Care Of High Risk Patients & Provision Of High Risk Services

Female Doctor Female Doctor

a) Emergency Patients

  • Staffing
    ER Physicians, ER Nurses, EMTs
  • Competency:
    Physicians: BLS, SCLS + other Life Support Courses,
    Nurses: BLS, ACLS + other Life Support Courses, EMT: BLS
  • Process: Initial Triage, Emergency Room Assessment
  • Document: Focus on ER Assessment, History & Physical Examination, Consents for procedures, medication, investigation requiring management & critical care
  • Monitoring: Vital signs monitored during stay as required & prior to discharge as required
  • Equipment: As per need — ECG; Defibrillator, Pulse Oximeter, Ventilator
  • Evaluation: Compliance to relevant protocol, (e.g. door to needle, door to balloon, Sepsis, GI bleeding)

b) Code Blue

  • Staffing: Code Blue Team: ER Doctor, Internal Medicine Doctor, Anesthesia, ICU Nurse, ECG Technician, Hospital Nursing Supervisor
  • Competency: All staff— BLS & ACLS
  • Process:  Start BLS algorithm — CPR, Call emergency extension number, Code Blue Team take over, Use Crash Cart, Defibrillator, O2 as required.
  • Document: Code Blue Sheet, Document the entire process in the Progress Notes
  • Monitoring: Physiological Vital Parameters
  • Equipment: Pulse Oximeter, ECG Monitor, Cardiac monitor/ Defibrillator; Crash Cart and Oxygen Cylinder as required
  • Evaluation: Review of Code Blue cases thru CPR Committee, Review of Code Blue form completion.

c) Blood Transfusion

  • Staffing: Physician, Staff Nurse, Lab Technician
  • Competency: Nurse competency in IV Therapy + Blood Transfusion
  • Process: Take Informed consent, Check blood, Check vital signs as baseline then 15 minutes. For the first hour then hourly till end and after 1 hour post blood transfusion
  • Document: Informed Consent, Doctor’s Order Sheet, Progress Notes, Blood
  • Transfusion Documentation form
  • Monitoring: Monitor vital signs and transfusion reaction and report transfusion reaction (if any)
  • Equipment: Blood Transfusion set, 18G Cannula
  • Evaluation: CT Ratio, Blood Transfusion Reaction report


STOP TRANSFUSION! à call the Doctor on-duty and inform Blood Bank staff àStart IV Fluid (NS) àSend blood bag to Blood Bank for review àtake blood sample for other handàsend urine and blood sample for culture à complete Blood Transfusion Reaction form

d) Dialysis Patients

  • Staffing: Nephrology physicians; dialysis nurses, biomedical dialysis technicians
  • Competency: Trained and competent dialysis nurses, Physicians with granted privileges
  • Process: Initial assessment/ Triaging
  • Document:  Complete routine dialysis record, Physician Progress Notes (weekly), Nursing H & P (annually)
  • Monitoring: Pre & post dialysis weight, AVF graft access, vital signs hourly basis
  • Equipment: Hemodialysis machine; single use dialyzers
  • Evaluation: Urea Reduction Rate (URR), Dialysis water testing biochemical for ARO, microbiology, endotoxin level

e) Restraints Patients

  • Staffing: Physician and Nurses
  • Competency: Nurses training in monitoring restraint Know type of restraints
  • Process: Complete H&P; Document reason of restraint; use Physical Restraint Documentation form
  • Document: Doctor’s Order every 24 hours; Patient & Family Education; record intake output, Nurse Monitoring documentation: 15 min for 1 hr., hourly thereafter
  • Monitoring: Monitor (behavior, skin color, skin sensation, movement, nursing care), Fluid Intake & Output, Evaluate need of restraint within 24 hours, (Restraints every 2hrs & release for 1 hr.)
  • Equipment: Specialized restraint types, when required
  • Evaluation: Falls Risk Assessment

f) Comatose Patients

  • Staffing: ICU Physician; Nurses
  • Competency: Training in Critical Care; Competency Evaluation for all staff; ACLS trained
  • Process: Admission & Discharge Criteria; Skin Bundles; Plan of Care; Pain Mgt. in comatose
  • Document: Complete H&P; Document sedation agent
  • Monitoring: ICU flow sheet component monitoring Pain; End of Life care; VAP Bundle
  • Equipment: Central Monitor, Bed side Monitors, ECG monitor, Ventilator, Syringe and infusion pumps
  • Evaluation: Pressure Ulcer, Falls Risk Patient Identification

g) Infectious Patient

Patient Care Structure for Infectious Patients in relation to: Staffing, Competency, Process, Documentation, Monitoring, Equipment & Evaluation — refer to Infection Control policies and procedures for proper reference and adherence.

h) Immuno-compromised Patients

Patients Care Structure for Infectious Patients in relation to: Staffing Competency, Process, Documentation, Monitoring, Equipment & Evaluation-refer to Infection Control policies & procedures for proper reference and adherence.


i) Pain Management

  • Staffing: All healthcare providers
  • Competency:
  • Nurses with competency (epidural analgesia, patient controlled analgesia, pain management), doctors & Anesthetist with privileges
  • Process: Use of Pain Assessment Form & Pain Tools
  • Document: Completed H&P, pain & treatment documented in Doctors Progress
  • Monitoring: Notes and Nurses Progress Notes, Use of Pain Assessment Flow Sheet
  • Every 4 hours in acute care areas, Hourly in ICU or as per doctor’s order, Re-assess after 3o min. following any pharmacological or non pharmacological interventions and/ or as per standing order Outpatients are assessed at every encounter
  • Equipment: Syringe pump, PCA pump (if needed)
  • Evaluation: Pain Assessment Intervention & Re-assessment (AIR Cycle), Continuous Epidural Analgesia, Patient Controlled Analgesia


  1. really good information thank’s sharing about care of high risk patients and provision of high risk services..

  2. One way to do that is to identify patients at highest risk for hospitalization, ER visits and high-cost care, and then pour dedicated practice resources into the care of those patients.


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