List of High Alert medications and management

High-alert medications are those mediations involved in high percentage errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes. It is the policy of HEC to obtain monthly vital signs and weight on a monthly basis. The commonly used high-alert medications and the management plans in our population are:
Atypical Antipsychotics: All students on this class of medication are monitored with blood tests. This includes prolactin levels every 6 months, glucose and insulin levels every three months and lipid profile annually unless otherwise ordered by physician
Clozapine – Additional weekly CBC done for evaluation of white blood cells and entered into the national database. Regular EKG with additional testing such as echocardiogram may be ordered.
Risperdal
Zyprexa
Seroquel- Additional eye exam every 6 months
Geodon
Abilify
Mood stabilizers/ antiseizure: All students on this class of medications have levels and various blood tests on a regular basis.
Tegretol-Blood level, CBC and LFT (Liver function tests) every 6 months
Lithium- Blood levels, TSH ( thyroid) and BUN, Creatinine (kidney function) every 3 months
Depakote- Blood level, CBC, LFT every 3 months
Dilantin- Blood level, CBC and LFT every 3 months

The following medications are used in our population for aggression and hyperactivity but may affect blood pressure or heart rate. Baseline EKG is obtained with annual follow up unless otherwise ordered by physician.
Clonidine
Tenex
Effexor (antidepressant)

Stimulants- For all students on this class of medication, family history of underlying heart disease or sudden cardiac death is obtained at time of consent. A baseline EKG is obtained on admission or when stimulant is started with annual follow up.
Adderal
Concerta
Dexadrine
Vyvanse
Ritalin
Focalin
Metadate

Other medications
Wellbutrin – Review of history for seizures
Metformin- Glucose and insulin levels are obtained as ordered by physician. Additional daily testing of blood glucose may also be ordered.

https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf

https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161

https://www.ismp.org/sites/default/files/attachments/2017-11/tallmanletters.pdf

MEDICATION DISPOSAL

Policy:

Medication disposal should follow federal and state laws for all prescription, controlled, vitamins, minerals, herbal supplements and over-the-counter medications.

Practice:

Medications that are no longer needed by the student, have been discontinued, and are unable to be returned to the pharmacy should be disposed of according to applicable laws and guidelines. The Office of National Drug Control Policy (ONDCP) and the Environmental Protection Agency (EPA) jointly released guidelines for disposal of prescription medications. Controlled Substances must be destroyed so that they are unusable by another person to prevent diversion of the drugs.

d. Two nurses will verify the medications being disposed of and a
documentation of the disposal will be kept in the controlled
substance logbook.

e. Two nurses will then place all medications to be disposed of into a
2-millimeter, zip-lock bag. Hot tap water will then be added and
bag sealed. Let the medications dissolve for 5-15 minutes before
adding Absorb-all. Manipulate the sealed bag and its contents until
all moisture is absorbed.

f. Place the sealed bag and its contents into a garbage container in
the nursing area. Housekeeping can then discard the garbage bag
into the campus dumpster.

9. The 2-millimeter, zip-lock bags should be obtained through the food service supplier (Eastern Bag Company).

10. The Absorb-All should be obtained through the maintenance department supplier (Burnell Auto Parts).

1. Student Vacations/Leaves
Upon notification of an upcoming leave or student vacation, nursing orders a supply of medication from the pharmacy for the length of the leave plus two extra days to cover loss, spillage or extra days added onto the leave. Nursing packs medications and documents all those sent on the Medication Administration Log
All medications and instructions will be reviewed by nursing with staff or parent responsible for transport. Staff will review with parent/guardian upon arrival for visit.
When student travels unaccompanied, one of the three following options will be exercised:
Prescription for vacation medications will be mailed to student’s parent/guardian in time for it to be filled at a local pharmacy. A copy of the student’s insurance card will be sent with the prescription.
In an emergency, and as permitted by state law, physician may call prescription in to local pharmacy.
Medications can be mailed via Federal Express overnight service. Parents should be notified as to when medications are due to arrive.

2. Procedure for Dispensing by Non-Licensed Personnel
Medications cannot be dispensed by unlicensed personnel without their successful completion of the “Medication Certification Program” given by HEC registered nurses.
Staff will supervise medication administration only when an off-campus trip is necessary and student involved is unable to return to campus at medication time or when a nurse is not available.

Procedure for certifying staff is as follows:
1) Staff must have been employed by Hillcrest Educational Centers for at least three months to be considered for certification. He/she must have current certification in First Aid and CPR.
2) The decisions about whom to credential will be made by the head nurse of each campus after having consulted with the Program Director/Manager, supervisors, and others who might be in a position to evaluate the capabilities of that staff member.
3) Only R.N.s may certify staff.
4) Training sessions for certifying staff will include:
a) Review of medication procedure by nurse trainer.
b) Administration of test to staff: Staff must pass test with 100% correct score. If staff fails to pass test, nurse trainer may review missed material and re-administer test one time. If second attempt failed, staff must wait for at least one month and begin procedure again. If, after one month staff fails test again, he/she will no longer be considered eligible for credentialing.
5) When staff successfully passes training, nurse trainer will complete the “Certificate of Credential and Privilege to Supervise Medication Administration. Trainer will keep that record with guidelines in a special file in the nurses’ station. A copy of the certificate, along with guidelines will also be kept in the staff’s personnel file. Training coordinator should be notified of training. Recertification takes place on a yearly basis.

6) In the event that certified staff fails to follow medication procedure, an incident report and Medication error report must be filled out by the staff involved in the incident. Immediate notification of the circumstance must be provided to the supervisor on duty and the nursing department. Depending on the nature of the error and the staff understanding, certification can be withdrawn at any time.

3. Medication Refusal
When a student has failed or refused to take his/her medication, the refusal is documented in the student’s record, including the student’s stated rationale for refusing. When indicated, the nurse notifies the prescribing physician. The neurologist is notified of all refusals involving anti-convulsant medication. In addition, direct care staff is informed of any related safety concerns.

– are to be up-dated according to Mass State Regulations, which follow.

Immunizations

Immunization Catch Up Schedule

As Ordered by the Physician or At Nurses Discretion

A. Level One – Complete Bed rest

1. OOB to bathroom only.
2. Must remain in bed for all meals.
3. Assessment every 3-4 hours.
4. Limited visitors.

B. Level Two – Partial Bed rest

1. OOB to bathroom and for meals.
2. May intermittently engage in watching T.V., and other sedentary activities in the lounge area.

C. Level Three – Partial Activity

1. May attend classes.
2. May participate in all sedentary program activities.
3. May NOT participate in Gym, ABC, Sports, NYPUM or Off Campus Activities.

A. Falls

1. For all falls from greater than a height of 15 feet, encourage the student to lie still.
2. Assess for obvious injuries and treat with appropriate first aid
3. Keep child calm and call an ambulance for transport.

B. Strains / Sprains / Possible Fractures

1. Review history of injury
2. Assess alignment, ROM, and point of tenderness. Document distal pulse and sensation.
3. Apply ice.
4. Immobilize and elevate injured part, using pillows for support.

5. Use Ibuprofen or acetaminophen as directed by the manufacturer Call Physician if indicated and / or seek emergency care

A. Rashes / Acne / Skin Infections

1. When symptoms are observed, a complete skin assessment is necessary.
2. Review medication regimen, diet, and environmental factors.
3. Apply OTC ointments as indicated , observe for improvement
4. For acne, gently wash with anti-bacterial soap twice per day. Apply appropriate topical medication afterwards.
5. If assessment reveals impetigo or mild cellulitis, scrub area gently with antibacterial soap, apply antibiotic ointment BID and cover with a dry dressing. Instruct student and staff on necessary precautions to avoid spread of infection. Examine patient on a daily basis. Report findings to Physician.

B. Bites (Human)

1. Encourage bleeding if the skin is broken.
2. Cleanse with soap and warm water for 8 to 10 minutes.
3. Apply a dry sterile dressing.
4. Assess hepatitis status of both students involved
5. Report incident to the Physician and follow exposure procedure below:

1. The Campus Nursing Department will contact the Guardians of both students and inform them of the incident.
2. The Campus Nursing Department will attempt to obtain Consent from the Guardians for HIV testing as recommended by HEC pediatrician.
3. Documentation of the incident and notification of the physician, will be added to the student’s Progress Notes. The HIV testing report will be placed in a sealed envelope, labeled as confidential and placed in the “laboratory” section of the chart. Any medical follow-up will be coordinated by the physician.

C. Scratch; Break in Skin Integrity
Protocol following a break in skin integrity between students or student/staff.

Due to the possible complications from any break in skin integrity it is imperative that employees take appropriate measures to minimize exposures to blood for both students and staff.

Following a break in skin integrity:

Students:
4. Student should wash their hands with soap and water thoroughly if they were scratching, paying special attention to under the fingernails.
5. Check student for any broken skin areas; these areas should be cleaned with soap and water, and treated with a topical antibacterial cream/ointment.
6. Document the incident and any injuries to students.

Staff:
3. Staff should wash all abrasions, scratches, or broken skin areas thoroughly with soap and water, if available apply antibiotic cream.
4. Staff must complete an ART form to be filed with AO, regardless of the seriousness of the injury. This documents the injury in case a complication occurs.

When dealing with a student who is known to scratch as a defense or mode of aggression, staff should take appropriate precautions to protect themselves. Some suggestions would be to wear long sleeve shirts and pants, the use of gloves (vinyl or padded) or changing the positioning of student’s hands to minimize the ability to scratch skin.

D. Puncture Wounds

1. Assess bleeding, need for sutures or foreign body
2. Soak wound with antibacterial soap and water.
3. Apply antibiotic ointment with dressing.
4. Check status of Tetanus Immunization.
5. Monitor daily for possible signs of infection. Notify physician as needed.

E. Burns

1. 1st Degree- injury to top skin layer causing redness, pain and minor swelling healing in 3-6 days– cool compress / aloe or burn gel topically/ Tylenol or Motrin for pain
2. 2nd Degree- injury to skin layers beneath the top layer producing blisters, severe pain and redness with healing taking up to 2-3 weeks– cool compress / bacitracin or Silvadene topically followed by a sterile dressing. Do not puncture blisters. Monitor daily at dressing change for signs of infection. (SILVADENE SHOULD NOT BE USED FOR PATIENTS WITH SULFA ALLERGY ) Notify Physician.
3. 3rd Degree- injury to all the layers of the skin and underlying tissue making the skin appear waxy, leathery or brown– cool sterile compress. Transport to ER; notify Physician.

F. Eczema

1. Shower with tepid water once or twice a day.
2. Use mild soap (Dove unscented or generic equivalent).
3. Pat dry.
4. Apply topical prescription meds if any.
5. Apply hypo-allergenic moisturizer.
6. Notify physician if worse or no improvement in 2 weeks.

A. Painful or difficulty Urinating

1. Assess symptoms to include frequency, type of discomfort and duration. Obtain vital signs.
2. Obtain clean catch urine.
3. Dip urine or send to lab for urinalysis. If positive leucocyte esterase or the presence of WBCs are noted in the dip or urinalysis, send for culture. Report the results to M.D.

B. Nocturnal Enuresis Protocol

Nocturnal enuresis is repeated, accidental bed-wetting during the night. Children will vary in the age at which they are physically ready to have complete control over their bladders. About thirty percent of 4 year olds, ten percent of 5 year olds, five percent of 10 year olds, and one percent 18 year olds wet the bed.

a. Of those children with night time wetting, only a small proportion (~ 1-2%) have a problem that requires medical attention. Such medical conditions may include anatomical abnormalities, chronic infections, nerve abnormalities or diabetes.
b. Symptoms that may indicate an underlying medical condition include persistent or new wetting, painful or difficult urination and constant thirst.
It is important for team members to notify the medical department if a student develops any new symptoms.

c. Nocturnal enuresis may also have psychological causes, as bed-wetting tends to be more common in children who have suffered traumatic or stressful life experiences.

4. Protocol:
a. After the initial evaluation, which includes a visit with the pediatrician, psychiatrist and urine specimen for testing, each student will be educated about the nature of nocturnal enuresis and possible treatments including alarms and or medications. Education will be provided in an individualized manner by either a nurse or professional. Youth Development Professionals involved in student’s care will also have an opportunity to review specifics of treatment plan with team.
b. Extra linen and a way to discreetly dispose of dirty linens will be provided for each student.
c. Student should avoid all carbonated drinks, caffeine or chocolate containing drinks throughout the day. These have been associated with bladder irritation and/or increased urine production and may make bed-wetting worse.
d. Student should restrict fluids of all kinds after 7 PM. ~ 4 oz. of water or juice with medication or during athletic events is acceptable.
e. All students should empty their bladder just prior to going to bed.
f. “Tripping” at certain times through the night should ideally be coordinated with the student and team
g. When a student wets the bed (e.g. student wakes on own or bed-wetting alarm goes off), student should be encouraged to change clothes and sheets as well as shower. This will decrease urine smell and help preserve student’s self-esteem.
h. Behavior modification plan will reward dry nights as well as cooperation with changing wet bedding, restricting fluids, and emptying bladder before bed. This may be worked into student’s motivational plan from discussions in team.

6. Treatment:

Treatment of nocturnal enuresis can be difficult and usually involves a multifaceted approach that includes all members of the treatment team. Various combinations of suggested interventions may be necessary to support the student’s individual needs. Options regarding the use of alarms and medications along with staff support in waking and maintaining a clean environment should be discussed and changed when indicated.
In extremely difficult cases, it may be appropriate to have a student wear pull-ups while sleeping. This might be necessary after other measures had been exhausted and only with involvement of student and student’s guardian.

A. Simple Nausea without Vomiting

1. Assess general condition
2. Avoid irritating diet, ASA, spicy foods, hot sauce, and cold drinks.
3. Encourage appropriate fluids.
4. Maalox 10-15cc may be used as directed.

B. Vomiting

1. Assess possible cause, general associated symptoms, and temperature.
2. Observe amount, quantity, and duration.
3. Keep NPO, x2 hours, then give clear fluids and advance, as tolerated.
4. If vomiting persists, or if there is evidence of abdominal pain, fever, headache, dehydration, or diarrhea, notify physician.

C. Abdominal Pain

1. Assess for location, intensity, duration of discomfort, and any additional symptoms such as painful urination, flank pain, cough, or sore throat.
2. Take vital signs.
3. Palpate for tenderness or rigidity; listen for bowel sounds
4. Ascertain B.M. status and, if appropriate, date of LMP.
5. Obtain and process urine specimen (urine dip, culture) if urinary frequency or discomfort is noted.
6. Notify physician of prolonged pain, rebound tenderness, fever, abnormal U/A or any other concerning symptoms.
7. Ibuprofen may be used, as directed, for menstrual discomfort.

D. Constipation

1. Assess bowel status and bowel sounds; review medication regime.
2. Take temperature.

3. If no bowel movement in 48 hours, administer M.O.M. 15 to 30 cc .
4. If no results are evidenced in 10-12 hours repeat dose Notify the Physician if MOM not beneficial for fiber supplement or stool softener.
5. Increase fluids .
6. Encourage a high fiber diet (limit bananas).

E. Diarrhea

1. Assess frequency and quantity, of B.M.
2. Review medication regime and food intake in the last 24 hours.
3. Take temperature.
4. Encourage a bland, binding diet with adequate fluid intake x24 hours and advance as tolerated.
5. If symptoms persist or if there is any evidence of fever, tiny firm stools, or stools with frank blood or mucous, report to Physician immediately. Explosive diarrhea [9-10 episodes in 3-4 hours] should be reported immediately.

A. Cough/ URI

1. Assess cough.
2. Auscultate chest sounds, examine ears, throat, and cervical nodes.
3. Take temperature and respiration rate.
4. Review PMH for asthma or allergies.
5. If cough is productive and interfering with sleep or daily activities may administer generic Robitussin or Mucinex as noted in the medication list..
6. If cough is non-productive and interfering with sleep or daily activities may administer generic Robitussin DM or Mucinex Das noted in the medication list.
7. If cough is accompanied by chest pain, fever, back pain, or an abnormal lung exam (wheezes, rales or rhonchi) notify physician.

B. Nasal Congestion and Allergies

1. Assess symptoms
2. Encourage fluids and rest as deemed appropriate.
3. If cough or congestion interferes with sleep or activities and physical exam is otherwise normal, may offer Chlortrimeton, Claritin, Mucinex D or Sudafed, as recommended for age / weight.
4. Observe patient, and notify physician if symptoms continue for greater than 10 days, or, within 24 hours if there is fever or patient’s symptoms are worsening.

C. Allergic Reactions

.
1. Mild localized reaction (swelling, itching, redness or hives) may apply ice to site or give appropriate dose of Benadryl. Observe for any signs of systemic reaction for 12-24 hours. May also apply topical remedies such as calamine or hydrocortisone 1%.

D. Asthma

1. Follow patient’s treatment plan for use of inhalers if already in existence.
2. Obtain vital signs, including peak flow measurement.
3. Listen to breath sounds and audible wheezing; observe for retractions or respiratory distress.
4. If no treatment plan, and mild, have patient rest with continued monitoring.
5. Give ventolin/albuterol inhaler if ordered.
6. Notify physician.

Flu recommendations, treatment and procedures
(also see Chapter 8, Infection Control)

These ways to prevent the spread of flu illness should be noted and encouraged at every opportunity. These steps include:

• Cover your cough or sneezes into a tissue or inside of arm, not your hands, dispose of the tissue
• Avoid touching your eyes, nose and mouth
• Wash your hands frequently with soap and water or hand sanitizer
• Stay home if you are sick with fever over 100.4F
• Clean surfaces such as desks, tables, counters, and door knobs with antibacterial solutions

On the occasion that the flu reaches our students these procedures should be followed:

• All students will be observed for the following symptoms: fever above 100.4 F, cough, sore throat, body aches, headache, chills and fatigue
• When these symptoms occur, every effort will be made to isolate the student in their room or a designated infirmary area on campus (to be determined by PD and Head Nurse)
• Staff who are assigned to be with ill students will be provided with N95 masks, gloves and disinfectant wipes
• Observation of symptoms will continue. If the BMC diagnostic criteria for testing is fulfilled or if ordered by the physician, then a nasopharyngeal swab will be obtained and sent to BMC Lab
• MC lab will test the swab for Influenza A virus (results available within 24 hours), if present, a repeat specimen will be obtained and submitted to the State lab for subtyping
• Dr. Dempsey will be notified at which time anti-viral treatment may be initiated according to his orders
• If the testing does not reveal type A flu, isolation is not necessary. However, bed rest may be indicated depending on current symptoms assessed by the nurse on duty.
• Symptomatic treatment by staff and nursing will continue throughout the illness. This may include: Tylenol/ ibuprofen, fluids and rest.
• Documentation of information will be completed by nursing on the Student Isolation Log. This information will be used to follow isolation and testing processes. (see attached)
• Staff will use the Student Monitoring Sheet to record pertinent information for each student in the isolation room. (see attached)
• The Head Nurses at each campus will make daily decisions on the students entering and leaving the isolation infirmary area.
• Updates on available information will be relayed to staff in Community Meetings
• Decisions on limiting travel or visitation on and off campus will be made by the SMT

Supplies to have on hand:
Anti-bacterial wipes
N 95 Masks
Gloves
Tissues
Nasopharyngeal swabs
Ibuprofen/Tylenol
Ginger ale
Sports drink/ other clear fluids

A. Influenza Diagnostic Testing

Specimen kits to collect nasopharyngeal samples for Influenza A and B testing are available from the hospital’s main laboratory. The test detects both A and B disease; results will be available within 24 hours.

More specific testing is available from the State laboratory and will be sent to a referral lab. Each site should keep 2 – 3 kits on hand.

Berkshire Pathology Services will continue to send specimens by request to a reference laboratory for influenza and respiratory pathogen testing. Any respiratory specimens are acceptable for the reference laboratory. Please contact the microbiology laboratory for any questions regarding this or other testing for viral diagnosis.
Influenza
Flu recommendations, treatment and procedures
(also see Chapter 8, Infection Control)

These ways to prevent the spread of flu illness should be noted and encouraged at every opportunity. These steps include:

• Cover your cough or sneezes into a tissue or inside of arm, not your hands, dispose of the tissue
• Avoid touching your eyes, nose and mouth
• Wash your hands frequently with soap and water or hand sanitizer
• Stay home if you are sick with fever over 100.4F
• Clean surfaces such as desks, tables, counters, and door knobs with antibacterial solutions

On the occasion that the flu reaches our students these procedures should be followed:

• All students will be observed for the following symptoms: fever above 100.4 F, cough, sore throat, body aches, headache, chills and fatigue
• When these symptoms occur, every effort will be made to isolate the student in their room or a designated infirmary area on campus (to be determined by PD and Head Nurse)
• Staff who are assigned to be with ill students will be provided with N95 masks, gloves and disinfectant wipes
• Observation of symptoms will continue. If the BMC diagnostic criteria for testing is fulfilled or if ordered by the physician, then a nasopharyngeal swab will be obtained and sent to BMC Lab
• MC lab will test the swab for Influenza A virus (results available within 24 hours), if present, a repeat specimen will be obtained and submitted to the State lab for subtyping
• Dr. Dempsey will be notified at which time anti-viral treatment may be initiated according to his orders
• If the testing does not reveal type A flu, isolation is not necessary. However, bed rest may be indicated depending on current symptoms assessed by the nurse on duty.
• Symptomatic treatment by staff and nursing will continue throughout the illness. This may include: Tylenol/ ibuprofen, fluids and rest.
• Documentation of information will be completed by nursing on the Student Isolation Log. This information will be used to follow isolation and testing processes. (see attached)
• Staff will use the Student Monitoring Sheet to record pertinent information for each student in the isolation room. (see attached)
• The Head Nurses at each campus will make daily decisions on the students entering and leaving the isolation infirmary area.
• Updates on available information will be relayed to staff in Community Meetings
• Decisions on limiting travel or visitation on and off campus will be made by the SMT

Supplies to have on hand:
Anti-bacterial wipes
N 95 Masks
Gloves
Tissues
Nasopharyngeal swabs
Ibuprofen/Tylenol
Ginger ale
Sports drink/ other clear fluids

A. Influenza Diagnostic Testing

Specimen kits to collect nasopharyngeal samples for Influenza A and B testing are available from the hospital’s main laboratory. The test detects both A and B disease; results will be available within 24 hours.

More specific testing is available from the State laboratory and will be sent to a referral lab. Each site should keep 2 – 3 kits on hand.

Berkshire Pathology Services will continue to send specimens by request to a reference laboratory for influenza and respiratory pathogen testing. Any respiratory specimens are acceptable for the reference laboratory. Please contact the microbiology laboratory for any questions regarding this or other testing for viral diagnosis.

Comparative Profiles Of Antiviral Agents For Influenza

Student Flu Monitoring Sheet

Student Isolation Log