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Abdominal Pain Criteria

Objective of
Observation
Inclusion Criteria 1. Stable VS
2. Ancillary Signs/Sx - anorexia, N&V, fever, elevated WBC
3. Negative pregnancy test
4. Non-surgical abdomen
5. High likelihood (~70%) of discharge within 15 hours

Exclusion Criteria 1. Unstable VS (HR >110, SBP<100, RR > 22)


2. Immunocompromised patient (T-cells < 200, chemo,
transplant)
3. Pregnant pt (any gestation)
4. Bowel obstruction (even partial) or ileus
5. Cholecystitis (sonographic Murphy, pericholecystic fluid, GB
wall thickening>4mm, or dilated CBD)
6. Surgical abdomen - free air, rigidity, rebound tenderness
7. Hx of frequent ED visits for abdominal pain suspected
habitual patient / narcotic abuse

Available 1. Analgesics
Interventions 2. NPO, IV hydration, repeat CBC
3. Imaging studies as indicated (i.e. CT abd / pelvis,
ultrasound)
4. Serial VS
5. Serial exams Q2-4 hours while awake and as indicated
6. Surgical consultation as needed

Discharge Criteria 1. Pain and / or tenderness resolved or significantly improved


2. VS acceptable
3. No diagnosis requiring hospitalization

Admission Criteria 1. Persistent vomiting


2. Pain not resolving or worsening
3. Unstable VS
4. Clinical condition or positive testing that merits
hospitalization
5. Consultant preference
6. Surgical abdomen
Allergic Reaction Criteria
(Non
Anaphylaxis)
Objective of
Observation
Inclusion Criteria 1. Response to therapy in the ED
2. Erythroderma, urticaria, or angioedema not involving airway
3. Minimum 2-hours of stability or improvement in ED after
treatment

Exclusion Criteria 1. Hypotension (SBP <100), tachycardia > 110


2. O2 saturation consistently < 94% on room air
3. Suspicion of acute coronary syndrome
4. Stridor, respiratory distress, hoarseness
5. IV pressors required

Available 1. IV fluids as needed


Interventions 2. Frequent rechecks and documentation of clear airway
3. Antihistamines, corticosteroids
4. Cardiac monitoring (if indicated)
5. Inhaler or nebulizer treatments (if indicated)
6. Pulse oximetry
7. Repeat doses of SC epinephrine

Discharge Criteria 1. Resolution or improvement in clinical condition


2. Stable VS

Admission Criteria 1. Delayed worsening


2. Persistent wheezing or stridor
3. Inadequate response to therapy during observation
4. Inability to take po medications
5. Abnormal vital signs: SBP < 100mm or RR > 24/min or
hypoxia
Asthma Criteria
Objective of
Observation
Inclusion Criteria Alert and oriented, acceptable VS
Intermediate response to therapy - improving but still wheezing
PEFR (peak flow) 40-70% predicted (or personal best) after 2
agonists
2 agonist nebs (2 treatments or 10 mg albuterol) + steroids
given in ED
Minimum ED treatment time > 2 hours
Chest X-ray with no acute findings (pneumonia, pneumothorax,
CHF)
Exclusion Criteria Unstable VS or clinical condition - severe dyspnea, confusion,
drowsiness
Poor response to initial ED treatment:
Persistent use of accessory muscles, RR>40, or excessive effort
Elevated pCO2 (>50) plus decreased pH if ABG done
O2Sat < 92% on room air, unless documented chronic hypoxia
PEFR* < 40% predicted or personal best
Suspicion of ACS, new onset CHF, pneumonia
Available Serial treatments with nebulized 2 agonist and ipratropium
Interventions IV Magnesium Sulfate as needed.
Frequent reassessment. BNP if needed.
Systemic steroids (PO or IV)
Pulse oximetry, ABG, and oxygen with cardiac monitoring as
needed
Discharge Criteria Acceptable VS HR <100, RR <20 after ambulation (if able)
Pulse Ox >95% on RA (or return to baseline)
Resolution of bronchospasm or return to baseline status
PEFR > 70% predicted (or 70% personal best) if reliable
reading
Admission Criteria Progressive deterioration in clinical status or VS
Failure to resolve bronchospasm within 15 hours
Persistent PEFR < 70% of predicted (if reliable)
Hypoxic despite therapy, if not chronic state
Atrial Fibrillation Criteria
Objective of
Observation
Inclusion Criteria 1. Stable BP, HR under 110 consistently for one hour (with
treatment)
2. No chest pain with rate controlled
3. Normal chest X ray
4. No evidence of acute comorbidities - MI, CHF, PE, CVA,
etc.
5. Onset clearly less than 48 hours
6. Rhythm conversion drugs given prior to CDU (i.e.
propafenone 450mg PO if no CHF)
7. Cardiologist agrees with plan to observe (if notified)
Exclusion Criteria 1. HR not controlled under 110 with ED meds
2. IV vasoactive drips required (ie diltiazem)
3. Hemodynamically unstable i.e. BP
4. Ongoing ischemic chest pain after rate control
5. Acute comorbidities - Evidence of Acute MI, CHF, PE,
Sepsis, CVA / embolic event,
6. Recent comorbidities - Stroke/TIA within 3 months, Acute MI
within 4 weeks.
7. Chronic Atrial Fibrillation. Onset over 48 hours or unknown
8. Cardiologist or Primary Care physician chooses inpatient
admission
Available 1. Cardiac monitoring, pulse oximetry
Interventions 2. Vitals Q 2 hours for 6 hours, then Q4 hours
3. Anticoagulate if not contraindicated - PO ASA (325 mg ) or
subQ heparin (LMWH or UFH)
4. Rate control Options - Oral Cardizem, Verapamil, or beta
blockers
5. Testing - Serial tropoins, and ECGs at 2 and 6 hour from 1st
ED blood draw
6. TSH, 2D Echocardiogram if indicated
7. Educate patient on cardioversion (medical or electrical) if
initial obs treatment fails within 12 hours. Electrical
cardioversion to occur outside of the CDU
8. NPO at 12 hours from arrival in Observation Unit if not
spontaneously converted
Discharge Criteria 1. Patient converts and remains in NSR for over one hour
2. Negative diagnostic testing
3. Stable condition
4. Discuss home medication therapy with cardiologist
Admission Criteria 1. Failure to maintain control of rate under 100
2. Positive diagnostic testing ( as indicated for MI, PE, CHF,
etc.)
3. Unstable condition
Blunt Abdominal Criteria
Injury
Objective of
Observation
Inclusion Criteria 1. Cooperative patient with stable vital signs (RR>8 or <24,
SBP>100, P>60 or <110)
2. No Peritoneal Signs
3. Negative initial imaging studies (i.e. CT)
4. Pertinent lab results acceptable (e.g., Hgb)
5. Surgery consult documented
Exclusion Criteria 1. Uncooperative patient, patients requiring restraints
2. Impending alcohol withdrawal syndrome
3. ETOH estimated >200 mg/dL at transfer
4. Pregnancy >20 weeks
5. Abnormal vital signs (above)
6. CT scan not done or significant acute abnormality
Available 1. NPO initially, advance per physician
Interventions 2. Repeat Hct q 4-6 hours (if pertinent to patients
management)
3. Serial abdominal examinations (e.g. q 4 hours)
4. If indicated by physician, serial ultrasounds
5. Immediate reevaluation by ED physician or surgeon if
patient develops:
6. Significant vomiting
7. Increasing abdominal pain
8. Increased tenderness on serial abdominal exams
9. Worsening vital signs: Decreased BP, increased HR, fever
Discharge Criteria 1. Patient is ambulatory
2. Serial abdominal exams essentially negative
3. Repeat labs reviewed and stable(Specifically any Hb drop?)
4. Vital signs reviewed and stable
5. Patient able to tolerate PO
6. Appropriate follow-up established
7. Surgery agrees with disposition
Admission Criteria
Cellulitis Criteria
Objective of 1. The point of observing cellulitis is less about making it
Observation clinically improve, but rather making sure the patient doesn't
clinically worsen
Inclusion Criteria 1. Serial exams needed to exclude rapidly progressive cellulitis
2. Cellulitis which requires > 1 dose antibiotics
3. Temp < 40.C, WBC < 16,000 and WBC >4,000.
4. Cellulitis with a drained abscess which requires a brief
period of observation and wound care
Exclusion Criteria 1. Septic or toxic patients clinical appearance, evidence of
severe sepsis (Temp >40, SBP<100, RR>22, HR>100,
*acute organ dysfunction, lactate >4mmol/L )
2. Immunocompromized patients neutropenia, HIV,
transplant patients, ESRD/hemodialyisis patients, patients
on immunosuppressants or chemotherapy, post-
splenectomy patients.
3. High risk infections diabetic foot infections; infections
proximate to a prosthesis, percutaneous catheter or
*indwelling device; infections of the orbit or upper lip/nose,
neck; infections of >9% TBSA; extensive tissue sloughing;
suspicion of osteomyelitis or deep wound infection.
Available 1. Mark edges of cellulitis with indelible marker to monitor
Interventions progression
2. IV antibiotics - MRSA coverage as indicated (Vancomycin,
Bactrim, Clinda, Doxycycline)
3. Pertinent labs (CBC, glucose, blood or wound cultures
PRN)
Discharge Criteria 1. Improvement or no progression of cellulitis
2. Improved and good clinical condition (ie. No fever, good VS)
for 8 hrs.
3. Able to perform cellulitis care at home and take oral
medications
Admission Criteria 1. Increase in skin involvement
2. Clinical condition worse or not better (i.e. rising temp, poor
vitals)
3. Unable to take oral medications
4. Unable to care for wound at home, home care unavailable
Chest Injury Criteria
Objective of 1. Works best if most of the serious injury has been excluded
Observation prior to transfer

Inclusion Criteria 1. Blunt (typically MVC) or penetrating (superficial stab) chest


injury
2. Consultation with surgeon
3. Fewer than 3 rib fractures (excluding 1st or 2nd)
4. SBP >100, RR<24, O2Sat > 94% on 2L NC or less
5. CXR - absence of PTX, pulmonary contusion, wide
mediastinum
6. Negative Chest CT
7. Need for parenteral analgesia

Exclusion Criteria 1. Hemodynamic instability or hypoxia


2. Thoracic / Gen surg want to admit to floor or O.R.
3. Positive imaging studies - pneumothorax, pulmonary
contusion, wide mediastinum, pleural effusion, any vascular
injury
4. Acutely abnormal ECG (blocks / changes) or significant
arrhythmias
5. Other significant trauma - long bone fracture, head injury
6. Significant abdominal pain / tenderness

Available 1. Continuous cardiac and oxygen saturation monitor


Interventions 2. Analgesics
3. Incentive spirometry
4. Repeat CXR > 6 hours (or prn) after 1st CXR
5. Surgery consultation
6. Serial ECGs if suspicion for myocardial contusion

Discharge Criteria 1. Stable vital signs


2. No evidence of PTX, pulmonary contusion, pneumonia
3. Adequate oxygenation (pO2>94% or RA)
4. Pain controlled with oral medications
5. Adequate incentive spirometer performance if blunt injury

Admission Criteria 1. Abnormal vital signs HR>100, SBP<100, RR>22 despite


therapy
2. Poor incentive spirometer performance inadequate
pulmonary toilet
3. Intractable pain
4. Acute thoracic injury - PTX, pulmonary contusion,
pneumonia on repeat CXR
5. Hypoxia (<94%) on room air
Chest Pain Criteria
Objective of
Observation
Inclusion Criteria 1. ACS risk is low based on Reilly-Goldman(external link)
criteria
2. Chest discomfort is potentially due to cardiac ischemia
3. No acute ECG changes of ACS, negative initial troponin
(<0.04 or <0.15 if very low suspicion of ACS)
4. Acceptable vital signs

Reilly-Goldman Criteria:
Scoring : 1 point for each positive risk factor

1. EKG with ischemia or new infarction (either one below)


ST Elevation >1mm or pathologic Q waves in 2 or more
contiguous leads
Criteria not met if changes were present on prior EKG

2. Systolic Blood Pressure <100 mmHg (either one below)


Hypotensive reading at any point during the
emergency department stay

3. Congestive Heart Failure signs (either one below)


Rales heard above the bases bilaterally

4. Chest Pain worse than baseline Angina (either one below)


Known unstable Ischemic Heart Disease or
New post-infarction Angina or
Angina after a coronary revascularization procedure or
Pain similar to prior Myocardial Infarction

Interpretation of Reilly-Goldman Criteria


(with risk of major cardiac event in subsequent 30 days)

A. Very Low Risk (<1 %)


No risk factors
B. Low Risk (<5%)
Normal EKG and 1 or less risk factor
C. Moderate Risk (7%)
Normal EKG and 2 or more risk factors or
Suspected ischemia on EKG and 1 or less risk
factors
D. High Risk (18%)
Suspected MI on EKG or
Suspected ischemia on EKG and 2 or more risk
factors

Exclusion Criteria 1. Moderate to high risk criteria by Reilly / Goldman criteria


(Pain worse than usual angina or like prior MI, recent
*revascularization, SBP<110, rales above both bases).
2. New ECG changes consistent with ischemia
3. Positive troponin (>0.15) not known to be chronic
4. Stress test or cardiac imaging needed - but NOT available
while in the CDU
5. Chest pain is clearly not cardiac ischemia
6. Recent normal cardiac catheterization (no coronary
stenosis)
7. Private attending chooses hospital admission
Available 1. Continue saline lock, O2, cardiac and ST segment monitor,
Interventions nitrates prn, daily aspirin, and NO CAFFIENE if persantine
is planned, NPO six hours before stress test.
2. Serial Troponin I and ECGs at 2 and 6 hour from first ED
blood draw
3. No 6-hour level needed if negative provocative test done
after 2hr draw
4. 6 hour lab needed if positive delta (normal, but >50% rise)
between 1st two labs
5. Repeat EKG based on symptoms or ST monitor alert
show to CDU physician STAT
6. Stress testing and cardiac Imaging - if initial and 2 hour and
delta markers are negative
Discharge Criteria 1. Acceptable VS, stable symptoms, no serious cause of
symptoms identified
2. Normal serial cardiac markers and EKGs
3. Negative provocative test or cardiac imaging for ACS no
ischemic or reversible defects identified.
Admission Criteria 1. Unstable VS
2. Positive cardiac markers or EKGs
3. Positive provocative test ischemic or reversible perfusion
defect
4. CDU or personal physician discretion
5. Serious alternative diagnosis, e.g. PE, aortic dissection
COPD Criteria
Exacerbation
Objective of
Observation
Inclusion Criteria 1. Good response to initial therapy (-agonists, iaprotropium,
steroids).
2. No acute process on chest Xray (required)
3. Acceptable VS (PO2>90, HR<100, RR<24, SBP>100)
4. Alert and oriented
5. No indication of impending respiratory fatigue
Exclusion Criteria 1. Acute co-morbidities - Pneumonia, CHF, cardiac ischemia
2. Unstable VS or clinical condition
3. Acute confusion / lethargy, elevated pCO2 (if drawn) or
evidence of CO2 narcosis
4. Poor response to initial therapy
5. O2 sat < 85 on 2 L O2 after 5 mg aerosolized Albuterol
6. Persistent use of accessory muscles, RR>28 after initial
treatment
7. Estimated likelihood of discharge from observation unit is
less than 70%
Available 1. Serial treatments: -agonists Q2-4hr, iaprotropium Q6hr,
Interventions and steroids
2. Hydration, antibiotics if indicated
3. Pulse oximetry (continuous or q4hr), ABG if indicated
4. Supplemental oxygen as indicated
5. Reassessment Q4 hours
6. Cardiac monitoring, cardiac markers, ECGs, and BNP - as
needed
Discharge Criteria 1. Resolution of exacerbation or return to baseline status
2. Pulse-ox > 90% on room air or home FIO2, back to patients
baseline
Admission Criteria 1. Progressive deterioration in status, Unstable VS
2. Failure to resolve exacerbation within 18 hours
3. Co-existent pneumonia or CHF
4. Uncompensated pCO2 Retention
5. O2 sat < 90 % on room air or home FIO2
Deep Vein Criteria
Thrombosis
Objective of
Observation
Inclusion Criteria 1. Hemodynamically stable acceptable vitals, pulse ox.
2. No evidence of PE
3. No exclusion criteria, candidate for home Low Molecular
Weight Heparin (LMWH -Lovenox)
4. Labs - Normal PT, PTT, CBC, platelet count, and Cr.
5. Confirmed DVT (or suspected DVT with doppler not yet
available)
Exclusion Criteria 1. High likelihood of Pulmonary Embolism
2. Known hypercoagulable or bleeding disorder
3. High risk of bleeding complications e.g. active GI
bleeding, major surgery or trauma within 2wks, recent
intracranial bleed, recent head injury / tumor / AVM)
4. Social: unable to care for self or follow up, unable to obtain
outpatient LMWH, unable to follow up for outpatient
coumadin management.
5. Clinical conditions pregnancy, prosthetic heart valve, CRF
on HD, morbid obesity (>150kg)
Available 1. Venous imaging if not done in the ED
Interventions 2. Start LMWH (Lovenox)
3. Have patient give self first injection, or alternatively saline
practice injection
4. After heparin started, may give first dose of Coumadin 10
mg PO
5. Monitor at least 12hrs for bleeding or thrombo-embolic
complications
6. Consult pharmacist to review dosing and help arrange home
LMWH and coumadin for 5-7d
7. Nurse education: DVT, anticoagulation, signs/symptoms for
complications of DVT and anticoagulation
8. Patient to watch video and receive booklet.
Discharge Criteria 1. Acceptable VS, No clinical evidence of PE
2. Uncomplicated DVT (no thrombo-embolic or bleeding
events)
3. Adequate home care / support available
4. Outpatient follow up within 1-2 days for INR testing and
evaluation. Instruction for coumadin, LMWH, DVT, PE and
what to return for.
Admission Criteria 1. High risk DVT or PE identified
2. Unacceptable vital signs
3. Bleeding problems after anticoagulant
4. Home treatment not feasible
5. Physician discretion
Dehydration/ Criteria
Vomiting
/Diarrhea
Objective of
Observation
Inclusion Criteria 1. Acceptable VS
2. Mild to moderate dehydration
3. Self-limiting or treatable cause not requiring hospitalization
4. Mild to moderate electrolyte abnormalities
5. Evidence of dehydration vomiting / diarrhea, high BUN/Cr
ratio, orthostatic changes, poor skin turgor, high urine
specific gravity, hemoconcentration, etc.
6. Hyperemesis Gravidarum (Should consult Ob/Gyn prior to
transfer)
Exclusion Criteria 1. Dehydration is not clearly present
2. Unstable VS (hypotension, tachycardia, severe dehydration)
3. Cardiovascular compromise
4. Severe (>15%) dehydration
5. Severe electrolyte abnormalities
6. Associated cause not amenable to short term treatment:
bowel obstruction, appendicitis, bowel ischemia, DTs, DKA,
sepsis, etc.
Available 1. IV hydration (D5LR if hyperemesis gravidarum)
Interventions 2. Serial exams, monitor intake and output, vital signs
3. Antiemetic administration
Discharge Criteria 1. Acceptable VS
2. Resolution of symptoms, able to tolerate oral fluids
3. Normal electrolytes (if done)
Admission Criteria 1. Unstable VS
2. Associated cause found requiring hospitalization
3. Inability to tolerate oral fluids
Electrolyte Criteria
Abnormalities
Objective of Observe if only 1 electrlyte abnormality.
Observation 2 abnormalities do poorly in observation
Inclusion Criteria 1. Acceptable VS
2. Cause of electrolyte disturbance does not require
hospitalization
3. No co-moribidity requiring more prolonged hospitalization
4. Mild and rapidly correctable electrolyte abnormality
5. Hyperkalemia < 6.0 mEq/L, ECG with clear p-waves, at
most T-wave tenting, no QRS widening after >1 hour in the
ED
6. Hypokalemia > 2.5 mEq/L, with no ventricular ectopy on ED
monitoring for >1 hour.
7. Hyponatremia >120 mEq/L with normal mentation and a
reversible etiology (eg dilutional, drug-induced,
gastroenteritis, hyperemesis). Not psychogenic polydipsia,
SIADH
8. Hypernatremia < 155 mEq/L with normal mentation and
rapidly reversible etiology (e.g. NH patient with infection)
9. Hypercalcemia < 7.0 mEq/L (ionized) rapidly correctible
etiology
10. Hypocalcemia > 1.0 mEq/L (ionized), e.g. renal failure
11. Hypomagnesemia >2.0 mEq/L associated with other
electrolyte abnormalities
Exclusion Criteria 1. Unstable VS or cardiovascular compromise
2. Severe dehydration or severe electrolyte abnormalities (K
>6.0, K <2.5, Na >155, Na <120, iCa >7.0, iCa <1.0, Mg
<2.0)
3. Mental status changes
4. Associated cause not amenable to short term treatment:
bowel obstruction, appendicitis, bowel ischemia, DTs, DKA,
sepsis, some drug effects, etc.
5. Unlikely to be corrected within 15 hours
6. More than two acute electrolyte disturbances
Available 1. IV therapy (Normal saline for most) therapy targeting the
Interventions specific disorder, per CDU physician.
2. volume infusion for dialysis patients
3. Electrolyte replacement / correction, and repeat labs as
ordered by CDU physician
4. Serial vital signs and repeat clinical examination
Discharge Criteria 1. Acceptable VS
2. Resolution of symptoms, able to tolerate oral fluids
3. Improved electrolytes
Admission Criteria 1. Unstable VS
2. Associated cause found requiring hospitalization
3. Inability to tolerate oral fluids
Head Injury Criteria
Objective of
Observation
Inclusion Criteria 1. Normal CT scan of brain
2. Acceptable Vital Signs
3. Headache, dizziness, transient vomiting, transient amnesia
are acceptable
4. EtOH level <100 for intoxicated patients
5. Patients mentating clearly
Exclusion Criteria 1. Unstable VS
2. Abnormal CT Scan of brain
3. Depressed skull fracture
4. Penetrating skull injury
5. Focal neurologic abnormality or significant confusion
6. Uncooperative patient, restraints, or sitter required
7. Acute psychiatric disorder, suicidal patient
Available 1. Serial neurologic exams including vital signs every 2-4
Interventions hours, as ordered
2. Analgesics
3. Antiemetics
4. Neurosurgical consultation if indicated
5. Repeat CT scan as indicated
Discharge Criteria 1. Acceptable VS
2. Normal serial neurologic exams
Admission Criteria 1. Deterioration in clinical condition
2. Development of any exclusion criteria
Headache Criteria
Objective of
Observation
Inclusion Criteria 1. Persistent pain in tension or migraine headache
2. Hx of migraine with same aura, onset, location and pattern
3. Drug related headache
4. No focal neurological signs
5. Normal CT scan (if done)
6. If LP is needed, then it must be done and normal (unless
failed attempt and IR consult for LP arranged in ED
BEFORE transfer to CDU, and low risk patient).
Exclusion Criteria 1. Focal neurologic signs
2. Meningismus
3. Elevated intraocular pressure as cause (i.e. glaucoma)
4. Abnormal CT scan
5. Abnormal LP (if performed)
6. Hypertensive emergency (diastolic BP > 120 with
symptoms)
7. Suspected temporal arteritis
8. Blocked VP shunt
9. Frequent ED visits suspected habitual patient, narcotic
seeking behavior
Available 1. Serial exams including vital signs,
Interventions 2. Neuro checks: level of alertness, speech, motor function
3. Analgesics
Discharge Criteria 1. Resolution of pain
2. Other to take patient home
3. No deterioration in clinical course
Admission Criteria 1. No resolution in pain
2. Deterioration in clinical course
3. Rule in of exclusionary causes
Heart Failure Criteria
Objective of Only for previously diagnosed disease
Observation
Inclusion Criteria 1. Previous history of CHF
2. Acceptable VS: SBP >100, R < 32, HR <130
3. Pulse-ox >90 on room air after initial treatment,
correctable to > 92 on Oxygen by NC.
4. High likelihood of correction to baseline status within
24 hours with good home support
5. No acute co-morbidities (like pneumonia, atrial
fibrillation, altered mental status, etc.)
Exclusion Criteria 6. New onset CHF
7. Acute cardiac ischemia (EKG changes, positive
cardiac markers, ongoing ischemic chest pain,
unstable angina) or new arrythmias
8. Unstable VS after treatment (HR>130, SBP<85 or
>180, RR>32, Pox<92 on O2 by NC)
9. Acute co-morbidities - sepsis, pneumonia, new
murmur, confusion
10. Abnormal labs - Severe anemia (Hb<8), renal failure
(BUN>40 or Cr>3), Na<135
11. Patient requiring vasoactive drips, invasive or
noninvasive ventilation (bipap)
12. Evidence of poor perfusion (confusion, cool
extremity, weakness, N/V)
Available 13. Cardiac monitoring, strict Intake/Output, vital signs
Interventions Q4hr, weight on arrival
14. Oxygen per respiratory guidelines with pulse
oximetry (continuous or q4hours)
15. Serial EKGs, and cardiac markers (TnI, CK, and CK-
MB) - 3 and 6hrs from 1st lab draw.
16. Medication as indicated IV diuretics (home dose),
nitropaste, ACE Inhibitors, ASA
17. Repeat electrolytes q6 hours or prn
18. Echocardiography (if not done within 30d) and
cardiology consultation - as indicated
19. CHF education and smoking cessation education
Discharge Criteria 1. Subjective improvement no chest pain, orthopnea, or
exertional dyspnea above baseline
2. Acceptable VS (O2 sat at baseline or >94%, RR
<20HR<100, SBP >100 or baseline,).
3. Negative serial ECGs and cardiac markers, good
electrolytes, acceptable echo if done
4. Evidence of adequate diuresis 1L urine, decrease in
weight, decrease in JVD
5. CHF discharge checklist (ACEi, -blocker, HF/ diet/
smoking education, close followup)
Admission Criteria 1. New ischemic EKG changes, arrhythmia, cardiac markers,
or evidence of cardiac ischemia
2. Persistent hypoxia, rales, dyspnea
3. Poor response to therapy - Failure to improve subjectively
4. Poor home support
5. Physician judgment
Hyperemesis Criteria
Gravidarum
Objective of
Observation
Inclusion Criteria 1. Dehydration (mild to moderate)
2. Ketonuria
3. < 20 weeks pregnant
4. Stable vital signs
5. Ob/Gyn service or attending contacted & agrees
6. Minimally abnormal lab values that are correctable by IV
fluids
Exclusion Criteria 1. Pregnancy > 20 weeks
2. Unstable vital signs, severely abnormal lab values
3. Severely dehydrated
4. Urinary tract infection in pregnancy
Available 1. IV D5 LR or D5NS at 250 cc/hr until urine ketones clear,
Interventions then 150 cc/hr
2. Diet - ice chips advanced to clear fluids, dry diet when
tolerate fluids
3. Antiemetics: Zofran 4mg q6-hprn, Tigan 200mg IM q-6-h
prn, Compazine 5-10mg IV or IM q-6-h prn,
4. Dietary counseling
5. Disposition Criteria Rapid followup with OBGYN
Discharge Criteria 1. Stable vital signs, normal labs, urine ketones cleared
2. Taking oral fluids
3. Absence of significant nausea, no vomiting
Admission Criteria 1. Unstable vital signs
2. Uncorrected or worsening lab values
3. Unable to tolerate oral fluids
4. Private attending or EDP chooses admission
Hyperglcyemia Criteria
Objective of
Observation
Inclusion Criteria 1. Blood sugar > 300 & < 600 after ED treatment
2. Normal to near normal pH and total CO2 level
3. Readily treatable cause (e.g. non-compliance, UTI,
abscess)
Exclusion Criteria 1. New Onset or not previously diagnosed (exclusion as this
likely requires additional education resources)
2. DKA (pH <7.20, total CO2 <18, elevated serum acetone,
anion gap >18)
3. Hyperosmolar non-ketotic coma
4. Blood glucose > 600
5. Precipitating cause unknown or not readily treatable
6. Social issues precluding adequate outpatient
management

Available 1. IV hydration, 0.9NS at 150-250 cc/hr


Interventions 2. Bedside glucose q 2 hours until level < 300, then q 4 hours
3. Sliding scale insulin (see sliding scale guidelines)
4. Treat precipitating cause (antibiotics, I&D abscess, etc.)
5. Diabetic counseling
6. Repeat electrolytes q4hours until labs stable.
Discharge Criteria 1. Blood glucose < 250
2. Resolution of symptoms
3. Stable vital signs
4. Successful treatment of precipitating cause
5. Tolerating PO fluids
6. PCP follow up within 48 hours if new onset
7. Patient education materials: includes BG monitor, lancets,
strips, education video /book
Admission Criteria 1. Worsening symptoms
2. Unstable vital signs
3. Blood glucose remains > 250
4. Development of DKA
5. Unable to tolerate PO fluids
6. Poor candidate for home management
Hypertensive Criteria
Emergency
Objective of
Observation
Inclusion Criteria 1. Transfer Criteria
2. No evidence of acute end-organ injury
3. Acceptable VS
4. BP<250/130 after initial treatment
5. Normal mentation, normal head CT (only if done)
6. No acute ECG abnormalities, normal chest Xray, no acute
nephropathy (Cr, UA)
Exclusion Criteria 1. Evidence of end-organ injury: acute renal failure,
hypertensive encephalopathy, intracranial hemorrhage,
papilledema, focal neurologic abnormalities, CVA, CHF,
acute coronary syndromes, aortic dissection
2. Unstable VS
3. BP remains >250/130 after initial ED treatment
4. EKG changes not known to be old
5. Pregnancy
6. Continuous infusion required for control of BP
Available 1. Anti-hypertensive medications
Interventions 2. Give clonidine if clonidine withdrawal suspected
3. Treat secondary causes as indicated (pain, anxiety,
dehydration, etc)
4. Serial VS and neuro checks
5. Cardiac monitoring
6. Pulse oximetry as needed
7. Urine drug screen for cocaine if indicated
Discharge Criteria 1. Acceptable VS
2. BP < 200/110
3. No new symptoms
4. Outpatient treatment and follow-up arranged
Admission Criteria i. Development of any exclusion criteria
2. Symptoms worsen or persist
3. BP>200/110
Hypoglcyemia Criteria
Objective of
Observation
Inclusion Criteria 1. Blood sugar below 40 mg% pre Rx (if obtained) and 80 post
treatment
2. Symptoms resolved with administration of glucose
3. Type I or Type II Diabetes
4. Etiology determined (e.g. missed a meal)
Exclusion Criteria 1. Intentional overdosage of hypoglycemic medications
2. Use of long acting oral hypoglycemic agent such as diabeta
3. Insufficient change in symptoms with administration of
glucose
4. Fever, hypothermia (T < 35C or T > 38C)
5. D5-D10 drip required to maintain euglycemia
Available 1. Dietary food tray
Interventions 2. Serial exams and vital signs
3. IV hydration, K administration or electrolytes as indicated
4. Serial lab - repeat glucose Q2-4hr and as indicated
5. IV D-50 (or oral juice if alert) for hypoglycemia and
confusion notify physician
6. Diabetic counseling as needed
Discharge Criteria 1. Resolution of symptoms
2. Capable adult supervision
3. Bedside glucose over 80 mg%
4. Resolution of precipitating factor
5. Follow up with primary care
Admission Criteria 1. Deterioration of clinical signs
2. Persistent deficits in neurological status
3. Bedside glucose consistently < 80
Pneumonia Criteria
Objective of
Observation
Inclusion Criteria 1. History, exam, and CXR consistent with acute pneumonia
2. PORT score class <3 (if calculated)
3. O2 saturation >92 % on room air at the time of CDU
admission
4. Outpatient support and home capable of managing
pneumonia if discharged
5. Initial dose of antibiotics given in the ED
Exclusion Criteria 1. Persistantly abnormal vitals after ED treatment (O2
saturation <92% on RA, HR >120, SBP<100, RR >30, T<35
or >40 C)
2. Significantly abnormal ABG if done (pCO2>45, pH<7.35)
3. Potential respiratory failure
4. Multi-lobar pneumonia
5. Unlikely to be discharged in 24 hours, poor candidate for
outpatient therapy
6. Immunocompromised patients: HIV, PCP pneumonia,
chemotherapy, chronic corticosteroid use, active cancer,
sickle cell disease, asplenic patients.
7. High risk patients: Nursing home patient, cancer, cirrhosis,
ESRD, altered mental status, nosocomial etiology,
aspiration risk (ie. bulbar stroke)
8. High suspicion of DVT/PE, SARS, H1N1, or TB
(HIV/AIDS, institutionalized, recent prison, native of
endemic region, history of pulmonary TB, apical disease on
CXR)
Available 1. Antibiotics based on contemporary guidelines for
Interventions pneumonia
2. Supplemental oxygen and bronchodilator therapy as
needed. Steroids and indicated.
3. Analgesics as needed for pain, myalgias, or cough/sputum
4. Serial vital signs, cardiac and oxygen saturation monitoring
(continuous or intermittent)
5. Assistance with activities of daily living as needed
Discharge Criteria 1. Subjective and clinical improvement during CDU stay
2. Acceptable vital signs during observation period
3. Patient able to tolerate oral medications and diet
Admission Criteria 1. Patient not subjectively improved enough to go home
2. Lack of clinical progress or clinical deterioration.
3. Unable to safely discharge for outpatient management
4. Physician discretion
Pyelonephritis Criteria
Objective of
Observation
Inclusion Criteria 1. Acceptable vital signs and normal mentation
2. Clinical evidence of pyelonephritis (flank pain, urgency,
frequency, dysuria)
3. UA evidence of pyelonephritis (significant pyuria, nitrates,
and/or leukocyte esterase)
4. Not suitable for discharge from the ED
5. Urine cultures obtained
Exclusion Criteria 1. Male patients
2. Pregnant females
3. Abnormal VS after ED treatment (SBP <90, HR >120, T<35
or >40 C)
4. Mental status changes
5. Significant comorbidities diabetes, renal failure, sickle cell
disease
6. Immunosuppressed patients - HIV, transplant patients,
chronic high dose steroids, asplenic
7. Urinary tract anatomic abnormality (solitary kidney, reflux, or
indwelling device)
8. Urethral or ureteral obstruction (ie. kidney stones, urinary
retention)
9. Poor candidate for outpatient treatment of pyelonephritis (ie
poor home support)
Available 1. IV hydration, antiemetics, antipyretic
Interventions 2. IV antibiotics based on contemporary guidelines for
pyelonephritis
3. Advance to oral antibiotics, antiemetics, and analgesics as
tolerated
4. Imaging as needed (CT or ultrasound)
Discharge Criteria 1. Resolution or improvement of systemic symptoms
2. Ability to take po medications
3. Stable vital signs
4. Require followup , when and where.
Admission Criteria 1. Clinical deterioration or lack of adequate improvement
2. Inability to tolerate oral meds or hydration
3. Unstable vital signs or evidence of septic shock
4. Abnormal imaging (ureteral obstruction or emphysematous
pyelonephritis, solitary kidney)
Renal Colic Criteria
Objective of
Observation
Inclusion Criteria 1. Diagnosis of renal colic established by helical CT, IVP or
ultrasound
2. Uncomplicated stone
3. Persistent pain or vomiting despite medication
4. Acceptable VS
5. Urology resident notified
Exclusion Criteria 1. Unstable VS
2. Clinical evidence of a UTI (fever, significant pyuria on a cath
specimen)
3. Solitary kidney
4. Relative large proximal stone (>6 mm) with high grade
obstruction
5. Acute renal failure
Available 1. IV Hydration
Interventions 2. As needed - IV narcotics, IV ketolorac, IV antiemetics
3. Diagnostic tests as needed - Delayed IVP films, ultrasound,
CT
4. Serial exams and vital signs
5. Strain urine for stone capture and analysis, U/A if not yet
done
6. Urology consultation as needed.
Discharge Criteria 1. Acceptable VS
2. Pain and nausea resolved or controlled
3. Passage of stone
Admission Criteria 1. Persistent vomiting or uncontrolled pain after 14 hours
2. Diagnosis of coexistent infection or significant abnormality
3. Change in diagnosis requiring further therapy or workup
Seizures Criteria
Objective of
Observation
Inclusion Criteria 1. Past history of seizures with breakthrough seizure or
subtherapeutic anticonvulsant level
2. No seizure in last 2 hours
3. New onset seizures with a normal neuro exam, normal head
CT, and neurology agreement
4. Blood work: electrolytes, blood glucose, anticonvulsant
levels (if appropriate), UDS / tox labs (as indicated).
Exclusion Criteria 1. Ongoing seizures or postictal state
2. Persistent focal neurological findings (e.g. Todds paralysis)
3. Clinical suspicion of meningitis or new CVA
4. Delirium of any etiology, including alcohol withdrawal
syndrome / DTs
5. Seizures due to toxic exposure (e.g. theophyline or carbon
monoxide toxicity) or hypoxemia
6. Pregnancy beyond first trimester / eclampsia
7. New findings on head CT
8. New EKG changes or significant arrhythmias
Available 1. Appropriate anticonvulsant therapy
Interventions 2. Seizure precautions
3. Cardiac and oximetry monitoring
4. Serial (q 2-4 hours) neuro checks and vital signs
5. Toxicological testing PRN
6. EEG or consultation as indicated
7. NPO or liquid diet as indicated
8. Neurology consult if new onset seizures
Discharge Criteria 1. No deterioration in clinical status
2. Therapeutic levels of anticonvulsants PRN
3. Correction of abnormal labs
4. Resolution of post-ictal or benzodiazepine-related sedation
5. Appropriate home environment
Admission Criteria 1. Deterioration of clinical status, mentation, or neuro exam
2. Rule in for exclusionary causes
3. Inappropriate home environment
4. Recurrent seizures or status epilepticus
5. Not sufficiently alert for discharge after 18 hours observation
Supraventricular Criteria
Tachycardia
Objective of
Observation
Inclusion Criteria 1. Conversion to sinus rhythm in the ED, but requires a period
of observation
2. Stable BP, HR under 110 consistently for one hour
3. No chest pain with rate controlled
4. No clinical suspicion of MI, CHF, PE, CVA
5. Primary MD or cardiology consulted and in agreement
Exclusion Criteria 1. Ongoing SVT
2. Abnormal vitals - BP or HR not controlled in ED, Fever
(T>100.4)
3. Ongoing ischemic chest pain
4. Acute comorbidities ACS, CHF, PE, Sepsis, CVA, etc.
5. Primary or on-call MD chooses inpatient admission
Available 1. Continuous cardiac and ST segment monitoring
Interventions 2. Monitor vital signs
3. Rate control: - PO Verapamil, PO beta blockers
4. Potential tests: Serial cardiac biomarkers, TSH, cardiac
echo, stress test
Discharge Criteria 1. Patient converts and remains in NSR for over two hours
2. Negative biomarkers
3. Suitable clinical condition for discharge
4. Discuss home meds with MD who will manage F/U care
Admission Criteria 1. Failure to keep HR under 100
2. Positive workup for other conditions (e.g. ACS, PE)
3. Unstable clinical condition
Syncope Criteria
Objective of
Observation
Inclusion Criteria 1. Minimum ED interventions: ECG, monitor, stool
guaiac, orthostatics, IV, labs
2. No acute dyspnea or history of CHF
3. No acute EKG changes, bundle branch block, or
significant arrhythmias
4. Vital signs normal
5. No new neurologic deficits
Exclusion Criteria 1. Abnormal or unstable vital signs (HR <50 or >100,
SBP<100 or >200, pO2<94%, RR>24)
2. ECG: BB blocks {LBBB; RBBB+LAFB; RBBB+LPFB - esp
with 1st degree heart block}; Prolonged QTc (>500mS), new
*ECG ST/T wave changes
3. Significant cardiac arrhythmias (v. tach, a fib, bradycardia,
etc)
4. Serious cause suspected ACS, PE, GI Bleed, sepsis,
AAA, IC bleed, etc
5. History of CHF, major valvular disease, family history of
sudden death (<50)
6. Significant injury (eg fracture, subdural). Lacerations
acceptable.
7. New CT or lab abnormalities (if done)
8. Unsafe home environment
Available 1. Serial vital signs, cardiac and ST segment monitoring take
Interventions postural BP
2. Serial CBC, cardiac biomarkers
3. Appropriate IV hydration, diet
4. Additional selective workup (based on patient):
5. Cardiac workup possible 2-D echo, stress imaging, tilt
testing, holter event monitor, pacemaker evaluation, EP
consult
6. PE work up possible D-dimer, CT chest, venous doppler
7. Neuro workup possible serial neuro checks, HCT,
neurology consult, EEG
Discharge Criteria 1. Benign course, stable vital signs
2. No arrhythmia documented on review of cardiac monitor
history screens
3. Acceptable home environment
4. Follow up with possible, holter event monitor PRN
Admission Criteria 1. Deterioration of clinical course
2. Significant testing abnormalities
3. Unsafe home environment
Toxicologic Criteria
Exposure
Objective of
Observation
Inclusion Criteria 1. Non-Suicidal Patient
2. Stable VS and mentation
3. Overdoses should be limited to the following compounds:
Phenytoin, Oral sulfonylureas, acetaminophen, and warfarin
4. Snakebites or Black Widow envenomation NOT requiring
antivenom
Exclusion Criteria 1. Suicidal ingestions
2. Unstable VS
3. Altered mental status or combativeness
4. Evidence of organ dysfunction as a result of ingestion
5. Toxicology service not consulted
Available 1. Repeat drug levels
Interventions 2. Antiemetic support
3. IV fluids
4. Toxicology service re evalation
Discharge Criteria
Admission Criteria
Transfusion of Criteria
Blood Products
Objective of
Observation
Inclusion Criteria 1. Symptomatic anemia or thrombocytopenia
2. Deficiency correctable by transfusion
3. Stable vital signs with recent labs verifying need for
transfusion
Exclusion Criteria 1. Unstable vital signs
2. Active bleeding present unless transfusing platelets for
thrombocytopenia and patient stable
3. End stage renal failure, dialysis patients
4. Hgb <5
Available 1. IV started, Pre-medicate and IV hydration as needed
Interventions 2. Type and Crossmatch sent if not previously done
3. Transfuse only leukocyte-reduced red cells or platelets per
Nursing protocol Repeat CBC at least 2 hours following
transfusion
Discharge Criteria 1. Stable vital signs
2. Symptoms improved
3. No fever for 1 hour after 1 unit PRBC's or 1 dose of platelets
for 2 hours after 2 units PRBC's
4. No evidence of fluid overload or CHF
5. No evidence of transfusion reaction per Nursing protocol
6. Satisfactory increase in hemoglobin following transfusion
Admission Criteria 1. Transfusion reaction
2. Unstable vital signs
3. Fluid overload, CHF
4. Unavailable blood products for 18hours
Transient Criteria
Ischemic Attack
Objective of
Observation
Inclusion Criteria 1. Transient ischemic attack resolved deficit, not crescendo
2. Negative head CT
3. Workup can be completed within ~18hrs
Exclusion Criteria 1. Head CT imaging positive for bleed, mass, or acute
infarction.
2. Known extra-cranial embolic source history of atrial
fibrillation, cardiomyopathy, artificial heart valve,
endocarditis, known mural thrombus, patent foramen ovale,
or recent MI.
3. Known carotid stenosis (>50%)
4. Any persistent acute neurological deficit or crescendo TIAs
5. Non-focal symptoms ie confusion, weakness, seizure,
transient global amnesia
6. Hypertensive encephalopathy
7. Severe headache or evidence of cranial arteritis
8. Acute medical or social (poor home support) issues
requiring inpatient admission
9. Prior large stroke - making serial neurological examinations
problematic
10. Pregnancy
Available 1. Neuro checks Q-2hr for 12 hrs, then Q4hr to detect stroke,
Interventions crescendo TIA, etc.
2. Neurology consult to detect occult stroke. Consider
hypercoagulable blood testing if <55 or as directed by
*neurology.
3. Carotid imaging with MRI/MRA - to detect surgical carotid
stenosis (>50%) and microinfarct
4. If contraindications to MRI/MRA and good renal function,
then CTA of head and neck vessels
5. If contraindications to MRI/MRA and poor renal function,
then carotid doppler
6. 2-D Echocardiography - to detect a cardioembolic source.
7. Cardiac monitoring for at least 12 hours for paroxysmal
atrial fibrillation
8. Appropriate antiplatelet therapy (Aspirin If on ASA then
Plavix OR Aggrenox)
9. TIA stroke preventive educational materials (lipids, smoking,
DM, HT, obesity, alcohol, stroke)
Discharge Criteria 1. No recurrent deficits, negative workup
2. Clinically stable for discharge home (on Asa 81mg/day)
Admission Criteria 1. Recurrent symptoms / deficit
2. Evidence of treatable vascular disease - ie >50% stenosis
of neck vessels
3. Evidence of embolic source requiring treatment (ie heparin /
coumadin) - ie mural thrombus, Paroxysmal atrial fibrillation
4. Unable to complete workup or safely discharge patient
within timeframe
5. Physician judgment
Upper Criteria
Gastrointestinal
Bleeding
Objective of
Observation
Inclusion Criteria 1. History of dark stool (not bright red) in last 24-48 hours
2. No more than 2 episodes of bright red blood
3. GI or surgery consulted for evaluation (or endoscopy) within
24hr
4. Normal PT/INR, Hgb >10, normal Cr.
5. Rectal exam for guiac and orthostatics vitals done in the ED
Exclusion Criteria 1. Unstable VS (HR>100, SBP<100, RR>22) or fever (T>38)
2. Significant orthostatic changes ( SBP>20); standing pulse
>110
3. More than 2 episodes of bright red bleeding
4. Active bleeding = fresh voluminous hematemesis, multiple
episodes of melena on day of arrival, or a significant amount
of bright red bowel movement per rectum
5. Hgb <8.0, or a drop of Hct >10 in 4 hours (if repeated in the
ED)
6. History of end stage liver disease, coagulopathy, portal
hypertension, esophageal varices, or coumadin
7. EKG Changes
8. Social issues = inadequate home support
Available 1. Serial Hct / Hgb Q6 hr
Interventions 2. Guaiac stools / emesis prn.
3. IV Hydration, PPI or H2 blockers IV
4. Frequent VS Q2 hours X3, then Q4hrs
5. NPO, I & O, clotting studies
6. GI Consult for possible endoscopy
Discharge Criteria 1. Normal or stable serial exams
2. Stable VS
3. No deterioration in clinical condition
4. If endoscopy - no active bleeding, and follow-up arranged
on PPI
Admission Criteria 1. Continual decrease in Hct/Hg
2. Recurrence of bleeding
3. Deterioration in clinical condition
4. Active bleeding by endoscopy
Vaginal Bleeding Criteria
Objective of
Observation
Inclusion Criteria 1. Heavy dysfunctional uterine bleeding, progestin in
ED
2. Bleeding in early pregnancy (quant HCG < 6000)
with ultrasound showing no ultrasonographic
evidence of intrauterine or ectopic pregnancy
3. Threatened abortion with ongoing bleeding
4. First trimester missed or inevitable spontaneous
abortion - OBGYN input REQUIRED
5. CBC results available, blood bank tube sent
Exclusion Criteria 1. Unresolved hemodynamic compromise in ED (HR>110,
SBP<90, HR rise >30 on standing)
2. Hematocrit < 20
3. EGA > 12 weeks
4. Coagulopathy (prolonged PT, PTT, thrombocytopenia)
Available 1. Serial vital signs and bleeding intensity checks (pad count)
Interventions 2. IV saline infusion
3. RhoGam for pregnant Rh-negative patients
4. Repeat hematocrit
5. Blood transfusion PRN
Discharge Criteria 1. Bleeding decreased
2. Vital signs stable
3. Repeat hematocrit acceptable
4. Uterine evacuation performed if indicated, patient recovered
from procedure
5. Proper follow up arranged
Admission Criteria 1. In-patient procedure required
2. Vital signs unstable
3. Bleeding intensity does not slow or increases