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Clinical Practice Guidelines, Protocols & Pathways



Chapter 0 : Templates for Protocols, Guidelines, Pathways

0.0 : Requirements for Clinical Protocols

0.0a : Template for Protocol

0.1 : Template for Guideline

0.2 : Template for Clinical Pathway

0.3 : Template for Education & Implementation Plan

Chapter 1 : Clinical Protocols

1.000a : Adrenalectomy Preoperative Evaluation

1.001 : Airway Management, Emergency Protocol - Adult

1.002 : Alarm Management

1.006a : Ambulatory Heart & Vascular - Electrocardiogram Evaluation

1.006b : Ambulatory Heart & Vascular - Imaging for Vascular Medicine Patients

1.006c : Ambulatory Heart & Vascular - Pre-Procedure Labs

1.006d : Ambulatory Heart & Vascular - Pulmonary Hypertension Evaluation & Treatment

1.006e : Ambulatory Heart & Vascular - Transthoracic Echocardiogram (TTE) Evaluations

1.010 : [RETIRED] Laboratory Testing for Patients Receiving Anticoagulant Therapy

1.011 : Anticoagulation Protocol: Left Atrial Ablation With Subtherapeutic INR

1.012 : Anticoagulation Protocol: Left Atrial Ablation With Therapeutic INR

1.015 : Calcium Chloride Infusion Titration in CRRT - Adult Critical Care

1.016 : Calcium Gluconate Infusion Titration in CRRT - Adult Critical Care

1.020 : Central Line Insertion & Management Protocol

1.021 : Critical Values and Timeframes for Reporting

1.021a : Declaration of Death by Neurologic Criteria (Brain Death)

1.022 : Diabetes Medication Management during Colonoscopy Prep and Test Day - Ambulatory

1.023 : Electrolyte Replacement Protocol - TCV 4W/TIMU

1.024 : Enhanced Recovery After Surgery (ERAS) - Hepatobiliary/Whipple Surgery

1.025 : Enhanced Recovery After Surgery (ERAS) - Colorectal Patients

1.025a : Enhanced Recovery After Surgery (ERAS) - Colorectal Protocol (with Spinal)

1.025b : Enhanced Recovery After Surgery (ERAS) - Colorectal Protocol (with Epidural)

1.026 : Enhanced Recovery After Surgery (ERAS) - GYN Full Protocol (with Spinal)

1.027 : Enhanced Recovery After Surgery (ERAS) - GYN Light Protocol

1.028 : Enhanced Recovery After Surgery (ERAS) - OB Repeat Cesarean

1.029a : Enhanced Recovery After Surgery (ERAS) - Thoracic Full

1.029b : Enhanced Recovery After Surgery (ERAS) - Thoracic Light

1.029c : Enhanced Recovery After Surgery (ERAS) – Thoracic Anesthesia Fluid Management

1.030 : Extravasation Protocol - Nonchemotherapeutic Vesicants And Irritants

1.050 : Heparin Dosing Nomogram - Adult Weight-based Protocol

1.050a : RN Standard Work Checklists for Initiating & Adjusting Heparin Nomogram

1.051 : [RETIRED] Dosing Protocol Worksheet: Argatroban - Adult

1.060 : Hypertonic Saline Administration Protocol - Adult Neuroscience

1.065 : [RETIRED] Indwelling Urinary Catheter Protocol: Insertion, Care, Discontinuation

1.065a : Bladder Scanner Algorithm - Adult

1.065c : Bladder Scanner / Urinary Retention Algorithm - CRRT

1.065d : Clean Intermittent Catheterization Algorithm

1.065e : ID/Traveler's Clinic - Hepatitis C Monitoring Protocol

1.065f : ID/Traveler's Clinic - Routine Travel and Preventative Vaccine Protocol

1.066 : Influenza Vaccination - Nurse Driven Protocol, Adult Inpatient

1.066a : Influenza Vaccination - Nurse Driven Protocol, Adult Ambulatory Care

1.066b : Influenza Vaccination - Nurse Driven Protocol, Pediatric

1.066c : Influenza Vaccination - PHARMACY Protocol, Pediatric

1.066d : Influenza Vaccination - Annual Dosing Reference

1.066e : Influenza Vaccination - PHARMACY Protocol, Adult

1.070 : Insulin Infusion Protocol - Adult Acute Care

1.071 : Insulin Infusion Protocol - Adult Critical Care

1.072 : Insulin Pump Protocol, Inpatient

1.080 : Ketamine Continuous Infusion Protocol - ERAS Thoracic Acute & TIMU

1.110 : Medical Emergency Team (MET) Rapid Response Activation for Adult Inpatients

1.111 : Medical Emergency Response Protocol - Neonatal NERT

1.115 : Medical Nutrition Therapy Protocol by Registered Dietitians/Nutritionists

1.118 : MRSA & VRE Surveillance Culture Orders for Ambulatory Clinics

1.120 : Non-urgent Oxygen Delivery Protocol By Nasal Cannula - Adult Acute

1.123 : Nuclear Cardiology/Stress Testing Protocol

1.124 : Pain Management (Ketamine) - Burn Hydrotherapy & Wound Care

1.124k : Parathyroidectomy Pre-operative Evaluation

1.125 : Pharmacy and Therapeutics Orders Optimization Protocol

1.127 : Pneumococcal Vaccination - Nurse-driven Protocol, Inpatient Adult

1.127a : Pneumococcal Vaccination - Nurse-driven Protocol, Adult Ambulatory Care

1.131 : Progressive Mobility Protocol, Heart Center

1.135 : Pronation Therapy for the patient with severe acute respiratory distress syndrome (ARDS)

1.140 : Remote Device Monitoring / Interrogation Protocol

1.145 : Scoliosis or Spinal Deformity Evaluation Protocol (Neurosurgery Clinic)

1.148a : Secondary Infusion Carrier Fluid Protocol for Adults and Pediatrics

1.148b : Secondary Infusion Carrier Fluid Protocol for Women's Services

1.155 : Nurse-Managed Pressure Ulcer Treatment Protocol

1.156 : Standing Order Protocol for Device Clinic / In-Hospital Follow Up

1.160 : Stroke Alert for Rapid Evaluation of Adult Inpatients and Emergency Department Patients

1.165 : Thyroidectomy Evaluation and Monitoring

1.170 : Tracheostomy Care Protocol - Adult Acute

1.175 : Trauma Rib Fracture

1.177 : Uncomplicated Urinary Tract Infection Protocol for Female Patients - Triage, Evaluation and Management by Telephone (Family Medicine at Primary Care Center)

1.180 : Ventilated Patient Transport Protocol At Discharge - Adult

1.185 : Warfarin Protocol for Specific Ambulatory Clinics

1.065b Pediatric Bladder Scanning Algorithm

1.071a: Insulin Infusion Protocol - Labor and Delivery

1.110a: Pediatric Rapid Response System

Chapter 2 : Clinical Practice Guidelines

2.000 : Albumin Usage in Adults

2.00a : Acute Myeloid Leukemia Antifungal Prophylaxis Guideline

2.001 : Alcohol Withdrawal Screening, Assessment and Treatment Guidelines

2.015 : Anticoagulation Dosing & Reversal Guidelines - Infants & Children <45kg

2.016 : Anticoagulation Management Guidelines for Endoscopic Procedures

2.020 : Antimicrobial Surgical Prophylaxis Guidelines

2.026 : Antithrombotic Medications and Electrophysiology Procedures Guideline

2.027 : Antithrombotic Medications and Cardiac Catheterization

2.028 : Antithrombotic Therapy - Perioperative Management

2.030 : Apnea Testing Guideline (End Of Life)

2.031 : Aspiration Prevention Adult Guideline

2.035 : Atrial Fibrillation Prophylaxis Guideline, Adult Cardiac Surgery

2.040 : Blood Component Transfusion Guidelines

2.045 : Burn & Wound Guideline

2.046 : Catastrophic Brain Injury Management Guideline

2.047 : Code 12 Roles

2.050 : COPD Evaluation And Management Guideline

2.055 : Pain, Agitation (Sedation), Delirium Treatment Guidelines - Adult Critical Care

2.056 : Delirium Recognition & Treatment Guidelines - Adult Acute Care

2.061 : Diabetes - Hypoglycemia Treatment Guideline (Adult)

2.070 : Diabetic Ketoacidosis (DKA) Guidelines - Adult Critical Care

2.075a : ECMO: Adult ECMO Guideline

2.075b : ECMO: Adult Veno-Veno ECMO Guideline

2.075c : ECMO: Adult ECMO Safety Check Guideline

2.075d : ECMO: Guideline for Transporting Adult ECMO Patients Within The Hospital

2.075e : ECMO: Bleeding Guideline for Adult ECLS Patients

2.075f : ECMO: Non-Bleeding Guideline for Adult ECLS Patients

2.075g : ECMO: Guideline for Setup and Priming the CARDIOHELP-i System HLS Set Advanced

2.075h : ECMO: Adult Veno-Veno ECMO Circuit with Maquet Rotaflow Pump and Quick Prime Reinfusion Bag Prime Check List

2.075i : ECMO: Guideline for Incorporating CRRT into the Adult ECMO Circuit

2.075j : ECMO: Adult ECMO Nursing Guideline

2.075k : ECMO: Patient Evaluation and Selection for Adult ECMO Support

2.075l : ECMO: Anticoagulation and Cannula Maintenance Schedule for Adult ECMO Weaning Guideline

2.075m : ECMO: Autotransfusion for ECMO patients

2.080 : Elimination Of Life-sustaining Measures - Adult

2.081 : [RETIRED] Elimination Of Life-sustaining Measures - Guidelines, Pharmacological Intervention (Adult Critical Care)

2.082 : [RETIRED] Elimination Of Life-sustaining Measures - Guidelines, Ventilator Support (Adult Critical Care)

2.085 : Emergency Management for Suspicion of Cardiac Event

2.086 : Factor VIIa Guideline, Adult

2.087 : Factor VIIa Guideline, Pediatric

2.090 : Fall Assessment And Prevention Guideline

2.095 : Febrile Neutropenia in the Oncology Setting, Guidelines for Care and Maintenance

2.100 : Fibrinolysis Guideline - Adults With PE & Cardiopulmonary Arrest

2.101 : Fibrinolysis - Alteplase TPA Preparation Guidelines

2.105 : Hip Fracture (Fragility)

2.110 : Glycemic Management Guideline - Adult Acute

2.115 : Glucommander Guideline, Adults Requiring Insulin Infusion (TCVICU, TIMU, CCU)

2.121 : Dosing Conversions Between Therapeutic Anticoagulants

2.125 : Hospital-Acquired & Ventilator-Associated Pneumonia (HAP/VAP) Evaluation & Management, Adult

2.128a : HeartMate II Left Ventricular Assist Device (LVAD), Clinical Management

2.128b : HeartMate III Left Ventricular Assist Device (LVAD), Clinical Management

2.128c : HeartWare Left Ventricular Assist Device (LVAD), Clinical Management

2.130 : [RETIRED] Hepatic Encephalopathy Guideline - First Line Treatment Algorithm, Adult Acute

2.132 : HIT & HITTS - Assessment and Treatment Guidelines

2.135 : Hyperkalemia Treatment Sequence - Adult/Inpatient

2.140 : Hypothermia, Therapeutic After Cardiac Arrest - Adult Guideline

2.142 : IdaruCIZUMAB (Praxbind) Guidelines

2.142a : Inhaled Nitric Oxide (iNO) Guideline

2.143 : Insertion of Enteral Feeding Tubes using an Electromagnetic Guidance System (CORTRAK 2 EAS)

2.144a : Insulin - Transition from Insulin Infusion Protocol to Subcutaneous Insulin (Adult Acute)

2.144b : Insulin - Subcutaneous Insulin Guidelines (Adult Acute)

2.145 : Intravenous Immunoglobulin, Adult & Pediatric

2.149 : Intravenous Administration of Bolus Dose Vasopressors - Adult Critical Care

2.150 : Intravenous Medication Administration Guidelines - Adult Acute Care

2.151 : Intravenous Medications Administration Supplement: Adult Intermediate Care Units

2.152 : Ketamine Infusion - Adult Critical Care/Intermediate Care/Post-Anesthesia Care/Palliative Care/5 Central

2.153 : Kidney Transplant Guidelines, Adult - Delayed Graft Function

2.154 : Kidney Transplant Guidelines, Adult - Immediate Graft Function

2.154a : Levels of Care Guidelines - Inpatient Adults and Children

2.154j : Lung Transplant Antifungal Prophylaxis Guideline

2.155 : Medical Emergency Team - Emergency Resuscitation Guideline: Device Application & Medication Administration

2.160 : Non-invasive Positive Pressure Ventilation Guideline

2.165 : Obstructive Sleep Apnea (OSA) - Screening & Treatment Guidelines (Adult Surgical)

2.167 : Out-of-OR Procedures Performed in the ICU

2.170 : Palliative Sedation Guidelines (3 East)

2.171 : Palliative Vasoactive I.V. Infusion Guideline (3 East)

2.174 : Parenteral Prostacyclin Therapy in Adult Inpatients

2.176 : Pharmacologic Management of Select Ophthalmic Indications (AMD, DME, RVO)

2.181 : Pneumonia Guideline - Ventilator Associated Pneumonia, Adult

2.185 : Pregnancy Testing Guidelines Before Receiving Ionizing Radiation

2.187 : Progressive Mobility Guideline – Adult Critical Care Patients on CRRT

2.188 : Progressive Mobility Guideline – Adult Critical Care Patient with Pulmonary Artery Catheters (PAC)

2.190 : [RETIRED, SEE 2.174] Prostacyclin Guideline Flolan and Veletri

2.191 : [RETIRED, SEE 2.174] Prostacyclin Guideline Remodulin

2.195 : Prothrombin Complex Concentrate, Human (KcentraTM) Adult Guidelines

2.196 : Prothrombin Complex Concentrate (Profilnine SD) - Management of Bleeding on Oral Anticoagulants

2.198 : Rituximab Usage Guideline

2.200a : Sedation for Diagnostic and Therapeutic Purposes - Adult & Geriatric

2.200b : Sedation for Diagnostic and Therapeutic Purposes - Pediatric

2.205 : Sepsis Guideline: Management Of Adult Sepsis

2.210 : Special Beds Guidelines: Rotation/Percussion Bed Modules, Kinetic Therapy

2.215 : Stress Ulcer Prophylaxis Guideline

2.220 : Care of the Patient with Non-Traumatic Intracerebral/Intraventricular Hemorrhage

2.221 : Care of the Patient with Acute Ischemic Stroke

2.221a : Thrombolytic Therapy for Acute Ischemic Stroke

2.221b : Endovascular Therapy for Acute Ischemic Stroke

2.221c : Management of Malignant Intracranial Hypertension in Ischemic Stroke Patients

2.222 : Care of the Patient with Non-Traumatic Subarachnoid Hemorrhage

2.223 : Depression Screening Following Stroke

2.225 : Subpleural catheter insertion and continous paravertebral nerve block for pain from VATS

2.227 : Total Artificial Heart Guideline (Syncardia TAH)

2.230 : Tracheostomy Care Guideline - Adult Critical

2.260 : Venous Thromboembolism and Acute Coronary Syndrome Treatment Guidelines

2.261 : Venous Thromboembolism VTE - Prophylaxis Guideline, Adult

2.262 : Venous Thromboembolism VTE Prophylaxis Guideline - Pediatric

2.263 : VTE Prophylaxis for Inpatients and Recently Discharged - Dept. of Surgery

2.264 : VTE Prophylaxis Guideline - Urology

2.266 : VTE Prophylaxis - Elective Hip & Knee Arthroplasty

2.267 : VTE Prophylaxis - Pregnancy & Postpartum

2.270 : Ventilator Weaning Guideline - Adult

2.279 : Warfarin Reversal Flowchart

2.280 : Warfarin Reversal - Vitamin K1 Phytonadione Therapy Guideline

2.283 : Wearable Cardioverter Defibrillator - Management of Adult Patients

2.285 : White Boards - Communication Tool

2.290 : Wound Biodebridement Guideline - Maggot Debridement Therapy

2.010: Antimicrobial Susceptibility Profiles (Antibiograms)

Ambulatory Emergency Care Guidelines

Pain Resource Manual - Guidelines for Acute, Procedural & Cancer Pain

Trauma Center Guidelines

Chapter 3 : Clinical Pathways

3.000 : RETIRED - Clinical Pathways - Full List And Hyperlinks

3.004a : Pathway: Enhanced Recovery After Surgery (ERAS) - Colorectal Surgery

3.004b : Pathway: Enhanced Recovery After Surgery (ERAS) - GYN Surgery Full

3.004c : Pathway: Enhanced Recovery After Surgery (ERAS) - GYN Surgery Light

3.004d : Pathway: Enhanced Recovery After Surgery (ERAS) - Whipple Surgery

3.004e : Pathway: Enhanced Recovery After Surgery (ERAS) - OB Repeat Cesarean Delivery

3.004g : Pathway: Enhanced Recovery After Surgery (ERAS) - Thoracic Surgery Full

3.004h : Pathway: Enhanced Recovery After Surgery (ERAS) - Thoracic Surgery Light

3.004i : Pathway: ERAS Total Joint

3.007 : Pathway: Gastric Bypass - Laparoscopic

3.008 : Pathway: Gastric Bypass - Laparoscopic Banding

3.009 : Pathway: Gastric Bypass - Open

3.010 : Pathway: Hip Fracture

3.011 : Joint Replacement, Total

3.012 : Pathway: Kidney Transplant, Adult - Delayed Graft Function

3.013 : Pathway: Kidney Transplant, Adult - Immediate Graft Function

3.014 : Pathway: Lung Transplant

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