EMG-2014-008 - University Hospital...EMG-2014-008 Page 1 of 6 Medical Directive Title: Emergency Department Asthma Medical Directive-Paediatric Age 1 to 17 years Lead Contact Person:

EMG-2014-008

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Medical Directive Title: Emergency Department Asthma Medical Directive-Paediatric Age 1 to 17 years

Lead Contact Person: Christina Scerbo, Clinical Educator, Cathy Trocchi, Respiratory Therapist & Alyson Wilson, Resource Nurse Physician Lead: Dr. Rod Lim, MD

Program: LHSC- Paediatric Emergency Department

Approval By: Medical Advisory Committee Original Effective Date: April 10, 2013

Revised Date: To Be Reviewed Date:

This Medical Directive Applies to the following sites:

All LHSC sites LHSC-UH LHSC-VH LRCP LHSC-SSA BFMC VFMC

Other:

This Medical Directive Applies to the following patient population:

In-Patients Out-Patients Adults Paediatrics Neonates

Order:

The Registered Nurse (RN) / Registered Respiratory Therapists (RRT) in the Paediatric Emergency Department will initiate the following assessments and treatment for the treatment of asthma in children;

• Physical assessment and chest auscultation• Vital signs (temperature, pulse, respirations and blood pressure)• Oxygen saturation (SpO2)• Weight• Paediatric Respiratory Assessment Measure (PRAM) score (Appendix A)• Initiate and titrate supplemental oxygen to maintain/obtain SpO2 greater than or equal to 92%

Mild Asthma Exacerbation: In the setting of PRAM score equal to 1-3 (including the presence of wheeze):

• Administer salbutamol: metered dose inhaler (MDI) with spacer device (100 mcg/puff) 4 to 8puffs per dose or nebulized 1.25 mg to 5 mg per dose in 3 mL sodium chloride 0.9%, as perflowchart (Appendices B &C) attached. Administer first dose as soon as possible. Mayadminister every 60 minutes. See flowchart (Appendix B). MDI with spacer is preferred deliverysystem unless continuous oxygen is required.

• Reassess vital signs and PRAM q 60 min. If PRAM worsening at next assessment, alertphysician.

June 8, 2016 June 8, 2019

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Moderate Asthma Exacerbation: In the setting of PRAM score equal to 4-7:

• Salbutamol: metered dose inhaler (MDI) with spacer device (100 mcg/puff) 4 to 8 puffs per dose or nebulized 1.25 mg to 5 mg per dose in 3 mL sodium chloride 0.9%, as per flowchart(Appendices B & C) attached. Administer first dose as soon as possible. May administer every 30 minutes as needed. See flowchart (Appendix B). MDI with spacer is preferred delivery system unless continuous oxygen is required.

• Dexamethasone (0.6 mg /kg; max dose 16 mg) PO once, as soon as possible following salbutamol: See Ontario Lung Association flowchart (Appendix B). Note that the maximum dose reflected in the Ontario Lung Association flowchart (Appendix B) is 12 mg. Based on literature the physician team within the department uses the maximum dose of 16 mg (Watnick et al, 2015).

• Reassess vital signs and PRAM q 30 min (if PRAM, Appendix A, score decreases reassess according to new score). If PRAM worsening at next assessment, alert physician.

Appendix Attached? Yes No

Recipient Patients:

Patients who are registered in the Paediatric Emergency Department presenting with symptoms of an acute asthma exacerbation (e.g. dyspnea, wheezing), under the care of an authorizing physician, who meet the following:

Inclusion Criteria: Patients ages 1 to 17 years with wheeze and/or cough AND asthma diagnosis OR past history of wheeze who have had a Paediatric Respiratory Assessment Measure (PRAM) (Appendix A).

Authorized Implementers: Position/Title Qualifications/Certifications

Registered Nurse Current registration with the College of Nurses of Ontario; Employee of LHSC in the Paediatric Emergency Department

See additional qualifications listed below under “Educational Requirements”

Registered Respiratory Therapist Current registration with the College of Respiratory Therapists of Ontario; Employee of LHSC

See additional qualifications listed below under “Educational Requirements”

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Indications & Contraindications: • IndicationsChildren aged 1 to 17 years with wheeze and/or cough AND asthma diagnosis OR past history ofwheeze, AND presenting with mild, moderate symptoms of asthma as assessed by PaediatricRespiratory Assessment Measure (PRAM) score ≥ 1.

• Contraindications:Severe Asthma Exacerbation (i.e. PRAM 8-12)

Re: medical directive in whole - croup or upper airway obstruction- caregiver refusal- If patient has any active chronic conditions other than asthma, suspend medical directive and obtainphysician assessment and orders for care.

Re: salbutamol - heart rate greater than 200 beats/min; and/or- known cardiac arrhythmia; and/or- Allergic to salbutamol →hold salbutamol and proceed with rest of medical directive. Obtain physicianassessment as soon as possible.

Re: dexamethasone - Patient unable to take medication via oral route →request physician assessment and orders andproceed with remainder of medical directive.- Patient with active or suspected incubation of chickenpox infection →hold dexamethasone andproceed with rest of medical directive. Obtain physician assessment as soon as possible.- Allergic to dexamethasone→hold dexamethasone and proceed with rest of medical directive. Obtainphysician assessment as soon as possible.

Medication / Drug Table: Please identify all medications/drugs, using the chart below, which are included under this medical directive by listing the AHFS classification and then identifying which drugs are INCLUDED and specific to your practice.

Note: medical directives for medication orders excludes: non-formulary medications, special access program medications/investigational drugs, off-label use medications, and narcotics, controlled drugs, and benzodiazepines (definition of practitioner as defined under CDSA and Narcotic Regs restricts prescribers).

For any off-label use of a specific medication to be included, the actual drug and indication must be listed individually and not in the AHFS classification section (e.g. Gabapentin for pain).

Drug Name (GENERIC) LIST INCLUSIONS

Indications Route of Administration

Special Consideration (e.g. monitoring, lab tests)

Salbutamol Bronchospasm Inhalation Monitor serum K+, glucose

Ipratropium bromide Bronchospasm in severe asthma exacerbation in the ER

Inhalation

Dexamethasone Airways inflammation Oral

(for formulary listings see - https://pharmapp.lhsc.on.ca/formulary_prod/public/search.php)

https://pharmapp.lhsc.on.ca/formulary_prod/public/search.php

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Consent Consent (verbal and/or implied) must be provided by patient or substitute decision maker prior to commencing medical directive. Guidelines for Implementing the Order/Procedure This medical directive allows registered nurses and registered respiratory therapists to initiate pharmacotherapy with inhaled bronchodilators and oral corticosteroid as soon as possible to children and adolescents who present to the Paediatric Emergency Department with a clinical picture consistent with asthma and who are entered into the Paediatric Emergency Department Asthma Clinical Pathway (Asthma Pathway). Although it is intended that these patients will be treated by a physician according to the Asthma Pathway, the earliest possible therapy initiated by nurse / respiratory therapist will allow symptom relief while awaiting assessment by the physician and is anticipated to shorten the patient’s length of stay in the ED and reduce the rate of hospital admission. Dosage, frequency and choice of medication will be determined by the patient’s age and degree of respiratory distress as described in the Asthma Pathway appended to this medical directive. The physician will be notified immediately at any time if the patient is not responding or is deteriorating with the planned treatment. Any untoward event suspected to be related to the implementation of this directive will be reported immediately to the attending physician. The event will also be documented in the patient’s chart. Educational Requirements

• Knowledge and understanding of Paediatric Emergency Department Asthma Care Pathway (P-EDACP)

• Review of “Paediatric Asthma at LHSC 2014 powerpoint presentation (posted on LHSC intranet Paeds ER and Respiratory Therapy websites)

• Successful completion of the P-EDACP learning module through: www.machealth.ca/programs/edacp/default.aspx (or iLearn when available)

• Additional learning/teaching resources available at: www.on.lung.ca and www.machealth.ca.

Appendix attached? Yes No References Alnaj, F., Zemek, R., Barrowman, N., & Plint, A. (2014). PRAM score as predictor of pediatric asthma hospitalization. Academic Emergency Medicine. 21, 872-878. Cronin, J. J. et al. (2015). A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbation of asthma in children who attend the emergency department. Annals of Emergency Medicine. S0196-0644(15), 1-12. Ducharme, F. M. et al. (2008). The Pediatric Respiratory Assessment Measure: A valid clinical score for assessing acute asthma severity from toddlers to teenagers. The Journal of Pediatrics. 152(4), 476-480. The Lung Association of Ontario. (2014). Paediatric Emergency Department Asthma Clinical Pathway.

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Documentation & Communication • Medication Record • Paediatric Respiratory Assessment Measure (PRAM) Record which includes vital signs

(temperature, pulse, respirations and blood pressure) and oxygen saturation (Appendix D) • Documentation on the PRAM Documentation Record (Appendix A); frequency as per PRAM

severity. PRAM 1-3: Reassess vital signs and PRAM q 60 min PRAM 4-7: Reassess vital signs and PRAM q 30 min

• Patient Education Checklist (Appendix E) • Asthma or discharge education for families (Appendix F)

Review and Quality Monitoring Guideline:

• If any unanticipated outcomes arise that affect the patient while performing this medical directive please notify Most Responsible Physician.

• General issues regarding this protocol will be addressed with a Paediatric Respirologist at LHSC-VC and Dr. Rod Lim, or a Paediatric Emergency Physician lead at LHSC-VC and a Paediatric Respiratory Therapy leader at LHSC.

• Any adverse events directly resulting from the implementation of this protocol shall be reported through the LHSC Adverse Events Management System (AEMS) as per LHSC policy (https://policy.lhsc.on.ca/policy/reporting-and-investigation-adverse-events-and-near-misses-involving-patients-visitors).

• Medical directive will be reviewed bi-annually with physicians, respiratory therapists, coordinator, manager, educator, and nurses from the Paediatric Emergency Department

This protocol will be reviewed at least every 3 years as per LHSC - The Use of Medical Directives/Pre- printed Protocols (PCC009) guidelines by the Medical Advisory Committee (MAC). • Authorized implementers will provide proof of obtaining at least 75% on the P-EDACP learning

module through www.machealth.ca and demonstrate knowledge and understanding of the use of this medical directive.

Professional Staff Approvals (Physician, Dentist, Midwife): • Identify all Professional Staff members (less than 10 list by individual name, greater than 10 list by

title & program) responsible for patients who may receive an order or procedure under this medical directive.

NAME DEPARTMENT / PROGRAM Edmonds, Marcia Paediatric Emergency Department

Helleman, Krista Paediatric Emergency Department Istasy, Victor Paediatric Emergency Department Joubert, Gary Paediatric Emergency Department Kilgar, Jenn Paediatric Emergency Department Lim, Rod Paediatric Emergency Department Loubani, Eman Paediatric Emergency Department Lynch, Tim Paediatric Emergency Department Mehotra, Shruti Paediatric Emergency Department Misir, Amita Paediatric Emergency Department Mosdossy, Greg Paediatric Emergency Department Poonai, Naveen Paediatric Emergency Department Rieder, Michael Paediatric Emergency Department Salvadori, Marina Paediatric Emergency Department Sangha, Gurinder Paediatric Emergency Department Warren, Dave Paediatric Emergency Department

https://policy.lhsc.on.ca/policy/reporting-and-investigation-adverse-events-and-near-misses-involving-patients-visitorshttps://policy.lhsc.on.ca/policy/reporting-and-investigation-adverse-events-and-near-misses-involving-patients-visitors

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Administrative Authorization Approval Form

Please note: signature pages are not to be signed until the medical directive has been approved. Name of Directive: Emergency Department Asthma Medical Directive-Paediatric Age 1 to 17 years Lead Contact Person (s): Dr. Rod Lim, Christina Scerbo, Clinical Educator, Cathy Trocchi,

Respiratory Therapist & Alyson Wilson, Resource Nurse IMPORTANT: This template is a general document that may need modification based on the needs of the directive. Please modify appropriately. • Identify all administrative bodies, including individuals (PPL’s, managers, directors, chiefs) and other

approving bodies (i.e. Medical Advisory Committee, Drug & Therapeutics Committee) that must approve the medical directive.

Administrative Authorizations

(approved by): Signature Date

Chair, LHSC Medical Advisory Committee - Dr. Mark MacLeod

Chief Nursing Executive, Quality & Patient Safety Officer, and Professional Scholarly Practice – Dr. Vanessa Burkoski

Chair, LHSC Drug & Therapeutics Committee, or delegate – Dr. Philip Jones

Site Chief, Paediatric Emergency Medicine – Dr. Rod Lim

Director Children’s Care – Jill Craven

Coordinator, Paediatric Emergency Medicine – Claire Martin

Manager, Respiratory Therapy , LHSC Kevin Tiggeloven

Implemented by: (Person(s) performing initiation or

person representing a large group and responsible for notification of that

group)

Signature Date

Respiratory Therapy , LHSC: Cathy Trocchi

Clinical Educator, Paediatric Emergency, LHSC Children’s Hospital: Christina Scerbo

Paediatric Emergency, LHSC Children’s Hospital, Registered Nurse: Alyson Wilson

Asthma Medical Directive – Paediatric Age 1 to 17 years

Appendix A

Copyright © 2014 Ontario Lung Association. All rights reserved. Without the prior written permission of the Ontario Lung Association, any and all copying, reproduction, distortion, mutilation, modification, or the

authorization of any such acts is strictly prohibited. September 2014

Emergency Department Paediatric Asthma Medical Directive Appendix B: Medical Directive Flowchart PRAM 0-3 (+ wheeze) PRAM 4-7 PRAM 8-12 Impending Respiratory

Mild Moderate Severe Failure

ADMINISTER:

OR

REPEAT:

• PRAM 0 to 3: q 60 minutes PRN, to a maximum of

2 doses in the first hour

• PRAM 4 to 7: q 30 minutes PRN, to a maximum

of 2 doses in first hour

ADMINISTER:

OR

REPEAT: (both salbutamol and ipratropium bromide)

• PRAM 8 to 12: q 20 minutes x 3 doses in the first hour

• “Impending Respiratory Failure”: repeat continuously

Administer oxygen as required to keep SpO2 ≥ 92%

ADMINISTER ORAL CORTICOSTEROIDS*:

for “Moderate” (PRAM 4-7) as soon as possible:

for “Severe” (PRAM 8-12) and “Impending Respiratory Failure” as soon as possible:

Dexamethasone 0.6 mg/kg PO x 1 dose (maximum 12 mg/dose)

*if patient unable to take medication via oral route, notify MD immediately

salbutamol metered dose inhaler (MDI) preferred, unless continuous oxygen required;

dose by patient’s age:

1 – 3 yrs = 4 puffs


7 yrs and older = 8 puffs

AND

ipratropium bromide metered dose inhaler (MDI) – 3 puffs

via metered dose inhaler (MDI) and age appropriate spacer;

allow 30 seconds between each puff; alternate each puff of ipratropium bromide with salbutamol

salbutamol (solution/nebule) via continuous nebulization, dose

by patient’s weight:

less than () 20 kg = 5 mg

AND

ipratropium bromide (solution/nebule):

250 mcg mixed with salbutamol; add normal saline for total

volume of 3mL

salbutamol metered dose inhaler (MDI) preferred, unless continuous oxygen required;

dose by patient’s age:



7 yrs and older = 8 puffs

via metered dose inhaler (MDI) and age appropriate

spacer; allow 30 seconds between each puff.

salbutamol (solution/nebule) via continuous nebulization,

dose by patient’s weight.:

less than () 20 kg = 5 mg

If necessary increase volume to 3 mL with normal saline

MD to assess STAT and remain in attendance until patient

is stabilized

If patient’s condition worsens at any time, notify physician immediately

NS7443 (2015/10/20) Side 1 See Over →

PAEDIATRIC RESPIRATORY ASSESSMENT MEASURE (PRAM) RECORD

KEY: BPM = Beats Per Minute; LPM = Litres Per Minute; C = Celsius ADDRESSOGRAPH

Date: (YYYY/MM/DD)

Time: (24 h clock)

Pre Medication ()

Temperature (C)

Respiratory Rate (BPM)

Heart Rate (BPM)

FiO2 (% or LPM)

SpO2

P R A M

S C O R E

Oxygen Saturation Room Air

> 95% 0

92-94% 1

< 92% 2

Suprasternal Retractions

absent 0

present 2

Scalene Retractions

absent 0

present 2

Air Entry normal 0

↓ base 1

↓ apex and base 2

minimal or absent 3

Wheezing absent 0

expiratory only 1

Inspiratory + Expiratory

2

audible without stethoscope 3

silent chest 3

Total PRAM Score

INITIALS

NS7423 (2015/10/20) Side 2

PAEDIATRIC RESPIRATORY ASSESSMENT MEASURE (PRAM) RECORD

KEY: BPM = Beats Per Minute; LPM = Litres Per Minute; C = Celsius ADDRESSOGRAPH

Date: (YYYY/MM/DD)

Time: (24 h clock)

Pre Medication ()

Temperature (C)

Respiratory Rate (BPM)

Heart Rate (BPM)

FiO2 (% or LPM)

SpO2

P R A M

S C O R E

Oxygen Saturation Room Air

> 95% 0

92-94% 1

< 92% 2

Suprasternal Retractions

absent 0

present 2

Scalene Retractions

absent 0

present 2

Air Entry normal 0

↓ base 1

↓ apex and base 2

minimal or absent 3

Wheezing absent 0

expiratory only 1

Inspiratory + Expiratory

2

audible without stethoscope 3

silent chest 3

Total PRAM Score

INITIALS

Copyright © 2014 Ontario Lung Association. All rights reserved. Without the prior written permission of the Ontario Lung Association, any and all copying, reproduction, distortion, mutilation, modification, or the authorization of any such acts is strictly prohibited. September 2014

Hospital Logo

Emergency Department Asthma Clinical Pathway Paediatric: 1 to 17 years Education Checklist

Patient Education Checklist Learning Goals Reviewed with Patient (To be completed by Physician / Nurse / Nurse Practitioner / RT / Pharmacist)

Initials & Comments

1. Assessed device/spacer technique and demonstrated optimal technique: Metered dose inhaler (MDI) with spacer: Ensure age/ability-appropriate valved spacer/device and demonstrate optimal technique Spacer with mouthpiece - Shake MDI canister and place end into holding chamber, breathe

out, place holding chamber mouthpiece into mouth and make a seal, release puff, inhale slowly (no whistle), hold for 10 seconds, exhale, wait 30 seconds between each puff of the same MDI.

Spacer with mask - Shake canister, place end of MDI into holding chamber, place mask over mouth and nose and make a seal, release puff, allow patient to inhale and exhale approximately 3 times. Wait 30 seconds between each puff of the same MDI.

2. Reviewed basics of asthma: Airway inflammation (swelling), increased mucus, and bronchospasm (airways narrow)

3. Symptom recognition: Cough, wheeze, chest tightness and/or shortness of breath

4. Reviewed asthma triggers: Know your asthma triggers Avoid cigarettes and secondhand smoke

5. Reviewed asthma medications: a. Relievers (e.g. Airomir®, Apo-Salvent®, Bricanyl®, Novo-salmol®, salbutamol,

or Ventolin®) – (often blue containers) Relax smooth muscle around airways. Rapid relief

b. Controllers (e.g. Advair®, Alvesco®, AsmanexTM beclomethasone, Flovent®, Pulmicort®, QVAR®, or Symbicort®, Zenhale®)

Treat airway inflammation and mucus; Need to be taken regularly even when feeling well.

c. Oral Steroids (e.g. prednisone, prednisolone) Treats severe airway inflammation and mucous Short term therapy

6. Asthma Quiz for Kids – (see reverse of discharge plan) Measure of current control

7. Arrange regular follow-up Family Physician, Paediatrician, Asthma Educator, Specialist

8. Discharge Plan and Prescription Given and explained If no drug plan, refer to Social Work or Trillium Fund (available through most pharmacies)

9. Hospital’s Asthma (if available) or The Lung Association booklet given to patient.

Name (print): ___________________________ Signature: _______________________________ Status:______

Date (YYYY/MM/DD):_______________________ Time:______________

D

My Medications

Controller: ________________________ ____puffs _____times a day (every day)

________________________ ____puffs _____times a day ____________________________________________ Reliever: _____________________ ____puffs every _____ hrs as needed

Use Reliever before exercise □

less than 4 hours

My Asthma is Under Control Breathing is good Running & playing normally Cough or wheeze less than 4 times a week Using reliever puffer less than 4 times per week Not missing school because of asthma/breathing Night time symptoms less than once per week

My Asthma May Not Be Well Controlled: If signs of a cold are developing Cough or wheezing is bothering you/your child Waking up because of asthma

ASTHMA ACTION PLAN Date:______________ Completed by:_______________________

My Asthma is out of Control: Very short of breath or severe wheezing Difficulty breathing “Pulling in” of skin between ribs Cannot do usual activities Tired because of effort of breathing Adapted with permission from Children’s Hospital of Eastern Ontario (CHEO)

1) If you need your reliever more often than every 4 hours seek medical attention

2) If your symptoms are not improving within 15 minutes of taking your reliever medication go to your nearest Emergency department or call 911

Take 6 puffs of reliever medication every 10-15 minutes on your way to the hospital.

a. less than 4 hours

DIS

CH

AR

GE

P

LA

N

My Medications Continue to take these medications after you go home.

Once completed, start using your Green Zone medications:

1) Oral Steroids: _________________________ for_______days

2) Controller: _____________________ ___puffs____ times a day (every day) _____________________ ___puffs____ times a day ________________________________________

3) Reliever: ______________________ ___puffs every_____hrs ______________________ ___puffs every_____hrs

□ Please see your doctor within ________ days

Appointment: ___________________________ □ Refer to Paediatric Asthma Clinic (Fax 58156) for: 1) Any child with recent asthma hospitalization 2) Patients with asthma and no family doctor/pediatrician 3) Patients with more than 2 visits to ED in the last year for croup/bronchiolitis/pneumonia/asthma 4) All patients with poor asthma control

Addressograph

Continue to use your Green zone medications AND: Use your reliever _____________ ___puffs every ____hrs _________________________________________________ _________________________________________________

If symptoms are worsening or not improved in

3-4 days see a doctor

Start taking oral steroid _________________once daily

ASTHMA QUIZ FOR KIDZ* YES NO

* Adapted with permission of the authors and the publisher: Ducharme FM, Davis GM, Noya F, Rich H, Ernst P. The Asthma Quiz for Kidz: a validated tool to appreciate the level of asthma control in children. Can Respir J, 2004; 11(8): 541-6.

SELF-MANAGEMENT

1. Know and avoid your triggers 2. Know your medication and how and when to take it. Take controller medications regularly. 3. Follow your action plan 4. After any emergency room visit, you need to schedule a follow-up appointment with a doctor in

the next 2 weeks. 5. Follow up with a doctor 2-4 times per year depending on your medication needs

6. Always have spare reliever medication available

Most common trigger in children is COLDS. Wash hands often. Follow the Yellow Zone at first sign of a cold.

Don’t smoke! Do not allow others to smoke in your home or car. Encourage your parents to STOP smoking. Even if they smoke outside, the smoke in their clothes and

hair can trigger your asthma.

Avoid fumes, chemicals, and strong scents.

Keep bathroom and basement dry. Avoid both decomposing leaves and garden waste in

the spring / fall seasons.

IF ALLERGIC – Please follow the recommendations for the things your child is allergic to. Avoid pets with fur or feathers.

Close windows during pollen season (Spring and Fall). Air-condition your home and car. Avoid freshly cut grass.

Wash bed sheets in hot water. Vacuum and dust regularly. Cover pillows and mattresses with dust mite-resistant covers.

COPY 1 – PATIENT, COPY 2 – MEDICAL CHART, COPY 3 - PHARMACY













1. Did you cough, wheeze, or have a hard time breathing 1-2 or more days out of the last 7 days?

2. Did you wake up at night because you were coughing, or wheezing, or having a hard time breathing 1 or more times in the last 7 days?

3. Did you use your blue puffer 4 or more times in the last 7 days?

4. In the last 7 days, did you do less exercise or sports because it was making you cough, wheeze, or you were having a hard time breathing?

5. In the last 30 days, did you miss school or regular activities because you were coughing, wheezing, or having a hard time breathing?

6. In the last 30 days, did you go to a clinic or a hospital without an appointment because you were coughing, wheezing, or having a hard time breathing?

• How many times did you answer YES? _____ • If you said YES 2 OR MORE TIMES, YOUR ASTHMA IS NOT WELL CONTROLLED. Talk to your mom and dad

about seeing a doctor.

EMG-2014-008 - Renewal Medical Directive Action FormEMG-2014-008 Paediatric Asthma PathwayEmergency Department Asthma Medical Directive-Paediatric Age 1 to 17 yearsMedical Directive Title:Christina Scerbo, Clinical Educator, Cathy Trocchi, Respiratory Therapist & Alyson Wilson, Resource NurseLead Contact Person:Dr. Rod Lim, MDPhysician Lead:LHSC- Paediatric Emergency DepartmentProgram:Medical Advisory CommitteeApproval By:To Be Reviewed Date:Revised Date:Original Effective Date: This Medical Directive Applies to the following sites: All LHSC sites LHSC-UH LHSC-VH LRCP LHSC-SSA BFMC VFMC Other: This Medical Directive Applies to the following patient population:Signature

EMG-2014-008 Appendix AEMG-2014-008 Appendix BEMG-2014-008 Appendix CEMG-2014-008 Appendix DEMG-2014-008 Appendix EEMG-2014-008 Appendix F

Documents

EMG-2014-008 - University Hospital...EMG-2014-008 Page 1 of 6 Medical Directive Title: Emergency Department Asthma Medical Directive-Paediatric Age 1 to 17 years Lead Contact Person: