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:
Medications
REVISION DATE:
PAGE: 1 of 17
Medical Directives
ED Outreach Services Medical Directive - Medications
Directive
EDOS03
Number:
Title: Medications Directive
Activation Date:
Sponsoring/Contact
Person(s)
(name, position, contact particulars):
Orders:
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
Title: Medication Order Table
Orders as identified on the appended order table:
1. Medication Order Table
Acetaminophen
Amoxicillin
Amoxicillin/Clavulanate
Azithromycin
Benadryl
Cefprozil
Ceftriaxone
Cefuroxime-AX
Cephalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Cloxacillin
EMLA
Epi 1:1000
Ipratropium
Lidocaine Jelly 2%
Macrobid
No
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 2 of
17
Moxifloxacin
Pancrelipase
Prednisone
Ranitidine
Salbutamol
Sodium Bicarbonate
Solu-Medrol
Trimethropin/Sulfamethoxazole
Recipient Patients:
Appendix Attached:
Yes
Title: Medication Order Table
No
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
Title: Medication Order Table
No
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.
CATEGORY:
Medical Directives
SUBJECT:
Medications
Indications:
Page 3 of
Appendix Attached:
Yes
Title: Medication Order Table
17
No
 Medications will be administered from 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
specifically 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. Acute Delirum and/or Confusion
2. Anaphylaxis
3. Cellulitis
4. Dehydration
5. Falls
6. Fever – Temperature greater than/equal to 38°C
7. Foley Catheter Difficulties
8. G-tube/Enteral Difficulties
9. Lacerations
10. Lower Respiratory Tract Infections
11. Upper Respiratory Tract Infections
12. Syncope
13. Urinary Tract Infections
14. Weakness/Dizziness
Contraindications:
See appended Order Table.
Consent:
Appendix Attached:
Yes
No
Title: Medication 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:
See appended Order Table.
Appendix Attached:
Yes
Title: Medication Order Table
No
CATEGORY:
Medical Directives
SUBJECT:
Medications
Documentation and Communication:
Page 4 of
Appendix Attached:
Yes
Title: Medication Order Table
17
No
Implementing staff will document the:

Medication order (including name of medication, dose, route, time of administration) in the order section
of the patient record, noting the medical directive name and number, signing off the order as per the
attending LTC physician (when attending LTC physician known)

Indications, administration, and patient response in accordance with any HRSRH record-keeping policies ED Outreach Services Flow Chart, and Medical Directive Form (EDOS03)
Note: Clear and timely notification, communication and documentation between the nurse and the physician are
critical to safe, proper use of a medical directive.
Review and Quality Monitoring
Guidelines:
Appendix Attached:
Yes
No
Title: Medication 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
Administrative Approvals:

ED Patient Care Team

Emergency/Medical Program Council

Professional Practice Council

Professional Advisory Committee

Medical Advisory Committee
Appendix Attached:
Yes
Title: Medication Order Table
No
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 5 of
17
Approving Physician(s)/Authorizer(s):
Appendix Attached:
Yes
No
Title: Medication Order Table
Appendix Attached in section under Laboratory Test and Diagnostic Procedures to cover Medical
Directives: EDOS01, EDOS02, EDOS03, EDOS04
References
Appendix Attached:
Yes
Title: Medication Order Table
No
List any references here as below and attach appendix or list references in Performance Readiness Assessment
form.
Public Health Agency of Canada: Canadian Immunization Guide, 6^th Ed. 2002. Talan, DA Tetanus immunity
and physician compliance with tetanus prophylaxis practices among emergency department patients presenting
with wounds. Ann Emerg Med. 2004 Mar;43(3):315-7.
Ernst A. et al. LAT vs TAC for Topical Anasthesia in Face and Scalp Lacerations. /American Journal of
Emergency Medicine. /1995;13(2):151-154.
Newberry, L. (Ed.). (1998). /Sheehy’s Emergency Nursing. Principles and Practice/. 4^th Ed. .Mosby: Toronto.
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.
Compendium of Pharmaceuticals and Specialties (CPS) 2007
Lacy,C: Armstrong,L;Lance, L Drug Information Handbook 2004
Sheehy's Emergency Nursing 5th Edition 2003 Chapter 14 Pain management
Jovey, Roman Managing Pain: The Canadian Healthcare Professional Reference: The Canadian Pain Society
2002
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 6 of
17
APPENDIX: Medication Order Table
Title
ED Outreach Services - Medication Administration
Number of Directive:
EDOS03
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Acetaminophen (Tylenol)
Indications
Fever (temperature greater than/equal
to 38°C)
325-975 mg PO q 4-6 hr
Mild/Moderate pain as follows:
or
650mg PR (if unable to take PO)
q 4 – 6 hr
Maximum 3200 mg/day

Headache pain

Ear, nose and/or throat pain

Musculoskeletal pain

Skin pain
Contraindications
Abdominal pain
Allergy or sensitivity to
acetaminophen,
Ingestion of therapeutic
acetaminophen in last 4 hours
Hepatitis, liver disease, intoxicated
patients
Care Map Guidelines
Cellulitis
Dehydration
Falls
Fever
Lacerations
Respiratory Tract
Infection
Syncope
Urinary Tract Infections
Weakness & Dizziness
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 7 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Salbutamol (Ventolin)
100 mcg/puff
4 to 8 puffs by MDI and aerochamber
with mask q15 – 20 ; max 3 doses
OR
Salbutamol (Ventolin) 5 mg/mL
Indications
Patients presenting with SOB and a
history of asthma or Chronic
Obstructive Pulmonary Disease
(COPD) with one or more of the
following symptoms:

Cough

Presence of respiratory distress,
wheeze, tightness or decreased
breath sounds during chest
auscultation
Carry out febrile respiratory illness
screening on all patients. If screen is
2.5 mg in 2 ml of normal saline via
positive, isolate patient prior to using
nebulizer mask. Repeat q15 – 20 minutes;
nebulizer.
max 3 doses
Contraindications
Care Map Guidelines
Allergy or sensitivity to salbutamol or Anaphylaxis
adrenergic amines (salmeteral,
terbutaline, albuterol, fomerterol)
Shortness of Breath
Mild/Moderate
Reassess and document
patient response and vital
signs within 15 minutes
following administration or
as indicated as per HRSRH
policies & procedure
guidelines
Utilize aerochamber for
all MDI administrations
Use droplet precautions
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 8 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Ipratropium (Atrovent)
20mcg/puff;
4 to 8 puffs via MDI and aerochamber
with mask q15 – 20 minutes ; max 3
doses
OR
Ipratroprium (Atrovent)
250mcg/ml
250 ug in 3mls NS via nebulizer
Repeat q15 – 20 minutes ; max 3 doses
Indications
Patients presenting with SOB and a
history of asthma or Chronic
Obstructive Pulmonary Disease
(COPD) with one or more of the
following symptoms:

Cough

Presence of respiratory distress,
wheeze, tightness or decreased
breath sounds during chest
auscultation
Carry out febrile respiratory illness
screening on all patients. If screen is
positive, isolate patient prior to using
nebulizer.
Contraindications
Allergy or sensitivity to Ipratropium
(Atrovent)
Care Map Guidelines
Anaphylaxis
Shortness of Breath
Mild/Moderate
Reassess and document
patient response and vital
signs within 15 minutes
following administration or
as indicated as per HRSRH
policies & procedure
guidelines
Utilize aerochamber for
all MDI administrations
Use droplet precautions
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 9 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Indications
Contraindications
Care Map Guidelines
Prednisone
50 mg tablet po X 1 dose
Mild/moderate SOB
Allergy or sensitivity to Prednisone
Shortness of Breath –
Mild/Moderate
Methylprednisolone
Mild/moderate SOB
Allergy or sensitivity to Solu-Medrol
Shortness of Breath
Mild/moderate
(Solu-Medrol)
40mg to 125 mg IV X 1 dose
Dilute in 50ml D5W or 0.9% normal
saline and infuse over 15 to 30 minute
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 10 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Lidocaine Jelly 2%, 200 mg/10mls
Approximately 5 minutes prior to any
urinary catheter insertion.
Indications
Any patient requiring urinary
catheterization who is not allergic to
amide anaesthetics
Apply to cover lacerations 30 minutes
prior to suturing.
Allergy to lidocaine or other aminetype topical anaesthetics (e.g.
articaine, bupivacaine, prilocaine,
mepivacaine, ropivacaine)
Care Map Guidelines
Foley Catheter
Difficulties
Urethral trauma or known structural
abnormality
May repeat x 2 to max of 400 mgs.
EMLA topical anaesthetic
Contraindications
Lacerations above the fascia requiring
suturing
Laceration to ear, nose, fingers, toes,
penis, no mucous
membranes
Known allergy or hypersensitivity
to any compound components
Lacerations
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 11 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Benadryl (Diphenhydramine)
50mg IM or IV x 1 dose
Indications
Allergic Reaction
Contraindications
Care Map Guidelines
Known allergy or sensitivity to
Diphenhydramine
Anaphylaxis
Known allergy or sensitivity to
adrenalin
Anaphylaxis
Known allergy or sensitivity to
Ranitidine
Anaphylaxis
Known allergy or sensitivity to
Cephalexin
Cellulitis
Itchiness
Rash
Epi (Adrenalin) 1:1000
0.3ml IM x 1 dose
Severe allergic reaction
Difficulty Breathing
Difficulty Swallowing
Ranitidine (Zantac)
50mg IV x 1 dose
Allergic Reaction
Itchiness
Rash
Cephalexin (Keflex)
500 mg po qid
First line treatment for mild/moderate
cellulitis
(S. aureus & Group A Strep)
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 12 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Indications
Contraindications
Ceftriaxone (Rocephin)
1gm - 2 gm IV q12-24 hr
First line treatment for mild/moderate
cellulitis in patients that are unable to
take and do not respond to oral
antibiotic
Known allergy or sensitivity to
Ceftriaxone
Cloxacillin (Apo-Cloxi)
500mg po qid
Second line treatment for
mild/moderate cellulitis
Known allergy or sensitivity to
Cloxacillin
Care Map Guidelines
Cellulitis
(S. aureus & Group A Strep)
Cellulitis
(S. aureus & Group A Strep)
Patient unable to take first line
antibiotics due to allergy and/or
sensitivity
Clindamycin (Cleocin)
300 – 450 mg po qid
Second line treatment for
mild/moderate cellulitis
Patient unable to take first line
antibiotics due to allergy or sensitivity
Known allergy or sensitivity to
Clindamycin
Cellulitis
(S. aureus & Group A Strep)
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 13 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Azithromycin (Zithromax)
500mg po on Day 1, then
250 mg po x 4 days
Indications
Contraindications
Third line treatment for mild/moderate Known allergy or sensitivity to
cellulitis
Azithromycin
Care Map Guidelines
Cellulitis
(S. aureus & Group A Strep)
Respiratory Tract
Infection
(S.pneumoniae, H.influenzae,
Gram –ve bacilli, S.aureus,
Legionella sp.,
C.pneumoniae)
Patient unable to take first or second
line antibiotic due to allergy or
sensitivity
First line treatment for suspected
respiratory tract infection
Pancrelipase (Cotazyme)
1 capsule
Blocked G-tube or feeding tube
Known allergy or sensitivity to
Pancrelipase
G-tube / Enteral
Difficulties
Sodium Bicarbonate
325mg tablet
Blocked G-tube or feeding tube
Known allergy or sensitivity to
Sodium Bicarbonate
G-tube / Enteral
Difficulties
Trimethropin/Sulfamethoxazole
(Septra)
First line treatment for suspected
urinary tract infection
Known allergy or sensitivity to
Trimethropin/Sulfamethoxazole
Urinary Tract Infection
(E.coli, S.saprophyticus,
Gram –ve bacilli)
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 14 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Indications
Contraindications
Care Map Guidelines
2 tablets bid or 1 double strength tablet
bid
Note
If CrCl 30-50 ml/min, reduce dose by
25% (i.e. 1.5 tabs bid)
If CrCl 15-30 ml/min, reduce dose by
50%
If CrCl is < 15 ml/min, do not administer
Macrobid
100 mg po bid
Note:
If CrCl is < 60 ml/min, avoid use.
Discuss with pharmacist
First line treatment for suspected
urinary tract infection
Known allergy or sensitivity to
Nitrofurantoin or Macrobid
Urinary Tract Infection
(E.coli, S.saprophyticus,
Gram –ve bacilli)
Amoxicillin (Amoxil)
Second line treatment for suspected
Known allergy or sensitivity to
Urinary Tract Infection
(E.coli, S.saprophyticus,
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 15 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
500 mg po q8h
Indications
urinary tract infection
Contraindications
Amoxicillin
Care Map Guidelines
Gram –ve bacilli)
Patient unable to take first line
antibiotic due to allergy or sensitivity
Ciprofloxacin (Cipro)
250 – 500 mg po bid
Note:
If CrCl is 5-29 ml/min, administer 250 –
500 mg q 24 hrs.
Amoxicillin/Clavulanate (Augmentin)
500 mg po tid OR 875 mg bid
Note
If CrCl 10-30ml/min, administer 250 –
Second line treatment for suspected
urinary tract infection
Known allergy or sensitivity to
Ciprofloxacin
Patient unable to take first line
antibiotic due to allergy or sensitivity
First line treatment for suspected
respiratory tract infection
Known allergy or sensitivity to
Amoxicillin/Clavulanate
Urinary Tract Infection
(E.coli, S.saprophyticus,
Gram –ve bacilli)
Respiratory Tract
Infection
(S.pneumoniae,
H.influenzae, Gram –ve
bacilli, S.aureus, Legionella
sp., C.pneumoniae)
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 16 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Indications
Contraindications
Care Map Guidelines
500 mg q12h.
If CrCl is < 10 ml/min, administer 250 –
500 mg q24 hours.
The 875 mg BID dose should not be
used if CrCl is less than 30 ml/min
Cefuroxime-AX (Ceftin)
500 mg po bid
First line treatment for suspected
respiratory tract infection
Known allergy or sensitivity to
Cefuroxime-AX
Respiratory Tract
Infection
(S.pneumoniae,
H.influenzae, Gram –ve
bacilli, S.aureus, Legionella
sp., C.pneumoniae)
Cefprozil (Cefzil)
500 mg po bid
First line treatment for suspected
respiratory tract infection
Known allergy or sensitivity to
Cefprozil
Respiratory Tract
Infection
(S.pneumoniae,
H.influenzae, Gram –ve
bacilli, S.aureus, Legionella
sp., C.pneumoniae)
Note:
CATEGORY:
Medical Directives
SUBJECT:
Medications
Page 17 of
17
Medication Order Table
ED Outreach Services - Medication Directive (EDOS03)
Orders
Indications
Contraindications
Care Map Guidelines
if CrCl is < 30ml/min, decrease dose by
50%
Moxifloxacin (Avelox)
400 mg po/IV od
First line treatment for suspected
respiratory tract infection
Known allergy or sensitivity to
Moxifloxacin
Respiratory Tract
Infection
(S.pneumoniae,
H.influenzae, Gram –ve
bacilli, S.aureus, Legionella
sp., C.pneumoniae)