ED Outreach Services MEDICAL DIRECTIVES
Hôpital régional de Sudbury Regional Hospital
ISSUED BY:
AUTHORIZED BY:
ISSUE DATE:
CATEGORY:
ED Patient Care Team
Emergency & Medical Program Council
SUBJECT:
Therapeutic Procedures Directive
REVISION DATE:
PAGE: 1 of 12
Medical Directives
ED Outreach Services Medical Directive - Therapeutic Procedures
Title: Therapeutic Procedures Directive
Activation Date:
Sponsoring/Contact
Person(s)
(name, position, contact particulars):
Orders:
Directive
EDOS04
Number:
Review due by:
Dr. Chris Bourdon, Interim Chief of Staff
Dr. Andrew Caruso, Interim Emergency Department Medical Director
Dr. Andre Roch, Physician Lead, Extendicare and TCU
Mary Beth Gibbons, RN, Clinical Lead – ED Outreach
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Orders for therapeutic procedures as identified on the appended:
1. Therapeutic Procedures Order Table
a) Saline Lock Insertion,
b) Peripheral IV Access with NS 30 mLs/hour,
c) Accessing Established Vascular Access Device with NS 30 mls/hour,
d) Initiate and Titrate Oxygen by mask or nasal prongs to maintain SaO2 ≥to 92%
e) Urinary Catheter Insertion
f) Application of Topical Skin Adhesive
g) Suturing of lacerations above the fascia and excluding the face.
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CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Recipient Patients:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Any patient presenting to the ED Outreach Services (within the HRSRH or Long Term Care facilities with who
the HRSRH has a Memorandum of Understanding) who meets the conditions identified in this directive.
Authorized Implementers:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
All ED Outreach Nurses and designated staff who have successfully completed the relevant ED Outreach
Services Medical Directive orientation program as described in Review & Quality Monitoring Guidelines.
Medical directive certification is to be completed every 2 years. The ED Outreach Nurse - Team Lead will
maintain a list of authorized implementers as part of the Medical Directive record.
All physicians involved in the ED Outreach Services will review the medical directives yearly and upon any new
directives added to the program. The ED Outreach Nurse - Team Lead and/or ED Medical Director will
make available to all new physicians to the ED Outreach Services a medical directive package which will be
signed prior to program involvement.
Indications:

Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Therapeutic procedures will be administered for the period beginning from when a patient is assessed by
the ED Outreach Nurse to first contact with the attending LTC physician, unless the attending LTC
physician orders implementation of the directive beyond that period.
 Prior to implementation of any directive, a patient assessment is completed in accordance with standards of
practice and any applicable HRSRH policy. Allergies and sensitivities must be documented.
 Specific indications are identified in the appended Order Table.
Definitions for indications used in the table:
1. Signs and symptoms of one or more of the following:
 SOB
 Diaphoresis
 Pallor
 Nausea/vomiting
 Syncope
 Weakness, lightheadedness, pre-syncope
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CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Lethargy
2. Fever – Temperature greater than/equal to 38°C
3. Hemodynamic instability – as manifested by one or more of the following:
 Pale
 Diaphoretic
 Tachypneic
 Tachycardia,
 Hypotensive
 Altered LOC

Contraindications:
See appended Order Table.
Consent:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Staff implementing the directive will obtain consent in accordance with the Health Care Consent Act and any
relevant HRSRH policies and procedures.
Guidelines for Implementing the Order
/ Procedure:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
See appended Order Table.
Documentation and Communication:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Implementing staff will document the:
 Specific orders in the order section of the patient record, noting the medical directive name and
number, and signing off the order with the implementer’s name and signature as per the
attending LTC physician (when attending LTC physician known)
 Indications, implementation and patient response in accordance with HRSRH record-keeping
policies -ED Outreach Services Flow Chart, and Medical Form (EDOS04)
Note: Clear and timely notification, communication and documentation between the nurse and the physician
are critical to safe, proper use of a medical directive.
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CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Review and Quality Monitoring
Guidelines:
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Staff identifying any untoward or unintended outcomes arising from implementation of orders under this
directive, or any issues identified with it will report these to LTC Physician as soon as possible for appropriate
disposition. This does not include untoward or unintended outcomes or issues that are possible clinical
sequelae regardless of whether a directive or direct order is used.
Certification process

LTC MD - yearly

ED MD renewal – yearly

ED Outreach Nurse recertification – every 2 years which will consist of a written test and/or
successful completion of certification exam and/or maintenance of competence process
Administrative Approvals:

ED Patient Care Team

Emergency/Medical Program Council

Professional Practice Council

Professional Advisory Committee

Medical Advisory Committee
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
Approving Physician(s)/Authorizer(s):
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
References
Appendix Attached:
Yes
No
Title: Therapeutic Procedures Order Table
List any references here as below and attach appendix, or list references in Performance Readiness Assessment
form (Module 1).
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
Page 5 of
11
Newberry, L. (Ed.). (1998). /Sheehy’s Emergency Nursing. Principles and Practice/. 4^th Ed. Mosby: Toronto.
Electrocardiogram in Acute Myocardial Infarction new England Journal Med. 2003: 348: 933-940
Guidelines 2006 for cardiopulmonary and Emergency Cardiovascular care: American Heart Association
Tintinelli,j.E Kelen,GD and Stapczynski, J.S Emergency medicine: A Comprehensive Study Guide, 6th Edition
2004.
Beveridge, R., Grunfeld, F., Hodder, R. (1996) Guidelines for the emergency management of asthma in adults.
[Electronic version]. CMAJ 155:25-37
Ontario Hospital Association (2007) Emergency Department Management of Asthma (Adult).
Fitchett, D., Goodman, S., Langer, A. (2001). New Advances in the management of acute coronary syndrome.
[electronic version]. CMAJ, 164(9)
Fenton,D. (2005 January 5). Acute Coronary Syndrome, retrieved July 25, 2005 from
http://www.emedicine.com/emerg/topic31.htm
AHA Guidelines, 2007 http://stroke.ahajournals.org/cgi/content/abstract/30/10/2033
Page 6 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Appendix
Therapeutic Procedures Order Table
Title and Number of Directive:
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Order
Indications
Contraindications
Guidelines
Page 7 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
a) Saline Lock
Insertion, or
b) Peripheral IV
Access with NS
30 mLs/hour, or
c) Accessing
Established
Vascular Access
Device with NS
30 mLs/hour
Signs and symptoms of one or more of the following
actual or potential:

Airway compromise

Respiratory distress

Hemodynamic instability / shock, dehydration
bleeding
Hemodialysis lines are not to be accessed
for the purposes of this medical directive

IV medication administration for pain,
symptom control and or/treatment,

To provide IV rehydration where dehydration
present and oral intake compromised,

To provide fluid resuscitation to improve
hemodynamic status
Indications
Signs and symptoms of one or more of the following
actual or potential:

Respiratory distress,

SaO2 less than/equal to 90%, or below established
desirable range for the individual patient

Hemodynamic instability

Altered LOC
Follow applicable
HRSRH policy
and procedure
guidelines
• central line
certification
 Altered LOC
In anticipation of one or more of the following:
Order
d) Initiate and Titrate
Oxygen by mask or
nasal prongs to
maintain SaO2
greater than/equal
to 92%:

Contraindications

Note: For possible CVA patients, O2
administration should only be considered
when SaO2 less than/ equal to 90%

Known CO2 retainer (88-92%)
Guidelines

Follow
applicable
HRSRH
policy and
procedure
guidelines
Page 8 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Page 9 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Order
e) Urinary Catheter
Insertion:
Straight in & out

For urine specimen collection in immobilized
patients where unable to collect by other means
Or

To assess and monitor fluid balance in patients
with actual or potential signs and symptoms of
hemodynamic compromise, and/or

Inability to void or difficulty voiding;
Or
Moderate to gross hematuria and inability to void
or difficulty voiding
Or
Indwelling urinary
catheter

Or
3-way catheter
Or
Coude-tip
Contraindications
Indications

Prior to insertion, administer Lidocaine

Pelvic trauma

Recent urethral surgery or bladder
reconstruction

Known strictures or previous difficult
catheterizations
Guidelines

Consider using
coude tip for
all male
patients

Follow
applicable
HRSRH
policy and
procedure
guidelines
Page 10 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Order
f) Application of
Topical Skin
Adhesive
Indications

Lacerations whose edges can be easily
approximated regardless of wound length
Contraindications

Any wound with evidence of active
infection, gangrene, or wounds of
decubitus etiology

Mucosal surfaces or across
mucocutaneous junctions (e.g., oral
cavity, lips), or on skin which may be
regularly exposed to body fluids or
with dense natural hair (e.g., scalp)

Known hypersensitivity to
cyanoacrylate or formaldehyde

Areas of stress or tension (e.g., joints)

Any wound found on the ears

Bites and puncture wounds

Areas of heavy contamination

Foreign body present in wound
Guidelines

Follow
applicable
HRSRH
policy and
procedure
guidelines
Page 11 of
CATEGORY:
Medical Directives
SUBJECT:
Therapeutic Procedures
11
Therapeutic Procedures Order Table
ED Outreach Services - Therapeutic Procedures Directive (EDOS04)
Order
f) Suturing / stabling
of tissue above the
fascia
Indications

Lacerations whose edges cannot be easily
approximated regardless of wound length

Areas of stress or tension (e.g., joints)
Contraindications

Any wound with evidence of active
infection, gangrene, or wounds of
decubitus etiology

Mucosal surfaces or across
mucocutaneous junctions (e.g., oral
cavity, lips), or on skin which may be
regularly exposed to body fluids or
with dense natural hair (e.g., scalp)

Any wound found on the face or
head

Bites and puncture wounds

Areas of heavy contamination

Foreign body present in wound
Guidelines

Follow
applicable
HRSRH
policy and
procedure
guidelines