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.
The RN making the evaluation uses the following procedure:
Experience, Training and/or Education
Evaluation of Competency
Scope of Supervision
Criteria for Provider Consultation and Referral
To appropriately expedite the care of patients with chemical exposures to eyes in order to minimize potential for related vision loss.
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:
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:
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:
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
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.
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
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.
The test cassette contains mouse anti-beta hCG antibody conjugated to colloidal gold and goat anti-alpha hCG antibody coated on the membrane.
• Test cassettes
• Disposable pipettes
• Instructional insert Materials
Required But Not Provided
• Specimen collection container
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.
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.
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.
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.
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
Consult Diagnostics hCG Combo Cassette Package Insert 09/13
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.
Collector – Staff member who obtains the specimen
Processor – Staff member who performs the test
POC – Point of Care
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)
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.
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.
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).
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.
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.
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