Nursing

THROAT SWAB FOR STREP OR GONNORHEA CULTURE

Effective Date: 
Mon, 02/01/2016
Revised: 
Tue, 01/03/2017
Policy: 

RNs evaluate students presenting to the Triage Nurse with symptoms of sore throat or concerns about sexually transmitted infections.  Under this Standardized Procedure the RN may obtain a rapid strep and/or standard throat culture prior to the clinician visit.  This standardized procedure will expedite access and patient flow.  Under this standardized procedure the RN may also obtain a throat culture for gonorrhea in an asymptomatic patient who meets CDC risk criteria.

Procedure: 

Procedure

The RN making the evaluation uses the following procedure:

  • Determine the patient's chief complaint and any associated complaints
  • Take the patient's vital signs
  • Use a flashlight to examine the patient's throat
  • Use appropriate Personal Protective Equipment:  gloves and mask (optional)
    • For patient's chief complaint about asymptomatic gonorrhea in the throat the CDC recommends throat swab for gonorrhea only in men who are having oral sex with other men.  Throat culture for gonorrhea should be one part of comprehensive STI testing.  If asymptomatic students at risk present to Triage with request for throat culture for gonorrhea, the RN should obtain the throat swab and if the student has not already been tested for HIV, Syphillis, and Chlamydia and gonorrhea from urethral site, the RN should direct the student to the Self-Directed STI Testing process via the UCSC Health Center Lab.  Students at risk for rectal gonorrhea should be scheduled with a clinician.
  • For patient's with chief complaint of sore throat, obtain a throat swab for rapid strep prior to clinician exam in the following situations:
    • Any of these clinical indications:
      • Exudative pharyngitis
      • Swollen, red pharynx
      • Focal complaint of sore throat PLUS fever over 100.5
    • Per clinician instruction or preference
    • By specific request of student or family for strep testing
  • Order rapid strep test and standard throat culture in the name of the provider who will see the patient.  (The lab will cancel a standard throat culture if a rapid strep test is positive.)
  • For gonorrhea cultures not going through for clinician visit, order the culture under the Medical Director's name
  • For strep throat culture:  use a Polyester Tipped Applicator to swab the throat
  • For a gonorrhea test:  use an Aptima Genprobe culture tube and the probe provided with the kit
  • Label the specimen
  • Obtain specimen and place in appropriate transport container
  • Deliver the specimen to the lab

Experience, Training and/or Education

  • Current California RN License
  • Completion of the UCSC Student Health Center orientation specific to obtaining throat swabs

Evaluation of Competency

     Initial Competency

  •     Observes experienced clinical staff member obtaining throat swab one time
  •      Demonstrates successful use of this procedure under direct clinical staff member supervision at least 3 times.  Use HC:888 form for competency sign offs

     On-going Competency

  •      Chart reviews of this procedure occur as part of the on-going Quality Assurance program of the UCSC Student   Health Center

     Scope of Supervision

  •      No direct clinician supervision
  •      Clinicians available as needed for consultation and referral

     Criteria for Provider Consultation and Referral

  •      A patient who appears severely ill or cannot open their mouth should be expedited to prompt clinician evaluation 
  •      Students who are symptomatic for a sexually transmitted infection or need education on risk reduction should be referred for a clinician visit

     Documentation

  •      RN documents according to the standards delineated in the UCSC Student Heath Center Policy on Documentation of Care

 

 

CHEMICAL EXPOSURE TO THE EYE

Effective Date: 
Wed, 09/02/2015
Policy: 

To appropriately expedite the care of patients with chemical exposures to eyes in order to minimize potential for related vision loss.

Procedure: 

1.  Patient calls or presents with history of chemical exposure to one or both eyes

2.  Staff member receiving this information informs the Charge Nurse in person or by phone.  During lunch, notify Same Day Clinic Nurse

3.  Charge Nurse:

  • Delegates nurse to begin eye irrigation with Lactated Ringers solution via the Morgan Lens.  Ophthalmic anesthesia eye drops may be used if needed to perform irrigation.  If only one eye is affected, be sure irrigation solution drains away from the unaffected eye. Contact lenses if in place should be removed immediately
  • Identifies a clinician who is immediately available to evaluate the patient
  • Delegates another staff member to find the Safety Data Sheet (SDS) of the chemical, print the SDS, and give it to  the treating clinician.  The quickest way to find an SDS may be to "google" it

4.  As soon as ophthalmic pH paper is available, check pH of both eyes (affected and unaffected) as a baseline and documented in the EMR.  Irrigation is continued until the pH of the affected eye is between 7.0 and 7.2.

5.  Documentation of the following is needed:

  • Time of exposure
  • Duration of exposure
  • Any flushing of the eye done prior to presentation at the SHC, including the type of fluid and length of irrigation
  • Accurate information about the chemical involved, especially the pH.  The SDS of the product should be referenced as soon as possible

6.  When the pH of the affected eye(s) is between 7.0 and 7.2, the clinician should perform a full ophthalmic exam, including:

  • Eversion of eyelids with sweep of fornices with wet cotton swab to detect and remove any particles
  • Fluorescence exam of cornea and conjunctival epithelium
  • Examination of unaffected eye, including pH, to assure that both eyes are not involved
  • Visual acuity including "pinhole" testing for patients who need correction     

7.  Clinician or their designee may consult poison control and/or ophthalmologist on-call for clinical guidance as appropriate to the situation.  UCSC Optometrist may be involved as needed, if on site.  If the patient needs transport to the hospital before pH is corrected, irrigation should continue during transport

 

Key Points: 
  • Irrigation of the eye with exposure to chemical should not be delayed for anything
  • SDS of the chemical involved should be accessed as soon as possible
  • Contact lenses if in place should be removed immediately

MEDICAL ASSISTANT STANDING ORDERS FOR PLACEMENT OF TUBERCULIN SKIN TEST (TST)

Effective Date: 
Wed, 09/02/2015
Reviewed: 
Mon, 10/03/2016
Revised: 
Wed, 12/21/2016
Policy: 

Purpose:  Expanding access to Tuberculosis skin testing supports the UCSC SHC Communicable Disease Screening Policy.  This includes screening of UCSC SHC staff under the Employee Health Screening criteria, as well as students that present for screening for tuberculosis for a number of reasons.  

Policy:  Under this Standing Order from the medical director, MAs who have successfully completed  the UCSC SHC TST placement training, may place tuberculin skin  tests (TST)  provided the patients and/or staff meet the following criteria:

 1.  Are required to receive this screening under the UCSC SHC Employee Health Communicable Disease Screening policy requirements
 2.  For students:  Meets the guidelines under the UCSC SHC Clinical Guidelines :Tuberculosis Testing

(see attached links).

Under this standing order, the medical director delegates the authority to supervise the MA to place TST to MDs, DOs, registered nurses, pharmacists, physician assistants and nurse practitioners.

TST may be placed by an MA only when there is a physician or advanced practice provider (NP, PA) on the premises of the Student Health Center.

Procedure: 

1.  Employee or student completes the TB Screen and Test form HC:330. (For students this questionnaire can be completed on-line and populates the EHR note using the Health e-Communicator secure messaging system.)
2.  The MA reviews the form to verify no prior positive TST or other active risk factors.  If prior history of positive TST or other positive risk factors, an RN or clinician is consulted for next steps.  If the patient is a UCSC SHC employee, the MA consults the Employee Health Nurse or designee.  No TST is to be placed on anyone with a history of previous positive TST. 
3.  If there are no contraindications the MA draws up 0.1cc of Tubersol.  In every instance the MA, prior to administration of the tuberculin skin test, must present the vial of Tubersol to a Registered Nurse, pharmacist, physician, physician assistant or nurse practitioner to verify the correct medication and dosage. 

4.  After verification, the MA cleans inner aspect of the patient's forearm, and injects intradermally, needle bevel up, creating a small wheal. Procedure is repeated in another location if no wheal is noted.
5.  Safety mechanism is activated, syringe is discarded in sharps container.
6.  The patient is notified that the test results need to be read in 48 to 72 hours by a SHC nurse.
7.  The MA documents test placement in the medical record per protocol

POINT OF CARE URINE PREGNANCY TESTING NURSING PROCEDURE

Effective Date: 
Wed, 03/18/2015
Policy: 

Human chorionic gonadotropin (hCG) is a glycoprotein hormone produced by the developing placenta shortly after fertilization. In normal pregnancy, hCG can be detected in urine as early as 7 to 10 days after conception. hCG levels continue to rise very rapidly, frequently exceeding 100 mIU/mL by the first missed menstrual period, and peaking in the 100,000-200,000 mIU/mL range about 10-12 weeks into pregnancy. The appearance of hCG in  the urine soon after conception, and its subsequent rapid rise in concentration during early gestational growth, make it an excellent marker for the early detection of pregnancy

 

The Consult Diagnostics hCG Combo Test is a rapid chromatographic immunoassay for the qualitative detection of human chorionic gonadotropin (hCG) in urine to aid in the early detection of pregnancy. The test utilizes a combination of antibodies including mouse monoclonal anti-hCG antibodies and goat polyclonal anti-hCG antibodies to selectively detect elevated levels of hCG. The assay is conducted by adding urine to the specimen well of the test cassette and observing the formation of colored lines. The specimen migrates via capillary action along the membrane to react with the colored conjugate.

Positive specimens react with the specific colored antibody conjugates and form a colored line at the test line region of the membrane. Absence of this colored line suggests a negative result. To serve as a procedural control, a colored line will always appear at the control line region if the test has been performed properly.

The test qualitatively detects the presence of hCG in urine specimen at the sensitivity of 20 mIU/mL for urine.

Procedure: 

REAGENTS

The test cassette contains mouse anti-beta hCG antibody conjugated to colloidal gold and goat anti-alpha hCG antibody coated on the membrane.

MATERIALS

Materials Provided

• Test cassettes

• Disposable pipettes

• Instructional insert Materials

Required But Not Provided

• Specimen collection container

• Timer

SPECIMEN COLLECTION AND PREPARATION

A urine specimen must be collected in a clean and dry container. A first morning urine specimen is preferred since it generally contains the highest concentration of hCG; however, urine specimens collected at any time of the day may be used. Urine specimens exhibiting visible precipitates should be centrifuged, filtered, or allowed to settle to obtain a clear specimen for testing.

Specimen Storage

Urine specimens may be stored at 36-46°F (2-8°C) for up to 48 hours prior to testing. For prolonged storage, specimens may be frozen and stored below -4°F (-20°C). Frozen specimens should be thawed and mixed before testing.

 

DIRECTIONS FOR USE:

Allow the test cassette,  specimen and/or controls to equilibrate to room temperature (59-86°F; 15-30°C) prior to testing.

1. Remove the test cassette from the sealed pouch and use it as soon as possible.

2. Place the test cassette on a clean and level surface. Hold the pipette vertically and transfer 3 full drops of urine  (approx. 100 µL) to the specimen well of the test cassette, and then start the timer. Avoid trapping air bubbles in the specimen well.

3. Wait for the red line(s) to appear. Read the result at 3-4 minutes for urine. Do not interpret results after the appropriate read time. It is important that the background is clear before the result is read.

Key Points: 

INTERPRETATION OF RESULTS

POSITIVE*: Two distinct red lines appear. One line should be in the control region (C) and another line should be in the test region (T). NOTE: A sample hCG concentration below the cut-off level of this test might result in a weak line appearing in the test region (T) after an extended period of time. A line in the test region (T) seen after the read time could be indicative of a low hCG level in the sample. If such results are seen, it is recommended that the test be repeated with a new sample in 48-72 hours or that an alternate confirmation method is used.

NEGATIVE: One red line appears in the control region (C). No apparent red or pink line appears in the test region (T).

INVALID: Control line fails to appear. Insufficient specimen volume or incorrect procedural techniques are the most likely reasons for control line failure. Review the procedure and repeat the test with a new test cassette. If the problem persists, discontinue using the test kit immediately and contact Technical Service at 1-877-441-7440, Option 2.

*NOTE: The intensity of the red color in the test line region (T) will vary depending on the concentration of hCG present in the specimen. However, neither the quantitative value nor the rate of increase in hCG can be determined by this qualitative test.

QUALITY CONTROL

Internal procedural controls are included in the test. A red line appearing in the control region (C) is the internal procedural control. It confirms sufficient specimen volume and correct procedural technique. A clear background is an internal negative background control. If the test is working properly, the background in the result area should be white to light pink and not interfere with the ability to read the test result. It is recommended that a positive hCG control (containing ≥ 20 mIU/mL hCG for urine)  and a negative hCG control (containing "0" mIU/mL hCG) be evaluated to verify proper test performance with each new lot, each new shipment, monthly as a check on storage, each new untrained operator and as otherwise required by your lab internal quality system procedures.

LIMITATIONS

 

1. Very dilute urine specimens, as indicated by a low specific gravity, may not contain representative levels of hCG. If pregnancy is still suspected, a first morning urine specimen should be collected 48 hours later and tested.

2. False negative results may occur when the levels of hCG are below the sensitivity level of the test. When pregnancy is still suspected, a first morning urine or serum specimen should be collected 48 hours later and tested.

3. Very low levels of hCG (less than 50 mIU/mL) are present in urine specimen shortly after implantation. However, because a significant number of first trimester pregnancies terminate for natural reasons, a test result that is weakly positive should be confirmed by retesting with a first morning serum or urine specimen collected 48 hours later.

4. This test reliably detects intact hCG up to 500,000 mIU/mL. It does not reliably detect hCG degradation products, including free-beta hCG and beta core fragments. Quantitative assays used to detect hCG may detect hCG degradation products and therefore may disagree with the results of this rapid test.

5. A number of conditions other than pregnancy, including trophoblastic disease and certain non-trophoblastic neoplasms including testicular tumors, prostate cancer, breast cancer, and lung cancer, cause elevated levels of hCG.  Therefore, the presence of hCG in  urine specimens should not be used to diagnose pregnancy unless these conditions have been ruled out.

6. This test provides a presumptive diagnosis for pregnancy. A confirmed pregnancy diagnosis should only be made by a physician after all clinical and laboratory findings have been evaluated.

Sensitivity and Specificity

The Consult Diagnostics  hCG Combo Test – Cassette detects hCG at a concentration of 20 mIU/mL or greater in urine. The test has been standardized to the W.H.O. Third International Standard. The addition of LH (300 mIU/mL), FSH (1,000 mIU/mL), and TSH (1,000 µIU/mL) to negative (0 mIU/mL hCG) and positive (25 mIU/mL hCG) specimens showed no cross-reactivity

REFERENCES

Consult Diagnostics  hCG Combo Cassette Package Insert     09/13

 

POINT OF CARE URINE PREGNANCY TESTING BY NURSING POLICY

Effective Date: 
Mon, 12/02/2013
Revised: 
Wed, 03/18/2015
Policy: 

To provide point of care clinical laboratory testing in various clinic areas to improve patient flow.

Under the direction of the Medical and Clinic Directors, trained  nursing staff can perform point of care urine pregnancy tests in designated clinic areas.
Oversight of the quality control system will be a shared, collaborative responsibility of the Medical and Clinic Directors.

DEFINITIONS
Collector – Staff member who obtains the specimen
Processor – Staff member who performs the test
POC – Point of Care

 

Procedure: 

A.  Training

1.   The Medical and Clinic Directors develop and supervise the processor-training program.
2.   Training records, including annual competency review, are documented and include date trained and certification by Medical Director (Attachment A, UCSC SHC Urine Pregnancy Test POC Training and Competency Record).
3.   Training is updated when a new test or test procedure is implemented.

B.  Specimen Collection and Processing (see link to POC Urine Pregnancy Testing Policy)

C.  Documentation

1.  Processor records test results on appropriate POC quality control log maintained at each testing station. (Attachment B, sample Point of Care Urine Pregnancy QC Log)
2.   Processor enters results for urine pregnancy tests in patient’s electronic health record (EHR).

3.  Point of Care Quality Control Logs are collected from clinics monthly and maintained by the medical Records Department for three years per UCSC SHC retention schedule.

D.  Quality Control and Calibration
1.   Processor checks expiration dates and assures that test kits and appropriate collection materials and forms are available for testing.
2.   Manufacturers’ recommended quality control and calibration steps are followed.
3.   Quality control testing is recorded in corresponding quality control log for each test being performed.
4.   Any abnormalities in quality control testing, such as an "Invalid result" will be noted on the "Problem Log" log with an explanation of the occurrence and resolution. The Processor's supervisor will be notified immediately.   If the control line fails to appear, this is considered an "Invalid result".   Insufficient specimen volume or incorrect procedural techniques are the most likely reasons for control line failure. Review the procedure and repeat the test with a new test cassette. If the problem persists, immediately discontinue using the test kit and notify supervisor.

5.   The Medical or Clinic Director or designee performs a quarterly review of this log.

E.  Quality Assurance
1.   Competency training of staff processors of POC clinical laboratory tests is conducted annually by the designated Clinic Manager, for all POC tests performed at SHC.
2.   Log monitoring
a.   POC logs in two clinical areas (Same Day Clinic and Floor 2 Primary Care Clinic).  Logs are monitored annually by the Medical or Clinic Director or designee, for the determined parameters and compared to the corresponding client record.
b.   Results are reported at SHC Quality Management Committee meetings
3.   Additional monitoring of POC logs in each area may include a random quality review by the designated Clinic Manager, comparing results documented in log to results documented in EHR.

F.  Quality Assurance Activity Reporting Process
1.   POC testing program monitoring, education and training, individual processor performance measures, and corrective action plans are reported quarterly to the Medical Director and the SHC Quality Management Committee.
 

MEDICAL ASSISTANT STANDING ORDERS FOR ADMINISTERING INFLUENZA VACCINE TO ADULTS

Effective Date: 
Wed, 11/06/2013
Reviewed: 
Wed, 11/06/2013
Revised: 
Thu, 10/23/2014
Policy: 

Purpose:  To reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the CDC for influenza vaccination.

Policy:  Under this standing order from the medical director, MAs may vaccinate patients against influenza provided the patients meet the following criteria. 
1.  The patient has no history of receiving an influenza vaccine for the current influenza season.
2. The Patient does not have any contraindications or precautions to influenza vaccine as defined on the Universal Vaccine Consent form.

Under this standing order, the medical director delegates the authority to supervise the MA to give influenza vaccine to MDs, DOs, registered nurses, pharmacists, physician assistants and nurse practitioners.

Influenza vaccinations may be given by an MA only when there is a physician or advanced practice provider (NP, PA) on the premises of the Student Health Center.

Procedure: 

1. Ask the patient if they have already been vaccinated for flu in this influenza season.
2. Provide the patient with the most current Vaccine Information Statement (VIS). 
3. Give the patient the Universal Consent for Immunization Form and ask them to complete and sign the form.  Review the Universal Consent form for contraindications or precautions, egg allergies.  Make sure the patient signs the consent.
4. If the patient has identified a contraindication, precaution, or history of egg allergy, refer the patient to a clinician for evaluation.
5. In every instance the MA, prior to administration of the vaccination, must present the vaccine to a Registered Nurse, pharmacist, physician, physician assistant or nurse practitioner to verify the correct medication and dosage. 
6. Administer the influenza vaccine as follows: Give 0.5ml of Influenza Vaccine IM in the deltoid muscle. 
7. Document each patients vaccine administration information in the Medical Record including the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, the name and title of the person administering the vaccination and "per Standing Order".   Document that the patient was given the VIS and include the publication date of the VIS in the note.
8. Instruct the patient to wait 15 minutes after their vaccination.
9. Be prepared and familiar with the protocol for the management of a medical emergency (http://shs-manual.ucsc.edu/policy/anaphylaxis-emergency-care-standardize... and/or  http://shs-manual.ucsc.edu/policy/responding-medical-emergencies).
10. Report all adverse reactions to influenza vaccine.  Complete an incident report and submit it to your supervisor for internal review.  The supervisor will assist the MA to submit a report to the federal Vaccine Adverse Event Reporting System (VAERS) at 111.vaers.hhs.gov or (800)822-7967.  VAERS report forms are available at www.vaers.hhs.gov or in Weblinks in the electronic medical record (PNC).
 

V. MA STANDING ORDERS

Effective Date: 
Thu, 10/24/2013

SCREENING FOR TUBERCULOSIS

Effective Date: 
Thu, 09/01/2011
Reviewed: 
Thu, 09/01/2011
Revised: 
Mon, 04/03/2017
Policy: 

This procedure allows the RN to administer tuberculosis (TB) screening tests, interpret the results of these tests, educate the student about their results, and facilitate additional follow-up for students with positive screening test results. Students present for screening for tuberculosis for a number of reasons including the UC-wide policy of screening all new and incoming students for their risk of TB.  According to the CDC, it is appropriate to begin screening for tuberculosis by using a risk assessment questionnaire.  Students who answer no to the risk assessment questions do not need further testing unless they are specifically required to show documentation of a TST/IGRA blood test.   Any student who answers yes to any TB risk assessment question (other than past positive TST) should continue the process of screening with a Tuberculin Skin Test (TST) or an IGRA  (Interferon Gamma Release Assay:  Quantiferon Gold or T-spot) blood test.   Per the CDC, history of receiving BCG may contribute to a false positive skin test.  To minimize the possibility that BCG might cause a false positive TST, in consult with the Santa Cruz County Public Health Department, an IGRA blood test is recommended for those with history of BCG who are asymptomatic for symptoms of TB.  It is also the practice at UCSC Student Health Services to offer an IGRA blood test if the placed TST for asymptomatic students with history of BCG has an induration of 10-14mm.  Indurations larger than this, regardless of BCG history are considered positive.  The IGRA blood test has no possibility of cross-reactivity from BCG.

Procedure: 

 

  • Student presents for screening test.
  • Review student’s completed risk assessment form.
 
1. For all negative risk assessment answers:
 
Determine reason student has presented for testing.  If their form does not require a TB test and their TB risk assessment questionnaire is negative then complete and sign the EMR standard "Letter" indicating “TB Negative by Risk Assessment.”
 
Screening Test Process:
 
If a screening test is required and there is no indication of active disease, review and assist the student to choose one of the two screening tests, either the TST or IGRA blood test.  Explain the considerations in choice of test:
TST is low cost but carries a risk of a false positive.
IGRA costs more.  Has a very low risk of a false positive.
IGRA is a blood test.  TST is a needle/skin test.
IGRA will reduce the chance of a false positive from previous BCG vaccination.
If TST is placed, then explain the need for a second office visit and the process for TST reading 48 to 72 hours after placement.
 
For IGRA, blood test results will be given using the standard UCSC SHC lab result notification system (secure message or phone).
 
2. For positive risk assessment answers:
 
Conduct symptom review:
In each situation, first assess for any indication of active disease by asking about cough, hemoptysis, weight loss, anorexia, and/or night sweats.  With any indication of active disease: mandatory mask, order 1 view CXR, arrange same-day clinician evaluation.  Give copy of SHC handout “TB FAQs”.
 
A. Yes answers to any of the  TB Risk Assessment Questions other than "History of positive TST or IGRA":  if negative current symptoms, continue the screening process,  proceed to “Screening Test Process” as above.
 
B. Yes to “History of positive TST or IGRA” and documentation of treatment (keep copy to scan in to the EMR):  if negative current symptoms = complete the students required form to read “Negative TB Risk Assessment per symptoms review”, or generate a letter from the EMR "Latent TB Rx Completed".  Add to Problem List:  "A15.9 Latent TB Treated".
 
C. Yes to “History of positive TST or IGRA” and stated treatment without documentation:  if negative current symptoms, order 1 view CXR, arrange same-day clinician evaluation. (Encourage and/or assist the student to obtain documentation of treatment for future reference).  Add to Problem List "R76.11 TB Latent or Positive Test", and include the statement "Stated treatment but no documentation"
 
D. Yes to “History of positive TST or IGRA” and stated no treatment:  if negative current TB symptoms review, order 1 view CXR, arrange same-day clinician evaluation.  Clinician adds to Problem List: "R76.11 TB Latent or Positive Test".
 
E. Yes to “History of positive TST 10-14mm & Negative IGRA"  if negative current TB symptoms, complete EMR pre-written letter "TB Negative by Risk Assessment”.
 
F.  Yes to positive TST or IGRA with documentation of negative CXR post positive TST, but no treatment:  if negative current TB symptoms, complete EMR pre=written letter called  “TB Negative by Risk Assessment” and provide copy to patient.  Give patient two handouts:  Latent TB Disease and LTBI Treatment.   Offer an appointment with a Clinician to review optional latent TB treatment.  RN updates Problem List:  "R76.11 TB Latent or Positive Test".
 
Positive symptoms review at any step of the screen process:
 
Assess for any indication of active disease by asking about cough, hemoptysis, weight loss, anorexia, and/or night sweats. With any indication of active disease: mandatory mask, order 1 view CXR, arrange same-day clinician evaluation.  Give copy of SHC handout “TB FAQs”.
 
Notification of results:
 
Negative results TST:  skin test results are read 48-72 hours after placement.  The nurse completes the students form or provide a copy of results using EMR generated form.  If form requires a two-step TB test, schedule next TST for 7 - 21 days after the initial test.  Two step testing is indicated for people who will be TB tested annually.   The two step tuberculosis test can find the small number of people who were exposed to tuberculosis a long time ago and need to have their immunity boosted with a first TB test in order to show this prior exposure on their second TB test.
 
If the results are needed for UC-wide TB Risk Screening Compliance, the nurse will "Add Event" to the Immunization Section of the EMR and update compliance manually. Students with positive results should forwarded to the Nursing Supervisor after "Add Event" is completed.
 
Positive TST:  
A positive reaction is measured in millimeters of induration, measured in one direction only,  perpendicular to the long access of the arm.  If a positive test is suspected, the nurse will have a second nurse or clinician confirm the result.  A positive reaction is defined by a combination of the millimeters of induration plus the circumstances of a patient’s condition and risk or exposure:
 
The UCSC SHC uses the CA Tuberculosis Controllers Association guideline as follows:
 
Reaction 0-4mm of induration are considered negative.
 
Reaction 5 mm - 9mm of induration are considered negative unless student has:
 
• Human immunodeficiency virus (HIV)-positive persons
• Recent contacts of tuberculosis (TB) case patients
• Fibrotic changes on chest radiograph consistent with prior TB
• Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 mg/d of prednisone for 1 month or more)
 
With any of the above  conditions present and a TST of 5-9mm, the student is considered positive for LATB
 
Reaction 10mm - 14mm of induration is considered positive.  Except students with a history of BCG.   With history of BCG and TST 10mm-14mm, offer IGRA. Provide the Quantiferon Fact Sheet.   A negative IGRA in this case is considered negative for LATB.
 
Reaction of 15mm or >, regardless of BCG history or negative IGRA, are considered positive for LATB.
 
Negative results IGRA:  Provide results using the UCSC SHC standard lab notification system; stress the importance of:   keeping a copy of the results for future proof of negative screening.  For patients with a history of previous positive TST and now a negative IGRA, instruct for future to avoid future TST testing, symptoms review only.
 
Positive or Equivocal IGRA:
Students with a positive or equivocal IGRA are to be contacted by phone with their
results.  Then follow the procedure for positive or equivocal IGRA below.
 
Follow-up on Positive results:
 
For students with a positive screening test, either TST or IGRA:
 
Assess again for any indication of active disease by asking about cough, hemoptysis, weight loss,
anorexia, and/or night sweats.  With any indication of active disease: mandatory mask, order 1
view CXR, arrange same-day clinician evaluation.
 
With no indication of active TB: order a 1-view PA chest x-ray and arrange a clinician
appointment on the same day as the x-ray to discuss treatment latent tuberculosis (LATB).   Give and review two handouts with patient:  Latent TB Disease and LTBI Treatment.  Clinician updates Problem List to indicate "R76.11 TB Latent or Positive Test"
 
Any positive results for students needing to meet UC-wide TB Risk Screening with or without symptoms should have chart note  forwarded to the Nursing Supervisor.
 
 
 
Equivocal IGRA:
Arrange a non-same day clinician appointment to review the results.
 
Additional Considerations:
If a student indicates that they have a history of (LATB) with treatment, assist them to obtain documentation of this.    If they have a negative review of symptoms for active TB, then determine if they will need a chest x-ray to satisfy the requirements of their program.
 
Students who are traveling to a high risk area should be reminded to be tested upon their return.
Patients referred by a clinician for testing are to be referred back to that clinician.
 
Experience, Training and/or Education
Current California RN License
Completion of UCSC orientation specific to Tuberculosis screening
 
Evaluation of Competency
Initial Competency:
Observes experienced RN implementing this procedure
Demonstrates successful use of this procedure under direct RN supervision at least three times
Submits a minimum of 5 chart notes demonstrating use of the procedure to the Clinic Director for review
 
On-going Competency:
Chart reviews of this procedure occur as part of the on-going Quality Assurance program of the UCSC Health Center.
 
Scope of Supervision 
No direct supervision required. Clinicians available on site for consultation and evaluation as needed.
 
Criteria for Provider Consultation and Referral
 
RN is to arrange same-day appointment with a clinician consult for any students with any indication of active disease on review of risk assessment form or after questioning.
RN is to consult with DOC or Patient Care Coordinator for any question about disposition of a particular case.
 
Documentation
RN documents according to the standards delineated in the UCSC Policy on Documentation of Care.

RN STANDARDIZED PROCEDURE MEDICATION LIST

Effective Date: 
Mon, 08/01/2011
Reviewed: 
Fri, 01/21/2011
Revised: 
Tue, 05/09/2017

LVN STANDING ORDERS FOR INITIATION OF TREATMENT FOR VACCINE ADVERSE REACTIONS IN ADULTS PATIENTS

Effective Date: 
Fri, 10/09/2009
Reviewed: 
Sun, 08/28/2011
Revised: 
Mon, 08/29/2011
Policy: 

Purpose: All vaccines have the potential to cause an adverse reaction.   In order to minimize adverse reactions, patients should be carefully screened for precautions and contraindications before vaccine is administered. Even with careful screening, reactions may occur. These reactions can vary from trivial and inconvenient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management.

Policy: Under these standing orders, eligible Licensed Vocational Nurses allowed by state law andwho have demonstrated competence in administration of oral and intramuscular medications, may initiate treatment of adverse reactions to immunizations.  Sign & symptoms of adverse reactions covered under this standing order include:  Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips,face, or throat); bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. 

Procedure: 

1. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms & immediately notify the UCSC Student Health Center Doctor On Call (DOC).

2. If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911) and notify the UCSC Student Health Center Doctor On Call (DOC).  This should be done by a second person, while the primary nurse assesses the airway, breathing, circulation, and level of consciousness of the patient.

3. Administer aqueous epinephrine 1:1000 dilution intramuscularly, 0.01 mL/kg/dose (adult dose ranges from 0.3 mL to 0.5 mL, with maximum single dose of 0.5 mL).

4. In addition, for systemic anaphylaxis, administer diphenhydramine either orally or by intramuscular injection; the standard dose is 1–2 mg/kg, up to 100 mg maximum single dose.

5. Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient’s head may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes.

6. If EMS has not arrived and symptoms are still present, may repeat dose of epinephrine every 10–20 minutes for up to 3 doses, depending on patient’s response and under the direction of the UCSC Student Health Center Doctor On Call (DOC).

7. Record all vital signs, medications administered to the patient, including the time, dosage, response, and the name of the medical personnel who administered the medication, and other relevant clinical information.

This policy and procedure shall remain in effect for all patients of the UCSC Student Health Center until rescinded.

Medical Director’s signature:

Electronically signed by Dr. Drew Malloy; original signed hard copies on file in the Assistant to the Executive Directors office  10/9/09

 

 

 

 

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