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EMERGENCY PROTOCOL,

POLICY AND GUIDELINES


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TABLE OF CONTENTS

EMERGENCY PROTOCOL, POLICY AND GUIDELINES 13


Guidelines for Emergency Kits/Carts 13.1
Guidelines for Vasovagal Syncope (Fainting) 13.4
Allergic Reactions including Acute Anaphylaxis, in Adults, Infants and 13.6
Children
Allergic Reaction/Anaphylaxis Record 13.12
Policy for Reviewing Emergency Protocols/Procedures 13.15
Emergency Checklist 13.16
Evaluation Tool for Practice Drill 13.17
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Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

GUIDELINES FOR EMERGENCY KITS/CARTS


IN PUBLIC HEALTH CLINIC SITES

A. GENERAL POLICY

Local factors such as anticipated EMS response time, the availability of a physician and the
ability of trained personnel to initiate an emergency procedure in the event of vasovagal
syncope, and/or an acute anaphylaxis/allergic reaction will determine the need for supplies
beyond the minimum and expanded protocol/procedure for some clinics. Emergency plans
and procedures should be coordinated with the local Emergency Medical System (EMS).

All emergency drugs and supplies should be kept together in a secured kit or cart that is
easily moveable and readily accessible/visible during clinic service hours. Inventory should
be checked monthly with careful attention to medication expiration dates and the working
condition of equipment.

B. DEFINITION OF EMERGENCY KIT/CART

Emergency kits/carts are those drugs and supplies which may be required to meet the
immediate therapeutic needs of clients and which are not available from other authorized
sources in sufficient time to prevent risk or harm to clients. Medications may be provided for
use by authorized health care personnel in emergency kits/carts, provided such kits/carts
meet the following requirements:

1. Storage

Emergency kits/carts shall be stored in limited-access areas and sealed with a


disposable plastic lock to prevent unauthorized access and to insure a proper
environment for preservation of the medications in them.

2. Labeling - Exterior

The exterior of emergency kits/carts shall be labeled so as to clearly and


unmistakably indicate that it is an emergency drug kit/cart and is for use in
emergencies only.

3. Labeling Interior

All medications contained in emergency kits/carts shall be labeled in


accordance with the name of the medication, strength, quantity, lot # and
expiration date.

Emergency Protocol, Policy and Guidelines 13.1


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

4. Removal of Medications

Medications shall be removed from emergency kits/carts only pursuant to nurse


protocol/procedure, by authorized clinic personnel or by a pharmacist.

5. Inspections

Each emergency kit/cart shall be opened and its contents inspected by the
authorized personnel monthly with the exception of oxygen (every 6 months).
The monthly inspection shall be documented on an Emergency Check-Off Log
sheet which includes:
a. the listing of all emergency supplies and equipment,
b. the name of the medication(s), its strength, quantity, lot # and expiration
date,
c. the staff members name who performed the inspection and
d. the inspection date.

Upon completion of the inspection, the emergency kit/cart shall be resealed with
the appropriate disposable plastic key.

6. Minimum Medication(s)

a. Epinephrine 1:1000, 1 mL (2 ampules)


b. Diphenhydramine 50 mg/mL (2 ampules)
c. Diphenhydramine elixir/solution 12.5 mg/5 mL (1 bottle)
d. (Optional) Diphenhydramine HCl 25,50 mg caps (1 bottle of each)
e. Methylprednisolone 125 mg (2 vials)
f. Portable oxygen (generally administered by nasal cannula in situations of
chest pain or difficulty breathing at 5 L/min, at 2 L/min if patient has
history of emphysema or chronic lung disease)

7. Minimum Supplies

a. Blood pressure cuffs (adult and child)


b. Stethoscope
c. Flashlight/extra batteries
d. Copy of emergency protocols/procedures
e. Allergic Reaction/Acute Anaphylaxis Record
f. Bag-valve-mask (AMBU) for resuscitation (adult and child)
g. Copy of initialed current Monthly Checklist of Drugs and Supplies
h. Nasal cannula for oxygen administration
i. Needles and syringes
j. Filter needles, 5 micron, for use when aspirating a medication from a
glass ampule, to reduce contamination

Emergency Protocol, Policy and Guidelines 13.2


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

8. Recommended Additional Supplies


(For use where additional protocol/procedures and trained personnel are
available)
a. IV needles/infusion sets
b. IV fluids (normal saline is recommended)
c. Gauze pads, tape
d. Epinephrine 1:10,000 for IV use
e. Oral airways (Adult/Child)
f. Pulse-oximeter
g. Automated external defibrillator (AED)

Emergency Protocol, Policy and Guidelines 13.3


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

GUIDELINES FOR
VASOVAGAL SYNCOPE (FAINTING)

DEFINITION AND ETIOLOGY


Syncope (fainting) is a transient vascular/neurogenic reaction marked by pallor, nausea,
sweating, bradycardia, and rapid fall in arterial blood pressure which, when below a critical
level, results in loss of consciousness. Vasovagal syncope usually occurs in the upright
position and is often preceded by warning symptoms (e.g., nausea, dizziness, weakness,
yawning, apprehension, visual blurring, sweating).

Vasovagal syncope is usually due to emotional stress related to fear or pain (e.g., having
blood drawn or an injection).

OBJECTIVE
The following may be observed:
1. Fall in blood pressure.
2. Slow pulse.
3. Pallor, perspiration.
4. May progress to loss of consciousness.

PROCEDURE
1. Place client in recumbent position; lower head to the extent possible and turn head
to side (prevents aspiration and tongue blocking airway). If sitting, do not lower
head by bending at waist (may further compromise venous return to heart).

2. Loosen any tightly-fitting clothing at neck/waist.

3. Monitor blood pressure and pulse; observe the client until completely recovered.

4. Do not give anything by mouth or allow the client to resume an upright position until
feeling of weakness has passed.

5. Suggest that the client be accompanied when leaving the clinic.

6. If client does not stabilize, call EMS or refer to closest medical facility.

Emergency Protocol, Policy and Guidelines 13.4


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

REFERENCES

1. Anthony S. Fauci et al., Harrisons Principles of Internal Medicine, 17th ed.,


McGraw-Hill Companies, Inc., 2008, Chapter 21, Syncope,
<http://www.accessmedicine.com/content.aspx?aID=2890809> (April 23, 2009).
2. Mark H. Beers, The Merck Manual of Diagnosis and Therapy, 18th ed., 2006, Chapter
16, Cardiovascular Disorders, Syncope,
< http://www.merck.com/mmpe/sec07/ch069/ch069e.html> (April 28, 2009).
3. C. K. Stone and Margaret Strecker-McGraw, Diagnosis & Treatment: Emergency
Medicine, 6th ed., 2007, Chapter 16, Syncope,
<http://www.accessmedicine.com/content.aspx?aID=3100314> (April 23, 2009).

Emergency Protocol, Policy and Guidelines 13.5


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

STANDARD PROTOCOL AND PROCEDURES FOR


ALLERGIC REACTIONS, INCLUDING ACUTE ANAPHYLAXIS
IN ADULTS, INFANTS AND CHILDREN

DEFINITIONS Allergic reactions that are potentially life-threatening (anaphylactic)


reactions, after exposure to an antigen which has been injected, ingested
or inhaled.

Reactions range from mild, self-limited symptoms to rapid death:

1. Mild to moderate allergic reactions involve signs and symptoms of


the gastrointestinal tract and skin. Observing the client for rapid
increase in severity of signs and symptoms is important, as the
sequence of itching, cough, dyspnea and cardiopulmonary arrest
can lead quickly to death.

2. Severe/anaphylactic reactions involve signs and symptoms of the


respiratory and/or cardiovascular systems. These may initially
appear minor (i.e., coughing, hoarseness, dizziness, mild
wheeze) but any involvement of the respiratory tract or circulatory
system has the potential to rapidly become severe. Death can
occur within minutes. Therefore, prompt and effective treatment is
mandatory if the clients life is to be saved.

ETIOLOGY Agents commonly associated with allergic reactions/anaphylaxis, include:


1. Antibiotics (especially penicillin).

2. Biologicals (non-human sera, gamma globulin, vaccines, blood


and blood products).

3. Local anesthetics.

4. Hymenoptera stings (bee, yellow jacket, wasp, hornet, fire ants).

5. Allergy extracts (skin-testing and treatment solutions).

6. Foods (especially eggs, nuts and shellfish).

7. Intravenous narcotics (heroin).

8. Alternative medicines (e.g., herbal or home remedies).

9. Environmental agents (e.g., pollens, grasses, molds, smoke,


animal dander).

SUBJECTIVE & 1. In 1-15 minutes clients may develop:

Emergency Protocol, Policy and Guidelines 13.6


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

OBJECTIVE a. Apprehension.
b. Flushing and/or skin edema.
c. Palpitations.
d. Numbness and tingling.
e. Itching.
f. Localized or generalized urticaria (rash, welts).
g. Choking sensation. (Indicates laryngeal edema which may
precipitate closure of the airway.)
h. Coughing and wheezing.
i. Difficulty breathing.
j. Nausea and vomiting.
k. Dizziness and fainting.

2. Severe respiratory compromise or shock may develop rapidly


with severe hypotension and vasomotor collapse.

ASSESSMENT Allergic reaction, severe (any respiratory or circulatory signs/symptoms;


anaphylaxis) to mild or moderate

PLAN THERAPEUTIC

1. Mild (minor) or Moderate Reactions (absolutely no respiratory


or circulatory signs)
Step 1 Diphenhydramine PO or IM
NOTE: Children younger than 2 years of age
should receive diphenhydramine only under the
direction of a physician.

For itching, redness, welts/hives without respiratory or circulatory signs or gastro-


intestinal symptoms of cramplike pain with nausea, vomiting or diarrhea.

Diphenhydramine Oral Dosing


12.5 mg/5 mL elixir/solution,
OR
25 mg or 50 mg capsules

Child older than 2 years of age: 1.25 mg/kg/dose (max 50mg) PO STAT
Adult: 50 mg to 100 mg PO STAT

Diphenhydramine IM Dosing
1 mg/kg body weight, up to 100 mg

Emergency Protocol, Policy and Guidelines 13.7


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

Diphenhydramine Oral Dosing Chart, Elixir/Solution (12.5 mg/5 mL)


Weight (kg) Diphenhydramine Oral Weight (kg) Diphenhydramine Oral
Elixir/Solution Dose (mL) Elixir/Solution Dose (mL)
9 4.5 mL 25 12.5 mL
10 5 mL 26 13 mL
11 5.5 mL 27 13.5 mL
12 6 mL 28 14 mL
13 6.5 mL 29 14.5 mL
14 7 mL 30 15 mL
15 7.5 mL 31 15.5 mL
16 8 mL 32 16 mL
17 8.5 mL 33 16.5 mL
18 9 mL 34 17 mL
19 9.5 mL 35 17.5 mL
20 10 mL 36 18 mL
21 10.5 mL 37 18.5 mL
22 11 mL 38 19 mL
23 11.5 mL 39 19.5 mL
24 12 mL 40 20 mL

OR
Diphenhydramine IM Dosing
(Dosing by body weight is preferred.)
(The standard dose is 1 mg/kg body weight,
up to 100 mg)
Weight* Diphenhydramine Dose
lbs (kg) (Injection: 50 mg/mL)
24-37 (11-17) 15 mg / 0.3 mL
37-51 (17-23) 20 mg / 0.4 mL
51-77 (23-35) 30 mg / 0.6 mL
77-99 (35-45) 40 mg / 0.8 mL
>99 (>45) 50 to 100 mg / 1 2 mL

Step 2 Complete Allergic Reaction Record


Step 3 Observe for 60 minutes
Step 4 If any respiratory or circulatory signs develop,
proceed to 2. below (Severe Reactions)
Step 5 If, after 60 minutes, the clients symptoms are
still limited to the skin and the client is
comfortable, then:
a. Tell client to take diphenhydramine every
6 hours as long as any signs/symptoms
are present.
b. Inform the client that he/she has an
apparent allergy to the causative agent
and advise that this information should be
provided to all healthcare givers in the

Emergency Protocol, Policy and Guidelines 13.8


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

future.
c. If the causative agent was a medication
being dispensed for additional use at
home, then this plan should be
reconsidered and an alternative
medication should be used that is in a
different chemical family which is not
regarded as having cross-reactivity with
the causative agent.
NOTE: Skin reactions that are extensive, but absolutely
confined to the skin, do not qualify as severe allergic
reactions; however, if tongue swelling is involved, this does
represent an anaphylactic reaction if present, proceed to 2.
below. Severe lip swelling (huge, bordering on grotesque)
may indicate additional swelling in the oropharynx if
present, proceed to 2. below.

2. Severe Reactions (remember, severity is defined by the


presence of any respiratory or circulatory signs/symptoms,
e.g., wheezing, laryngeal edema [stridor], hypotension,
whether these be mild, moderate or severe in themselves,
OR tongue swelling or severe lip swelling).

Step 1 Call for HELP


a. Have someone call EMS/911 and/or the
physician.
b. Assign one person to keep the anaphylaxis
record and be the timekeeper.
c. Do not leave the client unattended!

Step 2 If the client received an immunization, apply a


tourniquet above the injection site, if possible, to
reduce systemic absorption of the antigen.

Step 3 Procedures
a. Place patient in supine POSITION, legs
elevated.
b. Assure OPEN AIRWAY and begin CPR if
indicated.
c. Begin monitoring VITAL SIGNS with BP every
5 minutes.
d. Help to maintain position of comfort (sitting if
wheezing; supine with legs elevated if light-
headed or in shock).
e. Oxygen at 4-6L/minute by nasal cannula, face

Emergency Protocol, Policy and Guidelines 13.9


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

mask
OR
blow-by, if indicated and available.
f. Monitor with pulse-oximeter, if available.

Step 4 Administer epinephrine


NOTE: Administer into thigh (more effective at
achieving peak blood levels than into deltoid
area).
Epinephrine IM Dosing
(Dosing by body weight is preferred; the standard dose is 0.01 mg/kg body weight [including
for low birth weight babies], up to 0.5 mg.)
Weight* Epinephrine IM Dose
lbs (kg) (1mg/ml=1:1,000 wt/volume)
<9 (<4) Weigh baby and calculate appropriate dose
9-15 (4-7) 0.05 mg/0.05 mL
15-24 (7-11) 0.10 mg/0.10 mL
24-31 (11-14) 0.13 mg/0.13 mL
31-37 (14-17) 0.16 mg/0.16 mL
37-42 (17-19) 0.18 mg/0.18 mL
42-51 (19-23) 0.20 mg/0.20 mL
51-77 (23-35) 0.30 mg/0.30 mL
77-99 (35-45) 0.40 mg/0.40 mL
>99 (>45) 0.50 mg/0.50 mL
May repeat every 15-20 minutes PRN for a total of 3 doses
(<1.5 mL [1.5 mg] total)

Step 5 Give corticosteroid (methylprednisolone) to decrease


the incidence and severity of delayed reactions.
Corticosteroids may not influence the acute course
of the reaction; therefore, they have a lower priority
than epinephrine.
Methylprednisolone Sodium Succinate IM Dosing
(Dosing by body weight is preferred.)
(The loading dose is 2 mg/kg/dose, then 1mg/kg body weight every 6 hours for up to 5 days)
Weight* Methylprednisolone Sodium Succinate Loading Dose
lbs (kg) (Injection: 125mg/2mL)
<9 (<4) Weigh baby and calculate appropriate dose
9-15 (4-7) 14 mg / 0.22 mL*
15-24 (7-11) 22 mg / 0.35mL*
24-37 (11-17) 34 mg / 0..54 mL*
37-51 (17-23) 46mg / 0.74 mL*
51-77 (23-35) 70 mg / 1.12 mL*
77-99 (35-45) 90 mg / 1.44 mL*
>99 (>45) Weigh and calculate appropriate dose

* based on maximum weight in category

Emergency Protocol, Policy and Guidelines 13.10


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

Step 6 Assure that the Allergic Reaction/Anaphylaxis


Record (see pp. 13.11-13.12) has been completed
and a copy given to EMS personnel before they
transport the client.

CLIENT EDUCATION/COUNSELING
When a client is given an agent (e.g., antibiotic or vaccine) capable of
inducing anaphylaxis, he/she should be advised or encouraged to remain
in the clinic for at least 30 minutes.

REFERRAL

1. Immediately refer clients with wheezing, laryngeal edema,


hypotension, shock or cardiovascular collapse.

2. Refer to primary care provider for further evaluation those clients


with itching, redness welts/hives.

FOLLOW-UP

1. Place an allergy label on the front cover of the clients medical


record.

2. Educate the client/caretaker about medical alert bracelets for


anaphylactic reactions.

3. If the allergic reaction is immunization-induced, complete a


vaccine adverse event record (VAERS).

Emergency Protocol, Policy and Guidelines 13.11


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

ALLERGIC REACTION / ANAPHYLAXIS RECORD page 1

District/Clinic Site __________________________________________ Date _________________

Client Demographic Information:

Name: ______________________________________

DOB _____/_____/_____ AGE ________ months / years

Estimated/Actual Weight (please circle one) Infant / Child / Adult _____lbs/kg

Event which preceded reaction:


_____ Immunization
_____ Medication administered
_____ Biologicals administered
_____ Other: (please explain) ________________________________________________

TIME OF REACTION: ______ AM / PM TIME EMS CALLED: ______ AM / PM

Signs and Symptoms: (please check)


_____ Apprehension _____ Choking sensation
_____ Flushing and/or skin edema _____ Coughing/hoarseness/wheezing
_____ Palpitations _____ Difficulty breathing
_____ Numbness and tingling _____ Nausea and vomiting
_____ Itching _____ Severe hypotension
_____ Localized or generalized urticaria _____ Vasomotor collapse
(rash, welts) _____ Loss of consciousness

Other (e.g., dizziness): ___________________________________________________________

OTHER OBSERVATIONS / COMMENTS: _____________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

SIGNATURE OF RN/APRN:
__________________________________________________________

DISPOSITION: __________________________________________________________________

REVIEWER: ____________________________________________________________________

NOTE: Send copies of both pages of this record with client


referred to a physicians office or hospital

Emergency Protocol, Policy and Guidelines 13.12


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

ALLERGIC REACTION / ANAPHYLAXIS RECORD page 2

1. Call for HELP.


Have EMS called. Client Name:___________________________
Assign timekeeper/recorder.

DOB:_________________
2. Assure AIRWAY.
Check VITAL SIGNS q 5 minutes.
CPR if necessary. VITAL SIGNS
Time B/P Pulse Resp
_____ _ __/_ __ ____ __
3. FOR ITCHING, REDNESS, WELTS/HIVES OR GI SYMPTOMS: _____ _ __/_ __ ____ __
Diphenhydramine 12. 5 mg/5 mL Elixir OR _____ _ __/_ __ ____ __
Diphenhydramine 25 mg or 50 mg Capsules _____ _ __/_ __ ____ __
_____ __ _/_ __ ____ __
CHILD at least 2 years of age _____ __ _/_ __ ____ __
1.25 mg/kg/dose (up to 50 mg) PO, once _____ __ _/_ __ ____ __
ADULT 50-100 mg PO, STAT
OR
Diphenhydramine 50 mg/mL (vial) IM CPR Indicated: ________YES ______NO
TIME CPR started:__________AM / PM
WEIGHT IM DOSE
TIME CPR ended: __________AM / PM
24-37 lbs (11-17 kg) 15 mg / 0.3 mL
37-51 lbs (17-23 kg) 20 mg / 0.4 mL
51-77 lbs (23-35 kg) 30 mg / 0.6 mL
Diphenhydramine
77-99 lbs (35-45 kg) 40 mg / 0.8 mL
12.5 mg/5 mL (Elixir/Solution)
>99 lbs (>45 kg) 50 mg to 100 mg/1 -2 mL
OR 25 mg, 50 mg (Capsules)
TIME ORAL DOSE
4. FOR RESPIRATORY/CIRCULATORY SIGNS/SYMPTOMS
_______ ________
_______ ________
Epinephrine 1 mg/mL = 1:1,000 wt/volume (w/v)
WEIGHT IM DOSE
< 9 lbs (< 4 kg) Weigh/calculate dose
Diphenhydramine 50 mg/mL vial
9-15 lbs (4-7 kg) 0.05 mg / 0.05 mL TIME IM DOSE
15-24 lbs (7-11 kg) 0.10 mg / 0.10 mL
24-31 lbs (11-14 kg) 0.13 mg / 0.13 mL _______ ________
31-37 lbs (14-17 kg) 0.16 mg / 0.16 mL
37-42 lbs (17-19 kg) 0.18 mg / 0.18 mL
42-51 lbs (19-23 kg) 0.20 mg / 0.20 mL Epinephrine 1:1000 w/v ampule
51-77 lbs (23-35 kg) 0.30 mg / 0.30 mL
TIME DOSE ROUTE
77-99 lbs (35-45 kg) 0.40 mg / 0.40 mL
>99 lbs (>45 kg) 0.50 mg / 0.50 mL _______ ________ IM
_______ ________ IM
May repeat every 15-20 minutes as needed, for a total of 3 doses (no _______ ________ IM
more than 1.5 mL [1.5 mg] total).
Methylprednisolone Sodium Succinate IM
TIME DOSE ROUTE
AND, to decrease intensity/severity of delayed reactions
_______ IM
Methylprednisolone Sodium Succinate 2 mg/kg IM
(according to dosing table on p. 13.10).
TIME EMS ARRIVED:___________AM/PM

Emergency Protocol, Policy and Guidelines 13.13


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

REFERENCES

1. K. F. Austen, Harrisons Principles of Internal Medicine, 17th ed., 2008, Chapter


311, Allergies, Anaphylaxis, and Systemic Mastocytosis,
<http://www.accessmedicine.com/content.aspx?aID=2858746> (April 23, 2009).
2. Lexi-Comp Online, Lexi-Comp, Inc., 2009 <http://online.lexi.com> (April 22,
2009).
3. American Pharmaceutical Association, American Hospital Formulary Service, 2009,
pp.17-20, 1389-1395.
4. Karen M. Burke, Priscilla LeMone, Elaine L. Mohn-Brown and Linda Eby,
Trauma or Critical Illness, Medical-Surgical Nursing Care, 2nd ed., 2007, Chapter
13, Caring for Clients Experiencing Shock,
<http://online.statref.com/document.aspx?fxid=187&docid=149> (April 28, 2009).
5. Mark Boguniewicz, Ronina A. Covar and David M. Fleischer, Diagnosis &
Treatment: Pediatrics, 19th ed., 2008, Chapter 36, Allergic Disorders,
<http://www.accessmedicine.com/content.aspx?aID=3409411> (April 23, 2009).
6. Richard S. Krause, M.D., Anaphylaxis, Department of Emergency Medicine, State
University of New York at Buffalo School of Medicine,
<http://www.emedicine.com/emerg/topic25.htm#target1> (April 28,2009).
7. Brian H. Rowe and Stuart Carr, J.E. Tintinalli, G.D. Kelen, J.S. Stapczynski, O.J.
Ma and D.M. Cline, Tintinallis Emergency Medicine: A Comprehensive Study
Guide, 6th Edition, 2004, Chapter 34, Anaphylaxis and Acute Allergic
Reactions, <http://www.accessmedicine.com/content.aspx?aID=588677> (April
23, 2009). (Current)

Emergency Protocol, Policy and Guidelines 13.14


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

POLICY FOR REVIEWING EMERGENCY PROTOCOLS/


PROCEDURES IN PUBLIC HEALTH CLINIC SITES

A review of emergency protocol/procedures shall be completed at least once annually


at each clinic site. The Nursing Supervisor shall arrange for the annual review and
completion of the attached checklist.

Staff member(s) listed below participated in training updates for all age ranges and
performed in a mock emergency drill on .
(Date)

District Health Director:

Printed Name______________________________

Signature__________________________________ Date

District Public Health Nursing and Clinical Director:

Printed Name_______________________________

Signature__________________________________ Date

Name(s) of Staff Member(s)

Emergency Protocol, Policy and Guidelines 13.15


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

EMERGENCY CHECKLIST
FOR PUBLIC HEALTH CLINIC SITES

PURPOSE
To assure that each site is equipped and prepared to handle emergencies that may occur.
The Nursing Supervisor and District Public Health Nursing & Clinical Director will assure that
this checklist is completed annually for each site and that follow-up occurs for any
inadequacies/incomplete areas.

# EMERGENCY ITEM Complete/ Incomplete/ Comments


Adequate Inadequate
1. Emergency numbers posted on each
phone
2. Exits clear
3. Hallways clear
4. Staff able to describe action to take in
case of emergency
5. Staff demonstrates use of anaphylaxis
equipment
6. Emergency tray stored in secured
area except during clinic hours
7. Emergency tray stocked according to
district protocol for anaphylaxis
8. All staff trained in emergency
procedures and certified in CPR
(every 2 years)
9. Practice emergency drill(s) conducted
and documented at least annually.
NOTE: Drills should include age-
group variations (i.e., adults, infants
and children.)

County______________________

Nursing Supervisor: Printed Name ____________________________________

Signature _____________________________________

Date of Review: _______________ Date Corrected: __________________

District Public Health Nursing


& Clinical Director: Printed Name ____________________________________

Signature _____________________________________

Emergency Protocol, Policy and Guidelines 13.16


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

EVALUATION TOOL FOR PRACTICE DRILL

A. Response Team Yes No

1. Team effort utilized and well-coordinated. ________ ________

2. Response team timely. ________ ________

3. Client assessment complete. ________ ________

4. Code Blue* called. ________ ________

5. Emergency Medical Services/


physician notified. ________ ________

6. Emotional support provided to significant


others, if applicable. ________ ________

B. Client Outcome

1. Level of consciousness assessed. ________ ________

2. Vital signs monitored. ________ ________

3. Appropriate drugs given. ________ ________

4. CPR instituted, if applicable. ________ ________

5. EMS/physician responded. ________ ________

6. Documentation complete. ________ ________

C. Recommendations/Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Site__________________________________ Date___________________

Evaluator: Printed Name _______________________________________

Signature _______________________________________

*Though Code Blue is not specified in the anaphylaxis protocol/procedures,


it should be used to signal the emergency.

Emergency Protocol, Policy and Guidelines 13.17


Division of Public Health
Standard Nurse Protocols for Registered Professional Nurses
for 2010

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Emergency Protocol, Policy and Guidelines 13.18