow-up. H. Educate thefamily and caregiver about: 1. How to recognize signs and symptoms of secondary infection. 2. How to assess and ensure home safety. 3. The importance of keeping all small objects away from babies and small children. 4. How to manage feeding problems. 5. How to recognize signs of aspiration. 6. How to performemergency measures in the event of aspiration. I. Non-irritating, non-obstructing foreign bodies may produce few symptoms, even after a prolonged time. J. Initial symptoms of alaryngeal foreign body include: 1. Cough that soon becomes croupy and hoarse. 2. With profound obstruction, aphonia. 3. Hemoptysis 4. Dyspneawith stridor. 5. Cyanosis 6. Characteristic signs of a tracheo-bronchial foreign body include: a. Cough b. Wheezing c. Choking d. Stridor in patients with tracheal foreign body. e. Cyanosis in patients with major bronchial foreign body. K. Initial symptoms of abronchial foreign body are usually similar to thoseof thelarynx or trachea. In addition, look for: 1. Blood-streaked sputum. 2. Metallic tastewith metallic foreign bodies. 3. Bronchoscopy is the treatment of choice for removal of tracheobronchial foreign bodies. 4. Aspirated material may not be evident in chest x-ray or bronchoscopy. VI. Thoracotomy and subsequent bronchotomy may be needed to remove theforeign body as soon as possible. VII. X-ray or direct laryngoscopic examinations usually reveal or suggest thepresence of a foreign body in thelarynx. A. Direct laryngoscopy with arigid open-tubelaryngoscope, usually performed by an otolaryngologist, provides access and removal. B. Tracheotomy may be needed if dyspnea is severe. C. Treat complications, which may include secondary infection. D. Ensure that follow-up care in an outpatient settingis arranged. VIII. OptimalRecovery Course A. Day of Procedure: Operating/procedureroom to remove foreign body. Afebrile, respiratory status stable without stridor or oxygen need. Parenteral fluid weaned, diet tolerated, ambulatory. Discharge. B. Goal Length of Stay: Ambulatory C. Note:Goal length of stay assumes optimalrecovery, decision-making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriatefor their clinical status and care needs. IX. Extended Stay - Inpatient stay may be needed for: A. Respiratory symptoms following removal of foreign body B. Evidence of secondary infection
  47. 47. C. Inability to tolerate oral fluids and medications following removal D. Neurologic symptoms E. Possible prolonged stay extension if severe neurologic deficit F. Inadequate home situation X. Home Healthcare A. Assess theneed for home healthcare services. B. Most patients can be managed through telephonefollow-up. C. Home healthcare visits may be suitable for the patient who requires skilled assessment and management of follow-up care or complications, including: 1. Parenteral antibiotics. 2. Secondary infection. 3. Safety assessment of child's home and environment. 4. Psychosocial factors, including thepossibility of neglect or abuse, and make appropriatereferrals to community agencies. 5. Educate thefamily and caregiver about: a. How to recognize signs and symptoms of secondary infection. b. How to assess and ensure home safety. c. The importance of keeping all small objects away from babies and small children. d. How to manage feeding problems. e. How to recognize signs of aspiration. f. How to performemergency measures in the event of aspiration.
  48. 48. Asthma The Primary Care Provider Recommended Guidelines: I. Coordinate Care and AnticipateNeeds II. Be aware that: A. Prophylacticinhaled corticosteroids improve symptoms compared with placebo. B. Inhaled steroids are more effective than oral theophyllineand sodium cromoglycate. C. Beta2-agonists in acute severe asthmaare very effective; adding anticholinergic agents improves lung function and may reduce admission rates. III. Identify and eliminate known environmental triggers from the child's home environment: A. Skin testing identifies specific allergens. B. Most common triggers include dust mites and dust. C. Discourage smoking near thechild. D. Use air conditioning and dehumidifiers to help control temperaturechanges. E. Asthmaeducation, with thegoal of self-management, has been shown to be one of themain components of asthma management. IV. Educate patient, family, and caregiver about: A. How to recognize the symptoms that lead to an acute attack. B. Importance of starting treatment quickly when symptoms begin. C. How to use a peak flow meter. D. How to keep a peak flow diary. E. Importance of adhering to prescribed regimen. F. Activity with periods of rest. G. Nutrition and fluid intake. H. How to contact asthma education, resource, and support groups. V. Diagnosis depends on a careful history and physicalexamination, including: A. Family history of atopic conditions. B. Clinical manifestations, including dry, hacking, nonproductive cough, wheezing, prolonged expiration, retractions, dyspnea, apprehension, restlessness, shortened speech, pallor, cyanosis, retractions in infants, and hunching in older children. C. Abnormal pulmonary function test results, indicating decreased peak expiratory flow rates. D. Definitive diagnosis is made when obstruction of the airways is reversed with bronchodilators. VI. Assess complicating features, including sinusitis, GERD, and sleep disorders. VII. Hospitaladmission A. If admitted to ICU, monitor 1. Recovery from respiratory failure. 2. Acidosis, pH > 7.3. 3. Severe hypoxia, PO2 >60; oxygen saturation under 89% on room air. B. May betransferred to routine care if patient is: 1. Weaned from theventilator. 2. Oxygen requirement and PCO2 re stable and declining. C. If admitted to routine floor care for lesser severity: 1. Monitor humidity and oxygen saturation under 96% on room air. 2. Ability to tolerate oral feedings. 3. On parenteral and oral fluids. 4. On corticosteroids and possibly antibiotics if intercurrent bacterial infection suspected. 5. Monitor thefollowing:

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