50

Internship Survival Guide 2014-2015

University of Florida College of Medicine

Department of Pediatrics

2

Section Page

Important Phone Numbers 3

Patient Safety Report 7

Vitals by age, Top 10 Reading List 8

EPIC/ Home Access, List of Order Sets 10

Florida Map 12

Presentations/PBAR 13

I-PASS for Patient Hand Offs 14

PEWS 16

Responding to a Code 18

NICU 19

Newborn Sepsis Guidelines 20

Hyperbilirubinemia 21

PICU 22

Vents and ABG Interpretation 23

Asthma 24

Bronchiolitis Score 26

CF 27

Heme/Onc 28

Transfusion Tips 29

EKG 31

FEN 32

Clinic and immunizations 33-35

Development Chart 36

Duty Hour Logging 37-39

Chain of Command, When to Call ? 40

Procedures 42-44

Important Login Information 45

SMART Goals 47

Table of Contents

49

48

3

General Numbers

Admissions 50236

Bed Control 50233

Blood Bank 50377

Cardiology

- ECHO lab (reads) 392-2500

- ECHO 258-1927

- EKG (PICU) 413-0175

- EKG (Floor & NICU) 413-0174

- Heart Station (Holters) 50047

Child Life 46470

- Text pager 413-5068

Dialysis (peds) 50255

EEG 50334

ED Break Room 93517

Hospital (main) 265-0111

iHIRM 59375

Laboratory - Main 47737

- Chemistry 44869

- Hematology 44857

- Immunology 45328

- Microbiology (open 8am-5pm) 50165

- Rocky Point (main) 50172

- Rocky Point (chemistry) 72202

- Send Out 72200

- Virology 44778

Lactation (Brenda) 50317

Medical Records 44796

MRI 50106

MRI anesthesia 49982

OR Front Desk 50023

Pathology 50208

Pharmacy

- Inpatient (PICU) 42754

- Inpatient (Floor & NICU) 43401

- Outpatient (atrium/med plaza) 50405/58270

Pre-op 50076

PFTs (pulmonary) 50275

Poison Control 800-222-1222

Peds ID consults/ outpt scheduling 294-5481/294-5480

4

IMPORTANT PHONE NUMBERS

Radiology 50101

- PEDS Reading Room 44297/44294

- Body (night reads) 44385

- Bone 273-7159

- Chest 42820

- Interventional/Specials 50116

- File Room 50107

- Fluoroscopy 50102

- Neuro Reading Room 46570/44334/44381

- Nuclear Medicine 57050/46211

- Ultrasound 44363

- Vascular 50399

Recovery Room (PACU) 50038

Psychology clinic & consult fax 50294/50096

Peds Surgery pager 413-0746

Senior Phone 672-0953

TPN 44248

Transfer Center 50559

Transport (ShandsCair) 50222

Clinics

CMS

- Front Desk 334-0206

- Resident Room 334-0237/334-0207

- Resident Room 334-0242

- Adolescent 334-0297

- Fax 334-4041

Tower

- Front Desk 733-1770

- Backline 27534/27536/27537

- Fax 372-5164

PAH

- Front Desk 265-0724

- Backline 88236

Specialty Clinics (Med Plaza) 265-8250

Code blue 66

Security Stat 50911/nonstat 50109

Needle stick injury 1-866-477-6824 47

46

Important Information

How to Access Log in Name Password

Pedalink

- ILP

- PREP questions

www.pedialink.org or via

www.aap.org AAP ID # Set up yourself

Nelson’s Online http://site.ebrary.com/lib/

univflorida/

docDetail.action?

docID=10567389

None-must be on VPN None-must be on VPN

The Harriet Lane Hand-

book

http://site.ebrary.com/lib/

univflorida/

docDetail.action?

docID=10567408

None-must be on VPN None-must be on VPN

FL Shots www.flshots.com Organization ID: UFPC01 (for CMS) and UFPC02 (for

Tower)

Username: Last name plus

first letter of first name in all caps (i.e. Al Gator would be

GATORA)

Set up yourself

CANVAS Gatorlink username Gatorlink password

Genetics Patient Protocols http://www.peds.ufl.edu/

divisions/genetics/

fellowship.htm

Patient Protocols - then

enter Gatorlink username Gatorlink password

New Innovation Www.new-innov.com First letter of first name

and then last name

Set up yourself

Med student eval Medinfo.ufl.edu Gatorlink username Gatorlink password

5

Outpatient Departments

Allergy 265-8250

Cardiology 273-7770

Child Psychology 413-3338

CPT 334-1300

Dental (peds) 273-7643

- Backline 273-7645

Endocrinology 334-1390

Gastroenterology 273-9350

Genetics 294-5050

Hematology/Oncology 392-5633

Immuno/Rheum/ID 392-2961

Lactation Clinic (Mary’s cell/pager) 219-2335/413-4302

Nephrology 392-4434

Neurology 273-8920

Ortho Clinic 273-7001

- Backline (Teri Rhodes) 273-7379

Pulmonology 392-4458

Inpatient Floors & Workrooms

4200 50042 (fax 265-0946)

4400 50044 (fax 265-0467)

4500 50045 (fax 265-0793)

4433 Conference Room 44013

Blue Workroom (4530) 43450/47325/44057

Green Workroom (4270) 48208/43449/46200

Orange Workroom (4437) 43934/45259

ER 265-5437 (KIDS)

- Charge Nurse 745-8280

- Peds Resident Phone 51256 or 51257

- Peds Attending 745-8278

Mother/Baby (3500) 50035

Newborn Nursery 44097

NI2 50352

NI3 50033

- Fishbowl 44348/44124

PICU 51004/51005

- Fellow phone 494-8383

- Resident phone 745-8027

Housekeeping 50480

6

Housestaff Numbers

Pediatric Chair’s Office 273-9001

Pediatric Med Ed 273-8234

Tammy/Amy 273-8466/273-8594

- Fax 273-8593

Chief Pager 888-980-3608

Chief Office – Nora 50912

Chief Office – Kendall 50919

Clinical pharmacists

- Brian Kelly 45868/413-4054

- Lisa Taylor 413-1892

Dr. Black 50915/413-2048

Peds IT/Shands IT 273-5808/265-0526

PCCP 413-1454

Pediatric Team Phones

Green Team 317-5326

Senior Phone 672-0953

Outside Hospitals

Halifax (Daytona Beach) 386-254-4000

Leesburg Regional Medical Center 352-323-5762

Munroe Regional Medical Center 352-351-7200

N. FL Regional Medical Center (NFRMC) 352-333-4000

Ocala Regional Medical Center 352-401-1000

Putnam Community Medical Center (Palatka) 386-328-5711

Seven Rivers (Crystal River) 352-795-6560

Tallahassee Memorial 850-431-1155

Quest 800-282-6613

45

How to Access Log in Name Password

Peds E-mail

www.mail.ufl.edu Gatorlink username Gatorlink password

Shands Portal my.portal.shands.ufl.edu (Shands homepage)

Home screen for most

computers, otherwise use

link to left

Shands ID

Citrix/EPIC

citrix.shands.org Can access directly on

most computers, via link

to left, or via Portal

Shands ID

Stentor - Radiology On portal page (after

logging in), middle area

under “Clinical Applica-

tions”

Shands ID (to get onto

Portal)

SUF On-Call Schedule

(calling consults) On portal page (after

logging in), middle area

under “Clinical Tools”

Shands ID (to get onto

Portal)

Drug Reference On portal page (before

logging in), bottom left in

“Clinical Links”

No log-in needed

New Innovations

- Call Schedule

- Work Hours

- Evaluations

- Procedure Log

- Schedule

www.new-innov.com

Log-in WEEKLY for

work hrs & MONTHLY

for evals

Institution Login: ufl

Username: first letter of

first name and entire last

name (i.e. Al Gator would

be agator)

Set up yourself

Text Paging www.myairmail.com ufpeds gator

REMOTE (do it from home!)

remote.peds.ufl.edu Gatorlink username Gatorlink password

SHAREPOINT -List -PCP list -Intern guide

www.peds.ufl.edu

-Faculty & Staff

-Faculty & Staff Re-

sources

-Click Housestaff after

logging in for information

ufad\”gatorlink username” Gatorlink password If 3 blanks, put UFAD in

domain

Important Information

44

Procedure Log Remember to update frequently on New Innovations.

Required Procedures: Date Location/Supervisor’s Signature

Bag-mask ventila-

tion

Bladder catheterization

Giving immunizations

Incision and drainage of abscess

Lumbar Puncture

Neonatal endotracheal intubation

Peripheral intravenous catheter placement

Reduction of simple dislocation

Simple laceration repair

Simple removal of foreign body

Temporary splinting of fracture

Umbilical catheter placement

Venipuncture

Simulated placement of intraosseous line

Medical Knowledge

of the following:

Date Location/Supervisor’s Signature

Arterial line place-ment

Arterial puncture

Chest tube placement

Circumcision

Endotracheal intuba-tion of non-neonates

Thoracentesis

7

Patient Safety Report

How to Submit a Patient Safety Report Note: Do not press [enter ], always use [tab] or the

mouse to go to the desired field.

To report a new event, log in to the Shands portal (homepage on

hospital computers):

Click “Patient Safety Report – UF&Shands”

Select “Report an Event”: follow prompts

There is an option to place an ‘Express Report’ or you can

find the category of the incident and report it that way

8

Normal vital signs by age Temperature

36 – 38.5 UNLESS under 3 months, immunocompromised or

HEME/ONC - fever is 38 for them!

Heart Rate

Respiratory Rate

Blood Pressure

Find BP norms by age and height percentile at:

http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html

Age Sleeping Awake

Term -3 mo 80-160 85-205

3 mo-2 yrs 75-160 100-190

2-10 yrs 60-90 60-140

>10 years 50-90 60-100

Age Respiratory rate

Birth-6 weeks 30-60

Infant 24-40

2-6 years 22-34

6-10 years 18-30

Over 10 years 12-20

Age Wt SBP DBP

Preterm 1 40-60 20-36

Term Newborn 2-3 60-70 30-45

1 month 4 70-100 30-62

6 months 7 70-118 50-70

1 year 10 70-126 41-91

2-3 years 12-14 74-124 39-89

4-5 years 16-18 79-119 45-85

6-8 yrs 20-26 80-124 45-85

10-12 yrs 32-42 90-135 55-88

>14 >50 90-140 60-90

1-10 y/o 50thPercentile SBP=90 + (Age x 2)

5th Percentile SBP=70 + (Age x 2)

43

PROCEDURE GUIDE The procedures listed below and levels of ability in performing them are the

minimum requir ed by the Pediatr ic RRC. You will be exposed to and do

many other procedures during residency and you should document them all in

your procedure log on the ACGME website.

RRC training requirement

Patient Care and Procedural Skills: Residents must be able to competent-

ly perform procedures used by a pediatrician in general practice, including

being able to describe the steps in the procedure, indications, contraindica-

tions, complications, pain management, post-procedure care, and interpreta-

tion of applicable results. Residents must demonstrate procedural competence

by performing the following: Bag-mask ventilation Bladder catheterization Giving immunizations Incision and drainage of abscess Lumbar puncture Neonatal endotracheal intubation Peripheral intravenous catheter placement Reduction of simple dislocation Simple laceration repair Simple removal of foreign body Temporary splinting of fracture Umbilical catheter placement Venipuncture Complete training and maintain certification in PALS including

simulated placement of an intraosseous line and Neonatal Resusci-tation

Medical Knowledge: Residents must be competent in the under standing

of the indications, contraindications, and complications for the following: Arterial line placement Arterial puncture Chest tube placement Circumcision Endotracheal intubation of non-neonates Thoracentesis

http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf

42

PROCEDURE NOTES:

Lumbar puncture

Date/Time:

Indication:

Consent on chart:

Infant draped and prepped in sterile fashion. 22 g myelonate

spinal needle inserted between L 4-5.

On attempt #; yielded approximately ______ mL clear/ se-

rosanguiness/xanthochromic CSF.

Pt tolerated procedure well with minimal blood loss and no

complications.

Labs sent for:

Tube 1: G-stain, Cult, AFB/fungal stain

Tube 2: Glucose, protein

Tube 3: Special (HSV PCR)

Tube 4: Cell count, diff.

Intubations:

Date/Time:

Infant intubated with ______ETT and _____ blade on _____

attempt. Equal breath sounds heard bilaterally and color change

seen on CO2 detector. ETT taped at _____ cm at lip. CXR

obtained to confirm placement.

Circumcision:

Date/Time:

Indication: Phimosis, unwanted foreskin

Consent: Obtained and on chart

Time out preformed. 1% lidocaine (1.5 ml) used for DPNB.

Infant prepped and draped in sterile fashion. Gomco 1.1/1.3

used to perform circumcision. Estimated blood loss < 5 ml.

Infant tolerated procedure well. Aftercare instructions given to

mother.

9

Top 10 Reading List—Common Pediatric Diagnoses

Pneumonia

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202323/

Asthma

http://pedsinreview.aappublications.org/content/30/10/375

Acute bronchitis/bronchiolitis

http://pedsinreview.aappublications.org/content/30/10/386

Skin and subcutaneous tissue infections http://www.uptodate.com/

contents/evaluation-and-management-of-suspected-methicillin-

resistant-staphylococcus-aureus-skin-and-soft-tissue-infections-in-

children?

source=search_result&search=soft+tissue+infections&selectedTitl

e=9%7E150

Epilepsy

http://pediatrics.aappublications.org/content/127/2/389.full.html

Urinary tract infections

http://pediatrics.aappublications.org/content/early/2011/08/24/

peds.2011-1330

Otitis Media

http://pediatrics.aappublications.org/content/early/2013/02/20/

peds.2012-3488.abstract

Pharyngitis

http://circ.ahajournals.org/content/119/11/1541.full.pdf

ADHD

http://pediatrics.aappublications.org/

content/128/5/1007.full.pdf+html?sid=f19cb249-15a2-429b-9860-

92f2231d079b

10

Typing H&Ps/Discharge Summaries/Progress Notes

1) Log into patient’s chart and click on “Note” tab on left side

2) Find appropriate tab for work type (H&P, D/C Summary, etc)

3) Click on either New Note or Notewriter

4) Select appropriate template for work type - most have the

phrase SH IP PED _________(work type). Some services

have their own templates

5) Fill out entire template being sure to not miss any *** or

{bracketed areas}

6) You may use the partial dictation function (see above) at any

point

7) Indicate service team at the top of note, along with co-signing

physician (if you don’t indicate a co-signing physician your

note cannot be finalized)

8) Click “Accept” at bottom of note to finalize - if you click

“Pend” you can return and make changes without having to

create an “Addendum” but your note will remain hidden from

others

9) If you have any questions you may call 265-0526 (50526) at

any time for IT/EPIC assistance

Partial EPIC Dictations

1) Use the headset placed at dictation/PC terminal

2) In New Note or Notewriter, place cursor in area you want to

dictate

3) Click the “Blue microphone” on the toolbar

4) Click the “Record” button the player that appears

5) State and spell the patient’s full name, date of service, and

CSN

6) Dictate the partial dictation (Note: If you rewind and record,

you will overwrite you dictation)

7) Click “Accept” on the player. Dictation link will appear on

the document.

41

Supervision/When to Call?

SUPERB - Guide for Attending Supervision

S - Set expectations for when to be notified

U - Uncertainty is a time to contact

P - Planned communication

E - Easily available

R - Reassure resident not to be afraid to call

B - Balance supervision and autonomy for resident

___________________________________________________________

SAFETY - Resident Guide for Attending Input

S - Seek attending input early (prevents delays, quicker results)

A - Active clinical decisions (surgery, invasive procedure, etc)

F - Feel uncertain about clinical decisions

E - End of life care or family/legal discussions

T - Transitions of care (PICU, discharges, hospital transfers)

Y - You need help with the system/hierarchy (attending to attend-

ing discussions, etc)

Farnan, J.M. et al. Strategies for Effective On-Call Supervision for Internal Medicine Resi-dents: The SUPERB/SAFETY Model. Journal of Graduate Medical Education. 2010 March; 2(1): 46–52

40

Resident Concern Flow sheet

Patient Safety Risk Hotline: (352)538-2635

11

EPIC HELP emr .med.ufl.edu/training

EPIC from Home http://net-services.ufl.edu/provided_services/

vpn/anyconnect/

https://mycitrix.shands.org

EPIC Order sets for Pediatrics:

Failure to Thrive Physician’s Orders IP UF

Pediatric Bronchiolitis Physician's Orders IP UF

Pediatric Acute Gastroenteritis Physicians Orders IP UF

Discharge Pediatrics UF

Pediatric Cellulitis Physicians Orders IP UF

ALTE (Acute Life Threatening Event) Peds

Pediatric Fever without a Source: Infants 0-28 days old and high

risk infants 28-90 days old

Pediatric Pain Intervention Orders (Admission Supplement) IP UF

Pediatric Admission Order Set for Asthma IP UF

Pediatric IMC and Floor Admission Orders IP UF

Pediatric PICC Orders IP UF

Pediatric UTI (Urinary Tract Infection)/Pyelonephritis

Pediatric Pneumonia/Empyema

Pediatric NAT (Nonaccidental Trauma)

Pediatric Hyperbilirubinemia Order Set (for the floor

Failure to Thrive Physician’s Orders IP UF

Pediatric Bronchiolitis Physician's Orders IP UF

Pediatric Acute Gastroenteritis Physicians Orders IP UF

Discharge Pediatrics UF

Pediatric Cellulitis Physicians Orders IP UF

12

City County Lake Butler Union Alachua/Archer Alachua Lake City Columbia Bell Gilchrist Lawtey Bradford Belleview Marion Leesburg Lake Cedar Key/Chiefland Levy Live Oak Suwannee Cross City Dixie Mayo Lafayette Crystal River Citrus Melrose Alachua/Putnam Deland Volusia Micanopy/Newberry Alachua Dunnellon Mareion Ocala /Oklawaha Marion Fort White Marion Old town Dixie Hawthorn/ High Springs Alachua Palatka Putnam Interlachen Putnam Starke Bradford Inverness Citrus Trenton Gilchrist Jacksonville Duval Waldo Alachua Jasper/Jennings Hamilton Wildwood Sumter LaCross Alachua Williston Levy

39

Rotation/Shift Duty Hour Type

4200 days without overnight call Shift

4200 days with overnight call 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24

hours

Cards/GI Selective Shift

Time off between shifts (i.e. Acute AM

then PAH at night)

Break during shift/rotation

38

Rotation/Shift Duty Hour Type

Wards-Weekday, short Call Shift

Wards-Weekday, no short call Shift

Wards-Weekend, long call 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

Wards-Weekend, Sunday NF 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

Wards-Weekday Night Float Shift

NICU-Weekday Shift

NICU-Weekday NF Shift

NICU-Weekend (Friday or Saturday) 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

NICU-Weekend, Sunday NF 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

PICU-Weekday Shift

PICU-Weekday NF Shift

PICU-Weekend (Friday or Saturday) 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

PICU-Weekend, Sunday NF 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours

Newborn Nursery-Weekday or Weekend Shift

Back-up Call, not called in Back-up

Back-up Call, called in Log according to what you were called in for

Annual Leave Vacation/Leave

Sick Leave Sick

Conference Leave Education Leave

Continuity Clinic Continuity Clinic

Acute clinic Shift

PAH, no phone calls Shift

PAH, with phone calls Shift (log only the hours you were in clinic, do not

log phone call hours)

ED Shift

Adolescent Rotation Hours

Development Rotation Hours

Advocacy Rotation Hours

Elective Rotation Hours

Moonlighting (PAH or Abstracting) Moonlighting

Administrative Time (i.e. Time between

adolescent clinic in the AM and AR at

night, etc.)

Rotation Hours

Duty Hour Type by Rotation

13

Daily Presentations

Presentations can be problem-based vs system-based (varies from

attending to attending and from service to service)

For all general patients, please use the PBAR format:

- P = Problem (Chief complaint/problem)

- B = Background (History, overnight events, PE, labs)

- A = Assessment (Assessment of how patient is doing)

- R = Recommendations (Plan)

Each patient can have multiple problems, so go through each one

individually (always include disposition as the last problem)

New admissions will still need more information (what led up to

admission, HPI, etc), compared to those that have been in the hos-

pital for a couple days

This is similar to the SBAR format nurses use to communicate to

one another and should be using to communicate with physicians

(S = Situation instead of Problem)

Medical students are taught the PBAR method, so model this

while they rotate through Pediatrics

The “New” Patient The “Old” Patient

1 line: Identifying information and reason for admission

HPI

PBAR

The last problem is always disposition

1 line: Identifying information and recap of hospitalization

PBAR The last problem is always

disposition

The “new” patient vs. The “old’ patient

14

© 2011 I-PASS Study Group/Children’s Hospital Boston

All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu

I Illness Severity Stable, “watcher,” unstable

P Patient Summary Summary statement

Events leading up to admission Hospital course Ongoing assessment Plan

A Action List To do list Timeline and ownership

S Situation Aware-ness & Contin-gency Planning

Know what’s going on

Plan for what might happen

S Synthesis by Re-ceiver

Receiver summarizes what was heard

Asks questions

Restates key action/to do items

37

How to Log Duty Hours?

Log-on to www.new-innov.com and click Client Login

Enter ‘ufl’ for Institution, username and password are same

as your Gatorlink

Select either Log My Hours on the middle-right side of the

screen or from the drop-down menu (under Main), select Du-

ty Hours

Enter Duty Hours corresponding to the rotation/shift you

worked (see key on next page)

Enter Duty Hours on a daily basis

If there are any work hour violations, residents must leave a

comment explaining why the violation occur red (it will

then be reviewed by Chief Residents and Program Director)

Residents not entering their duty hours by Tuesday of each

week, will start to receive reminder emails that will also be

sent to the Chief Residents and Program Directors

Please be truthful when entering duty hours - we all must

abide by the ACGME Work Hours and want to know if there

are rotations/areas where residents aren’t meeting the require-

ments

36

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nd

with

ge

stu

re

Fin

e p

incer

gra

sp

, m

ark

s w

ith

cra

yo

n,

rele

ase

s v

olu

nta

rily

Walk

s

Se

pa

ratio

n a

nxie

ty,

dri

nks

fro

m c

up

with

help

15

mo

3-5

wo

rds,

ma

ture

ja

rgo

nin

g,

po

ints

to

bod

y p

art

2 c

ub

e t

ow

er

at

14

mo

& 3

cu

be

s a

t 1

6 m

o

Walk

s w

ell

at 1

4 m

o a

nd

ba

ck-

wa

rd/r

un

s a

t 1

6 m

o

So

lita

ry p

lay,

dri

nks f

rom

cu

p

co

op

era

tes w

ith

dre

ssin

g

18

mo

10

-25

wo

rds,

po

ints

to

3 b

od

y

pa

rts

4 c

ub

e t

ow

er,

scri

bb

les,

turn

s

2-3

pa

ge

s a

t a

tim

e

Th

row

s b

all,

ha

nde

dn

ess d

evel-

op

s

Hug

s p

are

nts

, u

se

s s

po

on

2

yrs

1/2

of

sp

ee

ch

is in

telli

gib

le, 2

w

ord

se

nte

nce

s,

2 s

tep

co

m-

ma

nd

s,

50

+ w

ord

s

6 c

ub

e t

ow

er,

ca

n d

raw

, u

nzip

s

zip

per

Kic

ks b

all,

thro

ws o

ve

rha

nd

, w

alk

s d

ow

n s

tair

s

Kis

se

s w

ith

pu

cke

r, r

em

ove

s

ga

rme

nt,

pa

ralle

l pla

y,

op

en

s

do

or,

cop

ies p

are

nts

in

ta

sks

3

yrs

3/4

sp

ee

ch

is inte

lligib

le,

3

wo

rd s

en

ten

ce

s,

na

me

s 1

co

lor,

25

0+

wo

rds

10

cu

be

to

we

r, c

an d

raw

cir

cle

, d

ries h

an

ds if

rem

ind

ed

Bro

ad

ju

mp

, ri

de

s tri

cycle

, b

ala

nce

s o

n o

ne

foo

t fo

r 1

-2 s

ec,

up

sta

irs w

ith

rail/

alt.

fee

t

Pu

ts o

n s

om

e c

loth

ing

, gro

up

p

lay, ta

ke

s t

urn

s,

un

dre

sse

s,

kn

ow

s f

ull

na

me

, g

en

de

r, a

ge

4

yrs

10

0%

in

telli

gib

le s

pe

ech,

4

wo

rd s

en

ten

ce

s,

kn

ow

s c

olo

rs,

kn

ow

s 4

pre

po

sitio

ns

Can

dra

w +

, d

raw

s a

pe

rso

n

with

3 p

art

s

Walk

up

& d

ow

n s

tair

s w

ith

rail

&

altern

atin

g f

ee

t, b

ala

nce

1 f

oo

t fo

r 3-4

se

c,

hop

, ca

tch

ball

Dre

sse

s w

ith

ou

t h

elp

, pla

ys

co

op

era

tive g

am

es,

bu

tto

ns,

tells

a s

tory

5

yrs

5 w

ord

se

nte

nce

s,

cou

nts

5-1

0

blo

cks, d

efin

es 5

fa

mili

ar

wo

rds,

kn

ow

s o

pp

osite

s

dra

w t

ria

ngle

/pers

on

(5-6

p

art

s),

pri

nts

a f

ew

le

tters

/ firs

t n

am

e,

tie

s s

ho

es

Walk

s u

p &

do

wn

sta

irs w

ith

ou

t ra

il, b

ala

nce

s o

n o

ne

fo

ot

for

5-

10

se

c,

skip

s

Pla

ys b

oard

ga

me

s,

follo

w

rule

s, lik

es t

o h

elp

in

hou

se

-h

old

ch

ore

s

Development Chart

15

I-PASS Handoff Essentials Better handoffs. Safer Care

Structured Verbal Handoff Begin with overview of entire service Need proper environment – limit interruptions Use IPASS mnemonic Employ closed loop communication

Printed Handoff Document Supplements verbal handoff May import elements from EMR Keeps information current with updates

High Level Skills Patient Summary Be concise and focused Establish working diagnosis Include semantic qualifiers Ensure check-back with receiver

Contingency Plans – “If this happens, then…” Problem solve before things go wrong Know potential therapies or interventions Identify most worrisome patients Articulate chain of command

© 2011 I-PASS Study Group/Children’s Hospital Boston

All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu

16

Ca

teg

ory

0

po

ints

1

po

int

2 p

oin

ts

3 p

oin

ts

Beh

avio

r

•Pla

yin

g

•Ap

pro

pri

ate

for

pat

ient

•Sle

epin

g

•Irr

itab

le &

con

sola

ble

•Irr

itab

le o

r ag

itat

ed &

is

not

con

sola

ble

•Let

har

gic

or

con

fuse

d

•Red

uce

d p

ain

re

spon

se

Ca

rd

iova

scu

lar

•Pin

k

•Cap

illa

ry r

efil

l 1

-2

seco

nd

s

•Pal

e

•Cap

illa

ry r

efil

l 3

sec

ond

s

•Gre

y

•Cap

illa

ry r

efil

l 4

sec

-on

ds

•Tac

hyca

rdia

of

20

above

norm

al r

ate

•Gre

y &

mott

-le

d

•Cap

illa

ry r

efil

l

≥ 5

sec

ond

s

•Tac

hyca

rdia

30 a

bove

nor-

mal

rat

e

•Bra

dyca

rdia

for

age

Resp

ira

tory

•Wit

hin

norm

al

par

amet

ers

•No r

etra

ctio

ns

•>1

0 a

bove

norm

al p

aram

e-te

rs

•Usi

ng a

cces

sory

mu

scle

s

•24-4

0%

FIO

2 o

r ≥

2 L

/min

O2

•An

y i

nit

iati

on o

f O

2

•> 2

0 a

bove

norm

al

par

amet

ers

•R

etra

ctio

ns

•>4

0%

FIO

2 o

r ≥

3 L

/min

O

2

•5 b

elow

nor-

mal

par

amet

ers

wit

h r

etra

ctio

ns

•G

run

tin

g

•≥ 5

0%

FIO

2 o

r

≥ 8

L/m

in O

2

Pediatric Early Warning Score (PEWS) System

35

Synagis Guidelines

(non-CLD)

34

20

14

-1

5 U

F P

ED

IAT

RIC

CL

INIC

VA

CC

INE

SC

HE

DU

LE

Bir

th/

Nu

rse

ry

2 m

o

4 m

o

6 m

o

12

mo

1

5 m

o

18

mo

2

yrs

4

-6 y

rs

11

-12

yrs

1

5 y

rs

18

yrs

HB

V

Pe

dia

rix

(DT

aP

+IP

V+

HB

V)

Pe

dia

rix

(DT

aP

+IP

V+

HB

V)

Pe

dia

rix

(DT

aP

+IP

V+

H

BV

)

DT

aP

Kin

rix

(DT

ap

+IP

V)

Td

ap

Ad

ace

l (>

11

yrs

) B

oo

str

ix

(> 1

0 y

rs)

Td

ap

ca

tch

up

>

12

yrs

H

ib w

ith

Pe

dia

rix

Hib

wit

h

Pe

dia

rix

Hib

wit

h

Pe

dia

rix

(N

ot

ne

ed

ed

if

P

ed

va

xH

IB a

t

2 a

nd

4 m

on

th)

Hib

M

MR

Pro

qu

ad

(M

MR

+V

ari

v

ax)

P

revn

ar

(PC

V1

3)

Pre

vn

ar

(PC

V1

3)

Pre

vn

ar

(PC

V1

3)

Pre

vn

ar

(PC

V1

3)

Va

riva

x

Va

riva

x C

atc

h u

p >

6 y

r o

f a

ge

(3

mth

s a

pa

rt till

ag

e 1

3 y

rs t

he

n 4

wks

ap

art

)

Ro

tari

x 1

/ R

ota

teq

1

(6 w

k -

14

wks

6 d

ys)

Ro

tari

x 2

/

Ro

tate

q 2

Ro

tate

q 3

(< 8

mo

nth

s 0

da

ys)

Hep

A

Hep

A

(6 m

ths a

fte

r

1st

do

se

)

H

ep

A c

atc

h u

p >

2 y

rs

M

en

actr

a

(MC

V4

)

Me

na

ctr

a (

MC

V4

) B

oo

ste

r

- a

t 1

6 y

rs, if fir

st d

ose

be

-tw

ee

n 1

1-1

2 y

rs

- a

t 1

6-

18

yrs

, if fir

st

do

se

be

twe

en

13

-15

yrs

Ga

rda

sil

[Gir

ls &

B

oys]

(H

PV

) 0

-2-6

m

ths

(24

wks

be

twe

en

d

ose

1 a

nd

3)

F

lu-M

ist:

IN

, 2

- 4

9 y

rs h

ealth

y,

Ju

ly -

Ma

y,

0.1

ml e

ach

no

str

il

F

lu-S

ho

t: I

M >

6 m

ths,

Se

p -

Ma

y,

0.2

5 m

l fo

r 6

mth

s

Flu

-Sh

ot:

Se

p -

Ma

y,

0.5

ml fo

r >

3 y

ea

rs

Flu

va

ccin

e: 2

do

se

s a

t le

ast

4 w

ks a

pa

rt f

or

ch

ildre

n <

9 y

rs r

eceiv

ing

fo

r th

e fir

st tim

e.

On

e d

ose

if

(re

ceiv

ed

2 d

ose

s o

f se

aso

nal flu

la

st ye

ar/

1 d

ose

of

se

aso

nal flu

in

tw

o p

revio

us s

ea

son

s)

and

an

y 2

00

9 H

1N

1 m

on

ova

len

t va

ccin

e

17

Total

Score PEWS Action Plan

0 - 2 pts No additional interventions required

3 pts

Notify CN to assess patient

Notify MD resident

Increase vital signs q1 hr x 3 with PEWS

4 pts

Notify CN to assess patient

Notify MD resident to assess patient within 15 minutes

Increase vital signs q1 hr x 3 with PEWS

5 pts

Notify CN to assess patient

Notify MD resident to assess patient within 15 minutes

Notify MD senior resident/fellow to assess patient within 15

minutes

Increase vital signs q1 hr with PEWS

6 pts

Notify CN to assess patient

Call SWAT

Notify MD resident, senior resident/fellow STAT

Notify MD Attending on service

Rapid Response Team: Condition H - Call #61 or SWAT - Call #69 Any category 3 call a SWAT

Code Blue Team: Call # 66

PEWS Action Plan

18

33

Clinic Tips Car seats:

Infants - Rear-facing seats until 2 years of age (or until

highest weight/height allowed by car seat manufacturer

reached)

Toddlers/Preschoolers - Forward-facing seats (5-point

harness) until outgrows (typically around age 4)

School-aged children - Booster seats (belt-positioning)

until 4’9” tall and between 8-12 years old

Older children - Seat belts (lap and shoulder); children

younger than 13 years old should ride in the back seat

FLSHOTS.com (keep log-in in your email!)

___________________________________________________

Anemia

Eyes: refer if >10 difference between eyes or worse than

Age 4 = 20/40

Age 5 = 20/30

Age 6 = 20/20

Age Anemia = Hgb 2 SD below

mean Mean

6mo-6yr 10.5 12

7-12yo 11 12.5

>12 ♀ 12 14

>12 ♂ 13 16

32

FEN:

Fluids- (General rules, does not always apply)

4ml/kg for each kg between 1-10kg +

2ml/kg for each kg between 11-20kg +

1ml/kg for each kg over 20kg or

Quick version for over 20 kg- just add 40 to weight

Most of time use D5 ½ NS + 10-20 meq KCl/L

- Exceptions: NS for brain tumors; no KCl for Onc pts

- ¼ NS for neonates

- NS is 154 meq/L Na and Cl

Maintenance Electrolytes-

Na+: 3meq/kg/day K+: 2meq/kg/day

Important Formulas

Anion Gap: Na – (Cl + HCO3)

Corrected Na : Na + [(glucose – 100) x 0.016]

Osmolality: 2x Na + glucose/18 + BUN/2.8

FE Na: Cr clearance:

Urine Na x serum Cr Urine Cr x urine Vol (ml)

Serum Na x urine Cr Serum Cr x time (min)

GFR estimated: PC x height (cm)/ serum Cr

(Proportionality Constant = 0.33 in LBW infants < 1 yo, 0.45 in

term infants < 1 yo, 0.55 in children 2-12, 0.55 in girls 13-21,

0.70 in boys 13-21)

GIR (glucose infusion rate): % dextrose x 10 x rate in ml/hr

60 x weight (kg)

19

NICU/NBN

Intubations:

Blade Size: 1 for term, 0 Term-30 wks, 00 < 30wks

Tape at: 6+ weight (kg)

Lines:

FEN:

Kcal/kg/day calculations:

Dextrose: ml/kg/day x % dextrose x 0.034

Lipids: ml/kg/day x 2

AA: g/kg x 4

Formulas:

GIR (glucose infusion rate): % dextrose x 10 x rate in ml/hr

60 x weight (kg)

Acid correction: For pH<7.2 OR Base deficit >10

NaHCO3 2mEq/kg/dose or ½ correction:

Base Deficit x 0.6xWt (kg)/2 Given over 30-60 minutes

Na Correction: Give ½ over 12-24 hours

[Na deficit – Na value] x weight(kg) x 0.6

ROP Guidelines: At 6 weeks. <30wks or <1500g

Car Seat Guidelines: <4 lbs= carbed, <37 wks Car seat test

HUS/MRI Guidelines: HUS 1 wk, MRI PTD. <30wks or <1250g

Synagis Guidelines: See next page

<1kg 1-2 kg 2-3 kg 3+ kg

ETT size 2.5 cm 3.0 cm 3.5 cm 3.5-4cm

UAC (Weight(kg) x 3) + 9 for T6-T9

Weight + 7 for L3-4

UVC UAC length /2 + 1

(Weight(kg) x 1.5) +5.5

20 kcal/oz 0.67 kcal/ml

22 kcal/oz 0.73 kcal/ml

24 kcal/oz 0.80 kcal/ml

20

Sepsis Guidelines—UFAdapted from MMWR Nov 19, 2010/Vol

59/No. RR-10 & AAP COFN May 2012 &

July 2013, “Pediatrics”.

Revised 1/2014 Donald Fillipps, MD

Medical Director Newborn Nursery

Signs of sepsis?Yes

Blood cultures, CBC w/ diff,

+/- CRP (CRP optional)

LP if sepsis strongly suspected.

CXR if respiratory symptoms

Start Ampicillin and Gentamicin

Maternal

Chorioamnionitis &

Baby Healthy

No

Yes

Blood cultures immediately. CBC

w/ diff, +/- CRP(CRP optional) at

age 6-12 hrs

Start Ampicillin and Gentamicin

Order vitals with hands-on nursing

assessments Q 4 hrs

History/symptoms Immediate

Management

Subsequent

Management

Consider transfer to NICU

Length of therapy determined by

clinical response, cultures, labs,

and physician judgment.

Repeat CBC w/ diff, +/-

CRP(CRP optional) at 48 hr.

D/C home if baby healthy, blood

cultures (-), and lab/s normal.

Prolonged antibiotic therapy if

suspicion high for sepsis or if

blood cx(+), or lab/s abnormal

Maternal GBS

prophylaxis indicated?

(GBS+, or GBS unknown

with any of the following:

<37 weeks or ROM>18hrs

or sibling with GBS)

(Scheduled c-section or c-

section for maternal indications,

prophylaxis NOT indicated)

No

NoRoutine newborn care

Yes

Received penicillin,

ampicillin or cefazolin

≥4 hr before delivery?

YesObservation in hospital for 24-48

hrs.If discharged home in <48 hrs,

should have follow-up

appointment within 24 hours.No

≥37 weeks and ROM

<18 hrs? (Inadequate

IAP and no other risk

factors)

Yes

Observation in hospital for 48 hrs.

Order vital sign checks

(Temp/HR/RR) with hands-on

nursing assessments Q 4 hrs

Either <37 weeks or

ROM > 18 hrs and

well appearing

No

Yes

Blood cultures, CBC w/ diff,

+/- CRP(CRP optional), at age 6-

12 hrs.

Begin vital sign checks

(Temp/HR/RR) and hands-on

nursing assessment Q 4 hrs

If baby develops symptoms of

sepsis or lab/s abnormal, start

Ampicillin and Gentamicin

If antibiotics are started &

baby remains healthy:

Option 1: Consider D/C home

at 48 hrs if baby healthy and

blood cultures negative

Option 2: Repeat CBC, diff, +/-

CRP(CRP optional) at 48 hrs.

D/C home if blood culture

negative and repeat lab/s

normal

Prolonged antibiotic therapy if

48 hr lab/s abnormal

* If GBS is negative but has risk factors of either <37 wks or ROM

>18hrs, the following options should be considered if baby appears

healthy: (Q 4 hr vitals and hands-on assessments for all)

1) Observe for 48 hrs without obtaining cultures or lab evaluation

2) Blood culture, CBC w/ diff, +/- CRP(CRP optional) at age 6-12 hrs;

start Amp & Gent if lab/s abnormal

If both risk factors present obtain blood cx, CBC w/ diff, +/- CRP at

age 6-12 hrs; start Amp & Gent if lab/s abnormal

31

EKG I. Rate: divide 300 by # of boxes

II. Rhythm: P’s, Q’s, 3 R’s

P waves upright in II = sinus rhythm

QRS wide or narrow

Rate, regular rhythm, related P waves

III. Intervals

PR: ~ 1 large box

QRS: ~ ½ large box

QT: ~ ½ the RR interval (drugs, lytes, CNS)

QT/square root (R-R)

IV. Axis: I and aVF

Normal: QRS + in I and aVF

RAD: QRS – in I and + in aVF

LAD: QRS + in I and – in aVF

Intermediate: QRS – in I and aVF

V. Hypertrophy

LVH: deep S in V1-2 + tall R in V5-6 = 35

RAA: prominent, peaked, pul. Leads (II, III, aVF)

LAA: p waves “M” in mitral leads (I, II, aVL)

RVH: tall R waves in V1 and RV strain

*Strain: asymmetric ST depression and T wave inv.

VI. Infarct (QRST )

Normal for Peds Q wave: small and narrow normally seen in

I, aVL, V5, V6

R wave progression: btwn V2 and V4

ST seg: smiley or frowny

T wave: normally inverted in III, aVF, aVL, V1

30

Transfusion Guidelines

Pre-Meds:

Only if history of reaction to blood products

Most febrile reactions occur with platelets

Blood (PRBC) Transfusion:

10 – 15 mL/kg

In a stable patient with normal cardiac function, 10 mL/kg can be

transfused over 2 hours

For patients with Hct less than 15 or Hgb less than 5 and stable, rule

of thumb is to give blood slowly. The transfusion volume is

patient’s Hgb x wt in kg over 2-3 hours. Wait a few hours and

reevaluate Hct and Hgb and cardiac status; base next transfu-

sion on new data.

For patients with Hct less than 15 or Hgb less than 5 and unstable

contact Heme/Onc before transfusing

For volume depleted patients who are unstable secondary to blood

loss, infuse as rapidly as possible.

This patient should be in PICU!

1 unit PRBCs = 250 mL (at least, sometimes as much as 500ml)

1 unit PRBCs ~ 3 pedisplit units

1 pedisplit = ~80 mL

Platelets:

10mL per kg

1-2 apheresis units is the maximum

Single donor (apheresis unit) = ~ 8 random donor units

Pre-pooled platelets are the equivalent of 6-8 different donors. For

infants and toddlers random donor units are acceptable. Once

patient is getting equivalent of 4 or more random donors, ½

apheresis unit should be ordered.

Average volume of apheresis unit = ~200-250 mL

Platelets are normally hung by gravity over ~15-20 min

21

Nomogram for designation of risk >36 weeks gestation

Hyperbilirubinemia

Guidelines for therapy >35 weeks gestation

Risk of hyperbilirubinemia: Bilitool.org

22

PICU

ETT SIZE = 4 + (pt’s age in yrs/4) Cuffed ETT tube = 3 + (pt’s age in yrs/4) ETT position (cm) at lip = 3 x ETT size (mm)

TV = 7-10 mL/kg PEEP = 5 cm H20 Fi02 - 0.4 to 1 (Adjust to keep 02 sat>90%) IMV=15/min for child & 20-30/min for infants PIP less than 35 cm H20, usually <25 cm H20 if normal lungs Inspiratory time = 0.5 – 0.6 sec infant; 0.7-0.8 sec child; 0.8 – 1.0 sec adolescent HYPOVOLEMIC / SEPTIC SHOCK: 10-20 mL/kg as rapid bolus of an isotonic, non-glucose contain-ing solution (i.e. lactated ringers or normal saline). Repeat PRN based on distal pulses, blood pressure, capillary refill. There is no maximum; the amount given is determined by the needs of the patient.

0 to 1 month Systolic pressure > 60mmHg 1 month to 1 year Systolic pressure > 70mmHg Greater than 1 year Systolic pressure > 70mmHg + 2x (Age) ≥ 10 yrs Systolic pressure > 90mmHg

INTUBATION

INITIAL VENTILATOR SETTINGS (volume mode)

MINIMAL BLOOD PRESSURE VALUES

29

Attributes for PRBCs and Platelets:

Leuko-reduced products:

Used to remove leukocytes. Leukocytes are a primary source of HLA antigens and filtering decreases devel-

oping alloimmunity.

Decreases febrile reactions. Filters majority of CMV out of product if donor is CMV +

Irradiated: Leuko-reduction does not filter all lymphocytes out of products, so all immune

compromised patients and must receive irradiated products.

Used to prevent graft versus host disease.

CMV Negative:

Donor is CMV – Used only in patients who are CMV – and candidates for allogenic transplant

Washed: Removes majority (~99%) of plasma proteins, electrolytes, and antibodies.

Used for patients with history of allergic or febrile reaction to plasma compo-

nents of blood products May be used for patients with IgA deficiency

Used in bone marrow transplant patients – see ABO/Rh compatibility chart

Packed:

Only an option for platelet products

Reduces volume Used in bone marrow transplant patients – see ABO/Rh compatibility chart

___________________________________________________________________

Sickle Cell Patients: Leuko-reduced

Sickle cell (Hgb S) negative

Preferably less than 5 days old – or freshest available if blood that recently donated is available. (This is to reduce the amount of iron patient receives.

As RBCs break down and age iron builds up in the blood unit. Because of

frequent transfusions Sickle Cell patients are at risk for developing iron overload.)

Does not need to be irradiated

Oncology Patients:

Leuko-reduced

Irradiated Other attributes per pt (i.e. CMV -, washed)

If patient has had Bone Marrow Transplant refer to ABO/Rh compatibility chart

for that patient

28

Hematology/Oncology In General:

- GI prophylaxis (ex: Prevacid) if pt is NPO/on steroids/NSAIDS

- Check the medication record (MAR) in the bedside chart to see times

chemo, antibiotics and if prn pain meds were given QAM. Make sure

they actually got the medicine!

Sickle Cell Disease:

- Pain crisis: pain control, hydration, anemia management

- With PCA or scheduled opiates, use continuous pulse ox and a laxa-

tive (ex: Colace); know PCA settings (basal amt, on demand amt and

frequency, lockout) and PO medication frequency.

- Toradol given for only 5 days, then Motrin

- Chest pain or fever: get CXR to look for acute chest syndrome

- If SCD and fever: culture Q24 with fever. Antibiotic of choice for

new fever is Ceftriaxone 75 mg/kg/day.

- Penicillin prophylaxis if pt ≤5 yo or asplenic

- Transfusions:

Know pt’s transfusion criteria, often 20/20 (Hct/platelets).

Consider consenting for blood transfusion during your H&P

pRBCs attributes: leukoreduced, sickle negative, <5 day old

Cancer patients:

- Absolute Neutrophil Count = total WBC x (% bands + % segs).

- Fever and Neutropenia: GO EXAMINE ANY neutropenic patient

with a fever! Bacter ial cultures Q24hr , Cefepime (usually until

counts recover), Add Vanc, if sick or if pt w/ AML. Consider fungal

cultures.

- If long term antibiotics or steroids needed, add fungal prophylaxis

(ex: Fluconazole), especially if neutropenic.

- Chemo Roadmap = what chemo drugs a patient is receiving, when

they are due and what they have gotten in the past, only the attending

can sign chemo orders (due by 5pm)

ANC normal >1500

1000 – 1500 mild neutropenia

500 – 1000 mod neutropenia

< 500 severe neutropenia

23

How to adjust the vent 101…

RATE ∆ P PEEP iTIME FiO2

To ↑ PaCO2

↓ ↓ N/A N/A N/A

To ↓ PaCO2

↑ ↑ N/A N/A N/A

To ↑ PaO2

N/A ↑ ↑ ↑ ↑

To ↓ PaO2

N/A ↓ ↓ N/A ↓

PaO2 PaCO2 pH HCO3 BE

Term 80-95 35-45 7.32-7.38 24-26 3

30-38 wks

60-80 35-45 7.30-7.35 22-25 3

< 30 wks 45-60 38-50 7.27-7.32 19-22 4

ABG Interpretation

I. Acidemia v. Alkalemia

pH: 7.38-7.42 II. Respiratory v. Metabolic

PaCO2 = 40 HCO3- = 24

III. Anion Gap AG = Na+ - (Cl- + HCO3

-) normal=10

IV. / Ratio

/ Ratio = (AG – 10)/(24 – [HCO3-])

↑1 alk; ↓1 acid

V. Resp Component

Winter Formula: Expected CO2 = 1.5[HCO3

-] + 8 ± 2

VI. Resp: Acute v. Chronic

Acute: CO2 of 10 = pH of 0.08

Chronic: CO2 of 10 = pH of 0.03

VII. A-a Gradient

A-a = PIO2 - (PaCO2/0.8) - PaO2 PIO2 = (760 - 47)*0.21 (on room air)

24

ASTHMA

Asthma Score 6-12:

Continuous neb Q 1h assessment

Asthma Score 2-5:

Q2h neb Q2h Assessment

Asthma Score 0-1: Hold therapy Q2h assessment

assessment

Discharge Home if:

Asthma Education Asthma Action Plan Follow up

Hold therapy Q 1h assessment Move if score is still

low X 2 Notify MD

Hold therapy Q 2h assessment Move if score is still

low X 2 Notify MD

Move if patient did not require albuterol For 4 hours

Notify MD

Give albuterol Q1hour assessment Move if score is still

highX2 Notify MD

Give albuterol Q 2h assessment Move if score is still

high X 2 Notify MD

Continue protocol if discharge criteria not fulfilled

Escalate Descalate Stable

Flowsheets available in EPIC:

Asthma Scoring System

ED PACE Asthma History

ED PACE Asthma Scoring System

27

Cystic Fibrosis

Print CF patient care form (on the portal)

Look at past H&P, D/C summaries for medication history, sputum

culture results

Airway clearance QID (Vest, CPT, IPV – ask pt what they use or

look at past hospital course/clinic notes)

Sputum culture labeled “CF sputum, extended sensitivities”

Remember annual labs (prealbumin, LFTs, PT/PTT, vitamin lev-

els) and monitoring labs (BMP if pt on Vanc, Vanc trough,

Tobra 2/8 hr levels)

Spirometry (pre- and post-bronchodilator) usually at the time of

admission (sometimes done in clinic) and then usually every

1-2 weeks until improvement seen

Consults to the appropriate services (Endo if pt has CFRD, GI/

Liver if pt has CF liver disease, Nutrition for help with nutri-

tional supplementation, and Pharmacokinetics if pt has drug

levels that will need adjusting)

PICC line consent at the time of admission (1-2 weeks of IV Abx)

ànd then fax PICC consult sheet and call PICC team (don’t

fax consult sheet w/o obtaining consent)

CXR following PICC line placement, if placement is delayed con-

sider earlier CXR

Everyday: ask pt to cough as par t of lung exam (productive?),

if CPT is in progress STOP IT with “pause” button to do exam.

26

Bronchiolitis Score

25

ASTHMA Out-patient: New Diagnosis: determine if it is asthma (if they respond to bronchodila-

tor treatment), and what type of asthma it is (intermittent or persistent)

Classification:

Treatment:

Mild Intermittent-

No daily medication

Only short acting beta agonist (Albuterol)

Mild Persistent

Low-dose inhaled corticosteroid daily (Flovent)

Short acting beta agonist (Albuterol) as needed

Moderate Persistent:

Low-dose inhaled corticosteroid (Flovent) AND long acting beta

agonist (Advair)

OR Medium dose inhaled corticosteroid

Short acting beta agonist (Albuterol) as needed

Severe Persistent

High dose inhaled corticosteroid

Long acting inhaled beta agonist

**If pt has ever been in the PICU for an asthma exacerbation

they should be followed by Pulmonary**

Mild

Intermittent Mild

Persistent Moderate

Persistent Severe

Persistent

Day ≤ 2 days/wk >2/week

but

<1/day

Daily Continual

Night ≤ 2 nights/

month >2 nights/

month >1 night/

wk Frequent

FEV1 ≥ 80% ≥ 80% 60-80% ≤ 60%