The Wexford Companies- Medical Guidelines-- New Mexico (2023)
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THE
WEXFORD
COMPANIES
Medical Guidelines
Region: New Mexico
The Wexford Companies
501 Holiday Drive
Suite 300
Pittsburgh, PA 15220
Phone: 412-937-8590
WEXFORD MILLER 000649
Medical Guidelines
Region: New Mexico
Corporate Authorization
This Medical Guidelines has been reviewed and approved by the following individual(s):
Stephen J. Ritz, D.O.
Chief Medical Officer, Wexford Health Sources, Inc.
Regional or State Medical Director
Facility Medical Director
Site Administrator/Site Manager (If applicable)
Date of Effectiveness: January 5, 2023
The Medical Guidelines are reviewed annually but may not require revision. If a change is made, a revision
date will be added and updated accordingly.
The contents of this manual are proprietary and confidential. This manual must be returned to the corporate office of
Wexford upon employee termination or end of contract.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000650
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Medical Guidelines
Region: New Mexico
Preface
This manual is intended to serve as a reference tool for clinicians practicing medicine in the jails and
prisons served by Wexford Health Sources, Inc. (Wexford Health). The manual contains clinical pathways,
treatment protocols, and algorithms designed to promote a standard level of quality and care at Wexford
Health sites. The goal of each clinical pathway is to assist the clinician in reaching the best possible
outcome for each patient, while reducing opportunities for errors or inefficiencies. Wexford Health’s
clinicians should incorporate the tools in this manual into daily practice.
The manual has been developed, and is maintained, by the Medical Advisory Committee of Wexford
Health. This committee is composed of clinical and administrative peers charged with developing
consensus on clinical issues utilizing the most recent professional standards, evidence-based studies,
and accepted practices.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all
patients. The specific strategies and pathways presented in this manual provide a clinical management
approach, but their application is a decision made by the practitioner accounting for individual
circumstances.
Medical management and information is continually changing as better treatments, testing, or approaches
are learned. Consequently, some items in this manual may become obsolete and, as a result, this manual
will continually evolve. Clinicians practicing at Wexford Health sites are encouraged to assist in
keeping this manual updated and useful by presenting new information, sharing successful clinical
approaches, and informing of adverse or suboptimal outcomes.
As always, Wexford Health encourages its practitioners to utilize all accepted resources in providing care,
as well as the leadership and advisement of its varied staff of medical directors and administrators. The
“Quest for Excellence” is never complete.
If there are any conflicts between these guidelines and client-specific guidelines, administrative directives
or institutional directives, then the respective client-specific guidelines, administrative directives or
institutional directives language is controlling to resolve such conflict. In cases where state and local laws
differ from these guidelines, Wexford Health will comply with the applicable local or state law.
Revised: 8/26/2015
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000651
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Medical Guidelines
Region: New Mexico
Table of Contents
Medical Advisory Committee: Mission Statement and Guidelines ....................................................... 9
M-003A: Pregnancy and Opioid Use ............................................................................................... 11
M-003A.01 Opioid Use Screening Form (SAMPLE) ........................................................................... 23
M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE) ...................... 24
M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE) ...................... 25
M-003A.03 Refusal to Participate in Medication Assisted Treatment (MAT) (SAMPLE) ....................... 26
M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria (SAMPLE) ................................... 27
M-003A.05 Clinical Opioid Withdrawal Scale (COWS) (SAMPLE) ...................................................... 28
M-004: Primary Care Guidelines .................................................................................................... 29
M-006: Therapeutic Shoes ............................................................................................................. 30
M-006: FORM: Receipt for Accountable Items (SAMPLE) ................................................................. 32
M-007: Hearing Aids ...................................................................................................................... 33
M-008: Blood Administration ......................................................................................................... 36
M-010: Enteral Nutrition and Nutritional Supplementation ............................................................ 43
M-010: FORM: Nutritional Supplement Request Form (SAMPLE) .................................................... 45
Morbidity Survey Report Form (SAMPLE) ........................................................................................ 46
Mortality Review Worksheet (SAMPLE) ............................................................................................ 48
M-018: Naloxone (Narcan): Guidance for Use in Opioid Suspected Ingestion/Overdose.................... 50
M-019: Medical Management of Patient Exposure to Bloodborne Pathogens .................................... 53
M-020: Air Ambulance Guidelines .................................................................................................. 64
M-021: Supplemental Oxygen Guideline......................................................................................... 67
M-022: Vivitrol® (Naltrexone) Re-Entry Program ............................................................................. 69
M-022.01 Opioid Use Screener (SAMPLE) ........................................................................................ 78
M-022.02 Consent for Vivitrol®/Naltrexone Program Participation (SAMPLE) ................................... 79
M-022.03 Vivitrol ®/Naltrexone Step-by-Step Guide for Nurses ....................................................... 80
Step 5. Materials .................................................................................................................................................82
Step 8. Observation .............................................................................................................................................82
Step 6: Drug/Patient Preparation .........................................................................................................................82
Step 9. Follow-Up (Medical) .................................................................................................................................82
Step 7: Injection ..................................................................................................................................................82
M-022.04 Patient Readiness Assessment (SAMPLE) ......................................................................... 83
M-022.05 Patient Counseling Tool - Vivitrol® (Naltrexone) ................................................................ 86
Cardiology Guidelines ..........................................................................................................................................87
Chronic Stable Angina: Clinical Assessment .................................................................................... 88
Chronic Stable Angina: Stress Testing/Angiography ........................................................................ 90
Chronic Stage Angina: Treatment .................................................................................................... 92
Unstable Angina―Practical, Evidence-Based.................................................................................... 94
Calculating the Risk of Coronary Artery Disease (CAD) .................................................................... 95
NYHA Functional Classification ...................................................................................................... 96
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Patient Risk Questionnaire ............................................................................................................. 97
Diagnostic Tests ............................................................................................................................. 99
Treatment Plan ............................................................................................................................. 100
Treatment Plan: Referral Guidelines .............................................................................................. 102
NYHA Functional Classification & Treatment Guidelines, , ............................................................. 103
Drug Therapy Selection ................................................................................................................ 104
NYHA Functional Classification & Guidelines ................................................................................ 105
Syncope ....................................................................................................................................... 106
When to Hospitalize a Patient with Syncope .................................................................................. 107
Algorithm for the Evaluation and Management of Patients Suspected of Having Acute Coronary
Syndrome (ACS) ........................................................................................................................... 108
Acute Ischemia Pathway ............................................................................................................... 109
Congestive Heart Failure: An Approach to Treatment ..................................................................... 110
Highlights of Optimal CHF Management ....................................................................................... 111
Deep Vein Thrombosis Guideline ......................................................................................................................... 113
Approach to the Patient with an Acutely Swollen Leg ..................................................................... 114
Dental Guidelines .............................................................................................................................................. 122
D-001: Oral Care ......................................................................................................................... 124
D-002: Generalized Procedure Guidelines .................................................................................... 127
D-003: Dental Sick Call Requests ................................................................................................ 129
DR-001: Dental Radiation Safe Operation Guidelines ................................................................. 131
DR-002: Dental Radiation Exposure to Pregnant Females Guidelines ......................................... 134
Dental Radiation Guidelines References ........................................................................................ 135
Dermatology Guidelines ..................................................................................................................................... 136
Dermatology Guidelines ................................................................................................................ 137
Durable Medical Equipment Guidelines ............................................................................................................... 146
Ankle-Foot Orthotics .................................................................................................................... 147
M-012: Knee Orthotics................................................................................................................. 148
M-013: Prosthesis........................................................................................................................ 150
Endocrine/Metabolic Disorders .......................................................................................................................... 151
Pharmacological Management of Type 1 and Type 2 Diabetes Mellitus Guidelines .......................... 152
Type I Diabetes Mellitus Flow Chart .............................................................................................. 176
Type II Diabetes Mellitus Flow Chart ............................................................................................. 177
Gastroenterology ............................................................................................................................................... 178
Management of Ulcerative Colitis .................................................................................................. 179
Medications Used to Treat Ulcerative Colitis .................................................................................. 180
Management of Crohn’s Disease ................................................................................................... 181
Medications Used to Treat Crohn’s Disease ................................................................................... 183
Management of Gastroesophageal Reflux Disease (GERD) Including Proton Pump Inhibitor (PPI) Taper
.................................................................................................................................................... 185
GERD: Patient Algorithm and PPI Taper ........................................................................................ 189
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Medications Use to Treat Uncomplicated Gastroesophageal Reflux Disease/Dyspepsia ................... 190
Management of Suspected of Recurrent Gastric or Duodenal Ulcer ................................................ 191
Medications Used to Treat Suspected or Recurrent Gastric or Duodenal Ulcer ............................... 192
General Surgery................................................................................................................................................. 193
General Surgery Guidelines .......................................................................................................... 194
The Repair of Abdominal Wall/Inguinal Hernias ............................................................................ 197
Hematology Guidelines ...................................................................................................................................... 199
Hematology Guidelines ................................................................................................................. 200
Hyperbaric Oxygen Therapy (HBO) Treatment Guidelines........................................................................................ 207
Hyperbaric Oxygen Therapy (HBO) Treatment Guidelines .............................................................. 208
Infectious Diseases ........................................................................................................................................... 210
Hepatitis B Guidelines .................................................................................................................. 211
Hepatitis C Virus Treatment Guideline .......................................................................................... 216
Initial Hepatitis Work Sheet .......................................................................................................... 220
Facts About Hepatitis B and C ...................................................................................................... 221
Infectious Disease: HIV Guidelines ............................................................................................... 223
MRSA Control Guidelines ............................................................................................................. 224
Appendix 1: Linen and Laundry Services ...................................................................................... 232
Appendix 2: MRSA Q&A (Corrections Professionals) ...................................................................... 233
Appendix 3: MRSA Q&A (Patients) ................................................................................................ 236
Appendix 4: MRSA Reporting Template ........................................................................................ 238
HIV Prophylactic Post Exposure Medications ................................................................................. 239
Sexually Transmitted Diseases Treatment Recommendations ........................................................ 243
Infirmary Services Manual .................................................................................................................................. 244
Infirmary Services ........................................................................................................................ 245
Appendix 1: Recommendations for Who Can Be Housed in an Infirmary ....................................... 254
Appendix 2: Recommendations for Who Should NOT Be Housed in an Infirmary ........................... 255
Influenza Outbreak Guidelines in Corrections ....................................................................................................... 256
Influenza Virus Management during a Confirmed Outbreak Correctional Institutions .................... 257
Medication Consent Forms (English and Spanish) ................................................................................................ 262
MEDICATION: BENADRYL (Diphenhydramine HCL) ..................................................................... 263
MEDICATION: COGENTIN (Benztropine Mesylate) ........................................................................ 265
MEDICATION: EFFEXOR (Venlafaxine HCL), EFFEXOR XR (Venlafaxine HCL Extended Release
Capsules) ..................................................................................................................................... 267
INFORMED CONSENT FOR ANTIPSYCHOTIC MEDICATION – FORM A .......................................... 269
Informed Consent for Psychotropic Medication – FORM B .............................................................. 271
MEDICATION: GEODON (Ziprasidone) ......................................................................................... 274
MEDICATION: HALDOL (Haloperidol), HALDOL DECANOATE (Haloperidol Decanoate) .................. 276
MEDICATION: LITHIUM ............................................................................................................... 278
MEDICATION: PAXIL (Paroxetine HCL) ......................................................................................... 280
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
MEDICATION: PROLIXIN (Fluphenazine HCL), PROLIXIN DECANOATE (Fluphenazine Decanoate) 282
MEDICATION: PROZAC (Fluoxetine HCL) ..................................................................................... 284
MEDICATION: REMERON (Mirtazapine) ....................................................................................... 286
MEDICATION: RISPERDAL (Risperidone) ..................................................................................... 287
MEDICATION: SEROQUEL (Quetiapine Fumarate) ....................................................................... 289
MEDICATION: TEGRETOL (Carbamazepine) ................................................................................. 291
MEDICATION: THORAZINE (Chlorpromazine HCL) ....................................................................... 293
MEDICATION: TRILAFON (Perphenazine) ..................................................................................... 295
MEDICATION: VALPROIC ACID ................................................................................................... 297
MEDICATION: VISTARIL (Hydroxyzine Pamoate)........................................................................... 299
MEDICATION: WELLBUTRIN (Bupropion HCL), WELLBUTRIN SR (Bupropion HCL Extended Release
Tablets) ........................................................................................................................................ 301
MEDICATION: ZOLOFT (Sertraline HCL) ...................................................................................... 303
Neurology Guidelines ......................................................................................................................................... 305
Neurology Guidelines .................................................................................................................... 306
Obstetrics/Gynecology ...................................................................................................................................... 309
Management of Cervical Cytology Interpretation ............................................................................ 310
Management of Cervical Cytology Interpretation ............................................................................ 311
Ophthalmology Guidelines .................................................................................................................................. 313
Ophthalmology Guidelines ............................................................................................................ 314
The Management of Cataracts ....................................................................................................... 319
The Management of Corneal Abrasions ......................................................................................... 321
The Management of Glaucoma ...................................................................................................... 328
Optometry ......................................................................................................................................................... 330
Routine Optometry Protocols and Procedures ................................................................................ 331
Eyeglasses and Contact Lens Protocols ......................................................................................... 332
Oral and Maxillofacial Surgery Guidelines ............................................................................................................ 335
Oral and Maxillofacial Surgery ...................................................................................................... 336
Orthopedic Surgery Guidelines ............................................................................................................................ 338
Orthopedic Surgery Guidelines ..................................................................................................... 339
Otolaryngology Guidelines .................................................................................................................................. 350
Otolaryngology ............................................................................................................................. 351
Pain Management ............................................................................................................................................. 356
Treatment of Mild to Moderate Pain .............................................................................................. 357
Treatment of Low Back Pain ......................................................................................................... 358
Pharmacologic Treatment of Chronic Pain ..................................................................................... 359
Pharmacologic Treatment of Migraine Headaches .......................................................................... 365
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Peer Review ...................................................................................................................................................... 369
M-001: Peer Review Activities ....................................................................................................... 370
Peer Review Notification Form ....................................................................................................... 371
Physician Peer Review Worksheet.................................................................................................. 372
Prison Rape Elimination Act................................................................................................................................ 380
Prison Rape Elimination Act Guideline .......................................................................................... 381
Respiratory Disorders......................................................................................................................................... 384
Acute Asthma ............................................................................................................................... 385
Severity of Asthma Exacerbation ................................................................................................... 386
Chronic Asthma Severity Classification/Management .................................................................... 387
Chronic Asthma ........................................................................................................................... 388
Asthma Control: Achieving the Best Outcomes with Medication Use and Targeted Patient Education
.................................................................................................................................................... 390
Summary of Guideline Recommendations for Periodic Health Examinations ............................................................ 394
Summary of Guideline Recommendations for Periodic Health Examinations .................................. 395
Summary of Guideline Recommendations for Periodic Health Examinations, Table 1: Wexford Health
.................................................................................................................................................... 397
Summary of Guideline Recommendations for Periodic Health Examinations, Table 2: Wexford Health–
Pregnant Females ......................................................................................................................... 402
Transgender Guidelines...................................................................................................................................... 404
Medical Management of Transgender Patient Guideline ................................................................. 405
Urology Guidelines............................................................................................................................................. 427
Urology Guidelines ....................................................................................................................... 428
Vascular Disorders............................................................................................................................................. 441
Vascular Surgery Guidelines ......................................................................................................... 442
JNC8 Hypertension Management Algorithm .................................................................................. 448
Vascular Surgery Guidelines ......................................................................................................... 453
Table 1: Classification of Blood Pressure for Adults ....................................................................... 454
Table 2: Causes for Lack of Responsiveness to Therapy ................................................................. 455
JNC 8 GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION IN ADULTS ............................ 456
Table 3: Risk Stratification Factors .............................................................................................. 458
Medications on the Wexford Health Corporate Formulary Used to Treat Hypertension .................... 459
Warfarin Management ....................................................................................................................................... 460
Warfarin Management .................................................................................................................. 461
Warfarin Drug Monograph ............................................................................................................ 462
Non-Vitamin K Oral Anticoagulant (NOAC) Guidelines for Utilization ............................................. 468
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000656
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Medical Guidelines
Region: New Mexico
Medical Advisory Committee: Mission Statement and Guidelines
The Medical Advisory Committee (MAC) is composed of health care clinicians and administrative
professionals appointed by the Corporate Medical Director (CMD) to guide medical and behavioral health
practices resulting in the best outcomes for individuals and agencies served by Wexford Health.
I.
MISSION STATEMENT
It is the mission of the MAC to develop consensus on clinical issues utilizing the most recent
professional standards, evidence-based studies, and accepted practices.
II.
PHILOSOPHICAL APPROACH
The MAC will actively advise and provide a diversity of perspectives to the CMD and corporate office
on matters relating to the effective and appropriate provision of medical and behavioral health care
to incarcerated persons.
The MAC will guide clinical services to reflect “best practices” and standards in correctional
medicine. Positions will be developed with reference to professional medical and correctional
standards, medical and correctional ethics, evidenced-based medicine, community standards of
care, and the clinical and field experience of committee experts. Mechanisms of guideline
development and practice include the development and implementation of treatment protocols,
algorithms and guidelines, and continuous quality improvement. Consistent with NCCHC Standard
P-A-03, clinical decisions and actions regarding health care provided to patients to meet their
serious medical needs are the sole responsibility of qualified health professionals.
MAC protocols, guidelines, and algorithms do not replace sound clinical judgment and may not
need to be strictly applied to every patient.
III.
GOALS
To advise and develop treatment tools for practitioners that will result in the best possible
outcome for each patient.
To promote practices that will reduce medical errors and encourage a uniform quality of care.
To determine the most effective and efficient practices in approaching clinical and treatment
challenges.
To guide practices which reduce medical risks.
To develop and promote practices that increase continuity of care.
To alert clinical and administrative staff of changes and updates in clinical knowledge,
practices, technology, trends, and emerging concerns.
To provide clinical and ethical advice for specific or complex patient cases.
To review patient cases where a difference of opinion exists between the site provider and the
Regional Medical Director and/or UM Medical Director. Qualified outside physicians may be
consulted for independent review when differences of opinion continue to exist between the
various members of the Medical Advisory Committee.
To participate in quality assurance activities.
IV.
MEMBERS
Members will be appointed by the Wexford Health CMD.
The Wexford Health CMD shall serve as the Chair of the Committee.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000657
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Medical Guidelines
Region: New Mexico
The size of the MAC will be determined by the CMD, and shall include at least one
representative from each major Wexford Health region.
Wexford Health clinical practitioners will constitute a majority of members at all times, but
the MAC will include Wexford Health administrative staff and reflect professionals from a
variety of disciplines.
Members will serve for a term of two years and may be reappointed.
Candidates may be nominated by a member of the Committee and approved by the CMD.
V.
MEETINGS
Frequency: Meetings will be conducted monthly at the discretion of the Chair.
Agenda: The agenda will be developed by the Chair and/or designee with the assistance of the
Vice President of Medical Services. Any member wishing to include an item on the agenda
should present the agenda item to the Chair for approval and inclusion.
The agenda will be developed by an individual designated by the Chair and/or designee and
distributed to the members at least one week prior to the next meeting.
Minutes: Minutes from the meeting will be completed by an individual designated by the Chair
and will be distributed to the members one week prior to the next meeting. The MAC will
review and approve the minutes.
VI.
MEMBERSHIP EXPECTATIONS
MAC members are expected to review the agenda and be prepared to offer suggested revisions
prior to the meeting.
All members are expected to actively participate and offer comments related to their expertise.
All members are expected to be present and timely.
All members will notify the Medical Director or designee if the member will not be in
attendance. If there are more than two unexcused absences by a member, the member may
be discharged from the MAC by the Chair.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000658
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Medical Guidelines
Region: New Mexico
M-003A: Pregnancy and Opioid Use
References: ACOG, ASAM, SAMSHA, ACA: 5-ACI-6A-41, 5-ACI-5E-11, 5-ACI-6A-10; NCCHC: P-F-05, MH-G-07,
J-F-05
I.
GUIDELINE
For the management of opioid use in pregnant patients Wexford Health’s guidance is based on the
guidelines set forth by SAMSHA, American Society of Addiction Medicine (ASAM) and The American
College of Obstetricians and Gynecologists (ACOG).
Pregnant patients with opioid use disorder should not undergo withdrawal from opioids.
Medication Assisted Treatment (MAT) is the standard of care for pregnant women with opioid use
disorder and will be provided for the duration of the pregnancy.
Coordination of care between with the OB/GYN and onsite medical/behavioral health is important
for pregnant women with opioid use disorder.
Decisions on MAT during the postpartum period will be based on client guidance and guideline.
II.
BACKGROUND INFORMATION
The National Institute on Drug Abuse (NIDA) defines addiction as a chronic disease that can be
managed and treated successfully. Like other chronic disease processes (e.g. diabetes,
hypertension), the successful treatment of substance use disorders depends on social support,
patients-provider rapport, as well as treatment availability.
Approximately 40–60% of patients relapse and resume illicit drug use in the first year after discharge
from substance abuse treatment programs, which is similar to a 60% relapse rate for adults
undergoing treatment for hypertension or asthma.
Barriers to treatment in pregnancy created by misguided guideline approaches result from a
fundamental misunderstanding of the chronicity of addiction and the need to provide ongoing
treatment for addiction disorders with both medical and psychosocial interventions.
Opioid use disorder (OUD) may involve illicit or prescription medications, as well as heroin,
methadone, buprenorphine diverted or misused prescription opioids, or other morphine-like drugs.
Opioid addiction is a chronic, relapsing disease.
Acute opioid withdrawal is physiologically stressful, characterized by profound activation of the
sympathetic nervous system with hypertension, tachycardia, and gastrointestinal symptoms. MAT
during pregnancy improves prenatal care, reduces illicit drug use, and minimizes the risk of fetal
in utero withdrawal.
Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic
observed in the general population. The number of women with opioid use disorder in labor and
delivery has recently more than quadrupled.
Opioid use during pregnancy is associated with substantial maternal, fetal, and neonatal risks.
These risks are related to repeated opioid exposure (e.g., risk of overdose) as well as factors
associated with opioid use (e.g., smoking, poor nutrition, needle sharing, unstable lifestyle).
Opioid exposure during pregnancy has been linked to negative health effects for both mothers and
their babies. These include maternal death and poor fetal growth, preterm birth, stillbirth, possible
specific birth defects, and neonatal abstinence syndrome. The effects of prenatal opioid exposure
on these children over time are largely unknown. However, using prescribed opioids for treatment
of opioid use disorder during pregnancy may be necessary and outweigh the risks of these potential
negative health outcomes.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000659
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Medical Guidelines
Region: New Mexico
Opiate use or misuse may include heroin, codeine, morphine, OxyContin, Tylenol #3,
hydromorphone, buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the
route of transmission.
III.
INTERVENTION
Medication Assisted Treatment (MAT) is defined as the use of FDA-approved medications, in
combination with counseling, and behavioral interventions to provide individualized whole patient
approach to treat opioid use disorders. This treatment combination can lead to more favorable
outcomes.
Medication Assisted Treatment (pharmacotherapy) of opioid use disorder (OUD) is recommended for
pregnant women with OUD and should be accompanied by close supportive clinical follow-up. The
goal is to prevent obstetric and neonatal complications associated with OUD as well as detox,
facilitate prenatal care, and help women avoid the myriad risks from the unstable lifestyle
associated with the drug culture (e.g., drug-related criminal activity, homelessness, domestic
violence, and infectious diseases).
The Substance Abuse and Mental Health Services Administration (SAMHSA) the American Society
of Addiction Medicine (ASAM) and the American College of Obstetricians and Gynecologists. (ACOG)
recommend MAT with either methadone or buprenorphine (without naltrexone which is Subutex)
for pregnant women with opioid use disorder.
IV.
MEDICATIONS USED FOR MAT
Buprenorphine - Subutex vs. Suboxone
1.
Buprenorphine belongs to a class of drugs called partial opioid agonist.
2.
The primary difference between Suboxone and Subutex is that Suboxone also contains
a substance called “naloxone” while Subutex does not:
a.
Subutex contains a single active ingredient: buprenorphine.
b.
Suboxone contains two active ingredients: buprenorphine and naloxone.
Methadone
1.
Methadone is a long-acting full opioid agonist.
2.
Understanding the signs and symptoms of intoxication verses withdrawal is imperative
when providing MAT intervention. If a patient is currently “intoxicated,” adding
medication could, in fact, cause an overdose. Clinical judgment is crucial during this
process since methadone is a Schedule II controlled medication.
Methadone or Buprenorphine
1.
While methadone has been the standard choice for pharmacotherapy of OUD during
pregnancy since the 1970s, buprenorphine is increasingly used because neonatal
withdrawal (also known as neonatal abstinence syndrome) appears to be less severe
when the mother is treated with buprenorphine as opposed to methadone.
2.
When determining the appropriate course of treatment, multiple factors must be
evaluated including medication availability, during and after incarceration.
Pregnant individuals already established on MAT (methadone or buprenorphine) should
continue the established medication.
1.
Switching/ changing from methadone to buprenorphine or from buprenorphine to
methadone is not recommended and may lead to withdrawal.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000660
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Medical Guidelines
Region: New Mexico
V.
Recognizing Signs and Symptoms of Opioid Intoxication and Withdrawal
The table below lists signs and symptoms of opioid intoxication and withdrawal.
Opioid Intoxication
Signs
Opioid Withdrawal
Signs
•
Bradycardia (slow pulse)
•
Tachycardia (fast pulse)
•
Hypotension (low blood pressure)
•
Hypertension (high blood pressure)
•
Hypothermia (low body temperature)
•
Hyperthermia (high body temperature)
•
Sedation
•
Insomnia
•
Miosis (pinpoint pupils)
•
Mydriasis (enlarged pupils)
•
Hypokinesis (slowed movement)
•
Hyperreflexia (abnormally heightened reflexes)
•
Slurred speech
•
Diaphoresis (sweating)
•
Head nodding
•
Piloerection (gooseflesh)
•
Increased respiratory rate
•
Lacrimation (tearing), yawning
•
Rhinorrhea (runny nose)
•
Muscle spasms
Symptoms
Symptoms
•
Euphoria
•
Abdominal cramps, nausea, vomiting, diarrhea
•
Analgesia (pain-killing effects)
•
Bone and muscle pain
•
Calmness
•
Anxiety
Source: Consensus Panelist Charles Dackis, M.D.
VI.
MAT OF INCARCERATED PREGNANT PATIENTS – GENERAL GUIDANCE
DO NOT STOP OPIOIDS IN PREGNANT PATIENTS.
Contact the clinician as soon as possible for any pregnant patients suspected of being severely
intoxicated.
For MAT, the patient should have clinical evidence of opioid dependency as well as a positive
pregnancy test.
Screening will be provided by staff upon discovery of opioid use to determine frequency and
severity of use. (See attached M-003A.01 Opioid Use Screening form.)
Record amount, route, and duration of habit/use considering the possibility of exaggerated
dosages.
All female patients assessed for opioid use will be tested for pregnancy prior to beginning an
opioid detox protocol. If pregnant, do not detox.
If available, an onsite urine drug test should be performed to confirm opioid use.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
A Clinical Opiate Withdrawal Scale (COWS) assessment should be conducted as soon as
possible
to
track
and
monitor
the
pregnant
patient.
(See
attached
M-003A.05 Clinical Opiate Withdrawal Scale.)
Call the clinician as soon as possible for any patients suspected of having a severe narcotic
withdrawal if determined by either signs/symptoms or through the COWS assessment.
Frequency of the COWS is typically directed by a clinician.
1.
The recommended frequency for a pregnant patient with a confirmed opioid use disorder
is typically between 4 to 8 hours until stable and the provider requests that COWS is
discontinued.
The clinician will be notified as soon as possible to ensure appropriate course of action is
taken to ensure the safety of the mother and her fetus.
1.
The provider should review both the Opioid Use Screening form and the COWS to
determine the course of action needed to determine the time frame to start MAT.
2.
The planned course of action will depend on the source of the opioids as described in
later sections.
An additional form called DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria has been
attached to this guideline to provide additional guidance when diagnosing OUD. (See attached
M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria.)
VII.
PREGNANT PATIENTS ENTERING THE FACILITY ESTABLISHED ON METHADONE THROUGH AN OTP
A Release of Information (ROI) should be obtained to discuss protected health information
with the OTP.
Confirmation of established methadone dose should be obtained as soon as possible.
A pregnant patient should NOT DETOX.
A clinician needs to be involved/contacted as soon as possible to ensure detoxing does not
occur.
If a pregnant patient arrives at the facility already established on methadone the onsite
provider will BRIDGE the prescription of methadone to ensure no harm comes to the patient
as well as the fetus.
1.
The DEA has clearly stated BRIDGING methadone in a PREGNANT INNMATE-PATIENT
is considered a MEDICAL intervention for the safety of the fetus, NOT an opioid
treatment intervention. Therefore, any clinician with a DEA license can BRIDGE
methadone.
a.
In bridging methadone, the primary purpose is not to provide drug treatment;
rather, it is to provide medical intervention to the fetus and to ensure no harm
comes to the fetus and mother until the patient can be taken to an opioid
treatment program OR services are continued by the current OTP provider.
b.
“Bridging” methadone is considered the period 72 hours following the first dose
administered.
c.
Contacting the patient’s current methadone provider and/or referring the patient
to the methadone clinic that manages your site's methadone patients must
certainly be a priority to ensure continuity of care within the time frame
expected. This can be accomplished by the following steps:
i.
Contact the patient’s current OTP provider and have them provide an order
(prescription) to your site to continue methadone. The 72-hour clock stops
when the methadone order from the OTP is received.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
ii.
d.
2.
Linking the patient to an OTP provider that can continue their current
methadone prescription will ensure that they receive needed treatment while
incarcerated.
The site’s contracted pharmacy will supply the methadone once the site’s DEA licensed
provider has written the patient-specific order.
a.
3.
Contact your site's OTP and set up the next available appointment for the
patient to be enrolled in their OTP (if the patient’s current OTP is outside
the geographic boundaries of your site).
The bridged order MUST include the verbiage “PREGNANT FEMALE.”
The site clinician should continue the current dose the pregnant patient is established
on UNLESS detox symptomatology becomes present.
a.
In this event the OTP clinician should be contacted for additional guidance.
Coordination with an OTP must be established for ongoing treatment of the pregnant patient.
Transportation must be arranged for a pregnant patient for transport to the OTP as
determined by the OTP physician and the onsite medical provider if deemed appropriate.
VIII. PREGNANT PATIENTS ENTERING THE FACILITY ESTABLISHED ON SUBUTEX THROUGH AN OTP
A release of information (ROI) should be obtained to discuss protected health information with
the OTP.
Confirmation of established Subutex dose should be obtained as soon as possible from the
OTP.
1.
A copy of the prescription is to be faxed from the current supervising OTP clinician.
A pregnant patient should NOT DETOX.
A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.
If a pregnant patient arrives at the facility already established on Subutex, a provider with a
DEA-X should order the Subutex to ensure no harm comes to the patient as well as the fetus.
1.
The new prescriber will typically assume the care of the opioid use disorder while the
patient is pregnant and incarcerated.
2.
If there is no available clinician with a DEA-X waiver then the patient will need to
continue care at the OTP.
The site clinician should continue the pregnant patient's current established dose UNLESS
detox symptomatology becomes present.
1.
In this event the OTP clinician should be contacted for additional guidance.
Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient.
IX.
PREGNANT PATIENTS ENTERING THE FACILITY ON PRESCRIBED OPIOIDS
A release of information (ROI) should be obtained to discuss protected health information with
the patient’s clinician.
A pregnant patient should NOT DETOX.
A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000663
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Medical Guidelines
Region: New Mexico
If a pregnant patient arrives at the facility already established on ongoing prescribed opioids,
a clinician should order the prescribed opioids to ensure no harm comes to the patient as well
as the fetus.
1.
The continuing of opioids does not automatically apply to opioids prescribed for an acute
condition.
The site clinician should continue the pregnant patient's current established medication/dose
UNLESS detox symptomatology becomes present.
1.
In this event the OB clinician should be contacted for additional guidance.
Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.
X.
PREGNANT PATIENTS ENTERING THE FACILITY ON OPIOIDS THAT WERE NOT PRESCRIBED AND
AVAILABILITY OF A PRESCRIBER WITH A DEA-X WAIVER TO PRESCRIBE SUBUTEX
Opiate use may include heroin, codeine, morphine, OxyContin, hydromorphone,
buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the route of
transmission.
A pregnant patient should NOT DETOX.
A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.
If a pregnant patient arrives at the facility on opioids that were not prescribed for the patient,
then a designated provider with a DEA-X license should be contacted for consideration of a
Subutex induction protocol.
Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.
XI.
SUBUTEX (BUPRENORPHINE WITHOUT NALOXONE) INDUCTION PROTOCOL
Because Suboxone (buprenorphine with naloxone) can precipitate withdrawal, pregnant
patients should not typically receive Suboxone.
Induction to Subutex typically involves considering the type of opioid – i.e., short-acting
opioids or long-acting opioids – that a patient is using.
If a patient is using short-acting opioids, there should be a minimum of 12 to 24 hours
between opioid use and buprenorphine administration, and, as a result, the patient should
exhibit mild to moderate withdrawal symptoms (as assessed by the COWS).
Induction can take place in one day or over a week.
1.
A typical induction takes place over a three-day to one-week period.
2.
The induction period is a time frame where constant monitoring is needed as well as
possible dosage adjustment – to ensure the individual is on an appropriate dose.
3.
It is important to ensure that the individual remains stable on that dose.
The following are general recommendations on Subutex induction:
1.
Recognizing that each patient is unique the following guidance is meant to be a guidance
not a prescribed plan of care.
2.
Providers should consider a patient’s recent drug history when determining a
therapeutic dose.
3.
Most patients can stay in outpatient status through induction.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000664
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Medical Guidelines
Region: New Mexico
XII.
4.
Initial dose may begin with 2 mg or 4 mg of Subutex and monitored for 2 to 4 hours.
5.
If withdrawal symptoms are not relieved, then additional Subutex can be administered,
followed by ongoing monitoring.
6.
If withdrawal symptoms persist, manage symptomatically with a suggested maximum
first day dose of Subutex of 8 mg.
7.
Patients who require an initial dose greater than 8 mg should be under direct
observation.
8.
If a patient is still exhibiting withdrawal on subsequent days, follow the same procedure
with a first dose equal to the total amount administered on the previous day plus 4 mg
until the patient has no withdrawal symptoms since the last dose.
9.
Typical recommendations are 8 mg –16 mg per day until withdrawal no longer occurs.
10.
The typical dose for most patients is 8 mg –16 mg per day by the end of the first week.
11.
Doses greater than 24 mg per day are not believed to offer any clinical advantage in
treatment.
SUBUTEX MAINTENANCE
The dose of Subutex must be adequate to be therapeutic for the individual.
Pregnant women may develop symptoms of withdrawal as pregnancy progresses and may
require dose increases in order to maintain the same plasma level.
The maternal dose should not generally be reduced during pregnancy to minimize neonatal
abstinence syndrome (NAS).
Buprenorphine (Subutex) dose reduction during pregnancy does not improve fetal outcomes
and may increase the risk of recurrent substance use disorder in the mother.
XIII. PREGNANT PATIENTS ENTERING THE FACILITY ON OPIOIDS THAT WERE NOT PRESCRIBED AND WITHOUT
THE AVAILABILITY OF A PRESCRIBER TO PRESCRIBE SUBUTEX
Opiate use may include heroin, codeine, morphine, OxyContin, Tylenol #3, hydromorphone,
buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the route of
transmission. A pregnant patient should NOT DETOX.
A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.
If a pregnant patient arrives at the facility on opioids that were not prescribed for the patient
the clinician should be contacted for consideration of an OTP.
Coordination with the accepting OTP needs to occur ASAP.
If the patient starts to exhibit significant withdrawal symptoms prior to being evaluated by
the OTP, then the patient should be sent to the ER for evaluation.
1.
The plan of care will follow the ER’s/hospital’s plan of care until follow-up with an OTP
can be arranged.
Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.
XIV. PATIENTS ON MAT POSTPARTUM TREATMENT
Subutex/Buprenorphrine – Postpartum
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
1.
Wexford Health recognizes that each client may have different guidelines or policies
related to MAT in the postpartum period. Wexford Health will work cooperatively with
their client’s policies and guidelines related to this subject.
2.
Following birth, most patients will be tapered off the MAT, unless the site has an existing
MAT program for non-pregnant patients.
3.
Tapering the patient off the MAT after birth should typically be done at a comfortable
rate and without inducing severe withdrawal symptoms.
a.
Tapering a patient off the MAT varies depending on the patient’s current dosage
of Subutex as well as the providers medical determination of the taper schedule.
b.
Tapering schedules should consider postpartum pain management for the
individual.
c.
Start nursing assessments
symptomatology.
with
the
COWS
to
monitor
withdrawal
i.
When Subutex leaves the body, the patient will experience not only physical
but emotional withdrawal.
ii.
With the risk of postpartum depression, the possibility of mother-child
separation following birth which could cause depression, as well as the
withdrawal from Subutex inducing depression, it is recommended that the
patient is referred to mental health services if available; if not available,
monitor the patient’s emotional status and follow up as needed.
d.
Gradually reduce the dose.
e.
Quitting or stopping Subutex abruptly is NOT recommended.
f.
Buprenorphrine half-life is 37 hours for a single dose.
g.
Create a taper schedule reducing the amount of Subutex given in increments.
h.
When monitoring withdrawal symptoms, if symptomatology is too prevalent and
causing extreme discomfort, return to the previous dose for a few days then
decrease again.
Methadone – Postpartum
1.
Wexford Health recognizes that each client may have different guidelines or policies
related to MAT in the postpartum period. Wexford Health will work cooperatively with
their client’s policies and guidelines related to this subject.
2.
Following birth, most patients will be tapered off the MAT, unless the site has an existing
MAT program for non-pregnant patients.
3.
Tapering the patient after birth should typically be done at a comfortable rate and
without inducing severe withdrawal symptoms.
a.
Tapering a patient varies depending on the patient’s current dosage of methadone
and should be determined by the off-site OTP medical provider (if applicable).
b.
Tapering schedules should consider postpartum pain management.
c.
Postpartum patients should be monitored for over sedation as therapeutic dosing
requirements may change.
d.
Frequent clinical assessments need to occur in monitoring methadone dosing
delivery to ensure over-sedation doesn’t occur.
e.
Start nursing assessments
symptomatology.
with
the
COWS
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
to
monitor
withdrawal
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i.
When methadone leaves the body, the patient will experience not only
physical but emotional withdrawal.
ii.
With the risk of postpartum depression, the possibility of mother-child
separation following birth which could cause depression, as well as the
withdrawal from methadone inducing depression, it is recommended that
the patient is referred to mental health services if available, if not available
monitor the patient’s emotional status and follow up as needed.
f.
Quitting or stopping methadone abruptly is NOT recommended.
g.
A gradual reduction in dosing is recommended.
h.
Methadone half-life is 24 to 36 hours for a single dose.
i.
XV.
This can vary person to person, there are several mitigating factors that can
influence half-life.
i.
Reduce the amount of methadone given in increments as instructed by the OTP
provider.
j.
When monitoring withdrawal symptoms, if symptomatology is too prevalent and
causing extreme discomfort, return to the previous dose for a few days then
decrease again or contact the OTP provider as soon as possible to discuss.
REFUSAL OF MAT – HOW TO MANAGE PREGNANT PATIENTS WITH OUD WHO REFUSE MAT
ALL individuals have a right to refuse treatment, if a pregnant female chooses to exercise
these rights, and refuse medical intervention, the following should occur:
1.
An urgent consultation with the OB/GYN specialist for your facility should occur within
48 hours.
2.
The OB/GYN specialist will determine the appropriate treatment for the pregnant
patient.
3.
This consultation can occur the following ways.
4.
a.
The OB/GYN clinician can be consulted via conference call for a peer-to- peer
review with the onsite provider.
b.
A face-to-face consultation occurs.
c.
If no OB/GYN is available for consultation within 48 hours, the pregnant patient
can be taken to the nearest emergency room to receive clearance as well as a
treatment plan.
Informed consent: the pregnant patient will be informed of ALL risks associated with
detoxification during pregnancy and a refusal of medical treatment form should be
signed and witnessed by staff.
The patient should be supervised throughout the duration of the detoxification process; follow
the OB/GYN clinician’s guidance as well as the following:
1.
Document signs and symptoms with the COWS assessment.
a.
2.
A COWS assessment should generally occur at minimum every 8 hours. The
frequency should be ordered by the onsite clinician.
If symptoms begin, suggesting a miscarriage may be occurring, inform the OB/GYN
clinician and follow their instructions, as well as:
a.
Transport the pregnant patient to the hospital when medically indicated.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
3.
Communication and monitoring the patient in collaboration with the OB/GYN specialist
is crucial throughout this process.
A referral to behavioral health services and/or a mental health screening should occur. This
will be determined by what is available at your facility, follow your facility's protocol.
1.
Individuals withdrawing/detoxing from opioids will exhibit several behaviors and
emotions throughout the detox process as the opiates leave their system.
2.
An individual may change their mind during the actual detox process. It is important to
“check with the individual” to ensure they want to continue detoxification without MAT.
If the OB/GYN clinician agrees with managing the patient's detox symptomatology, consider
other options to increase the individual's comfort level throughout the detox process. If the
patient consents, additional support can be provided in the following ways:
1.
Mild withdrawal can be treated with acetaminophen (Tylenol), aspirin, or nonsteroidal
anti-inflammatory drugs (NSAIDs) such as ibuprofen.
2.
Plenty of fluids and rest are important.
3.
Medications such as loperamide (Imodium) can help with diarrhea and hydroxyzine
(Vistaril, Atarax) may ease nausea. (Please refer to M-003: Drug Intoxication/Withdrawal
Guidelines for additional information.)
XVI. ATTACHMENTS
Provider Resources
References
M-003A.01 Opioid Use Screening Form
M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT)
M-003A.03 Refusal to Participate in Medication Assisted Treatment (MAT)
M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria
M-003A.05 Clinical Opioid Withdrawal Scale (COWS)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Provider Resources
Wexford Health supports all providers seeking additional experience as well as obtaining their waiver to
provide treatment with Buprenorphine. The following is a list of resources available to providers.
Substance Abuse Mental Health Services Administration (SAMHSA)
The Substance Abuse and Mental Health Services Administration (SAMHSA) (https://www.samhsa.gov)
is the agency within the U.S. Department of Health and Human Services (HHS) that leads public health
efforts to advance the behavioral health of the nation and to improve the lives of individuals living with
mental and substance use disorders, and their families.
Provider Clinical Support System (PCSS)
The Provider Clinical Support System (PCSS) (https://pcssnow.org/medication-assisted-treatment/) is a
program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) created
in response to the opioid overdose epidemic to train primary care providers in the evidence-based
prevention and treatment of opioid use disorders (OUD) and treatment of chronic pain.
The project is geared toward primary care providers who wish to treat OUD. PCSS is made up of a
coalition, led by American Academy of Addiction Psychiatry (AAAP), of major healthcare organizations all
dedicated to addressing this healthcare crisis. Through a variety of trainings and a clinical mentoring
program, PCSS’s mission is to increase healthcare providers’ knowledge and skills in the prevention,
identification, and treatment of substance use disorders with a focus on opioid use disorders.
American Society of Addiction Medicine (ASAM)
The American Society of Addiction Medicine (ASAM) (https://www.asam.org/asam-home-page) founded
in 1954, is a professional medical society representing over 6,000 physicians, clinicians and associated
professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving
the quality of addiction treatment, educating physicians and the public, supporting research and
prevention, and promoting the appropriate role of physicians in the care of patients with addiction.
National Institute on Drug Abuse (NIDA)
The mission of the National Institute on Drug Abuse (NIDA) (https://www.drugabuse.gov/) is to advance
science on the causes and consequences of drug use and addiction and to apply that knowledge to improve
individual and public health. This involves:
•
Strategically supporting and conducting basic and clinical research on drug use (including
nicotine), its consequences, and the underlying neurobiological, behavioral, and social
mechanisms involved.
•
Ensuring the effective translation, implementation, and dissemination of scientific research
findings to improve the prevention and treatment of substance use disorders and enhance public
awareness of addiction as a brain disorder.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
References
The following is a list of references consulted, reviewed and/or utilized in the development of this
guideline:
The American College of Obstetricians and Gynecologists (ACOG), Women's Health Care Physicians & The American Society of Addiction
Medicine (ASAM); ACOG Committee Opinion. Number 711, August 2017.
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP)
Series 63, Part 3. HHS Publication No. (SMA) 18-5063 Rockville, 2018.
Prescribing guidelines for Pennsylvania, Use of Addiction Treatment Medications in the Treatment of Pregnant Patients with Opioid Use
Disorder. The Commonwealth Pennsylvania 2016.
Center for Substance Abuse Treatment, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment
Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2005.
Peeler M, Fiscella K, Terplan M, Sufrin C. Best Practices for Pregnant Incarcerated Women with Opioid Use Disorder. J Correct Health Care.
2019;25(1):4–14. doi:10.1177/1078345818819855.
ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use; 2015.
Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use
Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.
Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use
Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2018.Substance Abuse and Mental Health Services Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture
of The CDM Group, Inc., and JBS International, Inc., under contract number 270-04-7049, with SAMHSA, U.S. Department of Health and
Human Services (HHS). Christina Currier served as the Government Project Officer, 2014.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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M-003A.01 Opioid Use Screening Form (SAMPLE)
Opioid Use Screening
Patient Name:
Date:
QUESTION
YES
1
Do you use opioids for larger amounts or over a longer period of time than intended?
2
Have you tried to cut down or control your opioid use?
3
Are you taking a lot of time finding opioids, using opioids, or recovering from opioids?
4
Do you have cravings or a strong desire to use opioids?
5
Have opioids interfered with your roles at work, school, or home?
6
Have you continued to use opioids despite people telling you that you need help?
7
Have you given up social, occupational or recreational activities due to opioids?
8
Have you continued to use opioids in situations where it is physically hazardous?
9
Do you continue using opioids despite knowing it is hurting you physically and mentally?
10
Have you noticed you needing more opioids to get the desired effect you want?
11
Have you gotten ill when trying to quit opioids or do you keep using to avoid withdrawal symptoms?
12
How many times have you been in treatment for opioid addiction?
13
Are you currently in an opioid treatment program?
NO
If Yes to 13 – Which one?
14
Are you currently on methadone under the supervision of a provider?
15
Are you currently on buprenorphine under the supervision of a provider?
This section is to be completed by staff.
Contact information of opioid treatment program:
Was contact made with OTP?
Was methadone/or buprenorphine RX confirmation received from OTP?
Signature:
Title:
Date:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE)
Consent to Participate in Medication Assisted Treatment (MAT)
Methadone
Buprenorphine Treatment
Pregnant
Not Pregnant
Patient’s Name:
ID:
I authorize and give voluntary consent to Wexford Health Sources Inc. to dispense and administer Medication Assisted Treatment
medications—including methadone or buprenorphine—to treat my opioid use disorder. Treatment procedures have been
explained to me, and I understand that I should take my medication at the scheduled time determined by the program physician,
or his/her designee, in accordance with federal and state regulations.
I understand that, like all other medications, methadone or buprenorphine can be harmful if not taken as prescribed. It has been
explained to me that I must follow the medication protocol of the program and safeguard these medications and not attempt to
“cheek” them nor share with anyone because they can be fatal to children and adults if taken without medical supervision. I also
understand that methadone and buprenorphine produce physical opioid dependence. Like all medications, they may have side
effects. Possible side effects, as well as alternative treatments and their risks and benefits, have been explained to me.
I understand that it is important for me to inform any medical provider who may treat me that I am currently in MAT. In this way,
the provider will be aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing
medications that might affect my treatment as well as my fetus.
I understand that I may withdraw voluntarily from this treatment program and discontinue the use of these medications at any
time. If I choose this option, I understand I will be offered medically supervised withdrawal as well as a need to sign a refusal of
treatment, and this may affect my unborn fetus and could possibly cause a miscarriage.
I understand that pregnant women treated with methadone or sublingual buprenorphine (SUBUTEX) have better outcomes than
pregnant women not in treatment who continue to use opioid drugs. Newborns of mothers who are receiving methadone or
buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal abstinence syndrome). The delivery hospital may
require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal
symptoms. Some babies may also need medication to stop withdrawal.
If I am or become pregnant, I understand that I should tell the medical staff right away so that I can receive or be referred to
prenatal care. I understand that there are ways to maximize the healthy course of my pregnancy while I am taking methadone or
buprenorphine.
Patient Name (Print):
Patient Signature:
Date:
Page 1 of 2
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000672
24
Medical Guidelines
Region: New Mexico
M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE)
Treatment Agreement
I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:
1. The risks and benefits of buprenorphine treatment have been explained to me.
2. The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and nonmedication
treatments) have been explained to me.
3. I will keep following my medication schedule that has been explained to me by the medical staff.
4. I will show up to medication time (as indicated by the facility) to receive my dosing on time as prescribed by the provider, and
I understand if I no-show to the medication time that I could possibly begin “withdrawal” which could be harmful to my baby.
5. Medication times:
6. I will take the medication exactly as my healthcare provider prescribes. If I want to change my medication dose,
I will speak with my healthcare provider first.
7. Taking the medication by snorting or by injection is also medication misuse and may result in supervised dosing at the clinic,
referral to a higher level of care, or change in medication based on my healthcare provider’s evaluation.
8. If I am going to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so that my
pain will be adequately treated.
9. I understand that random urine drug testing is a treatment requirement. If I do not provide a urine sample, it will count as a
positive drug test.
10. I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines
(drugs like Valium, Klonopin, and Xanax).
11. I understand that treatment of opioid use disorder involves more than just taking medication. I agree to comply with my
healthcare provider’s recommendations for additional counseling and/or for help with other problems.
12. I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.
13. I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting
buprenorphine treatment and been informed about methods for preventing pregnancy.
Patient Name (Print):
Patient Signature:
Date:
This form is adapted from the American Society of Addiction Medicine’s Sample Treatment Agreement, which is updated
periodically; the most current version of the agreement is available online at: (https://www.asam.org/docs/defaultsource/advocacy/sample treatmentagreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn).
Page 2 of 2
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000673
25
Medical Guidelines
Region: New Mexico
M-003A.03 Refusal to Participate in Medication Assisted Treatment (MAT) (SAMPLE)
Refusal to Participate in Medication Assisted Treatment (MAT)
Refusal of MAT Intervention
Patient’s Name:
Pregnant
Patient ID:
I REFUSE TO give voluntary consent to Wexford Health Sources Inc. to dispense and administer Medication Assisted Treatment
medications—including methadone or buprenorphine—to treat my opioid use disorder. Treatment procedures have been
explained to me, and I understand that, should I REFUSE medication INTERVENTION WHILE PREGNANT, that this puts me at
risk for miscarriage.
I understand that, I CAN REVOKE THIS REFUSAL AT ANY TIME. If I decide to change my mind, I will immediately notify medical
personnel.
I understand I will be offered medically supervised withdrawal as well as a need to sign a refusal of treatment, and this may affect
my unborn fetus and could possibly cause a miscarriage.
I understand that pregnant women treated with methadone or sublingual buprenorphine (SUBUTEX) have better outcomes than
pregnant women not in treatment who continue to use opioid drugs. Newborns of mothers who are receiving methadone or
buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal abstinence syndrome). The delivery hospital may
require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal
symptoms. Some babies may also need medication to stop withdrawal.
Signature of Patient:
Date:
Witness:
Name & Title (print):
Date:
Witness:
Name & Title (print):
Date:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000674
26
Medical Guidelines
Region: New Mexico
M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria (SAMPLE)
DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria
Patient Name:
ID:
This form is to provide assistance as well as documentation to diagnose individuals with OUD. Reviewing the Opioid Use
Screening tool, the COWS, as well as discussing the individual’s presentation with staff, should allow all providers to appropriately
diagnose individuals with an OUD to start MAT intervention or withdrawal management. Please refer to M-003 and M-003A for
additional guidance.
This tool is intended for guidance purposes only. Each provider has individual experience with OUD, and this tool is to assist when
certainty is questionable.
A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by at least two of the
following, occurring within a 12-month period:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Opioids are often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its
effects.
Craving, or a strong desire or urge to use opioids.
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or
exacerbated by the effects of opioids.
Important social, occupational, or recreational activities are given up or reduced because of opioid use.
Recurrent opioid use in situations in which it is physically hazardous.
Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following:
a.
A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b.
A markedly diminished effect with continued use of the same amount of an opioid.
Withdrawal, as manifested by either of the following:
a.
The characteristic opioid withdrawal syndrome.
b.
Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
Note: The last two criteria are not considered to be met for those individuals taking opioids solely under appropriate medical
supervision.
Number of criteria:
0–1
2–3
4–5
6+____
Interpretation:
No OUD
Mild OUD
Moderate OUD
Severe OUD
Comments/TX plan:
Provider’s Signature
Title
Date
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000675
27
Medical Guidelines
Region: New Mexico
M-003A.05 Clinical Opioid Withdrawal Scale (COWS) (SAMPLE)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000676
28
Medical Guidelines
Region: New Mexico
M-004: Primary Care Guidelines
Reference:
I.
ACA: 5-ACI-6D-10; NCCHC: A-05
GUIDELINE
Wexford Health’s primary care guidelines are intended to assist the health care staff in clinical
decision-making by describing a range of generally acceptable approaches for the diagnosis and
management of specific diseases or conditions. Although these guidelines are based on evidencebased research, they should not preclude the use of other methods directed at obtaining the same
results.
II.
PROCEDURE
The guidelines are continually updated and reviewed by the Medical Advisory Committee for
their suitability to the patient health care setting.
The guidelines do not supersede established state/county guidelines and/or facility
contractual obligations nor are they mandated for sites which have limited facility equipment
and resources.
All medical decisions regarding the care of patients should be made with consideration given
to the individual circumstances presented by the patient.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000677
29
Medical Guidelines
Region: New Mexico
M-006: Therapeutic Shoes
Reference: ACA: 5-ACI-6A-40; NCCHC: F-01
I.
PURPOSE
The purpose of this guideline is to provide clinical guidelines to determine the need for therapeutic
shoes and instructions for issuance.
II.
DEFINITIONS
Therapeutic shoes: Shoes that are designed or altered to provide a therapeutic benefit or
accommodation of a specific foot or lower extremity disorder. These should appear as black
leather boots to look as close as possible to the standard shoe or brogan issued to the patient
by the state. Different colors or styles should not be used.
Soft shoes: Shoes that are typically defined as tennis shoes, sneakers, running shoes, and
athletic shoes. Soft shoes are not issued by medical.
III.
CLINICAL CRITERIA
Post-surgical recuperation and recent foot trauma may require a therapeutic shoe or orthotic
device for a limited time only. The surgeon or attending clinician must describe in the order
the specific type of shoe or orthotic device required and the timeframe it will be used for.
Significant deformities usually require a specially designed orthotic device that assists the
patient in maintaining or approximating normal ambulation. These may be traumatic, postsurgical or congenital.
Bunions, calluses, corns, blisters, and hammer toes, do not require a therapeutic shoes.
Sometimes the aggravation of these conditions is due to ill-fitting shoes. If it is determined
that the patient would benefit from a better fitting shoe, the patient should be advised to
contact the laundry or appropriate area that issues shoes. Improper fitting shoes are a
frequent cause of foot problems, so at times, it may be necessary to contact health
administration for assistance in obtaining properly fitting shoes.
Patients who are suffering from flat feet and who are symptomatic may be issued arch
supports for their brogans in severe cases if clinically indicated.
Diabetic patients may be considered for therapeutic shoes if the following are met:
IV.
1.
Must have a documented history of previous foot ulcers or with a current ulcer and/or
significantly integumentary concerns despite conservative measures.
2.
Documentation in Diabetes chronic care clinic notes of failed trials of appropriate
conservative measures with regards to diabetic foot care. These include appropriately
fitting shoes, hygiene, and skin care.
ACTION
When the therapeutic shoes are issued, the patient will sign a form approved by the facility
(see Wexford Health’s “Receipt for Accountable Items,” Form #037) with the understanding
that replacement will be the obligation of the patient if such is needed in less than a year.
This form must be signed by a witness, stamped and dated, and filed under the miscellaneous
portion of the medical health record.
In the event that a patient may require shoe replacement less than one year following initial
receipt of the shoes and may not be able to obtain shoes at his/her own expense, the
Corporate Medical Director will carefully evaluate the circumstances involved and may
prescribe replacement shoes as an exception to guideline. In such case, the Corporate Medical
Director will properly record the conditions that warranted an exception to this guideline.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000678
30
Medical Guidelines
Region: New Mexico
V.
ASSOCIATED FORMS
Receipt for Accountable Items
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000679
31
Medical Guidelines
Region: New Mexico
M-006: FORM: Receipt for Accountable Items (SAMPLE)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000680
32
Medical Guidelines
Region: New Mexico
M-007: Hearing Aids
Reference:
I.
ACA: 5-ACI-6A-04; NCCHC: F-01
DEFINITIONS
Hearing Aid: Any wearable instrument or device designed for, offered for, or represented as
aiding persons with or compensating for, impaired hearing.
Hearing Loss: A threshold by audiographic interpretation that falls outside of the range of
normal hearing. For adults we tend to assume the upper range of normal hearing is being 25
dB HL.
Degree of Hearing Loss:
II.
Pure Tone Average
≤15 dB HL
16−25 dB HL
Degree of Handicap
None
Mild
26−40 dB HL
Mild-to-moderate
41−65 dB HL
66−90 dB HL
≥91dB HL
Moderate
Severe
Profound
GUIDELINE
This guideline is used to determine a patient’s candidacy for hearing amplification. Hearing
loss alone cannot determine candidacy for amplification. The individual’s communicative
requirements become the primary determining factor.
Hearing aid(s) will be provided when the criteria is met.
III.
1.
Hearing loss in the better ear of 40 dBHL or greater for the pure tone average of 500,
1000 and 2000 Hz.
2.
A spondee threshold (bisyllabic words equally emphasizing both syllables) in the better
ear of 40 dBHL or greater when pure tone thresholds cannot be established.
3.
As a general rule, one hearing aid will be provided, if there is bilateral hearing loss. The
audiologist will provide recommendation as to which ear will provide greatest hearing
improvement with amplification. In selected cases of severe, bilateral hearing loss, two
(2) hearing aids may be provided in consultation with the audiologist.
4.
Repair or replacement will be provided if the hearing aid is non-functional or damaged.
If there is negligence involved in losing or breaking a hearing aid, the offender will be
given a disciplinary ticket and will be charged for a replacement.
5.
Wexford Health will provide the most appropriate, cost-effective hearing aid.
PROTOCOL
Good health practice requires that a person with a hearing loss have a medical evaluation
before a hearing aid is considered. The purpose of the medical evaluation is to assure that all
medically treatable conditions that may affect hearing are identified and treated before a
hearing aid is considered. Conditions to be noted are:
1.
Visible congenital or traumatic deformity of the ear
2.
History of active drainage from the ear within the previous 90 days
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000681
33
Medical Guidelines
Region: New Mexico
3.
History of sudden or rapidly progressive hearing loss within the previous 90 days
4.
Acute or chronic dizziness
5.
Unilateral hearing loss of sudden or recent onset within the previous 90 days
6.
Audiometric air-bone gap equal to or greater than 15 decibels at 500, 1000, and 2000
Hertz
7.
Visible evidence of significant cerumen accumulation or a foreign body in the ear canal
8.
Pain or discomfort in the ear
Pure tone audiometric testing should be performed after medically ruling out causes of
hearing loss. To determine candidacy for an audiogram, an on-site screening will be performed
utilizing the AudioScope 3 hearing screening tool (see below instructions). Results will be
discussed in collegial conference for consideration of audiogram once testing is completed.
Patients with any hearing loss, especially if due to a surgical correction, such as otosclerosis
or acoustic neuroma, should be referred to an otolaryngologist for otomicroscopic exam.
Patients with presbycusis (loss of ability to perceive or discriminate sounds as a part of the
aging process) should be referred to an audiologist for possible hearing aid fitting.
The AudioScope 3 is to be used by the on-site medical staff when it is deemed necessary that
the patient may need an audiology work-up for hearing loss. The results of this screening
should be faxed to the UM department for physician review and collegial discussion if
necessary.
Operating instructions for the AudioScope 3
1.
Screening area should be relatively quiet and free from distracting conversation.
2.
Select the small, medium, or large ear speculum. Use the largest speculum that can be
inserted comfortably into the ear canal, a snug fit assures seal. There are no covers;
speculum should be cleaned with alcohol wipe between uses.
3.
Turn the AudioScope 3 “ON” by sliding the switch to 40 dB HL. The green “READY”
indicator will become illuminated indicating it is ready for use.
4.
Instruct the patient that he/she will hear a loud tone (or beep) and then some fainter
tones (or beeps). The patient is to respond every time a tone is heard with a verbal yes
or gross motor (raising a hand).
5.
Retract the patient’s pinna with the thumb and index finger, gently pull it up and back.
6.
Gently insert the speculum tip into the ear canal so you can visualize the tympanic
membrane (should look white/gray). If you cannot visualize the tympanic membrane
due to wax, the ear should be cleaned prior to performing the hearing exam.
7.
Depress the “START” button, the green light will then go out and the tone indicators will
illuminate sequentially.
8.
Observe each tone indicator and the patient’s response. If the test is disrupted, it can
be restarted by depressing the Start button again. You must keep the AudioScope3
stationary during the test.
9.
Repeat steps on opposite ear, rescreen if necessary. Turn the instrument “OFF” by
sliding the switch down.
10.
Complete the AudioScope Screening results form (sticker) and attach it to the patient’s
chart. Fax the results to the UM department for physician review.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000682
34
Medical Guidelines
Region: New Mexico
Example:
Recharging:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000683
35
Medical Guidelines
Region: New Mexico
M-008: Blood Administration
I.
GUIDELINE
In those facilities that have contracts with community vendors to provide blood components
(red blood cells, platelets, blood protein, and plasma) to the facility, Wexford Health has
established procedures for administering blood to those patients who have a demonstrated
deficiency. In such facilities, Wexford Health will:
II.
1.
Replace and maintain the patient’s blood volume and/or oxygen carrying capacity
2.
Ensure compatibility between the patient’s blood and the whole blood or packed red
blood cells that may be transfused
3.
Prevent the infusion of fibrin clots and microaggregates (broken-down blood cells)
WHO MAY PERFORM BLOOD ADMINISTRATION
Only licensed RN’s may administer blood.
III.
EQUIPMENT/FORMS
Blood unit and 250-cc bottle of normal saline. Clinical alert: Whole blood and red blood cells,
when administered with IV solution, must be given with saline solution.
Blood administration set, either straight line or Y-set.
Venipuncture tray, if patient does not already have an IV in place. An 18-gauge needle or 18gauge catheter should be used.
An 18-gauge needle if patient already has a primary IV line in place.
Alcohol swabs and tape
IV.
UNIVERSAL PRECAUTIONS
All clinical staff must adhere to universal blood and body fluid precautions while performing blood
administration. At a minimum, disposable gloves must be worn when handling blood products and
associated equipment. Refer to Wexford Health’s Infection Control Guidelines manual: “Universal
Blood and Body Fluid Precautions,” guideline number IC-004.
V.
PROCEDURES
Check order for transfusion in patient’s chart
Examine patient’s IV. An 18-gauge catheter or needle should be placed in a medium or largesized vein.
Take the patient’s vital signs to establish a baseline.
Take and record patient’s temperature. If patient is febrile (37.8º C or 100.0º F), notify the
provider before initiating the transfusion.
Assess for signs and symptoms of blood reactions during infusion.
Obtain or confirm signed consent from patient.
Obtain whole blood unit or packed blood cells unit from blood lab or blood bank.
Obtain the requisition form for the transfusion.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000684
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Medical Guidelines
Region: New Mexico
With lab technologist, check requisition form and lab blood record against the blood unit for
essential data: patient’s name and ID number, blood group and type (ABO and Rh), blood
unit number, and expiration date of blood unit.
With another RN, check the requisition form and the lab blood record with the information on
the patient’s identification band to make sure that all data matches. Essential data includes
patient’s name and ID number, blood group, blood type, blood unit number, and an expiration
date on the blood unit.
Sign the form with the other RN according to facility guideline. Remember that blood must be
started within 30 minutes from the time it is removed from refrigeration.
Document transfusion on the appropriate facility-approved form.
Monitor and document vital signs at a minimum of 5 minutes, 15 minutes, and then every 30
minutes after starting the transfusion and continue until one hour after the completion of the
transfusion.
VI.
ADMINISTERING BLOOD THROUGH A STRAIGHT LINE
Rotate the blood unit bag gently to mix the blood cells and plasma.
With blood administration set ready, pull back the tabs on the blood unit bag and expose the
port.
Carefully spike the port and hang the unit.
Fill the drip chamber by gently squeezing its flexible sides. Make sure the filter is submerged
in the blood.
Open the clamp on the tubing, run the blood through the tubing and cap the tubing.
If the patient needs a venipuncture, select a vein an insert an IV needle and tubing.
If the patient has a primary IV in place with an appropriate-sized needle, place an 18-gauge
needle (or larger needle) in the end of the blood unit tubing.
If the primary IV solution is not compatible with the blood to be infused, remove the primary
IV solution and cap it for sterility.
Spike a small bottle of normal saline and run this solution through the tubing.
Prime the blood unit tubing.
Swab the injection port with alcohol.
Insert the needle carefully and tape it into place.
Shut off the primary IV and begin the blood transfusion.
Give blood slowly for the first 15 minutes, approximately 20 drops per minute that equates to
100 cc/hr
Observe the patient closely for adverse reactions such as chilling, backache, headache,
nausea, vomiting, tachycardia, tachypnea, skin rash, or hypotension.
If there are no adverse effects, administer the blood unit at the prescribed rate.
Transfusion of the blood should be completed in less than four hours since blood deteriorates
rapidly after a two-hour exposure to room temperature.
Continue to monitor the patient throughout the transfusion.
When you have completed the transfusion, flush the line with normal saline, inject the
primary IV solution, and adjust the drip to the desired rate.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000685
37
Medical Guidelines
Region: New Mexico
Remove the blood unit bag and administration set. If you are going to transfuse a second unit
of blood, obtain that unit and a new administration set and repeat the procedure described
above.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000686
38
Medical Guidelines
Region: New Mexico
VII.
INTERVENTION: ADMINISTERING BLOOD THROUGH A Y-SET
Close all clamps on the Y-set.
Spike the small saline bottle, using aseptic technique, and then spike the blood bag.
Hang both the saline bottle and blood bag.
Open the clamp to the saline bottle and squeeze the sides of the drip chamber until the filter
is half covered and the drip chamber is full.
Open the main clamp and prime the rest of the tubing. To ensure easier flow, remove the cap
that protects the end of the IV tubing.
When the tubing is primed, replace the cap and close the main clamp.
Cleanse the injection port on the primary IV.
Affix a large-gauge needle to the end of the tubing and prime.
Insert the needle into the injection port and clamp off the primary IV flow.
Using saline solution, open the clamp to the saline bottle and turn clamp on the main tubing
to begin the flow to clear primary IV tubing
Clamp off the saline bottle and open the clamp to the blood bag.
Squeeze the sides of the Y-set drip chamber so that blood covers the entire filter.
Follow the procedure as you did with previous bottle.
When the blood bag is empty, clamp off the tubing to the bag, open the clamp to the normal
saline bottle and flush the line.
Close all clamps and remove the needle from the injection port.
Open the clamp on the primary IV and establish the desired rate of administration.
VIII. INTERVENTION: ADMINISTERING BLOOD COMPONENTS
Obtain blood component from lab or appropriate sources.
Obtain appropriate administration set.
Read directions for proper administration of the solution.
Identify rate at which blood component should infuse.
Check blood component therapy chart for appropriate rate, risk factors, and possible
complications.
For any adverse reaction, immediately stop the transfusion and notify the provider.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000687
39
Medical Guidelines
Region: New Mexico
Transfusion Reactions
CLINICAL MANIFESTATIONS
NURSING INTERVENTIONS
TYPE: Bacterial
1.
2.
3.
4.
5.
6.
7.
Sudden increase in temperature
Hypotension
Dry, flushed skin
Abdominal pain
Headache
Lumbar pain
Sudden chill
1.
2.
3.
4.
5.
6.
7.
Stop transfusion immediately.
Maintain IV site; change tubing as soon as possible.
Observe for shock. Monitor vital signs every 15 minutes until stable.
Obtain urine specimen. Insert foley if necessary.
Notify physician and obtain order for broad spectrum antibiotic.
Draw blood cultures before antibiotic administration.
Send blood tubing and bag to lab for culture and sensitivity; control hypothermia.
TYPE: Allergic
1.
2.
3.
Uricaria and hives, pruritis
Respiratory wheezing, laryngeal edema.
Anaphylactic reaction.
1. Stop transfusion immediately if symptoms are severe.
2. Monitor vital signs for possible anaphylactic shock.
3. If symptoms are mild, slow down transfusion and obtain order for antihistamine;
monitor for signs of progressive allergic reaction as transfusion continues.
TYPE: Hemolytic
IX.
1.
2.
Severe pain in kidney region and chest.
Pain at needle insertion site.
3.
4.
Fever (may reach 105°F), chills
Dyspnea and cyanosis
5.
Headache
6.
7.
Hypotension
Hematuria
1. Stop transfusion immediately.
2. Change IV tubing as soon as possible, maintaining patient IV. If necessary,
disconnect IV tubing from needle and run normal saline through IV tubing into
emesis basin. Reconnect tubing to needle and obtain new tubing as soon as
possible.
3. Administer oxygen.
4. Send two blood samples, from different sites, urine sample (cath if necessary),
blood, and transfusion record to lab.
5. Obtain orders for IV volume expansion and diuretic (mannitol) to ensure flushing of
kidneys to prevent acute renal tubular necrosis.
6. Monitor vital signs every 15 minutes for shock.
7. Monitor urine output hourly for possible renal failure. Foley catheter may need to
be inserted.
PREVENTING TRANSFUSION REACTIONS
Identify patient and blood bottle or bag.
1.
ID band number matches transfusion record number.
2.
Names spelled correctly on transfusion record.
3.
Blood bottle number and pilot tube number are same.
4.
Blood type matches on transfusion record and blood bottle.
Check with other RN before infusing.
Ask patient about allergy history and report any previous blood reactions.
Establish baseline vital sign data.
Start transfusion slowly to observe for severe reactions.
Maintain aseptic technique during procedure.
Observe time rules (length of time blood can hang) for administering blood.
Observe blood bag or bottle for bubbles, cloudiness, dark color, or black sediment, which is
indicative of bacterial invasion.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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Medical Guidelines
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Do not allow blood to remain at room temperature unnecessarily.
Blood Component Therapy
TYPE
USE
ADMINISTRATION
EQUIPMENT
ALERTS
To replace deficient coagulation
factors.
Hepatitis is a risk.
Any straight line administration set.
To increase intravascular
compartment.
Administer as rapidly as possible.
Use within 6 hours.
Administer at rate of 10 minutes a unit
(usually come in multiple plateletpacks).
Platelet transfusion set with special
filter to allow platelets to infuse
through filter.
Fresh Plasma
To prevent or treat bleeding
problems, especially in surgical
patients.
Platelets
To replace platelets in patients
with acquired or inherited
deficiencies (thrombocytopenia,
aplastic anemia). To replace
when platelets drop below 30,000
cu/mm (normal 150,000−350,000
cu/mm)
To treat oncology patients with
severe bone marrow depression
and progressive infections.
To treat granulocytopenic
patients with infections that are
unresponsive to antibiotics.
Granulocytes
To treat hypoproteinemia.
Serum Albumin
To treat agammaglobulinemia.
Coagulation Factors
Factor VIII
(cryoprecipitate)
Give one transfusion daily until
granulocytes increase or infection
clears.
Use Y-type blood filters and prime
with physiological saline. A
microaggregate filter is not used as
it filters out platelets.
Use within 48 hours after drawn.
To treat patients with gramnegative bacteremia or infections
where marrow recovery does not
develop.
To treat shock.
Gamma Globulin
Administer slowly, over two to four
hours.
To act as prophylaxis for hepatitis
exposure.
To treat patients with von
Willebrand’s disease.
To treat patients with factor VIII,
hemophilia A.
Give when granulocytes are below
500.
Observe for shaking, fever, chills
(treat with Tylenol before
transfusions).
Observe for hives and laryngeal
edema (treat with antihistamines).
Available as 5% or 25% solution.
Special tubing accompanies
albumin solution in individual boxes.
Infuse 25% solution slowly 1
ml/minute to prevent circulatory
overload.
Administer 100−200 cc (25% solution)
for shock patients and 200−300 cc for
hypoproteinamia.
Pooled plasma contains antibodies to
infectious agents.
Administer 0.25 ml−0.50 ml of
immune serum globulin per kg of body
weight every to four weeks.
Made from fresh-frozen plasma.
Given IM
Standard Syringe for component
drip set only.
Administer one unit cryoprecipitate for
each 6 kg of body weight initially,
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
TYPE
USE
To treat patients with factor IX,
hemophilia B.
Factor IX
ADMINISTRATION
EQUIPMENT
ALERTS
followed by 1 unit/3 kg of body weight
at 6- to 12-hour intervals until
treatment discontinued.
Administer one unit per five minutes.
Observe for febrile reactions: shaking,
fever, chills, and headache.
Administer in 12- to 24-hour cycle.
Any straight line set.
Preparation for administration is 400
to 500 u/vial. Must reconstitute in 10to 20-cc diluent.
One unit/lb. of body weight increases
the circulating factor activity by 5%.
Serum hepatitis can be transmitted.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000690
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Medical Guidelines
Region: New Mexico
M-010: Enteral Nutrition and Nutritional Supplementation
Reference: ACA: 5-ACI-5C-06; NCCHC: D-05
I.
GUIDELINE
A.
Enteral Nutrition Therapy
1.
Enteral nutrition generally refers to any method of feeding that uses the gastrointestinal
(GI) tract to deliver part or all of a person's caloric requirements.
2.
For the purposes of this guideline, enteral nutrition may be given by nasogastric,
jejunostomy, or gastrostomy tubes and can be provided safely and effectively in facilities
with appropriate infirmary capabilities.
3.
Enteral nutrition is considered reasonable and necessary for a patient with a
functioning gastrointestinal tract for whom oral feeding is impossible.
4.
Each request for enteral nutrition must contain a physician’s written order or
prescription and sufficient medical documentation (e.g., hospital records, clinical
findings from the attending physician) to permit an independent conclusion that the
patient’s condition meets the requirements of the guideline and that enteral nutrition
therapy is medically necessary.
a.
5.
B.
Approved requests are to be reviewed at periodic intervals of no more than
monthly by the Site and/or Regional Medical Director. Additional medical
documentation may be required to be obtained as part of this review.
Approval will be provided for no more than one month’s supply of enteral nutrients at
any one time. If a pump is involved, it must be supported by sufficient medical
documentation to establish that the pump is medically necessary, i.e., gravity feeding
is not satisfactory due to aspiration, diarrhea, dumping syndrome, etc. Pump selection
is based on the reasonable charge for the simplest model that meets the medical needs
of the patient as established by medical documentation.
Nutritional Supplementation
1.
Some patients, or clinicians on behalf of a patient, may request the addition of oral
supplementation of daily protein and caloric intake. Nutritional supplements (e.g. Boost,
Glucerna, Ensure, etc.) are often cited as one method to provide an additional caloric
source between meals and to boost protein and general caloric intake. Nutritional
supplementation is not covered under the guideline for patients with a functioning GI
tract and ability to utilize oral intake.
2.
Since oral nutritional supplements presumably produce clinical benefits through
increased nutrient intake, a similar increase in nutrient intake achieved by dietary
means should lead to similar clinical benefits.
NOTE:
This guideline is designed to address medical guidelines that are appropriate for the majority
of individuals with a particular disease, illness, or condition. Each person's unique clinical
circumstances may warrant individual consideration, based on review of applicable medical
records and discussion with the treating physician(s). This guideline does not constitute
medical advice, nor is it intended to govern the practice of medicine.
3.
Complete the Nutritional Supplement Request form and submit the completed form to
wexfordpurchasing@wexfordhealth.com by e-mail.
4.
A collegial review will be scheduled if necessary.
5.
Notification of approval status will be sent to the prescribing practitioner.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
6.
II.
Urgent requests are handled in a manner similar to urgent collegial requests for offsite
care. The site provider completes the Nutritional Supplement Request form, emails this
form to the UM nurse, and calls the UM Medical Director to discuss the urgent need for
the nutritional supplement
RELATED DOCUMENTS
Nutritional Supplement Request Form (Guideline and Form adopted from SCIP Manual)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000692
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Medical Guidelines
Region: New Mexico
M-010: FORM: Nutritional Supplement Request Form (SAMPLE)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000693
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Medical Guidelines
Region: New Mexico
Morbidity Survey Report Form (SAMPLE)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000694
46
Medical Guidelines
Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Mortality Review Worksheet (SAMPLE)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000696
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Medical Guidelines
Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000697
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Medical Guidelines
Region: New Mexico
M-018: Naloxone (Narcan): Guidance for Use in Opioid Suspected Ingestion/Overdose
Reference: ACA: 5-ACI-6A-08; NCCHC: D-01; D-07
I.
BACKGROUND
Opioids include not only prescription painkillers such as morphine, oxycodone, or
hydrocodone, but also heroin which has recently caused a spike in deaths related to
overdoses.
Opioid intoxication marked by unresponsiveness and respiratory depression is a lifethreatening emergency that requires staff cooperation at all levels.
Opioid overdose may result in death from coma and respiratory arrest.
Opioid overdose is reversible through the immediate administration of a quick-acting opioid
antagonist that blocks the action of the opioids, including heroin.
Naloxone (Narcan) is a quick-acting opioid antagonist and is indicated as a reversal agent for
known or suspected prescription or illicit opiate overdose.
Aggressive airway control must take precedence over pharmacologic reversal because the vast
majority of morbidity and mortality results from respiratory depression.
Contacting Emergency Medical Services after airway control is established is critical in order
to assure transfer to a facility equipped to handle drug overdoses.
II.
THE SCOPE OF THE OPIOID EPIDEMIC
According to NCCHC, drug overdose, primarily from opioids, is the fifth leading cause of death
in state prisons and the third leading cause of death in jails.
Deaths related to opioid painkillers and heroin in the community have quadrupled since1999.
Opioid overdoses may occur when a higher than recommended dose is ingested in a short
period of time, when the medication is combined with other drugs, such as benzodiazepines
or antidepressants, or when it is combined with "street" drugs, such as heroin. There may
also be a predisposition to drug dependence.
Use of opioid painkillers is a gateway to heroin abuse due to heroin being much cheaper and
easier to obtain and possessing a stronger effect.
III.
STOCKING NALOXONE (NARCAN)
Individual facilities should make decisions about stocking naloxone based on characteristics
of the facility including any history of opiate overdose, patient population, site-specific or
contract-specific guidelines, and recommendations of the Quality Management Committee.
If the correctional facility should consider maintaining naloxone as stock, sufficient quantity
of 1 mg/ml naloxone (Narcan) injection should be stocked to treat suspected opiate ingestion
in a patient.
IV.
Procedure FOR Evaluation and Treatment of a Suspected Opioid Ingestion
Initial Assessment
1.
Assess the patient for signs and symptoms of opioid toxicity/OD. Respiratory
depression, with respiratory rate of less than 12, requires use of naloxone (Narcan).
2.
Examples of clinical findings include:
a.
Shallow respirations/apnea, bradycardia
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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Medical Guidelines
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b.
Lethargy, decreased alertness, inability to talk
c.
Unresponsiveness
d.
Pupillary constriction
e.
Decreased muscle tone/limp body
f.
Slurred or unintelligible speech
g.
Pale, clammy skin
h.
Peripheral or central cyanosis
i.
Choking sounds, i.e., "death rattle"
3.
Consider ruling out hypoglycemia by obtaining fingerstick glucose prior to Narcan
administration.
4.
Establish airway and adequate oxygenation with a bag mask, if clinically appropriate.
5.
If clinically justified, have a staff member contact ambulance services for transport to
the emergency department.
Treatment
1.
Naloxone (Narcan) is a life-saving drug that can reverse the effects of an opioid overdose
when administered in time.
2.
Naloxone is non-addictive and is easy to administer, whether it's given IV or IM.
3.
Naloxone is a short-acting medication that will not reverse all opioid effects immediately.
Symptoms of opioid intoxication such as confusion, sedation, respiratory depression,
bradycardia, and decreased muscle tone may persist after administration of naloxone.
4.
If naloxone is used for a suspected long-term opiate user, only an amount sufficient to
return spontaneous respirations is recommended.
5.
Naloxone is Category C in pregnancy, and can be used if potential benefit justifies the
risk. Pregnant patients with opioid addiction issues are usually prescribed methadone
or Suboxone in addiction treatment centers to avoid drug withdrawal symptoms.
Preparation, Administration and Initial Monitoring of Naloxone (Narcan)
1.
For IV administration without cardiac arrest, dilute 1 mg naloxone with 9 ml NS in
a syringe to a total volume of 10 ml (diluted concentration of 0.1 mg/ml).
a.
Administer in 4 ml (0.4 mg) increments over 30 sec, while checking for respiration.
b.
If no respirations within 2 minutes, repeat the dose.
c.
Stop when breathing normally or when 10 mg limit has been reached.
d.
Obtain vitals (HR, BP, RR) every 15 minutes and monitor the patient for
respiratory depression for 1–2 hours, or until the patient is transported by
ambulance services.
e.
Monitor pupil size and assess for decreased level of consciousness/sedation.
f.
Watch for signs of opioid withdrawal (restlessness, anxiety, lacrimation,
diaphoresis)
2.
For IV administration with cardiopulmonary arrest from opioid overdose, may
administer 2 mg IV along with CPR procedure and repeat every 2 minutes.
3.
If no IV access can be obtained, administer 2 mg (undiluted) IM using anterolateral
aspect of thigh and monitor for spontaneous respirations.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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a.
Clinical reversal typically occurs within 5–10 minutes.
b.
If patient is still unresponsive, administer another dose.
c.
If a total dose up to 10 mg is not effective, opioid toxicity may not be the correct
diagnosis.
d.
Obtain vitals (HR, BP, RR) every 15 minutes and monitor the patient for
respiratory depression for 1-2 hours, or until the patient is transported by
ambulance services.
e.
Monitor pupil size and assess for decreased level of consciousness/sedation.
f.
Watch for signs of opioid withdrawal (restlessness, anxiety, lacrimation,
diaphoresis).
Possible Adverse Effects of Naloxone (Narcan)
V.
1.
Occasionally, naloxone can cause seizures, cardiac disturbances, and precipitate rapid
onset of opioid withdrawal symptoms. However, it still remains a life-saving drug for
those patients with suspected opioid overdose.
2.
To reduce the likelihood of withdrawal, naloxone should be given in small doses every
few minutes till the desired effect is reached.
REFERENCES
1.
National Commission on Correctional Healthcare Position Statement. "Naloxone in Correctional Facilities
for the Prevention of Opioid Overdose Deaths".
http://www.ncchc.org/naloxone-for-the-prevention-of-opioid-overdose-deaths
2.
Micromedex® 1.0 (Healthcare Series), (electronic version). Truven Health Analytics, Greenwood Village,
Colorado, USA. Available at: http://www.micromedexsolutions.com October 5, 2016.
3.
Department of Health and Human Services. "The Opioid Epidemic: By the Numbers",
www.hhs.gov/opioids.
4.
Khazan O. "The New Heroin Epidemic", The Atlantic 2014, October 30.
5.
West Virginia Department of Health and Human Resources, Office of Emergency Medical Services.
"Access to Opioid Antagonist Act: Senate Bill 335", accessed October 5, 2016.
6.
Consensus Statement of the American Academy of Pain Medicine and the American Society of Addiction
Medicine.
http://www.asam.org/docs/default-source/public-policy-statements/1opioid-definitions-consensus-2011.pdf?sfvrsn=0
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
M-019: Medical Management of Patient Exposure to Bloodborne Pathogens
Reference: ACA: 5-ACI-6A-12; NCCHC: B-02
I.
PURPOSE AND OVERVIEW
▪
Note: Specific guidance for management of exposures for employees or correctional staff is a
separate guideline.
▪
These guidelines for the Medical Management of Exposures are based on the recommendations
of the Federal Bureau of Prisons Clinical Guidance on exposures, U.S. Public Health Service
(USPHS) and the Centers for Disease Control and Prevention (CDC), as well as the requirements
of the Occupational Safety and Health Administration (OSHA).
▪
These guidelines provide specific recommendations for medically managing patients who have
experienced potential exposures to human immunodeficiency virus (HIV), hepatitis B virus
(HBV), and hepatitis C virus (HCV) through various means, including human bites and sexual
assaults.
▪
IMPORTANT:
Expert consultation on post-exposure management for HIV, HBV, and HCV is available:
Call PEPline, the National Clinicians' Post-exposure Prophylaxis Hotline, at
1-888-448-4911 (every day, 9 a.m. - 2 a.m. EST).
II.
TRANSMISSION RISK
HIV – Transmission Risk
The risk of viral transmission following an exposure incident depends on the type and extent of the
exposure. The per-incident transmission risk for HIV infection depends on the type of exposure, as
shown in the table below:
Table 1. Estimated Per-Incident Risk for Acquisition of HIV, by Exposure Route
Needle-sharing (injection drug use)
0.67%
Insertive anal intercourse
0.065%
Receptive anal intercourse
0.5.%
Insertive penile-vaginal intercourse
0.05%
Percutaneous needle stick
0.3%
Receptive oral intercourse
0.01%
Receptive penile-vaginal intercourse
0.1%
Insertive oral intercourse
0.005%
Source: CDC. Antiretroviral post-exposure prophylaxis after sexual, injection –drug use, or other non-occupational
exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services,
MMWR, 2005:54 (No. RR-2):7.
The risk of HIV infection appears higher with:
▪
Exposure to a larger quantity of blood or other infectious fluid
▪
Exposure to the blood of a patient with advanced, uncontrolled HIV disease, as indicated by
higher viral load
▪
A deep percutaneous injury
▪
Injury with a hollow-bore, blood-filled needle
▪
Exposure to a source with concomitant hepatitis C viral infection
▪
Sexual assault (due to mucosal trauma, multiple assailants, or traumatic intercourse)
▪
The presence of a sexually transmitted infection in either the source or the exposed individual.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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HBV and HCV – Transmission Risk
The risk of viral transmission after a percutaneous exposure incident is highest for HBV (especially
when the source is both HBsAg-positive and HBeAg-positive), followed by HCV and HIV, as shown
in Table 2 below.
Table 2. Average Transmission Risk After Percutaneous Injury
Hepatitis B:
37-62%
• HBsAg-positive/HBeAg-positive*
23-37%
• HBsAg-positive/HBeAg-negative*
Hepatitis C
1.8% (range 0-7%)
HIV
0.3%
* HBsAg = hepatitis B surface antigen; HBeAg = hepatitis B e antigen
Human Bites – Transmission Risk
Human bites have rarely resulted in transmission of HIV or HBV infection. There have been no
reports of transmission of HIV or HBV following a human bite that occurred as part of an
occupational exposure.
III.
STEPS IN POST-EXPOSURE MANAGEMENT
Background – Exposure with Intact Skin
Frequently, evaluation of a reported "exposure” reveals that no significant exposure actually
occurred (e.g., contact of intact skin with blood). These individuals should be counseled that this
type of exposure is not considered a “true exposure" and that no further follow-up is needed.
Exposed Patients
▪
If HIV post-exposure prophylaxis (PEP) is indicated, it is ideal to administer it within two hours
of the exposure incident.
▪
Prompt evaluations of both the exposed person and the source case are essential.
Consultation on post-exposure management for HIV, HBV, and HCV is available at:
PEPline, the National Clinicians' Post-exposure Prophylaxis Hotline, at
1-888-448-4911 (every day, 9 a.m. - 2 a.m. EST).
▪
Follow Steps 1- 5 below for post-exposure management.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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Step 1. Evaluate the Exposure
The following are general instructions for treating the exposure site:
▪
The injured skin or wound should be emergently cleaned with soap and running water for two
minutes.
▪
Mild bleeding should be allowed to continue freely for 30 seconds.
▪
Pressure should then be applied to stop bleeding and bandage as necessary.
▪
Aspiration, forced bleeding, and wound incision are not recommended.
▪
Antiseptics, bleach, or other cleansing agents should not be used.
▪
Mucous membranes should be rinsed with water for at least two minutes.
▪
Exposed eyes should be flushed with water or saline for at least two minutes.
1. Notate the type of body fluid.
•
•
Infectious body fluids are those that can potentially spread bloodborne pathogens.
─
Such body fluids include blood; tissue; fluids containing visible blood; semen; rectal and
vaginal secretions; breast milk; and cerebrospinal, synovial, pleural, peritoneal,
pericardial, and amniotic fluids.
─
Exposure to any of these fluids requires further evaluation.
Non-infectious body fluids are those that have not been demonstrated to spread
bloodborne pathogens.
─
These include feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus.
─
Exposure to these body fluids is not considered a significant exposure, unless they
contain visible blood.
o
Unless the fluid is visibly bloody, no further evaluation is required.
2. Notate the exposure type:
•
•
Percutaneous (injuries that occur when the skin is penetrated by a contaminated
sharp object).
─
Document the specific type of sharp, including the brand and gauge in the case of
needles.
─
Indicate whether the injury is:
o
Less severe (e.g., superficial injury; penetration with a solid needle such as a suture
needle)
o
More severe (e.g., deep puncture; penetration with a large bore, hollow needle; blood
visible on the device; needle that was used in an artery or vein).
Mucous membrane exposure (inside the eyes, nose, or mouth) or exposure to nonintact skin (e.g., chapped, dermatitis, abrasion, or open wound).
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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Medical Guidelines
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•
Human bite
─
Clinical evaluation must include the possibility that the person bitten and the person
who inflicted the bite both may have been exposed to a bloodborne pathogen.
─
Identify whether blood exposure is suspected.
o
•
•
•
This includes examining:
✓
The mouth of the biter (if known), to assess the likelihood that the bitten person
was exposed to the biter's blood.
✓
The wound of the person bitten, to determine if blood exposure to the mouth of
the biter (if known) occurred.
✓
All individuals who sustain a human bite should be assessed for tetanus
prophylaxis and possible antibiotic prophylaxis.
Sexual
─
Any allegation made by a patient of recent sexual assault should receive prompt forensic
evaluation by a healthcare professional trained in collecting sexual assault forensic
evidence.
─
For Post-Exposure Prophylaxis (PEP) evaluation, indicate the type of sexual exposure:
receptive anal intercourse, receptive vaginal intercourse, or other sexual exposure.
─
If the behavior is recurrent or occurred more than 72 hours ago, PEP is not typically
indicated.
Shared injection drug use equipment
─
Assess the nature/timing of the exposure and whether or not the behavior is recurrent.
─
If the behavior is recurrent or occurred more than 72 hours ago, PEP is not typically
indicated.
Intact skin
─
Exposure of intact skin (without signs of abrasion) to blood or other infectious body fluid
does not constitute an exposure and does not require follow-up.
Step 2. Evaluate the Source Case or Cases (If Known)
▪
To obtain information about the source case or cases, utilize all available information including
review the sources medical records and interviewing the source.
▪
Record previous and current laboratory results (HIV test results, HBsAg, and HCV antibody).
▪
If the source is known to be HIV+:
▪
o
Obtain results of the most recent HIV viral load and CD4+ T-cell count, history of
antiretroviral therapy, results of any resistance testing.
o
Resistance testing of the source case at the time of exposure is not useful because the results
will not be available in time to select the PEP regimen.
If HIV status of source is unknown:
o
Obtain an HIV test.
▪
Whenever the source case is known, the HIV status of the exposure source patient should be
determined to guide appropriate use of HIV PEP.
▪
Administration of PEP should not be delayed while awaiting test results.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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Medical Guidelines
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▪
If the source patient is determined to be HIV negative,
o
▪
PEP should be discontinued, and no follow-up HIV testing for the exposed patient is
indicated.
If source is HBsAg+:
o
Review documentation in the medical record and discuss the case.
Step 3. Evaluate the Health Status of the Exposed Person
▪
▪
▪
Obtain the following baseline labs on the exposed person (preferably within 24 hours):
o
HIV Test
o
Anti-HBs (if previously completed hepatitis B (Hep B) vaccination series or vaccination status
is uncertain, and if post vaccination anti-HBs test results are unavailable)
o
Total Anti-HBc (if post-vaccination anti-HBs < 10 ml U/mL or if not vaccinated or
incompletely vaccinated)
o
HCV Antibody (HCV Ab) (if not HCV Ab +)
o
A pregnancy test should ordinarily be obtained for females unless they have a history of
hysterectomy or are post-menopausal.
Assess vaccination status for tetanus and Hep B.
o
If available, note dates of Hep B vaccination and results of vaccine response testing. (Persons
with anti-HBs > 10 ml U/ml are considered responders and immune; those with anti-HBs <
10 ml U/ml are non-responders and potentially susceptible.)
o
Persons with unknown Hep B vaccine response status should be tested for anti-HBs.
Note other medical conditions, current medications, and drug allergies.
Step 4. Determine Need for HIV PEP (Post-Exposure Prophylaxis)
▪
Outlined below is the assessment process for determining need for HIV post-exposure
prophylaxis.
▪
Prompt assessment and follow-up is essential.
▪
Ideally, HIV PEP is initiated within two hours of the exposure.
▪
If PEP is delayed more than 36 hours, seek expert consultation.
Consultation on post-exposure management for HIV, HBV, and HCV is available at:
PEPline, the National Clinicians' Post-exposure Prophylaxis Hotline, at
1-888-448-4911 (every day, 9 a.m. - 2 a.m. EST).
▪
Determining the need for HIV PEP:
o
Recommendations for PEP are based on the HIV status of the source case, and the type and
conditions of the exposure.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000705
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Medical Guidelines
Region: New Mexico
o
The table below is adapted from USPHS/CDC recommendations and can be used as a clinical
tool to assist in determining the need for PEP.
o
Individuals exposed to a known or suspected HIV-infected source case should be
counseled about the need for the PEP regimen to be initiated promptly and carried out
for 28 days.
Table 3. HIV Exposures: PEP Recommendations
1. Exposure Type
2. Condition
Percutaneous
3. Recommendations Based on HIV Status of the Source
HIV+
HIV Status Unknown
Any severity
PEP
Consider PEP
Mucous Membrane
Small volume
Large volume
PEP
PEP
Generally no PEP
Consider PEP
Non-intact skin
Small volume
Large volume
PEP
PEP
Generally no PEP
Consider PEP
Sexual1,2
(<72 hrs/not recurrent)
Receptive anal or vag sex
Other sexual exposure
PEP generally recommended
PEP
Consider PEP
PEP not recommended
Sharing IDU equip1
<72 hrs/not recurrent
PEP
Consider PEP
(includes illicit tattoo)
1
2
PEP is generally not indicated 72 hours after exposure or if behavior is either frequent or recurrent. PEP may considered after longer
intervals (e.g., one week) on a case-by-case basis for exposures that represent an extremely high risk of transmission.
For the purposes of these guidelines, receptive anal and vaginal intercourse are the only types of sexual exposures that should be
considered for PEP (except if trauma or assault).
Adapted from:
CDC, MMWR. 2005;54(No. RR-9). At http://www.cdc.gov/mmwr/pdf/rr/rr5409.pdf
CDC, MMWR. 2005;54(No. RR-2). At http://www.cdc.gov/mmwr/PDF/rr/rr5402.pdf
USPHS. Infect Control Hosp Epidemiol. 2013;34(9); 875-892. At http://www.jstor.org/stable/10.1086/672271
▪
Preferred regimens for HIV PEP
o
PEP can still be associated with severe side effects and is not justified for exposures that
pose a negligible risk for transmission.
o
Recognizing that each case is unique. Consultation is available at: PEPline, the National
Clinicians' Post-exposure Prophylaxis Hotline, at 1-888-448-4911 (every day, 9 a.m. 2 a.m. EST).
o
The CDC along with the U.S Department of Health and Human Services has suggested HIV
medications as HIV PEP. Based on these suggestions we recommend:
Tenofovir Disoproxil Fumarate 300 mg 1 tablet daily plus
•
─
Lamivudine 300 mg 1 tablet daily plus
• Tivicay (dolutegravir) 50 mg 1 tablet daily
•
This regimen is given once daily as 3 different pills, typically for 28 days.
─
The regimen is tolerable, potent, conveniently administered, and associated with
minimal drug interactions.
─
Persons with decreased renal function, active HBV (HBsAg+) and/or pregnant may need
an alternative regimen.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000707
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Medical Guidelines
Region: New Mexico
▪
▪
Monitoring and management of PEP toxicity
o
Exposed individuals who are prescribed PEP should be monitored for drug toxicity by testing
at baseline and again at two weeks after starting PEP.
o
Monitoring should include at least a CBC and a CMP.
o
If toxicities are identified, modification of the regimen should be considered after expert
consultation.
Post-exposure follow-up
o
Individuals with exposure to HIV should receive follow-up counseling, post-exposure testing,
and medical evaluation-regardless of whether they receive PEP.
o
Follow-up HIV Testing:
─
▪
After baseline testing at the time of exposure, follow-up HIV-antibody testing should be
performed at the following intervals after the exposure date: 6 weeks, 12 weeks, and 6
months.
Special considerations for HIV PEP
o
While expert consultation regarding provision of HIV PEP is generally advised, it is considered
essential in the following special situations listed below.
o
Delayed initiation of HIV PEP: PEP for occupational exposures should generally not be
delayed beyond 24-36 hours post-exposure, PEP for sexual and injection drug use related
exposures should not typically be provided after 72 hours.
─
o
The maximum time interval after which PEP provides no benefit is unknown.
Unknown source (e.g., needle in a sharps container/tattoo needles):
─
Decide about using PEP on a case-by-case basis, in consultation with the PEPline.
o
The CDC does not recommend testing needles or other sharp instruments for HIV.
o
Known or suspected pregnancy in the exposed person:
─
Pregnancy does not preclude the use of optimal PEP regimens, and PEP should not be
withheld on the basis of pregnancy.
▪
─
o
The following medications are contraindicated for use in pregnant Women efavirenz
(during first trimester) and nelfinavir, as well as the combination of didanosine and
stavudine.
Source case has evidence of antiretroviral resistance:
─
o
Expert consultation should be sought in all cases in which antiretroviral
medications are prescribed to pregnant patients for PEP.
When the source patient's virus is known or suspected to be resistant to one or more of
the drugs being considered for the PEP regimen, then expert consultation is strongly
advised.
▪
If this information is not immediately available, the initiation of PEP, if indicated,
should not be delayed.
▪
The regimen can be modified after PEP has been initiated whenever such
modifications are deemed appropriate, based on relevant information received.
PEP side effects:
─
Health care providers who are knowledgeable about the possible drug toxicities, drug
interactions, and need for adherence should discuss these issues with the patient.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
─
RAL/FTC/TDF is generally well-tolerated, but side effects, if they occur, frequently can
be managed without changing the PEP regimen. Seek consultation when side effects are
difficult to manage.
Step 5. Determine Need for HBV Post-exposure Management
▪
General Principles
o
Prompt assessment and follow-up is essential in the evaluation and decision-making
regarding HBV post-exposure management.
o
Management of exposures to possible Hepatitis B virus (HBV) is dependent upon the source
case lab test results and the vaccination status of the exposed person.
o
*No HBIG should be given prior to examination of the lab serology and HBV vaccination
status of those involved in the exposure.
o
The source case:
─
o
o
The exposed person:
─
The exposed person should be assessed for Hepatitis B vaccination status and vaccine
response status (previous anti-HBs result).
─
Previously vaccinated persons who were not tested for anti-HBs (Hepatitis B surface
antibody = HBsAB) post-vaccination should be tested for anti-HBs.
▪
A HBV vaccine responder is defined as a person with anti-HBs ≥10 mIU/mL.
▪
A HBV vaccine non-responder is defined as a person with anti-HBs <10 mIU/mL.
Testing the source patient and the exposed person should occur simultaneously.
─
o
The source (if known) should be tested for Hepatitis B surface antigen (HBsAg); those
source cases that are HBsAg positive should be tested for HBeAg (Hepatitis B e antigen).
Testing the source patient should not be delayed while waiting for the exposed person’s
anti-HBs test results; likewise, testing the exposed person should not be delayed while
waiting for the source patient HBsAg results.
If the source is unknown, the Clinician should contact Dr. Dina Paul, Chronic Disease and
Case Management Director at Wexford Corporate for direction.
─
Dr. Paul is available at dpaul@wexfordhealth.com
─
Please write in the email subject line:
▪
─
•
URGENT QUESTION – HBIG
She may also be called at 412-937-8590 extension 221
Recommendations for post-exposure management of persons who sustain a bloodborne
exposure to an HBsAg positive or unknown source are outlined in the attached flow chart
taken from the Federal Bureau of Prisons Medical Management of Exposures guidelines. The
diagram on the following page (Management of Exposure to an HBsAg+ or Unknown Sources,
by Vaccination Status) makes recommendations based on serology and vaccination results.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Management of Exposure to an HBsAg+ or Unknown Sources, by Vaccination Status
3 DOSES &
RESPONDER1
3 DOSES &
RESPONSE UNKNOWN
3 DOSES &
ANTI HBS < 10 IU/L
Test for antiHBs2
No action
required
≥ 10 mlU/mL
Give HBIG3
&
Repeat vaccine
series
< 10 mlU/mL
2 SERIES OF 3 DOSES &
NON-RESPONDER
Give
HBIG3
Give
vaccine
dose #1
Give
HBIG3
4 weeks
Give
vaccine
dose #25
See Note #5
Give
HBIG3
Give
HBIG3
Give
vaccine
dose #35
Repeat
HBIG in 4
weeks
Test for anti-HBc & HBsAg to assess for evidence of HBV infection (≥6 months after exposure)
Test for Anti-HBs post-vaccination to assess for vaccine response 1
(1-2 months after vaccine completed & 4-6 months after HBIG administered)
Abbreviations: HBsAg = hepatitis B
surface antigen; anti-HBs = antibody to
hepatitis B surface antigen; anti-HBc =
antibody to hepatitis B core antigen;
HBIG = hepatitis B immune globulin
2
2 DOSES ONLY
(INCOMPLETE)
Test for total anti-HBc4. Do not delay HBIG/vaccine administration while awaiting results. If anti-HBc positive then see note #6.
Responder1
1
1 DOSE ONLY
(INCOMPLETE)
NOT VACCINATED
If either anti-HBc or HBsAg are positive see note # 7 below.
A responder is defined as a person
with anti-HBs ≥10 mIU/mL after ≥3
doses of HepB vaccine. A
nonresponder is defined as a person
with HBs <10 mIU/mL after 2 complete
vaccine series (usually ≥6 doses) of
HepB vaccine
3
Test for anti-HBs should be performed
1–2 months after the last dose of the
HepB vaccine series and 4–6 months
after administration of HBIG, to avoid
detection of passively administered
anti-HBs. Testing should use a
quantitative method that allows
detection of the protective concentration
of anti-HBs (≥10 mIU/mL).
5
4
6
7
HBIG should be administered intramuscularly as soon as possible after exposure when indicated. The effectiveness of HBIG
when administered >7 days after percutaneous, mucosal, or nonintact skin exposures is unknown. HBIG dosage is 0.06 mL/kg.
Persons who have anti-HBs <10mIU/mL, or who are unvaccinated or incompletely vaccinated, and sustain an exposure to a
source patient who is HBsAg-positive or has unknown HBsAg status, should undergo baseline testing for HBV infection as soon
as possible after exposure, and follow-up testing approximately 6 months later. Initial baseline tests = total anti-HBc; testing at
approximately 6 months = HBsAg and total anti-HBc. If total anti-HBc or HBsAg are positive then see note # 7.
If exposed person is currently in the middle of the HepB vaccination series, then continue vaccine series according to routine
schedule. If exposed person started vaccine sometime in the past, then give immediate post-exposure vaccine dose ASAP.
Dose 2 should be at least 4 weeks from dose 1; dose 3 should be at least 8 weeks from dose 2; and there should be at least 16
weeks between dose 1 and dose 3.
A positive anti-HBc indicates past or current HBV infection. Stop vaccination. Test for HBsAg: If positive see Note #7.
If anti-HBc positive and HBsAg is negative person is considered to have natural immunity to HBV and requires no additional
vaccination and no special evaluation unless they become immunosuppressed or immunocompromised. If HBsAg positive, then
evaluate for chronic HBV infection. See: BOP Clinical Practice Guideline. Stepwise Approach for Detecting, Evaluating and
Treating Chronic Hepatitis B Virus Infection
Adapted from: CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR. 2013, 62(10):1–24.
▪
•
** If HBIG/HBV vaccine is recommended by Dr. Dina Paul or based on blood testing
results, it should be given within 7 days of exposure.
•
Timeline:
─
Blood for serology testing should be drawn immediately after notification of possible
exposure.
─
Lab results should be received within 24-48 hours of submission.
─
HBsAg status of the source patient and anti-HBs status of the exposed patient should
be reviewed as soon as possible upon receipt of results and treatment plan determined.
─
If post-exposure management is warranted, Hepatitis B Immune Globulin (HBIG) should
be obtained and administered as soon as possible, within 7 days of initial exposure.
HBIG Drug Acquisition:
o
HBIG can be obtained within 24 hours from your facility’s emergency back-up
pharmacy or via next day shipment from Cardinal Health.
o
Cardinal Health is available by contacting Dr. Michelle Marrone, Senior Clinical Pharmacist.
─
Dr. Marrone is available at mmarrone@wexfordhealth.com
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000710
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Medical Guidelines
Region: New Mexico
─
o
Standard weight-based dosing is 0.06 mL/kg.
─
o
She may also be called at 412-937-8590 extension 271
Available HBIG products:
▪
Hepagam B, 5 mL vial
▪
Hyper Hep B SD, 5 mL vial
▪
Nabi-HB, 5 mL vial
One 5 mL vial will treat a patient weighing up to 185 lbs.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000711
63
Medical Guidelines
Region: New Mexico
M-020: Air Ambulance Guidelines
Reference: ACA: 5-ACI-6A-06; NCCHC: D-07
I.
PURPOSE AND OVERVIEW
Air ambulance vehicles are specially equipped to transport individuals with life threatening
emergencies to the hospital.
This guideline is designed to address medical guidelines that are appropriate for the majority of
individuals with a particular disease, illness, or condition. Each person's unique clinical
circumstances may warrant individual consideration, based on review of applicable medical records.
II.
GUIDELINE
Air ambulance transportation may be considered medically necessary when ALL the following
criteria are met:
•
The emergency transport vehicle must be specially designed and equipped for transporting the
sick or injured; and
•
It must have customary patient care equipment, supplies and also must have safety and
lifesaving equipment; and
•
The ambulance crew must consist of at least two (2) attendants. One (1) of these attendants
must be duly qualified to provide the medical care required during transport; and
•
The patient’s medical condition must require immediate and rapid transportation that cannot
be provided by land ambulance; and
•
Great distances or other obstacles (for example, heavy traffic) are involved in getting the patient
to the nearest hospital with appropriate facilities for treatment.
The term "appropriate facility” refers to a hospital that is capable of providing the required level and
type of care for the patient’s illness and has available the type of physician or specialist needed to
treat the patient’s condition.
Medical necessity for air transportation is established when the patient’s condition is such that the
time needed to transport the patient by land (greater than 30-60 minutes) poses a threat to the
patient’s survival or seriously endangers the patient’s health.
Following is a list of examples of cases for which ambulance could be justified; this list is not
inclusive of all situations that justify air emergency transportation, nor is it intended to justify air
emergency transportation in all locales for the circumstances listed.
•
Intracranial bleeding which requires neurosurgical intervention; or
•
Cardiogenic shock; or
•
Major Burns requiring treatment in a Burn Center; or
•
Conditions requiring treatment in a Hyperbaric Oxygen Unit; or
•
Multiple severe injuries; or
•
Life-threatening trauma; or
•
High risk pregnancy – (high risk of preterm delivery or high medical risk to mother or fetus).
The vehicle and crew utilized for air ambulance transport must meet all applicable local, state, and
federal regulatory certification and licensing requirements.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
The transfer of a patient from one hospital to another may be considered medically necessary if
medical appropriateness criteria are met and the transferring hospital does not have adequate
facilities to provide the medical services needed by the patient.
Examples of such services include:
•
Burn units; or
•
Cardiac care units; or
•
Trauma units; or
•
Severe rejection of transplant to transplant hospital.
The ambulance transport is covered ONLY if the hospital to which the patient is transferred is the
nearest with appropriate facilities.
Air ambulance transportation is considered not medically necessary when the above criteria have
not been met.
III.
NON-EMERGENCY TRANSPORT
In general, non-emergency air ambulance services are not considered medically necessary for the
treatment or transport of patient patients.
Non-emergency air ambulance transport is NOT considered medically necessary for the convenience
of the patient, family members/companions, or the provider(s) treating the patient.
Examples of non-covered air ambulance transportation:
IV.
•
Air emergency transportation used to transport a patient to a facility for treatment because
family or patient or treating provider(s) want treatment at that facility when there is an equally
competent facility nearby.
•
Air transport utilized for the patient or family’s convenience in a non-life threatening
circumstance.
PRONOUNCEMENT OF DEATH
Payment may be considered for an air ambulance service when the air ambulance responds to pick
up a patient, but the patient is pronounced dead before being loaded onto the ambulance for
transport (either before or after the ambulance arrives on the scene).
•
This is provided the air ambulance service would otherwise have been medically necessary.
In such a circumstance, the allowed amount is the appropriate air base rate for helicopter or other
aircraft.
•
However, no amount will be allowed for mileage that would have been allowed had the
transport of a living patient been completed.
A pronouncement of death is valid only when made by an individual authorized under State law to
make such a pronouncement.
Additionally, no payment is made if the dispatcher received pronouncement of death and had
sufficient time to abort the transport. Further, no payment is made if an aircraft has merely taxied
but not taken off or, at a controlled airport, has been cleared to take off but has not actually taken
off.
Air ambulance companies must use the modifier QL (Patient pronounced dead after ambulance
called) to indicate the circumstance when an air ambulance takes off to pick up a patient but the
patient is pronounced dead before the pickup can be made.
Air ambulance companies must maintain documentation, sufficient to show that:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
V.
•
The air ambulance was dispatched to pick up a patient;
•
The aircraft was en route to make the pickup;
•
The patient to whom the dispatch relates was pronounced dead before being loaded onto the
ambulance for transport;
•
The pronouncement of death was made by an individual authorized by State law to make such
a pronouncement; and
•
The dispatcher did not receive notice of such death pronouncement in sufficient time to permit
the transport to be aborted before in route for pick-up.
ADDITIONAL AIR MILEAGE
Additional air mileage or wait time may be considered in situations where additional mileage or wait
time is incurred due to circumstances beyond the ambulance pilot’s control. These circumstances
include, but are not limited to, the following:
•
Military base and other restricted zones, air-defense zones, and similar FAA restrictions and
prohibitions
•
Hazardous weather
•
Variances in departure patterns and clearance routes required by an air traffic controller
If the air transport meets the criteria for medical necessity, claims for air transports may account
for all mileage from the point of pickup including where applicable: ramp to taxiway, taxiway to
runway, take-off run, air miles, roll out upon landing, taxiing after landing.
If no transport of a patient occurs, no covered service is rendered. Therefore, when multiple ground
and/or air ambulance providers respond, payment may be made only to the ambulance provider
that actually furnishes the transport. Ambulance providers that arrive on the scene but do not
furnish a transport are not due payment.
If no transport of a patient occurs no covered service is rendered. Therefore, payment will not be
made to the ambulance company. This applies to situations in which the patient refuses to be
transported, even if medical services are provided prior to loading the member onto the ambulance.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000714
66
Medical Guidelines
Region: New Mexico
M-021: Supplemental Oxygen Guideline
Reference: ACA: 5-ACI-6C-06; NCCHC: F-01
I.
OVERVIEW
Oxygen is administered by devices that provide controlled oxygen concentrations and flow rates.
Oxygen therapy should maintain adequate tissue and cell oxygenation while avoiding oxygen
toxicity. Patient monitoring is provided to assure that the proper mixtures of gases, mists, and
aerosols are being received.
II.
GUIDELINES
Oxygen and oxygen supplies may be considered medically necessary for appropriately selected
patients only in cases when oxygen is prescribed by a physician, and the prescription must specify:
•
A diagnosis of the disease requiring use of oxygen.
•
Oxygen concentration and flow rate.
•
Frequency of use (if an intermittent or leave in oxygen therapy, order must include time limits
and specific indications for initiating and terminating therapy).
•
Method of delivery.
•
Duration of use (if the oxygen is prescribed on an indefinite basis, care must be periodically
reviewed to determine whether a medical need continues to exist).
Oxygen therapy may be considered medically necessary for:
•
Severe lung disease, defined as either: a resting arterial oxygen partial pressure (PaO2) below
55 mm Hg; or O2 saturation less than 90%; or symptoms associated with oxygen deprivation,
(i.e. Impairment of cognitive processes, restlessness, or insomnia). Examples of severe lung
disease include, but are not limited to:
o
Chronic obstructive pulmonary disease (COPD)
o
Pulmonary fibrosis
o
Cystic Fibrosis
o
Bronchiectasis
o
Recurring congestive heart failure due to chronic cor pulmonale
o
Chronic lung disease complicated by erythrocytosis (hematocrit >56%)
Supplemental oxygen therapy may be considered medically necessary during sleep in an individual
with ANY of the following conditions:
•
Unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure,
or erythrocytosis and hematocrit is greater than 56%.
•
When obstructive sleep apnea (OSA), other nocturnal apnea, or a hypoventilation syndrome
has been ruled out and there is documentation of desaturation during sleep to an SaO2 of
equal to or less than 88% for greater than 30% of the night.
•
When an individual with documented OSA, other nocturnal apnea, or a hypoventilation
syndrome experiences desaturation during sleep to a SaO2 of equal to or less than 88% for
greater than 30% of the night which persists despite use of continuous positive airway pressure
(CPAP) or non-invasive positive pressure ventilation (NIPPV) devices.
Oxygen therapy is considered not medically necessary for the following conditions:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
•
Angina pectoris in the absence of hypoxemia.
•
Breathlessness without evidence of hypoxemia.
•
Severe peripheral vascular disease resulting in clinically evident desaturation in one or more
extremities.
•
Terminal illnesses that do not affect the lungs.
Portable oxygen systems may be considered medically necessary only if the patient ambulates on a
regular basis.
Oxygen saturations cannot be performed by a Durable Medical Equipment company or a respiratory
equipment provider.
Services that do not meet the criteria of this guideline will not be considered medically necessary.
Medical guidelines do not constitute medical advice, nor are they intended to govern the practice of
medicine. They are intended to reflect Wexford Health Sources’ medical necessity guidelines. This
guideline is designed to address medical guidelines that are appropriate for the majority of individuals
with a particular disease, illness, or condition. Each person’s unique clinical circumstances may
warrant individual consideration, based on review of applicable medical records.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000716
68
Medical Guidelines
Region: New Mexico
M-022: Vivitrol® (Naltrexone) Re-Entry Program
Reference: ACA; SAMSHA; ALKERMESE; FDA Vivitrol® Prescribing Guidelines
Reviewed: May 27, 2022
I.
GUIDELINE
Medication Assisted Treatment (MAT) in the form of Vivitrol, prior to release, has been shown to
lessen chances of relapse or overdose of opioids once the patient is released back into the
community.
In facilities with a Vivitrol program, Wexford Health medical personnel will collaborate with site
administration, Behavioral Health Therapists and, if applicable, community stakeholders to identify
incarcerated patients who would benefit from an initial dose of Vivitrol prior to release from
incarceration.
Wexford Health's guidance is based on the recommended best practices, as well as guidelines set
forth by the pharmaceutical company Alkermes that manufactures Vivitrol, Substance Abuse and
Mental Health Administration (SAMSHA) and the Food and Drug Administration (FDA) and the
American Correction Association (ACA).
II.
INFORMATION
There are two (2) forms of naltrexone, Vivitrol is an extended-release naltrexone injection and
naltrexone is a short-acting oral tablet. Both versions of naltrexone are U.S. Food and Drug
Administration approved to help patients avoid relapse in opioid as well as alcohol dependence
AFTER detoxification.
The U.S. Federal Drug Administration (FDA) approved naltrexone oral in 1983 and Vivitrol in 2010
for the treatment of opioid addiction. Naltrexone and Vivitrol were both FDA-approved to treat
alcohol dependence in 2006.
Vivitrol® (naltrexone injection) is the extended-release version of naltrexone and is administered by
intramuscular injection once a month. Vivitrol helps patients avoid relapse and reduces recidivism.
Vivitrol injection is also used to treat alcoholism by reducing the urge to drink alcohol. This may
help patients drink less or stop drinking altogether. Naltrexone (oral or extended-release injection)
will not decrease the effects of alcohol recently consumed.
Vivitrol or naltrexone is not a cure for drug addiction or alcoholism.
Vivitrol® is manufactured by Alkermes Inc., which may provide the first shot, at no cost, for a
patient in a correctional facility.
III.
WARNINGS AND PRECAUTIONS
A.
Vulnerability to Opioid Overdose Following Vivitrol Injection
1.
After opioid detoxification, patients are likely to have a reduced tolerance to opioids.
2.
Vivitrol blocks the effects of exogenous opioids for approximately 28 days after
administration.
3.
As the blockade wanes and eventually dissipates completely, use of previously tolerated
doses of opioids could result in potentially life-threatening opioid intoxication
(respiratory compromise or arrest, circulatory collapse, etc.).
4.
Cases of opioid overdose with fatal outcomes have been reported in patients who used
opioids at the end of a dosing interval, after missing a scheduled dose, or after
discontinuing treatment.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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5.
Patients should be informed of this increased sensitivity to opioids and the risk of
overdose.
6.
Any attempt by an individual to overcome the Vivitrol blockade by taking opioids may
lead to fatal overdose.
7.
a.
Although Vivitrol is a potent antagonist with a prolonged pharmacological effect,
the blockade produced by Vivitrol is surmountable. The plasma concentration of
exogenous opioids attained immediately following their acute administration may
be sufficient to overcome the competitive receptor blockade.
b.
This poses a potential risk to patients who attempt, on their own, to overcome the
blockade by administering large amounts of exogenous opioids.
Patients should be told of the serious consequences of trying to overcome the opioid
blockade.
a.
B.
C.
This increased sensitivity and risk of fatal outcome including death should be
explained to patient by both the Behavioral Health Therapists and medical staff
members.
Possible Injection Site Reactions Following Vivitrol Injection
1.
Vivitrol injections may be followed by pain, tenderness, induration, swelling, erythema,
bruising, or pruritus; however, in some cases injection site reactions may be very severe.
2.
Injection site reactions not improving may require prompt medical attention, including,
in some rare cases, surgical intervention.
3.
Inadvertent subcutaneous/adipose layer injection of Vivitrol may increase the likelihood
of severe injection site reactions.
4.
Select proper needle size for the patient body habitus and use only the needles provided
in the carton.
5.
Patients should be informed that any concerning injection site reactions should be
brought to the attention of their healthcare provider.
Possible Precipitation of Opioid Withdrawal Following Vivitrol Injection
1.
When withdrawal is precipitated abruptly by administration of an opioid antagonist to
an opioid-dependent person, the resulting withdrawal syndrome can be severe.
a.
2.
Some cases of withdrawal symptoms have been severe enough to require
hospitalization, and in some cases, management in the ICU.
To prevent occurrence of precipitated withdrawal, opioid-dependent patients, including
those being treated for alcohol dependence, should be opioid-free (including tramadol)
before starting Vivitrol treatment:
a.
An opioid-free interval of a minimum of 7–10 days is recommended for patients
previously dependent on short-acting opioids.
b.
Patients transitioning from buprenorphine or methadone may be vulnerable to
precipitated withdrawal for as long as two weeks (14 days).
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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D.
E.
3.
If a more rapid transition from agonist to antagonist therapy is deemed necessary and
appropriate by the healthcare provider, monitor the patient closely in an appropriate
medical setting where precipitated withdrawal can be managed.
4.
Patients should be made aware of the risk associated with precipitated withdrawal and
be encouraged to give an accurate account of last opioid use.
Possible Hepatotoxicity Following Vivitrol Injection
1.
Cases of hepatitis and clinically significant liver dysfunction have been observed in
association with Vivitrol.
2.
Warn patients of the risk of hepatic injury; advise them to seek help if experiencing
symptoms of acute hepatitis.
3.
Discontinue use of Vivitrol in patients who exhibit acute hepatitis symptoms.
Possible Depression and Suicidality Following Vivitrol Injection
1.
F.
IV.
Alcohol- and opioid-dependent patients taking Vivitrol should be monitored for
depression or suicidal thoughts.
When Reversal of Vivitrol Blockade Is Required for Pain Management
1.
For Vivitrol patients in emergency situations, suggestions for pain management include
regional analgesia or use of non-opioid analgesics.
2.
If opioid therapy is required to reverse the Vivitrol blockade, patients should be closely
monitored by trained personnel in a setting staffed and equipped for CPR.
PROCESS FOR REFERAL AND EVALUATING APPROPRIATENESS FOR PROGRAM PARTICIPATION
A.
B.
Referrals
1.
Referrals will be identified by the onsite Behavioral Health Therapists working
collaboratively with the NMCD and potentially other stakeholders.
2.
Once a possible candidate is identified the patient will be referred to Medical for
evaluation of the medical appropriateness in program participation.
Criteria for Evaluating Appropriateness for Program Participation
1.
The patient must have a clinically significant problem with alcohol and/or opioids.
2.
The patient must be motivated for treatment and committed to staying substance free.
3.
Drug and alcohol use:
a.
The patient must be free from active substance use (of all substances).
b.
The patient must be free from ALL opioids for a minimum of 7–10 days. Longer
acting opioids may need 14 days or longer (e.g., methadone).
c.
The patient must be at least seven (7) days free from ALCOHOL use. (Studies show
increase success with alcohol abstinence if the individual is at least seven (7) days
without alcohol consumption.) This is for individuals prescribed Vivitrol for
alcoholism, not opioid use disorder (OUD).
d.
Refer to the Opioid Use Screener tool (see M-022.01 Opioid Use Screener).
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
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4.
5.
Timing with release date:
a.
Referrals to medical from Behavioral Health Therapists should typically occur
approximately four (4) to five (5) weeks prior to the patients release from custody
date (PRD).
b.
Screening Labs should be conducted approximately three (3) weeks prior to the
patients PRD.
c.
The patient will ideally be assessed by the medical provider for program
participation appropriateness two (2) weeks prior to the patients PRD.
d.
If found to be medically appropriate by the medical provider, the patient will
participate in the nursing assessment and naltrexone challenge preferably
immediately following the provider assessment.
e.
If the patient passes the nursing assessment, as well as the Naltrexone Challenge,
the patient should receive 0the Vivitrol injection the same day.
f.
The patient should be within two (2) weeks of his/her projected release date
(PRD) for the Vivitrol injection to be administered.
Choosing the patient — additional criteria for the Behavioral Health Therapist
and medical to consider:
a.
For the program to be successful, the patient must have access to Vivitrol
following release.
b.
The patient must sign an agreement to participate in ongoing treatment following
release, this may include a treatment program or a provider’s office.
c.
The patient must have insurance coverage (or is eligible to receive an application
for benefits upon release or qualifies for grant funding program).
d.
The patient also must be absent from any manufacturer-identified exclusion
criteria as well as contraindications listed below:
i.
The patient is currently receiving opioid analgesics.
ii.
The patient is expected to require opioid analgesics for pain.
iii.
A patient who is in acute opioid withdrawal.
iv.
A patient with a positive urine drug screen for opiates.
v.
A patient who has failed the naltrexone challenge.
vi.
Hepatotoxicity has been observed, by elevated AST or ALT or both.
vii.
Stable chronic Hepatitis B or C is not a contraindication to receiving the
injection, but a provider’s evaluation is needed.
1)
Acute Hepatitis is a contraindication.
viii.
Testing indicates severe renal failure, or moderate to severe renal
insufficiency.
ix.
The patient has a diagnosed unstable psychiatric illness.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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V.
x.
The patient has a positive pregnancy test.
xi.
The patient has exhibited hypersensitivity to Vivitrol/naltrexone or any of
the components of Vivitrol/naltrexone.
TESTING/EVALUATION FOR PROGRAM APPROPRIATENESS
A.
The designated Behavioral Health Therapist shall discuss the course of treatment with the
patient and complete a Consent for Vivitrol®/Naltrexone Program Participation form (see
M-022.02, Consent for Vivitrol®/Naltrexone Program Participation).
1.
The Behavioral Health Therapist will also need to obtain the patients’ signature on the
consent form.
2.
This paperwork needs to be forwarded to the designated medical staff member.
B.
The designated Nurse will enter the orders for the designated laboratory testing at the to be
completed three (3) weeks prior to release and set up a provider appointment for two (2)
weeks prior to release from custody.
C.
The laboratory tests shall include:
D.
1.
Urine pregnancy test (females)
2.
CMP
3.
Hepatitis B Surface Antigen (HBsAG)
4.
Hepatitis C Antibody (HCV Ab)
During the medical provider visit the designated provider will review the lab results and
conduct the examination.
1.
If the provider determines that the patient is clinically appropriate for Vivitrol, the
designated provider shall order (preferably to occur the same day):
a.
An onsite urine drug screen
i.
b.
Upon the naltrexone challenge being negative and the nursing assessment has
determined the patient appropriate, the provider will order:
i.
2.
VI.
Upon the urine drug screen being negative, the naltrexone challenge.
One (1) Vivitrol 4cc deep intramuscular injection to be administered.
This injection will occur concurrently with the provider examination so there is a
provider present during the injection to monitor any reaction.
THE ROLE OF BEHAVIORAL HEALTH THERAPIST
A.
To assure that the patient experiences a smooth transition back into the community linking
the patient with post-release care is imperative to the success of the patient.
1.
Scheduled follow-up after release:
a.
The patient must have a scheduled follow-up appointment with a designated
community-based treatment program or a community-based provider that
will continue Vivitrol once released.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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i.
B.
VII.
Coordination of this follow-up service after release from custody will be the
responsibility of the Behavioral Health Therapist.
1)
This appointment will be scheduled to ensure resources are available
to the patient upon release.
2)
The post-appointment must be scheduled prior to the referral to
medical services to ensure the patient has adequate access to services
post-release.
3)
Individuals without community resources upon release, would not be
appropriate for the Vivitrol release program.
ii.
Providing a warm hand-off to transfer care upon release provides the patient
with a follow-up appointment for their second injection, as well as ensures
that continuity of care is provided.
iii.
Obtaining a release of information with the provider and/or clinic will
provide a foundation to ensure the patient has a smooth transition upon
reentry.
Three (3) to five (5) weeks prior to the PROJECTED RELEASE DATE, the Behavioral Health
Therapist or designee, shall confirm that an appointment has been made with the partnered
community Vivitrol provider to allow for continued services following release, and inform the
medical team, as well as the patient of the confirmed appointment.
NURSING PROCEDURES
A.
Assessment Prior to Naltrexone Oral Challenge
1.
Nursing staff will conduct the nursing readiness assessment once the provider orders a
naltrexone challenge.
2.
The nursing assessment is completed to ensure no signs or symptoms of opioid
withdrawal are present.
3.
Nursing should ensure negative results on urine pregnancy tests for all female
candidates. Vivitrol has not been studied in pregnancy.
4.
Reminder: Withdrawal from opiates is dangerous to the fetus and a pregnant patient
should be referred the Subutex program (see M-003A: Pregnancy and Opioid Use) for
treatment.
5.
Nursing should ensure that the onsite urine drug screen (UDS) is negative for opiates.
a.
6.
B.
If the UDS is positive for any substance confer with the provider prior to
administering the naltrexone challenge.
Nursing should ensure that the provider has evaluated the patient and reviewed the
relevant laboratory studies prior to administering the challenge.
Naltrexone Oral Challenge
1.
The naltrexone challenge is a one-time dose of naltrexone 25 mg (half of a 50mg tab) by
mouth to ensure the patient has no adverse effects from the medication and is fully
opiate free.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
2.
The naltrexone challenge shall occur in the health services unit where the patient shall
be observed for withdrawal signs and symptoms.
3.
Refer to the nursing decision making tree for the step-by-step process (see M-022.03,
Vivitrol®/Naltrexone – A Step-by-Step Guide for Nurses) as well as the nursing
assessment for directions.
a.
C.
D.
Complete the Patient Readiness Assessment form (see M-022.04, Patient
Readiness Assessment).
i.
Vital signs
ii.
Recent opioid use
iii.
Pregnancy test (if applicable)
iv.
Conduct baseline COWS
v.
If score is 4 or less – and good evidence exists of no use in the past 7–10
days, proceed with naltrexone challenge by administering naltrexone 25mg
by mouth.
vi.
The naltrexone challenge involves oral administration of 25 mg of naltrexone
(i.e., half of a 50 mg tab), and is negative if no withdrawal signs or symptoms
are apparent after 1½ hours (90 minutes).
vii.
Observe for 90 minutes
viii.
Repeat COWS
ix.
Upon clearance from the naltrexone challenge, the nursing staff shall follow
the provider’s order for the daily naltrexone oral or Vivitrol injection as well
as documentation of the process on the assessment form.
Assessment Prior to Vivitrol Injection
1.
A nursing assessment should be reviewed to ensure no signs or symptoms of opioid
withdrawal are present. (If the injection occurs, directly following the naltrexone
challenge additional assessment is not indicated.)
2.
Nursing should ensure negative results on urine pregnancy tests for all female
candidates.
3.
Nursing should ensure that the urine drug screen is negative for all substances and the
patient had a negative naltrexone challenge (25 mg administered orally) with no opioid
withdrawal present.
4.
Administer the Vivitrol injection per provider order if deemed appropriate by the nursing
assessment, naltrexone challenge and urine drug screen.
Nursing Preparation and Administration of Vivitrol
1.
Vivitrol is supplied in single-use cartons.
2.
The products shall be visually inspected for particulate matter and discoloration prior
to administration.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
3.
Vivitrol shall be suspended only in the diluent supplied and must be administered only
with one (1) of the needles supplied.
4.
Select needle length based on the patient’s body size.
5.
a.
Consider using the 2-inch needle with protection device for patient with a large
amount of subcutaneous tissue overlying the gluteal muscle.
b.
Alternative treatment shall be considered for patients whose body type precludes
an intramuscular injection with one of the provided needles.
Warming the injection:
a.
6.
E.
After preparation, a properly mixed suspension will be milky white, will not contain
clumps, and moves freely down the walls of the vial.
The injection:
1.
Vivitrol should be injected into deep muscle tissue to minimize risk of adverse injection
site reaction.
a.
2.
Vivitrol should NOT be administered intravenously, subcutaneously, or into
adipose tissue.
Proceed with dorsogluteal injection (upper outer quadrant, aspirate for blood).
a.
F.
If there is not the mechanism to pull the injection from refrigeration 30–45
minutes prior to administration, then warm the diluent vial to near body
temperature by rolling it in the hand until no longer cool to the touch. (If the dose
is not used, return to refrigeration as soon as possible).
Avoid injecting subcutaneously or into adipose.
3.
If unable to inject due to a clogged needle, withdraw, replace the needle, and repeat
procedure.
4.
Observe/monitor patient for an additional 10 minutes after injection for any immediate
adverse reaction.
5.
Check for injection site reaction.
6.
Give patient educational material (see M-022.05, Patient Counseling Tool – Vivitrol®) as
well as educate patient on signs and symptoms.
7.
Remind patients they cannot take opiates while on naltrexone.
8.
Note in the patient’s chart noting the patient has received a Vivitrol injection and that
no narcotics should be given to the patient.
9.
Inform patient of what procedures to follow if they need to follow up with medical
regarding side effects.
It is important to remember: each Vivitrol shot is extremely costly, administering the shot at
the right time is important, since Alkermes only supplies one, no-cost shot per patient, so
timing is everything.
1.
If a patient receives an injection and the patients release does not occur when
originally scheduled, the medical team and MNDOC administrators shall
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
determine the course of action, whether Vivitrol is continued, or if an alternative
plan of care is appropriate.
2.
G.
H.
Upon review, if it is determined that there is not additional funding available
for the continuance of vivitrol, the patient would be transitioned at the
appropriate time, to Naltrexone Oral 50 mg tablet daily. This transition should
occur in place of the next injection.
Storage of Vivitrol
1.
Vivitrol shall be stored under specific temperature-controlled conditions to ensure
proper delivery and patient safety.
2.
The entire carton should be stored in the refrigerator (2°C–8°C, 36°F–46°F).
Unrefrigerated, Vivitrol microspheres can be stored at temperatures not exceeding 25°C
(77°F) for no more than seven (7) days prior to administration. Do not expose
unrefrigerated product to temperatures above 25°C (77°F).
3.
Vivitrol should not be frozen.
Vivitrol Injection Training
1.
Training will be provided by Alkermes, the pharmaceutical company that provides
Vivitrol, as well as Wexford staff.
2.
Training on the Vivitrol guideline will be provided to all appropriate staff as well. This
training will be provided by staff members knowledgeable about this Vivitrol guideline.
VIII. ATTACHMENTS
M-022.01 Opioid Use Screener
M-022.02 Consent for Vivitrol®/Naltrexone Program Participation
M-022.03 Vivitrol®/Naltrexone Step-by-Step Guide for Nurses
M-022.04 Patient Readiness Assessment
M-022.05 Patient Counseling Tool - Vivitrol®
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
M-022.01 Opioid Use Screener (SAMPLE)
Opioid Use Screener
Patient Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
ID:
Date:
Question
Have you used opioids for larger amounts or over a longer period than intended?
Have you tried to cut down or control your opioid use?
Were you taking a lot of time finding opioids, using opioids, or recovering from opioids?
Do you have cravings or a strong desire to use opioids?
Have opioids interfered with your roles at work, school, or home?
Have you previously continued to use opioids despite people telling you that you need
help?
Have you given up social, occupational or recreational activities due to opioids?
Have you continued to use opioids in situations where it is physically hazardous?
Do you continue using opioids despite knowing it is hurting you physically and mentally?
Have you noticed you needing more opioids to get the desired effect you want?
Have you gotten ill when trying to quit opioids or do you keep using to avoid withdrawal
symptoms?
How many times have you been in treatment for opioid addiction?
Are you currently in an opioid treatment program?
If yes to 13 – Which program?
Are you currently on methadone under the supervision of a provider?
Are you currently on buprenorphine under the supervision of a provider?
YES
NO
This section is to be completed by staff
Contact information of opioid treatment program (OTP):
Was Contact made with OTP?
Was methadone / or buprenorphine RX confirmation received from OTP?
Staff Signature/ Title:
Date:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Region: New Mexico
M-022.02 Consent for Vivitrol®/Naltrexone Program Participation (SAMPLE)
Consent for Vivitrol Injection or Naltrexone Oral
Program Participation
Patient Name:
DOB:
Patient ID#:
This document is presented to you, as you have expressed interest in participating in the Vivitrol/naltrexone program offered by Wexford Health to
assist you in your recovery process. Medication Assisted Treatment (MAT) for Opioid Use Disorder or Alcoholism is not a substitute for addiction
counseling or treatment and must be used in conjunction with counseling and/or treatment to promote positive outcomes.
Naltrexone (or the injection Vivitrol) will assist you in your early recovery efforts by reducing cravings to use alcohol and/or opiates.
Utilizing MAT allows individuals to focus on addressing additional treatment needs to include cognitive, emotional, and social issues as well as re-entry
needs such as housing, employment, and community re-unification.
To be referred for MAT, you have met certain criteria, which suggest you are engaged in recovery and intend to refrain from future substance misuse.
You must be free from opioids 7 to 10 days prior to starting Vivitrol injection or naltrexone oral.
When used as prescribed, Vivitrol/naltrexone reduces your craving for alcohol and/or opiates, as stated above, and if you do relapse, it will block the
high that accompanies opioid or alcohol use.
Discontinuing naltrexone or Vivitrol could result in a life-threatening overdose when returning to a previous level of drug use, as tolerance to opiates
decreases because of the use Vivitrol/naltrexone.
The use of Vivitrol/naltrexone could be associated with not feeling the usual effects of opioid-containing medications. This includes medicines for pain,
nausea, and diarrhea.
Prior to your first dose of medication, program staff will meet with you to discuss specifics of Vivitrol/naltrexone use. To ensure you are appropriate for
the medication, a liver enzyme panel and a measurement of BUN and creatinine will be performed to ensure that you do not have active liver
impairment.
Additional tests or procedures could be ordered by the provider depending on your medical history. After being medically cleared, you will be scheduled
to receive your first small dose of medication, prior to administering a full dose. Medical staff will monitor your response to the medication to ensure no
reaction occurs before administering your first Vivitrol injection or full dose of naltrexone oral.
Vulnerability to Opioid Overdose:
•
After opioid detoxification, individuals are likely to have a reduced tolerance to opioids. Vivitrol blocks the effects of opioids for approximately
28 days after administration. As the blockade wanes and eventually dissipates completely, use of previously tolerated doses of opioids
could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.).
•
Cases of opioid overdose with fatal outcomes have been reported in individuals who used opioids at the end of a dosing interval, after
missing a scheduled dose, or after discontinuing treatment. There is an increased sensitivity to opioids and the risk of overdose.
Narcan/naloxone for the emergency treatment of opioid overdose, should be kept on hand. Narcan/naloxone is available at most
pharmacies, at no cost.
•
Although Vivitrol/naltrexone is a potent antagonist with a prolonged pharmacological effect, the blockade produced by Vivitrol/naltrexone is
surmountable. The plasma concentration of opioids attained immediately following administration may be sufficient to overcome the
competitive receptor blockade. This poses a potential risk to all individuals who attempt, on their own, to overcome the blockade by
administering large amounts of opioids.
•
Any attempt to overcome the Vivitrol/naltrexone blockade by taking opioids may lead to fatal overdose.
I have fully reviewed the information provided to me on Vivitrol/naltrexone. I understand that participation in this program begins with successful
participation in treatment programing. I understand that by agreeing to participate in this program, I am agreeing to remain drug-free, attend all
scheduled appointments, and remain compliant with the medication regimen. Upon agreeing to engage in this program, I will meet with medical staff
to review specific details of taking Vivitrol/Naltrexone. I understand that the Vivitrol injection is extended release and will last approximately 4 weeks
before needing an additional injection, and the Naltrexone oral is short acting and will last up to 24 hours before needing your next dose
I have fully reviewed the information provided to me on Vivitrol/naltrexone. I understand that participation in this program begins with successful
participation in treatment programing. I understand that by agreeing to participate in this program, I am agreeing to remain drug-free, attend all
scheduled appointments, and remain compliant with the medication regimen. Upon agreeing to engage in this program, I will meet with medical staff
to review specific details of taking Vivitrol/naltrexone. I understand that the Vivitrol injection is extended release and will last approximately 4 weeks
before needing an additional injection, and the naltrexone oral is short acting and will last up to 24 hours before needing your next dose
I understand that my participation in this program is voluntary, and that I may revoke this consent at any time. By signing this form, I am indicating my
interest in further pursuing the use of Vivitrol/naltrexone as part of my recovery efforts.
Patient Signature:
Date:____/___/____ Patient ID#: ___________________
Staff Signature:
Date: ____/___/____
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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M-022.03 Vivitrol ®/Naltrexone Step-by-Step Guide for Nurses
Vivitrol ®/Naltrexone – A Step-by-Step Guide for
Nurses1
Step 1. Patient History
1
Step 2. Medical Evaluation
Step 3. Shared DecisionMaking
Adapted from MAT Training, Providers' Clinical Support System for Medication Assisted Training, SAMHSA
Page 1 of 3
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
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Vivitrol ®/Naltrexone – A Step-by-Step Guide for Nurses (cont'd)
Step 4. Assessment–Patient Readiness
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
Page 2 of 3
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Vivitrol ®/Naltrexone – A Step-by-Step Guide for Nurses (cont'd)
Step 5. Materials
• Refrigeration: Keep XR-naltrexone (VIVITROL®)
always refrigerated (36°F–46°F).
• Remove from refrigeration at least 30 minutes
before administration. If not used, it can be returned
to the refrigerator.
• IM Injection setup (gloves, alcohol, and/or betadine
swab, sterile gauze pads, adhesive bandage, and
sharps container)
• Follow directions on the package
Step 8. Observation
• Oral naltrexone – administer remaining 25 mg dose
• Observe patient for 10 minutes for any immediate
adverse reaction.
• Check for injection site reaction
• Give patient educational material as well as educate
patient on signs and symptoms
• Remind patients they cannot take opiates while on
naltrexone
• Flag patient's chart
Step 6: Drug/Patient Preparation
• Assess body habitus of patient – layer of fat over
muscle not greater than length of injection needle
(2"/usually BMI < 40)
• Review medication preparation and injection via
package insert
• There is a video available for instructional teaching;
ask your DON for the link.
Step 7: Injection
• Vivitrol should be injected into deep muscle tissue to
minimize risk of adverse injection site reaction
• Inform patient of what procedures to follow if they
need to follow up with medical regarding side effects
Step 9. Follow-Up (Medical)
• Facilitate appointment scheduling for the patient's
next follow-up with a Wexford provider. If the client
is on the pre-release program the appointment was
scheduled by the Behavioral Health Staff and written
in the chart. If the patient is on oral while
incarcerated follow-up is every 90 days unless
otherwise indicated by provider.
• MAR is updated and accurate
• Missed doses are reported to your DON/HSA for
reporting to their ARS counselor
• Proceed with dorsogluteal injection (upper outer
quadrant, aspirate for blood)
• Alternate buttock with subsequent injection
• Avoid injecting subcutaneously or into adipose
• If unable to inject because of clogged needle,
withdraw, replace the needle, and repeat procedure
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
Page 3 of 3
WEXFORD MILLER 000730
82
Medical Guidelines
Region: New Mexico
M-022.04 Patient Readiness Assessment (SAMPLE)
Patient Readiness Assessment
Vivitrol®/Naltrexone Nursing Administration
Patient Name
Consent Received and Signed:
Yes
ID:
Date:
)
MAT While Incarcerated
No
Pre-release MAT (Estimated Injection date:
Yes
No
Yes
No
Yes
No
Vital Signs
BP:
Pulse:
RR:
Is the patient currently on any Withdrawal Management?
Females: Provide Urine Pregnancy test:
Positive (inform clinician)
Baseline COWS Score:
Yes
No
Negative (proceed)
Questions for Patient
1
2
3
Are you currently taking any opiates?
Do you understand that starting Naltrexone can cause immediate withdrawal if you are currently using any
opiates?
Drug Use in the Past 14-30 Days Date of Last Use
Route
Amount
Heroin
Suboxone
Tramadol
Oxycodone
Vicodin
Any Other Drug Use (Describe):
4
Patient enrolled in substance abuse treatment services?
5
Provided Vivitrol education materials and reviewed potential side effects as well as discussed importance of
compliance and the risk of overdose.
Naltrexone (p.o.) Challenge Procedure
1. Baseline COWS
(if 4 or less proceed with the challenge) (see COWS, page 3)
2. Administer naltrexone 25 mg p.o. and observe for 90 minutes
3. COWS Challenge score
(if change is less than 2 proceed with XR-naltrexone injection or additional 25 mg of oral
naltrexone)
4. Positive naltrexone challenge assessment (COWS increases more than 2); conduct a urinalysis – panel dip test and follow nursing
Naltrexone Step-by-Step Guide for “use”
Results:
5. No need for repeated challenge on the day following the naltrexone challenge unless there was a new episode of use
6. Any additional contraindications to starting naltrexone? (Upcoming surgery)
Yes
No
List:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
Page 1 of 3
83
WEXFORD MILLER 000731
Medical Guidelines
Region: New Mexico
Patient Readiness Assessment (Cont'd)
Vivitrol Injection Administration
Injection Delivered:
Yes
No
Time:
IM - Dorsolateral/Upper outer quadrant (side):
Observe for 10 minutes following the injection
Any injection complications?
Yes
No
Immediate sensitivity reaction?
Yes
No
If yes describe reaction/ plan:
If no Injection was given, please explain reason.
Nurse Signature
Print Name
File in Medical Record or Scan to EMR – File as Vivitrol/Naltrexone: Nurse ADM
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000732
84
Page 2 of 3
Medical Guidelines
Region: New Mexico
Patient Readiness Assessment (Cont'd)
Clinical Opiate Withdrawal Scale (COWS)
For each item, circle the number that best describes the patient’s signs or symptoms. Rate on just the relationship to opiate withdrawal. For example,
if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.
Patient’s Name:
Reason for this assessment:
Date and Time:
Resting Pulse Rate:
beats/minute
Measured after patient is sitting or lying for one minute
0
pulse rate 80 or below
1
pulse rate 81 – 100
2
pulse rate 101 - 120
4
pulse rate greater than 120
Sweating: Over past ½ hour not accounted for by room temperature or
patient activity
0
no report of chills or flushing
1
subjective report of chills or flushing
2
flushed or observable moistness on face
3
beads of sweat on brow or face
4
sweat streaming off face
Restlessness: Observation during assessment
0
able to sit still
1
reports difficulty sitting still, but is able to do so
3
frequent shifting or extraneous movements of legs/arms
5
unable to sit still for more than a few seconds
Pupil size
0
pupils pinned or normal size for room light
1
pupils possibly larger than normal for room light
2
pupils moderately dilated
5
pupils so dilated that only the rim of the iris is visible
Bone or joint aches If patient was having pain previously, only the
additional component attributed to opiates withdrawal is scored
0
not present
1
mild diffuse discomfort
2
patient reports severe diffuse aching of joints/muscles
4
patient is rubbing joints or muscles and is unable to sit still
because of discomfort
Runny nose or tearing Not accounted for by cold symptoms or allergies
0
1
2
4
not present
nasal stuffiness or unusually moist eyes
nose running or tearing
nose constantly running or tears streaming down cheeks
/
/
:
GI Upset: Over last ½ hour
0
no GI symptoms
1
stomach cramps
2
nausea or loose stool
3
vomiting or diarrhea
5
multiple episodes of diarrhea or vomiting
Tremor Observation of outstretched hands
0
1
2
4
no tremor
tremor can be felt, but not observed
slight tremor observable
gross tremor or muscle twitching
Yawning Observation during assessment
0
no yawning
1
yawning once or twice during assessment
2
yawning three or more times during assessment
4
yawning several times/minute
Anxiety or irritability
0
none
1
patient reports increasing irritability or anxiousness
2
patient obviously irritable / anxious
4
patient so irritable or anxious that participation in assessment is
difficult
Gooseflesh skin
0
3
5
skin is smooth
piloerection of skin can be felt or hairs standing up on arms
prominent piloerection
Total Score:
The total score is the sum of all 11 items
Initials of person completing assessment:
Page 3 of 3
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000733
85
Medical Guidelines
Region: New Mexico
M-022.05 Patient Counseling Tool - Vivitrol® (Naltrexone)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000734
86
Cardiology
Cardiology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000735
000735
Medical Guidelines
Region: New Mexico
Chronic Stable Angina: Clinical Assessment
Figure 1
AHCPR indicates Agency for Health Care Guideline and Research
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000736
88
Medical Guidelines
Region: New Mexico
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000737
89
Medical Guidelines
Region: New Mexico
Chronic Stable Angina: Stress Testing/Angiography
Figure 2
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000738
90
Medical Guidelines
Region: New Mexico
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000739
91
Medical Guidelines
Region: New Mexico
Chronic Stage Angina: Treatment
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000740
92
Medical Guidelines
Region: New Mexico
*Conditions that exacerbate or provoke angina
Medications:
Other medical problems:
• Vasodilators
• Excessive thyroid
replacement
• Vasoconstrictors
Other cardiac problems:
• Profound anemia
• Uncontrolled hypertension
• Tachyarrhythmias
• Bradyarrhythmias
• Hyperthyroidism
• Valvular heart disease (espec.
AS)
• Hypertrophic cardiomyopathy
• Hypoxernia
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000741
93
Medical Guidelines
Region: New Mexico
Unstable Angina―Practical, Evidence-Based
GUIDELINES FOR OUTCOME-EFFECTIVE MANAGEMENT
Patients with Unstable Angina with and Without PCI
Adapted, updated, and based upon ACC/AHA Recommendations (September 2000) for UA/NSTEMI and ACC/AHA 1999 MI
Guidelines.
CHEST PAIN TRIAGE
TRIAGE ASSESSMENT
Non-Ischemic
• Pain Description • Age • Sex • CAD Hx
• Cocaine • Risk Factors for CAD
Non-Cardiac
Possible or Definite ACS
ST-Segment Elevation or
New or Presumably New
Bundle Branch Block
Evaluate and Treat
Suspected Etiology
New ST-Segment
Depression or T-wave
Inversion
Initial Cardiac Enzymes
Elevated
12-LEAD ECG WITHIN 10 MINUTES
Intravenous Access
Oxygen
Continuous ECG Monitor
Aspirin (alternative clopidogrel for
aspirin-intolerant patients)
• Cardiac Markers
Consider
- Beta Blockers
- Nitroglycerin
- Morphine Sulfate
•
•
•
•
No EKG Change or Normal EKG
RISK STRATIFY
• Complete H&P
• Consider
− Serial EKGs or Continuous Segment Monitoring
− Second Set Cardiac Markers (at 6 Hours after
Chest Pain onset)
− If first Troponin obtained at < 6 hours, obtain
second set between 6 –12 hours
− 2-D Echocardiogram
• Observation 4-12 hours
− Emergency Department
− Chest Pain Unit
− 24 Hours Observation
− Admission
• Pain Relief (initiate or intensify)
− Beta-Blocker
− Nitroglycerin
− Morphine Sulfate
RE-EVALUATE PATIENT FOR HIGH-RISK STATUS
ACCORDING TO THE FOLLOWING CRITERIA:
• Presence of chest pain
• Two or more episodes of resting angina during the
previous 24 hours
• History of three or more cardiac risk factors
(diabetes, smoking, elevated LDL-cholesterol)
• Known coronary artery disease (CAD), defined as
documented 50 % or greater stenosis in at least one
major coronary artery
• Prior chronic aspirin intake for CAD prevention
PE:
• Age 65 years or greater
• Congestive heart failure
ECG:
• New ST-segment deviation of 0.5 mm or greater in limb
or precordial leads
• New pathological Q waves
• Sustained ventricular tachycardia
Markers:
• Significant elevation of cardiac markers
History:
YES
LOW RISK
• Treat Suspected
Etiology
• Consider Stress
Testing to provoke
Ischemia (prior to
discharge or as an
outpatient)
• Follow-up as needed
Enoxaparin (preferred)
or unfractioned heparin
EKG change or marker
increase
YES
NO
Follow Protocols/Guidelines for NSTEMI or STEMI,
depending on nature of EKG changes
Early PCI
IF ANY ONE OF THE FOLLOWING
• Recurrent Angina • CHF • Hemodynamic
Instability • Sustained V-Tach
• PCI within 6 months • Prior CABG
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
Medical Management
(Includes enoxaparin or
unfractionated heparin)
Continued Medical Therapy
WEXFORD MILLER 000742
94
Medical Guidelines
Region: New Mexico
Calculating the Risk of Coronary Artery Disease (CAD)
I.
HIGH RISK (85−99%)
ANY OF THE FOLLOWING
II.
1.
Definite angina in men greater than 60 years, women greater than 70 years
2.
Hemodynamic or ECG changes with pain
3.
History of CAD
4.
Maried symmetrical T-wave inversion in precordial leads
5.
ST increase or decrease of greater than 1 mm
6.
Variant angina
7.
Rest pain greater than 20 minutes
8.
Pulmonary edema
9.
Low blood pressure
INTERMEDIATE RISK (15−84%)
NO HIGH-RISK FACTORS, BUT ANY OF THE FOLLOWING
III.
1.
Definite angina in men less than 60 years, women less than 70 years
2.
Probable angina in men greater than 60 years, women greater than 70 years
3.
Probable nonanginal chest pain in patients with diabetes or patients without diabetes
with more than two other risk factors
4.
Extracardiac vascular disease
5.
ST depression of 0.5−1 mm
6.
T-wave inversion greater than 1 mm in leads with dominant R waves
LOW RISK (0.01−14%)
NO HIGH- OR INTERMEDIATE-RISK FACTORS, BUT MAY HAVE
1.
Chest pain, probably not angina
2.
One risk factor (not diabetes)1
3.
T-wave flat or inverted less than1 mm in leads with dominant R waves
4.
Normal ECG
Risk factors: diabetes, smoking, hypertension, and elevated cholesterol levels
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
1
WEXFORD MILLER 000743
95
Medical Guidelines
Region: New Mexico
NYHA Functional Classification
NYHA CLASS
DEFINITION
I
No Limitations:
Ordinary physical activity does not cause undo fatigue, dyspnea, or palpitation.
Slight Limitation of physical activity:
Such patients are comfortable at rest, ordinary physical activity results in fatigue,
palpitation, dyspnea, or angina.
Marked Limitation of physical activity:
Although patients are comfortable at rest, less than ordinary activity will lead to
symptoms.
Inability to carry on any physical activity without discomfort:
Symptoms of congestive failure are present even at rest. With any physical activity,
increased discomfort is experienced.
II
III
IV
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000744
96
Medical Guidelines
Region: New Mexico
Patient Risk Questionnaire
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000745
97
Medical Guidelines
Region: New Mexico
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000746
98
Medical Guidelines
Region: New Mexico
Diagnostic Tests
INITIAL VISIT (frequency)
• Lipid Panel – (5 yearly if normal)
• Chest x-ray (PA & lateral)
• Fasting Glucose/Hgb A 1c – (once)
• Electrocardiogram
• TFTS
• Echocardiogram (if not done previously)
• Iron
(If indicated)
• ESR
ADDITIONAL LABORATORY TESTS*
• Creatinine
• Magnesium
• Sodium
• Albumin
• Potassium
*Should be done initially (if not done previously) &
when changing diuretic
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000747
99
Medical Guidelines
Region: New Mexico
Treatment Plan
(Circle one of the following)
NYHA Functional Classification: I
II
Patient Status:
Stable
Improved
II
IV
Worse
Follow-up Items:
Nutrition
Exercise
Education
Adverse factors
Follow-up Frequency
Referral
Medications
NUTRITION ADVICE
INSTRUCT PATIENT TO:
❑ Follow a low-salt diet
❑ Avoid salty or processed foods, or canned
foods with a high salt content
❑ Avoid adding salt to food when cooking or at
the table
❑ Read labels – Avoid food with more than
300 mg of sodium per serving
❑ Give nutrition information material
❑ Arrange visit with CHF Care Manager
where applicable
MEDICATIONS
❑
Provide office education materials
INSTRUCT PATIENT TO:
❑ Get and keep prescriptions filled
❑ Take medications every day
Talk to doctor or nurse about ways to
remember and what to do if a dose is
missed
EDUCATIONAL ADVICE
❑
❑
❑
Supply office education materials
Arrange referral to CHF Care Manager
Remind patient to:
• Weigh themselves every day before
breakfast
• Record the weight
• IMMEDIATELY report any weight gain of 2
lbs. or more a day for two consecutive days
EXERCISE
INSTRUCT PATIENT TO:
❑ Be as active as possible
❑ Break down tasks to small activities to avoid
becoming short of breath or overly tired
❑ Avoid heavy lifting (more than 10 pounds)
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000748
100
Medical Guidelines
Region: New Mexico
ADVERSE FACTORS NEEDING ATTENTION
❑
❑
❑
❑
Environmental (smoking, alcohol, drugs)
Co-morbidities (elevated lipids, elevated blood pressure,
obesity, diabetes)
Lifestyle issues (age, occupation, economically
challenged)
Psychological (mentally challenged (IQ), predictable poor
compliance, depression, weak family or at-home
support)
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000749
101
Medical Guidelines
Region: New Mexico
Treatment Plan: Referral Guidelines
CONSIDER REFERRAL TO
CARDIOLOGIST FOR:
CONSIDER REFERRAL TO
CARDIOLOGIST IF:
Any patient at your discretion
❑
❑
RV failure greater than LV failure
❑
❑
Valvular disease as the cause of
failure
❑
❑
Diastolic failure
❑
❑
•
HOCM
•
Arrythmia
•
Chest pain
❑
(With positive exercise test)
❑
Systolic failure less than 40 years
old.
❑
Systolic failure
(Greater than 40 years old with
positive exercise test)
❑
Any patient with poor response to
Tx
❑
❑
NYHA Class II, III, & IV
Patients hospitalized for CHF
(DRG127)
Patients with adverse factors/comorbidities
Any patient at provider’s
discretion
Problem patient
• Patient missing office visits
• Patient failed to fill
prescriptions
• Other suspected noncompliance
• Regimen too complex or too
expensive
• Frequent visits to PCP
• Having drug side effects
• Reluctant to take meds
chronically
Complex socio-economic
situation
• Living alone
• Co-morbidities
• Excessive alcohol/substance
abuse
• Dietary indiscretion
• Lack of education
• High absentee rate from
work/school
Hospice appropriate
• NYHA class IV despite optimal
diuretic and vasodilator therapy
• Ejection fraction is less than or
equal to 20% (if test result is
available)
• Resistant symptomatic
supraventricular or ventricular
arrhythmias
• H/O cardiac arrest and
resuscitation in any setting
• H/O syncope of any cause
• Embolic CVA of cardiac origin
• Concomitant HIV disease
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000750
102
Medical Guidelines
Region: New Mexico
NYHA Functional Classification & Treatment Guidelines2, 3, 4
NYHA
Class
Definition
Initial Treatment*
Medication 5,6,7
Follow-Up
Guidelines
No Limitations:
Ordinary physical activity does not cause
undo fatigue, dyspnea, or palpitation.
•
•
•
•
•
Obtain lab tests
Obtain X Ray
Obtain Echocardiogram
Medications
Revisit in 2 weeks
ACE INHIBITOR
+/-DIURETICS
WARFARIN/ASA
@ 3 months (if tests
normal), then annually
(if patient stable)
Slight Limitation of physical activity:
Such patients are comfortable at rest,
ordinary physical activity results in fatigue,
palpitation, dyspnea, or angina.
•
•
•
•
•
Obtain lab tests
Obtain X Ray
Obtain Echocardiogram
Medications
Revisit in 2 weeks
ACE INHIBITOR
DIGOXIN
+/-DIURETICS
WARFARIN/ASA
@ 3 months,
then 2 times per year
III
Marked Limitation of physical activity:
Although patients are comfortable at rest,
less than ordinary activity will lead to
symptoms.
• Obtain lab tests
• Obtain X Ray
• Obtain Echocardiogram
within 24 hours
• Medications
• Revisit in 1 weeks
ACE INHIBITOR
DIGOXIN
+/-DIURETICS
WARFARIN/ASA
@ 2 Weeks, then at 1
month intervals for 3
months, then at 3
month intervals
IV
Inability to carry on any physical
activity without discomfort:
Symptoms of congestive failure are
present even at rest. With any physical
activity, increased discomfort is
experienced.
• Consider Referral to
Cardiologist for possible
admission
• Consider referral to Hospice
for symptomatic care
I
II
ACE INHIBITOR
DIGOXIN
+/-DIURETICS
WARFARIN/ASA
• Consider hospital
admission for
diagnostic work-up,
referral to
Cardiologist, or
follow-up weekly
• If still class IV on
optimal therapy,
consider Hospice
referral
2
All CHF patients should be anticoagulated. Warfarin preferred if LVEF less than or equal to 40%. Aspirin as alternative if Warfarin contraindicated.
3
If ACE inhibitor not tolerated, use other vasodilators
4
Use thiazide diuretics with caution in patients with severe CHF
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 000751
103
Medical Guidelines
Region: New Mexico
Drug Therapy Selection
Category
Diuretics
Thiazide
Combination
Drug
Starting Dose
Maximum Dose
Common/Serious Side Effects
Hydrochlorothiazide
25 mg q.d.
100 mg q.d.
Metalozone
(Zaroxolyn)
5 mg q.d.
20 mg q.d.
Hypokalemia; Hyponatremia:
Hyperglycemia; Hyperuricemia;
Metabolic alkalosis
Triamterene/HCTZ
(Dyazide)
1 tablet q.d.
(37.5/25 mg))
2 tablet q.d.
Hypokalemia; Metabolic acidosis of
more concern
Furosemide
20−40 mg q.d.
Bumetanide
0.5 mg q.d.
240 mg b.i.d.;
Titrate to signs/symptoms of
fluid overload
10 mg q.d.; (Clinical response)
Orthostatic Hypotension; Hypokalemia;
Renal insufficiency; Hypomagnesemia;
Hyperglycemia; Hyperuricemia;
Tinnitus; Dry mouth; Photosensitivity
Loop
ACE
Inhibitor
Other
Vasodilators
(If ACE
inhibitor not
tolerated)
Digoxin
Anticoagulants
Enalapril
2.5−5 mg b.i.d.
Target
Dose/Day
.
10 mg b.i.d.
Lisinopril
10 mg q.d.
20 mg q.d.
Hydralazine
10 mg q.i.d.
40 mg q.i.d.
Isosorbide Dinitrate
10 mg t.i.d.
40 mg t.i.d.
Losartan
25 mg q.d.
100 mg q.d.
Digoxin
Warfarin
ASA
less than 70 y.o. or Scr
less than 1.5, then 0.25
mg/d;
greater than 70 y.o. or
Scr greater than 1.5,
then 0.125 mg/d
5 mg p.o. then titrate to
INR of 2−3
80−325 mg/day
Maximal
Dose/Day
20 mg b.i.d.
40 mg q.d.
Hypotension; Cough; Headache; Taste
disturbances; Renal insufficiency;
Hyperkalemia; Angioedma
Hypotension; Headaches; Numbness;
Tingling; Flushing; Sinus tachycardia;
Lupus-like syndrome; Hypotension;
Hyperkalemia; Renal insufficiency;
Dizziness; Headache; Flushing;
Peripheral edema
Arrhythmia
(ventricular tachycardia; heart block);
Headache; Dizziness; Visual
disturbances
0.5 mg q.d.
Dose appropriate to maintain
INR of 2−3
325 mg/day
Bleeding
Bleeding
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
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NYHA Functional Classification & Guidelines
NYHA
Class
I
Follow-Up Guidelines
NEXT VISIT: 3 months (if tests normal), then annually (if patient stable)
II
NEXT VISIT: 3 months, then 2 times per year
III
NEXT VISIT: 2 weeks, then at 1-month intervals for 3 months, then at 3-month intervals
IV
Consider hospital admission for diagnostic work-up, referral to Cardiologist, or follow-up
weekly
If patient remains Class IV despite optimal therapy, consider hospice referral
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
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Syncope
The flow diagram proposed by the Task Force on Syncope of an approach to the evaluation of
syncope
Syncope
History, physical examination, supine and upright BP, standard ECG
Unexplained syncope
Certain or suspected
diagnosis
Evaluate/confirm
disease/disorder
Diagnosis made
Initial evaluation
No
Structural heart disease or
abnormal ECG
No structural heart disease
and normal ECG
Cardiac evaluation
+
Frequent or
severe
Single/rare
NMS
evaluation
No further
evaluation
-
+
-
Re-appraisal
Treatment
Treatment
Treatment
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
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When to Hospitalize a Patient with Syncope
I.
FOR DIAGNOSIS
Suspected or known significant heart disease
Syncope occurring during exercise
Syncope causing severe injury
Family history of sudden death
Other categories that occasionally may need to be admitted:
II.
1.
Patients without heart disease but with sudden onset of palpitations shortly before
syncope in supine position and patients with frequent recurrent episodes
2.
Patients with minimal or mild heart disease when there is high suspicion of cardiac
syncope
FOR TREATMENT
Cardiac arrhythmias as cause of syncope
Syncope due to cardiac ischaemia
Syncope secondary to the structural cardiac or cardiopulmonary diseases
Stroke or focal neurological disorders
Severe orthostatic hypotension
Cardioinhibitory neurally-mediated syncope when pacemaker implantation is planned
III.
WHEN IS IT SAFE NOT TO HOSPITALIZE?
Patients with isolated or rare syncopal episodes, in whom there is no evidence of structural heart
disease and who have a normal baseline ECG, have a high probability of having a neurocardiogenic
syncope and a low risk of having cardiac syncope. These patients have a good prognosis in terms of
survival irrespective of the results of head-up tilt test. The evaluation of these patients generally
can be completed entirely on an ambulatory basis. Patients with neurally-mediated syncope, in the
absence of structural heart disease and normal ECG, have a good prognosis in terms of survival,
and generally do not need specific treatment apart from counseling and general measures already
defined.
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
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Algorithm for the Evaluation and Management of Patients Suspected of Having Acute Coronary Syndrome (ACS)
The pathways do not replace sound clinical judgment, nor are
they intended to strictly apply to all patients.
Noncardiac diagnosis
Chronic stable angina
Symptoms Suggestive of ACS
Definite ACS
Possible ACS
No ST elevation
Treatment as indicated
by alternative diagnosis
See ACC/AHA
Guidelines for Chronic
Stable Angina
Nondiagnostic ECG
Normal initial serum
Cardiac markers
ST and/or T wave changes
Ongoing pain
Positive cardiac markers
Hemodynamic abnormalities
Observe
Follow-up at 4-8 hours;
ECG; cardiac markers
No recurrent pain;
Negative follow-up studies
ST elevation
Evaluate for
reperfusion therapy
See ACC/AHA
Guidelines for Acute
Myocardial Infarction
Recurrent ischemic pain or
positive follow-up studies:
Diagnosis of ACS con
Stress study to provoke ischemia
Consider evaluation of LV function ifischemia is present
(Tests may be performed either prior to discharge or as outpatient
Negative:
Potential diagnoses: nonischemic
discomfort; low-risk ACS
Positive:
Diagnosis of ACS confirmed
Adapted from NEJM 2001; 344;1941
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Admit to hospital
Manage via acute ischemia pathway
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Acute Ischemia Pathway
The pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Acute Coronary Syndromes
No ST-segment elevation
Obtain ECG; measure cardiac isoenzymes and troponins
Myocardial infarction with ST-segment
elevation (or equivalent or new LBB on ECG
High risk (chest pain at rest, evidence of
injury on ECG, elevated cardiac-isoenzymes
or troponins)
Catheterization
laboratory
available
Catheterization
laboratory not
available
Aggressive therapy with anti-ischemic agent
(IV nitroglycerin, beta-blocker), antiplatelet
agent (aspirin, clopidogrel), or antithrombin
(unfractionated or low-molecular-weight
heparin)
Primary
percutaneous
revascularization or
stenting and
abciximab
Bolus infusion of
fibrinolytic agent
with or without GB
llb/llla inhibitor
High risk (elevated cardiac isoenzymes or
troponins, ST-segment depression, persistent
angina at rest)
Catheterization
laboratory
available
Treatment with
abciximab or
eptifibatide plus
unfractionated or
low-molecularweight heparin
Urgent
percutaneous
revascularization,
with intent to
insert stent
Catheterization
laboratory not
available
Intermediate risk (chest
pain and ST-segment
depression stabilized)
Low risk (no elevation in cardiac
isoenzymes or troponins, no STsegment depression, chest pain
resolved)
Admission to CCU;
therapy with tirofiban and
unfractionated lowmolecular-weight heparin
Admission to CCU or telemetry
Therapy with aspirin,
unfractionated or low-molecularweight heparin (no GP llb/llla
inhibitor
Admission to
CCU: treatment
with tirofiban
(preferred) or
eptifibatide plus
unfractionated or
low-molecularweight heparin
Noninvasive risk stratification
Exercise
MPI
Defer
percutaneous
revascularization
Diagnostic coronary
angiography
Inducible
ischemia
Pharmacologic
stress with
vasodilator, MPI,
or DSE
No ischemia
Secondary prevention (e.g., aspirin, clopidogrel, beta-blocker, angiotensin-converting-enzyme inhibitor, statin.
Adapted from NEJM 2001; 344;1941
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Congestive Heart Failure: An Approach to Treatment
*Adapted from THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM – MAY 2000
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Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Highlights of Optimal CHF Management
I.
HIGHLIGHTS OF OPTIMAL CHF MANAGEMENT*
Obtain an echocardiogram to identify cause of heart failure and decide if cardiology referral
indicated
Stratify according to NYHA classification
Explore possibility of sub-clinical depression
Refer appropriate patients to CHF nurse care manager
Select therapy according to NYHA classification
1.
All patients with LVEF less than 40% should receive maximally tolerated doses of ACE
INHIBITORS and Beta-Blockers proven to reduce mortality, preferably Coreg.
2.
ARBs (angiotensin receptor blockers) are recommended in patients who are intolerant
to ACE inhibitors.
3.
Aldosterone receptor antagonists (e.g., spironolactone) are recommended in patients
with NYHA Class II-IV who have LVEF ≤35%.
4.
Diuretics are recommended in patients with fluid retention.
5.
All patients to be ANTICOAGULATED (especially if EF less than 40)
6.
a.
Warfarin preferred;
b.
ASA as alternative
Refer for cardiology consultation according to guidelines
Screen for NSAIDs.
Pneumococcal Vaccination:
1.
Age less than 65, not severely immunocompromised:
a.
2.
3.
For those who have not received any pneumococcal vaccine or for those whose
vaccination history is unknown, a single dose of PPSV23 (Pneumovax) vaccine
should be considered.
Age 65 and older, not severely immunocompromised:
b.
For those who have not received any pneumococcal vaccine or for those whose
vaccination history is unknown, a single dose of PCV13 (Prevnar) vaccine in
addition to a single dose of PPSV23 (Pneumovax) should be considered.
c.
Timing of vaccines - Patients should be immunized with PCV13 (Prevnar) vaccine
first, then PPSV23 (Pneumovax) vaccine 1 year later.
d.
If the patient has received PPSV23 (Pneumovax) when less than 65, a minimum
interval of 5 years between doses should be maintained between the PPSV23
Pneumovax vaccines.
Severely immunocompromised patients (e.g. chronic renal failure, malignancy, HIV,
organ transplant, congenital immunodeficiency, sickle cell disease):
e.
For those who have not received any pneumococcal vaccine or for those whose
vaccination history is unknown, a single dose of PCV13 (Prevnar) vaccine in
addition to a single dose of PPSV23 (Pneumovax) should be provided.
f.
Timing of vaccines – Patients should be immunized with PCV13 (Prevnar) first then
PPSV23 (Pneumovax) vaccine at least 8 weeks after receiving the PCV13 (Prevnar)
vaccine.
*Adapted from UTMB Guidelines – 04/03
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g.
II.
If the patient has received PPSV23 (Pneumovax) when less than 65, a minimum
interval of 5 years between doses should be maintained between the PPSV23
Pneumovax vaccines.
REFERENCE
*
Yancy C, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart
failure: a report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiology 2013 62(16): 1495-1539.
*Adapted from UTMB Guidelines – 04/03
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Deep
Vein Thrombosis
Thrombosis Guideline
Deep Vein
Guideline
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Approach to the Patient with an Acutely Swollen Leg
I.
INTRODUCTION
The age-standardized incidence of first-time venous thromboembolism (VTE) is approximately 2.0
per 1000 person-years. Rates were higher in men than women, and increased with age in both
sexes. In the Longitudinal Investigation of Thromboembolism Etiology (LITE) study, most of the 191
cases of secondary VTE were associated with more than one underlying condition. These included
cancer (48%), hospitalization (52%), surgery (42%), and major trauma (6%). There was no
antecedent trauma, surgery, immobilization, or diagnosis of cancer in 48% of cases. When
approaching the patient with suspected DVT of the lower extremity, it is important to appreciate
that only a minority of patients actually have the disease and will require anticoagulation. Given
the potential risks associated with proximal lower extremity DVT that is not treated (e.g., fatal
pulmonary emboli) and the potential risk of anticoagulating a patient who does not have a DVT (e.g.,
fatal bleeding), accurate diagnosis is essential.
II.
RISK FACTORS FOR DVT
Risk factors for DVT should be sought in all patients. These include:
III.
1.
History of immobilization or prolonged hospitalization/bed rest
2.
Recent surgery
3.
Obesity
4.
Prior episode(s) of venous thromboembolism
5.
Lower extremity trauma
6.
Malignancy
7.
Use of oral contraceptives or hormone replacement therapy
8.
Pregnancy or postpartum status
9.
Stroke
HISTORY
Classic symptoms of DVT include swelling, pain, and discoloration in the involved extremity.
There is not necessarily a correlation between the location of symptoms and the site of
thrombosis. Often, pain in the calf is the only complaint in patients with documented
iliofemoral DVT.
A positive family history is particularly important, since a well-documented history of venous
thrombosis in one or more first-degree relatives strongly suggests the presence of a hereditary
defect.
Women should be carefully questioned regarding use of oral contraceptives or hormone
replacement therapy as well as their obstetric history. The presence of recurrent fetal loss
suggests the possible presence of an inherited thrombophilia or antiphospholipid antibodies.
Questions should include the presence of significant disorders, such as collagen-vascular
disease, myeloproliferative disease, atherosclerotic disease, or nephrotic syndrome and about
the use of drugs which can induce antiphospholipid antibodies such as hydralazine,
procainamide, and phenothiazines.
The patient should also be questioned about a past history of cancer, and the results, if any,
of regular screening examinations for cancer (e.g., mammography, colonoscopy, pelvic
examinations) since recurrent thrombosis in spite of therapeutic anticoagulation with oral
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anticoagulants is more frequent in patients with VTE in association with an occult neoplasm
or recurrent cancer. Other findings that may suggest an underlying malignancy are
constitutional symptoms such as loss of appetite, weight loss, fatigue, pain, hematochezia,
hemoptysis, and hematuria.
IV.
PHYSICAL EXAMINATION
Physical examination may reveal a palpable cord (reflecting a thrombosed vein), calf pain,
ipsilateral edema or swelling with a difference in calf diameters, warmth, tenderness,
erythema, and/or superficial venous dilation.
In the general physical examination, special attention should be directed to the vascular
system, extremities (e.g., looking for signs of superficial or deep vein thrombosis), chest, heart,
abdominal organs, and skin (e.g., skin necrosis, livedo reticularis). There may be pain and
tenderness in the thigh along the course of the major veins ("painful deep vein syndrome").
Tenderness on deep palpation of the calf muscles is suggestive, but not diagnostic. Homan's
sign is also unreliable.
However, each of the above signs and symptoms is nonspecific and has low accuracy for
making the diagnosis of DVT. Accordingly, further diagnostic testing is required to confirm or
exclude the diagnosis of DVT.
Phlegmasia cerulea dolens: Phlegmasia cerulea dolens is an uncommon form of massive
proximal (e.g., iliofemoral) venous thrombosis of the lower extremities associated with a high
degree of morbidity, including sudden severe leg pain with swelling, cyanosis, edema, venous
gangrene, compartment syndrome, and arterial compromise, often followed by circulatory
collapse and shock. Delay in treatment may result in death or loss of the patient's limb.
Patients with these finding must be sent to a higher level of care immediately and not kept in
the infirmary for their initial anticoagulation.
Screening for malignancy: Because venous thromboembolism may be the first manifestation
of an underlying malignancy, rectal examination and stool testing for occult blood should be
performed and women should undergo a pelvic examination to rule out the presence of a
previously unsuspected pelvic mass or malignancy. However, a routine exhaustive search for
an occult malignancy is neither warranted nor cost effective.
Even in patients with recurrent idiopathic DVT, who represent a high risk group, a cancer, if
present, will usually have made its presence known during the interval period between
thrombotic events.
V.
LABORATORY TESTING
The initial laboratory evaluation in patients with venous thrombosis should include a
complete blood count and platelet count, coagulation studies (e.g., prothrombin time,
activated partial thromboplastin time), renal function tests, and urinalysis.
Consideration should be given to obtaining a prostate-specific antigen measurement in men
over the age of 50. Any abnormality observed on initial testing should be investigated
aggressively.
VI.
DIFFERENTIAL DIAGNOSIS
When approaching the patient with suspected DVT of the lower extremity, it is important to
appreciate that only a minority of patients (17−32% in two large series) actually has the disease.
Several studies have identified common causes of leg pain in patients suspected of having DVT with
negative venograms:
Muscle strain, tear, or twisting injury to the leg: 40%
Leg swelling in a paralyzed limb: 9%
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Lymphangitis or lymph obstruction: 7%
Venous insufficiency: 7%
Popliteal (Baker's) cyst: 5%
Cellulitis: 3%
Knee abnormality: 2%
Unknown: 26%
VII.
DIAGNOSIS
The diagnostic test of choice is the venous duplex ultrasound with compression. This test has a
positive predictive value of 94%.
VIII. PRETEST PROBABILITY
Ultrasonography test for DVT are most useful when the results are combined with an assessment
of pretest probability of DVT. The Wells score is the most validated probability scoring system. In
one study conducted by Wells, DVT was documented in 3%, 17%, and 75% of patients with low,
moderate, or high pretest probabilities, respectively. A review of 15 studies in which the Wells score
was tested concluded the following:
Patients in the low pretest probability category had a median negative predictive value for DVT
of 96% (range: 87−100%), indicating the usefulness of the Wells score for ruling out DVT
The median negative predictive value for DVT in patients with a low pretest probability was
improved further by the presence of a negative test for D-dimer (median value 99%, range:
96−100%)
Positive predictive values for DVT rarely exceeded 75% for patients in the high pretest
probability category, indicating that these rules alone were not as useful for identifying
patients who did have thrombosis.
IX.
PRETEST PROBABILITY OF DEEP VEIN THROMBOSIS (WELLS SCORE)
Clinical feature
Active cancer (treatment ongoing or within the previous 6 months or palliative)
Paralysis, paresis, or recent plaster immobilization of the lower extremities
Recently bedridden for more than 3 days or major surgery, within 4 weeks
Localized tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling by more than 3 cm when compared to the asymptomatic leg (measured below tibial
tuberosity)
Pitting edema (greater in the symptomatic leg)
Collateral superficial veins (nonvaricose)
Alternative diagnosis as likely or more likely than that of deep venous thrombosis
Score
High probability
Moderate probability
Low probability
Modification
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Score
1
1
1
1
1
1
1
1
-2
3 or greater
1 or 2
0 or less
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This clinical model has been modified to take one other clinical feature into account: a previously documented deep vein
thrombosis (DVT) is given the score of 1. Using this modified scoring system, DVT is either likely or unlikely, as follows:
DVT likely
2 or greater
DVT unlikely
1 or less
Adapted from Wells, PS, Anderson, DR, Bormanis, J, et al, Lancet 1997; 350:1795 and Wells, PS, Anderson, DR, Rodger, M, et al. N Engl J
Med 2003; 349:1227.
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A review of 15 studies in which the Wells score was tested concluded the following:
Patients in the low pretest probability category had a median negative predictive value for DVT
of 96% (range: 87−100%), indicating the usefulness of the Wells score for ruling out DVT
The median negative predictive value for DVT in patients with a low pretest probability was
improved further by the presence of a negative test for D-dimer (median value 99%, range:
96−100%)
Positive predictive values for DVT rarely exceeded 75% for patients in the high pretest
probability category, indicating that these rules alone were not as useful for identifying
patients who did have thrombosis.
X.
SCREENING FOR A HYPERCOAGULABLE STATE
Although we can identify patients at increased risk for inherited thrombophilia, there is no clear
clinical value to screening for the following reasons:
Even if a hypercoagulable workup uncovers abnormalities predisposing to VTE, the strongest
risk factor for VTE recurrence is the prior VTE event itself, particularly if idiopathic.
Patients with idiopathic VTE, whether or not they have an identifiable inherited
thrombophilia, are at high risk for recurrence (as high as 7−8% per year in some studies) after
warfarin is discontinued, at least for the first few years after the event. Thus, the presence or
absence of an inherited thrombophilia will usually not change the decision regarding length
of warfarin therapy. Screening information can be used to identify family members with an
inherited thrombophilia, but anticoagulant prophylaxis is rarely recommended in
asymptomatic affected family members outside of high risk situations.
XI.
TREATMENT OF DVT
Rationale: The primary objectives of treatment of DVT are to prevent and/or treat the following
complications:
1.
Prevent further clot extension
2.
Prevention of acute pulmonary embolism
3.
Reducing the risk of recurrent thrombosis
4.
Treatment of massive iliofemoral thrombosis with acute lower limb ischemia and/or
venous gangrene (i.e., phlegmasia cerulea dolens)
5.
Limiting the development of late complications, such as the postphlebitic syndrome,
chronic venous insufficiency, and chronic thromboembolic pulmonary hypertension.
Use of the Suspected DVT Guideline Algorithm:
When presented with a patient complaining of acute unilateral extremity swelling, the provider
should first perform a targeted history, family history, and physical examination as described above.
A Wells Score calculation should then be performed. If the Wells Score is 0 or less (low), a D-dimer
should be performed. If the D-dimer is <500ng/ml by ELISA or negative by the SimpliRED assay,
then no ultrasound or further testing is necessary unless other clinical factors increase the clinical
suspicion of a DVT (see Figure 1).
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Suspected DVT Guideline Algorithm
Figure 1
If the Wells calculation is intermediate or high then further testing with venous duplex
Ultrasonography is required.
Positive Ultrasonography
Patients with the following clinical features should be sent to the Emergency Room and
be admitted if Ultrasonography is positive:
1.
Phlegmasia cerulea dolens or marked extremity swelling where neurovascular
compromise is considered
2.
Renal Failure or a calculated creatinine clearance of <40ml/min (contraindication to
LMW heparin)
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3.
Any absolute contraindication to anticoagulation (active PUD, h/o esophageal varicies,
recent hemorrhagic CVA or brain tumor, etc.)
Patients with none of the above clinical features but who have an intermediate or high Wells
Score should be scheduled for an urgent venous duplex ultrasound preferably on the day of
presentation. If the urgent venous duplex ultrasound cannot be performed until the next day,
then LMW heparin (Lovenox) should be started at a dose of 1mg/kg subcutaneously every 12
hours until the venous duplex is performed.
Patients with positive venous duplex ultrasounds who return to the correctional facility should
be continued on Lovenox and Coumadin initiated at 5mg by mouth daily. Coumadin therapy
should be monitored and adjusted as outlined in Wexford Health’s Medical Advisory
Committee guideline, Warfarin Drug Monograph, page WM–4. In elderly patients and in those
at high risk of bleeding or who are undernourished, debilitated, or have heart failure or liver
disease, the starting dose should be reduced. The Coumadin and Lovenox should be
overlapped for approximately 4–5 days.
Oral anticoagulation with warfarin should prolong the INR to a target of 2.5.
Duration of Treatment
The duration of anticoagulation therapy varies with the clinical setting as well as with patient
values and preferences:
1.
Patients with a first thromboembolic event in the context of a reversible or time-limited
risk factor (e.g., trauma, surgery) should be treated for at least three months.
2.
Patients with a first idiopathic thromboembolic event should be treated for a minimum
of three months. Following this, all patients should be evaluated for the risk/benefit
ratio of long-term therapy.
Indefinite therapy is preferred in patients with a first unprovoked episode of PROXIMAL DVT
who have a greater concern about recurrent VTE and a relatively lower concern about the
burdens of long-term anticoagulant therapy (see Figure 2).
In patients with a first isolated unprovoked episode of DISTAL DVT, three months of
anticoagulant therapy, rather than indefinite therapy, appears to be sufficient (see Figure 2).
Figure 2
Proximal DVT
Distal DVT
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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General Medical Management
The general medical management of the acute episode of DVT is individualized. Once
anticoagulation has been started and the patient's symptoms (i.e., pain, swelling) are under
control, early ambulation is advised.
During initial ambulation, and for the first two years following an episode of VTE, use of an
elastic compression stocking has been recommended to prevent the postphlebitic syndrome.
XII.
REFERENCES
1. In the clinic. Deep venous thrombosis. Ann Intern Med 2008; 149:ITC3.
2. Lechner, D, Wiener, C, Weltermann, A, et al. Comparison between idiopathic deep vein
thrombosis of the upper and lower extremity regarding risk factors and recurrence. J Thromb
Haemost 2008; 6:1269.
3. Cushman, M, Tsai, AW, White, RH, et al. Deep vein thrombosis and pulmonary embolism in two
cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med 2004; 117:19.
4. Alikhan, R, Cohen, AT, Combe, S, et al. Risk factors for venous thromboembolism in hospitalized
patients with acute medical illness: analysis of the MEDENOX Study. Arch Intern Med 2004;
164:963.
5. Goodacre, S, Sutton, AJ, Sampson, FC. Meta-analysis: The value of clinical assessment in the
diagnosis of deep venous thrombosis. Ann Intern Med 2005; 143:129.
6. Qaseem, A, Snow, V, Barry, P, et al. Current diagnosis of venous thromboembolism in primary
care: a clinical practice guideline from the American Academy of Family Physicians and the
American College of Physicians. Ann Intern Med 2007; 146:454.
7. Birdwell, BG, Raskob, GE, Whitsett, TL, et al. The clinical validity of normal compression
ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med
1998; 128:1.
8. Huisman, MV, Buller, HR, Ten Cate, JW, Vreeken, J. Serial impedance plethysmography for
suspected deep-vein thrombosis in outpatients. N Engl J Med 1986; 314:823.
9. Hull, RD, Hirsh, J, Sackett, DL, et al. Clinical validity of a negative venogram in patients with
clinically suspected venous thrombosis. Circulation 1981; 64:622.
10. Gorman, WP, Davis, KR, Donnelly, R. ABC of arterial and venous disease. Swollen lower limb-1:
general assessment and deep vein thrombosis. BMJ 2000; 320:1453.
11. Wells, PS, Anderson, DR, Bormanis, J, et al. Value of assessment of pretest probability of deepvein thrombosis in clinical management. Lancet 1997; 350:1795.
12. Tamariz, LJ, Eng, J, Segal, JB, et al. Usefulness of clinical prediction rules for the diagnosis of
venous thromboembolism: a systematic review. Am J Med 2004; 117:676.
13. Kearon, C, Kahn, SR, Agnelli, G, et al. Antithrombotic therapy for venous thromboembolic
disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Edition). Chest 2008; 133:454S.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Dental
Dental Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000770
000770
Medical Guidelines
Region: New Mexico
I.
PREFACE
The development of this technical instruction incorporates input from other Wexford Health
departments. The intent is to serve as an effective guide for dental services and to set forth
standards for contracted dental services.
The enclosed guidelines and standards established herein are subject to ongoing additions,
deletions, or changes as the delivery of quality health care is a dynamic process.
Additionally, it must be stated that the following procedure guidelines do not supersede any
contracted entity policies and procedures, but serve as supplemental information in the
absence of client policies for dental services.
II.
PURPOSE AND MISSION
To provide quality dental care to residents in a cost-effective manner under the direction of
state licensed dentists and adhering to the guidelines, if any, set forth by the contracting
clients.
The primary mission of Dental services shall be the prevention, control, and correction of oral
conditions which are detrimental to the health of the residents or impose a hardship in the
rehabilitation of the residents.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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D-001: Oral Care
I.
WEXFORD HEALTH, ACA, AND NCCHC STANDARD
Oral care under the direction and supervision of a dentist licensed in the state will be available to
each patient. Care shall be timely and includes immediate access for urgent or painful conditions.
II.
WEXFORD HEALTH COMPLIANCE INDICATORS
All aspects of the above-mentioned standard should be addressed by site specific written
guideline and defined procedures.
Oral screening by the dentist or qualified health care professionals trained by the dentist will
be performed within seven (7) days (Prisons and Juvenile) or 14 days (Jails) of admission to
the correctional system.
Instruction in oral hygiene and preventive oral education will be given within one (1) month
(Prisons and Jails) or 14 days (Juvenile) of admission.
An oral examination will be performed by a dentist within 30 days (Prison), 60 days (Juvenile),
or 12 months (Jails) of Admission.
Oral treatment, not limited to extractions will be provided according to a treatment plan based
upon a system of established priorities for care (Refer to treatment priority classification)
Radiographs will be appropriately used in the development of the treatment plan.
Consultation through referral to oral health care specialists will be available as needed.
Each patient will have access to the preventive benefits of fluorides (in accordance with facility
guidelines) and in a form determined by the dentist to be appropriate for the needs of the
individual.
Where oral care is provided on site, contemporary infection control procedures will be
followed.
III.
DEFINITIONS
Oral care includes instructions in oral hygiene, examination, and treatment of dental
problems. Instruction in oral hygiene minimally includes information on plaque control and
the proper brushing of teeth.
Oral screening includes visual observation of the teeth and gums and notation of any obvious
or gross abnormalities requiring immediate referral to a dentist.
Oral examination by a dentist includes taking or reviewing the patient’s oral history, and extra
oral head and neck examination, charting of teeth, examination of the hard and soft tissue of
the oral cavity with a mouth mirror, explorer, and adequate illumination, and taking and
reading any necessary radiographs.
Oral treatment includes the full range of services that in the supervising dentist’s judgment
are necessary for proper mastication and maintaining the patient’s oral and general health
status.
Oral treatment includes but is not limited to:
1.
X-rays
2.
Restorations (fillings)
3.
Treatment of infections
4.
Oral surgery (i.e., extraction of infected and non-restorable teeth)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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5.
Emergency treatment
6.
Post-operative treatment
7.
Non-surgical periodontal services
8.
Prosthetic devices including dentures and partials and repairs.
9.
Limited endodontic therapy (root canal therapy)
10.
Oral hygiene instructions, dental health education, and appropriate follow up
procedures.
Infection Control practices are defined by the American Dental Association and the Center for
Disease Control and Prevention as including sterilizing instruments, disinfecting equipment,
and properly disposing of hazardous waste.
Regional Dental Director is a dentist licensed in the state where the dental services are
provided and is responsible for the programmatic/clinical supervision of statewide or regional
dental services.
Institutional or Site Dental Director is a dentist licensed in the state where the dental services
are provided and is responsible for the programmatic/clinical supervision of dental services
at any facility (site) dental clinic.
Dental Coordinator is the trained and licensed individual responsible for the administrative
coordination of a site’s dental clinic operations and assisting the dentist with the examination
and treatment of the patients.
Dental Hygienist is the licensed individual who, along with dentists and dental coordinators,
is responsible for providing preventive education in oral hygiene in addition to providing
treatment for periodontal problems, and follow-up appointments for periodontal maintenance
on the patients.
IV.
PRIORITIZING DENTAL CARE
Priority of comprehensive dental services should be established by oral examination and
implementation of a classification system. The findings from the oral examination which
includes a periodontal score should be analyzed to arrive at a generalized categorization or
classification.
Basic dental care can be categorized as:
1.
Elective care
2.
Corrective care
3.
Interceptive care
4.
Urgent care
5.
Emergency care
Using the above criteria as a starting point, the classification of dental patients should be
based upon the following generalized factors:
V.
CLASSIFICATION I
Patients presents with incipient or no tactical or radiographically observable caries. The patient’s
periodontal condition would be classified as code 1 (gingivitis) or code 0 (none). Patients meeting
these criteria shall be classified as Type I.
These patients should be scheduled and any therapy begun within twenty-four (24) months of
entering the system. However all therapy should be provided within the shortest time frame
practicable.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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VI.
CLASSIFICATION II
Patient presents with tactically determined cavitations due to caries or cavitation observable
radiographically and/or may present with code 3 (moderate) periodontal disease in one or more
sextants and/or code 2 (early) periodontal diseases in three or more sextants.
Patients meeting these criteria shall be classified as Type II. These patients should be scheduled
and therapy begun within twelve (12) months of entering the system.
However all oral surgery, non-surgical periodontal therapy and restorative services should be
provided within the shortest time frame practicable.
VII.
CLASSIFICATION III
Patient presents with frank observable cavitations due to caries, code 4 (Advanced) periodontal
diseases in one or two sextants and/or code 3 (moderate) periodontal disease recorded in three or
more sextants and/or conditions to warrant removable prosthodonic therapy to restore masticatory
function. It cannot be immediately determined that immediate extraction is the treatment required
for the caries and/or periodontal disease. Patients meeting these criteria shall be classified as Type
III.
These patients should be scheduled and therapy begun within ninety (90) days of entering the first
receiving facility. All oral surgical, non-surgical periodontal therapy, restorative services, and
rehabilitative procedures should be accomplished within the shortest timeframe practicable.
VIII. CLASSIFICATION IV
Patient presents with gross observable cavitation due to caries or code 4 (Advanced) periodontal
disease recorded in three or more sextants. The caries and/or periodontal condition require the
immediate extraction of one or any number of teeth.
Also, the patient may require antibiotic therapy prior to the oral surgery. This urgent condition
should be classified as Type IV.
These patients, ideally, should be treated at the initial intake facility if at all practical and possible.
When the immediate extractions have been accomplished at the initial intake facility, the patient
can be reclassified as appropriate prior to being assigned to their first facility. If the patient is
reassigned prior to completion of the necessary extractions, the receiving facility must schedule and
initiate therapy as quickly as possible upon patient entry.
The patient should be kept on an active treatment list after reclassification if necessary to complete
treatment. All oral surgical, non-surgical periodontal therapy, restorative services, and rehabilitative
procedures should be accomplished within the shortest time frame practicable.
IX.
CLASSIFICATION V
Patient presents with obvious active infection, edema (possible developing cellulites), pain, or
obvious suspicious oral neoplasm. This is the true emergency patient and should be classified as
Type V.
These patients must be initially treated at the initial intake facility. They may not be reassigned
to another facility pending the resolution of the infection or the outcome of the diagnostic
biopsy.
When the oral condition has been stabilized the patient is reclassified as appropriate. It should be
obvious that patients with extensive, active dental disease should not be assigned to a facility that
does not have a dental clinic, but instead should be assigned to a facility with adequate dental
coverage.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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D-002: Generalized Procedure Guidelines
I.
GENERALIZED PROCEDURE GUIDELINES
The following clinical procedure guidelines offer only the basic recommendations for dental services.
Services must be rendered within the limits governed by the facilities (Juvenile, Jails, Adult Prisons)
and the limited resources of dental services per client contract.
In general, the following dental guidelines apply:
Dental examinations
1.
Initial examinations with panoramic x-ray and bitewing x-rays, followed by biennial
exams (every two (2) years) and biennial bitewings and panoramic x-ray every five (5)
years.
Emergency treatment (self-explanatory)
Restorative Dentistry
1.
Routine restoration of teeth without nerve exposure will be provided. Restoration will be
done with fillings of amalgam material for posterior teeth and composite resin material
for anterior teeth.
Oral Surgery
1.
Extraction of teeth which are not restorable due to infection, decay, periodontal disease,
or trauma will be provided. Most oral surgery procedures will be performed by the staff
dentist. This will include routine extractions, alvedectomies, bone reduction, cyst
removal, biopsies, and impactions, within the limits of the individual operator’s
proficiency. The more difficult cases should be referred to oral surgeons. Collegial review
between the Site Dental Director and Regional Dental Director should occur before
routine off-site oral surgery is scheduled. Emergency off-site oral surgery should follow
written site guidelines, per security and medical protocols.
Periodontal treatment
1.
Non-surgical treatment of gum disease will be provided. This consists of deep cleaning
(sub gingival scaling, root planning, gingival curettage). Teeth with severely advanced
periodontal disease will not be treated.
2.
Routine dental cleanings shall be provided within the limits of the resources of Dental
Services.
Endodontic treatment (Root canal)
1.
Endodontic therapy shall be limited to front teeth or teeth supporting prosthetics, which
have good periodontal support and enough remaining tooth structure to restore.
Endodontic therapy will be considered on a case by case basis in consultation with the
Dental Director.
Removable Prosthetics
1.
Full Dentures
a.
Residents entering the system with no teeth and no dentures, who will be
incarcerated at a facility for longer than six (6) months from the start of making a
denture, will be provided a denture (s) if they request the service. Residents who
have all their teeth extracted, for clinical reasons, while incarcerated at a facility,
and who will be incarcerated for longer than six (6) months from the start of
making a denture, will be provided dentures if they request the service. Dentures
will not be remade more frequently than every five (5) years and only when
clinically necessary.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
Partial Dentures
a.
Partial dentures will only be provided to residents to restore incising and
masticatory function and only if the responsible dentist determines that the
patient’s health and/or rehabilitation would otherwise be adversely affected.
b.
When such devices are contraindicated for security reasons, the Dentist and
Health Services Administrator will work in conjunction with the facility
administration to try to obtain alternatives so the oral health needs of the patient
are met.
c.
Partial dentures will only be made if the patient will be incarcerated for longer
than six (6) months from the start of making the partial denture and the service
is requested. Partial dentures will not be made more frequently than every five (5)
years and only when clinically necessary.
d.
Partial dentures will only be made after all other dental work is complete and the
patient demonstrates good oral hygiene.
Fixed Prosthetics
1.
Crowns and Bridges
a.
No cast (precious or non-precious metal) or porcelain crowns or bridges will be
provided under any circumstances. The cost of fixed prosthetics in terms of
provider time and appliance materials precludes their use in the corrections
environment.
b.
Residents entering the system with existing crowns or bridges may have them
recemented if they come off and if the underlying tooth structure is healthy.
Otherwise acrylic crowns or stainless steel crowns will be used for badly broken
down teeth.
Orthodontics (Braces)
1.
No orthodontic treatment shall be provided. Residents entering the system with existing
braces will be given the option of removal of their braces by a staff dentist. Exceptions
for this guideline will occur with some short time residents at juvenile facilities and jails.
In these situations written site guidelines will dictate alternative treatment services.
Sports or Night Guards
1.
No sports or night mouth guards will be routinely provided to the residents. In unusual
cases, occlusal splints may be provided for cases involving extreme bruxism (grinding
of teeth) or diagnosed temporal-mandibular joint dysfunction. Collegial review between
the site and Regional Dental Directors should occur before any appliance fabrication
occurs.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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D-003: Dental Sick Call Requests
I.
GUIDELINE
Patients seeking dental treatment should use a state and/or corporate approved dental sick call
request form to have their requests prioritized so treatment can be scheduled accordingly.
Once a written request is received, the patient's dental chart should be reviewed along with the
medical history to determine the priority level of the request. This chart review should be conducted
by the staff dentist, dental coordinator (assistant) or, in their absence, by the medical (nursing) staff
according to site-specific written protocol.
II.
SCHEDULING PROCESS
Emergency care receives the top priority. Care for residents with true dental emergencies shall
be available at all times, either through the dental department or the medical staff at each
facility. Emergency dental care consists of:
1.
Relief of severe pain
2.
Control of bleeding
3.
Treatment of acute infection
4.
Treatment of injuries to the teeth supporting structures
These true emergency individuals are scheduled before anyone else on a daily clinical basis.
Medically compromised individuals in this group may dictate consultation with the medical
staff to develop a clinical resolution to the emergency dental problem.
Urgent care receives second priority for scheduling and includes any dental scenario that
could quickly evolve into an emergency situation if not treated on a timely basis. These
individuals too, if medically compromised, may require consultation with the medical staff to
develop a clinically acceptable solution to their dental problem.
Corrective care or treatment going forward from a pre-diagnosed treatment program should
receive third priority scheduling consideration. These dental sick call requests come from
individuals who know or have been told of dental treatment needs and send in requests to
begin, continue, or finish treatment. These requests must be reviewed and even though the
situation is not emergent or urgent, the individual should be placed on a treatment list if
he/she has not already been placed on the list from the intake screening at their current
facility.
Interpretive care must be given a fourth priority when considering the schedule. These
appointments usually involve recall checkups and biennial exams and x-rays. These
appointments are necessary but should not take precedence over any emergent or urgent
requests.
III.
SUMMARY
The process for prioritizing dental sick call requests should consider all the preceding information
and the final determination of scheduling must be made based upon the professional judgment of
the clinical staff.
IV.
CONCLUSION
Dental clinical situations not covered by the aforementioned guidelines should be resolved by
the site dental director and if necessary through the utilization of collegial review and
consultation with the regional dental director.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Dental treatment for the medically compromised patient must involve consultation with the
site medical staff to develop a clinically acceptable protocol for providing dental services.
These guidelines do not replace sound clinical judgment; nor are they intended to strictly
apply to all patients.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
DR-001: Dental Radiation Safe Operation Guidelines
I.
OBJECTIVE
The purpose of these guidelines is to assure uniform compliance with the current accepted practices
in the use of ionizing radiation. All dental staff using and/or exposing radiographs should adhere
to these guidelines as closely as possible. The primary intent of these guidelines is to keep patient
radiation exposure to a minimum and to eliminate radiation exposure of patients and staff. These
Radiation Safe Operation Guidelines will be reviewed annually to ensure compliance with New
Mexico Department of Health regulations.
II.
III.
ORDERING X-RAYS
A.
All radiographs must be recorded in writing and reviewed by a licensed dentist. The number
of films, the date and the signature of the dentist ordering the films must be entered in the
patient’s record.
B.
The patient’s medical and dental history should be reviewed, and an oral examination
performed before dental radiographs are ordered.
C.
Previous radiographs, especially those taken recently, should be evaluated before ordering
films which would cover the same area.
D.
The ultimate objective in radiographing patients is to keep the dose as low as reasonably
achievable. However, patients should not be treated without necessary radiographs.
E.
Digital X-rays should be used available.
F.
Radiographs should not be taken on patients who cannot cooperate due to mental or physical
handicaps. An attempt to do so will usually result in unacceptable films and therefore
unnecessary exposure to the patient.
G.
Retake radiographs may be ordered if the diagnostic information needed is not available on
any of the films covering a particular area. The dentist should make the determination of the
need for retakes.
H.
X-rays may be taken for diagnostic purposes only. No films may be taken for administrative
purposes.
I.
Patient’s identity should be verified prior to any X-rays being performed. The patient should
be asked to identify themselves by stating their full name and ID number.
RADIOGRAPHIC EXPOSURE
A.
Dental X-ray equipment are in the following areas:
Make, model, serial number
Area location (Room number, building, floor)
Type of unit (intraoral or panorex, portable)
Make, model, serial number
Area location (Room number, building, floor)
Type of unit (intraoral or panorex, portable)
Make, model, serial number
Area location (Room number, building, floor)
Type of unit (intraoral or panorex, portable)
B.
Radiographic exposures may be made by dental staff members who are licensed by the State
of New Mexico Dental Board. Should a dental staff member allow their dental license to expire,
they must renew their dental license prior to returning to the facility. X-rays will not be taken
by un-licensed dental staff.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IV.
C.
When taking radiographs, the patient must be protected with a lead apron and a thyroid
shield. If patient is pregnant, X-rays will only be taken in emergency situations and 2 lead
aprons will be placed over abdomen.
D.
All personnel, who must remain in the room, shall be behind a barrier or a minimum of 6 feet
from the primary beam at an angle of 90 to 135 degrees to the beam during exposure.
E.
Radiation exposure shall follow the guidelines of ALARA (As Low As Reasonably Achievable)
to minimize patient exposure.
F.
Film-holders should be used to position the films. If this is not possible because of anatomical
restrictions the patient may use finger pressure to hold the film in place.
G.
During each exposure, the operator should stand behind a protective barrier, the patient must
be observed at all times during an exposure, either through direct vision or using a specially
mounted mirror. If shielding is not available, the operator should stand a least six feet away
from, and at an angle of 90 to 135 degrees to the primary beam. Movable shields should be
used when available and must be positioned in a designated location. A pregnant operator
should follow the above recommendations; in addition, a lead apron may be worn by the
operator for extra protection.
H.
All dental staff in an area associated with frequent operation of X-ray producing equipment is
to wear dosimetry badges to monitor the level radiation exposure OR a clinic area badge is to
be placed 6 feet from the cone. The exposure limit (MPD=Maximum Permissible Dose) for
radiation workers is 50 mSv per year.
I.
In the event of an overexposure being recorded on the quarterly radiation badge reports, the
individual would be contacted to:
1.
Identify the reported exposure AND
2.
Try to determine how and when this overexposure might have occurred.
J.
If the exposure exceeded the occupational dose limits for adults a letter would be sent to the
New Mexico Department of Health, Bureau of Radiation Protection, indicating the exposure
identified in the quarterly radiation badge report. If there were no obvious reasons for the
reported overexposure and it was felt that the individual did indeed receive the excess
radiation, that individual would not be allowed to continue taking films until their total
reported exposure, including the most recent overexposure, again falls below the Maximum
Permissible Dose (occupational dose limit).
K.
A copy of the New Mexico Environment Department, Radiation Control Bureau Regulations is
available at https://www.env.nm.gov/rcb/regulations/
REGULATION AND MONITORING OF X-RAY EQUIPMENT
A.
All X-ray equipment should meet state and federal performance standards. The State of New
Mexico requires that the X-ray machines be calibrated per New Mexico regulations.
B.
Radiographic film is used at this facility.
C.
X-Ray processors are used at this facility.
D.
New Mexico requires that: “Each registrant (dentist) shall inform individuals working in or
requesting any portion of a restricted area of the occurrence of radiation in such portions of
the restricted area; shall instruct such individuals in the safety problems associated with the
exposure to such radiation and in precaution or procedures to minimize exposure; shall
instruct such individuals in the applicable rules for the exposure; shall instruct such
individuals in the applicable rules for the protection of personnel from exposure to radiation;
and shall advise such individuals of reports of radiation exposure which those individuals
may request pursuant to this rule.”
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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E.
The New Mexico Department of Health Notice to Employees must be posted where staff is
engaged in activities subject to the Radiation Control Bureau regulations.
F.
Transfer, disposal or installation of radiation-generating equipment must be reported as
specified by the New Mexico Environment Department regulations.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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DR-002: Dental Radiation Exposure to Pregnant Females Guidelines
I.
OBJECTIVE
To ensure safe environment and proper procedures are followed for ionizing radiation exposure to
pregnant staff during the entire known gestation period.
Scope of guideline: All employees of Mid America Health, Inc. (MAH), PrevMED, Ind (PrevMED),
and any professional group serviced by MAH or PrevMED (all jointly designated “Company”) are
required to follow this guideline.
II.
PROCEDURE
A.
Employees must notify MAH management immediately upon knowledge of a pregnancy. See
the attached form.
B.
Once MAH has been notified by an employee that they are pregnant they will be given the
option to request an individual monitoring device specifically designed for fetal monitoring.
In addition, they will be supplied with a special lead apron designed for use by pregnant
employees.
C.
Restricting exposure to the fetus does not mean that it is necessary for pregnant employees
to avoid work with dental X-ray units or in the area of our dental X-ray unit. This guideline
is simply to establish and to inform the employee, and to provide the opportunity for additional
protection.
D.
No MAH dental unit area has been identified which would be considered likely to result in a
dose of ionizing radiation that would be harmful to the fetus. However, the above procedure
has been adopted out of caution and protection for MAH staff.
E.
All employees will be advised of this guideline upon hire and annually upon review of MAH
Dental X-ray procedures.
F.
Any questions regarding the safe operation of X-ray generating equipment should be directed
to the New Mexico Environment Department at (505) 827-2855. Written inquiries should be
sent to PO Box 5469 Santa Fe, NM 87502-5469.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Dental Radiation Guidelines References
1.
Kantor, Mel L., et al. Efficacy of dental radiographic practices: options for image receptors,
examination selection, and patient selection. JADA 1989; 119:259-266.
2.
Guidelines for prescribing dental radiographs. Kodak Publication No. N-80A, 1997.
3.
Radiation-use Guidelines for Dental Education Facilities. Journal of Dental Education, Vol. 55, No. 7,
1991; 463-466.
4.
Radiation Protection Rules, Ohio Administrative Code, Ohio Department of Health, 2004.
5.
Regulatory Guide, Instruction of Individuals, Ohio Administrative Code, Ohio Department of Health,
2001.
6.
Goaz and White, Oral Radiology: Principles and Interpretation, second edition, C.V. Mosby, 1987.
7.
Brooks SL: A study of selection criteria for intraoral dental radiography, Oral Surg Oral Med Oral
Pathol 62:234, August,1986
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Dermatology
Dermatology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
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000784
Medical Guidelines
Region: New Mexico
Dermatology Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Acne
Consider: Patient education that
improvement is often delayed may
be considered an important aspect
of care. Improvement in acne is
dependent upon both the resolution
of existing lesions and the
prevention of new lesion formation.
In general, at least two to three
months of consistent adherence to a
regimen is necessary to assess
treatment efficacy, and the initial
response may consist of a
noticeable reduction (rather than
complete clearance) of active acne
lesions. The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
availability and the response to
previous treatments. Adjustments to
the regimen may be needed to
identify the most effective regimen
and responses to specific treatments
vary from patient to patient.
Changes to the treatment regimen
to optimize tolerability and efficacy
are often needed. Medications that
may be considered include but not
limited to: Benzoyl peroxide, topical
antibiotics, oral antibiotics and
topical retinoids.
At the discretion of the clinician
depending on the clinical scenario
Acne Keloidalis Nuchae
Consider: Education of the patient
concerning the condition. To
minimize exacerbations, it may be
advised to encourage patients to:
At the discretion of the clinician
depending on the clinical scenario
Acne keloidalis nuchae (AKN) is a
chronic inflammatory condition that
leads to scarring of the hair follicles,
development of keloid-like papules
and plaques, and scarring alopecia
on the nape of the neck and
occipital scalp. AKN occurs mostly in
darker skinned races with curly or
kinky hair.
The natural course of disease starts
with the early formation of inflamed
papules with marked erythema.
Secondary infection can lead to
1.
Avoid picking, rubbing, or
scratching the affected area
2.
Discontinue close shaving,
trimming, or razor or clipper
edging of the posterior hairline
3.
Avoid irritation from tight-fitting
hats, helmets, or high-collared
shirts
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
pustules and abscess formation in
some cases. Over time, continued
inflammation leads to pronounced
fibrosis and keloid formation with
coalescence of the papules into
large plaques and nodules. Later
stages of presentation include
chronic scarring and/or scarring
alopecia without active
inflammation.
The selection of therapy should be
individualized and based upon
consideration of the extent of
disease, adverse effects, onsite
treatment availability and the clinical
response to previous treatments.
Alopecia Areata
Consider: Education of the patient.
The treatment of alopecia areata
may be considered as cosmetic. As
such, the selection of therapy, or the
decision to initiate therapy, should
be individualized and based upon
consideration of the extent of
disease, adverse effects, onsite
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical scenario
Consider: Patient education - The
goals of treatment are to reduce
symptoms (pruritus and dermatitis),
prevent exacerbations, and minimize
therapeutic risks. Skin care
techniques that may help include
decreasing the frequency of
showering, cautious use of soaps,
moisturizing soaps and avoiding
scratching.
At the discretion of the clinician
depending on the clinical scenario
Alopecia areata is a chronic,
relapsing, immune-mediated
inflammatory disorder affecting hair
follicles resulting in nonscarring hair
loss. The severity of the disorder
ranges from small patches of
alopecia on any hair-bearing area to
the complete loss of scalp, eyebrow,
eyelash, and body hair. Although up
to 50 percent of patients who
present with patchy alopecia areata
experience spontaneous hair
regrowth within one year, most will
relapse months or years after
remission
Atopic Dermatitis (Eczema)
Offsite Care to Consider
Medical management may include
topical corticosteroids, intralesional
injection topical or oral antibiotics
and retinoids.
Standard treatment modalities for
the management of these patients
are centered around the use of
topical anti-inflammatory
preparations and moisturization of
the skin The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Offsite Care to Consider
availability and the response to
previous treatments.
Medications to consider: Mild
topical steroids such as 1%
Hydrocortisone Cream or
Triamcinolone Cream 0.1% b.i.d.
may be helpful but treatment varies
according to the severity.
Condylomata Acuminata
(Anogenital Warts)
Consider: Evaluation and education
of the patient. The selection of
therapy should be individualized
and based upon consideration of
the extent of disease, adverse
effects, treatment availability,
availability of a clinician to apply and
the response to previous treatments.
1.
Imiquimod 5% cream: Apply a
thin layer 3 times per week (on
alternate days) prior to bedtime;
leave on skin for 6 to 10 hours,
then remove with mild soap and
water. Continue until there is
total clearance of the
genital/perianal warts or for a
typical maximum duration of
therapy of 16 weeks.
2.
Trichloroacetic acid (TCA) 80%
Topical: Applied by a health care
provider and allowed to dry to a
white frost on wart tissue before
patient sits or stands. Therapy
may be repeated weekly if
necessary. As a general
guidance, Health care provider
should use caution to avoid
applying excessive amounts or
exposing surrounding tissue to
solution.
3.
Electrosurgery (hyfrecation):
Warts can be destroyed with
electrocautery. After the
injection of a local anesthetic,
warts are desiccated and are
either left to fall off or curetted.
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Epidermal Inclusion Cyst
Consider: Treatment of stable,
uninfected epidermoid cysts is not
typically necessary. Inflamed,
ruptured cysts that are not infected
may resolve spontaneously without
therapy, although they tend to
recur. The plan of care is dependent
on the clinical situation, but the
clinician may want to consider just
ongoing observation and periodic
measuring.
At the discretion of the clinician
depending on the clinical scenario
Consider: The treatment of keloids
may be considered as cosmetic
depending on the clinical situation
and history. As such any treatment
plan will need to be individualized.
The clinician may want to discuss
with the patient his/her needs,
concerns, and expectations. Patients
with keloids should be informed
that there is a high recurrence risk
associated with all treatment
options.
At the discretion of the clinician
depending on the clinical scenario
Onychomycosis
Consider: The treatment of toenail
fungus may be considered as
cosmetic depending on the clinical
situation and history. As such, the
selection of therapy should be
individualized and based upon
consideration of the extent of
disease, adverse effects, treatment
availability and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical scenario
Pseudofolliculitis Barbae
Consider: Patient education about
the condition. Approach to therapy:
Because the clinical manifestations
of pseudofolliculitis are a
consequence of the entry of hair
into the interfollicular skin, the
primary approach to therapy
consists of measures to prevent this
At the discretion of the clinician
depending on the clinical scenario
Epidermoid cysts, also called
epidermal cysts, epidermal inclusion
cysts, or "sebaceous cysts," are the
most common cutaneous cysts.
They can occur anywhere on the
body and typically present as
asymptomatic, skin-colored dermal
nodules often with a clinically visible
central punctum. The size ranges
from a few millimeters to several
centimeters in diameter.
Keloids and/or Hypertrophic
Scars
Keloids and hypertrophic scars
represent an excessive tissue
response to dermal injury. Keloids
are fibrous growths that extend
beyond the original area of injury to
involve the adjacent normal skin.
Hypertrophic scars may have a
similar clinical appearance, but in
contrast with keloids, remain
confined within the boundaries of
the wound area and tend to regress
spontaneously over time.
Pseudofolliculitis barbae (PFB)
(Pseudofolliculitis of the beard),
often colloquially referred to as
"razor bumps," "shave bumps," or
"ingrown hairs," is a common
cutaneous condition that develops
as a result of the removal of facial
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
hair. Usually in Afro-American men
or men with tightly curly hair. PFB
most frequently occurs in
association with shaving and results
from an inflammatory response to
the cutaneous entrapment of
recently cut, short hairs. PFB
typically presents with firm papules
and pustules in the beard area.
occurrence. The approach to an
individual patient management
primarily is guided by the clinical
presentation and response to prior
therapies. Typically, the most
effective and safe intervention for
the treatment of PFB is the
permanent discontinuation of
shaving that has induced the
condition. Patients who are able to
do this usually notice significant
clinical improvement within a few
months.
Post-inflammatory
hyperpigmentation, secondary
bacterial infection, scarring, and
keloid formation are potential
complications.
Psoriasis
Psoriasis is a common chronic skin
disorder that is characterized by
erythematous papules and/or
plaques with a silver scale, although
other presentations can occur. Many
cases are not severe enough to
directly affect general health and are
generally treated in the outpatient
setting.
Offsite Care to Consider
Treatments may include:
1.
Shave/Clipping pass – shaving is
not recommended with this
condition.
2.
1% hydrocortisone cream to
reduce inflammation of papular
lesions.
3.
Benzoyl peroxide daily prn
4.
Cleocin Gel and/or Erythromycin
Topical
Consider: The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
availability and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical scenario
Medications:
1.
Medium-potency steroids that
may include Triamcinolone 0.1%
Cream is a typical starting point
for mild disease.
2.
High-potency steroid creams
that may include Triamcinolone
0.5% Cream or 0.1% Ointment
b.i.d. is a typical starting point
for moderate disease, it is
suggested to not exceed 60
g/week.
3.
Methotrexate is an established
therapy that continues to play a
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Offsite Care to Consider
role in the management of
moderate to severe plaque
psoriasis.
Scabies
Consider: The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, onsite
treatment availability and the
response to previous treatments.
Typically, treat with weight-based
Ivermectin per protocol (refer to
Wexford’s Infection Control
guideline, IC-013, Ectoparasite
Control – Scabies/Lice, Infection
Control Guideline manual); Repeat
weight-based Ivermectin in 14 days.
At the discretion of the clinician
depending on the clinical scenario
Seborrheic Keratosis
Consider: Onsite diagnosis of
seborrheic keratosis is usually based
on the clinical appearance of "stuck
on," warty, well-circumscribed, often
scaly hyperpigmented lesions
located most commonly on the
trunk, face, and upper extremities.
Treatment or removal of these
benign skin lesions is not generally
indicated. Onsite biopsy may be
considered if diagnosis is in
question.
At the discretion of the clinician
depending on the clinical scenario
Consider: Evaluation and education
of the patient. Oral antifungal
therapy is the primary treatment for
tinea capitis. Patients usually
respond well to treatment. The
optimal treatment regimens for
adults remain unclear. Typical oral
antifungal doses for adults:
At the discretion of the clinician
depending on the clinical scenario
Seborrheic keratoses present as
well-demarcated, round or oval
benign lesions with a dull, verrucous
surface and a typical stuck-on
appearance. They are generally
asymptomatic, but in some patients,
there may be chronic irritation due
to friction trauma The number of
seborrheic keratoses can vary from
an isolated lesion to literally
hundreds.
Tinea Capitis
Tinea capitis is a fungal infection of
the scalp that most often presents
with pruritic, scaling areas of hair
loss. Dermatophyte fungi are the
major causes of tinea capitis. The
infection is often contracted from
another human or an animal
through direct contact.
1.
Terbinafine 250 mg per day for
4–6 weeks
2.
Itraconazole 5 mg/kg per day
(maximum 400 mg per day) for
4–6 weeks
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
3.
Offsite Care to Consider
Fluconazole
a.
Daily dosing: 6 mg/kg per
day (maximum daily dose
is 400 mg) for 4–6 weeks
b. Weekly dosing: 8 mg/kg
once weekly for 8–12
weeks
4.
Concomitant treatment with 1%
or 2.5% selenium sulfide
shampoo may be used for the
first two weeks because it may
reduce transmission.
Consider: Treatment choices often
depends typically on the extent of
the condition and consists of topical
or systemic antifungal drugs.
Dermatophyte infections usually
respond well to a course of
appropriate treatment. Common
reasons for failure to respond to
antifungal therapy include
inadequate administration of
treatment (e.g., stopping treatment
as visible scale resolves) or an
incorrect diagnosis.
At the discretion of the clinician
depending on the clinical scenario
Tinea Pedis (Athlete’s Foot
Fungus)
Consider: The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
availability and the response to
previous treatments. Daily washes
with soap and water, dry feet well,
treat with antifungal cream.
At the discretion of the clinician
depending on the clinical scenario
Tinea Versicolor
Consider: The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
availability and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical scenario
Tinea Corporis
Tinea corporis – a fungal infection of
body surfaces other than the feet,
groin, face, scalp hair, or beard hair
Tinea versicolor (i.e., pityriasis
versicolor) is a common superficial
fungal infection. Patients with this
disorder often present with
hypopigmented, hyperpigmented,
or erythematous macules on the
trunk and proximal upper
extremities. Unlike other disorders
utilizing the term tinea (e.g., tinea
Patient education — Prior to
treatment, patients should be
advised that changes in cutaneous
pigment often persist after
successful treatment. Restoration of
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
pedis, tinea capitis), tinea versicolor
is not a dermatophyte infection. The
causative organisms are saprophytic,
lipid-dependent yeasts.
normal pigmentation may take
months after the completion of
successful therapy.
Offsite Care to Consider
Recurrence is very common
especially in warmer, more humid
climates which may impact a clinical
decision to initiate treatment or not
initiate treatment.
Treatments may include:
1.
DHS 2% zinc shampoo (8 oz.
bottle) applied for five minutes
per day for two weeks.
2.
Selenium 2.5% lotion (4 oz.
bottle) applied for 10 minutes
for seven days.
3.
Oral therapy is generally
reserved for patients with tinea
versicolor that is refractory to
topical therapy or widespread
disease that makes the
application of topical drugs
difficult.
• Fluconazole 300 mg per
week for 2–4 weeks
• Itraconazole 200 mg daily
for seven days
Warts, Non-Anogenital
(Common, plantar and flat
warts)
Consider: The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, adverse effects, treatment
availability and the clinical response
to previous treatments.
1.
Patient education: The option to
defer treatment should be
discussed with patients.
Although most warts in
immunocompetent patients
eventually resolve without
treatment, warts may spread or
persist and resolution is
unpredictable.
2.
Many wart therapies require
prolonged treatment or multiple
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Offsite Care to Consider
office visits and have
inconsistent efficacy. Clinicians
should communicate
expectations for the treatment
course as well as the possibility
of treatment failure and
recurrence.
Medications to consider:
1.
Salicylic Acid topical applied
twice daily up to 12 weeks as a
typical first line therapy. Cover
daily with Band-Aid until
removed.
2.
Trichloroacetic acid (TCA) 80%
solution once weekly
applications have been used for
warts on the palms and soles.
Clinical pathways do not replace sound clinical judgment nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Durable
Durable Medical
Medical Equipment
Equipment
Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000794
000794
Medical Guidelines
Region: New Mexico
Ankle-Foot Orthotics
I.
GUIDELINE
The purpose of this guideline is to provide clinical guidelines to determine the need for therapeutic
ankle-foot orthotic devices and instruction for issuance.
II.
DEFINITION
Ankle-Foot Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak
or deformed body part, or for restricting or eliminating motion in a diseased or injured part of the
body. An orthotic can be either prefabricated or custom-fabricated. Are for ambulatory individuals
with weakness or deformity of the foot and ankle who require stabilization for medical reasons and
have the potential to benefit functionally (i.e., AFO, foot drop splints).
III.
GENERAL GUIDELINES
Prefabricated devices should be trialed prior to requesting a custom made device (i.e., off the shelf
prefabricated foot drop splint, verses a custom made AFO). Patients should display willingness and
ability to comply with treatment regimen.
IV.
CLINICAL CRITERIA
Ankle flexion contracture: a condition in which there is shortening of the muscles and/or
tendons that plantar-flex the ankle with the resulting inability to bring the ankle to zero
degrees by passive range of motion. (Zero degrees ankle position is when the foot is
perpendicular to the lower leg.)
Plantar flexion contracture (i.e., a non-fixed contracture) when reasonable expectation of the
ability to correct or prevent the contracture in those who may become ambulatory; and
contracture is interfering or expected to interfere significantly with the patient’s functional
abilities; and used as a component of a therapy program that includes passive stretching of
the involved muscles and/or tendons.
Foot drop: a condition in which there is weakness and/or lack of use of the muscles that
dorsiflex the ankle, but there is the ability to bring the ankle to zero degrees by passive range
of motion.
V.
ACTION
When the orthotic or prosthesis is issued, the patient will sign a form approved by the facility (see
Wexford Health’s receipt for Accountable Items” Form #037) with the understanding that
repair/replacement is contingent on assessment of the prosthesis. If the prosthesis loss or damage
is related to neglect or misuse by the patient, replacement will be contingent on findings of the case
and decision of the Regional Medical Director. This form must be signed by a witness, stamped and
dated, and filed under miscellaneous portion of the medical health record.
Adapted from the BlueCross of California Clinical UM Guidelines 12/01/05
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
M-012: Knee Orthotics
I.
GUIDELINE
The purpose of this guideline is to provide clinical guidelines to determine the need for therapeutic
knee orthotic device and instruction for issuance.
II.
DEFINITION
Knee Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or
deformed body part, or for restricting or eliminating motion in a diseased or injured part of the body.
Knee orthotics are designed to allow protected and controlled motion of injured knees that have
been treated operatively or non-operatively, assist or provide stability for unstable knees during
activities of daily living and may be either prefabricated (off-the-shelf) or custom-made.
III.
GENERAL GUIDELINES
Prefabricated devices should be trialed prior to requesting a custom made device. Patients
should display willingness and ability to comply with treatment regimen.
IV.
CLINICAL CRITERIA
Prefabricated functional or rehabilitative knee braces are considered medically necessary
for patients with:
1.
Documented anterior or posterior cruciate ligament (ACL or PCL) tears, or functional
instability episodes due to cruciate ligament insufficiency who elect non-surgical
treatment.
2.
Grade II or III medial collateral or lateral collateral ligament sprain for support for
ambulation. These need to be hinged braces where one can control the range of motion.
3.
Posterior cruciate and/or posterior lateral reconstruction, including those undergoing
reconstruction after knee dislocation.
4.
In the post op recovery phase anterior cruciate ligament (ACL) repair.
5.
Major ligaments and bony reconstruction above the knee such as patella or quadriceps
tendon repair, medial and lateral collateral ligament repair.
6.
Major fractures requiring fairly early post-op motion such as patella fracture or a tibial
plateau fracture.
Custom-made unloader knee braces or prefabricated functional rehabilitative braces are
considered medically necessary in members with osteoarthritis and are:
V.
1.
Candidates for high tibial osteotomy or total knee arthroplasty (replacement) that may
elect non-surgical treatment.
2.
Predicting the success of high tibial osteotomy versus total knee arthroplasty.
3.
Severe patello-femoral arthrosis in conjunction with medial or lateral compartment
arthrosis.
ACTION
When the orthotic or prosthesis is issued, the patient will sign a form approved by the facility (see
Wexford Health’s Receipt for Accountable Items,” form #037) with the understanding that
repair/replacement is contingent on assessment of the prosthesis. If the prosthesis loss or damage
is related to neglect or misuse by the patient, replacement will be contingent on findings of the case
Adapted from the BlueCross of California Clinical UM Guidelines 12/01/05
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Region: New Mexico
and decision of the Regional Medical Director. This form must be signed by a witness, stamped and
dated, and filed under miscellaneous portion of the medical health record.
Adapted from the BlueCross of California Clinical UM Guidelines 12/01/05
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
M-013: Prosthesis
I.
GUIDELINE
The purpose of this guideline is to provide general guidelines for issuance or repair of prosthetic
devices.
II.
DEFINITION
An artificial device used to replace a missing body part, such as a limb.
III.
GENERAL GUIDELINES
In general, a physician prescribes an artificial limb or prosthesis when a patient has lost a
limb and a functional level of one or greater is expected.
1.
Functional Levels: Throughout this guideline "Functional Levels" are used to guide the
appropriateness of lower limb prosthesis. Provided below are definitions of these levels.
Please note that within the functional classification hierarchy, bilateral amputees often
cannot be strictly bound by functional level classifications.
2.
Level 0: Does not have the ability or potential to ambulate or transfer safely with or
without assistance and prosthesis does not enhance their quality of life or mobility.
3.
Level 1: Has the ability or potential to use prosthesis for transfers or ambulation on
level surfaces at fixed cadence. Typical of the limited and unlimited ambulator.
4.
Level 2: Has the ability or potential for ambulation with the ability to traverse low-level
environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited
ambulator.
5.
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the
ambulator who has the ability to traverse most environmental barriers and may have
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond
simple locomotion.
6.
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic
ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the
prosthetic demands of the child, active adult, or athlete.
Amputee patients, who did not attempt to acquire prosthesis for greater than one year prior
to incarceration, shall not be considered candidates for issuance of prosthesis unless there is
a change in clinical indications and or rehabilitative goals. The case is to be reviewed with the
Regional Medical Director. The patient must clearly display ability, initiative and willingness
to participate in a prosthetic limb-training regimen.
A patient must show compliance with a weight reduction program prior to requesting
replacement prosthesis socket when the socket is needed due weight gain stump enlargement.
Wexford Health will furnish an ocular conformer for enucleated patients. Issuance of
prosthetic eyes is considered cosmetic and not medically necessary.
IV.
ACTION
When the orthotic or prosthesis is issued, the patient will sign a form approved by the facility (see
Wexford Health’s Receipt for Accountable Items” form #037) with the understanding that
repair/replacement is contingent on assessment of the prosthesis. If the prosthesis loss or damage
is related to neglect or misuse by the patient, replacement will be contingent on findings of the case
and decision of the Regional Medical Director. This form must be signed by a witness, stamped and
dated, and filed under miscellaneous portion of the medical health record.
Adapted from the BlueCross of California Clinical UM Guidelines 12/01/05
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Endocrine/ Metabolic Disorders
Disorders
WEXFORD MILLER
WEXFORD
MILLER 000799
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Medical Guidelines
Region: New Mexico
Pharmacological Management of Type 1 and Type 2 Diabetes Mellitus Guidelines
I.
GUIDELINE/PURPOSE
These guideline recommendations summarize the Wexford Health guidelines for patients being
treated for Type 1 and Type 2 Diabetes Mellitus.
These recommendations are provided only as assistance for clinicians making clinical decisions
regarding the care of their patients. As such, they cannot substitute for the individual judgment
brought to each clinical situation by the patient’s clinician. As with all clinical reference resources,
they reflect the best understanding of the science of medicine at the time of development, but they
should be used with the clear understanding that continued research may result in new knowledge
and recommendations.
II.
CLASSIFICATION OF DIABETES
A.
B.
Type 1 Diabetes Mellitus
1.
Type 1 diabetes is characterized as a disease of absolute insulin deficiency which is a
result of autoimmune destruction of pancreatic beta cells.
2.
Approximately 5 to 10% of patients with diabetes have type 1 diabetes mellitus.
3.
Patients with undiagnosed type 1 diabetes may present with diabetic ketoacidosis (DKA)
or may have a more gradual presentation with symptoms of hyperglycemia which may
include polyuria (increased urination), polydipsia (increased thirst) and polyphagia
(increased appetite).
4.
Type 1 diabetes mellitus is typically characterized by the following:
a.
Diagnosis as a child or adolescent (although it can occur at any age)
b.
Lean body type or BMI less than 25 kg/m2
c.
Normal insulin sensitivity (insulin requirements typically do not exceed 0.7 units
of insulin/kg body weight over 24 hours)
d.
Displays evidence of anti-beta cell autoimmunity
e.
May be more prone to ketosis or DKA than type 2 diabetics
Type 2 Diabetes Mellitus
1.
Type 2 diabetes mellitus is characterized by hyperglycemia often associated with
progressive loss of insulin secretion from the beta cells along with superimposed insulin
resistance which results in a relative insulin deficiency.
2.
Type 2 diabetes mellitus is the more common form of diabetes mellitus, with
approximately 90% of patients diagnosed with type 2 diabetes.
3.
Obesity, age and physical inactivity are often associated with type 2 diabetes.
4.
Type 2 diabetes mellitus is typically characterized by the following:
a.
Diagnosis more likely to be an adult.
b.
Patient is overweight or obese (i.e., BMI ≥ 25 kg/m2, and often far exceeding that
BMI).
c.
High likelihood to have a family history of diabetes
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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III.
d.
If treating with insulin, patient may require large doses to control blood sugar due
to insulin resistance. Insulin resistance is often associated with abdominal
obesity, hypertension, lipid abnormalities, atherosclerosis, and hyperuricemia.
e.
No evidence of anti-beta cell specific antibodies.
f.
Less likely to have a history of diabetic ketoacidosis (DKA), but may have a history
of hyperosmolar coma.
g.
More likely to have symptoms of “metabolic syndrome” such as hypertension or
hyperlipidemia.
DIAGNOSTIC CRITERIA FOR PRE-DIABETES AND DIABETES MELLITUS
A.
B.
Patients should be evaluated for diabetes if they display any of the following:
1.
Symptoms of hyperglycemia
2.
Symptoms that may be the result of complications of diabetes
3.
Clinical presentations in which diabetes is considered in the differential diagnosis
4.
Significantly elevated glucose level on blood testing
ADA Diagnostic Criteria
1.
The ADA diagnostic criteria for diabetes and pre-diabetes in non-pregnant adults is
shown in Table 1.
2.
Pre-Diabetes
a.
Pre-diabetes is terminology that encompasses both impaired glucose tolerance
(IGT) and impaired fasting glucose (IFG) or hyperglycemia that does not meet
the diagnostic criteria for diabetes.
b.
Both IGT and IFG as well as a an A1C range of 5.7-6.4% are associated with a
high risk for diabetes and cardiovascular disease.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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TABLE 1. ADA DIAGNOSTIC CRITERIA FOR DIABETES AND PRE-DIABETES (IN NON-PREGNANT ADULTS)
IV.
DIABETES SCREENING
A.
Diabetes Screening Recommendations
1.
Routine universal screening is recommended in all patients for type 2 diabetes at age
45.
2.
Routine screening for type 2 diabetes should be considered when clinically indicated,
based on risk factors for diabetes.
a.
3.
Screening can be prioritized for patients who are considered overweight (BMI ≥ 25
kg/m2, or ≥ 23 kg/m2 in Asian Americans) with additional risk factors which
include: hypertension, hyperlipidemia, first-degree relative, sedentary lifestyle,
high-risk ethnic or racial group, history of gestational diabetes mellitus, polycystic
ovary syndrome, history of vascular disease, or other conditions know to be
associated with insulin resistance.
Screening Intervals
a.
Testing may be repeated every three years when fasting plasma/serum glucose is
≤ 100 mg/dl of A1C is ≤ 5.7%
b.
Follow-up screening for patients with pre-diabetes should occur annually.
i.
Patients with IFG or IGT are at an increased likelihood for developing
diabetes within 5 years and annual screening is recommended for these
patients.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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V.
INITIAL TREATMENT PLAN
A.
VI.
Treatment Plan Development
1.
The treating clinician should develop and review the initial diabetic treatment plan with
the patient.
2.
Involvement of the patient in the development of the treatment plan is pivotal to its
success and should include adequate training to empower the patient to prevent,
recognize, and treat hyperglycemia and hypoglycemia.
3.
The following are recommended components of a treatment plan:
a.
Education on diabetes drug treatment; self-monitoring; recognizing and treating
severe hypoglycemic and hyperglycemic episodes; and identifying the signs of
diabetic complications such as diseases of the eyes, kidneys, and nervous system.
b.
A discussion of potential treatment options and addressing patient concerns that
may improve adherence and outcomes.
c.
Instruction on the patient’s specific drug treatment regimen and methods for
monitoring glucose.
d.
Necessary lifestyle modifications such as improving food selection, increasing
physical exercise, and stopping smoking.
e.
Importance of annual eye exams (funduscopic) by an ocular professional.
f.
Need for regular self-examination of the feet.
g.
Need for regular self-examination of the skin, including insulin injection sites.
h.
Importance of regular dental examinations and treatment.
i.
Need for regular screenings: fasting blood glucose, A1C, lipid levels, and kidney
monitoring (typically a BMP or CMP).
j.
Consideration of daily aspirin therapy to prevent cardiovascular events in some
patients at higher risk.
k.
Importance of annual influenza vaccinations.
TREATMENT OF TYPE 2 DIABETES
A.
Treatment Goals
1.
Based on the results of multiple randomized trials and correctional considerations, a
reasonable A1C target for patients with diabetes is <7.0–7.5%.
2.
It is recognized, however, that glycemic goals should be individualized, as very
stringent goals may not be appropriate or practical for some patients.
a.
3.
Glycemic targets are generally set somewhat higher (e.g., A1C <8%) for older
patients and those with comorbidities or a limited life expectancy and little
likelihood of benefit from intensive therapy.
Clinical judgment, based on the potential benefits and risks of a more intensified
regimen, should be applied for every patient.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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B.
Wexford Preferred Treatment Regimens for Type 2 Diabetes
1.
Selection of antihyperglycemic agents in the treatment of Type 2 DM should be based
on their effectiveness in lowering A1C levels, safety profiles and tolerability.
TABLE 2. SUMMARY OF WEXFORD FORMULARY ANTIDIABETIC AGENTS FOR TYPE 2 DIABETES
INTERVENTIONS*
EXPECTED
TOTAL
DECREASE IN
A1C (%)**
ADVANTAGES
DISADVANTAGES
STEP 1: LIFESTYLE INTERVENTION AND METFORMIN
Lifestyle
1–2
Low cost, additional health benefits.
Fails as monotherapy for most
patients in the first year.
Metformin
1–2
Weight-neutral, no hypoglycemia,
inexpensive, self-carry.
GI side effects, contraindicated in
renal impairment, rare lactic acidosis.
STEPS 2 AND 3: ADDITIONAL MEDICATION
Insulin
≥2.5
No dose limit, inexpensive
formulations available.
Hypoglycemia, weight gain; requires
pill line.
Sulfonylureas
(i.e., Glipizide)
1–1.5
Inexpensive.
Hypoglycemia, weight gain,
decreased efficacy over time.
C.
Lifestyle Interventions
1.
2.
For the vast majority of patients, a lifestyle intervention program to increase activity
levels, improve dietary choices, and promote weight loss (as indicated) should be
included as part of diabetes management.
a.
Being overweight and lack of exercise are the most important modifiable risk
factors for type 2 diabetes.
b.
Weight management and increasing exercise have been shown to have a beneficial
effect on controlling glycemia in both type 1 and type 2 diabetes.
Nutrition
a.
3.
Nutrition Counseling and Education
i.
Nutrition counseling for patients with diabetes is considered an important
component of diabetes self-management.
ii.
Nutrition education, conducted individually or potentially in group settings,
should help patients understand how their food choices, carbohydrates in
particular, directly affect diabetes control.
iii.
Patients should also strive for day-to- day consistency in the times that they
eat and in the amount of carbohydrates they consume.
Physical activity
a.
Regular exercise can significantly improve glycemic control and contribute to
weight reduction.
b.
All patients with diabetes should be counseled on the benefits of increased
physical activity, as well as the degree of exercise best suited to them.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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c.
D.
Sedentary patients may need be medically evaluated prior to undertaking aerobic
physical activity that goes beyond the intensity of brisk walking.
Metformin
1.
Metformin, a biguanide, reduces hepatic glucose production in the presence of insulin
and reduces hyperglycemia.
2.
Metformin reduces A1C levels by 1–2%.
3.
In contrast to sulfonylureas, metformin is associated with weight loss or no weight gain,
is risk-neutral for hypoglycemia, and may reduce cardiovascular risk.
4.
Recommendations
5.
a.
Unless contraindicated, metformin in combination with lifestyle changes is
recommended as initial treatment for most type 2 diabetes.
b.
Metformin can also be used in combination with insulin and sulfonylureas.
c.
Pre-Diabetes: Metformin therapy should also be considered for patients with prediabetes, particularly those with BMI>35 kg/m2.
d.
Metformin ER (Glucophage XR) is an extended-release product and allows for
dosing to be once daily as compared to twice daily dosing regimens associated
with metformin immediate release (IR).
i.
Metformin ER has been associated with less gastrointestinal side effects
than metformin immediate release products.
ii.
However, the maximum daily dose of Metformin ER is 2000 mg/day as
compared to the maximum daily dose of Metformin IR which is 2550
mg/day.
iii.
In patients who are doing well with immediate-release metformin,
continued use of the IR product is usually recommended as there is
little additional benefit documented with ER tablets.
Precautions
a.
Metformin should be discontinued during acute illnesses where dehydration
is a significant risk or where respiratory acidosis is possible, since metformin
use in these situations may result in life-threatening lactic acidosis.
b.
Metformin is not recommended for individuals with unstable or severe renal
dysfunction (eGFR <30 mL/min) or for initiation of therapy when eGFR is 30
to 45 mL/min.
c.
Metformin should be withheld 48 hours before and after surgery or IV
contrast radiograph studies; the patient should be well-hydrated both before
and after these procedures.
i.
Discontinue metformin at the time of or before iodinated contrast imaging
procedures in patients with an eGFR between 30 to 60 mL/minute/1.73
m2, in patients with a history of hepatic disease, alcoholism, or heart
failure, and/or in patients who will receive intra-arterial iodinated contrast.
ii.
Re-evaluating an eGFR 48 hours should be considered following the imaging
procedure; metformin may be reinitiated once renal function is stable.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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iii.
Metformin can cause vitamin B12 deficiency with an associated anemia
and neuropathy.
iv.
Patients who discontinue metformin are often switched to agents with
increased risk for hypoglycemia, making continuation of metformin therapy
advantageous when possible.
v.
Metformin-associated lactic acidosis is rare, and
continue metformin therapy for patients with
controlled, but have creatinine levels above
monitoring renal function as described in Table 3
clinicians may choose to
diabetes who are wellthe threshold, closely
below.
TABLE 3. METFORMIN IN STABLE RENAL DYSFUNCTION
EGFR
(ML/MIN)
MAXIMUM DAILY DOSE
SUGGESTED MONITORING
>60
2550 mg
Monitor renal function at least annually.
45 to 59
2000 mg
Monitor renal function at every 3 to 6 months.
30 to 44
1000 mg
Monitor renal function every 3 months.
Do NOT initiate metformin therapy, although metformin
may be continued in patients already taking it.
<30
Do NOT use.
N/A
Adapted from: PL Detail-Document, Clinical Use of Metformin in Special Populations. Pharmacist’s
Letter/Prescriber’s Letter. March 2015.
E.
F.
Insulin
1.
Insulin has often been used to treat insulin-resistant type 2 diabetes, and it is the most
effective drug to decrease glycemia.
2.
In adequate doses, insulin can decrease any level of elevated A1C to meet a therapeutic
goal.
3.
Initial therapy is aimed at increasing basal insulin supply.
4.
Patients may require pre-meal, regular insulin, as well.
5.
Insulin therapy has beneficial effects on triglyceride and HDL cholesterol levels, but is
associated with weight gain of about 2–4 kg that may have an adverse effect on
cardiovascular risk.
6.
Insulin therapy is also associated with hypoglycemia.
Sulfonylureas
1.
Sulfonylureas stimulate insulin secretion and require endogenous insulin production.
The various sulfonylureas have equivalent efficacy, reducing A1C by 1–1.5%.
a.
2.
Second-generation sulfonylureas such as glipizide, glyburide, and glimepiride
have more favorable side effect profiles and fewer drug interactions than firstgeneration sulfonylureas such as chlorpropamide, tolazamide, and tolbutamide.
In patients for whom metformin is contraindicated, sulfonylureas can be prescribed as
monotherapy, or they can be combined with other oral agents.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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G.
3.
The combination of insulin and sulfonylureas may increase the risk of
hypoglycemia, and caution is advised if these therapies are used concurrently.
4.
Hypoglycemia (particularly in the elderly and patients with renal insufficiency) and
weight gain are the two most common adverse effects of sulfonylurea therapy.
5.
All sulfonylureas are metabolized by the liver and excreted in the urine; therefore, they
should be used with caution in patients who suffer from either renal or hepatic
insufficiency.
6.
Glipizide has less renal toxicity than the other sulfonylureas and can be used in patients
with renal insufficiency if the creatinine clearance is >10 mL/min.
7.
Sulfonylureas have a relatively high secondary failure rate (5–10% per year), most likely
due to the gradual decline of endogenous insulin production over time.
8.
Clinical Precaution for Sulfonylureas
a.
Hypoglycemia caused by sulfonylureas can be prolonged or recurrent, due to the
drugs’ long duration of action.
b.
Symptomatic hypoglycemia that cannot be managed with frequent feedings over
a 24-hour period should be treated in a hospital setting.
c.
The combination of insulin and sulfonylureas may increase risk of hypoglycemia.
Alternative Medications in the Treatment of Type 2 Diabetes
1.
Both oral and injectable medications are available as alternative medications for
treatment of type 2 diabetes, however their use should only be considered under
special circumstances.
2.
Thiazolidinediones
a.
3.
Thiazolidinediones (TZDs) increase the insulin sensitivity of target cells without
increasing pancreatic insulin secretion, and may lower the A1C by up to 1.3%.
Clinical Precaution for TZDS
a.
TZDs may precipitate heart failure and peripheral edema. Initiation of TZDs
in New York Heart Association Class III or IV heart failure is contraindicated, and
TZDs are not recommended for use with any degree of symptomatic heart failure.
b.
Increased risks of myocardial infarction and death have been associated with
rosiglitazone.
c.
Due to potential for drug-induced liver injury, serum liver function tests should
be obtained at baseline.
i.
4.
It is suggested to monitor liver function studies (hepatic panel or CMP)
approximately every two months for one year, and then periodically
thereafter.
Dipeptidyl Peptidase 4 (DDP-4) Inhibitors
a.
The DPP-4 inhibitors reduce the breakdown of endogenous GLP-1, resulting in
increased glucose-dependent insulin secretion and decreased glucagon secretion.
b.
These oral agents are better tolerated than the GLP-1 agonists, but they only
reduce the A1C by about 0.7%.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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5.
Glucagon-Like Peptide 1 (GLP-1) Agonists
a.
The GLP-1 agonists activate receptors that enhance glucose-dependent insulin
secretion, slow gastric emptying, promote satiety, and decrease hepatic glucose
production.
b.
These injectable medications have a glucose-dependent mechanism of action and
can decrease the A1C up to 1.5% or more.
i.
Benefits of GLP-1 agonists include weight reduction, reduced postprandial
glucose levels and no risk of hypoglycemia.
ii.
Disadvantages:
1)
6.
VII.
Necessity of pill line administration, high cost, and gastrointestinal
side effects.
Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors
a.
The SGLT-2 inhibitors block glucose reabsorption in the kidney, increasing the
amount of glucose excreted in the urine.
b.
These oral agents can reduce the A1C up to 1% and can be used in combination
with other oral therapies.
i.
Benefits of SGLT-2 inhibitors are weight loss, blood pressure lowering, no
risk of hypoglycemia, and efficacy at all stages of type 2 diabetes.
ii.
Disadvantages:
1)
Cost is a disadvantage for these therapies, and side effects include
genitourinary infections, frequent urination, dizziness and
hypotension.
2)
Euglycemic ketoacidosis is also possible on these medications.
WEXFORD TREATMENT ALGORITHM FOR TYPE 2 DIABETES MELLITUS
A.
Goals (Recommended)
1.
Initiation of medication is generally recommended when the A1C is >7.0–7.5%, or above
the individualized goal.
2.
In order to achieve glycemic goals as soon as possible, medications should be adjusted
as titration allows (i.e., adjustment may occur as often as every 3 days for insulin and
every week for metformin).
3.
Until glycemic goals are achieved, the patient should generally be seen at least monthly
to adjust medications, based on plasma/serum glucose data, and to counsel the patient
on diet and exercise.
4.
The A1C should generally be obtained every three months until the patient has reached
the individualized goal. (There is no benefit in ordering the A1C at less than three-month
intervals.)
5.
An A1C above the individualized goal (usually 7–7.5%) typically suggests the need for
further intensification of diet, exercise, and medication management or improvement in
medication compliance.
6.
Insulin therapy, in addition to lifestyle changes, may be necessary initially in cases of
uncontrolled diabetes, which may present as plasma/serum glucose levels >250 mg/dl,
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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random glucose levels consistently >300 mg/dl, A1C >10%, or the presence of ketonuria
or symptomatic diabetes with polyuria, polydipsia, and weight loss.
B.
Step 1: Lifestyle Modification and Metformin
1.
It is generally recommended that drug treatment be initiated along with lifestyle
intervention at the time of type 2 diabetes diagnosis but individual circumstances vary.
2.
Presuming there are no contraindications, metformin is the initial drug of choice for
the following reasons: effective glycemic control, absence of weight gain, absence of
hypoglycemia, low level of side effects, and high level of acceptance.
3.
An eGFR should be obtained prior to initiating metformin.
4.
a.
Metformin is contraindicated in patients with eGFR <30 mL/min, and should not
be initiated in patients with eGFR <45 mL/min.
b.
If metformin is contraindicated, then insulin, glipizide, or glimepiride may be used
as the initial therapy.
Titration of metformin is advised to minimize gastrointestinal side effects.
TABLE 4. TITRATION OF METFORMIN
C.
D.
Step 2: Adding a Sulfonylurea or Insulin
1.
If lifestyle interventions plus a maximally tolerated dose of metformin (with good
compliance) fail to achieve or sustain glycemic goals within two to three months, then
generally another medication should be added.
2.
Addition of insulin or a sulfonylurea is generally recommended. The A1C level will
determine, in part, which agent should be selected next.
3.
Insulin should be considered for patients with A1C >8.5%, or who have symptoms of
hyperglycemia.
4.
Insulin is considered a fundamental tool for treating type 2 diabetes; initiation of insulin
should not be delayed in patients who fail to meet glycemic goals.
Step 3: Add or Adjust Insulin Therapy
1.
If lifestyle interventions plus metformin and a second medication fail to achieve glycemic
goals, the next step is to start or intensify insulin therapy.
2.
Usually, there is no benefit to prescribing three oral agents.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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E.
3.
If plasma/serum glucose and A1C goals are not met in a compliant patient on two oral
agents, e.g., metformin and glipizide, the most effective next step is to add NPH insulin.
4.
Intensification of insulin therapy usually consists of additional injections, often
including regular insulin prior to selected meals to reduce postprandial glucose
excursions.
5.
In general, once insulin has been started, sulfonylureas are discontinued due to concern
for sustained, severe hypoglycemia.
Additional Observations
1.
The majority of patients with type 2 diabetes will require multiple medications over time.
a.
2.
The first-line oral agents utilized within Wexford are metformin, glipizide, and
glimepiride.
a.
If these oral agents are contraindicated or not tolerated, the use of other oral
antihyperglycemic agents should be considered on a case-by-case basis.
3.
Drug selection should be based on glucose-lowering effectiveness, mechanism of action,
side effect profile, and other factors that may reduce diabetes complications, e.g., weight
loss or improvement in lipid profile.
4.
When adding antihyperglycemic medications, the synergy of particular combinations
and other interactions should be considered.
a.
F.
This is because patients with type 2 diabetes have both insulin resistance at the
tissue level and declining pancreatic insulin production.
As a rule, antihyperglycemic drugs with different mechanisms of action will have
the greatest synergy.
Appendices
1.
Appendix 1: Treatment Algorithm for Type 2 Diabetes
2.
Appendix 2: Initiation and Adjustment of Insulin Regimens in Type 2 Diabetes
VIII. TREATMENT OF TYPE 1 DIABETES MELLITUS
A.
Treatment
1.
Patients with type 1 diabetes generally present with acute diabetes symptoms, as well
as significantly elevated blood glucose levels.
a.
Given the acute onset of symptoms, type 1 diabetes is usually detected soon after
symptoms develop.
b.
Treatment goals for type 1 diabetes are the same as those for type 2 (see Appendix
3).
2.
Insulin therapy is the cornerstone of medication management, and
antihyperglycemic agents are not indicated in patients with type 1 diabetes.
3.
Furthermore, it has been clearly demonstrated that intensive insulin therapy results in
improved glycemic control and reduction in diabetes- related complications (including
nephropathy, retinopathy, neuropathy, and cardiovascular morbidity and mortality.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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B.
Insulin
1.
Commonly prescribed insulin within a correctional setting includes short-acting
insulin which is Regular (human) insulin and intermediate-acting insulin which is
NPH (human) insulin.
2.
LONG-ACTING INSULINS (insulin glargine and insulin detemir) are frequently utilized
in the community (i.e., outside the correctional setting) in place of intermediate-acting
insulin (NPH).
a.
Insulin glargine (Lantus, Semglee) has virtually no peak and can often be
administered once daily.
b.
A disadvantage of insulin glargine is that it cannot be mixed with other insulins
and thus requires a separate injection.
c.
Studies comparing glargine and detemir with NPH have shown that the two
longer-acting agents have no superiority over NPH in terms of glycemic
control;
i.
d.
3.
A1C values are no lower with long-acting insulins than they are with NPH
insulin.
It is important to note that evening doses of NPH insulin should be given at
bedtime or as close to bedtime as feasible.
RAPID-ACTING INSULINS are often utilized in the community in place of short-acting
(regular) insulin.
a.
In general, rapid-acting insulin are not typically utilized in the correctional
setting.
b.
If used, rapid acting insulins must be carefully timed to avoid the risk of
hypoglycemia.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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TABLE 5. ONSET AND PEAK OF COMMONLY USED INSULIN PREPARATIONS
INSULIN OR INSULIN ANALOGUE
ULTRA-RAPID-ACTING
ACTION PROFILE
Onset
Peak
Insulin lispro (Humalog)
10–20 min
30 min–90 min
Insulin aspart (Novolog)
10–20 min
30 min–90 min
30 min–1 hour
2–4 hours
1–3 hours
4–10 hours (~8 hours)
SHORT-ACTING
Regular (human) Humulin R/Novolin R
INTERMEDIATE-ACTING
NPH (human) Humulin N/Novolin N
LONG-ACTING
Insulin glargine (Lantus, Semglee)
1–3 hours
No peak, ~ 24hr duration
Insulin detemir (Levemir)
1–3 hours
9 hours–unknown
Source: McCulloch, DK. Insulin therapy in type 2 diabetes mellitus. In: UpToDate, Nathan DM (Ed), UpToDate, Waltham, MA.
C.
Insulin Therapy
1.
Conventional Insulin Therapy involves single daily injections, or two injections per
day—usually twice-daily administration of a combination of short-acting (regular) and
intermediate-acting (NPH) insulins.
a.
2.
3.
Conventional insulin therapy is typically utilized in correctional facilities.
Intensive Insulin Therapy describes treatment with three or more insulin injections
per day, including basal and pre-meal.
a.
Intensive insulin therapy aims to provide a more physiologic profile of insulin.
b.
Although research findings strongly support the use of intensive insulin
therapy, there are associated drawbacks:
i.
Greater effort is required on the part of the patient to coordinate diet,
activity, insulin administration, and glucose monitoring.
ii.
Greater effort is required to assure that insulin and mealtimes are
coordinated.
iii.
There is up to a three-fold increase in the incidence of hypoglycemia (a
significant concern for correctional facilities).
iv.
Weight gain is more likely, sometimes limiting patient compliance .
Sliding Scale Insulin Therapy refers to the use of varying doses of regular insulin in
response to hyperglycemia.
a.
Sliding scale insulin therapy is generally not a recommended strategy for
long-term management of patients with diabetes.
b.
See Appendix 4 for information on replacing sliding scale insulin therapy for
patients in long-term care situations.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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D.
Design of Multiple-Dose Insulin Regimen for New Type 1 Patients
1.
Patients who are newly diagnosed with type 1 diabetes ordinarily can be started on a
total daily dose of 0.2 to 0.4 units of insulin per kg per day; most will eventually require
0.6 to 0.7 units per kg per day.
2.
Initially, the total daily dose should be composed as follows:
a.
NPH insulin: Approximately half the total dose should be NPH insulin,
administered twice daily.
i.
b.
3.
In general, two-thirds of the total NPH dose should be given in the morning
and one-third at bedtime (or as close to bedtime as feasible).
REGULAR insulin: The other half of the total daily insulin dose should usually
consist of pre-meal, regular insulin.
i.
The dosing of pre-meal insulin is based upon the usual meal size and calorie
count.
ii.
Nutritional consistency is critical for maintaining adequate glycemic control.
iii.
When NPH insulin is utilized as part of the regimen, a pre-lunch bolus of
regular insulin is generally not necessary.
Clinical Precaution for Multiple-Dose Insulin Regimens
a.
A disadvantage of insulin glargine (Lantus) is that it cannot be mixed with any
other insulins.
b.
Fixed-dose insulin combinations (e.g., 70/30 insulin preparations) are
generally not suggested for insulin-dependent patients who need to achieve
target A1C levels.
i.
Fixed-dose insulin formulations are typically not flexible enough to match
changes in caloric intake with appropriate doses of short-acting and longacting insulin.
c.
For patients with type 1 diabetes, and any patient with type 2 diabetes who require
short- acting insulin, a process must be in place to ensure that patients have
access to glucose monitoring on an as-needed basis in order to achieve optimal
control and to avoid hypoglycemia.
d.
Rapid-acting insulin should be avoided in most circumstances; the benefit
versus risk of using these agents within the correctional environment needs
to be carefully assessed and appropriately justified on a case-by-case basis.
i.
Anything that keeps the patient from eating within 20–30 minutes after a
rapid-acting insulin injection is very likely to induce symptomatic
hypoglycemia.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IX.
UTILIZATION OF INSULIN
A.
Insulin Administration
1.
Patients who require insulin should be educated on the appropriate and safe
administration of insulin:
2.
Administration
3.
4.
5.
a.
Directly observed self-administration of insulin is recommended whenever
feasible.
b.
Insulin should be administered subcutaneously at a 45poli-to-90 degree angle at
a clean injection site, using clean hands.
c.
Absorption is fastest from injections into the abdominal wall (>2 inches from the
umbilicus), making this site preferable for pre-meal (regular) insulin therapy.
d.
Injections into the leg or buttock result in slower absorption and are thereby
appropriate for the evening dose of intermediate-acting (NPH) insulin.
e.
Rotating injection sites is recommended to prevent lipodystrophy.
Procedure For Mixing Regular and NPH Insulin
a.
Regular insulin should be drawn up first, followed by the NPH (being careful not
to inject the regular insulin into the NPH vial).
b.
Administering the mixture of regular/NPH insulin within 15 minutes of drawing
them up is advised.
Infection Control Issues
a.
Insulin syringes should be used only once; they should never be used on more
than one patient or reused in the same patient.
b.
Infection control procedures should be established to prevent the recapping of
insulin needles following injection, or the handling of contaminated syringes by
other patients or health care providers.
c.
Used insulin syringes should be promptly disposed of in puncture-resistant
containers.
d.
Measures should be taken to avoid contamination of insulin solution when using
multi-dose vials.
INSULIN PUMPS are rarely necessary for patients with type 2 diabetes.
a.
B.
Newly incarcerated patients with type 1 diabetes who are already on insulin
pumps should usually be maintained on the pump.
Insulin and Food Intake in the Correctional Setting
1.
The correctional environment poses known challenges for coordinating insulin
administration with food intake, particularly for patients on short-acting (regular)
insulin.
a.
The consequences of insulin/food mismatch are, at best, suboptimal control of
hyperglycemia; at worst, the result of insulin/food mismatch is frequent and
potentially severe hypoglycemic episodes.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
X.
b.
Because of the many factors in a correctional environment that can interfere with
the optimal timing of insulin and food, the insulin regimen should be as “forgiving”
as possible.
c.
The shorter the onset and peak of the insulin, the more critical it is to coordinate
food intake with insulin administration.
d.
Consequently, rapid-acting insulin is generally not utilized within the correctional
facility.
Timing of Short-Acting (Regular) Insulin
a.
Short-acting insulin is typically administered two-to- three times per day; ideally,
it should be administered prior to a meal to allow some absorption of insulin prior
to the rise in blood glucose that occurs during a meal.
b.
However, if the timing of meals is uncertain, regular insulin can be administered
immediately after eating (rather than before).
c.
Although the patients will have a short period of postprandial hyperglycemia, this
approach causes fewer long-term consequences and good diabetic control can still
be achieved.
REFERENCES
1.
American Diabetes Association. Diabetes management in correctional institutions. Diabetes Care.
2007;30(suppl 1):S77–S84. Available at:
http://care.diabetesjournals.org/content/30/suppl_1/S77.full
2. American Diabetes Association. 2017 Standards of medical care in diabetes. Diabetes Care.
2017;40(suppl 1):S1–S135. Available at: http://care.diabetesjournals.org/content/40/Supplement_1
3. Federal Bureau of Prisons (2017). Management of Diabetes. Retrieved from
http://www.bop.gov/resources/health_care_mngmt.jsp
4. Lipska,KJ, Bailey, CJ, Inzucchi, SE. Use of metformin in the setting of mild-to-moderate renal
insufficiency. Diabetes Care. 2011;34(6):1431-1437. Available at:
http://care.diabetesjournals.org/content/34/6/1431.long
5.
McCulloch, DK. Insulin therapy in type 2 diabetes mellitus. In: UpToDate, Nathan DM (Ed), UpToDate,
Waltham, MA. Accessed on March 29, 2016.
6.
Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: a consensus
algorithm for the initiation and adjustment of therapy. Diabetes Care. 2006;29(8): 1963–1972. Available
at: http://care.diabetesjournals.org/cgi/content/full/29/8/1963
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XI.
APPENDIX 1: TREATMENT ALGORITHM FOR TYPE 2 DIABETES
1.
EXCEPTION: Generally, insulin should be utilized if severely uncontrolled DM, i.e., plasma/serum glucose
>250 mg/dL, random glucose consistently >300 mg/dL, A1C >10%, ketonuria, or symptomatic diabetes
with polyuria, polydipsia, & weight loss.
2.
Use metformin unless contraindicated, i.e., if eGFR<45 ml/min; if age >80 (unless renal sufficiency
established); or chronic liver failure. A sulfonylurea can often substitute for metformin if it is
contraindicated.
3.
Or other individualized A1C goal.
4.
* Check A1C typically every 3 months until <7.0–7.5%, or at other individualized treatment goal; then,
every 6 months.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XII.
APPENDIX 2: INITIATION AND ADJUSTMENT OF INSULIN REGIMENS IN TYPE 2 DIABETES
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XIII. APPENDIX 3. TREATMENT GOALS FOR NON-PREGNANT PATIENTS WITH DIABETES
GLYCEMIC CONTROL
A1C1
Pre-prandial capillary plasma glucose2
Peak post-prandial capillary plasma glucose2,3
<7.0–7.5%
90–130 mg/dl
<180 mg/dl
Key concepts in setting glycemic goals:
• A1C is the primary target for glycemic control.
• Goals should be individualized.
• Certain patient populations, i.e., pregnant women and the elderly, require special considerations.
• Less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia.
• Postprandial glucose may be targeted if A1C goals are not met despite reaching pre-prandial glucose goals.
BLOOD PRESSURE
Blood pressure goal
LIPIDS
<140 / <90 mmHg
4
Age <40 years
No risk factors
ASCVD risk factor(s)*
ASCVD
None
Moderate or high-intensity statin
High-intensity statin
Age 40–75 years
No risk factors
ASCVD risk factors*
ASCVD
Moderate-intensity statin
High-intensity statin
High-intensity statin
Age >75 years
None
ASCVD risk factors*
ASCVD
Moderate-intensity statin
Moderate or high-intensity statin
High-intensity statin
*
ASCVD (atherosclerotic cardiovascular disease) risk factors include LDL cholesterol ≥100 mg/dL, high blood
pressure, smoking, overweight and obesity, and family history of premature ASCVD.
1
The ADA’s Standards of Medical Care in Diabetes – 2017 sets the A1C diagnostic cut point as 6.5%. Based on
the results of multiple randomized trials and correctional considerations, the BOP recommends A1C <7.0–7.5%
as a reasonable treatment goal for most patients with diabetes. Less stringent goals may be appropriate for
some patients.
2
Many glucometers automatically convert capillary blood glucose values to plasma glucose values. Check the
glucometer. Glucometers that do not automatically convert values report blood glucose values that may be 10–
15% lower than plasma glucose values.
3
Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal.
4
As per 2013 ACC/AHA Blood Cholesterol Guideline.
Adapted from: American Diabetes Association. 2017 Standards of medical care in diabetes. Diabetes Care.
2017;40(suppl 1): S1–S135.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XIV. APPENDIX 4: STRATEGIES TO REPLACE SLIDING SCALE INSULIN (SSI)
CURRENT REGIMEN
SUGGESTED STEPS FOR REPLACING SSI REGIMEN
SLIDING SCALE INSULIN (SSI) THERAPY refers to the use of varying doses of regular insulin in response to
hyperglycemia. Sliding scale insulin therapy is generally not a recommended strategy for long-term
management of patients with diabetes.
SSI is the sole insulin treatment.
• Review average daily insulin requirement over prior 5–7 days.
• Give 50–75% of the average daily insulin requirement as basal
•
•
•
SSI is being used in addition to
scheduled basal insulin.
insulin.
Stop SSI.
Use noninsulin agents or fixed-dose mealtime insulin for
postprandial hyperglycemia.
Consider giving basal insulin in the morning to impact
postprandial hyperglycemia and reduce risk of early
morning/nocturnal hypoglycemia.
• Add 50–75% of the average insulin requirement used as SSI to
the existing dose of basal insulin.
• Use noninsulin agents or fixed-dose mealtime insulin for
postprandial hyperglycemia.
SSI is being used in addition to
basal and scheduled meal time
insulin (i.e., correction dose
insulin).
• If a correction dose is required frequently, add the average
SSI is used in the short-term due
to irregular dietary intake or acute
illness (<14 days).
• Short-term use may be needed for acute illness and irregular
correction dose before a meal to the scheduled mealtime insulin
dose at the preceding meal.
For example: If glucose is consistently elevated before lunch,
requiring 2–3 unit corrections, the scheduled breakfast dose of
insulin could be increased by the average correction dose
(2 units).
Similarly, if glucose values are elevated before breakfast,
requiring correction doses, the scheduled basal insulin dose
could be increased by the average correction dose used.
dietary intake.
• Stop SSI and return to previous regimen as health and glucose
stabilize.
SSI is used for wide fluctuations
in glucose levels in patients with
cognitive decline and/or irregular
dietary intake on a chronic basis.
• Use scheduled basal and mealtime insulin based on individual
needs, with the goal of avoiding hypoglycemia.
• May use simple scale such as “Give 4 units of mealtime insulin
•
if glucose>300 mg/dL.”
Keep patients hydrated, especially if glucose levels are very
high (e.g., >300 mg/dL).
Adapted from: 2017 Standards of medical care in diabetes. Diabetes Care. 2017;40(suppl 1): S1–S135..
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XV.
APPENDIX 5: ORAL MEDICATIONS FOR TREATMENT OF TYPE 2 DIABETES
ORAL AGENTS FOR TREATMENT OF TYPE 2 DIABETES — DOSING AND SIDE EFFECTS
Agent
Initial Dose
& Treatment
Maximum
Dose
BIGUANIDES
Initial
Elderly
Dose
Side
Effects
Drug
Interaction
Caution is advised for use of metformin therapy in patients with stable mild to moderate renal impairment.
Contraindications to metformin therapy: elevated creatinine (>1.7mg/dL), or a creatinine clearance <30mL/min in
the elderly; history of renal insufficiency, hepatic dysfunction, or serious cardiovascular or pulmonary compromise.
Metformin
(Glucophage)
• 500 mg with a meal.
• Based on patient’s
tolerance to metformin &
glycemic response,
increase dosage by 500
mg/day at weekly intervals,
adding a dose to another
meal.
• TID dosing not required for
2550 mg/day
(850 mg TID)
500 mg
OR
2500 mg/day
OR
Metformin
ER
2000 mg/day
Nausea and diarrhea,
which usually subside
over 1 week; to
alleviate, may limit
rate of dose increase.
Hypoglycemia only
if metformin is given
with sulfonylurea or
insulin.
efficacy, but may decrease
GI complaints.
• Doses <1500 mg/day
unlikely to achieve
therapeutic effect as
monotherapy.
Alcohol; cimetidine;
amiloride; digoxin;
morphine; procainamide;
quinidine; ranitidine;
triamterene; trimethoprim;
vancomycin; furosemide;
calcium channel blocking
agents, especially
nifedipine.
Withhold 48 hours
prior to and following
surgery or IV contrast
x-ray studies.
• Doses >2000 mg/day have
little added benefit.
SULFONYLUREAS (SUS) —SECOND GENERATION
Glimepiride
(Amaryl)
• 1–2 mg daily with breakfast
or first main meal.
8 mg
once daily
0.5–1 mg Hypoglycemia &
weight gain.
• Increase at 1–2 mg
increments every 1–2
weeks, as needed.
Use glimepiride only if
creatinine clearance is
>30 mL/min.
Glipizide,
short-acting
(Glucotrol)
Glipizide,
extended
release
(Glucotrol XL)
• 5 mg/day, 30
min before
breakfast.
40 mg/day
Give BID
when dose
• Increase dose by 2.5–5 mg reaches 15
weekly, as needed.
mg.
Use glipizide only if
creatinine clearance is
>10 mL/min.
20 mg/day
• 5 mg/day at breakfast.
• Increase dose by 2.5 –5 mg
Alcohol; coumadin; azole
antifungals;
asparaginase;
corticosteroids; thiazide
diuretics; lithium; beta
blockers; cimetidine;
ranitidine; cyclosporine;
quinolones; MAO
inhibitors;
chloramphenicol;
octreotide; pentamidine.
2.5 5 mg
Hypoglycemia &
weight gain.
Same as glimepiride
above.
2.5 mg
Hypoglycemia &
weight gain.
Same as glimepiride
above.
at 3-month intervals, based
on A1C.
Use glipizide only if
creatinine clearance is
>10 mL/min.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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ORAL AGENTS FOR TREATMENT OF TYPE 2 DIABETES — DOSING AND SIDE EFFECTS
Initial Dose
& Treatment
Agent
Glyburide
(DiaBeta,
Micronase)
Glyburide,
microcrystalline
(Glynase)
Maximum
Dose
• 2.5–5 mg/day.
• Increase dose by 2.5–5 mg
20 mg/day
• 1.5–3 mg/day.
• Increase dose by <1.5 mg
12 mg/day
Initial
Elderly
Dose
1.25–
2.5 mg
Side
Effects
Drug
Interaction
Hypoglycemia &
weight gain.
Same as glimepiride
above.
1.25 mg Hypoglycemia &
weight gain.
Same as glimepiride
above.
no more often than every
7 days.
Use glyburide only if
creatinine clearance is
>50 mL/min.
weekly, if needed.
Use glyburide only if
creatinine clearance is
>50 mL/min.
GLITAZONES (THIAZOLIDINEDIONES OR TZDS)
(Actos)
• 15–30 mg once daily.
• Increase to 45 mg once
Rosiglitazone
• 4 mg once daily or 2 mg
Pioglitazone
(Avandia)
15 mg
Edema, weight gain.
Decreases oral
contraceptive
efficacy.
8 mg/day
2 mg
Edema; fluid retention Same as pioglitazone
may cause or
above.
exacerbate CHF;
weight gain; possible
increased risk of MI;
increased LDL-C.
• 25 mg TID with first bite of
100 mg TID
with meals
25 mg
• Increase dose to 50 mg TID
50 mg TID
with meals
(in patients
<60 kg)
Diarrhea (33%),
abdominal pain (12%),
flatulence (77%).
Serum transaminase
elevations may
occur at doses
>50 mg TID.
Absorbents; intestinal
agents such as activated
charcoal; digestive
enzyme preparations
containing carbohydratesplitting enzymes such as
amylase or pancreatin
• 25 mg TID at the start of
100 mg TID
Flatulence, diarrhea,
abdominal pain.
Digoxin, propranolol,
ranitidine, GI enzymes
• 120 mg TID, 1 to 30
120 mg TID
Hypoglycemia &
weight gain
Beta-adrenergic blocking
agents; drugs
metabolized by the
cytochrome p450 system;
erythromycin;
ketoconazole;
miconazole;
sulfonamides; MAO
inhibitors; NSAIDS;
anticoagulants (warfarin
derivatives).
45 mg/day in
monotherapy
30 mg/day
daily monotherapy or 30 mg
in combo
once daily as combo
therapy
therapy.
BID.
• Increase to 8 mg once daily
or 4 mg BID in 12 weeks, as
needed.
Erythromycin; calcium
channel blocker;
corticosteroids;
cyclosporine; HMB-CoA
reductase inhibitors;
triazolam; trimetrexate;
ketoconazole;
itraconazole
ALPHA-GLUCOSIDASE INHIBITORS
Acarbose
(Precose)
meals; lower dose may be
needed if gastrointestinal
distress is noted.
with meals after 4–8 weeks.
Miglitol
(Glyset)
OR
each meal.
GLINIDES
Nateglinide
(Starlix)
minutes before meals.
• Patients close to A1C goal
may be started at 60 mg
TID.
60 mg
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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ORAL AGENTS FOR TREATMENT OF TYPE 2 DIABETES — DOSING AND SIDE EFFECTS
Agent
Repaglinide
(Prandin)
Initial Dose
& Treatment
• 0.5 mg with each meal if
A1C <8%.
• 1–2 mg with each meal if
A1C >8%.
Maximum
Dose
4 mg
with meals
(max 16 mg
per day)
Initial
Elderly
Dose
0.5 mg
Side
Effects
Drug
Interaction
Hypoglycemia &
weight gain.
Same as nateglinide
above.
Arthralgia,
nasopharyngitis,
headache, upper
respiratory infection.
MAO-Inhibitors, SSRIs,
quinolone antibiotics,
salicylates.
May require dose
reduction of
concomitant insulin
therapy. Concomitant
SU use is not
recommended; reduce
SU dose if used.
• Increase by 1 mg weekly,
as needed.
Contraindicated in
moderate-to-severe hepatic
dysfunction.
DIPEPTIDYL PEPTIDASE 4 (DPP-4) INHIBITORS
Alogliptin
(Nesina)
• 25 mg daily.
• If CrCl is 30 to 60 mL/min,
25 mg daily
25 mg
daily
initial dose is 12.5 mg daily.
• If CrCl <30 mL/min, initial
dose is 6.25 mg daily.
Linagliptin
(Tradjenta)
Saxagliptin
(Onglyza)
• 5 mg once daily.
• 2.5 to 5 mg once daily.
• If CrCl <50 mL/min, 2.5 mg
once daily.
Sitagliptin
(Januvia)
• 100 mg once daily.
• If CrCl is 30-49 mL/min,
dose is 50 mg daily.
5 mg daily
5 mg daily Same as alogliptin
above.
CYP3A4 inducers, MAOInhibitors, SSRIs,
quinolone antibiotics,
salicylates.
May require dose
reduction of
concomitant insulin
therapy. Concomitant
SU use is not
recommended; reduce
SU dose if used.
5 mg daily
Max dose
with strong
CYP3A4/5
inhibitors is
2.5 mg daily.
2.5 mg
Same as alogliptin
above.
Same as linagliptin
above (drug interactions
and cautions in yellow).
Potential for additional
drug interactions.
100 mg
100 mg
Same as alogliptin
above.
Same as linagliptin
above (drug interactions
and cautions in yellow).
• If CrCl <30 mL/min, dose is
25 mg daily.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
Region: New Mexico
ORAL AGENTS FOR TREATMENT OF TYPE 2 DIABETES — DOSING AND SIDE EFFECTS
Initial Dose
& Treatment
Agent
Maximum
Dose
Initial
Elderly
Dose
Side
Effects
Drug
Interaction
Genitourinary
infections, polyuria,
hypotension,
increased fracture risk.
Ketoacidosis and
serious UTI resulting
in hospitalization is
possible.
Carbamazepine,
efavirenz, fosphenytoin,
MAO-Inhibitors,
phenobarbital, phenytoin,
primidone, rifampin,
ritonavir, quinolone
antibiotics.
Increased risk of
hypotension and
hyperkalemia with
concomitant anti-HTN
therapies.
SODIUM-GLUCOSE COTRANSPORTER 2 (SGLT-2) INHIBITORS
Canaglifozin
(Invokana)
• 100 mg once daily.
• Increase to 300 mg once
300 mg daily
100 mg
daily
daily.
• If CrCl<45-60 mL/min, max
dose is 100 mg daily.
Do not use if CrCl
<45 mL/min.
Dapagliflozin
(Farxiga)
• 5 mg once daily.
• May increase to 10 mg
10 mg daily 5 mg daily Same as canaglifozin
above.
• 5 mg once daily.
• May increase to 15 mg
15 mg daily
• 10 mg once daily,
• May increase to 25 mg
25 mg daily
once daily.
Do not use if CrCl
<60 mL/min.
Ertugliflozin
(Steglatro)
5 mg daily Same as canaglifozin
above.
MAO-Inhibitors, SSRIs,
salicylates, quinolone
antibiotics.
Same as dapagliflozin
above.
once daily
Do not use if CrCl
<45 mL/min.
Empagliflozin
(Jardiance)
10 mg
daily
Same as canaglifozin
above.
Same as dapagliflozin
above.
daily.
Do not use if CrCl
<45 mL/min.
Adapted from: Federal Bureau of Prisons (2017). Management of Diabetes.
http://www.bop.gov/resources/health_care_mngmt.jsp
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Type I Diabetes Mellitus Flow Chart
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000824
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Medical Guidelines
Region: New Mexico
Type II Diabetes Mellitus Flow Chart
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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177
WEXFORD
COMPANIES
Gastroenterology
Gastroenterology
WEXFORD MILLER
WEXFORD
MILLER 000826
000826
Medical Guidelines
Region: New Mexico
Management of Ulcerative Colitis
The pathways do not replace sound clinical judgment. Nor
are they intended to strictly apply to all patients.
1
Patient with confirmed diagnosis of
ulcerative colitis.
Educate the patient about UC
- Lifestyle
- Diet
- Med adherence
2
3
Does the patient
have only ulcerative
proctitis?
yes
4
Initiate oral sulfasalazine or topical
mesalamine. Evaluate in 4-6
weeks.
5
Are symptoms
improved or
improving?
no
no
6
10
12
11
Does the patient
only have disease
of the descending or
sigmoid colon?
Are
symptoms
severe?
yes
no
13
yes
Consider infirmary stay if
clinically indicated. Begin oral
sulfasalazine or balsalazide.
Evaluate in 1-2 weeks
The symptoms are
mild to moderate.
18
17
Are
symptoms
improved or
improving?
Consider infirmary stay if
clinically indicated. Begin oral
sulfasalazine or balsalazide,
Evaluate in 1-2 weeks
no
yes
21
Continue oral sulfasalazine
or balsalazide therapy for 6
months; then taper.
If tapering has failed
twice, consider collegial
review. Evaluation for
immunomodulators.
Taper corticosteriod.
Continue oral sulfasalazine
or topical mesalamine for
6 months; then taper.
Implement one or more of the
following interventions:
(1) Increase oral sulfasalazine or
balsalazide to maximum tolerated dose.
(2) Add oral corticosteriod.
(3) Consider collegial review.
Reevaluate in 2-6 weeks.
19
26
yes
Consider Collegial
Review
20
yes
8
9
Begin oral sulfasalazine or
balsalazide therapy. Evaluate
in 4-6 weeks.
no
7
no
15
16
Continue oral sulfasalazine or topical
mesalamine. Add a topical
corticosteroid product. Evaluate in 2-4
weeks.
Are symptoms
improved or
improving?
no
14
The patient has
pancolitis.
Are
symptoms
severe?
Continue oral sulfasalazine or
topical mesalamine therapy for
6 months; then taper.
yes
Are
symptoms
improved or
improving?
22
Begin slow oral
corticosteriod taper.
yes
Is tapering
successful?
Initiate parenteral
corticosteriods.
Consider collegial
review.
no
25
24
no
23
yes
Continue oral
sulfasalazine or balsalazide
for all but mild,
first episode.
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Approved by the P&T Committee 11/11/2015; format revisions 2/11/2019
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
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Medications Used to Treat Ulcerative Colitis
MAINTENANCE
DOSE
SIDE EFFECTS*
24 hr.
Therapy
Cost $
4−6 g/day
Not effective
Nausea, vomiting, dyspepsia,
anorexia, diarrhea, rash, yelloworange urine and skin,
photosensitivity
$
6.75 g/day
3-6.75 g/day
Headache, abdominal pain,
nausea, vomiting, diarrhea,
arthralgia
$
ACTIVE
DOSE
SULFASALAZINE
(Azulfidine) Tablets and entericcoated tablets: 500 mg
BALSALAZIDE
(Colazal) Tablets 750 mg
MESALAMINE (5-ASA)
(Asacol®) Delayed-release tabs
400 mg
4.8 g/day
non-formulary
(Pentasa®) Controlled-release
caps 250 mg
2−4 g/day
non-formulary
(Canasa®) Suppository 500 mg
500
non-formulary
mg/day
(Rowasa® enema) Suspension
2−4 g q. hs
4 g/60 mL
2.4 g/day
1.5−4 g/day
1 g/day
CORTICOSTEROIDS
Prednisone
Hydrocortisone enema or foam
non-formulary
1.5−3
g/day
ACTIVE
DOSE
0.5
mg/kg/day
1 daily at
bedtime
IMMUNOMODULATORS
ACTIVE
DOSE
(Imuran®) Azathioprine 50
mg
(Purinethol®) 6-Mercaptopurine
non-formulary
1.5−2.5
mg/kg/day
1−2
mg/kg/day
Tablets are noted with the most
side effects. Abdominal pain or
discomfort, belching, nausea,
flatulence, headache, fever,
pharyngitis, rash, flu syndrome
2−4 g/day
MAINTENANCE
DOSE
Not effective
MAINTENANCE
DOSE
1−1.5 mg/kg/day
1−1.5 mg/kg/day
$$
$$
$$$
2−4 g/day
OLSALAZINE (5-ASA)
(Dipentum®) 250 mg capsule
non-formulary
$$
Headache, diarrhea, pain or
cramps, nausea, dyspepsia,
arthralgia
SIDE EFFECTS*
Edema, insomnia, immunosuppression, electrolyte
disturbances, adrenal
suppression
SIDE EFFECTS*
Risk of infection, immuno suppression, bond marrow
suppression, hepatitis,
pancreatitis
$$$
COST $
$
$$
COST $
$
$
* Not all side effects listed are seen with different dosage forms. The listed side effects occur with a greater than
3% incidence.
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Management of Crohn’s Disease
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
1
3
2
Are the
symptoms
severe?
Patient with confirmed diagnosis of
Crohn’s disease.
Educate the patient about CD
- Lifestyle
- Diet
- Med adherence
no
4
Initiate therapy with oral
sulfasalazine.
Follow up in 4-8 weeks.
5
yes
no
Go to Box 9.
6
Are symptoms
improved or
improving?
Continue sulfasalazine for
6 months before tapering.
yes
8
7
Increase dose of sulfasalazine to
maximum tolerated. Consider
addition of an antimicrobial.
Follow-up in 2-3 weeks.
yes
Are symptoms
improved or
improving?
yes
no
9
Add oral corticosteroid. Follow
up in 2-3 weeks.
10
Go to Box 6.
11
Are symptoms
improved or
improving?
yes
Continue sulfasalazine
therapy and taper
corticosteroid over 2-6
weeks.
no
12
Increase corticosteroid.
Evaluate for
immunosuppressant therapy. If
corticosteroid already at
maximally tolerated dose,
consider collegial review.
If tapering is successful, go
to Box 6. If unsuccessful, go
to box 12.
Adapted from the American College of Gastroenterology.
Approved
by pathways
the P&T Committee
11/11/2015
Clinical
do not replace
sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medications Used to Treat Crohn’s Disease
*According to American College of Gastroenterology Guideline, mesalamine products have limited role in treatment of
Crohn’s Disease
ACTIVE
DOSE
MAINTENANCE
DOSE
SULFASALAZINE
(Azulfidine) Tablets and entericcoated tablets: 500 mg
MESALAMINE (5-ASA)*
(Asacol®) Delayed-release tabs
400 mg
non-formulary
(Pentasa®) Controlled-release
caps 250 mg
non-formulary
(Canasa®) Suppository 500
mg-non-formulary
(Rowasa® enema ) Suspension
4 g/60 mL
non-formulary
OLSALAZINE (5-ASA)
(Dipentum®) 250 mg capsule
non-formulary
CORTICOSTEROIDS
Prednisone
Hydrocortisone enema or foam
non-formulary
IMMOMODULATORS
(Imuran®) Azathioprine 50 mg
(Purinethol®) 6Mercaptopurine-non-formulary
(Flagyl®) Metronidazole 250 mg
3−4 g/day
4 g/day
2.4 g/day
2.4 g/day
4 g/day
4 g/day
1 g/day
1 g/day
4 g q. hs
4 g/day
1 g/day
1 g/day
ACTIVE
DOSE
MAINTENANCE
DOSE
0.5−1
mg/kg/day
1 daily at
bedtime
ACTIVE
DOSE
2−2.5
mg/kg/day
1−2
mg/kg/day
up to 10
mg/kg/day
Not effective
MAINTENANCE
DOSE
1−2 mg/kg/day
1−1.5 mg/kg/day
Up to 250mg p.o.
QID
SIDE EFFECTS*
Nausea, vomiting,
dyspepsia, anorexia,
diarrhea, rash, yellow-orange
urine and skin,
photosensitivity
24 hr.
Therapy
Cost $
$
$$
Tablets are noted with the
most side effects.
Abdominal pain or
discomfort, belching, nausea,
flatulence, headache, fever,
pharyngitis, rash, flu
syndrome
$$
$$
$$$
Headache, diarrhea, pain or
cramps, nausea, dyspepsia,
arthralgia
SIDE EFFECTS*
Edema, insomnia, immunosuppression, electrolyte
disturbances, adrenal
suppression
SIDE EFFECTS*
Risk of infection, immuno suppression, bond marrow
suppression, hepatitis,
pancreatitis
Peripheral neuropathy,
nausea, leukopenia,
questionable cancer
$$$
COST $
$
$$
COST $
$
$
$
* Not all side effects listed are seen with different dosage forms. The listed side effects occur with a greater than 3%
incidence.
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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WEXFORD
COMPANIES
Management
Management of
of Gastroesophageal
Gastroesophageal
Reflux
Reflux Disease
Disease (GERD)
(GERD)
Including
Taper
Including Proton
Proton Pump
Pump Inhibitor
Inhibitor (PPI)
(PPI) Taper
WEXFORD MILLER 000832
Medical Guidelines
Region: New Mexico
Management of Gastroesophageal Reflux Disease (GERD) Including Proton Pump Inhibitor (PPI)
Taper
I.
PURPOSE
The purpose of this document is to summarize current medical literature guidelines and
recommendations concerning GERD management. References are listed in the appropriate section
and include major gastroenterology organizations, FDA approval guidelines and medication package
insert information.
II.
BACKGROUND
Gastroesophageal Reflux Disease (GERD) is a commonly encountered diagnosis in clinical practice,
affecting about 10−20% of people in Western countries on a weekly basis. A systematic review found
that ≈ 38% of the general population complained of dyspepsia. Treatment for GERD is discussed
below and generally involves proton pump inhibitors (PPIs). Patients taking PPIs for extended
periods of time have been shown to be more susceptible to adverse events including hip, wrist, and
spine fractures, C.Dif infections, pneumonia, hypomagnesemia, and vitamin B12 deficiency.
Literature has documented overutilization of PPIs and lack of symptom re-evaluation in the
ambulatory care setting. Thus, it is prudent to routinely evaluate the clinical need for PPIs in
patients and attempt to discontinue PPIs in patients who may not require long-term therapy.
Because abrupt PPI discontinuation can lead to gastric acid rebound, a slow taper is the preferred
discontinuation method, as it can take three (3) months for gastric acid to return to pre-drug
baseline levels.
III.
DEFINITIONS
GERD: Symptoms or mucosal damage produced by abnormal reflux of gastric contents into
the esophagus.
This definition has been revised over the years in the medical literature. Symptoms with or
without esophageal mucosal injury both constitute the current GERD definition. GERD is
further subdivided into two additional subcategories:
ERD: Erosive Reflux Disease
NERD: Non-erosive Reflux Disease
The symptoms of heartburn and regurgitation (below) are the most reliable for making a
presumptive diagnosis based on history alone; however, symptom sensitivity has limitations.
Studies have shown that the sensitivity of heartburn and regurgitation for the presence of
EGD confirmed erosive esophagitis to be 30−76% and the specificity to be from 62−96%.
IV.
SYMPTOMS AND RISK FACTORS
Symptoms highly specific for GERD:
1.
Heartburn
2.
Retrosternal burning/discomfort
3.
Acid regurgitation
4.
Belching
5.
Symptoms often aggravated by recumbency or bending over
6.
Symptoms often relieved by antacids
Alarm Signs and Symptoms that suggest complicated disease:
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
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1.
Dysphagia (difficulty swallowing)
2.
Odynophagia (painful swallowing)
3.
Bleeding
4.
Weight loss
5.
Anemia
Risk factors for Barrett’s esophagus:
V.
1.
Twice as common in men than women
2.
Tends to occur in middle-aged Caucasian men who have had heartburn for many
(typically >10) years
3.
Patients older than age 50 with significant heartburn or that which required regular use
of medications to control heartburn for several years
GERD: PATIENT APPROACH (SEE ALGORITHM)
Patients presenting with uncomplicated GERD symptoms should have their current
medications reviewed for those known to decrease lower esophageal LES/tone.
Medications that can decrease LES tone:
1.
Nitrates
2.
OCPs
3.
Calcium channel blockers
4.
Benzodiazepines
5.
Tricyclic antidepressants
Changes to alternate medications maybe considered.
Medications that increase stomach acid and effect stomach lining, such as steroids and
NSAIDs should be reviewed for necessity and length of treatment.
Lifestyle Modification:
VI.
1.
Patients that present with symptoms highly specific for GERD without alarm symptoms
should first be counseled on lifestyle modification. Numerous studies have indicated
that lifestyle modification in uncomplicated GERD patients have shown to control
symptoms. Patients should be educated about factors that may precipitate reflux.
2.
Weight loss is recommended for GERD patients who are overweight or have had recent
weight gain. Weight gain even in subjects with a normal BMI has been associated with
new onset GERD symptoms. Multiple studies have demonstrated reduction in GERD
symptoms with weight loss.
3.
Head of bed elevation and avoidance of meals 2−3 h before bedtime for patients with
nocturnal GERD.
4.
Elimination of foods that can decrease LES tone: Includes chocolate, caffeine, alcohol,
acidic foods such as oranges and tomatoes and/or spicy foods, citrus products, fatty
foods, mint flavoring.
GERD TREATMENT: PATIENT DIRECTED THERAPY
Antacids are options for patient-directed therapy for heartburn and regurgitation. These agents are
useful in treatment of milder forms of GERD. Antacids have been shown to be more effective than
placebo in the relief of symptoms induced by a heartburn promoting meal. These medications can
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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be used pre-meal or in the post prandial period and can be taken regularly for a trial period of 14
days. Success rates for these medications are increased with lifestyle modification (above). When
symptoms persist despite continuous use or alarm symptoms or signs develop, the patient should
be advised to seek medical attention.
VII.
GERD TREATMENT: ACID SUPPRESSION
The proton pump is part of a cellular mechanism that maintains the acidic environment of
the stomach. The pH balance of the bloodstream and other tissues is about 7.4; the stomach
functions at a pH of around 2.0―many thousands of times more acidic. Other cells in the
body would die at that level of acid, yet the proton pump and stomach lining support this
acidity to facilitate digestion. Proton pump inhibitor drugs (PPIs) shut down this important
physiological process. Acid suppression is the mainstay of therapy for GERD. PPIs provide the
most rapid symptomatic relief and heal esophagitis in the highest percentage of patients.
Although less effective than PPIs, histamine 2-receptor antagonists (H2RA) may be effective
in some patients with less severe GERD.
Studies show that 70−80% of patients with erosive reflux disease (ERD) and 60% of patients
with non-erosive reflux disease (NERD) demonstrate complete healing and relief after a
standard eight (8) week course of PPI therapy. Partial relief of GERD symptoms after a
standard eight (8) week course of PPI therapy has been found in 30−40% of patients and did
not differ in patients taking PPI once or twice daily. PPIs should be taken first thing in the
morning, 30−60 minutes before a meal to assure maximal efficacy.
The FDA has approved PPI use for maximum of eight (8) weeks for the following conditions:
1.
Symptomatic GERD
2.
Healing erosive esophagitis
3.
Duodenal ulcers
4.
Gastric Ulcers
5.
H. Pylori eradication (as part of combination therapy)
6.
Treatment of NSAID-induced gastric ulcers
The risks associated with prolonged PPI use are well documented and include:
1.
Profound increases in the prevalence and distribution of chronic atrophic gastritis in
patents with H Pylori infection
2.
Reversible (on stopping chronic PPI) gastric endocrine cellular hyperplasia
3.
Parietal cell hyperplasia and hypertrophy resulting from hypergastrinemia associated
with hypochlorhydria induced by a PPI. This provides the physiological basis for
rebound hyperchlorhyria transiently associated with cessation of therapy with a PPI
4.
Malabsorption (due to increased gut pH) of nutrients: B12, Calcium, Iron Deficiencies
5.
Risk of gastrointestinal bacterial overgrowth (secondary to more alkaline stomach pH)
6.
Risk factor for Clostridium difficile infection
7.
Risk factor for community acquired pneumonia
8.
Increase fracture risk: for chronic PPI use of one (1) year or longer, or at high doses for
shorter duration (Males = Females)
9.
Hypomagnesemia: Seen in some patients; monitor those with known arrhythmia
10.
Spontaneous Bacterial Peritonitis in Cirrhotic patients
The FDA has published a statement regarding the potential risks of chronic PPI use:
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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“The clinical risk/benefit of any medical intervention or therapy always should be evaluated for
each patient and appropriate use of therapy should be directed accordingly. Because PPIs are
overprescribed in many patients, in particular for continued long-term use, the clinical effects
always should be reviewed and attempts should be justified to stop any therapy that may not
be needed.”
VIII. PPI USE
An 8-week course of PPIs is the therapy of choice for both symptom relief and healing of
erosive esophagitis, with success rates of 70−80% with ERD and 60% with NERD. There are
no major differences in efficacy between the different PPIs. PPI therapy should be initiated at
once a day dosing 30−60 minutes before the first meal of the day. Following this initial 8-week
course, patients should be re-seen to evaluate symptom control, compliance, lifestyle and
dietary modifications and presence alarm signs/symptoms. Providers need to be educated on
the standard success rates of the 8-week PPI course and the physiological basis for rebound
symptoms that come with abrupt PPI cessation. There are many studies that report
“dependence issues” with PPIs and when a PPI is started, physicians typically have difficulty
stopping it.
The following recommendations on weaning a patient’s PPI are as follows:
1.
Skip a PPI dose every 3rd day substituting H2RA once daily for 14 days
2.
Then skip a PPI dose every other day with H2RA substitution for 14 days
3.
Then eliminate the PPI and switch to an H2RA for PRN use for the next 30−60 days
4.
Then use antacids or H2RAs on a PRN basis for patient directed therapy (above)
The FDA has approved PPI use for longer than eight (8) weeks for the following conditions:
IX.
1.
Maintenance of refractory erosive esophagitis
2.
Hypersecretory conditions (i.e., Zollinger―Ellison Syndrome)
3.
Maintenance of unhealing duodenal ulcers
4.
Biopsy proven Barrett’s esophagus
5.
Prevention of NSAID-induced gastric ulcers (up to 12 week maximum)
REFERENCES
1.
Impact of Clinical Pharmacists’ Recommendations on a Proton Pump Inhibitor Taper Protocol in an
Ambulatory Care Practice. Bundeff, PharmD, et. al. Journal of Managed Care Pharmacy. 2013:; 19 (4)
324-333.
2.
Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Katz, Gerson, Vela.
Am J Gastroenterol 2013; 108:308:328.
3.
American Gastroenterological Association Medical Position Statement on the Management of
Gastroesophageal Reflux Disease. Kahirlas, Shaheen, Vaezi. Am J Gastroenterol. 2008. 08.045.
4.
What are the effects of medical therapy of parietal cells? What are the consequences when medical
treatment is stopped? Tougas, Riddell, Driman. OLESO Knowledge/ Vol 6 Barrett’s Esophagus/ Articles/
vol 2/art007.html
5.
Safety Labeling Changes Approved by FDA Center for Drug Evaluation and Research (CDER. May 2011.
6.
Lansoprazole (Prevacid®) FDA Approval Package Insert. Tap Holdings Incorporated. March 16, 2010.
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Region: New Mexico
GERD: Patient Algorithm and PPI Taper
Patient with GERD
symptoms
No alarm signs/symptoms
1. Review MAR for meds that lower LES tone:
•
Consider Medication Change(s)
2. Review MAR for steroids, NSAIDS:
•
Consider Medication Change(s)
3. Lifestyle Modification:
•
Weight Loss
•
HOB elevation
•
Avoidance of bedtime meals/ eating
•
Avoidance of acidic foods or those that lower LES tone
•
Document discussion
•
Reschedule patient for 2 month follow –up *sooner w alarm signs/ symptoms
•
Rx PRN TUMS/H2RA x 2 months
2 months
Alarm signs/symptoms: document
in assessment with stool guaiac
results (+/-)
Collegial review for further
work up
Success: RTC p.r.n.
No alarm signs/symptoms
Automatic follow-up appointment,
document weight, success or failure
of lifestyle modifications
Still with GERD sx without alarm sx consider:
•
H.Pylori Stool Ag testing when indicated
•
Once daily PPI therapy:
o Once daily 30-60" before am meal
o Rx for 8 weeks: educate patient on success rates with 8
week therapy (70-80% successful with GERD; 60%
successful with NERD)
o Schedule 8 week follow-up
No sx relief/alarm sx
Improvement
Collegial review for
further studies
Rev. 6/1/2016
Institute PPI Taper:
•
Day 1-14: Skip PPI every 3rd day
•
Give Rx for H2RA x 14 days
•
Day 15-28: Skin PPI every other day
•
Alternate with H2RA: Rx x 14 days
•
Day 28-60: Eliminate PPI
•
P.r.n. daily H2RA: Rx with amount limit x 60 days
•
Schedule 3 month follow-up
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Region: New Mexico
Medications Use to Treat Uncomplicated Gastroesophageal Reflux Disease/Dyspepsia
ACTIVE DOSE
MAINTENANCE
DOSE
SIDE EFFECTS*
24 hr. Therapy
Cost $
HISTAMINE 2 RECEPTOR ANTAGONISTS (H2-blockers)
Ranitidine
600 mg/24 hrs.
300 mg/24 hrs.
Famotidine
40 mg /24 hrs.
40 mg/24 hrs.
Dizziness, sedation,
headache, rash,
nausea/vomiting,
constipation, diarrhea
$$
$
PROTON PUMP INHIBITORS
Prilosec OTC
40 mg/q.d.
20/q.d.
Headache, dizziness, rash,
diarrhea, nausea/vomiting,
abdominal pain, taste
perversion
$
5 mg q.i.d.
Restlessness, drowsiness,
diarrhea, weakness, rash,
nausea, depression,
insomnia
$
PROKINETIC AGENTS
Metoclopramide
40 mg/24 hours
ANTACIDS
Maalox
45 ml/Q3−6 hrs.
Tums
2 T q. 2 hrs.
Constipation, stomach
15−45 ml/Q3−6 hrs. cramps, impaction, nausea,
vomiting, discolored feces
2 T q.i.d.
Flatulence, headache
$
$
Adapted from the American College of Gastroenterology.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Management of Suspected of Recurrent Gastric or Duodenal Ulcer
Adapted from UTMB Utilization Guidelines.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Medications Used to Treat Suspected or Recurrent Gastric or Duodenal Ulcer
MAINTENANCE DOSE
Ranitidine (Zantac®)
600 mg/day
150 mg/day
Famotidine (Pepcid)
duodenal ulcer only
20 mg/day
20 mg/day
Dose/Frequency
Duration
Omeprazole (Prilosec)
20 mg BID
10–14 days
$
Amoxicillin
1 gm BID
10–14 days
$
500 mg BID
10–14 days
$$
500 mg BID
10–14 days
$
Triple Therapy
Clarithromycin (Biaxin)
Metronidazole (Flagyl)-use
if PCN ALLERGY only
SIDE EFFECTS*
24 hr. Therapy
Cost $
ACTIVE DOSE
Headache, diarrhea,
nausea, elevated liver
enzymes, blurred vision,
vertigo, malaise,
thrombocytopenia
$$
$
* Not all side effects listed are seen with different dosage forms. The listed side effects occur with a greater
than 3% incidence.1,2
Chey WD, Wong BCY, et al. “American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection”, Am J Gastroenterol
2007; 102: 1808-25.
1
2
Crowe SE. “Treatment regimens for Helicobacter pylori”, www.uptodate.com
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
General
General Surgery
Surgery
WEXFORD MILLER
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Medical Guidelines
Region: New Mexico
General Surgery Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Gallstone Disease
(Complicated)
Consider: Evaluation of the patient.
At the discretion of the clinician
depending on the clinical scenario.
The term gallstone disease refers
to gallstones that cause
symptoms. The term complicated
gallstone disease refers to
gallstone-related complications
which include acute
cholecystitis, cholangitis,
gallstone pancreatitis and
gallstone ileus.
Gallstones (Incidental
Finding)
Most individuals with gallstones
are asymptomatic. In such
individuals, gallstones are
detected incidentally on
abdominal imaging. The majority
of patients found to have
incidental gallstones will remain
asymptomatic. Patients who
develop symptoms typically
report biliary colic. It is unusual
for a previously asymptomatic
patient to present with
complications of gallstone
disease without first having had
episodes of biliary colic.
Gallstone Disease
(Uncomplicated)
The term gallstone disease refers
to gallstones that cause
symptoms.
The term uncomplicated
gallstone disease refers to biliary
colic in the absence of
gallstone-related
complications.
The selection of work-up/therapy should
be individualized and based upon
consideration of the presentation, the
patient’s known history and examination,
availability of a clinician to evaluate,
capabilities of the facility for patient
monitoring, and the availability of
laboratory studies.
Consider: Patient education about the
findings recognizing the majority of
patients with gallstones are
asymptomatic and will remain so
throughout their lives.
Consider: RUQ ultrasound
Consider Emergency Room (ER)
evaluation if signs/symptoms of
peritonitis, febrile, jaundiced,
abnormal laboratory studies, nonresolving biliary colic or clinically
unstable.
Referral is not typically needed for
asymptomatic patient so it is at the
discretion of the clinician
depending on the clinical scenario.
Of those with incidental (asymptomatic)
gallstones, it is estimated that
approximately 15 to 25 percent will
become symptomatic after 10 to 15
years of follow-up.
Consider: Evaluation of the patient and
potential urgent laboratory studies (CBC,
CMP, amylase and lipase).
At the discretion of the clinician
depending on the clinical scenario.
Consider RUQ ultrasound.
The selection of work-up/therapy should
be individualized and based upon
consideration of the presentation, the
patient’s known history and examination,
availability of a clinician to evaluate,
capabilities of the facility for patient
monitoring, and the availability of
laboratory studies.
Uncomplicated gallstone disease should
be suspected in a patient with biliary
colic, a normal physical examination, and
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
normal laboratory tests (CBC, LFTs,
amylase and lipase).
Such patients should generally undergo
a RUQ ultrasound study to determine if
there are gallbladder stones or sludge
(unless the diagnosis of stones or sludge
is already known).
Consider: Low-fat diet, pain medication,
possible intravenous fluids, infirmary or
observation housing.
Patient education about gallstones,
regular exercise, potential weight loss,
and avoiding triggers.
GI Bleeding (Occult)
Consider GI malignancy, ulcer,
fissures, bowel or vascular
disease;
For guaiac + stools, after
avoidance from red meat and
Vitamin C
GI Bleeding (Overt)
(Tarry stools, melena,
hematemesis, coffee-ground
emesis)
Stool or emesis guaiac is
positive
Hemorrhoids
Symptoms: pain, protrusion; or
blood on stool with bowel
movement.
Rectal Exam: soft varicosity with
masses.
Consider: Determine etiology through
history and examination, consider
checking a CBC.
The selection of a treatment plan should
be individualized and based upon the
patient’s known history and examination,
laboratory studies, etc.
At the discretion of the clinician
depending on the clinical scenario.
Upper endoscopy and/or
colonoscopy may be indicated
depending on clinical situation,
generally in consultation with
specialist.
Consider: The selection of a treatment
plan should be individualized and based
upon consideration of the extent of
disease, the patient’s known history and
examination, hemodynamic stability,
treatment availability, availability of a
clinician to evaluate, capabilities of the
facility, availability of STAT laboratory
studies.
At the discretion of the clinician
depending on the clinical scenario
but generally will need referral
urgently or emergently depending
on the presentation.
Consider: Evaluation and education of
the patient. The selection of therapy
should be individualized and based upon
consideration of the extent of disease,
the patient’s known history and
examination, treatment availability, and
the response to previous treatments.
At the discretion of the clinician
depending on the clinical scenario.
General: Numerous medications, many
over-the-counter, are available to treat
hemorrhoids.
Available Formulary Medications:
Consider: Patients with
hemorrhoids and one of the
following conditions should
generally be considered for
possible colonoscopy regardless of
age:
• Anemia
• Bleeding that is atypical of
hemorrhoids
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
• Hydrocortisone 1% Rectal Cream
(Anusol-HC)
• A concomitant change in
bowel patterns
• Hemorrhoidal suppositories
(Preparation H)
• A personal history of
colorectal polyps
• Nupercainal (Dibucaine 1%) local
anesthetic ointment
• A family history of
inflammatory bowel disease or
colorectal cancer in a firstdegree relative
Thrombosed: Consider lancing, follow
with treatment above.
Advise or prescribe increase fiber and
increased water intake.
• Other suspected pathologic
pelvic changes that could
contribute to the patient's
symptoms.
Hernia (Abdominal Wall
and/or Inguinal)
Consider: See Wexford’s Guideline “The
Repair of Abdominal Wall/Inguinal
Hernias.”
See Wexford’s Guideline “The
Repair of Abdominal Wall/Inguinal
Hernias.”
Ingestion of Foreign Body
Consider: If clinically stable, consider
monitoring the patient with serial KUB xrays.
At the discretion of the clinician
depending on the clinical scenario
and the items reportedly
swallowed.
Most items will pass uneventfully thru
the intestine if seen initially the
stomach/intestines.
Consider Emergency Room (ER)
evaluation if signs of peritonitis,
obstruction, perforation, or
clinically unstable.
Consider: Urgent surgical referral if
failure to progress or high-risk
objects (large, sharp) or high-risk
patient (intrinsic bowel disease,
adhesions).
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Region: New Mexico
The Repair of Abdominal Wall/Inguinal Hernias
An abdominal hernia is a protrusion of abdominal contents through the abdominal wall and/or muscle
fascia that normally contains it. Abdominal wall hernias are very common. Hernias may be congenital or
acquired.
I.
THE TWO MAIN ETIOLOGICAL FACTORS FOR ACQUIRED HERNIAS ARE:
Increased intra-abdominal pressure (e.g., straining, lifting or obesity)
Abdominal weakness (e.g., advancing age or malnutrition)
II.
IN GENERAL, HERNIAS MAY BE CLASSIFIED AS:
Reducible
Incarcerated
Strangulated
Reducible hernias, in which the herniated contents may be returned to the abdominal cavity
either spontaneously or manually, generally pose no medical risk to the patient. Incarcerated
hernias contain viable abdominal contents that cannot be easily returned to the abdominal
cavity, usually due to the presence of a narrow opening (“neck”) relative to the size of the
protrusion. Incarcerated hernias are at risk for strangulation and require urgent surgical
surveillance. Strangulated hernias contain abdominal contents whose venous return has
been compromised and thus represent a surgical emergency.
III.
COMPLICATIONS OF HERNIA REPAIR INCLUDE:
Infection
Urinary retention
Scrotal hematoma
Damage to the ileoinguinal nerve
Ischemic orchitis
IV.
RECURRENT HERNIA
Recurrence of hernias after surgical repair may occur and varies with herniorrhaphy
technique and the presence of recognized risk factors:
1.
Longstanding large hernia (poor tissue quality)
2.
Overly rapid return to daily activity after repair
3.
Incomplete surgical dissection and
4.
Comorbid conditions, such as obesity, corticosteroid use, poorly-controlled diabetes
mellitus and COPD.
Each subsequent operation for recurrent hernia is more technically difficult and carries an
increasing rate of failure. An operation to repair a recurrent hernia has a 1 in 5 chance of
failing, and additional operations approach a 50% failure rate.
In summary, herniorrhaphy is not a benign surgical procedure, and the risk factors listed
above are often compounded in the correctional setting.
Based upon the current medical literature regarding the natural history of abdominal hernias,
their repair and recurrence, it is Wexford Health’s position that:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
1.
Patients with stable abdominal wall hernias are not, in general, candidates for
herniorrhaphy and will be monitored and treated with appropriate non-surgical therapy.
2.
Patients with incarcerated hernias are usually candidates for herniorrhaphy and should
be considered for early surgical evaluation.
3.
Patients with strangulated abdominal wall hernias are candidates for herniorrhaphy
and should be referred urgently for surgical evaluation.
4.
Hernias which do not impact on a patient’s ADLs in this setting would not be in
consideration for repair.
Decisions regarding patient suitability for consideration of abdominal wall
herniorrhaphy must be made on a case-by-case basis. These recommendations are
intended only as a guide for the site physician and are not intended to replace handson clinical judgment.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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WEXFORD
COMPANIES
Hematology
Hematology Guidelines
Guidelines
WEXFORD MILLER
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000847
Medical Guidelines
Region: New Mexico
Hematology Guidelines
Diagnosis
Anemia
See following sub-categories:
• Microcytic
• Normocytic
• Macrocytic
Onsite Care to Consider
This MCV-based approach addresses
anemia in healthy outpatients, which is
often an incidental finding or may be
identified when a CBC is performed to
evaluate mild symptoms such as fatigue.
Offsite Care to Consider
See sub-categories:
• Microcytic
• Normocytic
• Macrocytic
This approach is not appropriate for
individuals who are acutely ill with fever,
bleeding, neurologic symptoms, or any
severe cytopenia (hemoglobin <7 to 8
g/dL; platelet count <50,000/microL,
absolute neutrophil count [ANC]
<1000/microL).
It may be helpful to consider the history,
CBC, MCV, and reticulocyte count (if
available) simultaneously.
Anemia: Microcytic (MCV <80 fL)
1.
Consider establishing etiology if
unknown
2.
Consider the patient’s known
medical history
Common Causes:
• Iron-Deficiency
• Thalassemia
• Anemia of Chronic Disease (Less
Likely)
• Anemia of Acute Inflammation
(Less Likely)
3.
Labs to consider: Reticulocyte
count, serum iron, transferrin/TIBC,
ferritin
4.
Additional labs to consider
depending on the clinical scenario:
hemoglobin electrophoresis, if
considering potential GI source
consider obtaining stool occult
blood testing x 3 / FIT testing
5.
Females: Consider questioning
patient about menses. Consider
performing pelvic exam
6.
Treatment is dependent on
potential cause: Consider Ferrous
Sulfate 325 mg b.i.d. for one month;
if CBC improves, continue to treat
for approximately 6 months.
Anemia: Normocytic (MCV 80100fL)
1.
Consider establishing etiology if
unknown
Common Causes:
2.
Consider the patient’s known
medical history
• Iron Deficiency
At the discretion of the
clinician depending on the
clinical scenario.
Consider colonoscopy, upper
endoscopy
Females: Consider pelvic
ultrasound
At the discretion of the
clinician depending on the
clinical scenario.
Consider possible hematology
consultation if severe or does
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
• Vitamin B12 Deficiency
3.
Review medications
• Folate Deficiency
4.
Labs to consider: Reticulocyte
count, peripheral smear, CMP
5.
Additional labs to consider:
Additional or subsequent testing
should be based on the clinical
scenario
• Chronic Liver Disease
6.
Consider underlying disease
• Chronic Alcohol Use
7.
Treatment: Consider addressing
co-morbid or underlying condition
• Anemia of Chronic Disease
• Anemia of Acute Inflammation
• Medication-Induced
• Infection
• Hemolysis
Offsite Care to Consider
not correlate with co-morbid
condition.
• Hypothyroidism
• Other Potential Causes
Anemia: Macrocytic (MCV >100fL)
Common Causes:
•
Vitamin B12 Deficiency
•
Folate Deficiency
•
Copper Deficiency
•
Anemia of Chronic Disease
•
Anemia of Acute Inflammation
•
Medication-Induced
•
Chronic Liver Disease
•
Chronic Alcohol Use
•
Myelodysplastic Syndrome
•
Hypothyroidism
•
Other Potential Causes
Lymphocytosis
The normal range (i.e., two standard
deviations above and below the mean)
for the white blood cell (WBC) count in
adults is 4400 to 11,000 cells/microL in
most clinical laboratories. Lymphocytes
generally constitute 8 to 33 percent of
WBCs in peripheral blood.
1. Consider establish etiology if
unknown
2.
Consider the patient’s known
medical history
3.
Review medications.
4.
Labs to consider labs: Reticulocyte
count, CMP, Vitamin B-12, folate,
TSH
5.
Additional labs to consider:
Additional or subsequent testing
should be based on the clinical
scenario
6.
Treatment: Consider addressing
underlying cause or underlying
condition
Consider: Urgency of evaluation — The
urgency of evaluation of lymphocytosis is
guided by the patient's clinical condition,
the degree and rate of rise of
lymphocytosis (if known), and worrisome
findings (e.g., leukemic blasts) on the
blood smear.
If the cause of lymphocytosis is not
known, an absolute lymphocyte count
(ALC) >50,000 cells/microL may require
At the discretion of the
clinician depending on the
clinical scenario.
Consider possible hematology
consultation if severe or does
not correlate with co-morbid
condition.
At the discretion of the
clinician depending on the
clinical scenario.
Consider possible hematology
consultation depending on the
clinical situation or if the lab
results do not correlate with
known condition.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
• Absolute lymphocyte count –
The absolute lymphocyte count
(ALC) is used to quantitate
lymphocytes in peripheral blood
(rather than the percentage of
lymphocytes in the WBC
differential count).
prompt evaluation and hematology
consultation to make an initial
assessment about the urgency of further
testing.
• ALC is calculated as follows:
ALC (cells/microL) = WBC
(cells/microL) x percent
lymphocytes ÷ 100
• Normal values for ALC generally
correspond to 1000 to 4000
lymphocytes/microL, but may vary
in different laboratories.
• Lymphocytosis corresponds to
ALC >4000 cells/microL for adults.
Common Causes:
• Infectious Causes
• Drug Hypersensitivity Reactions
• Asplenia
Offsite Care to Consider
Lab testing to consider: The abnormal
CBC and differential count should be
repeated to exclude laboratory error.
Additional lab testing to consider: CMP,
ESR, and CRP
Further testing should be based on the
clinical presentation and the patient’s
history and examination
Treatment to consider: In general,
reactive lymphocytosis can be expected
to persist while the underlying
inflammatory and/or infectious process is
active. Lymphocytosis caused by an acute
condition (e.g., infection) should resolve
within one to two months; a longer
duration of lymphocytosis might raise
concerns regarding an underlying
malignant process.
• Other
Lymphocytopenia
(See above)
Lymphocytopenia corresponds to
ALC <1000 cells/microL for adults.
Lymphocytopenia may be caused by
many conditions. Examples include
viral infections, such as HIV, influenza,
coronaviruses (e.g., SARS, COVID-19),
hepatitis, measles; bacterial,
mycobacterial, fungal, and parasitic
infections; protein-energy
undernutrition; systemic diseases;
congenital immunodeficiency
disorders, such as common variable
immunodeficiency; and chemotherapy
or immunosuppressive therapy,
including glucocorticoids.
Determine etiology. HIV testing. Review
medications. Prevention of
opportunistic infections as appropriate.
At the discretion of the
clinician depending on the
clinical scenario.
Consider hematology
consultation if persistent.
Consider hospitalization if
febrile.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Diagnosis
Neutropenia
• Neutropenia refers to a decrease
in circulating neutrophils, which
for adults corresponds to <1500
cells/microL in most clinical
laboratories.
• Neutropenia can be categorized
as:
• Mild – ANC ≥1000 and <1500
cells/microL
• Moderate – ANC ≥500 and
<1000 cells/microL
• Severe – ANC <500
cells/microL
• The causes of neutropenia vary
and include:
Onsite Care to Consider
Offsite Care to Consider
Consider: Confirmation that the
neutropenia is real through confirmation
and peripheral smear review.
At the discretion of the
clinician depending on the
clinical scenario.
Additional lab testing that may be
considered include ESR, CRP, CMP, HIV,
HCV AB, HBsAG, vitamin B12, folate, and
copper levels.
Consider: The urgency of
evaluation of neutropenia is
guided by the patient's clinical
condition, severity of
neutropenia, and the presence
of worrisome findings on the
blood smear. Management of
infections and other
emergency conditions should
not be delayed by evaluation
of the cause of neutropenia.
The selection of evaluation and/or
treatment should be individualized and
based upon consideration of the patient’s
history and exam, metabolic
abnormalities, extent of disease, patient’s
risk of complications from the known or
unknown disease, and treatment and/or
clinician availability, and the response to
any previous treatments.
• Benign ethnic neutropenia –
Benign ethnic neutropenia (BEN)
is an inherited cause of
mild/moderate neutropenia in
individuals of African descent and
certain other ethnic groups that is
not associated with increased
infections.
• Familial neutropenia
• Congenital neutropenia
• Infection – Neutropenia can be
seen with viral (e.g., hepatitis, HIV,
Epstein-Barr virus [EBV]), bacterial,
parasitic, and rickettsial infections.
• Medications – Predictable, dosedependent effects of cytotoxic or
immunosuppressive agents are
the most common reason for
medication-associated
neutropenia.
• Other medications have been
associated with severe
idiosyncratic isolated neutropenia,
which typically occurs within three
months of starting a new drug.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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203
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
• Nutritional – Deficiencies of
dietary vitamins and minerals
(e.g., vitamin B12, folate, copper)
typically cause neutropenia in
association with other cytopenias
• Hematologic malignancies
• Rheumatologic disorders –
Rheumatoid arthritis, systemic
lupus erythematosus, and other
rheumatologic disorders may be
associated with neutropenia
• Autoimmune neutropenia
• Aplastic anemia – Neutropenia
may be the initial or predominant
manifestation, but aplastic anemia
is typically manifest as
pancytopenia
• Chronic idiopathic neutropenia
Pancytopenia
Pancytopenia refers to decreases in all
peripheral blood lineages
• Red blood cells – Hemoglobin
<12 g/dL for non-pregnant
women and <13 g/dL for men
• Absolute neutrophil count (ANC)
<1800/microL
• Platelets – Platelet count
<150,000/microL
While there are numerous possible
causes of pancytopenia, the differential
diagnosis should narrow following an
initial history and physical examination,
screening laboratory studies, and
examination of the peripheral blood
smear. Initial testing should also
identify urgent/emergent situations
and determine the need for (and
urgency of) hematology or emergency
room referral.
Consider: Potential explanations for
pancytopenia should emerge from the
initial history, physical examination,
screening laboratory studies, and review
of a peripheral blood smear.
Additional studies or referrals will depend
on the working or known diagnoses.
The selection of evaluation and/or
treatment should be individualized and
based upon consideration of the patient’s
history and exam, metabolic
abnormalities, extent of disease, patient’s
risk of complications from the known or
unknown disease, and treatment and/or
clinician availability, and the response to
any previous treatments.
At the discretion of the
clinician depending on the
clinical scenario.
Consider hematology
consultation if persistent
depending on the clinical
scenario.
Consider hospitalization if
febrile.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Thrombocytopenia
Degrees of thrombocytopenia can be
further subdivided into:
• Mild (platelet count 100,000 to
150,000/microL)
• Moderate (50,000 to
99,000/microL)
• Severe (<50,000/microL)
These numbers, however, must be
interpreted in the context of the
underlying disease, and higher or
lower values may be expected for
certain conditions.
Onsite Care to Consider
Consider: Confirmation that the
thrombocytopenia is real (e.g., not a
laboratory error or an in vitro artifact) is
done by repeating the CBC and reviewing
the peripheral blood smear (or
requesting review), especially if the
platelet count does not make sense
within the context of the clinical picture.
Offsite Care to Consider
At the discretion of the
clinician depending on the
clinical scenario.
Consider hematology consult
or emergency room,
depending on the clinical
scenario.
Potential explanations for
thrombocytopenia may emerge from the
initial history, physical examination,
screening laboratory studies, and review
of a peripheral blood smear.
Examination generally should include
attention to the skin (e.g., petechiae,
purpura, ecchymosis), liver, spleen, and
lymph nodes.
Additional studies may include testing for
HIV, HCV Ab, HBsAG.
Potential referrals will depend on the
working or known diagnoses.
The selection of evaluation and/or
treatment should be individualized and
based upon consideration of the patient’s
history and exam, metabolic
abnormalities, extent of disease, patient’s
risk of complications from the known or
unknown disease, and treatment and/or
clinician availability, and the response to
any previous treatments.
Thrombocytosis
Platelet >450,000/microL
Reactive processes account for most
cases of thrombocytosis in all age
groups and clinical settings. Common
causes of reactive thrombocytosis
include:
• Anemia/Blood loss – Iron
deficiency, blood loss, hemolysis
• Infection – Viral, bacterial,
mycobacterial, and fungal causes
Consider: Confirmation that the
thrombocytosis is real through repeat
testing and peripheral smear review.
At the discretion of the
clinician depending on the
clinical scenario.
Additional lab testing that may be
considered include ESR, CRP, iron studies,
ferritin
Consider hematology consult,
depending on the clinical
scenario.
The selection of evaluation and/or
treatment should be individualized and
based upon consideration of the patient’s
history and exam, metabolic
abnormalities, extent of disease, patient’s
risk of complications from the known or
unknown disease, and treatment and/or
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
• Non-infectious inflammation –
Malignancy, rheumatologic
conditions, trauma, reactions to
medications
• Post-splenectomy – Postsplenectomy or functional
asplenia (e.g., sickle cell disease)
Onsite Care to Consider
Offsite Care to Consider
clinician availability, and the response to
any previous treatments.
Consider reducing the risk of thrombosis
in select patients.
Consider: Potential treatment of the
underlying condition if reactive.
Non-reactive causes include the
potential of malignancy.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Hyperbaric
Therapy (HBO)
Hyperbaric Oxygen
Oxygen Therapy
(HBO)
Treatment Guidelines
Treatment
Guidelines
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Hyperbaric Oxygen Therapy (HBO) Treatment Guidelines
I.
DEFINITION OF TREATMENT:
Hyperbaric oxygen (HBO) is a treatment, in which a patient breathes 100% oxygen intermittently
while inside a treatment chamber at a pressure higher than sea level pressure (i.e., >1 atmosphere).
In certain circumstances, it represents the primary treatment modality, while in others it is an
adjunct to surgical or pharmacologic interventions.
Treatment can be carried out in either a mono - or multiplace chamber. The former accommodates
a single patient; the entire chamber is pressurized with 100% oxygen, and the patient breathes the
ambient chamber oxygen directly. The latter holds two or more people and the chamber is
pressurized with compressed air while the patients breathe 100% oxygen via masks, head hoods,
or endotracheal tubes. According to the UHMS definition and the determination of The Centers for
Medicare and Medicaid Services (CMS) and other third party carriers, breathing 100% oxygen at 1
atmosphere of pressure or exposing isolated parts of the body to 100% oxygen does not constitute
HBO2 therapy. The patient must receive the oxygen by inhalation within a pressurized chamber.
Current information indicates that pressurization should be to 1.4 atm abs or higher.
II.
COVERED CONDITIONS:
The guideline of covered conditions has been developed utilizing the guidelines of CMS (Center for
Medicare and Medicaid Services) and the Undersea and Hyperbaric Medical Society.
Acute carbon monoxide intoxication
Air or gas embolism
Decompression illness
Gas gangrene (Clostridial myositis and myonecrosis)
Crush injuries and other acute traumatic ischemias when combined with other standard
therapeutic measures
Progressive soft tissue necrotizing infections (necrotizing fasciitis)
Acute peripheral arterial insufficiency
Preservation of compromised skin grafts and flaps
Chronic refractory osteomyelitis unresponsive to conventional medical and surgical treatment
over a prolonged period of time
Osteoradionecrosis as an adjunct to conventional therapy
Cyanide poisoning
Acute thermal burn injury consisting of deep second or third degree burns
Actinomycosis as an adjunct when treatment utilizing conventional medical and surgical
treatment has failed
Idiopathic acute sensoneural hearing loss
Diabetic wounds of the lower extremity which meet all over these criteria:
1.
Are due to type I or II diabetes
2.
Have a wound classification of Wegner grade III or higher
3.
Have failed an adequate course of wound care utilizing standard measures over a
prolonged time frame.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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III.
CONDITIONS THAT ARE NOT COVERED:
Those conditions which are NOT covered include, but are not limited to:
Chronic cutaneous, decubitus, or venous ulcers
Chronic peripheral vascular insufficiency
Myocardial infarction
Cardiogenic shock
Sickle cell anemia
Acute or chronic cerebral vascular insufficiency
Organ transplantation
Pulmonary emphysema
Multiple sclerosis
Acute cerebral edema
Arthritic disease
Anemia
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Infectious
Infectious Diseases
Diseases
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Hepatitis B Guidelines
I.
PURPOSE:
The purpose of this guideline is to provide the most clinically up to date recommendations for the
medical management of correctional patients with Hepatitis B.
II.
REFERENCES:
Chronic Hepatitis B: Update 2009. American Association for the Study of Liver Diseases.
Hepatology, September 2009, pages 661–662 and pages 1–36.
Stepwise Approach for Detecting, Evaluating, and Treating Chronic Hepatitis B Virus
Infection.
Federal Bureau of Prisons Clinical Practice Guidelines.
January 2011.
http://www.bop.gov/news/medresources.jsp.
III.
PREVALENCE OF CHRONIC HBV IN CORRECTIONS:
In 2008 it was estimated that 1.0-3.7% of the total US custody population in federal and state
prisons had serologic markers of chronic HBV infection. Based on this estimate the prevalence of
chronic HBV is 2–6 times higher among prison residents than in the non-incarcerated community.
IV.
HBV TRANSMISSION
In the US, which is considered a low-prevalence area, injection drug use and sexual intercourse
with an infected partner account for 50–80% of all new cases of HBV infection. Perinatal
transmission from mother to child and household contact with a person infected with HBV are the
primary modes of transmission from high-prevalence areas such as: Asia, the South Pacific, subSaharan Africa, and certain populations in the Arctic, South America, and the Middle East. Other
less common modes of transmission include chronic hemodialysis, certain occupational exposures,
blood transfusion and organ transplant (rare). Tattooing with shared, contaminated needles or
needle-like devices is another potential mode of HBV transmission, especially if these tattoos are
performed in jails and prisons. INDA with shared straws or other paraphernalia is also a potential
mode of transmission. HBV is viable for at least seven days on environmental surfaces and can be
transmitted by sharing contaminated household items such as razors and toothbrushes.
V.
NATURAL HISTORY OF CHRONIC HBV
The majority of adults acutely infected with HBV eventually clear HBsAg from the blood and develop
antibodies to HBsAg (HBsAB +) that confer long-term protection/ immunity from re-infection. Only
a small subset of adults acutely infected with HBV develop chronic HBV infection (HBsAg positive
for > 6 months). The risk of chronic HBV infection is much greater for persons from parts of the
world where HBV is endemic and acquired perinatally. Immunosuppressed individuals also are
more likely to develop chronic HBV infection. Once established, chronic HBV resolves spontaneously
with clearance of HBsAg and development of HBsAb+ in less than 1-2% of patients per year.
VI.
CHRONIC HBV INFECTION COURSE
The course of chronic HBV is varied and unpredictable and may result in one of three main
presentations: chronic HBV, inactive HBsAg carrier state or resolved infection. Chronic HBV is
associated with active hepatic necroinflammation and progressive fibrosis. The diagnostic criteria
are listed below.
VII.
DIAGNOSTIC CRITERIA FOR CHRONIC HEPATITIS B INFECTION
Chronic Hepatitis B:
Need the following criteria
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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1.
HBsAg positive > 6 months
2.
Serum HBV DNA > 20, 000 IU/ mL
3.
Persistent or intermittent elevation in AST/ ALT
4.
Liver biopsy (when performed) showing chronic hepatitis with moderate or severe
necroinflammation
Inactive HBsAg carrier state:
1.
HBsAg positive > 6 months
2.
HBeAg-, anti-HBe+
3.
Serum HBV DNA < 20, 000 IU/ mL
4.
Persistently normal AST/ ALT
5.
Liver biopsy (when performed) confirms absence of significant hepatitis
Resolved Hepatitis B:
1.
Previous known history of acute or chronic Hepatitis B or the presence of HBcAb+,
HBsAb +
2.
HBsAg –
3.
Undetectable serum HBV DNA
4.
Normal ALT levels
VIII. SEROLOGIC MARKERS IN THE DIAGNOSIS OF HBV INFECTION:
An array of HBV serologic markers are useful in characterizing various phases of HBV infection.
Table 1 below summarizes the interpretation of serologic markers for HBV. Antigens are also
extremely important in understanding chronic Hepatitis B infection and its prognosis. The Hepatitis
B e Antigen (HBeAg) is a protein associated with viral replication. In acute HBV infection, loss of
HBeAg occurs early, before the loss of HBsAg. Persistence of HBeAg in chronic HBV is associated
with higher levels of HBV DNA and liver inflammation, and a greater risk for cirrhosis and
hepatocellular carcinoma (HCC).
IX.
HBV GENOTYPES:
Eight genotypes of HBV have been identified labeled A through H. The prevalence of HBV genotypes
varies depending on the geographical location. All known HBV genotypes have been found in the
US. Recent data suggest the HBV genotypes may play an important role in the progression of HBVrelated liver disease as well as response to interferon therapy. Studies of nucleoside analogue (NA)
therapies have not shown any relation between HBV genotypes and response. Therefore, checking
HBV genotypes in clinical practice is not currently recommended.
X.
LIVER BIOPSY:
The purpose of a liver biopsy is to assess the degree of liver damage and to rule out other causes of
liver disease. Liver biopsy is most useful in persons who do not meet clear cut guidelines for
treatment listed below. Because HBV infected patients with elevated ALT values may have abnormal
histology and can be at increased risk of mortality from liver disease especially those above age 40.
Thus, decisions on liver biopsy should be made through the course of a collegial discussion that
takes into consideration age, LFT elevation, HBeAg status, HBV DNA levels and other clinical
features suggestive of chronic liver disease and portal hypertension.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XI.
MANAGEMENT OF CHRONIC HBV INFECTION: (SEE FIGURE 1):
Patients who meet criteria for chronic HBV infection (defined above) should be tested for HBeAg.
Depending on a patient’s HBeAg status, management of chronic HBV infection differs. See Figure
1A and B.
XII.
PERIODIC SCREENING FOR HCC:
Per the AASLD, surveillance of HBV patients at high risk for HCC is recommended. Guidelines
recommend AFP and ultrasound every 6–12 months for either patients with Chronic HBV and HBV
carriers at high risk for HCC: Patients in these groups, for which AFP and U/S were recommended
include: Asian men over 40 years of age, Asian women over 50 years of age, persons with cirrhosis,,
persons with a family history of HCC, Africans (from sub Saharan Africa) over 20 years of age, or
any carrier with persistent or intermittent ALT elevation and/ or high HBV DNA level > 20,000 IU/
mL or over the age of 40.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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1 IU = 5.82 copies
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XIII. TREATMENT OF CHRONIC HEPATITIS B:
Patients identified as having chronic HBV (defined above) and those specified for treatment in the
Figure 1 parts A and B should begin Nucleoside Analog (NA) treatment. The NA recommended by
Wexford Health is Lamivudine (trade name Epivir) 150 mg p.o. QD. Literature concerning viral
resistance for Lamivudine shows that up to 30% of virologic breakthrough observed in clinical trials
is related to medication noncompliance. Thus, this medication must be given direct observed
therapy (DOT) to insure compliance within the correctional setting to limit the development of viral
resistance. Patients are started on Epivir 150 mg p.o. QD, DOT. In six months they are evaluated
with labs drawn to include: HBsAg, HBeAg, anti-HBe, LFTs, HBV DNA. Nucleoside analog dose
reduction is necessary for patients with renal insufficiency. The endpoint of treatment for HBeAg
positive patients is HBeAg seroconversion. Treatment may be discontinued in patients who have
confirmed HBeAg seroconversion (HBeAg loss and anti-HBe detection on 2 occasions, 1–3 months
apart). The durability of response after cessation of treatment is expected to be 70–90%. Viral
relapse and exacerbations of hepatitis may occur after discontinuation of lamivudine therapy,
including patients who have developed HBeAg seroconversion, and may be delayed up to 1 year
after cessation of treatment. Thus, all patients should be closely monitored after treatment is
discontinued (every 1–3 months for the first 6 months, and every 3–6 months thereafter).
Reinstitution of lamivudine treatment is usually effective in patients who have not developed
resistance. Alternative treatment may be considered in patients who do not respond to lamivudine
(i.e., Tenofovir - trade name Viread - 300 mg per day). This decision will be made during a collegial
discussion
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Hepatitis C Virus Treatment Guideline
Updated:
November 30, 2016
NOTE: If there is a conflict between this guideline and the Administrative Directive or Institutional
Directive, then the respective Administrative Directive or Institutional Directive language is controlling to
resolve such conflict.
I.
PURPOSE AND OVERVIEW
The purpose of this guideline is to provide the most clinically up to date recommendations for the
medical management of correctional patients with Hepatitis C. In light of the rapidly changing HCV
treatment landscape, Wexford Health will continue to monitor the AASLD/ IDSA/ IAS-USA websites
(www.hcvguidelines.org) as well as the latest Federal Bureau of Prisons (FBOP) Clinical Practice
Guidelines and provide revised guidance as necessary. See the References section for a complete
citation.
II.
PREVALENCE OF HCV IN CORRECTIONS
Twelve to thirty-five percent (12%–35%) of the incarcerated population in the US has chronic HCV
infection. Comparatively, the prevalence of HIV in the US incarcerated population is 2%–5%. The
prevalence of HCV in the US non-incarcerated population is 1.3%. Therefore, there is a substantially
higher patient population with HCV in the correctional system.
III.
HCV TRANSMISSION
Hepatitis C Virus is primarily transmitted by blood borne routes of infection: IVDA with shared
needles, INDA with shared straws or spoons, tattoos with shared needles, blood transfusion prior
to 1992, clotting factor transfusion prior to 1987. Sexual transmission occurs but at much lower
transmission rates. Vertical transmission occurs in 5%. HCV is not transmitted by breast feeding,
kissing, sharing a cup with someone, or by casual contact (i.e., shaking hands with someone,
hugging someone or sharing a cell with someone).
IV.
HCV NATURAL HISTORY
The natural history of HCV is such that 50%–80% of HCV infections become chronic. Progression
of chronic HCV infection to fibrosis and cirrhosis may take years in some patients and decades in
others – or, in some cases, may not occur at all. Most complications from HCV infection occur in
people with cirrhosis. Cirrhosis is a condition of chronic liver disease marked by inflammation,
degeneration of hepatocytes, and replacement with fibrotic scar tissue.
Patients with advanced hepatic fibrosis (primarily stage 3) have a 10% per year rate of
progressing to cirrhosis (stage 4).
Those with cirrhosis have a 4% per year rate of developing decompensated cirrhosis, and a
3% per year rate of developing hepatocellular carcinoma.
Screening method: The preferred screening test for HCV infection is an immunoassay that
measures the presence of antibodies to HCV antigens, referred to as the HCV Antibody (Ab)
or anti-HCV.
V.
INITIAL EVALUATION OF ANTI-HCV POSITIVE RESIDENTS: BASELINE WORK-UP FOR HCV CHRONIC CLINIC
Enroll in Hepatitis C Chronic Clinic.
Consider further education on the prevalence, transmission routes, and natural history of
Hepatitis C Virus infection.
Baseline history and physical examination.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Labs including: CBC, plt, PT/INR, HIV screen, Hepatitis B Surface Antigen (HBsAg), Hepatitis
B core Antibody total (HBcAb total), Hepatitis A Antibody total (HAV-Ab total), Hepatitis B
Surface Antibody (HBsAb).
Unless the patient has potential exclusionary criteria for HCV treatment as listed under
section IX, lab for Quantitative HCV RNA viral load testing should be ordered to determine if
the patient has active or resolved HCV infection. This is a non-preferred viral lab test that
requires approval prior to being drawn.
Unless otherwise clinically indicated, testing for other causes of liver disease – i.e., antinuclear
antibody (ANA), ferritin, iron saturation, ceruloplasmin – are not routinely ordered in the
evaluation of a patient with a positive HCV Ab test.
APRI Calculation (see below).
VI.
CALCULATION OF THE AST TO PLATELET RATIO INDEX (APRI) TO ASSESS THE DEGREE OF FIBROSIS
The APRI score, a calculation based on results from two blood tests (the AST and the platelet
count), is a non-invasive test that assesses liver fibrosis.
The formula for calculating the APRI score: AST/ ALT ULN (= 40) x 100/ platelet count (10⁹).
1.
An APRI score of ≥ 1.0 may be used to predict the presence of cirrhosis. At this cutoff,
the APRI score has a sensitivity of 48%, but a specificity of 94%, for predicting cirrhosis.
Patients with an APRI score ≥ 1.0 should have an abdominal ultrasound performed to
identify other findings consistent with or suggestive of cirrhosis.
2.
Patients with an APRI score of < 0.7 have a low likelihood of having significant liver
fibrosis.
3.
Patients with an APRI score between 0.7–1.0 may or may not have significant liver
fibrosis. For these patients other labs should be reviewed. If any of the following labs
are positive, the patient should be considered for an abdominal ultrasound to identify
other findings consistent with or suggestive of cirrhosis:
4.
VII.
a.
Platelet count < 170,000
b.
INR > 1.0
c.
Albumin < 3.7
An APRI score is not necessary for diagnosing cirrhosis if cirrhosis has already been
diagnosed by other means.
PRIORITY CRITERIA FOR HCV TREATMENT
Determination of whether priority criteria for HCV treatment are met is an important part of
the initial evaluation and ongoing management of residents with chronic HCV infection.
Although all patients with chronic HCV may benefit from treatment, certain cases are at
higher risk for complications or disease progression and require more urgent consideration
for treatment. The AASLD as well as the FBOP guidelines have established priority criteria to
ensure that those with the greatest need are identified and treated first. Per the referenced
most current guidelines:
1.
The treatment recommendations per the AASLD and IDSA guidelines state that
“Immediate treatment is assigned the highest priority for those patients with advanced
fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant
recipients, and patients with severe extrahepatic Hepatitis C (type 2 or 3 mixed
cryoglobulinemia with end-organ manifestations (i.e., vasculitis), proteinuria, nephrotic
syndrome, or membranoproliferative glomerulonephritis.)”
http://www.hcvguidelines.org/full-report/when-and-whom-initiate-hcv-therapy
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
Highest priority for treatment (in addition to conditions specified above):
a.
HIV co-infection
b.
Chronic HBV co-infection
VIII. POTENTIAL EXCLUSION CRITERIA FOR HEPATITIS C TREATMENT
Patient Refusal.
Inadequate Length of Stay (LOS): Typical LOS criteria require residents to have 12 months left
on sentence to provide adequate time for work-up, initiation and completion of HCV
treatment. As treatment course length is rapidly changing with the advent of new medications,
this requirement is not static and patients will be reviewed on a case by case basis.
Contraindications to, or significant drug interactions with, any component of the treatment
regimen.
Patients with GFR < 30.
Patients with decompensated cirrhosis (*exceptions can and will be made on a case by case
basis; these patients should be submitted for treatment evaluation and recommendations
detailed to the providers).
Pregnancy: especially for any regimen that would require ribavirin or interferon.
Patients that cannot demonstrate a willingness and ability to adhere to a rigorous treatment
regimen and to abstain from high-risk activities while incarcerated.
IX.
PATIENTS THAT ARE NOT TREATMENT CANDIDATES
The patient should be educated that although they may not meet treatment criteria at this
time, they are not excluded from meeting criteria for treatment in the future.
The reason for the non-candidacy should be clearly documented in the HCV Chronic Clinic
Progress Note.
The patient should continue to be followed in HCV chronic clinic every six (6) months with
labs (as above).
All patients should be re-reviewed at each HCV chronic clinic. Should the reason for their
non-candidacy change (i.e., their APRI score increases or they previously refused treatment
but now consent to treatment, etc.) they should be re-submitted for evaluation (specified
below).
X.
POTENTIAL CANDIDATES FOR HCV TREATMENT
To begin the submission for HCV treatment consideration, the site medical provider will fill
out the Wexford Health Initial Hepatitis Worksheet, in full, and fax or email attach it to the
Chronic Disease and Case Management Director: dpaul@wexfordhealth.com or fax: 412539-0422.
The Chronic Disease and Case Management Director will then correspond (either via fax, email
or phone) with the site medical provider regarding the next step in management.
As most correctional systems do not have an EMR, results (lab result copy or radiology study
reports) must be sent to the Chronic Disease and Case Management Director’s attention as
soon as they are received (in paper form) at the site.
Patients that have been fully worked up but do not meet priority treatment criteria will not be
approved for HCV treatment at this time. This designation will be made by the Chronic
Disease and Case Management Director and will be detailed in an electronic progress note
that will be emailed to the site and should be printed and placed into the patient’s chart.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Recommendations for follow-up and re-submission for treatment consideration are always
incorporated into these recommendations.
XI.
XII.
REFERENCES
7.
Evaluation and Management of Chronic HCV Infection. Federal Bureau of Prisons Clinical Practice
Guidelines. July 2015. http://www.bop.gov/news/medresources.jsp.
8.
Recommendations for Testing, Managing and Treating Hepatitis C. American Association for the Study of
Liver Diseases (AASLD) / IAS – USA. August 7, 2015. http://www.hcvguidelines.org
ATTACHMENTS
Initial Hepatitis Work Sheet
Facts About Hepatitis B and C
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Initial Hepatitis Work Sheet
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Facts About Hepatitis B and C
Updated: November 30, 2016
I.
WHAT IS HEPATITIS AND WHAT ARE THE DIFFERENT FORMS?
"Hepatitis" means an inflammation of the liver. The liver is an important organ in the body that
processes nutrients, filters the blood, and fights off infections. When the liver is inflamed or
damaged, its function can be affected. Heavy alcohol use, illicit drug use, some medications and
certain medical conditions can cause hepatitis. Hepatitis (liver inflammation) can often be caused
by a virus. In the United States, the most common types of viral hepatitis are caused by Hepatitis
A, Hepatitis B, and Hepatitis C. Hepatitis A is spread through contaminated food or water. Hepatitis
B and C are primarily spread through contact with human blood. Sexual transmission of Hepatitis
B and C can also occur, but is more common with Hepatitis B infection. There are vaccines used to
prevent the infection of Hepatitis A and Hepatitis B. There is no vaccine for the prevention of
Hepatitis C.
II.
HOW DO YOU KNOW IF YOU HAVE HEPATITIS B OR C?
The majority of people infected with Hepatitis B or C do not have any symptoms at the time of
infection. Many people with Hepatitis B or C do not know they are infected. In order to know if you
have been infected with Hepatitis B or C, a specific blood test for each of these viruses is necessary.
III.
HOW DO YOU "CATCH" HEPATITIS B OR C?
Both Hepatitis B and C are primarily spread through contact with human blood. Up to 40% of
people with Hepatitis B or C never learn how they were infected. You are considered at high risk for
Hepatitis B or C infection if you:
IV.
•
Had a blood transfusion before 1992
•
Had a blood product transfusion (i.e., plasma or clotting factor) before 1987
•
Injected drugs using with shared needles
•
Snorted drugs with shared spoons or straws
•
Had tattoos or body piercing performed with shared needles or implements
•
Had sex with someone with Hepatitis B or C
•
Were born to a Hepatitis B or C infected mother (at the time of delivery)
THE WAYS HEPATITIS B OR C ARE NOT TRANSMITTED
Hepatitis B and C cannot be transmitted by:
V.
•
Kissing someone
•
Shaking hands with someone
•
Breast feeding
•
Hugging someone
•
Sharing a cell with someone
ARE HEPATITIS B AND C COMMON?
Both Hepatitis B and C are common. In the U.S. there are about 1.2 million people with Hepatitis
B and over 4 million people with Hepatitis C. The prevalence of Hepatitis C in the U.S. nonincarcerated population is 2%-5%. The prevalence of Hepatitis C in the U.S. incarcerated population
is 12%-35%.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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VI.
WHAT HAPPENS TO PEOPLE WITH CHRONIC HEPATITIS C?
Most people (50%-80%) that are infected with Hepatitis C become chronically infected. Chronic
infection means that the Hepatitis C virus continues to live in the bloodstream of the infected
person. The majority of persons with chronic Hepatitis C infection (80%) will not have significant
liver damage long term. About one third of persons with chronic Hepatitis C will not even have liver
lab abnormalities over the course of their lifetime. Progression of chronic Hepatitis C infection to
significant liver damage may take years in some patients and decades in others - or, in some cases,
may not occur at all. To know which patients with chronic Hepatitis C are at higher risk of
developing significant liver damage, laboratory studies (labs) must be followed regularly.
VII.
WHY IS THERE A NEED FOR TREATMENT?
As stated, the majority of persons with chronic Hepatitis C infection will not have significant liver
damage long term. But the minority (< 20%) may develop significant liver damage over the course
of years to decades. Identifying those persons with chronic Hepatitis C who have significant liver
damage or those whose labs are trending toward significant liver damage is important, as these
individuals may benefit from treatment of their Hepatitis C. Following patients' lab values over time
is the way to determine if their liver function is stable and normal or abnormal and to figure out
their need for treatment.
VIII. HOW CAN I PROTECT MYSELF FROM GETTING HEPATITIS B OR C?
Avoid having your blood mix with anyone else's blood. This means not sharing needles, straws,
spoons or any implement that punctures the skin (including tattoo needles or devices). Use a
condom for sexual intercourse. Do not share personal items such as razors, toothbrushes, or nail
clippers as these items may contain traces of blood.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Infectious Disease: HIV Guidelines
I.
ANTIRETROVIRAL THERAPY
Recommendations for Initiating Antiretroviral Therapy in Treatment–Naïve Patients
Panel’s Recommendations
•
•
•
II.
Antiretroviral therapy (ART) is recommended for all HIV-infected individuals, regardless of
CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV
infection.
ART is also recommended for HIV-infected individuals to prevent HIV transmission.
When initiating ART, it is important to educate patients regarding the benefits and
considerations regarding ART, and to address strategies to optimize adherence. On a caseby-case basis, ART may be deferred because of clinical and/or psychosocial factors, but
therapy should be initiated as soon as possible.
GUIDELINES FOR PRIMARY PROPHYLAXIS*
Opportunistic Infection
CD4 Threshold
Recommended Drug
Alternative
Pneumocystis carinii
pneumonia
CD4 less than 200
TMP/SMZ DS
Dapsone
Tuberculosis
All CD4 counts if TST
greater than 5 mm
Isoniazid (exclude active
disease)
Rifampin and PZA
Mycobacterium avium
complex
CD4 less than 50
Azithromycin
Rifabutin
TMP/SMZ DS
Dapsone +
pyrimethamine +
leukovorin
Toxoplasmosis
CD4 less than100
*When CD4 counts exceed these thresholds for 3−6 months, prophylaxis may be discontinued.
III.
GUIDELINES FOR VACCINATIONS
Agent
Indication
Hepatitis B
Hepatitis A
S. Pneumonia
Influenza
Anti-HBc neg
Consider
CD4 greater than 200
Annually, in season
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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MRSA Control Guidelines
I.
INTRODUCTION
In recent years, a growing problem has emerged in the United States of skin infections resistant to
the typical antibiotics. The infection is called “MRSA” for “methacillin-resistant staphylococcus
aureus.” Fortunately, most of the infections can be treated with alternative antibiotics or other
remedies, but these treatments can be expensive and complicated. The best solution is early
detection and good prevention.
II.
IMPLICATIONS FOR CORRECTIONAL FACILITIES
Because the infection can spread person-to-person, institutional settings such as jails and prisons
which have dense populations are common environments for the condition. The Centers for Disease
Control and Prevention began recognizing and reporting on this phenomenon in 1999, and is now
widespread. Commonly mistaken for “spider bites” or other soft tissue infections, most of these
lesions are actually MRSA. Adequate control of the infection requires a multidisciplinary effort.
III.
PROCEDURE
Intake Screening
To reduce the risk of residents entering any facility with untreated or contagious skin
infections:
1.
All residents should receive information about the skin infection during the initial
institution orientation.
2.
All residents should be questioned upon entry about the presence of open sores or
“spider bites” during the health screening process.
3.
All residents should receive a visual skin inspection by screening staff upon entry.
4.
Sending institutions should be requested to notify receiving institutions in advance if
sending a patient with a current MRSA infection.
5.
All residents should be showered if possible and receive clean linen upon entry.
6.
Any patient with positive findings should be referred to the clinician on the same day.
7.
All suspicious wounds should be cultured.
Management
Persons with wound infections will be placed on appropriate antibiotics depending on the
culture results.
Interim Guidelines for Empiric Oral Antimicrobial Treatment of Outpatients with
Suspected MRSA Skin and Soft Tissue Infections (SSTI) 1
Selection of empiric therapy should be guided by local S. aureus susceptibility and modified
based on results of culture and susceptibility testing. The duration of therapy for most SSTI
is 7−10 days, but may vary depending on severity of infection and clinical response. NOTE:
Before treating, clinicians should consult complete drug prescribing information in the
manufacturer’s package insert or the PDR.
1
Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections, Federal Bureau of Prisons – Clinical Practice Guidelines,
August 2005
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Antimicrobial
Adult Dose
Pediatric Dose
Trimethoprimsulfamethoxazole
(TMP- SMX) DS
I tablet (160 mg TMP/800
mg SMX) p.o. b.i.d.
Base dose on TMP: 8–12 mg IMP (& 40–60 mg SMX) per
kg/day in 2 doses; not to exceed adult dose
Minocycline or
doxycycline
100 mg p.o. b.i.d.
Not recommended for pediatric use − suggest
consultation with infectious disease specialist before use
Clindamycin
300-450mg p.o. q.i.d.
10−20mg/kg/day in 3−4 doses; not to exceed adult dose
NOTE: If Group A streptococcal infection is suspected, oral therapy should include an agent
active against this organism (β-lactam, macrolide, clindamycin). Tetracyc lines and
trimethoprim-sulfamethoxazole, although active against many MRSA, are not recommended
treatments for suspected GAS infections.
NOTE: Outpatient use of quinolones or macrolides. Fluoroquinolones (e.g., ciprofloxacin,
levofloxacin, moxifloxacin, gatifloxacin) and macrolides (e.g., erythromycin, clarithromycin,
azithromycin) are NOT recommended for treatment of MRSA because of high resistance rates.
If fluoroquinolones are being considered, consult with infectious disease specialist before use.
NOTE: Outpatient use of Linezolid in SSTI. Linezolid is costly and has great potential for
inappropriate use, inducing antimicrobial resistance, and toxicity Although it is 100%
bioavailable and effective in SSTI, it is not recommended for empiric treatment or routine use
because of these concerns It is strongly recommended that linezolid only be used after
consultation with an infectious disease specialist to determine if alternative antimicrobials
would be more appropriate.
If considering clindamycin, isolates resistant to erythromycin and sensitive to clindamycin
should be evaluated for inducible clindamycin resistance (MLSB phenotype) using the “D
test.” Consult with your reference laboratory to determine if ”D testing” is routine or must be
specifically requested. If inducible resistance is present, an alternative agent to clindamycin
should be considered.
1.
2.
Patients with potentially contagious infections such as wounds with uncontained
drainage, weeping cellulitis, or multiple sites should be assigned to isolation in singlecell housing to reduce the risk of transmission.
a.
Provide liquid antibacterial soap regimen
b.
Daily linen exchanges, if possible
c.
Facility provides cleaning supplies each shift for patient to clean room
d.
Isolation continues until culture is negative (number of cultures to be determined
by Medical Director)
If possible, residents with MRSA should be restricted from transferring to another
facility (a “medical hold”) until the infection is resolved.
Evaluation and Treatment2
1.
Initial Assessment
2
Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections, Federal Bureau of Prisons – Clinical Practice Guidelines,
August 2005
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
a.
Conduct targeted history and physical: check for fluctuance, crepims and
cellulitis
b.
Assess risk factors for MRSA infection, including recent hospitalization
c.
Assess risk factors for systemic infection, e.g., recent injection drug use, prior
endocarditis
d.
Diagnostic tests:
i.
If signs of systemic infection (lymphangitis, fever, tachycardia) —> blood
cultures
ii.
If wound drainage available → wound cultures
iii.
If MRSA pneumonia suspected → chest x-ray and sputum cultures
Conservative Treatment
For uncomplicated infections, without systemic S/S. use conservative treatment prior
to antibiotics.
a.
3.
i.
Incision and drainage (I & D): In conjunction with the use of warm soaks or
compresses, drain accessible fluid collections, particularly loculated soft
tissue infections. Frequently reassess to determine if repeated drainage is
warranted.
ii.
Foreign devices: When possible, remove catheters I foreign devices related
to the infection.
Empiric Therapy for Suspected S. aureus Infection
a.
4.
Warm soaks and compresses: Soak infected area or apply warm compresses for
20 minutes, 2 to 3 times per day until infection clears. Perform on a case by case
basis, consulting with the infection control officer regarding how to safely
implement.
If systemic infection/sepsis possible → admit as inpatient and consider empiric
IV vancomycin If mild to moderate illness (e.g., significant cellulitis associated
with abscess, fever, lymphangitis) and cultures unobtainable or nondiagnostic →
consider empiric antibiotic therapy:
i.
If no MRSA risk factors and no other MESA infections in population →
empiric
treatment
with
first
generation
cephalosporin,
or
amoxicillin/clavulanate, or erythromycin.
ii.
If MRSA outbreak or MRSA risk factors → treat with TMP-SMX or
clindamycin.
Targeted Antibiotic Therapy
If cultures and antibiotic sensitivities are available → target antibiotic therapy
accordingly
a.
Highly resistant MRSA isolates and serious infections → usually require IV
vancomycin.
b.
If susceptible → consider treatment with TMP-SMX or clindamycin.
c.
Can consider other antibiotics based on susceptibility results.
Monitor closely since in vitro sensitivities may not correlate with clinical response.
Persistent or recurrent disease may indicate nonadherence, new infection, or
resistance.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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5.
Decolonization
In context of significant MRSA outbreak → can consider decolonization of nares with
2% mupirocin b.i.d. for five (5) days. Consult first with corporate office given benefit is
unproven.
6.
Treatment Follow-up
a.
Re-evaluate one (1) week after completion of antibiotic treatment and examine for
recurrent lesions.
For uncontained draining lesions → document clinical improvement and two (2)
consecutive negative wound cultures 72 hours apart before discontinuing
containment, periodic follow-up as clinically warranted.
Prevention/Infection Control
1.
Hand hygiene and personal protective equipment (PPE) Hands should be routinely
washed with soap and running water before eating, after using the lavatory, when visibly
dirty, and when there has been contact with blood or other body fluids, mucous
membranes or broken skin, Hands should be washed with soap and running water for
at least 20 seconds.
Patients and staff should have access to sufficient opportunities and necessary supplies
for good personal hygiene. The availability of these supplies should be regularly
assessed and remedied as necessary, PPE is indicated if health care personnel,
correctional officers, or other residents are likely to have contact with blood/body fluids,
e.g., gloves to protect hands from contact; mask or face/eyewear and gowns as needed
to protect from sprays and splashes.
2.
Environmental cleaning and disinfection. Environmental contamination is a less likely
reservoir of infection than person-to-person contact; therefore environmental sanitation
cannot substitute for personal hygiene. However, MRSA can exist on environmental
surfaces, in particular those commonly touched by the hands of residents, corrections
officers, and health care staff. Cleaning protocols and schedules should be established
for all areas of each facility. Correctional workers should conduct sanitation inspections
of living and bathroom areas, and any lapses in sanitation should be corrected. It is
important to read the disinfectant instruction label to make sure it is used safely and
appropriately. Most disinfectant products require cleaning of visibly soiled surfaces
prior to applying the disinfectant. Also, routine use of disinfectants is not without risk.
Many of the active ingredients in disinfectant products can burn or irritate the skin and
eyes, and in some cases can cause respiratory irritation.
3.
Laundry. The availability of supplies for environmental cleaning should be regularly
assessed and remedied as necessary. All washable (non-porous) surfaces of bathrooms
and living areas that are commonly touched should be disinfected routinely (e.g., daily,
and when visibly soiled). Routine disinfection should be performed with a bleach
solution, (see Appendix 2 for guidance on use of bleach) or an Environmental Protection
Agency (EPA)-registered disinfectant according to manufacturer’s instructions. A list of
appropriate
disinfectants
is
located
on
the
EPA
Website
at
http://www.epa.gov/oppad001/chemregindex.htm
Equipment with damaged surfaces that cannot be cleaned should be repaired or
discarded. Persons using exercise equipment should also use barriers to bare skin, such
as a towel or clean shirt. The Federal Bureau of Prisons recommends that recreational
equipment, such as weight benches, should be routinely wiped clean after each use with
a clean towel
Laundry contamination with MRSA is also less likely to be a reservoir of infection than
person-to-person contact; therefore laundering procedures cannot substitute for
personal hygiene. When laundry is washed at cool water temperatures (<720 Fahrenheit
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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or 22.20 Centigrade), a detergent formulated for cold water should be used. The
disinfectant capability of chlorine bleach is well established; and its use is the most
effective means of reducing the bacterial count in laundered items at any temperature.
The relative antimicrobial effectiveness of oxygenated (color safe) bleaches has not been
established and oxygenated bleach is not current approved for disinfecting and
sanitizing by the EPA. Drying laundry on “hot” settings will help eliminate bacteria.
Soiled linen can be a source of microbial contamination, which may infrequently cause
infections. The risk of disease transmission from soiled linen is minimal. All soiled linen
should be handled and laundered in the same manner regardless of the individual’s
specific diagnosis. Appendix 3 contains infection control guidance regarding the
management of linen and laundry.
4.
Patients with MRSA infections. Educational information should be provided to residents
with MRSA infections. The decision to allow residents to change their own bandages
should be made on a case-by-case basis. Patients who are allowed to change their own
bandages will need access to gloves, soap and water, bandages, and plastic trash bags,
and should receive instruction on the proper procedure for changing a bandage in order
to minimize the possibility of cross contamination.
Health care staff should examine residents diagnosed with skin and soft tissue
infections to determine the risk of spread to others. Patients with uncontrolled drainage
should be restricted from recreation and common areas. Separate toilet facilities are
preferred and are a priority for residents with draining peri-rectal and thigh lesions,
Patients with uncontained drainage should not shower at the same time as the general
population. They should be issued two towels and instructed to use one to sit on as a
barrier when using the bench in the dressing area. Toilet, shower and dressing areas
should be cleaned and disinfected before the general population uses the facility again.
These precautions may be discontinued 24 hours after the wound has resolved
(drainage can be contained with a simple dressing or drainage has stopped), even if
antibiotic therapy is incomplete.
Single cell housing is not typically required for persons with non-draining MRSA skin
infections, or draining infection that is contained by a simple dressing. Single cell
housing should be considered for mentally ill, cognitively impaired, and uncooperative
residents. Terminal cleaning of the cell should be done before assigning the cell to
another patient. For residents with contained drainage, the health care provider will
need to determine if activity restriction is warranted on a case-by-case basis.
Regardless of where the MRSA-infected patient is housed, sanitation measures should
be strictly enforced. Patients should change into clean clothing any time clothing has
been soiled with wound drainage. Linens should be changed frequently and when visibly
soiled.
Towels and washcloths should be changed daily. Patients with skin infections should
generally shower daily, provided this does not interfere with wound healing.
Hand hygiene should be re-emphasized for staff working with a patient diagnosed with
MRSA infection. Hands should be routinely washed with soap and running water for 20
seconds. Clean, non-sterile gloves should be worn when contact with wound drainage
is anticipated, and hand washing should be performed before and after every contact
with an infected patient, even if gloves are worn. Staff who might have contact with
patients with grossly draining wounds should wear clean, non-sterile gowns during
contact and immediately discard the gown before contact with any other persons or
surfaces. Security devices (e.g., handcuffs, and other reusable restraints) should be
routinely (e.g., daily) disinfected, and also disinfected after use if a patient is known to
have skin or soft tissue infection, or if visibly soiled.
During transfers, interruptions in care for MRSA infection should be minimized. If
patients with MRSA infection must be transferred, the receiving institution’s health care
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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personnel should be made aware of the pending arrival of infected patients and their
health status.
At the time of transfer, the wound should be dressed with a clean bandage that contains
wound drainage. Transfer officers should follow the precautions described above with
regards to hand washing, gloves if touching wounds or drainage, disposal of dressings,
and disinfection of equipment and exposed surfaces. Cleaning and disinfection of
transport vehicles should be performed on a routine basis.
If drainage from a wound is not adequately contained, escort officers should be notified
of the patient’s condition and education on appropriate infection control measures
should be reinforced. If appropriate because of inadequately contained wound drainage,
seats should be covered with a disposable, impermeable sheet, and
cleaning/disinfection of exposed surfaces should take place after transport is
completed.
Patients with MRSA skin infections who are scheduled for release should be offered
enough antibiotics to complete treatment, counseled on basic infection control
measures to prevent transmission to household members and other anticipated close
contacts, and advised regarding obtaining follow-up medical services. In addition,
draining infections should be adequately bandaged to contain drainage prior to release.
Education/Increased Awareness
Key educational points are summarized below:
1.
2.
For patients:
a.
Practice good hand hygiene. Hands should be routinely washed with soap and
running water before eating, after using the lavatory, when hands are visibly dirty,
and when there has been contact with blood or other body fluids, mucous
membranes, or broken skin.
b.
Maintain good personal hygiene through regular showers and by keeping your
living space clean, including regular laundering of sheets and pillowcases.
c.
When hand washing, use soap and water for at least 20 seconds.
d.
Take care of your skin and any cuts or scratches. If you notice any lumps, bumps
or lesions, never try to open them yourself. Always follow up with the health care
staff for evaluation as soon as possible.
e.
Do not share personal items such as towels, razors and toothbrushes.
f.
Cover damaged skin (cuts, scrapes and scratches) and draining wounds with
bandages.
g.
Carefully dispose of bandages containing pus or blood.
h.
Shower regularly with soap and warm water (very hot water may dry the skin and
make it more prone to cracks and other damage).
i.
Use a barrier (a clean towel or clothing) between your skin and equipment that is
shared with others, like exercise equipment in the gym.
For corrections officers and staff:
a.
Practice good hand hygiene. Encourage patients to practice proper hand washing
as well.
b.
Encourage patients to take regular showers with soap and warm water.
c.
Discourage sharing of personal items such as towels, razors and toothbrushes.
d.
Be observant. Encourage patients with skin lesions to follow up with the health
care staff as soon as possible.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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3.
e.
Use personal protective equipment (PPE) whenever you expect to have contact
with a patient’s blood or body fluids.
f.
Read the disinfectant instruction label to make sure it is used safely and
appropriately. Most disinfectant products require proper cleaning of surfaces prior
to applying the disinfectant.
g.
House individuals with draining wounds separate from other patients, to the hill
extent possible.
h.
Follow your agency’s infection control guidelines.
Other ways to reduce transmission:
a.
Launder sheets, towels, uniforms and underclothing with hot water and detergent
and dry on a hot setting or use a detergent which has the same effect.
b.
Wear gloves when handling dirty laundry at the facility.
c.
Regularly clean sinks, showers and toilets.
d.
Use contact precautions (e.g., gown and gloves) for wound care. This includes the
use of personal protective equipment (e.g., gloves +1- gown) whenever contact may
occur with a patient’s blood or body fluids.
e.
Cover draining wounds and damaged skin (sores, cuts, scratches and scrapes)
with bandages.
f.
Carefully dispose of bandages containing pus or blood.
Surveillance
1.
Cases should be tracked by the institution’s Infectious Disease nurse.
2.
Reports regarding the number of cases should be reported at least monthly to the
central office of the correctional system, Medical Director of the facility, and to the local
health department.
3.
A cluster of MRSA is two or more, epidemiologically related (e.g., a housing unit
supervised by a single correctional post), culture-positive cases of MRSA infection.
Clusters of cases as defined above should be brought to the attention of the institution’s
Medical Director and/or Regional Medical Director, immediately. The Medical Director
will determine if the cases must be reported to the local health department.
Outbreak
1.
Two or more cases define an outbreak. When this occurs, an immediate investigation
should begin to determine the extent of the outbreak.
2.
Isolation and containment of individuals or housing areas suspected in an outbreak is
to be considered.
3.
The medical director shall notify the institution’s director of any outbreak.
Resources
Further information about MRSA can be found on the Website links listed below:
1.
Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections (Federal
Bureau of Prisons) http://www.bop.gov//news/PDFs/rnrsa.pdf
2.
Video
on
MRSA
Awareness
(Federal
http://www.bop.gov//news/medresources.jsp
3.
MRSA Fact Sheet (Illinois Department of Public Health)
Bureau
of
Prisons)
http://www. idph.state.il.us/public/hb/hbmrsa.htm
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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4.
Methicillin-Resistant Staphylococcus aureus Infections in Correctional Facilities
Morbidity
and
Mortality
Weekly
Report;
February
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5205a4.htm
7,
2003
Morbidity and Mortality Weekly Report; October 17, 2003
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5241a4.htm
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Appendix 1: Linen and Laundry Services
I.
INFECTION CONTROL GUIDANCE FOR STAFF
All soiled linen is considered potentially infectious.
Hand washing should be performed after having contact with all soiled linen.
Protective barrier apparel should be used as follows:
1.
Gloves should be worn for actual or potential contact with soiled linen contaminated
with blood or body substances.
2.
Gowns should be worn for the management of soiled linen if contamination of the
worker’s clothing is likely to occur.
3.
Masks should be worn if there is potential for exposure to aerosolized blood or body
substances. This may occur if soiled linen is extensively agitated.
Handle soiled linen as little as possible and with a minimum of agitation to prevent gross
microbial contamination of the air and of persons handling the linen.
All soiled linen should be bagged at the location where it was used.
Place all linen in leak-proof laundry bags. Double bagging of soiled linen is not required when
leak-proof laundry bags are used.
Caution must be exercised to help prevent laundry bags from being overfilled.
Loose linen should never be thrown directly into laundry chutes.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Appendix 2: MRSA Q&A (Corrections Professionals)
I.
WHAT IS MRSA?
MRSA stands for “Methicillin-Resistant Staphylococcus aureus.” MRSA is a type of Staphylococcus
aureus (“staph”) bacteria that is resistant to some antibiotics.
Many people think that MRSA routinely causes unusually severe disease. Although some people
become ill with serious infections such as pneumonia, bloodstream infections, or bone infections,
these types of illness are rare in healthy people who get MRSA skin infections. With prompt, proper
medical care, MRSA can be treated successfully.
II.
WHAT ARE THE SYMPTOMS OF A STAPH/MRSA INFECTION?
Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean that a
person has a staph or MRSA skin infection. Occasionally, staph, including MRSA, also can cause
more serious problems such as surgical wound infections, bloodstream infections and pneumonia.
The only way to tell the difference between MRSA and other staph infections is with lab tests.
III.
HOW IS MRSA DIAGNOSED?
A health care professional will take a sample on a sterile swab (like a Q-tip) from the infected area.
The sample will be sent to a laboratory to see if the infection is caused by staph. If the infection is
caused by staph, additional tests will be needed to determine if the staph is MRSA. Blood and other
body fluids also can be tested for staph.
IV.
HOW ARE MRSA SKIN INFECTIONS TREATED?
Incision and drainage is the primary treatment for abscesses (collections of pus) and should be
performed whenever possible. Sometimes treatment requires the use of antibiotics. If antibiotics are
needed, it is important to use the medication as directed unless a doctor says to stop. If the infection
has not improved within a few days after seeing a doctor, it is important to contact the doctor again.
MRSA infections also require good wound and skin care: keeping the area clean and dry, washing
hands after caring for the area, and carefully disposing of any bandages.
V.
IS MRSA A PROBLEM IN CORRECTIONAL FACILITIES?
MRSA is not necessarily a problem in all correctional facilities. Many people, including patients and
corrections officers, carry staph (including MRSA) in their nose or on their skin, do not know they
are carrying it, and do not get skin infections.
However, some conditions can lead to MRSA/staph infections in prisons and jails (see below) and
in other settings where people have a lot of direct contact and skin damage can occur, like sports
teams.
VI.
WHAT KINDS OF CONDITIONS CAN LEAD TO A MRSA/STAPH INFECTION?
Direct skin-to-skin contact: To get a MRSA or other staph infection, you must get bacteria
on your skin or in your nose. Staph, including MRSA, are spread by direct skin-to-skin
contact. In correctional facilities, this can occur when one person shakes hands with another,
tackles or wrestles with another person, gets “patted down” without gloves, or has some other
direct contact with the skin of another person. This happens in any situation where there is
direct contact, not just in jails or prisons.
Poor hand hygiene: The best way to prevent skin infections, and many other infections, is to
wash hands frequently. MRSA and other staph can be removed from the hands by washing
with soap and water or by using a hand sanitizer.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Lack of attention to cuts and scrapes: MRSA and other staph need to get into the skin
before an infection occurs, often through a scrape, scratch, or wound. MRSA also can enter
the body when non-sterile equipment is used in body piercing and tattooing.
Contact with personal items contaminated with drainage from infected scrapes, cuts,
and other wounds: These items include contaminated bandages, towels, bars of soap, topical
preparations3, athletic or gym equipment, and uniforms or other clothing.
Note: Risk of transmission is low from environmental surfaces that are not contaminated by
skin wounds or frequent direct skin contact. (Additional information about environmental
cleaning and disinfection is provided in MRSA Infections: Information for Jails and Prisons.)
People with MRSA and other staph skin infections - especially boils or wounds that are
swollen and have pus - can most easily spread staph to others. Skin infections should
be taken seriously and treated appropriately.
VII.
WHAT ABOUT FAMILY AND FRIENDS OUTSIDE THE PRISON OR JAIL?
It is normal to be concerned about spreading MRSA and other staph to family and friends outside
the jail or prison. However, your family and friends do not have a greater chance of getting MRSA
or other staph infections from you just because you work in a correctional facility. There are many
ways to reduce the risk of spreading MRSA and other staph, starting with frequent hand washing.
(See additional prevention steps below.)
Keep in mind that many people, inside and outside correctional facilities, carry staph on their skin
and do not have an infection. These people are “colonized” with staph. In some places, such as
hospitals and nursing homes, MRSA and other staph infections are relatively common. In other
words, there are many ways that people are exposed to MRSA and other staph.
VIII. HOW CAN MRSA BE PREVENTED AND CONTROLLED IN CORRECTIONAL FACILITIES?
As with other infectious diseases, basic infection control practices should be followed.
Practice good hand hygiene. Wash your hands and encourage patients and their visitors to
practice proper hand washing as well.
Be observant. Encourage patients with skin lesions to follow up with health care staff as soon
as possible. See a doctor if you are concerned about having a skin infection.
Cover draining wounds and damaged skin (sores, cuts, scratches and scrapes) with bandages.
Carefully dispose of bandages containing pus.
Use contact precautions (e.g., gown and gloves) for wound care.
Take care of your skin (avoid dry skin, cuts and scrapes, and keep cuts and scrapes clean
and covered) and encourage patients to do the same.
Encourage patients to take regular showers with soap and warm water.
Do not share personal items such as towels, razors and toothbrushes. Encourage patients
not to share personal items.
Use appropriate personal protective equipment (PPE) (for example, gloves) whenever you
expect to have contact with a patient’s blood or body fluids.
Follow your agency’s infection control guideline.
3
Ointments, balms, Lotions, deodorants, antibiotic creams
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IX.
WHAT ARE OTHER MEANS FOR REDUCING MRSA TRANSMISSION?
Launder sheets, towels, uniforms and underclothing with hot water and detergent and dry on
a hot setting, or use a detergent which has the same effect.
Wear gloves when handling dirty laundry at the facility.
Regularly clean sinks, showers and toilets.
Common sense approaches to keeping surfaces clean will reduce the levels of all bacteria, as
well as many respiratory viruses, on environmental surfaces. In addition, targeted,
appropriate use of surface disinfectants is recommended when MRSA transmission is a
concern.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Appendix 3: MRSA Q&A (Patients)
I.
WHAT IS MRSA?
MRSA stands for “Methicillin-Resistant Staphylococcus Aureus.” MRSA is a type of Staphylococcus
aureus (“staph”) bacteria that is resistant to some antibiotics.
Many people think that MRSA routinely causes unusually severe disease. Although some people
become ill with serious infections such as pneumonia, bloodstream infections, or bone infections,
these types of illness are rare in healthy people who get MRSA skin infections. With prompt, proper
medical care, MRSA can be treated successfully.
II.
WHAT ARE THE SYMPTOMS OF AN INFECTION CAUSED BY MRSA?
Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean that a
person has a staph or MRSA skin infection. Occasionally, staph, including MRSA, also can cause
more serious problems such as surgical wound infections, bloodstream infections and pneumonia.
The only way to tell the difference between MRSA and other staph infections is with lab tests.
Ask to see the health care staff if you think you have a skin infection. They will decide what tests
and treatment are necessary, if any.
III.
HOW ARE MRSA INFECTIONS TREATED?
Incision and drainage is the primary treatment for abscesses (collections of pus) and should be
performed whenever possible. Sometimes treatment requires the use of antibiotics. If antibiotics are
needed, it is important to use the medication as directed unless a doctor says to stop. If the infection
has not improved within a few days after seeing a doctor, it is important to contact the doctor again.
MRSA infections also require good wound and skin care: keeping the area clean and dry, washing
hands after caring for the area, and carefully disposing of any bandages.
IV.
IS MRSA A PROBLEM IN CORRECTIONAL FACILITIES?
MRSA is not necessarily a problem in all correctional facilities. Many people, including patients and
corrections officers, carry staph (including MRSA) in their nose or on their skin, do not know they
are carrying it, and do not get skin infections.
However, some conditions can lead to MRSA/staph infections in prisons and jails (see below) and
in other settings where people have a lot of direct contact and skin damage can occur, like sports
teams.
V.
WHAT CAN LEAD TO A MRSA/STAPH INFECTION IN A PRISON OR JAIL?
Direct contact: To get a MRSA or other staph infection, you first must get the bacteria on your
skin. Staph, including MRSA, are spread by direct skin-to-skin contact. In correctional
facilities, there may be regular, frequent direct contact among patients and correctional
officers. For example, when one person shakes hands with another, tackles or wrestles with
another person, gets “patted down” without gloves, or has some other direct contact with the
skin of another person, staph can be passed from one person to another. This happens in any
situation where there is direct contact, not just in jails or prisons.
Staph also can spread by contact with items that have been used by people with staph on
their skin, like towels or athletic equipment shared in the gym.
Lack of hand washing: The best way to prevent skin infections, and many other infections,
is to wash your hands frequently. MRSA and other staph can be removed from your hands by
washing with soap and water. Daily showering is helpful to remove bacteria from the skin.
Wearing shower shoes can protect your feet from bacteria and fungi as well.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Cuts and scrapes: To cause infection, MRSA and other staph need to get into the skin. This
can happen through a scrape, scratch or wound. MRSA also can enter the body when nonsterile equipment is used in body piercing and tattooing.
Contact with personal items contaminated with drainage from infected scrapes, cuts
and other wounds. These items include contaminated bandages, towels, soaps, topical
preparations*4, athletic or gym equipment, and uniforms or other clothing.
People with MRSA and other staph skin infections—especially boils or wounds that are
swollen and have pus—are most likely to spread staph to others. Skin infections should
be taken seriously. If you have a skin infection, ask to see the health care staff.
VI.
WHAT ABOUT FAMILY AND FRIENDS OUTSIDE THE PRISON OR JAIL?
It is normal to be concerned about spreading MRSA and other staph to family and friends outside
the jail or prison. There are many ways to reduce the risk of spreading MRSA and other staph,
starting with frequent hand washing. See additional prevention steps below.
VII.
HOW CAN MRSA BE PREVENTED AND CONTROLLED IN CORRECTIONAL FACILITIES?
Practice good hand hygiene. Wash your hands often with soap and water for at least 20
seconds.
Take care of your skin and any cuts or scratches. If you notice any lumps, bumps or lesions,
never try to open them yourself. Always ask the health care staff to look at it as soon as
possible)
Avoid getting dry skin. Dry skin can crack and make an infection more likely. Do not share
personal items such as towels, razors and toothbrushes.
Cover damaged skin (cuts, scrapes and scratches) and draining wounds with bandages.
Carefully dispose of bandages containing pus or blood.
Shower regularly with soap and warm water.
Use a barrier (clean towel or clothing) between your skin and equipment that is shared with
others, like exercise equipment in the gym.
Request to see the health care staff if you think you have a skin infection.
The best way to prevent MRSA infections, and many other infections, is to wash your hands
frequently.
4
Ointments, balms, lotions, deodorants, antibiotic creams
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Appendix 4: MRSA Reporting Template
Patients – MRSA SSTI
Month/Year
Total Wounds
Wounds Cultured
MRSA + Culture
Staff
% MRSA +
Cultures
MRSA identified
≤10 days after
adm.
Acquired Prior
to Custody*
MRSA identified
≥11 days after
adm.
Acquired While
in Custody*
MRSA + Culture
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
Average
*Definition is for surveillance purposes only.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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HIV Prophylactic Post Exposure Medications
I.
BACKGROUND
Percutaneous exposures continue to occur for healthcare workers. The average risk of acquisition
of HIV through percutaneous exposure to HIV-infected blood is approximately 0.3%. The risk is
increased by:
Deep injury to the exposed health care worker
Visible blood on the device
Large bore hollow needle
Exposure of the device to the source patient’s vein or artery
High viral titer in known or suspected HIV-positive source patient
II.
PROCEDURE
The following medications and dosages should be used for HIV prophylactic post exposures:
1.
Basic Regimen:
Zidovudine (Retrovir, AZT, ZDV) 300 mg b.i.d. +
Lamivudine (Epivir, 3TC) 150 mg b.i.d.+
Lopinavir/Ritonavir (Kaletra) 400/100 mg b.i.d.
At least two doses of the basic regimen must be on hand at all times. The medication must
+be kept in a secure location where the medical staff can access it immediately.
The medication is to be used for all staff including state correctional employees.
The physician on duty must determine whether the injury is a significant exposure and which
dosage/regimen is appropriate.
PEP should be initiated as soon as possible (i.e., within a few hours rather than days) but, if
appropriate for the exposure, PEP should be started even when the interval since exposure
exceeds 36 hours.
Other considerations (when choosing antiretroviral agents) include pregnancy in the
healthcare worker and exposure to virus known or suspected to be resistant to the
antiretroviral drugs.
Finally, access to clinicians who can provide post-exposure care should be available during
all working hours, including nights and weekends.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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III.
STEP 1: EVALUATION OF EXPOSURE
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IV.
STEP 2: DETERMINE THE HIV STATUS OF THE SOURCE
1
2
3
4
5
6
7
8
Semen or vaginal secretions; cerebrospinal, synovial, pleural, peritoneal, pericardial, or amniotic fluids.
Exposures to OPIM must be evaluated on a case-by-case basis. In general, these body substances are considered a low risk for transmission in healthcare
settings. Any unprotected contact to concentrated HIV in a research laboratory or production facility is considered an occupational exposure that requires
clinical evaluation to determine the need for PEP.
Skin integrity is considered compromised if there is evidence of chapped skin, dermatitis, abrasion, or open wound.
Contact with intact skin is not normally considered a risk for HIV transmission. However, if the exposure was to blood, and the circumstance suggests a
higher volume exposure (e.g., an extensive area of skin was exposed or there was prolonged contact with blood), the risk for HIV transmission should be
considered.
The combination of these severity factors (e.g., large-bore hollow needle and deep puncture) contributes to an elevated risk for transmission if the source
person is HIV-positive.
A source is considered negative for HIV infection if there is laboratory documentation of a negative HIV antibody, HIV polymerase chain reaction (PCR), or
HIV p24 antigen test result from a specimen collected at or near the time of exposure and there is not clinical evidence of recent retroviral-like illness.
A source is considered infected with HIV (HIV positive) if there has been a positive laboratory result for HIV antibody, HIV PCR, or HIV p24 antigen or
physician-diagnosed AIDS.
Examples are used as surrogates to estimate the HIV tier in an exposure source for purposes of considering PEP regimens and do not reflect all clinical
situations that may be observed. Although a high HIV titer in an exposure source has been associated with an increased risk for transmission, the possibility
of transmission from a source with a low HIV titer\ also must be considered.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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V.
STEP 3: DETERMINE THE POST-EXPOSURE PROPHYLAXIS (PEP) RECOMMENDATIONS
Exposure Type
HIV Positive Class I
HIV Positive Class 2
Percutaneous—Less Severe
Recommend basic regimen
Recommend expanded regimen
Percutaneous—More Severe
Recommend expanded regimen
Recommend expanded regimen
Mucous Membrane/Non-intact Skin—Small Volume
Consider basic regimen
Recommend basic regimen
Mucous Membrane/Non-intact Skin—Large Volume
Recommend basic regimen
Recommend expanded regimen
1
VI.
Source of unknown HIV status: PEP generally not warranted, consider basic regimen for source with HIV risk factors.
Unknown source: PEP generally not warranted; consider basic regimen where exposure to HIV-infected person likely
REFERENCE
Adapted from Updated US Public Health Service Guidelines for the Management of
Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Post
exposure Prophylaxis. www.jstor.org/stable/10. 1086/672271.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Sexually Transmitted Diseases Treatment Recommendations
DX
Recommendation
Alternative Regimen
Primary and Secondary Syphilis
Early Latent Syphilis (less than 1
year duration)
Benzathine penicillin 2.4 million units IM in a
single injection
1.
Doxycycline 100 mg p.o. b.i.d. for 14 days
Latent Syphilis (greater than 1
year duration or unknown)
Benzathine penicillin 2.4 million units IM for
three doses at 1-week intervals
1.
Doxycycline 100 mg p.o. b.i.d. for 28 days
Neurosyphilis
Aqueous crystalline penicillin G 18−24 million
units per day, administered as 3−4 million
units IV every 4 hours or continuous infusion,
for 10−14 days
Procaine penicillin 2.4 million units IM once daily
plus Probenicid 500 mg orally four times a day,
both for 10–14 days
Syphilis during pregnancy
Penicillin regimen appropriate for stage of
syphilis
Penicillin allergic pregnant patients should be
desensitized to penicillin
1.
Gonorrhea
Ceftriaxone 250 mg IM in a single dose
+Azithromycin 1 g PO as a single dose
1.
Chlamydia
1.
Chlamydia during pregnancy
Amoxicillin 500 mg orally three times
daily for 7 days
1.
Acyclovir 400 mg three times daily for
7−10 days
OR
Acyclovir 200 mg orally five times daily
2.
Genital herpes (HSV), recurrence
Doxycycline 100 mg orally twice daily for
7 days
OR
Azithromycin 1 g orally in a single dose
1.
Genital herpes (HSV), first clinical
episode
2.
Ciprofloxacin 500 mg orally in a single dose
OR
Levofloxacin 250 mg orally in a single dose
AND Azithromycin 1g PO as a single dose
Plus, treat for Chlamydia infection if it has
not been ruled out
Episodic therapy:
1. Acyclovir 400 mg three times daily for 5
days
1.
Azithromycin 1 g orally in a single dose
Suppressive therapy:
1. Acyclovir 400 mg orally twice daily,
indefinitely
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Infirmary
Infirmary Services
Services Manual
Manual
WEXFORD MILLER
WEXFORD
MILLER 000892
000892
Medical Guidelines
Region: New Mexico
Infirmary Services
I.
PURPOSE
The purpose of this Infirmary Services Manual is to establish procedures for providing infirmary
services. A separately defined medical area/infirmary shall be maintained that provides organized
bed care and services for patients admitted for 24 hours or more and is operated for the expressed
or implied purpose of providing nursing care and observation for persons who do not require a
higher level of inpatient care.
II.
GUIDELINE
The inpatient unit shall be available to provide limited medical and nursing services for patients
with health care problems in an inpatient setting. Inpatient services may include medical care,
isolation, observation, first aid, nursing care and post-operative care. Patients may also be assigned
to the inpatient unit for sheltered housing. In-patient care is not used as a substitute to hospital
level care (ICU, medical/surgical acute care), or a licensed nursing care facility. It is generally
recommended that all patients discharged from acute inpatient facilities be placed in the infirmary
for observation, unless such a patient is deemed stable for the general population. Clinical issues
are the responsibility of the Site Medical Director or designee and operational issues are the
responsibility of the Health Services Administrator and the Director of Nursing.
III.
SPECIFICATIONS
Inpatient units will be able to provide the following:
Twenty-four hour nursing coverage. A supervising RN is on site at least once every 24 hours.
24-hour on-call physician coverage.
The frequency of physician rounds will be determined by site specific guideline based on the
categories of care provided but all sites will meet a minimum of physician rounds and resulting
documentation of patient condition three (3) times/week.
All patients will be housed in cells within sight or hearing of health staff. This may be
accomplished by a call button system. (The use of non-medical staff to alert health staff does
not constitute compliance.)
All patients discharged from a hospital admission (not an Emergency Room visit unless
specified by the ER provider) will be admitted as acute status until they are seen by the
provider and released from such status.
There will be an inpatient medical record for each person on the unit.
Admission and discharge from the unit occur only on the order of a physician or other provider
(NP’s, PA’s, dentists) where permitted by their scope of practice. This will be specified in the
site specific guideline.
Inpatient unit care (correlates to infirmary care).
Infirmary care will be directed by the physician designee or Regional Medical Director in
his/her absence.
Nursing services will be provided under the direction of a registered nurse.
A manual of nursing care procedures is available and is consistent with the states nurse
practice act and licensing requirements.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IV.
PROCEDURE
Definitions:
1.
Infirmary Admission: In the inpatient unit, all patient care is under the supervision of
the Medical Director or designee. Examples include, but are not limited to, medical
conditions which require continuous monitoring by physicians and nurses, patients
recovering from surgery, patients receiving long-term IV antibiotics, etc.
2.
Observation Admission: An observation admission is a stay of less than 24 hours for
the purpose of monitoring a patient. Examples include, but are not limited to,
observation and assessment, dressing changes, diagnostic testing preps, preparing a
patient for surgery, etc.
3.
Shelter Housing/Maintenance Care: This is care for patients who by virtue of a physical
condition are not candidates for general population. Their need for this type of housing
is primarily for support, supervision, and safety.
4.
Discharge Status: This applies to a patient who has been discharged from the inpatient
unit by a physician but is awaiting transport to his/her regular housing unit by security.
General standards for infirmary admissions:
1.
All hospital discharges will first be sent to infirmary unless the infirmary physician.
2.
Security must ensure that the on-site medical director or the on-call physician has
accepted all hospital discharges. No discharge will be accepted without a hospital
discharge summary. The discharge summary shall include at a minimum:
a.
Admitting and discharge diagnoses
b.
Condition
c.
Summary of hospital course
d.
Procedures performed
e.
Diet
f.
Discharge medications
g.
Special care requirements
h.
Needed follow-up appointments
3.
Each placement of a patient in the infirmary shall be considered an acute infirmary
admission, unless identified as a 23-hour observation admission.
4.
The accepting physician (site physician or on-call physician) should make every effort
to ensure that physician to physician communication has occurred. If the
communication was not initiated by the discharging hospital, or did not occur and/or
a written discharge summary was not received by the accepting infirmary physician, the
Regional Medical Director and Chief Medical Officer should be notified so that the
appropriate medical and administrative leadership at the discharging hospital can be
notified.
5.
Mental health infirmary admissions may or may not involve the assignment of suicide
observation status (SOS) (suicide precautions), depending upon whether the patient is
determined to be at risk for serious self-injury. Patients without risk for serious selfinjury, but who nevertheless present with acute symptoms of mental impairment (e.g.,
disorientation, delusions hallucinations, disorganized speech), may be admitted for
observation without suicide precautions. The admitting clinician must order the
frequency of the observations and any other restrictions.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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6.
Each medical infirmary admission shall provide a medical plan of care developed by the
clinician for each patient (reflected in the orders and/or SOAPE note). This plan shall
include directions to health care staff regarding their roles in the care and supervision
of the patient. The Site Medical Director will provide general supervision for all personnel
authorized to admit patients to the infirmary.
Documentation:
1.
A nursing assessment will be completed and documented within two (2) hours of
admission.
2.
A mental health assessment will be completed and documented for mental health
infirmary admissions. Mental health or medical nursing assessments will be completed
each shift unless otherwise ordered by the clinician. Patients admitted for mental health
reasons who have acute or exacerbated chronic medical problems or patients admitted
for medical concerns who exhibit mental health impairment shall be assessed according
to physician consent.
3.
A patient admitted to the infirmary shall have a separate and complete inpatient record
which shall contain, at the minimum:
a.
Chief complaint
b.
History of present illness
c.
Admitting orders that include the admitting diagnosis, medication, diet, activity
restrictions, diagnostic tests required and other follow-up
d.
Past history and review of systems
e.
Vital signs (on admission and at least every shift thereafter unless otherwise
ordered by the physician)
f.
Initial impression
g.
Medical care plan (as per paragraph II.C above)
h.
Nursing and clinician progress notes/shift assessments
i.
Mental health nursing progress notes/shift assessments; and
j.
Discharge summary
4.
A nursing assessment is required on each shift for infirmary and observation medical
and mental health patients. This may be accomplished by use of a nursing assessment
shift flow sheet. Additional information related to the assessment will be documented
on the back of the nursing form. All documentation shall be placed in chronological
order.
5.
A physician admitting note will be conducted on all infirmary admissions within 24
hours of the patient’s arrival in the infirmary for any medical reason. The physician
admitting note will document at least the following: a complete patient medical, social
and family history, clinical chart review, review of systems, admitting diagnosis, activity
restrictions, assessment and differential diagnosis, laboratory and diagnostic studies
required, physician orders for medications, diet, and plan of care.
6.
Physician progress notes will be written following all physician rounds, a minimum of
three (3) times/week and with any noted change in patient condition. All infirmary
patients must be within sight or sound of staff.
7.
Provided at the physician’s discretion, patients will be given information on Advance
Directives and given the choice of completing the Advance Directive form according to
the guideline on advance directives.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Infirmary Medications:
1.
When a patient is admitted to the infirmary, he/she is to bring all keep-on-person (KOP)
medications with her/him. When these medications are for medical conditions
unrelated to the admitting medical/mental health condition, e.g., chronic clinic meds,
the medications may be continued from the patient’s own supply when so indicated by
a physician’s order. Patient medications that are to be used during the inpatient stay
will be kept in a designated area in the nursing unit of the infirmary in the Pyxis unit
(if available) or in patient specific blister packs.
2.
Within 48 hours of discharge from the infirmary, a discharge summary shall be
completed by the physician or clinical associate. The discharge summary shall include
the course of treatment in the infirmary, final diagnosis, medications, and follow up
care. In addition, the summary shall be signed and dated by the clinician completing
the report. A copy of this summary is placed in the patient outpatient record.
Infirmary Admission:
1.
PHYSICIAN
a.
Gives a written or verbal order for admission
b.
Gives written or verbal orders regarding patient care
c.
Completes a clinical chart review and admission note within 24 hours excluding
weekends.
d.
Makes rounds per site-specific guideline but a minimum of three (3) times/week
and other times as needed for change in patient condition. Physician progress
notes will be written following all rounds and other patient contact.
e.
Reviews most recent nursing notes
f.
Writes a note specifying changes in treatment/plan of care in the in-patient unit
progress notes
g.
Writes new orders on the order sheet; signs off on verbal orders
Reviews, initials and dates all diagnostic results. Progress notes are written to
explain any abnormally lab and diagnostic results along with a plan of care to
address or further investigate abnormal results.
2.
NURSING
a.
Ensures that the physician orders are processed and carried out
b.
Completes a nursing admission assessment within 2 hours of admission
c.
Performs and documents a head-to-toe assessment:
i.
Every shift
ii.
As ordered by the physician
d.
Makes rounds with the physician as appropriate
e.
Notifies the physician of any significant change in the patient’s condition and
documents the contact in SOAPE format
f.
Takes vital signs (temperature, pulse, respirations, BP, pain scale) at least once
per shift and/or more frequently if instructed by physician or as indicated by the
nurse’s nursing assessments.
g.
Uses the graphics flow sheet to document vital signs, weight, I/O, ADL’s
h.
Ensures that treatment orders, medications, etc., are administered as prescribed
and are documented
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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i.
Documents that activities of daily living are being met
j.
Documents patient teaching and education
k.
Gives verbal and written reports with the oncoming shift before leaving the unit
l.
Notifies the on-call physician of abnormal study results (e.g., x-ray, lab, EKG,) if
no physician present.
23-hour Observation Status:
1.
23-hour observation status does not require an infirmary record. This is considered
outpatient status. All information (e.g., physician orders, progress notes) will be
documented in the patient’s regular chart. If the patient remains in the infirmary more
than 23 hours, an admission order must be obtained and an infirmary record initiated.
All information documented prior to the actual admission time shall remain in the
outpatient record.
2.
23-hour medical observation status: The on-call physician must be notified of this
action within a reasonable period of time.
a.
b.
PHYSICIAN
i.
Gives a written or verbal order for admission
ii.
Gives written or verbal orders regarding patient care
iii.
Writes a completed admit note within twenty-four (24) hours of admission
iv.
Completes a clinical chart review within twenty-four (24) hours excluding
weekends of admission and writes an admission note.
v.
Writes a note specifying changes in treatment/plan of care in the infirmary
progress notes
vi.
Writes new orders on the order sheet; signs off on verbal orders
vii.
Reviews, initials and dates all diagnostic results
viii.
If approaching maximum hours allowed for observation, makes decision
whether to admit, discharge, etc.
ix.
Progress notes are written per guideline if observation status exceeds 24
hours.
NURSING
i.
Ensures that the physician’s orders are processed and carried out
ii.
Completes a nursing admission assessment within 2 hours of admission
iii.
Performs a head-to-toe assessment at least once daily and documents; other
shifts do a focused note in SOAPE format
iv.
Makes daily rounds with the physician as appropriate
v.
Notifies the physician of any significant change in the patient’s condition
and documents the contact in SOAPE format
vi.
Takes vital signs (temperature, pulse, respirations, BP, pain scale) daily
and/or more frequently if instructed by physician or as indicated by the
nurse’s nursing assessments
vii.
Uses the graphics flow sheet to document vital signs, weight, I/O, ADL’s
viii.
Ensures that treatment orders, medications, etc., are administered as
prescribed and are documented
ix.
Documents that activities of daily living are being met
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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c.
d.
x.
Documents patient teaching and education daily
xi.
Gives a report and does walking rounds with the oncoming shift before
leaving the unit
xii.
23-hour mental health observation status: Nursing staff may place a
patient in the infirmary or an isolation management room (IMR) if the
assessment identifies the presence of psychotic symptoms or risk of serious
self-injury or other types of symptoms that may reflect possible mental
impairment; however, the on-call psychiatrist must be notified immediately.
(1)
Physician orders must be obtained as to the level of observation
required (minimally q. 15 minutes) and what articles the patient is
allowed to have (e.g., clothing). These are to be recorded in the
outpatient record.
(2)
Mental health staff shall be notified of this admission and the patient
shall be assessed by mental health staff on the morning of the next
workday. Documentation of necessary follow-up will be made by
mental health staff after an evaluation and such documentation will
be entered in the medical record. Any change in the patient’s
condition prior to the evaluation must be reported to the physician.
(3)
Appropriate documentation must be initiated if any observation
frequency (e.g., every 15 minutes) is ordered by the physician. The
form will be filed under miscellaneous in the outpatient record.
(4)
A patient who requires SOS precautions (not just observations) due to
assessed risk for serious self-injury shall not be placed on 23-hour
observation status. Any SOS level of precaution requires an MHTC or
infirmary admission.
PSYCHIATRIST
i.
Gives a written or verbal order for admission
ii.
Gives written or verbal orders regarding patient care
iii.
Writes a completed admit note within twenty-four (24) hours of admission
excluding weekends.
iv.
Completes a clinical chart review within twenty-four (24) hours of admission
and writes progress note
v.
Makes rounds on designated patients
vi.
Writes a note specifying changes in treatment/plan of care in the infirmary
progress notes
vii.
Writes new orders on the order sheet; signs off on verbal orders
viii.
Reviews, initials and dates all diagnostic results. Progress notes are written
to explain any abnormally lab and diagnostic results along with a plan of
care to address or further investigate abnormal results.
ix.
If approaching maximum hours allowed for observation, makes decision
whether to admit, discharge, etc.
x.
Progress notes are written if observation status exceeds 24 hours.
MENTAL HEALTH NURSING
i.
Ensures that the physician’s orders are processed and carried out
ii.
Completes a nursing admission assessment within two (2) hours of
admission
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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iii.
Performs a head-to-toe assessment at least once daily and documents; other
shifts do a focused note in SOAPE format
iv.
Makes rounds with the physician as appropriate
v.
Notifies the physician of any significant change in the patient’s condition
and documents the contact in SOAPE format
vi.
Documents patient teaching and education daily
vii.
Gives a report and does walking rounds with the oncoming shift before
leaving the unit
viii.
Rewrites a 1:1 watch form every four (4) hours
Sheltered Housing/Maintenance Care
1.
2.
PHYSICIAN
a.
Gives a written or verbal order for admission
b.
Gives written or verbal orders regarding patient care
c.
Writes a completed admit note within twenty-four (24) hours excluding weekends
of admission
d.
Completes a clinical chart review and writes progress notes if being admitted from
other than the in-patient unit
e.
If being admitted from the in-patient unit, a progress note is written including the
reason for transfer
f.
Changes in treatment/plan of care are to be noted in the infirmary progress notes
with orders written on the order sheet
g.
Reviews, initials, and dates all diagnostic results. Progress notes are written to
explain any abnormally lab and diagnostic results along with a plan of care to
address or further investigate abnormal results.
h.
Conducts rounds as indicated by the patient’s needs, with minimally an
assessment and completion of a progress note every week
i.
Every 90 days writes an order for continued sheltered housing/care, to indicate
why alternative housing could not be considered
NURSING
a.
If patient is coming from in-patient unit for admission, makes a note in chart
about the reason for the admission
b.
If the patient is coming from other sites, completes a nursing admission
assessment within two (2) hours of admission
c.
Performs and documents a head-to-toe assessment:
i.
Biweekly
ii.
As ordered by the physician
d.
Takes vital signs, weekly or more frequently if ordered, and records them on
graphic flow sheet
e.
Completes SOAPE charting as indicated by patient’s condition/needs, or at least
biweekly
f.
Completes graphic sheet daily for activities of daily living
g.
Writes and follows care plan
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Discharged but not immediately transferred to regular housing unit:
1.
2.
PHYSICIAN
a.
Makes rounds weekly
condition/needs
or
more
frequently,
b.
Writes progress note if change in condition
c.
Writes orders as appropriate for condition
as
indicated
by
patient’s
NURSING
a.
Maintains medical record chart until physically transported from the unit
b.
Performs and documents a head-to-toe assessment:
c.
i.
Biweekly
ii.
As ordered by the physician
Completes SOAPE charting as indicated by the patient’s condition/needs, or at
least biweekly.
Discharge procedure:
1.
PHYSICIAN
a.
Writes an order for discharge indicating that the patient is to be discharged from
the in-patient unit back to the regular housing assignment
b.
Updates chrono form
c.
Completes a discharge summary that will include:
d.
2.
i.
Clinical course in the in-patient unit
ii.
Current active medical problems
iii.
Medications
iv.
Pending appointments
v.
Specific discharge instruction
In the event that the security staff does not transfer the patient on the same day
as discharge, the summary is to be kept in the front of the medical jacket as well
as in the infirmary section of the medical record. Physician will update summary
if condition changes before transfer. Progress notes will be written by the
physician daily until patient is moved out of the infirmary or changed to housing
status at which time progress notes will be written at a minimum of three (3) times
per week.
NURSING
a.
Once the order for discharge has been written:
i.
Notes discharge order
ii.
Takes off any orders on discharge summary which may need attention
before transfer occurs
iii.
Breaks down chart according to protocol
iv.
Enters discharge into In-Patient Log
v.
Changes to Discharge Care standards and charting if transfer of patient is
not immediate
vi.
Notes chrono
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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vii.
Gives a copy of the chrono to the Unit Manager and the original to Medical
Records
b.
Makes an entry in the progress note indicating: Patient instructions given
c.
Notifies the following of the discharge:
d.
e.
i.
Correctional unit manager via memo
ii.
In-patient unit charge nurse verbally
Copy of chrono to the following:
i.
Medical Records (original)
ii.
Classification/Case Worker
iii.
To chart
When the patient is physically leaving the in-patient unit:
i.
Places all MARs and patient specific medications inside of the medical
transport bag
ii.
Places discharge summary in top of section 2
iii.
Completes medical record receipt and places completed medical chart with
all volumes and x-rays into transport bag
iv.
Locks transport bag and has transport officer sign the medical records
receipt
v.
Keeps a copy of the medical record receipt
vi.
Enters discharge into the log
vii.
Notifies security to have room cleaned
viii.
Deletes the patient’s name from the nursing report, diet list, and Kardex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Appendix 1: Recommendations for Who Can Be Housed in an Infirmary
A.
Pneumonia
B.
Medical observation
C.
Non-displaced fracture, or stabilized displaced fracture with no neuro-vascular compromise
(until evaluated by physician)
D.
Cellulitis
E.
Dehydration (hemodynamically stable)
F.
Urolithiasis
G.
1st and 2nd degree Burns <20% of body
H.
Osteomyelitis
I.
Hypertension without acute symptoms, i.e., severe headache, altered mental status
J.
COPD with acute exacerbation, but oxygen saturation >85%
K.
URI
L.
Moderate CHF
M.
Administration of I.V. antibiotics
N.
Moderate gastroenteritis
O.
Diabetes stabilization without associated mental changes (hyperglycemia with mild
dehydration)
P.
Wound care (including debridement of some wounds)
Q.
Chronic chest pain management – non-cardiac or cardiac with normal EKG and negative
Troponin
R.
Mild to moderate trauma (case-specific)
S.
Pyelonephritis
T.
Inflammatory Bowel’s Disease (uncomplicated by severe fluid loss or bleeding) only if
accompanied by bleeding or fluid loss
U.
Opportunistic infections secondary to AIDS (uncomplicated)
V.
24-hour observation after ER visit and hospital discharge
W.
Rule out TB (negative airflow rooms)
X.
Lumbar puncture, depending on physician skill level
Y.
Paracentesis, depending on physician skill level
Z.
Hospice care (must have signed DNR)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Appendix 2: Recommendations for Who Should NOT Be Housed in an Infirmary
A.
Syncope, depending on symptoms
B.
Severe lower and upper GI Bleeding
C.
Frank hemoptysis, depending on vital signs, blood volume and X-Ray capability
D.
Frank hemetemesis, depending on vital signs and blood volume
E.
Frank hematochezia, depending on vital signs and blood volume
F.
Lacerated tendons
G.
Obvious open fracture
H.
Penetrating Injuries, unless determined to be in a non-vital area
I.
New onset arrhythmia
J.
DKA: BS >500 associated with mental changes
K.
Semi-coma/coma
L.
Myocardial Infarction
M.
Abdominal-peritoneal symptoms, due to inflammation or possible ruptured viscus or signs of
rebound tenderness or abdominal rigidity
N.
Acute blood loss and hemodynamically unstable
O.
Temp. >105 and <94 (lower temp taken rectally)
P.
Severe abnormal electrolytes: K+ <2.5 or >6.0; Na+ <120, depending on other symptoms, i.e.,
abnormal EKG or altered mental status
Q.
Acute altered mental state in non-mental health patient
R.
Respiratory emergency (resp. >30 and <8; oxygen saturation <90%; using accessory
respiratory muscles)
S.
Status epilepticus
T.
Pulmonary edema
U.
Unstable angina
V.
Anaphylactic shock
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Influenza
Influenza Outbreak
Outbreak Guidelines
Guidelines in
in
Corrections
Corrections
WEXFORD MILLER
WEXFORD
MILLER 000904
000904
Medical Guidelines
Region: New Mexico
Influenza Virus Management during a Confirmed Outbreak Correctional Institutions
I.
INTRODUCTION
This guideline serves to standardize the approach to an influenza outbreak in correctional facilities.
Recommendations on the appropriate use of influenza vaccines and diagnostic testing will not be
addressed here. The above references were used to summarize up-to-date information on the
current recommendations for an influenza outbreak, including isolation procedures and antiviral
use.
II.
INFLUENZA VIRUS TRANSMISSION
Influenza viruses are thought to spread from person to person primarily through large-particle
respiratory droplet transmission (i.e., when an infected person coughs or sneezes near a susceptible
person). This type of transmission requires close contact between source and recipient persons,
because droplets generally travel only short distances (approximately ≤6 feet) through the air.
Airborne transmission over longer distances (i.e., from one patient’s room to another) has not been
documented and is not thought to occur. Indirect contact transmission via hand transfer of
influenza virus from virus-contaminated surfaces or objects to mucosal surfaces of the face (i.e.,
nose and mouth) or airborne transmission via small particle aerosols in the vicinity of the infectious
person also might occur; however, this relative contribution of the different modes of influenza
transmission is unclear. The typical incubation period for influenza is 1−4 days (average=2 days).
The serial interval time (the time between onsets among epidemiologically related cases) for
influenza among household contacts is estimated to be 3−4 days. Adults can shed influenza virus
from the day before symptoms begin through 5−10 after the illness onset. However, the amount of
virus shed, and the presumed infectivity, decreases rapidly by 3−5 days after illness onset, with
shedding completed in most persons by 5−7 days after illness onset. Prolonged viral replication has
been reported in adults with severe disease, including those with comorbidities or those patients
receiving corticosteroid therapy. Severely immunocompromised persons can shed virus for weeks
or months.
III.
DEFINITIONS:
Influenza like Illness: Abbreviated ILI. Defined in patients with fever (100°F (38°C) plus either
cough or sore throat − in the absence of a known cause other than influenza.
Exposure: Defined as having been in a setting where there was a high likelihood of contact
with respiratory droplets and/or body fluids of a person with ILI.
Close Contact: Typically does not include activities such as walking by an infected person or
sitting across from a symptomatic patient in a waiting room or office.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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IV.
CLINICAL SIGNS AND SYMPTOMS OF UNCOMPLICATED SEASONAL INFLUENZA INFECTION
Clinical findings include a toxic appearance in the initial stages, hot and moist skin, a flushed face,
and injected eyes. Influenza-like illness (ILI) is defined in patients with fever (100◦F (38◦C)) plus
either cough or sore throat - in the absence of a known cause other than influenza.
Range of
Symptoms
Fever
Cough
Malaise
Chills
Headache
Anorexia
Rhinorrhea
Myalgia
Sore throat
Tender cervical LAD
GI symptoms
V.
Percentage
Frequency
≈100%
≈85%
≈80%
≈70%
≈65%
≈60%
≈60%
≈53%
≈50%
≈10%
<10%
PATIENTS AT HIGH RISK FOR THE COMPLICATIONS OF INFLUENZA
Influenza virus infection has been associated with worsening of certain clinical conditions.
Individuals in the following risk groups have a higher risk of developing complications to seasonal
influenza:
Pregnant women or post-partum women within two (2) weeks of delivery
Adults 65 years of age or older
Persons with Chronic Pulmonary disorders, including Asthma
Persons with Cardiovascular disorders, except hypertension
Persons with Renal disorders
Persons with Hepatic disorders
Persons with Hematological disorders (including sickle cell anemia)
Persons with neurologic disorders (including cerebral palsy, epilepsy, stroke, intellectual
disability, mod-severe developmental delay, muscular dystrophy, spinal cord injury)
Persons with serious mental health disorders
Persons with Neuromuscular disorders
Persons with Diabetes mellitus
Persons with immunosuppression, including that caused by medications or HIV+
Morbid obesity (BMI ≥40)
Term
Isolation
Quarantine
Definition
Confining individuals who are sick with influenza either to single rooms or by cohorting them with other
influenza patients.
Confining asymptomatic persons who are contacts of influenza cases, while they are in the incubation
period (until 4 days after exposure ended). The purpose is to assure that patients who are known to
have been exposed to the flu virus are kept separate from other patients to assess whether they
develop flu symptoms.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
VI.
MANAGEMENT AND CONFINEMENT OF SUSPECT AND CONFIRMED CASES
Patients with confirmed influenza infections or those with ILI should be placed in isolation.
Immediately place a face mask on all individuals who are identified as having ILI symptoms.
They should be isolated or cohorted with other sick patients.
Rooms where patients with ILI are either housed alone or cohorted should be designated
“Influenza Isolation Units.” In general, no special air handling is needed. Depending on how
ill the patients are, bunk beds may or may not be suitable. Ideally the unit should have a
bathroom attached. If not, patients will have to wear a face mask to go to the bathroom outside
the room. The door to this unit should remain closed with signage indicating that it is an
Influenza Isolation Unit and listing recommended personal protective equipment (PPE).
Within the Influenza Isolation Unit, Standard Precautions should be followed. This includes
either respirator or face mask for the patient (depending on guidance from the Medical
Director). Healthcare personnel caring for patients should wear gloves for direct patient
contact or contact with potentially contaminated areas in the patient’s environment, eye
protection (goggles or face shield) if splash or spray of body fluids is anticipated, and face
masks. Gowns are recommended by the CDC if health care providers are within 6 feet of the
patient. Hand hygiene is recommended before donning and after removing gloves.
Identify close contacts to flu cases and quarantine them in a separate unit.
The duration of quarantine during an influenza outbreak in a facility is four (4) days.
As feasible, beds/cots of quarantined patients should be placed at least 3−6 feet apart. These
patients should be restricted from being transferred, having visits, or mixing with the general
population.
A face mask is recommended for staff who are in direct, close contact (within 6 feet) of
quarantined patients.
Once multiple flu cases occur within multiple housing units, a decision may be made to
abandon contact investigation and the subsequent quarantine of contacts. Lock-down should
be considered on a case-by case basis.
Actively monitor the number, severity, and location of cases of ILI.
Separate patients with ILI from others by placing them in individual cells when possible
Consider separating cell mates of sick patients for 48 hours for observation
Provide care of patients with ILI, including scheduled temperature checks and access to
increased p.o. fluids. Also provide tissue, a plastic bag for the proper disposal of used tissues,
and alcohol-based hand sanitizers
Restrict movements of patients with ILI within the facility and restrict patients from leaving,
transferring from or to another facility during the seven (7) days after the onset of symptoms
or until 24 hours after symptoms resolve, whichever is longer, unless necessary for medical
care, infection control, or lack of isolation space.
If multiple patients become ill with confirmed influenza virus infection, they should be housed
in a designated area of the institution specifically for sick persons (i.e., infirmary or other).
Designate staff to care for these individuals only, and do not have these patients circulating
in other parts of the institution. Limit movement of designated staff between different parts of
the institution to decrease the risk of staff spreading influenza to other parts of the facility.
Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned
separately, but they should not be shared without thorough washing. Linens (such as bed
sheets and towels) should be washed by using laundry soap and tumbled dry on a hot setting.
Individuals should wash their hands with soap and water or an alcohol-based hand sanitizer
immediately after handling dirty laundry.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Assess and treat as appropriate soon-to-be released patients with ILI or other flu symptoms
and make direct linkages to community resources to ensure proper isolation and access to
medical care.
The facility health care providers should identify and address the special health needs of
persons at high risk for complications following infection with seasonal influenza.
VII.
ANTIVIRAL POST-EXPOSURE PROPHYLAXIS RECOMMENDATIONS
Antiviral post-exposure prophylaxis involves providing medication to prevent development of
influenza. Because use of antiviral medications for prophylaxis may contribute to the development
of antiviral resistant influenza strains, antiviral prophylaxis should be provided under a limited
number of circumstances, as detailed below.
VIII. INFLUENZA POST-EXPOSURE CHEMOPROPHYLAXIS EFFECTIVENESS
Post-exposure chemoprophylaxis with a neuraminidase inhibitor (oseltamivir = Tamiflu®) generally
should be reserved for those who have had recent close contact with a person with confirmed
influenza. Persons who receive an antiviral medication for chemoprophylaxis might still acquire
influenza virus infection and be potentially able to transmit influenza virus, even if clinical illness
is prevented.
IX.
INFLUENZA POST-EXPOSURE CHEMOPROPHYLAXIS INDICATIONS
Chemoprophylaxis with antiviral medications is not a substitute for influenza vaccination
when influenza vaccine is available. Adverse events associated with antiviral medications are
generally mild and self-limited but might result in morbidity resulting from medication side
effects that outweigh the potential benefit of antiviral chemoprophylaxis. In addition,
indiscriminate use of chemoprophylaxis might promote resistance to antiviral medications or
reduce antiviral medication availability for treatment of persons at higher risk for influenza
complications or who are severely ill. Patients receiving post-exposure antiviral
chemoprophylaxis should be informed that chemoprophylaxis lowers but does not eliminate
the risk for influenza, that susceptibility to influenza returns once the antiviral medication is
stopped, and that influenza vaccination is recommended if available. Patients receiving
chemoprophylaxis should be educated to seek medical evaluation as soon as they develop a
febrile respiratory illness suggestive of influenza because influenza virus can still occur while
a patient is on chemoprophylaxis and might indicate infection with a virus resistant to the
antiviral medication used. Two guiding principles must be used when considering postexposure chemoprophylaxis:
1.
For the purposes of assessing possible exposure, the infectious period—the time period
when an exposure may have occurred - is one day before ILI symptoms occur until 24
hours after fever ends.
2.
Antiviral prophylaxis generally is not recommended if more than 48 hours have elapsed
since the last contact with an infectious person. Prophylaxis is not indicated when
contact occurred before or after, but not during, the ill person’s infectious period.
Current guidelines recommend the following persons for post-exposure chemoprophylaxis:
1.
Close contacts of a person with confirmed influenza infection or ILI that are at high risk
for influenza complications (listed above) but have not been vaccinated against the
influenza virus strains circulating at the time of exposure.
2.
Unvaccinated healthcare workers who have occupational exposures and who did not
use adequate personal protective equipment at the time of exposure
3.
Antiviral agents should not be used for post-exposure prophylaxis in healthy patients.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
Region: New Mexico
4.
X.
Antiviral prophylaxis generally is not recommended if more than 48 hours have elapsed
since the last contact with an infectious person. Prophylaxis is not indicated when
contact occurred before or after the ill person’s infectious period (defined above).
TREATMENT OF UNCOMPLICATED INFLUENZA INFECTION
Oseltamivir (Tamiflu®) is indicated for the treatment of uncomplicated acute illness due to influenza
infection if the patient has been symptomatic for ≤2 days. Dose is 75 mg capsules p.o. b.i.d. x 5
days. If CrCl <30 mL/min, dose is decreased to 75 mg p.o. q.d. x 5 days.
XI.
POST-EXPOSURE CHEMOPROPHYLAXIS
Oseltamivir (Tamiflu®) is indicated for post-exposure chemoprophylaxis as listed above.
Oseltamivir should be initiated after close contact with an infected individual. Dose is 75 mg
p.o. q.d. x 10 days.
Live attenuated influenza vaccine should not be administered within two (2) weeks before
Oseltamivir or 48 hours after an Oseltamivir course (due to the Oseltamivir decreasing the
efficacy of the influenza vaccine).
XII.
REFERENCES
Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza. Recommendations of
the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and
Prevention. MMWR. Vol. 60/No. 1. January 21, 2011.
Seasonal Influenza in Adults and Children—Diagnosis Treatment, Chemoprophylaxis, and
Institutional Outbreak management: Clinical Practice Guidelines of the Infectious Diseases
Society of America (IDSA). CID 1009: 48 (15 April). 1003-1032.
Federal Bureau of Prisons Clinical Practice Guidelines on Pandemic Influenza Plan Modules
1-4. October 2012.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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WEXFORD
COMPANIES
Medication
Medication Consent
Consent Forms
Forms
(English
(English and
and Spanish)
Spanish)
WEXFORD MILLER
WEXFORD
MILLER 000910
000910
Medication Consent Forms
MEDICATION: BENADRYL (Diphenhydramine HCL)
PURPOSE: This medication can be used to treat side effects of certain medications.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, blurred vision,
constipation, nausea, dry mouth, difficulty urinating, headaches, nervousness, increased thirst.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
Forgetfulness, confusion, balance problems.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1-2 hours, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff, orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000911
263
Medication Consent Forms
WEXFORD HEALTH SOURCES, INC.
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
BENADRYL (Diphenhydramine HCL)
PROPÓSITO: Esta medicación puede usarse para tratar efectos secundarios de ciertas medicaciones.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
visión borrosa, estreñimiento, náuseas, sequedad en la boca, dificultad al orinar, dolores de cabeza, nerviosismo,
aumento de la sed.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Olvido o falta de memoria, confusión, problemas con el equilibrio.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 1-2 horas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica. Si usted decide dejar de tomar
la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su médico si existe una
posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000912
264
Medication Consent Forms
MEDICATION: COGENTIN (Benztropine Mesylate)
PURPOSE: This medication can be used to treat side effects of certain medications.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Blurred vision, constipation, nausea,
dry mouth, difficulty urinating, headaches, nervousness, increased thirst, increased sensitivity to light, drowsiness,
decreased sweating.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Muscle
weakness, forgetfulness, confusion, vomiting, rash, dizziness.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1 day, and significant benefit may
require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by telling
the doctor or any other health care staff. If you decide to stop taking the medication, it will not affect your ability to
receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Patient Name
ID#
Date of Birth
Institution
Prescribing Practitioner Signature:
Name/Title Stamp
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000913
265
Medication Consent Forms
WEXFORD HEALTH SOURCES, INC.
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
COGENTIN (Benztropine Mesylate)
PROPÓSITO: Esta medicación puede usarse para tratar efectos secundarios de ciertas medicaciones.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Visión borrosa,
estreñimiento, náuseas, sequedad en la boca, dificultad al orinar, dolores de cabeza, nerviosismo, sed incrementada,
sensibilidad incrementada a la luz, somnolencia, disminución en los sudores.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Debilidad muscular, pérdida de memoria, confusión, vómitos, sarpullido, mareos.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 1 día, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El doctor
pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que colme
las necesidades del recluso.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica. Si usted decide dejar de tomar
la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su médico si existe una
posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000914
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Medication Consent Forms
MEDICATION: EFFEXOR (Venlafaxine HCL), EFFEXOR XR (Venlafaxine HCL Extended Release
Capsules)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, insomnia, blurred vision,
constipation, nausea, dry mouth, difficulty urinating, lightheadedness when getting up, sexual dysfunction,
nervousness, weight loss.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Thyroid
problems, changes in blood pressure, slurred speech, balance problems, vomiting, bleeding/irritated gums, increased
risk of suicide.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 weeks, and significant benefit
may require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000915
267
Medication Consent Forms
WEXFORD HEALTH SOURCES, INC.
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
EFFEXOR (Venlafaxine HCL), EFFEXOR XR (Venlafaxine HCL Cápsulas de
Liberación Extendida)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con trastornos depresivos.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
insomnio, visión borrosa, estreñimiento, náuseas, sequedad en la boca, dificultad al orinar, mareos al ponerse de pie,
disfunción sexual, nerviosismo, pérdida de peso.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Problemas de la
tiroides, cambios en la presión arterial, pronunciar mal al hablar, problemas de equilibrio, vómitos, encías que pierden
sangre/irritadas, incremento en el riesgo de suicidio.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos. Los tratamientos alternativos pudieran incluir otras medicaciones,
terapias ocupacionales, y terapias verbales tales como la terapia socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 2-3 semanas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
de que la medicación no esté causando ningún problema fisiológico grave.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente o por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medication Consent Forms
INFORMED CONSENT FOR ANTIPSYCHOTIC MEDICATION – FORM A
MEDICATION:
PURPOSE: This medication is used to treat serious emotional and mental conditions.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid long periods of time in sunlight without use of sunscreen; avoid
exposure to sunlamps. Avoid too much exercise, extreme heat, or other activities that are likely to dehydrate you unless
you are able to get enough water. Antacids containing aluminum or magnesium should not be taken 1 hour before
taking this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with an
antipsychotic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask questions
about my treatment and have answered all my questions. I understand that I can discuss any other questions I
might have about my treatment with the doctor and that a signed copy of this form will be given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000917
269
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA-FORMULARIO A
MEDICACIÓN:
PROPÓSITO: Esta medicación es usada para tratar graves afecciones emocionales y mentales.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES:
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES:
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales [de actividades] y terapias verbales tales como asistencia socio-psicológica o terapia conductista [del
comportamiento].
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio
significativo podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el
tratamiento, en la mayoría de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor
pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse que la medicación no este causando ningún
problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica. Si usted decide dejar de tomar
la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su médico si existe una
posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite largos períodos
de tiempo al sol sin el uso de protector solar [sunscreen], evite exponerse a lámparas solares. Evite hacer mucho
ejercicio, el calor extremo, u otras actividades que tengan probabilidad de deshidratarlo, al menos que pueda obtener
suficiente agua. Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar
esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000918
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Medication Consent Forms
Informed Consent for Psychotropic Medication – FORM B
MEDICATION:
PURPOSE: This medication is used to treat serious emotional and mental conditions.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
____________________________________________________________________________________________
____________________________________________________________________________________________
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within _________, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff, orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff has given me a chance to
ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000919
271
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA – FORMULARIO
B
MEDICACIÓN:
PROPÓSITO: Esta medicación es usada para tratar afecciones emocionales y mentales graves.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES:
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES:
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos. Los tratamientos alternativos pudieran incluir otras medicaciones,
terapias ocupacionales y terapias verbales tales como asistencia socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de
, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente o por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000920
272
Medication Consent Forms
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000921
273
Medication Consent Forms
MEDICATION: GEODON (Ziprasidone)
PURPOSE: This medication is used to treat symptoms associated with disorders of thoughts, perceptions, behavior,
and/or affect.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, and/or
weight gain.
OTHER POTENTIAL, SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, dizziness, neuroleptic malignant syndrome, reduced urine output, increased glucose, cholesterol, and
triglycerides, EKG changes.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid too much exercise, extreme heat, or other activities that
are likely to dehydrate you unless you are able to get enough water. Antacids containing aluminum or magnesium
should not be taken 1 hour before taking this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask
questions about my treatment and have answered all my questions. I understand that I can discuss any other
questions I might have about my treatment with the doctor and that a signed copy of this form will be given
to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID No
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000922
274
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
GEODON (Ziprasidone)
PROPÓSITO: Esta medicación es usada para tratar los síntomas asociados con trastornos de los pensamientos, percepciones,
el comportamiento y/o el afecto
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
endurecimiento muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamados
Disquinesia Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como mareos), visión
borrosa, sequedad bucal, estreñimiento, y/o aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de ataques, mareos, síndrome maligno neuroléptico, reducción en la producción
de orina, incremento en la glucosa, colesterol y triglicéridos, cambios en los electrocardiogramas (ECG).
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es la
terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas indeseables,
que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias ocupacionales, y terapias
verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso de
tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio significativo
podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría
de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio
de vez en cuando, para asegurarse que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación, en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si usted
decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su
médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros fármacos de venta libre; evite conducir un vehículo y otras actividades
que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite hacer mucho ejercicio, el calor
extremo, u otras actividades que tengan la probabilidad de deshidratarlo, al menos que pueda conseguir suficiente agua.
Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar esta medicación y nunca
inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del Departamento
Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha dado y explicado
información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo tratado. También me
han informado acerca de tratamientos alternativos, los riesgos y los peligros relacionados con este tratamiento, los
efectos secundarios posibles que yo pudiera experimentar por causa de este tratamiento y la cantidad de tiempo que
estaré tomando este fármaco. El personal departamental me ha dado una oportunidad de hacer preguntas acerca
de mi tratamiento y han contestado a todas mis preguntas. Yo entiendo que puedo hablar con el doctor acerca de
otras preguntas que yo pudiera tener acerca de mi tratamiento y entiendo que me darán una copia firmada de este
formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000923
275
Medication Consent Forms
MEDICATION: HALDOL (Haloperidol), HALDOL DECANOATE (Haloperidol Decanoate)
PURPOSE: This medication is used to treat symptoms associated with disorders of thoughts, perceptions, and/or
behavior.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, and/or
weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, problems with blood cells, lower ability to fight infection, reduced urine output, neuroleptic malignant
syndrome.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid long periods of time in sunlight without use of sunscreen; avoid
exposure to sunlamps. Avoid too much exercise, extreme heat, or other activities that are likely to dehydrate you unless
you are able to get enough water. Antacids containing aluminum or magnesium should not be taken 1 hour before taking
this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask questions
about my treatment and have answered all my questions. I understand that I can discuss any other questions I
might have about my treatment with the doctor and that a signed copy of this form will be given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name_______________________________
ID#
Race/Sex
Date of Birth _____________________________
Institution _______________________________
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000924
276
Medication Consent Forms
Medicación:
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
HALDOL (Haloperidol), HALDOL DECANOATE (Decanoato de Haloperidol)
PROPÓSITO: Esta medicación es usada para tratar los síntomas asociados con los trastornos de pensamientos,
percepciones, y/o el comportamiento.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
endurecimiento muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son
llamados Disquinesia Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como
mareos), visión borrosa, sequedad bucal, estreñimiento, y/ó aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Riesgo incrementado de temblores, problemas con los glóbulos de la sangre, menor capacidad para
combatir infecciones, producción reducida de orina, síndrome neuroléptico maligno.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio
significativo podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el
tratamiento, en la mayoría de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor
pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse que la medicación no este causando ningún
problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite largos períodos
de tiempo al sol sin el uso de protector solar [sunscreen], evite exponerse a lámparas solares. Evite hacer mucho
ejercicio, el calor extremo, u otras actividades que tengan probabilidad de deshidratarlo, al menos que pueda obtener
suficiente agua. Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar
esta medicación y nunca inmediatamente después
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000925
277
Medication Consent Forms
MEDICATION: LITHIUM
PURPOSE: This medication is used to treat symptoms associated with disorders of mood.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, blurred vision, diarrhea,
dehydration, nausea, hand tremors, increased thirst and urination, and weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Muscle
weakness, thyroid problems, forgetfulness, confusion, agitation, rash, acne, and anxiety.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1-2 weeks, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medication Consent Forms
Medicación:
LITIO [LITHIUM]
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con los trastornos del estado de ánimo.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
visión borrosa, diarrea, deshidratación, náuseas, temblores en las manos, aumento en la sed y en orinar, y aumento
de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Debilidad muscular, problemas de la tiroides, pérdida de memoria, confusión, agitación,
sarpullido, acné y ansiedad.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos. Los tratamientos alternativos pudieran incluir otras medicaciones,
terapias ocupacionales, y terapias verbales tales como socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 1-2 semanas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurar
que la medicación no esté causando ningún problema psicológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000927
279
Medication Consent Forms
MEDICATION: PAXIL (Paroxetine HCL)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Blurred vision, constipation, diarrhea,
nausea, dry mouth, difficulty urinating, headaches, sexual dysfunction, lethargy, increased appetite, dizziness, weight
gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Changes
in blood pressure, changes in heart rate, balance problems, increased risk of suicide, seizures, sweating, skin rash,
and ringing in the ears.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 weeks, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff, orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000928
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Medication Consent Forms
Medicación:
PAXIL (Paroxetine HCL)
PROPÓSITO: Esta medicación es usada para tratar los síntomas asociados con trastornos depresivos.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Visión borrosa,
estreñimiento, diarrea, náuseas, sequedad en la boca, dificultad al orinar, dolores de cabeza, disfunción sexual,
letargo, aumento en el apetito, mareos, aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Cambios en la presión arterial, cambios en el ritmo cardíaco, problemas de equilibrio,
incremento en el riesgo de suicidio, ataques, sudores, sarpullido en la piel, y zumbido en los oídos.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 2-3 semanas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000929
281
Medication Consent Forms
MEDICATION: PROLIXIN (Fluphenazine HCL), PROLIXIN DECANOATE (Fluphenazine Decanoate)
PURPOSE: This medication is used to treat serious symptoms associated with disorders of thoughts, perceptions, and/or
behavior.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, and/or
weight gain.
OTHER POTENTIAL, SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, reduced urinary output and neuroleptic malignant syndrome.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid long periods of time in sunlight without use of sunscreen; avoid
exposure to sunlamps. Avoid too much exercise, extreme heat, or other activities that are likely to dehydrate you unless
you are able to get enough water. Antacids containing aluminum or magnesium should not be taken 1 hour before taking
this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask questions
about my treatment and have answered all my questions. I understand that I can discuss any other questions I
might have about my treatment with the doctor and that a signed copy of this form will be given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000930
282
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
PROLIXIN (Fluphenazine HCL), PROLIXIN DECANOATE (Decanoato de
Flufenazina)
PROPÓSITO: Esta medicación es usada para tratar síntomas graves asociados con trastornos de los pensamientos,
percepciones, y/ó comportamiento.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia, rigidez
muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamados Disquinesia
Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como mareos), visión borrosa, sequedad
bucal, estreñimiento, y/ó aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de temblores, producción reducida de orina y síndrome maligno neuroléptico.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es la
terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas indeseables,
que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias ocupacionales y terapias
verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso de
tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio significativo
podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría
de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio
de vez en cuando, para asegurarse que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si usted
decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su
médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite largos períodos de
tiempo al sol sin el uso de protector solar [sunscreen], evite exponerse a lámparas solares. Evite hacer mucho ejercicio, el
calor extremo, u otras actividades que tengan probabilidad de deshidratarlo, al menos que pueda obtener suficiente agua.
Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar esta medicación y nunca
inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del Departamento
Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha dado y explicado
información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo tratado. También me
han informado acerca de tratamientos alternativos, los riesgos y los peligros relacionados con este tratamiento, los
efectos secundarios posibles que yo pudiera experimentar por causa de este tratamiento y la cantidad de tiempo que
estaré tomando este fármaco. El personal departamental me ha dado una oportunidad de hacer preguntas acerca
de mi tratamiento y han contestado a todas mis preguntas. Yo entiendo que puedo hablar con el doctor acerca de
otras preguntas que yo pudiera tener acerca de mi tratamiento y entiendo que me darán una copia firmada de este
formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000931
283
Medication Consent Forms
MEDICATION: PROZAC (Fluoxetine HCL)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Insomnia, constipation, diarrhea,
headaches, nervousness, anxiety, tremor, dry mouth.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Change
in appetite, abnormal sweating, seizures, skin rash, increased risk of suicide, change in blood pressure, change in
heart rate.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 weeks, and significant benefit
may require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000932
284
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
PROZAC (Fluoxetine HCL)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con trastornos depresivos.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Insomnio,
estreñimiento, diarrea, dolores de cabeza, nerviosismo, ansiedad, temblor, sequedad en la boca.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS EN POTENCIA INCLUYEN, PERO SIN
LIMITACIONES: Cambio en el apetito, sudores anómalos, ataques, sarpullido en la piel, riesgo incrementado de
suicidio, cambio en la presión arterial, cambio en el ritmo cardíaco.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 2–3 semanas. y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000933
285
Medication Consent Forms
MEDICATION: REMERON (Mirtazapine)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Agitation, anxiety, insomnia, seizures,
blurred vision, dry mouth, constipation, lightheadedness when getting up, headaches, nausea, vomiting, increased
appetite, weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Balance
problems, liver and kidney abnormalities, problems with blood cells leading to lowered ability to fight infection,
increased risk of suicide.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 weeks, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask
questions about my treatment and have answered all my questions. I understand that I can discuss any other
questions I might have about my treatment with the doctor and that a signed copy of this form will be given
to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000934
286
Medication Consent Forms
MEDICATION: RISPERDAL (Risperidone)
PURPOSE: This medication is used to treat symptoms associated with disorders of thoughts, perceptions, behavior
and/or affect.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, weight
gain, nasal irritation.
OTHER POTENTIAL, SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, problems with blood cells leading to lower ability to fight infection, increased prolactin levels, and
neuroleptic malignant syndrome and increased levels of glucose, cholesterol, and triglycerides..
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid too much exercise, extreme heat, or other activities that are
likely to dehydrate you unless you are able to get enough water. Antacids containing aluminum or magnesium should
not be taken 1 hour before taking this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask questions
about my treatment and have answered all my questions. I understand that I can discuss any other questions I
might have about my treatment with the doctor and that a signed copy of this form will be given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000935
287
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
RISPERDAL (Risperidone)
PROPÓSITO: Esta medicación es usada para tratar los síntomas asociados con los trastornos de los pensamientos,
percepciones, comportamiento y/ó afecto.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia, rigidez
muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamdos Disquinesia
Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como mareos), visión borrosa, sequedad
bucal, estreñimiento, aumento de peso, irritación nasal.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de temblores, problemas con los glóbulos sanguíneos lo cual conduce hacia una
capacidad más baja para combatir infecciones, niveles incrementados de prolactina, y síndrome neuroléptico maligno.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es la
terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas indeseables,
que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias ocupacionales y terapias
verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso de
tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio significativo
podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría
de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor pudiera ordenar análisis de
laboratorio, de vez en cuando, para asegurarse que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si usted
decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su
médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros fármacos de venta libre; evite conducir un vehículo y otras actividades
que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite hacer mucho ejercicio, el calor
extremo, u otras actividades que la probabilidad de deshidratarlo, al menos que pueda conseguir suficiente agua. Los
antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar esta medicación y nunca
inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del Departamento
Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha dado y explicado
información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo tratado. También me
han informado acerca de tratamientos alternativos, los riesgos y los peligros relacionados con este tratamiento, los
efectos secundarios posibles que yo pudiera experimentar por causa de este tratamiento y la cantidad de tiempo que
estaré tomando este fármaco. El personal departamental me ha dado una oportunidad de hacer preguntas acerca
de mi tratamiento y han contestado a todas mis preguntas. Yo entiendo que puedo hablar con el doctor acerca de
otras preguntas que yo pudiera tener acerca de mi tratamiento y entiendo que me darán una copia firmada de este
formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000936
288
Medication Consent Forms
MEDICATION: SEROQUEL (Quetiapine Fumarate)
PURPOSE: These medications are used to treat symptoms associated with disorders of thoughts, perceptions, behavior,
and/or affect.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, and/or
weight gain.
OTHER POTENTIAL, SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, dizziness, neuroleptic malignant syndrome, increased glucose, cholesterol, and triglycerides, cataracts.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems. The
doctor will review the medication and its effect on a regular basis.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by telling the
doctor or any other health care staff. If you decide to stop taking the medication, it will not affect your ability to receive
other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid too much exercise, extreme heat, or other activities that are
likely to dehydrate you unless you are able to get enough water. Antacids containing aluminum or magnesium should
not be taken 1 hour before taking this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask
questions about my treatment and have answered all my questions. I understand that I can discuss any other
questions I might have about my treatment with the doctor and that a signed copy of this form will be given
to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner:________________________________
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000937
289
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
SEROQUEL (Quetiapine Fumarate)
PROPÓSITO: Estas medicaciones son usadas para tratar los síntomas asociados con trastornos de los pensamientos,
percepciones, comportamiento, y/o afecto.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia, rigidez
muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamados Disquinesia
Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como mareos), visión borrosa, sequedad
bucal, estreñimiento, y/o aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS EN POTENCIA INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de ataques, mareos, síndrome neuroléptico maligno, incremento en la glucosa,
colesterol, y triglicéridos, cataratas.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es la
terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas indeseables,
que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias ocupacionales y terapias
verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso de
tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio significativo
podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría
de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio
de vez en cuando, para asegurarse que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica. Si usted decide dejar de tomar la
medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele a su médico si existe una
posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros fármacos de venta libre; evite conducir un vehículo y otras actividades
que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite hacer mucho ejercicio, el calor
extremo, u otras actividades que tengan la probabilidad de deshidratarlo, al menos que pueda conseguir suficiente agua.
Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar esta medicación y nunca
inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del Departamento
Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha dado y explicado
información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo tratado. También me
han informado acerca de tratamientos alternativos, los riesgos y los peligros relacionados con este tratamiento, los
efectos secundarios posibles que yo pudiera experimentar por causa de este tratamiento y la cantidad de tiempo que
estaré tomando este fármaco. El personal departamental me ha dado una oportunidad de hacer preguntas acerca
de mi tratamiento y han contestado a todas mis preguntas. Yo entiendo que puedo hablar con el doctor acerca de
otras preguntas que yo pudiera tener acerca de mi tratamiento y entiendo que me darán una copia firmada de este
formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000938
290
Medication Consent Forms
MEDICATION: TEGRETOL (Carbamazepine)
PURPOSE: This medication is used to treat symptoms associated with disorders of mood.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, blurred vision, nausea,
difficulty urinating, sexual dysfunction, nervousness, changes in appetite, upset stomach.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Balance
problems, vomiting, rash, problems with blood cells leading to lowered ability to fight infection, yellowing of the
skin and eyes, and swelling of the legs.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1 week, and significant benefit may
require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000939
291
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
TEGRETOL (Carbamazepine)
PROPÓSITO: Esta medicación es usada para tratar los síntomas asociados con los trastornos del estado de ánimo.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
visión borrosa, náuseas, dificultad al orinar, disfunción sexual, nerviosismo, cambios en el apetito, malestar
estomacal.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Problemas de equilibrio, vómitos, sarpullido, problemas con los glóbulos sanguíneos que llevan
hacia la disminución de la capacidad para combatir infecciones, amarillamiento de la piel y los ojos, e hinchazón de
las piernas.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
LA DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del
lapso de tiempo de 1 semana, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo.
El doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima
que colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para
asegurarse que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000940
292
Medication Consent Forms
MEDICATION: THORAZINE (Chlorpromazine HCL)
PURPOSE: This medication is used to treat symptoms associated with disorders of thoughts, perceptions, and/or
behavior.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation,
sensitivity to sunlight, and/or weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, problems with blood cells leading to lower ability to fight infection, dizziness, and neuroleptic malignant
syndrome.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid long periods of time in sunlight without use of sunscreen;
avoid exposure to sunlamps. Avoid too much exercise, extreme heat, or other activities that are likely to dehydrate
you unless you are able to get enough water. Antacids containing aluminum or magnesium should not be taken 1
hour before taking this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask
questions about my treatment and have answered all my questions. I understand that I can discuss any other
questions I might have about my treatment with the doctor and that a signed copy of this form will be given
to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000941
293
Medication Consent Forms
Medicación:
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
THORAZINE (Chlorpromazine HCL)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con los trastornos de los pensamientos,
percepciones, y/ó comportamiento.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
rigidez muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamados
Disquinesia Tardiva), dificultad al orinar, presión arterial reducida (lo cual pudiera experimentarse como mareos), visión
borrosa, sequedad bucal, estreñimiento, sensibilidad a la luz solar, y/ó aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de ataques, problemas con los glóbulos sanguíneos lo cual lleva a disminuir
la capacidad de combatir infecciones, mareos, y síndrome neuroléptico maligno.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio
significativo podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el
tratamiento, en la mayoría de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor
pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse que la medicación no este causando ningún
problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite largos períodos
de tiempo al sol sin el uso de protector solar [sunscreen], evite exponerse a lámparas solares. Evite hacer mucho
ejercicio, el calor extremo, u otras actividades que tengan probabilidad de deshidratarlo, al menos que pueda obtener
suficiente agua. Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de tomar
esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000942
294
Medication Consent Forms
MEDICATION: TRILAFON (Perphenazine)
PURPOSE: This medication is used to treat symptoms associated with disorders of thoughts, perceptions, and/or
behavior.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, muscle stiffness, abnormal
involuntary movements (some of which may be persistent and are called Tardive Dyskinesia), difficulty urinating,
lowered blood pressure (which may be experienced as light-headedness), blurred vision, dry mouth, constipation, and/or
weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Increased
risk of seizures, reduced urine output, and neuroleptic malignant syndrome.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available and that this class of medication will relieve undesirable symptoms better and more quickly
than other treatments. Alternative treatments may include other medications, activity therapies, and talk therapies such as
counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within a few days (though some may take several
weeks or months), and significant benefit may require regular and long-term usage. The doctor may adjust the dosage
during treatment, in most cases, to the minimum dosage that meets the needs of the patient. The doctor may order
laboratory tests from time to time to ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by notifying
the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it will not affect
your ability to receive other health care. Notify your physician if there is a possibility that you are pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Avoid long periods of time in sunlight without use of sunscreen; avoid
exposure to sunlamps. Avoid too much exercise, extreme heat, or other activities that are likely to dehydrate you unless
you are able to get enough water. Antacids containing aluminum or magnesium should not be taken 1 hour before taking
this medication and never right after.
I understand that by signing this form, I am agreeing to let Department of Corrections staff treat me with a
psychotropic drug. Departmental staff have given me, and explained, information about the nature of this
treatment and the reason I am being treated. I have also been informed about alternative treatments, the risks
and hazards associated with this treatment, the possible side effects that I may experience from this treatment,
and the length of time that I may be taking this drug. Departmental staff have given me a chance to ask questions
about my treatment and have answered all my questions. I understand that I can discuss any other questions I
might have about my treatment with the doctor and that a signed copy of this form will be given to me.
Time/Date:
Patient Signature:
Time/Date:
Patient Name
ID#
Date of Birth
Institution
Prescribing Practitioner Signature:
Name/Title Stamp
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000943
295
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
TRILAFON (Perphenazine)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con trastornos de pensamientos, percepciones
y/o comportamiento.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
rigidez muscular, movimientos involuntarios anómalos (algunos de los cuales pudieran ser persistentes y son llamados
Disquinesia Tardiva), dificultad para orinar, presión arterial baja (lo cual pudiera experimentarse como mareos), visión
borrosa, sequedad bucal, estreñimiento, y/o aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Incremento en el riesgo de ataques, producción de orina reducida, y síndrome neuroléptico
maligno.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales, y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de unos pocos días (aunque algunos pudieran llevar varias semanas o meses), y para lograr un beneficio
significativo podría requerir un uso regular y a largo plazo. El doctor pudiera ajustar la dosificación durante el
tratamiento, en la mayoría de los casos, a la dosificación mínima que colme las necesidades del recluso. El doctor
pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse que la medicación no este causando ningún
problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. Evite largos períodos
de tiempo al sol sin el uso de protector solar [sunscreen], evite exponerse a lámparas solares. Evite hacer mucho
ejercicio, el calor extremo, u otras actividades que tengan la probabilidad de deshidratarlo, al menos que pueda
obtener suficiente agua. Los antiácidos que contengan aluminio o magnesio no deberían ser tomados 1 hora antes de
tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000944
296
Medication Consent Forms
MEDICATION: VALPROIC ACID
PURPOSE: This medication is used to treat symptoms associated with disorders of mood.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, diarrhea, nausea,
headaches, nervousness, cramps, indigestion, lethargy.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO:
Confusion, vomiting, rash, problems with blood cells leading to lowered ability to fight infection, yellow skin/eyes,
swelling of the face, hair loss, pancreatitis, swelling of the legs, blurred vision, liver abnormalities.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1 week, and significant benefit may
require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000945
297
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
ÁCIDO VALPROICO
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con los trastornos del estado de ánimo.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
diarrea, náuseas, dolores de cabeza, nerviosismo, calambres, indigestión, letargo.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Confusión, vómitos, sarpullido, problemas con los globules sanguíneos que conducen hacia una
capacidad disminuida para combatir las infecciones, amarillamiento de la piel/ojos, hinchazón de la cara, pérdida del
cabello, pancreatitis, hinchazón de las piernas, visión borrosa, anomalías hepáticas.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales, y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 1 semana, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros fármacos de venta libre; evite conducir un vehículo y otras
actividades que requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. El retiro abrupto o la
discontinuación de la medicación pudiera causar problemas médicos.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000946
298
Medication Consent Forms
MEDICATION: VISTARIL (Hydroxyzine Pamoate)
PURPOSE: This medication is used to treat symptoms associated with disorders of anxiety.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, constipation, nausea, dry
mouth, lightheadedness when standing, headaches, hand tremors.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Rash.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 1-2 hours, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff, orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature:
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000947
299
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
VISTARIL (Hydroxyzine Pamoate)
PROPÓSITO: Esta medicación se usa para tratar los síntomas asociados con los trastornos de ansiedad.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
estreñimiento, náuseas, sequedad bucal, mareos al estar de pie, dolores de cabeza, temblores en las manos.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Sarpullido.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos por sí solos. Los tratamientos alternativos pudieran incluir otras medicaciones,
terapias ocupacionales, y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro de 1-2
horas, y un beneficio significativo pudiera requerir el uso regular y a largo plazo. El doctor pudiera ajustar la
dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que colme las necesidades
del recluso.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000948
300
Medication Consent Forms
MEDICATION: WELLBUTRIN (Bupropion HCL), WELLBUTRIN SR (Bupropion HCL Extended
Release Tablets)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Agitation, anxiety, insomnia, seizures,
blurred vision, dry mouth, constipation, lightheadedness when getting up, headaches, nausea, vomiting, increased
appetite, weight gain.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Balance
problems, liver and kidney abnormalities, increased risk of suicide.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medications, activity therapies, and
talk therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 weeks, and significant benefit
may require regular and long term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Patient Name
ID#
Date of Birth
Institution
Prescribing Practitioner Signature:
Name/Title Stamp
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000949
301
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
WELLBUTRIN (Bupropion HCL), WELLBUTRIN SR (Bupropion HCL Tabletas
de Liberación Extendida)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con trastornos depresivos.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Agitación,
ansiedad, insomnio, ataques, visión borrosa, sequedad en la boca, estreñimiento, mareos al ponerse de pie, dolores
de cabeza, náuseas, vómitos, aumento del apetito, aumento de peso.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Problemas de equilibrio, anomalías hepáticas y renales, riesgo incrementado de suicidio.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 2–3 semanas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarias posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000950
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Medication Consent Forms
MEDICATION: ZOLOFT (Sertraline HCL)
PURPOSE: This medication is used to treat symptoms associated with depressive disorders.
COMMON SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Sleepiness, insomnia, constipation,
diarrhea, nausea, dry mouth, difficulty urinating, sexual dysfunction, headaches, nervousness, dizziness, drowsiness,
indigestion.
OTHER POTENTIAL SIGNIFICANT SIDE EFFECTS INCLUDE, BUT ARE NOT LIMITED TO: Changes
in blood pressure, vomiting, fatigue, increased risk of suicide.
ALTERNATIVE TREATMENT: It has been determined, at this time, that this category of medication is the most
effective therapy available, and that this class of medication will relieve undesirable symptoms better and more
quickly than other treatments alone. Alternative treatments may include other medication, activity therapies, and talk
therapies such as counseling or behavior therapy.
APPROXIMATE LENGTH OF CARE: The medication usually acts within 2 – 3 Weeks, and significant benefit
may require regular and long-term usage. The doctor may adjust the dosage during treatment, in most cases, to the
minimum dosage that meets the needs of the patient. The doctor may order laboratory tests from time to time to
ensure that the medication is not causing any serious physiological problems.
NOTIFICATION: You should understand that you can decide to stop taking this medication at any time by
notifying the doctor or any other health care staff orally or in writing. If you decide to stop taking the medication, it
will not affect your ability to receive other health care. Notify your physician if there is a possibility that you are
pregnant.
RISK AND HAZARDS: Avoid alcohol and other nonprescription drugs; avoid driving a vehicle and other activities
that require alertness until adjusted to side effects. Abrupt withdrawal or discontinuation of medication may cause
medical problems. Antacids containing aluminum or magnesium should not be taken 1 hour before taking this
medication and never right after.
I understand that by signing this form I am agreeing to let the Department of Corrections treat me with a
psychotropic drug. Departmental staff have given me, and explained information about the nature of this
treatment and the reasons I am being treated. I have also been informed about alternative treatments, the
risks and hazards associated with this treatment, the possible side effects that I may experience from this
treatment, and the length of time that I may be taking this drug. Departmental staff have given me a chance
to ask questions about my treatment and have answered all my questions. I understand that I can discuss any
other questions I might have about my treatment with the doctor and that a signed copy of this form will be
given to me.
Time/Date:
Patient Signature:
Time/Date:
Prescribing Practitioner Signature: _______________________
Name/Title Stamp
Patient Name
ID#
Date of Birth
Institution
Race/Sex
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000951
303
Medication Consent Forms
CONSENTIMIENTO INFORMADO PARA MEDICACIÓN PSICOTRÓPICA
Medicación:
ZOLOFT (Sertraline HCL)
PROPÓSITO: Esta medicación es usada para tratar síntomas asociados con trastornos depresivos.
LOS EFECTOS SECUNDARIOS COMUNES INCLUYEN, PERO SIN LIMITACIONES: Somnolencia,
insomnio, estreñimiento, diarrea, náuseas, sequedad bucal, dificultad al orinar, disfunción sexual, dolores de cabeza,
nerviosismo, mareos, adormecimiento, indigestión.
OTROS EFECTOS SECUNDARIOS SIGNIFICATIVOS POTENCIALES INCLUYEN, PERO SIN
LIMITACIONES: Cambios en la presión arterial, vómitos, fatiga, riesgo incrementado de suicidio.
TRATAMIENTO ALTERNATIVO: Se ha determinado, en estos momentos, que esta categoría de medicación es
la terapia disponible más eficaz y que esta clase de medicación aliviará mejor y más rápidamente los síntomas
indeseables, que otros tratamientos. Los tratamientos alternativos pudieran incluir otras medicaciones, terapias
ocupacionales y terapias verbales tales como la socio-psicológica o terapia del comportamiento.
DURACIÓN APROXIMADA DE LA ATENCIÓN MÉDICA: La medicación usualmente actúa dentro del lapso
de tiempo de 2–3 semanas, y para lograr un beneficio significativo podría requerir un uso regular y a largo plazo. El
doctor pudiera ajustar la dosificación durante el tratamiento, en la mayoría de los casos, a la dosificación mínima que
colme las necesidades del recluso. El doctor pudiera ordenar análisis de laboratorio de vez en cuando, para asegurarse
que la medicación no este causando ningún problema fisiológico serio.
NOTIFICACIÓN: Usted debería entender que puede decidir dejar de tomar esta medicación en cualquier momento,
notificándole al doctor o a cualquier otro miembro del personal de atención médica, verbalmente y por escrito. Si
usted decide dejar de tomar la medicación, ello no afectará su capacidad para recibir otra atención médica. Notifíquele
a su médico si existe una posibilidad de que usted esté embarazada.
RIESGOS Y PELIGROS: Evite el alcohol y otros medicamentos de venta libre; evite manejar un vehículo y otras
actividades que le requieran estar alerta, hasta que se haya ajustado a los efectos secundarios. La interrupción abrupta
o el retiro de la medicación podría causar problemas médicos. Los antiácidos que contengan aluminio o magnesio
no deberían ser tomados 1 hora antes de tomar esta medicación y nunca inmediatamente después.
Yo entiendo que al firmar este formulario me estoy poniendo de acuerdo en permitirle al personal del
Departamento Correccional que me traten con un fármaco psicotrópico. El personal departamental me ha
dado y explicado información acerca de la naturaleza de este tratamiento y de la razón por la cual estoy siendo
tratado. También me han informado acerca de tratamientos alternativos, los riesgos y los peligros
relacionados con este tratamiento, los efectos secundarios posibles que yo pudiera experimentar por causa de
este tratamiento y la cantidad de tiempo que estaré tomando este fármaco. El personal departamental me ha
dado una oportunidad de hacer preguntas acerca de mi tratamiento y han contestado a todas mis preguntas.
Yo entiendo que puedo hablar con el doctor acerca de otras preguntas que yo pudiera tener acerca de mi
tratamiento y entiendo que me darán una copia firmada de este formulario.
Hora/Fecha:
Firma del Recluso:
Hora/Fecha:
Firma del Médico que Receta:
Nombre/Título Sello
Nombre del Recluso
ID Nº ________________ Raza/Sexo
Fecha de Nacimiento:
Institución
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000952
304
WEXFORD
COMPANIES
Neurology
Neurology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000953
000953
Medical Guidelines
Region: New Mexico
Neurology Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Bell’s Palsy
Consider: If onset within 3 days of
onset consider a short course of
prednisone 60-80mg a day for one
week with no taper. For severe palsy
may consider co-administration of
oral valacyclovir at a dose of 1000
mg three times daily for one week
or acyclovir at a dose of 400 mg five
times daily for 10 days, along with
prednisone. Eye care as needed.
Consider: At the discretion of the
clinician depending on the clinical
scenario recognizing that offsite
imaging is not typically needed,
however, consider head imaging
(CT Scan) for compelling symptoms
or history/exam not consistent with
Bell’s Palsy
Dementia
Consider: Dementia is a disorder
that is characterized by a decline in
cognition involving one or more
cognitive domains (learning and
memory, language, executive
function, complex attention,
perceptual-motor, social cognition).
The deficits must represent a
decline from previous level of
function and be severe enough to
interfere with daily function and
independence. The most common
form of dementia in older adults is
Alzheimer disease (AD), accounting
for 60 to 80 percent of cases. The
work-up and treatment will
therefore need to be individualized
based on presumptive cause and
the patient. General guidance is to
review medications, perform labs
that may include: CBC, TSH, B-12
level, CMP, RPR. The treatment plan
will need to be individualized based
on the potential cause or causes of
dementia identified.
Consider: At the discretion of the
clinician depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000954
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Headache
Consider: Headache is among the
most common medical complaints.
An overview of the approach to the
patient with a chief complaint of
headache will need to be
individualized depending on the
patient’s clinical history, physical
exam and medication therapies
tried. As such, a treatment plan will
need to be individualized to the
specific type of headache identified
or cause of headache identified but
treatment may include, rest,
behavioral therapies, non-opioid
analgesic medications, avoidance of
pain-producing activities,
headache-specific medications,
ongoing review of medications.
Consider: Emergency referral for
altered mental status, ataxia,
sudden extreme onset and/or high
suspicion.
Mild Cognitive Impairment
(MCI)
Consider: Mild cognitive
impairment (MCI) is an intermediate
clinical state between normal
cognition and dementia. While
specific subtle changes in cognition
can occur in normal aging, MCI can
also be a precursor to dementia. At
the same time, MCI may also
represent a reversible condition in
the setting of depression, as a
complication of certain
medications, or during the recovery
from an acute illness. The work-up
and treatment will therefore need
to be individualized based on
presumptive cause and the patient.
Consider: At the discretion of the
clinician depending on the clinical
scenario
Seizures (Acute)
Consider for the acute
management: Protect patient,
maintain airway, administer oxygen,
diazepam or lorazepam, check
glucose.
Consider for acute seizure: At the
discretion of the clinician
depending on the clinical scenario,
typically status epilepticus requires
ER evaluation.
Consider for care after the acute
seizure episode: Care, work-up and
treatment will need to be
individualized based on the
patient’s history, presentation,
presumptive cause, response to
Consider for new onset seizure:
neurology consult, urgent CT head
and EEG.
Consider: Head imaging for
abnormal neurological exam or
compelling symptoms or history.
Consider for complex cases and
potential pseudo-seizures:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
treatment, compliance with antiepileptic medications, lab studies
including for known seizure
patients, consider blood levels of
medications.
Neurology consult, and/or
psychiatric consultation
Seizures (Chronic)
Consider for chronic management:
Classify seizure type, monitor for
anti-epileptic drug toxicity and
depending on the medication
periodically follow levels, “low
bunk” housing and decreased risk
work assignments. Anti-epileptic
medication generally not necessary
if isolated alcohol or drug-related
seizure. Taper off medication if
seizure-free greater than two years.
Consider: At the discretion of the
clinician depending on the clinical
scenario
Stroke
Consider: Primary prevention
including modify risk factors,
manage chronic illnesses.
Consider for acute symptoms: ER
evaluation ASAP
Recognizing the multi-factorial
causes associated with stroke the
care/treatment will need to be
individualized follow-up treatment
may include aspirin daily (if not
acute bleed), exercise program,
healthy diet, weight loss (if
appropriate), discourage smoking,
manage blood pressure, and
aggressive lipid management if
ischemic stroke.
Consider for follow-up care: At the
discretion of the clinician
depending on the clinical scenario
but generally following stroke,
assess rehabilitation potential,
consider physical therapy,
occupational therapy, and/or
speech therapy.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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WEXFORD
COMPANIES
Obstetrics/Gynecology
Obstetrics / Gynecology
WEXFORD MILLER
WEXFORD
MILLER 000957
000957
Medical Guidelines
Region: New Mexico
Management of Cervical Cytology Interpretation
Wexford Health Sources - Management of Cervical Cytology Interpretation
(Based on the 2001 Bethesda System Terminology)
PAP SMEAR - CYTOLOGY RESULTS
(-----------------------------------Epithelial Cell Abnormalities-----------------------------------------)
Low-grade
Squamous
Intraepithelial
lesion (LSIL)
Atypical
Squamous
Cells (ASC)
Normal
ASC-US
(undetermined
significance)
HPV +
High-grade
Squamous
Intrathelial
lesion (HSIL)
Squamous
Cell
Carcinoma
ASC-H (cannot
exclude HSIL)
(-----------------------------Glandular Cell Abnormalities-----------------------------)
Atypical Glandular
Cells (AGC)
AGC - Favor
Neoplasm
Endometrial*,
Endocervical or
Endocervical
Glandular Cells
Favor Neoplasm
Endocervical
Adeno
Carcinoma In
SITU (AIS)
OR Glandular Cells
Not otherwise specified
yes
no
HIV +
yes
no
Repeat Pap
12 months
Colposcopy
& Biopsy
Repeat Pap
4-6 months
In HIV + or
In HIV + or
HPV + women
HPV + women
Repeat normal
Repeat ASC-US
Paps q 6 mos X2
Paps q 6 mos X2
then q 12 mos
then q 12 mos
CIN I/II/III
yes
Colposcopy
& Biopsy
CIN I/II/III
Colposcopy
& Biopsy
CIN I/II/III
yes
Loop Electrosurgical
Colposcopy w/ES *
& Biopsy
CIN I/II/III
Colposcopy
& Biopsy
CIN I/II/III
yes
yes
Colposcopy w/ES*
& Biopsy
CIN I/II/III
yes
Loop Electrosurgical Excisional Procedure
Excisional Procedure
(LEEP)
yes
Gynecologic
Oncology
Consultation
(LEEP) OR Cold-knife Conization (Preferred)
+ Squamous Cell Cancer
+ Adenocarcinoma
negative
negative
Discuss appropriate
f/u with GYN
(See below)
Correlation of Findings:
Diagnosis:
* Endometrial sampling should be done in conjunction with Colposcopy in women with
AGC and atypical endometrial cells who are >35 yo or who have unexplained vaginal bleeding
and in women with AIS
Any discrepancies between cytological assessment and histopathologic findings should prompt a cyto-histological correlation between the
Cytologist and Pathologist in order to determine the specimen adequacy and to reach a conclusion as to which specimen should prevail
to guide clinical decision making for next steps.
HPV alone
ASC-H with negative Colpo
LSIL with negative Colpo
HSIL with negative Colpo
CIN I
CIN II & III
Microinvasive Cancer < 3mm
Invasive Cancer > 3mm
Observation and treatment of visible warts
Observation. Repeat PAP/Cytology and HPV testing at 6 & 12 months with repeat colposcopy if ASC-US or greater
Observation. Repeat PAP/Cytology at 6 & 12 months with repeat colposcopy if ASC-US or greater
Cyto-Histo Correlation. If HSIL upheld, given high risk, proceed with diagnostic excisional procedure in non-pregnant patients
Observation. Discuss in Collegial Review for possible oblative therapy versus Cone Biopsy or LEEP
Collegial Review - Cone Biopsy or LEEP, Appropriate follow-up based on findings
Collegial Review - Cone Biopsy or LEEP, Appropriate cancer follow-up based on findings
Collegial Review - Consideration of radical hysterectomy and/or radiation therapy as per GYN Oncologist
Wexford’s Management of Cervical Cytology Guideline is based upon the 2001 Bethesda System of Cytology Reporting and the 2001 Consensus Guidelines for the Management of Women with Cervical Cytological
Abnormalities (JAMA – April 24, 2002)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
WEXFORD MILLER 000958
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310
Medical Guidelines
Region: New Mexico
Management of Cervical Cytology Interpretation
I.
CLINICAL NOTES & STATISTICS
Women with cervical cytology results interpreted as ASC have a 5−17% chance of having CIN
II or III confirmed with cervical biopsy.
Women with cervical cytology results interpreted as ASC-H have a 24−94% of having CIN II or
III confirmed with cervical biopsy although the risk for invasive cervical cancer remains low
at 0.1−0.2%.
Immunosuppressed women with ASC are at increased risk of CIN II or III.
Post-menopausal women with ASC are at decreased risk of CIN II or III.
Between 31−60% of all women with ASC will have high risk types of HPV infection identified.
Reflex HPV testing, where a sample for HPV DNA testing is co-collected at the time of the
cytology collection and then is processed only in the event of ASC-US results can minimize
the need for repeat gynecological examinations.
40−60% of women can be spared colposcopy when HPV testing is done with the initial PAP
smear or following ASC-US results.
All immunocompromised women with ASC-US on cytology should be referred for colposcopy
irrespective of CD4 cell count, HIV viral load, or antiretroviral therapy.
Approximately 15−30% of women with LSIL on cervical cytology will have CIN II or III on
subsequent cervical biopsy.
Approximately 70−75% of women with HSIL on cervical cytology will have CIN II or III on
subsequent cervical biopsy and 1−2% will have invasive cervical cancer.
The AGC category is associated with substantially greater risk for cervical neoplasia than the
ASC or LSIL categories
Women with cervical cytology results interpreted as AGC have a 9−54% chance of having CIN
confirmed with cervical biopsy.
Women with cervical cytology results interpreted as AGC have a 0−8% chance of having
adenocarcinoma in SITU confirmed with cervical biopsy.
Women with cervical cytology results interpreted as AGC have a 1−9% chance of having
invasive carcinoma confirmed with cervical biopsy.
The cytological interpretation of AIS is associated with a very high risk or AIS (48−69%) or
invasive cervical adenocarcinoma (38%).
II.
SPECIAL CONSDERATIONS:
Post-menopausal women with cervical cytology noted as ASC-US (with evidence of atrophy
and no contra-indications to estrogen therapy) can be treated with intravaginal estrogen and
cytology can be repeated one (1) week after completion of therapy. If cytology is then negative,
repeat cytology in 6 months and if negative again, resume annual pap smears. If cytology
following estrogen therapy still shows ASC-US or higher, move to colposcopy.
Post-menopausal women with cervical cytology notes as LSIL (with evidence of atrophy and
no contra-indications to estrogen therapy) can be treated with intravaginal estrogen and
cytology can be repeated one (1) week after completion of therapy. If cytology is then negative,
repeat cytology in 6 months and if negative again, resume annual pap smears. If cytology
following estrogen therapy still shows ASC-US, LSIL or higher, move to colposcopy.
Adolescents with LSIL can be managed more conservatively with observation, HPV DNA
testing, and a repeat cytology six (6) months following the index PAP. If either the HPV testing
Based upon the 2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities (JAMA – April 24, 2002)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
WEXFORD MILLER
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000959
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Medical Guidelines
Region: New Mexico
is positive or the repeat cytology in six (6) months shows ASC, LSIL or higher then colposcopy
should be performed.
Based upon the 2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities (JAMA – April 24, 2002)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
WEXFORD MILLER
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000960
312
WEXFORD
COMPANIES
Ophthalmology
Ophthalmology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000961
000961
Medical Guidelines
Region: New Mexico
Ophthalmology Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Cataracts
Consider: See Wexford’s guideline,
“The Management of Cataracts.”
See Wexford’s guideline, “The
Management of Cataracts.”
Chalazion
Consider: Patient education - Small
chalazia often resolve without
intervention over days to weeks. For
larger lesions, draining can be
facilitated by using warm
compresses placed on the eye for
about 15 minutes four times per day
with a gentle massage. Antibiotics
are not typically indicated since a
chalazion is a granulomatous
condition.
At the discretion of the clinician
depending on the clinical scenario.
Consider: Therapy should be
directed at the likely etiology of
conjunctivitis suggested by the
history and physical examination.
At the discretion of the clinician
depending on the clinical scenario.
A chalazion typically presents as a
painless localized eyelid swelling.
Examination of the inner eyelid
reveals a non-tender, rubbery
nodule.
Chalazia and hordeola can have a
similar appearance; however,
chalazia tend to be painless and are
less erythematous and angryappearing.
Conjunctivitis, Bacterial
Patients with bacterial conjunctivitis
typically complain of redness and
discharge in one eye, although it
can also be bilateral. The purulent
discharge continues throughout the
day and is thick and globular. The
discharge differs from that of viral or
allergic conjunctivitis, which is
mostly watery during the day, with a
scant, stringy component that is
mucus rather than pus.
Examination: If the eye is matted
shut, consider using a warm
washcloth to soften the debris/bond
before opening.
Patient education: Both bacterial
and viral conjunctivitis are both
highly contagious and spread by
direct contact with secretions or
contact with contaminated objects.
Infected individuals should not share
handkerchiefs, tissues, towels,
cosmetics, linens, or eating utensils.
Patients should be instructed to
wash hands frequently with soap
and water especially after contact
with the eyes.
Medications to consider: There are
multiple antibiotic drops that may
be used. Ciprofloxacin, ofloxacin and
erythromycin ophthalmic are on
formulary.
•
Erythromycin 5 mg/gram
ophthalmic ointment 0.5 inch
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Offsite Care to Consider
(1.25 cm) 4 times daily for 5 to 7
days.
Conjunctivitis, Viral
Viral conjunctivitis typically presents
as conjunctival injection with watery
or mucoserous discharge and a
burning, sandy, or gritty feeling in
one eye. The second eye usually
becomes involved within 24 to 48
hours, although unilateral signs and
symptoms do not rule out a viral
process.
The conjunctivitis may be part of a
viral prodrome followed by
adenopathy, fever, pharyngitis, and
upper respiratory tract infection, or
the eye infection may be the only
manifestation of the disease.
•
Ofloxacin 0.3% ophthalmic
drops (preferred agent in
contact lens wearer) 1 to 2
drops 4 times daily for 5 to 7
days.
•
Ciprofloxacin 0.3% ophthalmic
drops (preferred agent in
contact lens wearer)1 to 2 drops
4 times daily for 5 to 7 days.
Consider: Therapy should be
directed at the likely etiology of
conjunctivitis suggested by the
history and physical examination.
At the discretion of the clinician
depending on the clinical scenario.
Patient education: Both bacterial
and viral conjunctivitis are both
highly contagious and spread by
direct contact with secretions or
contact with contaminated objects.
Infected individuals should not share
handkerchiefs, tissues, towels,
cosmetics, linens, or eating utensils.
Patients should be instructed to
wash hands frequently with soap
and water especially after contact
with the eyes.
Corneal Abrasion
Consider: See Wexford’s guideline,
“The Management of Corneal
Abrasions.”
See Wexford’s guideline, “The
Management of Corneal Abrasions.”
Corneal Foreign Body
Consider: See Wexford’s guideline,
“The Management of Corneal
Abrasions and Corneal Foreign
Bodies.”
Consider: See Wexford’s guideline,
“The Management of Corneal
Abrasions and Corneal Foreign
Bodies.”
Glaucoma
Consider: See Wexford’s guideline,
“The Management of Glaucoma.”
See Wexford’s guideline, “The
Management of Glaucoma.”
Hordeolum (Stye)
Consider: Patient education Hordeola can be managed with
warm, moist compresses placed on
the affected areas frequently (e.g.,
At the discretion of the clinician
depending on the clinical scenario.
A hordeolum (stye) is an abscess of
the eyelid that presents as a
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
localized painful and erythematous
swelling.
for 5 to 10 minutes three to five
times per day) in order to facilitate
drainage. Massage and gentle
wiping of the affected eyelid after
the warm compress can also aid in
drainage.
Chalazia and hordeola can have a
similar appearance; however,
chalazia tend to be painless and are
less erythematous and angryappearing.
Most hordeola resolve
spontaneously and do not require
specific intervention.
Iritis
Iritis is the Inflammation of the
anterior uveal tract. It is called iritis
or anterior uveitis; when the
adjacent ciliary body is also
inflamed, the process is called
iridocyclitis.
Classic symptoms include redness,
photophobia and pain often
described as dull ache; however,
with chronic forms of the disease,
these symptoms may be completely
absent.
The cardinal sign of iritis is ciliary
flush: injection that gives the
appearance of a red ring around the
iris. Typically, there is no discharge
and only minimal tearing.
Offsite Care to Consider
There is little evidence that
treatment with topical antibiotics
promotes healing but may be
considered in select patients.
Consider: The selection of therapy,
or the decision to initiate therapy,
should be individualized and based
upon the patient’s history and
examination, consideration of the
extent of the condition and
symptoms, potential adverse effects
of the treatment and the response
to previous treatments.
Involvement of an ocular
professional in an urgent manner is
the general approach to an acute
case but it is at the discretion of the
clinician depending on the patient’s
unique clinical history and scenario.
Ophthalmic steroid drops should be
used with caution in a patient with a
red eye. An urgent evaluation of the
patient with an ocular professional
or a provider to ocular professional
telephonic consultation is generally
advised prior to starting ocular
steroids.
The diagnosis is presumptive until
presence of inflammatory cells or
exudative “flare” is confirmed by slit
lamp examination.
Iritis can be caused by any one of
many infections, inflammatory, and
infiltrative processes. These include
tuberculosis, sarcoidosis, syphilis,
toxoplasma, and reactive arthritis.
Many cases are idiopathic.
Milia
Milia are pinpoint, multiple, firm,
white lesions that usually occur on
Consider: Patient education about
the condition.
At the discretion of the clinician
depending on the clinical scenario.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
both the upper and lower eyelids
and face. Milia are common lesions
and they may occur at all ages.
Since milia are benign lesions,
treatment is generally not necessary.
Milia are caused by the plugging of
hair follicles (pilosebaceous units) by
keratin.
Post-Enucleation Ocular
Conformer
Offsite Care to Consider
To prevent clogged hair follicles,
patients should be advised to
regularly wash the face while
avoiding heavy facial creams.
Consider: Wexford Health will
consider the need for ocular
conformer for enucleated patients
on a case-by-case basis.
At the discretion of the clinician
depending on the clinical scenario.
Issuance of a prosthetic eye is
typically considered cosmetic and
not typically medically necessary.
Pterygium
A pterygium (also called surfer’s eye)
is a fleshy overgrowth of the
conjunctiva that typically starts
medially and grows laterally and
may affect one or both eyes. Risk
factors include excessive exposure
to sunlight in people who spend
time outdoors, work outdoors and
have chronic eye irritation.
Xanthelasma
Xanthelasma are soft, yellow
plaques that usually appear
symmetrically on the medial aspects
of the eyelids. They occur most
often in middle-aged and older
adults, tend to be painless, and
build gradually over time. Larger
xanthelasma may cause discomfort.
Consider: Patient education on the
condition.
Patients with a small pterygium can
be treated symptomatically for
redness and irritation with artificial
tears or other ocular lubricants.
Ophthalmology evaluation may be
warranted if the pterygium is greater
than 2.5 mm onto cornea and
affecting visual acuity but is at the
discretion of the clinician depending
on the unique clinical scenario.
The management of patients with
larger lesions that impair visual
acuity or eye movement usually
involves surgical excision of the
pterygium. The decision to perform
surgical excision also varies based
on the rate of documented growth
and degree of induced astigmatism.
Surgery should be avoided for
cosmetic reasons alone, as
pterygium may recur, often times
with irritative symptoms.
Consider: Patient education about
the condition.
At the discretion of the clinician
depending on the clinical scenario.
Consider obtaining a lipid panel if
not already performed.
Xanthelasma lesions themselves
generally do not require treatment.
Lipid-lowering drug therapy may
induce regression of xanthelasma in
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Dyslipidemia is present in
approximately 50% of adult patients
with xanthelasma.
some patients, but the effect is not
consistent.
Offsite Care to Consider
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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The Management of Cataracts
I.
CATARACTS
A cataract may be defined as any opacity of the ocular lens that may or may not be associated with
visual problems and manifests as an obstruction of the red orange reflex on funduscopy. Cataracts
are one of the leading causes of blindness. Cataracts may be congenital or acquired.
The following is a list of the most common risk factors for the development of acquired
cataract:
1.
Diabetes mellitus and high glucose levels
2.
Regular corticosteroid use
3.
Advancing age (multifactorial)
4.
Female sex
5.
African-American race
6.
Over-exposure to ultraviolet radiation
7.
Excessive consumption of alcohol
8.
Smoking
Not all cataracts are symptomatic. The symptoms of cataract involve diminished or altered
vision:
1.
Blurred vision, double vision, ghost images, the impression of a "film" over the eyes
2.
Glare
3.
The need for frequent changes of eyeglass prescriptions, which may not improve vision
Based upon the current medical literature regarding generally accepted indications for
cataract removal, including subjective symptomatology, objective reproducible clinical
findings and the presence of co-existing conditions, it is Wexford Health’s position that:
1.
Consideration of cataract surgery is indicated when maximally corrected bilateral
Snellen visual acuity is 20/60 or worse and such surgery offers a reasonable likelihood
of improvement in visual function
2.
Consideration of cataract surgery is indicated when the lens opacity inhibits optimal
management of posterior segment ocular disease or the lens causes inflammation, angle
closure, or medically unmanageable open-angle glaucoma
3.
Cataract extractions will be performed on one eye only as per the ophthalmologist’s
recommendation for optimizing visual acuity and when the above criteria are met
4.
Evaluation by ophthalmologist for consideration of cataract surgery is indicated when
presence of hypermature (morgagnian) cataract is present.
5.
Bilateral cataract extraction will be considered if needed to manage posterior segment
ocular disease
6.
Consideration of surgery for visually impairing cataract is not indicated if:
a.
The patient does not desire surgery
b.
Maximally corrected bilateral Snellen visual acuity is 20/50 or better
c.
Surgery will not likely improve visual function
d.
The patient is able to satisfactorily carry out his or her activities of daily living
with or without changes in eyeglasses, lighting, or other non-operative means
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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e.
The patient cannot safely undergo surgery because of co-existing medical or
ocular conditions
f.
Appropriate postoperative care cannot be arranged.
Note: Activities of daily living refer to those functions or activities, which are performed by
individuals without assistance, thus allowing for personal independence in everyday living.
They include eating, bathing, dressing, toileting, transferring, and continence.
Decisions regarding patient suitability for consideration of cataract surgery must be
made on a case-by-case basis. These recommendations are intended only as a guide for
the site physician and are not intended to replace clinical judgment.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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The Management of Corneal Abrasions
I.
CORNEAL ABRASIONS
Corneal abrasion is often used to refer to any defect in the corneal surface epithelium. Corneal
abrasions can be classified as traumatic, including foreign body related and contact lens related, or
spontaneous. Spontaneous defects in the corneal epithelium may occur with no immediate
antecedent injury or foreign body. Eyes that have suffered a previous traumatic abrasion or eyes
that have an underlying defect in the corneal epithelium are prone to this problem.
II.
DIAGNOSIS
Any patient who complains of severe eye pain with photophobia and/or foreign body sensation
preventing opening of the eye generally can be presumed to have a corneal epithelial defect. The
provider must then first rule out penetrating trauma, and second an infectious infiltrate, especially
herpes simplex virus infection.
III.
INDICATIONS FOR CONSULTATION OR REFERRAL TO AN OCULAR PROFESSIONAL
A.
B.
Patients with isolated corneal abrasions and the following findings should undergo urgent
evaluation by an ocular professional:
1.
Corneal infiltrate, white spot, or opacity suggestion ulceration
2.
Foreign body that cannot be removed
3.
Hypopyon (pus in the anterior chamber)
Urgent referral to an ocular professional is generally indicated in patients with the following
physical findings at follow-up but individual clinical situations may vary:
1.
A larger epithelial defect
2.
An abrasion with a purulent discharge
3.
A drop in vision of more than one to two lines on a Snellen chart (e.g., drop from 20/20
to 20/80)
4.
Corneal abrasion that has not healed after 3 to 4 days
a.
IV.
These findings suggest a retained foreign body, poor healing, superinfection, or
infectious keratitis.
MANAGEMENT
A.
The approach to treatment of corneal abrasions is summarized in the following algorithm.
Treatment options vary based upon the subtype of corneal abrasion.
B.
Traumatic and foreign body abrasions
1.
General Information:
a.
Eye examination, typically including fluorescein staining, is an important
diagnostic tool.
b.
Administration of topical antibiotics and, for large abrasions, cycloplegics have
been the mainstay of therapy for decades, along with routine follow-up until the
eye is healed.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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c.
2.
3.
Patching was previously routine but is no longer recommended for most patients.
(See 'Patching' below.)
Contaminated Material:
a.
Patients who have a corneal abrasion with contaminated material (farm
instruments, vegetable matter) are at risk for developing bacterial keratitis; this
is the most common cause of bacterial keratitis among agricultural laborers in
undeveloped countries.
b.
These patients generally warrant daily monitoring for corneal infiltrate or
ulceration.
Foreign Body Removal
a.
If a corneal foreign body is detected, an attempt can be made to remove it by
irrigation after the instillation of topical anesthetic.
i.
b.
An attempt can then be made to remove the foreign body with a moistened swab,
using direct visualization.
c.
Foreign bodies under the lid can be removed after flipping the lid.
d.
If the foreign body cannot be dislodged by irrigation or with a swab, the patient
should be evaluated urgently by an individual trained in the use of instruments
to dislodge foreign bodies off the ocular surface.
e.
Preferably, foreign body should be removed within 24 hours.
i.
4.
While awaiting removal, the patient should generally be treated in the
meantime with a topical antibiotic ointment four times a day and no patch.
Rust Ring
a.
5.
This is particularly helpful in the case of multiple superficial foreign bodies
(e.g., sand).
After removal of a foreign body containing iron there is often a residual rust ring
and reactive infiltrate.
i.
Patients with rust ring should be treated as patients with corneal abrasions.
ii.
The rust ring itself is not harmful and will usually resorb gradually.
iii.
If there is failure of the epithelium to heal after 2 to 3 days, the referral to
an urgent ocular professional should be considered.
Topical Antibiotics
a.
b.
Low-Risk Abrasions:
i.
For adults with low-risk abrasions (e.g., not associated with contact lens
wearing, not caused by a foreign body, and not located over the central
cornea), close observation without prescribing topical antibiotics is a
reasonable option.
ii.
Such patients may still benefit from a topical ophthalmologic lubricant to
reduce pain.
Higher Risk Abrasions:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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i.
6.
1)
An ointment is generally considered better than drops because it
functions as a lubricant and may reduce disruption of the remaining
and newly generated epithelium.
2)
For patients who wear contact lenses, select an ointment or drop that
covers for Pseudomonas species (e.g., ciprofloxacin, ofloxacin, or, if
fluoroquinolones are not available, tobramycin or gentamicin).
3)
For patients who are not contact lens wearers, erythromycin ointment
is a good choice, used 4 times daily for 3 to 5 days.
4)
For patients who are not contact lens wearers and who insist on a
drop rather than an ointment, sulfacetamide 10 percent,
polymyxin/trimethoprim, ciprofloxacin, or ofloxacin are reasonable
choice).
5)
Aminoglycosides should be avoided in these patients because
aminoglycosides can be toxic to the epithelium.
Ocular Steroids (Typically Avoided):
a.
7.
Considerations for selection of topical antibiotics include:
Antibiotic preparations containing steroids are typically avoided because they
reduce host resistance to superinfection and may make a missed diagnosis of
herpes simplex virus epithelial keratitis or microbial keratitis worse.
Pain control — The approach to pain control for corneal abrasions varies according to
the size of the abrasion:
a.
b.
Small corneal abrasions – Most small abrasions (less than one-fourth of corneal
surface area [e.g., a round abrasion that is 4 mm across]) will generally heal
overnight if the lid is closed and there is no rubbing or squeezing.
i.
Mild to moderate pain can typically be controlled with a very short course
of an oral NSAID or acetaminophen.
ii.
In the few select patients more advanced analgesia coverage is needed and
is at the clinician’s discretion.
Large corneal abrasions – A large abrasion will not generally heal overnight and
additional measures may be required for pain control and to allow for healing.
i.
Short courses of medications of 2-4 days is generally adequate.
ii.
Cycloplegic (parasympatholytic drops) and patching may also be considered
in some patients, especially those with abrasions that cover >50 percent of
the corneal surface as follows:
1)
Cycloplegic drops – Cycloplegics are parasympatholytic drops that
inhibit the miotic (pupil-constricting) response to light; it is this
response to light that causes the ache and photophobia of corneal
abrasion. These drops do not relieve foreign-body sensation.
2)
Patients with large abrasions who are particularly photophobic can be
treated for up to 48 hours with cyclopentolate (0.5 to 1 percent) one
drop twice daily or homatropine (2.5 to 5 percent) one drop daily.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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3)
c.
Cycloplegics make the pupil large, causing glare, and also block
accommodation, thereby interfering with near work such as reading.
i)
Cyclopentolate 0.5 or 1 percent has the shortest duration of
action, but still lasts for 24 to 36 hours.
ii)
Thus, patients with small abrasions that heal overnight typically
find that the side effects of cycloplegic drops outweigh the
benefit of pain control.
Patching for pain control:
i.
Patching may decrease the pain of large corneal abrasions.
ii.
Patching is not generally recommended for small abrasions.
iii.
Because of the risk of infection, patients with corneal abrasions who also
use contact lenses should not be patched. (See the abrasions and recent
contact lens wear section below.)
iv.
Technique:
v.
1)
Suggestion: If the decision is made to apply a pressure patch for pain
control caused by a large corneal abrasion, proper application is
important.
2)
Generally, a properly applied patch precludes blinking. Improper
application may allow the patient to blink under the patch or worse,
abrade the cornea further.
3)
Patching is generally performed as follows:
i)
Assemble two gauze eye pads and three strips of tape.
ii)
Apply antibiotic ointment to the eye by instilling a small amount
(0.5 to 1 inch ribbon) in the inferior lid.
iii)
Fold one pad in half.
iv)
Ask the patient to gently close both eyes.
v)
Use the folded patch to occupy the space over the globe in the
orbit and apply pressure to the globe.
vi)
Place the second pad over the folded pad.
vii)
Ask the patient or an assistant to apply firm pressure to the
second pad, while it is being taped firmly with the three strips
of tape. These strips are most effective if place obliquely from
the midline over the nose toward the cheekbone.
viii)
Ask the patient to open the eyes and report if the lid under the
patch can be raised. If it can, then the patch has not been
applied successfully and generally should be redone.
ix)
Leave the patch in place overnight, and generally for no more
than 24 hours.
Abrasions and recent contact lens wear
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1)
Contact lens wearers who present with a corneal epithelial defect
should be examined to look for a corneal infiltrate, which is a white
spot or opacity, or an ulcer, representing a surface breakdown,
thinning, or necrosis that occurs in an area of infiltration.
2)
Any patient with such a finding should be seen by an ocular
professional on an emergent basis.
3)
If a corneal abrasion is present and no infiltrate is seen, patients with
recent contact lens wear require timely topical antibiotics that are
effective against Pseudomonas species (e.g., ciprofloxacin, ofloxacin)
or, if fluoroquinolone eye drops or ointment are not available or cannot
be used in an individual patient, then tobramycin or gentamicin.
4)
Because of the risk of infection, patients with abrasions in the setting
of recent contact lens wear should not be patched.
i)
8.
Patching of what appeared to be sterile abrasions can lead to
sight-threatening infection.
5)
The patient should be checked in in an urgent/emergent timeframe
by an ophthalmologist or optometrist to confirm the absence of a
corneal infiltrate or ulcer.
6)
Patients should refrain from wearing contacts until the eye is fully
healed as determined by an ophthalmologist or optometrist.
7)
Infectious pseudomonas keratitis
ulcerative process that can result in
within 24 hours. Even if perforation
averted, there is often permanent
corneal transplantation.
is a fulminant, necrotizing,
corneal melting and perforation
and vision loss on that basis is
corneal scarring that requires
Treatment to Generally Avoid:
a.
Topical corticosteroids
i.
Corneal abrasions should generally not be treated with a topical
corticosteroid because of the increased potential for secondary infection or
exacerbation of missed herpes simplex virus or microbial keratitis.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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V.
MANAGEMENT OF CORNEAL ABRASIONS ALGORITHM
Patient with severe eye pain and foreign body sensation
Rule out penetrating injury
Eye examination, including fluorescein, consistent with the presence of
corneal abrasion
History suggestive of abrasion subtype?
Direct trauma to globe
followed immediately by
foreign body sensation
History of material
falling or flying into
the eye
Searing eye pain that
awakens the patient
from sleep or is caused
by eye opening in the
morning. History of prior
abrasions may also be
present.
Traumatic abrasion
Foreign body abrasion
Recurrent erosion
Remove foreign body
or refer urgently to an
ocular professional if
unable to remove.
Contact lens wear
Contact lens abrasion
Rule out infiltrate or opacity; must be
referred to an ocular professional
emergently if present.
Topical antibiotic therapy with erythromycin ointment (ointment preferred because of
lubricant function) OR sulfacetamide 10%, polymyxin/trimethoprim, ciprofloxacin, or
ofloxacin drops.
Patients with recurrent erosion do best with ointment rather than drops and may respond
to erythromycin ointment or over the counter lubricant with as frequent as hourly
application.
Topical antibiotic therapy effective
against: Pseudomonas species (e.g.,
ofloxacin, ciprofloxacin, tobramycin,
or gentamicin).
Pain relief with cycloplegia and narcotics optional. Pressure patch for less than 24 hours
(optional) although contraindicated if foreign body still present (may be used after removal
of foreign body). Generally, avoid the use of topical anesthetic or ocular steroid.
Pain relief with cycloplegia and
narcotics is optional. Pressure patch
is not advised. Typically, not
suggested to use topical steroid.
Follow-up not required if small (< 1/4 of cornea surface area [e.g., a round abrasion that is
4 mm across]), symptoms improve, vision is good, and there is no foreign body still present.
Follow-up frequently/daily until
healed to rule out infiltrate or ulcer.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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VI.
FOLLOW-UP
A.
Most small corneal abrasions (less than one-fourth of corneal surface area (e.g., a round
abrasion that is 4 mm across) heal within 24 to 48 hours.
1.
Follow-up of small abrasions should be considered but may not be necessary as long as
symptoms resolve.
a.
B.
VII.
Such patients should be instructed to return if eye drainage or decreased vision
occurs or if symptoms persist beyond 48 hours.
Larger abrasions, abrasions from contact lens, abrasions that are associated with decreased
vision, generally warrant daily/frequent follow-up until healing has occurred.
REFERENCES
1.
Adapted from UpToDate’s “Corneal Abrasions and Corneal Foreign Bodies: Management.” Accessed 12-2821.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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The Management of Glaucoma
I.
BACKGROUND
Glaucoma is a group of diseases that adversely affects vision by causing damage to the optic nerve.
Usually, these patients will have elevated intraocular pressure (IOP) readings by tonometry. Normal
IOP is defined as 10−23 mm Hg. Less commonly, glaucoma may exist with normal IOP readings. In
those with normal IOP, glaucoma is suspected by increased cup/disc ratios, abnormal cupping or
frank changes in the optic nerve on ophthalmoscopic exam. Glaucoma is more commonly seen in
advancing age, particularly in those over age 60 or in those with a family history of glaucoma. It is
more common in African Americans and the overall incidence is 0.5%.
II.
CLASSIFICATION
Primary Glaucoma (most common)
1.
2.
Open Angle
a.
Caused by decrease in outflow of aqueous humor
b.
90% of cases
c.
Family history usually present
d.
More commonly seen in myopic patients (greater than 5 diopters)
e.
More commonly seen in males of African American descent
Closed Angle
a.
Caused by obstruction in outflow of aqueous humor due to a narrow anterior
chamber angle determined by gonioscopy
b.
Less common
c.
Shallow anterior chamber
d.
Primarily seen in hypermetropic, 45−60 year-old age group
e.
May present as acute episodic provoked by pupillary dilation (e.g., pharmacologic
mydriasis or after entering a darkened room)
Secondary (acquired, infrequent), causes include:
III.
1.
Chronic steroid use
2.
Infectious causes
3.
Autoimmune disorders
PRESENTATION/SYMPTOMS
Most are asymptomatic until significant peripheral visual field loss has developed, thus the need
for screening. Acute glaucoma is uncommon; they may present with intense pain (that may mimic
headache) and may be associated with nausea/vomiting, photophobia, lacrimation and visual halos
seen around light sources.
IV.
SCREENING AND MONITORING
Tonometry: Recommended Screening Intervals 1
1
Those with any high-risk factors, every one to two years after age 35.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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1.
At ages 35 and 40
2.
After age 40, every two to four years
3.
After age 60, every one to two years
Ophthalmoscopic examination looking for abnormal cup/disc ratio greater than 0.6, or by
abnormal disc configuration
1.
Correlate findings with tonometry
2.
Include ophthalmoscopic exam with physical examinations
Visual Field Testing − evaluates visual field integrity
1.
Documents status of visual fields and changes
2.
Generally indicated yearly for those diagnoses with glaucoma or glaucoma-suspect
3.
Disadvantages:
a.
Requires specialized equipment and personnel
b.
Requires patient cooperation
Pachymetry − assesses corneal thickness that may affect tonometry readings, indicated in
selected cases.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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WEXFORD
COMPANIES
Optometry
Optometry
WEXFORD MILLER
WEXFORD
MILLER 000978
000978
Medical Guidelines
Region: New Mexico
Routine Optometry Protocols and Procedures
Routine eye exams will be provided to eligible patients every two years for patients under age 50.
Routine eye exams will be provided to eligible patients annually for patients over age 50.
I.
ROUTINE ON-SITE OPTOMETRIC EYE EXAMINATIONS INCLUDE THE FOLLOWING:
Problem oriented history
Visual acuity
Eye health assessment including tonometry when indicted
Refraction
Disposition
Eyeglass order generation, accelerated recall or referral when indicated
Documentation and record keeping
Upon intake, every patient shall receive an eye screening and visual acuity assessment as part of
his/her initial intake physical conducted by the on-site nursing staff or other designated on-site
medical department personnel. Patients who do not meet the vision portion of the intake physical
shall be scheduled for routine optometry clinic:
J.
Pass/Fail screening protocol(s) as listed in section II;
Patients entering the system wearing prescription spectacle or contact lenses will be
scheduled for routine optometry clinic;
Patients with a previous diagnosis of glaucoma, other eye disease or other medical condition
will be scheduled for baseline optometry assessment and appropriate recall/monitoring;
Patients with a positive family history of glaucoma, other eye disease or other medical
condition will be scheduled for baseline optometry assessment and appropriate
recall/monitoring.
Patients under age 50 who passed the visual portion of the intake physical or who are requesting
routine optometry services within two years of their last routine eye examination provided in the
system shall be screened for eligibility prior to being scheduled to see the optometrist. Patients
over age 50 shall be screened if requesting an eye exam if it has been less than one year. Pass/Fail
screening protocol(s) are listed in section II.
II.
THE FOLLOWING SCREENING CRITERIA APPLY:
20/40 acuity in one or both eyes with correction – acuity testing to be performed by the
nursing or on-site medical staff;
Emergence or manifestation of any ocular or systemic sign or symptom that the medical
director, nursing staff or other on-site medical staff feel require optometry assessment;
Diagnosis of another immediate family member with glaucoma, other eye disease or other
medical condition with potential ocular manifestations;
As referred by the medical director or medical department.
Patients scheduled for on-site optometry services beyond the scope of routine exams, such as a
more advanced ophthalmologic assessment of suspected eye disease or annual dilated retina
evaluation of diabetic patients, should be scheduled as per the protocols and procedures established
for
the
health
condition
and/or
as
directed
by
the
managing
physician/optometrist/ophthalmologist.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Eyeglasses and Contact Lens Protocols
I.
EYEGLASSES
The Department shall pay for one pair of eyeglasses when determined medically necessary by
an optometrist/ophthalmologist.
All eyeglasses will meet or exceed FDA and ANSI Z-80 Dress Safety standards.
The Department will supply one male zyl (plastic) frame style and one female zyl (plastic) frame
style in multiple sizes. Frame style options, such as different color selection or upgraded frame
options including metal frames, will NOT be supplied or available to patients through the
eyeglass program.
1.
Any change from the standard issue frame style will only be supplied when medically
indicated and approved through established Department protocols and procedures.
Lenses will be clear CR-39 plastic single vision or strait top multifocal design.
1.
Any change from clear standard CR-39 plastic or strait top multifocal design lenses will
require authorization as medically indicated and approval through established
Department protocols and procedures prior to the order being sent to the lab for
processing.
2.
Tints and/or photochromatic lens options will only be supplied when authorized as
medically indicated.
3.
Medical conditions which may require tinted lenses include:
a.
Albinism
b.
Chronic/recurrent Iritis
c.
Fixed/dilated pupils
d.
Iris anomaly(s)
e.
Other medical conditions on an “as needed” basis
4.
Subjective photophobia is NOT a medical indication for tinting.
5.
Cataracts, glaucoma, diabetic retinopathy, peripheral corneal scarring are conditions
where tinted lenses do not provide any therapeutic purpose.
6.
Polycarbonate lenses will only be supplied when authorized as medically indicated and
for such conditions as functionally monocular patients, amblyopes or when 100% UV
blocking is medically indicated
7.
High index lens materials will only be supplied when authorized as medically indicated
by excessive refractive error
8.
For patients assigned to job duties requiring eye wear:
a.
9.
It is the facility’s responsibility to provide eyewear to patients assigned to work
assignments requiring sun protection or other eye protection. Exception to this
area would include amblyopic patients who should be fitted with polycarbonate
eyeglasses.
Any other lens option(s) or upgrade(s) other than clear CR–39 plastic or strait top
multifocal design will only be supplied when authorized as medically indicated.
Replacement eyeglasses will be provided by the Department every two years OR when there is
a +0.50 diopter/20 degree axis shift and/or one line of acuity improvement and/or as
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
indicated by the examining optometrist/ophthalmologist, or when the integrity of the current
pair of eyeglasses justifies new glasses due to severely scratched lenses, broken frames, etc.
1.
The patient shall be financially responsible for the cost incurred for the
replacement/repair of frames and/or lenses damaged or destroyed due to negligence or
deliberate destruction.
a.
2.
If sufficient funds are not available in the patient’s account and the medical staff
has determined that the patient’s visual health would be adversely affected, the
eyewear will be replaced and arrangements made to reimburse the Department
from the patient’s account when funds become available.
The Department shall repair and/or replace all frames and lenses damaged or destroyed
as a direct result of a patient’s work assignment(s).
a.
The work supervisor shall determine whether the damage occurred as direct result
of a patient work assignment.
A patient may not possess more than two pair of prescription eyeglasses at any time during
their incarceration.
1.
2.
II.
A patient is permitted to keep their current glasses worn upon intake if approved by the
intake facility. When transferring from the intake facility to another facility or a
subsequent intra-facility transfer, the decision of the intake facility shall be honored
and the patient permitted to retain current glasses until:
a.
The current prescription is no longer medically correct; or
b.
The current lenses and/or frames are destroyed, lost or damaged.
A patient shall not be permitted to assume the responsibility of discarding any extra
pair(s) of eyeglass in excess of two. The extra pair will be turned into the medical
department where arrangements will be made at the patient’s expense to send them to
the patient’s home, stored in property or given to Security to dispose of properly.
CONTACT LENSES
Contact lenses shall only be provided when deemed medically necessary and authorized
through established Department protocols and procedures for conditions such as true
aphakia and keratoconus and shall be addressed on a case-by-case basis.
1.
The Department shall be responsible for supplying necessary solutions and other
materials for the maintenance of authorized medically necessary contact lenses.
Contact lenses are provided only for medical needs such as:
1.
Keratoconus
2.
Severe myopia or hyperopia (greater than +/- 15 diopters) where standard lenses do not
afford adequate refraction.
3.
Other medical needs as determined on a case-by-case basis.
Patients entering the system wearing contact lenses will be permitted to retain his/her current
contact lenses only until Department issued prescription eyeglasses are obtained.
1.
The patient shall be responsible for the cost of supplying through the medical
department all necessary solutions and other materials for the maintenance of contact
lenses until such time as eyeglasses are acquired.
2.
Upon receipt of prescription eyeglasses, the patient’s contact lenses will be turned into
the medical department where arrangements will be made at the patient’s expense to
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
send them to the patient’s home, stored in property or given to Security to dispose of
properly.
3.
Patients entering the system with both acceptable contact lenses and prescription
glasses will be required to discontinue contact lens wear and the contact lenses disposed
of as indicated in the preceding subsection II.B.
The type of contact lens, hard or soft, is determined by the optometrist and not by patient
request.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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WEXFGRD
COMPANIES
Oral
Oral and
and Maxillofacial
Maxillofacial Surgery
Surgery
Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000983
000983
Medical Guidelines
Region: New Mexico
Oral and Maxillofacial Surgery
DX
Primary (Unit) Rx
Acute Infections of the
Oral Cavity
Pain, swelling, trismus, elevated temperature,
airway compromise, dysphasia, elevated tongue
Rx: Airway security antibiotics, incision and
drainage, culture, sensitivity, gram stains
Dental Caries
involving pulp,
periodontal disease
Pain, thermal sensitivity, tooth mobility,
cellulites/abscess
Rx: Antibiotics, extraction, refer to restorative
dentistry, endodontics if indicated
Impacted Molars
Symptomatic
Fractured teeth with or
without pulp exposure
I. Fracture of
Mandibular body and
ramus fractures
II. Mandibular
condyle
III. Traumatic Injuries
of teeth and Alveolar
process
IV. Maxilla (Lefort
Fractures)
V. Orbit, blow out
fractures
VI. Naso-orbitalethmoid complex
Mandibular condyle
dislocation
Pain, pressure, shifting teeth pericoronitis, cysts,
dysphagia, asymptomatic
Rx: Antibiotics, X-ray diagnosis, surgical
extraction
Pain, thermal sensitivity
Rx: Refer for restorative dentistry, endodontics,
extractions
Pain, swelling, malocclusion, bleeding,
motor/sensory nerve deficits
Rx: Refer to Oral Surgery
Trismus, open bite, mandibular deviation, pain,
swelling, malocclusion
Rx: Refer to Oral Surgery
Gingival laceration, mobile alveolar segment, pain,
malocclusion, bleeding
Rx: Tooth refosetion, splinting, surgical removal
of alsetor segment
Mobility of maxilla, visual changes, motor/sensory
deficits, periorbital ecchymosis, pain, swelling,
malocclusion
Rx: Refer to Oral Surgery
Restricted eye movement, visual changes,
motor/sensory deficits, periorbital ecchymosis,
pain, swelling
Rx: Refer to Oral Surgery
Epistaxis, cerebral spinal rhinorrhea, nasal
dysfunction, telechanthus, visual changes, facial
asymmetry, motor/sensory deficits, pain, swelling
Rx: Refer to Oral Surgery
Open lock, pain
Rx: Reduction with/without immobilization
Refer to Oral Surgery if unable to
reduce
Secondary (Wexford Health) Rx
*Unless emergent, conduct collegial review.
Refer Emergent if airway involved.
May warrant possible referral to OS for
biopsy, excisions
Refer to Endodontist only if complicated
endodontics is involved, the tooth is crucial
to arch integrity, there is a good
periodontal support and a long
incarceration is expected.
Refer Routine if not able to do at unit or
Urgent if infected.
None
Refer Urgent for reduction and
immobilization
Refer Urgent for reduction and
immobilization
Refer to OS if beyond capability of the unit
Refer Urgent for reduction and
immobilization
Refer Urgent for orbital exploration and
reconstruction
Refer Urgent for reduction and
immobilization, orbital exploration and
reconstruction
Refer Urgent for reduction
Adapted from THE UNIVERSITY OF TEXAS MEDICAL BRANCH/TEXAS DEPT. OF CRIMINAL JUSTICE GUIDELINES, APRIL 1996
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
WEXFORD
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Medical Guidelines
Region: New Mexico
DX
Traumatic injuries to
soft tissue of head and
neck
Osteomyelitis
maxilla/mandible
Osteoradionecrosis of
maxilla/mandible
Maxillary/mandibular
discontinuity bony
defects
Temporomandibular
joint disease
Benign or malignant
pathology of the jaws
and adjacent area
Complicated
Exodontia
Primary (Unit) Rx
Lacerations, pain, swelling, bleeding, tissue
emphysema, motor/sensory deficit, cosmetic injury
Rx: Multi-layered closure and dressing
Refer to Oral Surgery if beyond capabilities of
unit
Pain, swelling, pathologic fracture, motor/sensory
nerve deficit
Rx: IV antibiotics (define), culture, sensitivity,
gram stain, debridement, wound care, and
hyperbaric oxygen.
Refer to Oral Surgery
Pain, swelling, bone exposure pathological fracture
Rx: Wound care, IV antibiotic (define), hyperbaric
oxygen, debridement and bone grafting.
Refer to Oral Surgery
Unable to fabricate dentures
Rx: Mandibular and maxillary tori reduction.
Pain, restricted mandibular opening, malocclusion,
clicking crepitus in opening and closing
Rx: Conservative TX muscle relaxants,
fabrication of interocelusal splints.
Pain, swelling, displacement of teeth, bone
expansion, radiopaque/radiolucent lesions,
pathological fracture, motor/sensory nerve deficits,
metastatic changes
Rx: X-ray evaluation, R/O Metastatic Disease,
needle aspiration, biopsy, definitive surgery.
Refer to Oral Surgery
Oroantral communications, iatrogenic fractures.
Secondary (Wexford Health) Rx
*Unless emergent, conduct collegial review.
Refer Urgent for reduction and
immobilization if fractures are present or
within 24 hours to sutures lacerations.
Refer Urgent
Refer Urgent
Refer Routine if beyond capabilities of the
unit.
Refer Routine or Urgent if “closed lock” is
present or for severe pain
Refer Urgent for surgical treatment
Refer to OS.
Adapted from THE UNIVERSITY OF TEXAS MEDICAL BRANCH/TEXAS DEPT. OF CRIMINAL JUSTICE GUIDELINES, APRIL 1996
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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WEXFORD
COMPANIES
Orthopedic
Orthopedic Surgery
Surgery Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000986
000986
Medical Guidelines
Region: New Mexico
Orthopedic Surgery Guidelines
Diagnosis
Offsite Care to Consider
Onsite Care to Consider
I. Fractures and Dislocations
Closed Fractures (Recent)
1.
Non-displaced
Consider: Splint, ice, pain management
and elevation
At the discretion of the clinician
depending on the clinical
scenario: Consider onsite
management, ER or Ortho
Referral Urgent
2.
Displaced
Consider: Splint, ice, pain management
and elevation
At the discretion of the clinician
depending on the clinical
scenario: Consider ER or Ortho
Referral Urgent
Open Fractures (Recent)
1.
Clean
Consider: Irrigate, sterile dressing,
possible prophylactic antibiotics, Tetanus
immunization and pain management
Consider emergent referral to ER
or Orthopedics
2.
Dirty
Consider: Irrigate, sterile dressing,
prophylactic antibiotics, Tetanus
immunization and pain management
Consider emergent referral to ER
or Orthopedics
Consider: Splint, ice, elevation and pain
management
Consider emergent referral to ER
or Orthopedics
Fracture with Nerve Deficit
(Recent)
Joint Dislocation (Recent)
1.
Closed
Consider: Onsite reduction, and then
splint, symptomatic pain management
If successful, consider referral to
Ortho; if unsuccessful consider
emergent to ER or Orthopedics
2.
Open
Consider: Splint, sterile dressing, Tetanus
immunization, symptomatic pain
management
At the discretion of the clinician
depending on the clinical
scenario: Consider ER or Ortho
Referral Emergent
II. Lumbosacral Spine
Acute Lower Back Pain
1.
No Neurological Deficit
Consider: Ice/heat and/or NSAIDs and/or
muscle relaxant and/or acetaminophen
At the discretion of the clinician
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
2.
Nerve Deficit (foot drop,
absent reflexes,
incontinence)
Consider: Bed rest, ice/heat and/or
NSAIDs and/or muscle relaxant and/or
acetaminophen
At the clinical discretion of the
clinician consider emergent
referral to ER or emergent
imaging
3.
Fracture (Acute)
Consider: Clinician’s plan of care is
dependent on the clinical scenario
including mechanism of injury, patient,
type of fracture, patient presentation,
symptoms
ER or Ortho or Neurosurgery
evaluation at discretion of
provider depending on the clinical
scenario
Fracture Compression
(Recent)
1.
Compression with no
neurologic deficit
Consider: Activity modification,
analgesics, laboratory evaluation to
diagnose secondary causes of
osteoporosis, an exercise program can be
initiated when pain has diminished
At the discretion of the clinician
depending on the clinical scenario
2.
Compression with
neurologic deficit
Consider: Activity modification,
analgesics, laboratory evaluation to
diagnose secondary causes, an exercise
program can be initiated when pain has
diminished
Consider emergent referral to ER
and/or emergent imaging and/or
urgent referral to neurosurgery or
orthopedic spine specialist
Radiculopathy
Consider: Recognizing that the most
common cause of radiculopathy is nerve
root compression from intervertebral disc
herniation or spondylosis, producing
painful symptoms but often a selflimiting course. Patients should, however,
be evaluated for less common
mechanisms associated with permanent
and progressive neurologic disability, as
prompt diagnosis and treatment may
improve outcome and as such a
treatment plan may need to be
individualized but treatment may include,
rest, non-opioid analgesic medications,
stretches, avoidance of pain-producing
activities, systemic glucocorticoids
At the discretion of the clinician
depending on the clinical scenario
Scoliosis, Kyphosis
Consider exercise, analgesic medications
with heat for acute pain periods
At the discretion of the clinician
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000988
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Tumors or Infection (new
diagnosis)
Consider symptomatic treatment while
initiating diagnostic evaluation and
treatment
At the discretion of the clinician
depending on the clinical scenario
Tumors or Infection
(established diagnosis)
Consider: Pain management while
treatment is ongoing
At the discretion of the clinician
depending on the clinical scenario
III. Hand and Wrist
Fractures and Dislocations
See Section I: Fractures and Dislocations
Lacerations
1.
No neurological or tendon
involvement
Consider: Cleanse w/saline irrigation,
Steri-Strip and/or suture, tetanus, oral
antibiotic
At the discretion of the clinician
depending on the clinical scenario
2.
With nerve and tendon
involvement, clean wound
Consider: Cleanse/irrigate, sterile
dressing, oral antibiotic, tetanus
Refer Urgently to ER/Hand
Surgeon/Orthopedics
3.
Nerve or tendon involved
with dirty wound
Consider: Cleanse/irrigate, sterile
dressing, oral or IV antibiotic, tetanus
Refer Urgently to ER/Hand
Surgeon/Orthopedics
Carpal Tunnel or Cubital
Tunnel
Consider: Splint, analgesics/NSAIDs,
glucocorticoids injections and/or oral
glucocorticoids
At the discretion of the clinician
depending on the clinical scenario
Old Tendon or Nerve Injury
Consider: No treatment unless
unsatisfactory functional level
At the discretion of the clinician
depending on the clinical scenario
Ganglion Cyst
Consider: Reassurance, observation,
measure, educate. If bothersome
symptoms may consider aspiration (high
rate of recurrence)
Consider routine referral if
bothersome and symptomatic
treatment unsuccessful and
surgery is being considered.
Crushed Fingertip w/Nail
Bed Injury
Consider: Cleanse/irrigate, sterile
dressing, oral antibiotic, tetanus
At the discretion of the clinician
depending on the clinical scenario
Amputations
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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341
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
1.
Fingertip not involving bone
Consider: Oral antibiotic with sterile
dressing daily, whirlpool daily, review
tetanus status
At the discretion of the clinician
depending on the clinical scenario
2.
Fingertip involving bone
Consider: Sterile dressing, antibiotics.
review tetanus status
Refer urgently to ER/Hand
Surgeon/Orthopedics
3.
Amputation or near
amputation
Consider: Sterile dressing, antibiotics,
review tetanus status
Typically, refer to ER
Tendonitis
1.
No locking or triggering
Consider: Splint, NSAIDs, analgesics,
activity modification (no sports)
At the discretion of the clinician
depending on the clinical scenario
2.
Locking or triggering
Consider: Splint, NSAIDs, activity
modification (no sports)
At the discretion of the clinician
depending on the clinical scenario
Infection
1.
Superficial Wound
Consider: Sterile dressing, antibiotics
At the discretion of the clinician
depending on the clinical scenario
2.
Deep (Flexor Tendon or
palm abscess)
Consider: Sterile dressing, antibiotics
At the discretion of the clinician
depending on the clinical scenario
– May consider ER/Hand
Surgeon/Orthopedics
IV. Elbow
Fractures and Dislocations
Consider - See Section I: Fractures and
Dislocations
Check carefully for radial / medial / ulnar
nerve injury
At the discretion of the clinician
depending on the clinical scenario
– May consider ER/Orthopedics
Bursitis
Consider: NSAIDs; aspiration,
glucocorticoid injection
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics
Lateral or Medial
Epicondylitis
Consider: activity modification, NSAIDs,
acetaminophen, steroid injections,
bracing, targeted strength exercises,
glucocorticoid injection
At the discretion of the clinician
depending on the clinical scenario
– May consider musculoskeletal
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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MILLER 000990
342
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
ultrasound, MRI and/or
Orthopedics
V. Shoulder
Fractures and Dislocations
Consider: See Section I: Fractures and
Dislocations
At the discretion of the clinician
depending on the clinical scenario
Acute Pain with No
Fracture or Dislocation
Consider: Ice, NSAIDs, pain management,
sling or shoulder immobilizer with ROM
exercises at 1-3 weeks
MRI/Ortho evaluation at
discretion of provider depending
on the clinical scenario
Chronic Pain
Consider: NSAIDs, ROM exercises, activity
modification, glucocorticoid injection
MRI/Ortho evaluation at
discretion of provider depending
on the clinical scenario
Multiple shoulder
dislocations
Consider: Education on preventing
dislocations along with strengthening
internal rotators exercises, activity
modification
MRI/Ortho evaluation at
discretion of provider depending
on the clinical scenario
AC Joint Separation
1.
Acute
Consider: Sling, ice, pain management,
exercises as tolerated
MRI/Ortho evaluation at
discretion of provider depending
on the clinical scenario
2.
Chronic
Consider: Analgesics, range of motion
(ROM) exercises
MRI/Ortho evaluation at
discretion of provider depending
on the clinical scenario
Clavicle Fracture
1.
Acute
Consider: Ice, sling or shoulder
immobilizer
ER or Ortho evaluation at
discretion of provider depending
on the clinical scenario
2.
Chronic
Consider: Analgesics PRN
Ortho evaluation at discretion of
provider depending on the clinical
scenario
VI. Foot and Ankle
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Metatarsalgia
1.
Diffuse Forefoot Pain
Consider: Treat symptomatically with
NSAIDs
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
2.
Arthritis
Consider: Treat symptomatically with PRN
acetaminophen and/or NSAIDs
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
3.
Morton’s/Interdigital
Neuroma (Plantar web space
pain)
Consider: Metatarsal pads, pain
management, NSAIDs, footwear review
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
Hallux Valgus
1.
Bunion
Consider: Symptomatic pain
management,
wide toe box shoes, NSAIDs PRN
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
2.
Hallux rigidus – 1st MTPJ
stiff, osteoarthritis on X-ray
Consider: Over the counter orthotics,
NSAIDs, symptomatic pain management,
glucocorticoid injection
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
3.
Hallux limitus
Consider: Over the counter orthotics,
NSAIDs, symptomatic pain management,
glucocorticoid injection
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
Toenail, Ingrown (mild to
moderate)
Consider: Education about nail trimming,
importance of footwear that fits, If
possible, soak in soapy water multiple
times per days for 10 - 20 minutes while
pushing the lateral nail fold away from
the nail plate, symptomatic pain
management
At the discretion of the clinician
depending on the clinical scenario
Toenail, Ingrown (moderate
to severe)
Consider: Education about nail trimming,
importance of footwear that fits, If
possible, soak in soapy water multiple
times per days for 10 - 20 minutes for 1-2
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000992
344
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
weeks while pushing the lateral nail fold
away from the nail plate during the
soaking, partial nail avulsion (removal),
pain management
Toes (Claw, Hammer, or
Mallet)
Consider: Symptomatic treatment with
NSAIDs and/or acetaminophen wide toe
box shoes
At the discretion of the clinician
depending on the clinical scenario
Calluses
Consider: Counsel about prevention and
avoiding ill-fitting shoes, pain
management, application of salicylic acid
(plasters or ointment) or urea-based
creams after paring down the callus.
At the discretion of the clinician
depending on the clinical scenario
Corns
Consider: Counsel about prevention and
avoiding ill-fitting shoes, pain
management, application of salicylic acid
(plasters or ointment) or urea-based
creams after paring down the callus.
At the discretion of the clinician
depending on the clinical scenario
Fracture, Toe Fracture
Uncomplicated
Consider: Immobilization by taping the
injured toe to the adjacent toe (buddy
taping), pain management
At the discretion of the clinician
depending on the clinical scenario
Fracture, Metatarsal
Fracture (uncomplicated,
minimal or non-displaced)
Consider: Ice, elevation, if the fracture is
minimally or nondisplaced and
conditions requiring emergency referral
have been excluded, initial treatment
includes immobilization in a posterior
splint and non-weight-bearing with a
follow-up visit in three to five days
At the discretion of the clinician
depending on the clinical scenario
Fracture, Metatarsal
Fracture (uncomplicated,
displaced)
Consider: Ice, elevation, reduction,
splinting
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics or
Podiatry
Midfoot Deformities
1.
Pes Planus (Flat Foot)
Consider: Observation - rarely requires
intervention, off-the-shelf orthotics,
stretches, weight loss, activity changes
At the discretion of the clinician
depending on the clinical scenario
2.
Pes Cavus (High Arch)
Consider: Observation - rarely requires
intervention, stretches, off-the-shelf
orthotics
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000993
345
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
3.
Arthritis
Consider: NSAIDs and/or acetaminophen,
targeted exercises
At the discretion of the clinician
depending on the clinical scenario
4.
Fracture Dislocation
Consider: Reduce, splint, pain
management
At the discretion of the clinician
depending on the clinical scenario
– May consider ER, Orthopedics
or Podiatry
Consider: NSAIDs and/or acetaminophen,
arch supports, inject with
steroid/lidocaine.
At the discretion of the clinician
depending on the clinical scenario
Hindfoot
1.
Plantar Fasciitis, Heel Spur,
Diffuse Heel Pain
Ankle (Sprains)
1.
Acute
Consider: Rest, ice, compression,
elevation
At the discretion of the clinician
depending on the clinical scenario
2.
Chronic - More than 2
sprains in 6 months or
chronic instability
Consider: Rest, ice, compression,
elevation,
strengthen peroneal (lateral calf) muscles,
proprioceptive training
At the discretion of the clinician
depending on the clinical scenario
Consider: Splint, ice and elevate
At the discretion of the clinician
depending on the clinical scenario
– May consider ER, Orthopedics
or Podiatry
Ankle/Dislocations
Fractures
Infection
1.
Diabetic Ulcer
Consider: The management of diabetic
foot ulcers typically begins with a
comprehensive assessment of the ulcer
and the patient's overall medical
condition, as such care will need to be
individualized but may include wound
culture (if discharge), wound care,
debridement, possible targeted systemics
antibiotics, elevation, footwear
evaluation, off-loading pressure from the
area and tighter glucose control
At the discretion of the clinician
depending on the clinical scenario
– May consider ER, Wound Care,
Orthopedics or Podiatry
2.
Gangrene (Dry)
Consider: Wrap wound lightly wrapped
with bulky dry gauze, possible antibiotics
At the discretion of the clinician
depending on the clinical scenario
– May consider urgent
Orthopedics or Podiatry
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000994
346
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
3.
Gangrene (Wet = Infection)
Consider: Prepare patient for referral,
wound care, possible antibiotics
(depending on time of referral)
At the discretion of the clinician
depending on the clinical scenario
– May consider ER or urgent
Orthopedics or Podiatry
4.
Osteomyelitis
Consider: Treatment of osteomyelitis
includes consideration of issues related
to debridement, management of infected
foreign bodies (if present), antibiotic
selection, and duration of therapy and as
such must be individualized to the
patient
At the discretion of the clinician
depending on the clinical scenario
– May consider urgent
Orthopedics or Podiatry
Achilles Tendonitis
Consider: Activity modification, heel lifts,
NSAIDs and/or acetaminophen, ice or
heat.
At the discretion of the clinician
depending on the clinical scenario
Achilles Tendon, Rupture
Consider: Splint, crutches, analgesic
medication
At the discretion of the clinician
depending on the clinical
scenario; May consider
Orthopedic or Podiatry
consultation
Calcaneus, Fracture
Consider: Bulky type dressing, splinting,
elevation, ice, pain management.
At the discretion of the clinician
depending on the clinical
scenario; May consider
Orthopedic or Podiatry
consultation
VII. Knee
Acute Knee Injury, No
Fracture
Consider: Ice, elevation, NSAIDs and/or
acetaminophen, pain management as
indicated, crutches, active exercises as
tolerated
At the discretion of the clinician
depending on the clinical scenario
Chronic Knee Pain
Consider: NSAIDs or acetaminophen,
quadriceps exercises, aspirate any
effusions, glucocorticoid injection
At the discretion of the clinician
depending on the clinical scenario
Unstable Knee (ACL, PCL,
etc.)
Consider: Recognize that each case is
unique and there is not one approach to
a patient with knee instability treatment
may include, NSAIDs, pain management,
activity modification, targeted exercises
to improve stability
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000995
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Medical Guidelines
Region: New Mexico
Onsite Care to Consider
Offsite Care to Consider
Meniscal Injuries
Consider: Management of meniscal tears
depends upon the type of tear, the
presence of significant mechanical
symptoms (e.g., knee locking), the
presence of a persistent knee effusion,
age, activity level, and the presence of
osteoarthritis or other structural knee
damage and as such treatment needs to
be individualized but may include rest,
pain management, activity restrictions,
targeted knee exercises.
At the discretion of the clinician
depending on the clinical scenario
Repeat Locking or Effusions
Consider: NSAIDs and/or acetaminophen,
activity modification, Joint aspiration
At the discretion of the clinician
depending on the clinical scenario
Dislocation of Knee
Consider: Attempt reduction, pain
management and prepare for likely
emergent referral
Typically needs emergent referral
to the ER
Dislocation of Patella
Consider: Reduce, ice, elevation, splint
At the discretion of the clinician
depending on the clinical scenario
will typically need referral to ER or
urgent orthopedics if not reduced
Crepitus or Grinding
Consider: NSAIDs and/or acetaminophen,
isometric quad exercises, glucocorticoid
injection
At the discretion of the clinician
depending on the clinical scenario
Patellar Tendinopathy
Consider: NSAIDs (topical or oral), ice,
activity modification – (no sports),
isometric quad exercises
At the discretion of the clinician
depending on the clinical scenario
– May consider Orthopedics
Diagnosis
VIII. HIP AND PELVIS
Fracture
Consider: Clinician’s plan of care is
dependent on the clinical scenario
including mechanism of injury, patient,
type of fracture, patient presentation,
symptoms
ER or Ortho evaluation at
discretion of provider depending
on the clinical scenario
Acute Injury w/o Fracture
Consider: Crutches, NSAIDs and/or
acetaminophen, analgesics
At the discretion of the clinician
depending on the clinical scenario
Chronic Pain
Consider: Acetaminophen or NSAIDs,
activity modification (no sports) cane,
ROM & strengthening exercises
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000996
348
Medical Guidelines
Region: New Mexico
Diagnosis
Dislocation
Onsite Care to Consider
Consider: Reduce ASAP, pain
management, typically treated as a
medical emergency
Offsite Care to Consider
At the discretion of the clinician
depending on the clinical scenario
with consideration for ER referral
IX. CERVICAL SPINE
Fracture
Consider: Stabilize the spine, the
disposition of patients with spinal column
injury depends primarily upon fracture
stability and concomitant injuries.
At the discretion of the clinician
depending on the clinical scenario
with consideration for ER referral
Chronic Pain
Consider: The differential diagnosis of
neck pain is broad. The majority of neck
pain complaints are likely related to
musculoskeletal causes, but numerous
other conditions can present with neck
pain so care will need to be
individualized and may include, soft
collar, NSAIDs, analgesics, heat
At the discretion of the clinician
depending on the clinical scenario
X. RIB/STERNAL
Fracture
Consider: Symptomatic analgesics,
activity modification including no sports
At the discretion of the clinician
depending on the clinical scenario
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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WEXFORD
COMPANIES
Otolaryngology
Otolaryngology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 000998
000998
Medical Guidelines
Region: New Mexico
Otolaryngology
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Otitis Externa
Consider: The selection of therapy should
be individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
The term "external otitis" (also
known as otitis externa or
swimmer's ear) refers to
inflammation of the external
auditory canal or auricle. Topical
antibiotics are highly effective for
treating external otitis.
Consider: Patient Education items:
1.
Avoid the use of ear plugs or other
items inserted in the ear canal until
healed.
2.
Avoid putting Q-tips or other objects
into the ear even if there is an itch.
Consider as an alternative, more costeffective, clinically effective option:
Otitis Media
Acute otitis media (AOM) is an
acute, suppurative infectious
process marked by the presence of
infected middle ear fluid. The
infection is most frequently
precipitated by impaired function
of the Eustachian tube, resulting in
the retention and suppuration of
retained secretions. AOM may also
be associated with purulent
1.
Using Maxitrol Ophthalmic in place
of Cortisporin Otic.
2.
Eyedrops may be utilized in the ear.
3.
Neomycin/polymixin/dexamethasone
(Maxitrol) ophthalmic preparation
can be used when rapid symptom
relief is desired and if the tympanic
membrane is intact and there is no
concern of hypersensitivity to
aminoglycosides.
4.
Typically, TID-QID administration is
required for effectiveness.
5.
Maxitrol should be avoided in
chronic/eczematous otitis externa.
Consider: The selection of therapy should
be individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
For pain consider: NSAIDS or
acetaminophen.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 000999
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
otorrhea if there is a ruptured
tympanic membrane. AOM usually
responds promptly to antimicrobial
therapy.
Treatment to consider:
Offsite Care to Consider
• Treat possible causes of Eustachian
tube dysfunction such as allergy,
acid reflux, smoking or sinusitis.
Antibiotics consider:
• Augmentin 875/125 1 tablet BID for
10 days
• Ceftin 500mg 1 tablet BID for 10
days.
• Doxycycline 100mg 1 tablet BID for
10 days – Generally considered a
3rd line agent.
Sinusitis, Acute
Acute rhinosinusitis (ARS) is
defined as symptomatic
inflammation of the nasal cavity
and paranasal sinuses lasting less
than four weeks.
VIRAL: The most common etiology
of ARS is a viral infection.
• Treatment for acute viral
rhinosinusitis (AVRS) typically
focuses on symptomatic
management as it typically
resolves within 7 to 10 days.
BACTERIAL: Patients who fail to
improve after ≥10 days of
symptomatic management are
more likely to have acute bacterial
rhinosinusitis (ABRS).
• Many patients with ABRS have
self-limited disease that
resolves without antibiotic
therapy. Patients rarely
develop complications of
bacterial infection beyond the
nasal cavity into the central
nervous system, orbit, or
surrounding tissues.
Consider: The selection of therapy should
be individualized.
AVRS consider: Patients with acute viral
rhinosinusitis (AVRS) should be managed
with supportive care. There are no
treatments to shorten the clinical course
of the disease.
At the discretion of the clinician
depending on the clinical
scenario
ABRS consider: Observation (watchful
waiting for a seven-day period) with
symptomatic management for
immunocompetent patients with ABRS.
The symptomatic management of ABRS
is similar to that of acute viral
rhinosinusitis (AVRS).
Antibiotics (if being considered):
• Augmentin 875/125 1 tablet BID for
10 days
• Doxycycline 100mg 1 tablet BID for
10 days
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001000
352
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Consider: Patient education. The
selection of therapy should be
individualized and based upon
consideration of the extent of the
condition and symptoms, and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
• Patients treated with
antibiotics may have a shorter
course of illness; however,
they also experience more
adverse events.
Sinusitis, Chronic
Chronic rhinosinusitis (CRS) is
defined as an inflammatory
condition involving the paranasal
sinuses and linings of the nasal
passages, which typically persists
for 12 weeks or longer.
The diagnosis generally has at least
2 of 4 cardinal signs and symptoms
(mucopurulent drainage, nasal
obstruction, facial
pain/pressure/fullness, and
decreased sense of smell).
CRS cannot be "cured" in most
patients, and therapy is intended to
reduce symptoms and improve
quality of life. Thus, the goals of
CRS therapy include the following:
Therapies to consider:
• Smoking cessation
• Intranasal saline
• Intranasal corticosteroids
• Oral corticosteroids
• Antibiotics depending on the
presentations and for acute
exacerbations
• Montelukast (Singulair)
• Antihistamines
• Control of mucosal
inflammation and edema
• Maintenance of adequate
sinus ventilation and drainage
• Treatment of colonizing or
infecting micro-organisms, if
present
• Reduction in the number of
acute exacerbations.
Tympanic membrane
perforation
A ruptured eardrum is a hole or
tear in the eardrum. The most
common causes of a ruptured
eardrum are:
Consider: Patient’s history and exam.
• If purulent discharge, consider an
oral antibiotic (for otitis media).
At the discretion of the clinician
depending on the clinical
scenario
• Consider observing the condition
for 3-4 weeks or as felt to be
clinically appropriate depending on
the clinical situation.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
• Ear infections – The infection
can cause fluid to build up
and press on the eardrum.
Treatment is primarily supportive, as TM
perforations generally heal
spontaneously.
• Poking the eardrum – This
happens if the patient pokes a
Q-tip, or other object into
their ear canal.
The ear should be kept dry as much as
possible since it can predispose to
infection if the ear is wet.
Most of the time ruptured
tympanic membranes heal
themselves.
Tinnitus
Tinnitus is a perception of sound in
proximity to the head in the
absence of an external source.
It can be perceived as being within
one or both ears, within or around
the head, or as an outside distant
noise.
Tinnitus can be continuous or
intermittent. Although both may
have a significant impact on the
patient, the latter is not usually
related to a serious underlying
medical problem. The sound may
be pulsatile or non-pulsatile.
Pulsatile tinnitus raises more
concern for underlying significant
pathology, though non-pulsatile
tinnitus may also be associated
with underlying disease.
Tonsilitis (Recurrent)
Chronic tonsillitis refers to the
presence of infection and/or
inflammation of the oropharynx or
tonsils for at least 3 months.
Patients with chronic tonsillitis or
pharyngitis often have sore throats
that get better during antibiotic
treatment, but symptoms recur as
Offsite Care to Consider
Consider: Patient education regarding
the condition and the importance of
keeping the ear dry when showering.
Consider: Patient education. The
selection of therapy should be
individualized and based upon the
consideration of the extent of the
condition and symptoms, patient’s
history, examination of the patient and
the response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Potential treatment for tinnitus includes
correcting identified comorbidities as
well as directly addressing the effects of
tinnitus on quality of life.
For many patients, tinnitus is a chronic
condition; goals of treatment are to
lessen its impact and any associated
disability, rather than to achieve absolute
cure.
Several treatment modalities have been
studied, including behavioral treatments
and medications, but the benefit for
most of these interventions has not been
conclusively demonstrated in
randomized trials.
Consider: Patient education. The
selection of therapy should be
individualized and based upon the
consideration of the extent of the
condition and symptoms, patient’s
history, examination of the patient, any
testing for Group A Streptococcus and
the response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Patient education to consider:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
soon as the antibiotic is
discontinued.
• Advising the patient that if they
have a virus, antibiotics won't help.
The cause of chronic tonsillitis is
likely multifactorial including
various viruses (e.g., Adenovirus,
Epstein-Barr virus), bacteria
including Group A Streptococcal
(GAS) infection, gastroesophageal
reflux disease, and possibly
allergies.
• Get lots of rest
Offsite Care to Consider
• Drink warm or very cold fluids to
help with throat pain
• Gargle with warm water or warm
salt water 3-4 times per day
• Take over-the-counter or prescribed
pain relievers such as
acetaminophen or NSAIDS.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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WEXFORD
COMPANIES
Pain
Pain Management
Management
WEXFORD MILLER
WEXFORD
MILLER 001004
001004
Medical Guidelines
Region: New Mexico
Treatment of Mild to Moderate Pain
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001005
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Medical Guidelines
Region: New Mexico
Treatment of Low Back Pain
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Pharmacologic Treatment of Chronic Pain
The following guidelines are based on current medical evidence and guidelines from leading organizations.
Updates will be made as new evidence becomes available. This document is intended to be used as an
aide to practitioners and to promote quality patient care. Individual patient clinical data should be
considered when applying this information.
I.
PURPOSE
These guidelines are intended to assist in the pharmacologic treatment of chronic pain in adult
patients. The treatment of migraine headaches or cancer-related pain and the treatment of acute
pain due to injury or post-operatively are not addressed in these guidelines.
II.
DEFINITION
The American Society of Anesthesiologists define chronic pain as pain of any etiology not directly
related to neoplastic involvement, associated with a chronic medical condition or extending in
duration beyond the expected temporal boundary of tissue injury and normal healing, and adversely
affecting the function or well-being of the individual.1
III.
DETERMINE BIOLOGICAL MECHANISMS OF PAIN2
Neuropathic Pain
1.
Examples: Sciatica from nerve root compression, diabetic peripheral neuropathy,
trigeminal neuralgia, and post-herpetic neuralgia
2.
Pain Characteristic: Burning or shooting/stabbing
3.
Physical Findings: Numbness; sensitivity to a non-noxious stimulus like light touch or
rubbing or coolness of the skin
Muscle Pain
1.
Myofascial pain: regional muscle soft tissue pain commonly involving the neck,
shoulders, trunk, arms, low back, hips and lower extremities
2.
Pain Characteristic: Painful muscle dysfunction in one or several muscles in a region of
the body with loss of range of motion; and tenderness at muscle sites that causes a
referred pain in a typical distribution (trigger points).
3.
Physical Findings: Taut bands of muscle; a muscle twitch may be produced with
palpation or needling the affected muscle
Inflammatory Pain
1.
Examples: Arthritis, infection, tissue injury, and postoperative pain
2.
Physical Findings: Heat, redness and swelling at pain site
Mechanical/Compressive Pain
IV.
1.
Examples: Muscle/ligament strain sprain; degeneration of disks or facets, or
osteoporosis with compression fractures
2.
Pain Characteristic: Aggravated by activity and temporarily relieved by rest
GENERAL PRINCIPLES FOR PHARMACOLOGIC MANAGEMENT
A thorough medication history is helpful to the development of an effective treatment plan.
It is helpful to define refine goals of therapy before prescribing, and tailor medications to meet
the individual goals of each patient
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Identify and treat specific source(s) of pain, and base the initial choice of medication(s) on the
severity and type of pain.
1.
Give drugs and adequate therapeutic trial.
2.
When treating inflammatory or neuropathic pain, benefits may take weeks or longer to
appear.
Educate patients on potential risks and benefits of drug therapy.
Select appropriate drug therapy based on:
1.
Characteristic of the agent (onset, duration, available routes of administration, dosing
intervals, side effects)
2.
Patient factors (age, co-existing diseases, other medications, and response to previous
treatments)
Establish a pain management plan that may include the addition of other drugs:
1.
Rational poly-pharmacy may include the use of two or more drugs with complementary
mechanisms of action that may provide greater pain relief with less toxicity and lower
doses of each drug.
2.
Generally, avoid prescribing two drugs in the same class at the same time.
3.
Be alert for possible interactions with other medication the patient is taking or additive
side effects
Titrate doses to achieve optimal balance between analgesic benefit, side effects, and functional
improvement.
Taper and discontinue drugs that do not meet treatment goals.
Use caution before starting a patient on long-term opioid therapy.
V.
PHARMACOLOGIC TREATMENT OF NEUROPATHIC PAIN 2,3,4,5
Appropriately manage or eliminate the underlying cause of pain.
Regional or local pain:
1.
2.
Consider use of capsaicin 0.075% cream―applied four (4) times daily.
a.
Instruct patients to wash hands before and after each application and avoid
mucous membranes
b.
Less frequent application increases frequency of burning and stinging
Lidocaine patch
a.
Usually applied for 12 hours only, then removed for 12 hours
b.
Variable absorption, may require up to 3 patches
c.
Avoid in patients with cardiac issues
Diabetic Neuropathy Treatment Options:
1.
Nortriptyline (Pamelor)
a.
Usual starting dose: 25 mg qhs, may increase by 25 mg/day every 7-21 days as
tolerated
b.
Major Drug Interactions:
i.
Contraindicated with MAOIs and Reglan
ii.
Selected antibiotics, antiarrhythmics, tramadol, cyclobenzaprine, 1st
generation antipsychotics, and SSRIs can cause QT interval prolongation
and/or serotonin syndrome when co-administered with nortriptyline
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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c.
2.
6-8 weeks, including 2 weeks at the highest dosage
Duloxetine (Cymbalta)
a.
Usual dose: Start at 30 mg daily x 1 week, then 60 mg daily.
a.
Major Drug Interactions-
b.
3.
Adequate trial duration:
tolerated
i.
Contraindicated with MAOIs and Reglan
ii.
Selected antibiotics, antiarrhythmics, tramadol, cyclobenzaprine, 1st
generation antipsychotics, lithium and SSRIs can cause QT interval
prolongation and/or serotonin syndrome when co-administered with
duloxetine
Adequate trial duration: 4-6 weeks
Gabapentin (Neurontin) – third-line
a.
Consider if a contraindication, intolerance, or documented failure despite
compliance at therapeutic doses with previously listed options
b.
Usual starting dose: 300 mg qhs or 300-400 mg BID, may increase by 100--300
mg BID every 7-21 days as tolerated, adjust for renal function as below:
Renal Function Creatinine Clearance
(mL/min)
60
Total Daily Dose Range (mg/day)
30 to 59
400 to 1400
15 to 29
200 to 700
15
100 to 300
900 to 3600
c.
For patients, with renal function < 30 ml/min, once daily dosing is needed
d.
Adequate trial duration: 8 weeks titration plus 2 weeks at maximum dose
Post-Herpetic Neuralgia Treatment Options:
1.
2.
First-line: Nortriptyline (Pamelor)
a.
Usual starting dose: 10 to 25 mg orally at bedtime; may increase dosage by 25
mg every 2 to 4 weeks until response is adequate.
b.
Maximum dosage of 125 mg per day is suggested.
c.
Major Drug Interactions:
i.
Contraindicated with MAOIs and Reglan
ii.
Selected antibiotics, antiarrhythmics, tramadol, cyclobenzaprine, 1st
generation antipsychotics, and SSRIs can cause QT interval prolongation
and/or serotonin syndrome when co-administered with nortriptyline
Second-line: Gabapentin (Neurontin)
a.
Usual starting dose: 300 mg orally on day 1, 300 mg twice a day on day 2, and
300 mg 3 times a day on day 3 (or 400 mg BID instead)
i.
May increase by 100-300 mg BID every week as tolerated
ii.
May increase up to 1800 mg/day (divided into 2-3 doses)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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b.
c.
3.
Adjust for renal function as below:
Renal Function Creatinine Clearance
(mL/min)
60
Total Daily Dose Range (mg/day)
30 to 59
400 to 1400
15 to 29
200 to 700
15
100 to 300
900 to 3600
For patients, with renal function < 30 ml/min, once daily dosing should be
considered.
Other Option: lidocaine patch
a.
Usually applied for 12 hours only, then removed for 12 hours
b.
Variable absorption, may require up to 3 patches
c.
Avoid in patients with cardiac issues
Classic Trigeminal Neuralgia Treatment Options:
1.
2.
3.
Carbamazepine (Tegretol)
a.
Usual starting dose: 100 to 200 mg twice daily, dose may be increased by 100 mg
every other day.
b.
Typical total maintenance dose: 300-800 mg/day, given in 2-3 divided doses.
c.
The maximum suggested total dose is 1200 mg/day.
d.
Major Drug Interactions:
i.
Contraindicated with many HIV drugs
ii.
May cause reduced efficacy of multiple drugs such as anticonvulsants,
antipsychotics, and antifungals
iii.
May cause elevation of carbamazepine levels and subsequent symptoms of
toxicity (hematologic, neurological and liver abnormalities)
Oxcarbazepine (Trileptal)
a.
Less drug interactions and safety concerns than Tegretol
b.
Usual starting dose: 150 mg twice daily, may be increased as tolerated in 300 mg
increments every third day until pain relief occurs.
c.
Typical maintenance dose: 300-600 mg twice daily.
d.
The maximum suggested total dose is 1800 mg/day.
Other Options:, lamotrigine (Lamictal)
a.
Usually requires slow titration from 25 mg/day to 200 mg BID max dose to prevent
rash
b.
Limited efficacy data
Fibromyalgia Treatment Options:
1.
Duloxetine (Cymbalta)
a.
Usual initial dose: 30 mg orally once daily for 1 week; increase to usual dosage
of 60 mg once daily based on tolerability; MAX 60 mg once daily
b.
Major Drug Interactions-refer to Sections C or D for details
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
3.
4.
VI.
Nortriptyline (Pamelor)
a.
Usual starting dose: 25 mg qhs, may increase by 25 mg/day every 7 days as
tolerated
b.
Major Drug Interactions—refer to Section C or D for details
Cyclobenzaprine (Flexeril)
a.
Low dose of 5 mg qhs shown to improve sleep, fatigue, and depression
b.
Contraindicated in cardiac conduction disturbances, arrhythmias, congestive
heart failure and hyperthyroidism.
c.
Multiple major drug interactions –
i.
Contraindicated with ziprasidone (Geodon) and MAOIs
ii.
SSRIs, SNRIs, antipsychotics – possible risk of serotonin syndrome and/or
QT interval prolongation
Pregabalin (Lyrica)
a.
Not available generically
b.
Usual dosing range is 75 mg BID-150 mg TID
c.
Schedule V Drug
d.
Associated with improvement in pain, global assessment and function, and sleep
PHARMACOLOGIC TREATMENT OF MUSCLE PAIN2
Scientific evidence of the effectiveness of treatment for muscle pain is lacking.
Drug Therapy:
VII.
1.
Low dose nortriptyline may be helpful (refer to Section V.C for drug interactions).
2.
Cyclobenzaprine up to 7 days per 180 days.
a.
Up to 10 mg three times a day can be used.
b.
Contraindicated in cardiac conduction disturbances, arrhythmias, congestive
heart failure and hyperthyroidism.
c.
Multiple major drug interactions –
i.
Contraindicated with ziprasidone (Geodon) and MAOIs
ii.
SSRIs, SNRIs, antipsychotics – possible risk of serotonin syndrome and/or
QT interval prolongation
PHARMACOLOGIC TREATMENT OF INFLAMMATORY PAIN
Non-steroidal anti-inflammatory drugs (NSAIDs) should be used for periodic flare-ups of mild
to moderate inflammatory or non-neuropathic pain.2
A 2006 comparative effectiveness review, updated in 2011, funded by the Agency for
Healthcare Research and Quality (AHRQ) of analgesics for osteoarthritis did not find clear
differences in efficacy of different NSAIDs, but did find differences in risk of serious harms. 6
Chronic NSAID use increases risk of renal insufficiency (especially in diabetics). Monitor renal
function and blood pressure.2
All NSAIDs carry a risk of gastritis and bleeding. 2
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Available NSAIDs on Wexford Corporate Formulary
6,7:
Classification
Drug
Usual Analgesic Dose/Interval
Salicylate (acetylated)
Aspirin
325−650mg every 4−6 hours
Salicylates (nonacetylated)
Salsalate
750−1000mg every 8−12 hours
Ibuprofen
Acetic acids
Diclofenac
400 mg every 4−6 hours
500 mg every 12 hours (naproxen base)
-OR550 mg every 12 hours (naproxen sodium)
50mg every 8 hours
Enolic acids
Meloxicam**
7.5−15mg every 24 hours
Propionic acids
Naproxen
**Partially selective NSAID | # should not be used longer than five (5) days; not indicated for chronic pain | Bolded font = On the Wexford Health
Corporate Formulary
VIII. PHARMACOLOGIC TREATMENT OF MECHANICAL/COMPRESSIVE PAIN
Medications are less effective. Treatment of causes may include surgical decompression or
stabilization, splinting, strengthening and use of assistive devices.
Acetaminophen (Tylenol) and NSAIDs are typically considered as initial choices of treatment
for mild to moderate pain.
Medication selection may depend on specific risk factors and co-morbidities.
Opioids may be considered for symptoms while other measures are being performed.
IX.
FOOTNOTES
1.
Rosenquist EWK. “Evaluation of Chronic Pain in Adults”. www.UpToDate.com, accessed June 12, 2017.
2.
National Institute for Health and Care Excellence (NICE). “Neuropathic Pain: the Pharmacological
Management of Neuropathic Pain in Adults in Non-Specialist Settings“,
https://www.ncbi.nlm.nih.gov/books/NBK11822/, accessed May 30, 2017.
3.
Dworkin RH, O’Connor AB, Audette J, et al. “Recommendations for the Pharmacological Management of
Neuropathic Pain: An Overview and Literature Update”, Mayo Clin Proc. 2010 (March); 85(3): S3-S14.
4.
Bril et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American
Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and
the American Academy of Physical Medicine and Rehabilitation. Neurology 2011; 76: 1758-65.
5.
Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. “2012 Canadian Guidelines for the Diagnosis and
Management of Fibromyalgia Syndrome”, available online.
6.
Singh MK. “Trigeminal Neuralgia Treatment and Management”, 2016. Accessed at
http://emedicine.medscape.com.
7.
Al-Quliti KW. Update on neuropathic pain treatment for trigeminal neuralgia: The pharmacological and
surgical options. Neurosciences. 2015;20(2):107–14
8.
Agency for Healthcare Research and Quality. Comparative Effectiveness Review Number 38. Analgesics
for osteoarthritis: An update of the 2006 comparative effectiveness review. Executive
summary.www.effectivehealthcare.ahrq.gov/ehc/products/180/805/Analgesics-Update_executivesummary_20111007.pdf. Accessed August 7, 2013.
9.
Solomon DH. NSAIDs: Therapeutic use and variability of response in adults. In: UpToDate, Furst, DE
(Ed), UpToDate, Waltham, MA, 2013.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Pharmacologic Treatment of Migraine Headaches
The following guidelines are based on current medical evidence and guidelines from leading organizations.
Updates will be made as new evidence becomes available. This document is intended to be used as an
aide to practitioners and to promote quality patient care. Individual patient clinical data should be
considered when applying this information.
I.
PURPOSE
These guidelines are intended to assist in the pharmacologic treatment of migraines in adult
patients.
II.
DEFINITION
The American Academy of Neurology defines migraine headaches as a chronic condition with
episodic manifestations characterized by attacks of head pain and neurologic, gastrointestinal, and
autonomic symptoms that vary in frequency, duration, and disability among sufferers and between
attacks.
III.
GENERAL PRINCIPLES OF MANAGEMENT
Establish a diagnosis.
1.
Migraine headaches are diagnosed usually by patient history, recognizing the following
characteristics:
2.
The diagnosis of migraines without aura is typically given when at least five attacks
fulfill the following criteria:
a.
Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated).
b.
Headache has at least two of the following characteristics:
c.
3.
i.
Unilateral location
ii.
Pulsating quality
iii.
Moderate or severe pain intensity
iv.
Aggravation by or causing avoidance of routine physical activity (e.g.,
walking or climbing stairs)
During the headache at least one of the following is present:
i.
Nausea, vomiting, or both
ii.
Photophobia and phonophobia
The diagnosis of migraines with typical aura is usually given when at least two attacks
fulfill the following criteria:
a.
One or more of the following fully reversible symptoms:
i.
Visual
ii.
Sensory
iii.
Speech/language
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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b.
At least two of the following characteristics:
i.
At least one aura symptom spreads gradually over ≥5 minutes, and/or two
or more symptoms occur in succession
ii.
Each individual aura symptom lasts 5 to 60 minutes
iii.
At least one aura symptom is unilateral
iv.
The aura is accompanied, or followed within 60 minutes, by headache
4.
Subtypes of migraine include migraine with brainstem aura, hemiplegic migraine,
retinal migraine, vestibular migraine, menstrual migraine, and chronic migraine.
5.
Diagnostic testing, including EEG, is not indicated in the routine evaluation of
headaches.
a.
Neuroimaging may be considered in patients with unexplained, abnormal neuro
exam, atypical headache features, or additional risk factors, such as immune
deficiencies.
Educate migraine sufferers about their condition and help them identify and eliminate
triggers.
Involve patients in managing their migraines.
1.
Encourage patients to use headache diaries to track triggers, frequency and severity of
headaches, and response to treatment.
2.
Encourage the patient to identify and avoid triggers.
Discuss the rationale for each particular treatment, how to use it, and what adverse events
are likely.
1.
Treatment choice depends on frequency and severity of attacks, the presence and degree
of temporary disability, and associated symptoms such as nausea/vomiting.
2.
Co-morbidities such as heart disease may limit treatment choices, while other comorbidities such as epilepsy, hypertension or obesity can help establish the most
effective regimen.
Taper and discontinue drugs that do not meet treatment goals.
Consider preventive treatment if the following is present:
IV.
1.
Frequent headaches (>2/week)
2.
Migraine significantly interferes with patient's daily routines, despite acute treatment
3.
Contraindication to, failure, adverse effects, or overuse of acute therapies
PHARMACOLOGIC TREATMENT OF MIGRAINE HEADACHES
Acute migraine attacks - mild to moderate
1.
First line treatment in patients who are not pregnant and do not have decompensated
cirrhosis, acute hepatitis, or fulminant liver failure, is Excedrin Migraine
(acetaminophen/aspirin/caffeine).
a.
Dosing:
i.
Up to two tablets per occurrence per 24 hours.
ii.
Do not use more than three times per week to avoid re-bound migraine
symptoms, sleep disturbances, and reflux symptoms.
iii.
Dispense 24 tablets per month.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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2.
Other recommended first-line options in patients who are not pregnant and do not have
decompensated cirrhosis, acute hepatitis, or fulminant liver failure, include ibuprofen
(Motrin), naproxen (Naprosyn), or aspirin.
3.
Pregnant patients should use Tylenol in place of NSAIDs and combination analgesics.
4.
In patients with severe hepatic impairment and decompensated cirrhosis - risk versus
benefit should be considered.
Acute migraine attacks - moderate to severe
1.
Injectable ketorolac (Toradol) can be used in patients with moderate to severe
symptoms, such as nausea or vomiting, and is as effective as other agents such as
intranasal sumatriptan and intravenous prochlorperazine.
a.
Dosing
i.
Weight of 50 kg or greater:
(1)
ii.
Weight of less than 50 kg:
(1)
iii.
2.
Single dose should not exceed 15 mg IV or 30 mg IM
Age of 65 years or greater:
(1)
b.
Single dose should not exceed 30 mg IV or 60 mg IM
Single dose should not exceed 15 mg IV or 30 mg IM
Contraindications: pregnancy, advanced renal disease or renal impairment,
recent or history of GI bleeding or perforation, history of or active peptic ulcer
disease, suspected or confirmed cerebrovascular bleeding, hypersensitivity to
aspirin or other NSAIDs, concurrent use with aspirin or other NSAIDs
Sumatriptan (Imitrex) is an alternative in patients without cirrhosis who have
moderate to severe symptoms, presence of nausea or vomiting, or who do not respond
to treatments for mild to moderate symptoms.
a.
Generally, avoid using more than two times per week to prevent re-bound
migraines.
b.
Contraindications: history of arrhythmias, stroke, ischemic heart disease,
coronary artery vasospasm, ischemic bowel disease, peripheral vascular disease,
uncontrolled hypertension, and severe hepatic impairment.
Preventive therapy for migraines
1.
2.
General principles:
a.
Start low and increase dose slowly until benefits are achieved or limited side
effects occur
b.
Give the drug an adequate trial at adequate dose (two to three months).
c.
Avoid interfering medications (e.g., overuse of acute medications).
d.
Monitor the patient's headache diary.
e.
Re-evaluate therapy. If headache is controlled at six months, consider tapering or
discontinuing treatment.
Medications with best clinical supportive data for migraine prevention
a.
Beta-blockers (atenolol, metoprolol)
i.
Atenolol: start at 25 mg daily, may increase up to 100 mg/day
ii.
Metoprolol: start at 50 mg per day in two divided doses, may increase up to
200 mg/day
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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b.
c.
V.
Valproic Acid (Depakote)
i.
Dosing: 250 mg twice a day, up to a maximum of 1000 mg/day
ii.
Adverse effects: nausea, somnolence, tremor, dizziness, weight gain, hair
loss; rare-liver failure, pancreatitis
iii.
Contraindications: pregnancy
Topiramate (Topamax)
i.
Dosing: 25 mg/day, with slow titration by 25 to 50 mg/week to the
maximum of 100 mg twice daily
ii.
Adverse effects: paresthesia, fatigue, anorexia, diarrhea, weight loss,
difficulty with concentration, nausea, and taste perversion
iii.
Precautions: Category in D in pregnancy
iv.
Warnings: Potential for abuse in correctional institutions
FOOTNOTES
1.
2.
American Academy of Neurology. “Migraine Headache: Summary of evidence-based guideline for
clinicians”, updated 2009,
https://www.aan.com/guidelines/home/getguidelinecontent/120, accessed June 2, 2017.
3.
Silbertstein, SD. “Practice parameter: Evidence-based guidelines for migraine headache (an evidencebased review): Report of the Quality Standards Subcommittee of the American Academy of Neurology”,
Neurology 2000; 55: 754-762.
4.
National Institute for Health and Care Excellence (NICE). “Headaches in over 12s: diagnosis and
management”. Clinical guideline, published September 2012, updated 2015.
www.nice.org.uk/guidance/cg150.
5.
Bajwa ZH, Smith JH. “Preventive treatment of migraine in adults”, www.UpToDate.com, accessed
February 5, 2018.
6.
Taggart E, Doran S, Kokotillo A, et al. Ketorolac in the treatment of acute migraine: a systematic review.
Headache. 2013;53(2): 277-87.
7.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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COMPANIES
Peer
Peer Review
Review
WEXFORD MILLER
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M-001: Peer Review Activities
I.
PURPOSE
Wexford Health recognizes that peer review is an essential activity in order to maintain integrity and
quality of patient care and to monitor clinicians practice patterns, identify strengths and
weaknesses. The intent is to use the process as an educational activity through feedback to the
clinicians. Such peer review activities will be confidential Quality Management Program material
that will be marked confidential and by state statute will not be discoverable. The results are not
intended to be used in a punitive manner. The peer review will meet both the ACA standard 4-4411
and the NCCHC standard P-C-02.
II.
PROCEDURE
Peer reviews will be conducted, at a minimum, on an annual basis. If more frequent review
is mandated by contract, it shall be done as required. The peer review(s) will be completed in
ninety (90) calendar days from this date.
Peer review will be done for medical practitioners, M.D. or D.O., physician assistants, ARNP’s,
psychiatrists and psychologists. The state regional medical director(s) will establish and
implement a process or system for this activity using the tool(s) attached for medicine and
mental health. When weaknesses are identified, it will be the responsibility of the regional
medical director to initiate a corrective plan and follow up for effectiveness. Jail facilities in a
state will be the purview of the state regional medical director. Where there is no prison facility
in a state, the CMO will ensure, through delegation, an individual responsible to complete the
review. The director of behavioral health will have the same responsibility for the mental
health component.
Peer review, when completed, will be reviewed by the state regional medical director/director
of behavioral health and signed off. The documents will then be forwarded to the corporate
chief medical officer. The completed material will be kept in a parallel file for each provider
and will be reviewed as part of the recredentialing appointment every two years.
Peer review will also include a simple questionnaire that will be used to query, for example,
staff including, at random, correctional officers, nursing, secretarial, clerical staff as to the
clinicians ability to communicate, cooperate, respect, listen, professional appearance and
demeanor, comportment and sense of judgment. Included should be a random sampling of
patients being queried as to their perception of their level of confidence in their care, education
provided by the clinician, health progress etc.
III.
ASSOCIATED FORMS
Peer Review Notification Form
Physician Peer Review: Chronic Care Clinic Worksheet
Physician Peer Review: Sick Call Worksheet
Physician Peer Review: Lab/X-ray Worksheet
Physician Peer Review: Infirmary Admissions Worksheet
Psychiatrist Peer Review Worksheet
Psychologist Peer Review Worksheet
Form PR-001C: Dental Review Form
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Peer Review Notification Form
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Physician Peer Review Worksheet
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Prison
Act
Prison Rape
Rape Elimination
Elimination Act
WEXFORD MILLER
WEXFORD
MILLER 001028
001028
Prison Rape Elimination Act Guideline
I.
GUIDELINE
Wexford Health supports the Department in its zero-tolerance relating to nonconsensual acts,
offender on offender sexual abuse, sexual misconduct, and staff sexual harassment in accordance
with the standards set forth in the Prison Rape Elimination Act of 2003 (PREA).
II.
APPLICABILITY
All divisions, facilities, and programs Department-owned and contracted, as specified in contract.
III.
DEFINITIONS
Health Services Administrator: the manager of the Health Services Program, ultimately
responsible for the operation and management of the Health Services program at the site level
Department Employee: means a person employed by the Department. This term does not
include Wexford Health staff
Incarcerated Offender: any individual detained in a Department-owned, operated, or
contracted facility who is sentenced or committed to Department of Corrections supervision
Nonconsensual Sex Act: a sexual act upon an incarcerated offender perpetrated by another
offender if the victimized offender does not consent or is mentally incapable of consent or
when the perpetrator is an employee, contractor, or volunteer unless the act is part of a lawful
search.
Nonconsensual Sexual Contact: touching of an incarcerated offender directly or through
clothing of the genitalia, anus, groin, breast, inner thigh, or buttocks for sexual gratification
perpetrated by another offender if the victimized offender does not consent or is mentally
incapable of consent or perpetrated by an employee, contractor, or volunteer, unless the act
is part of a lawful search.
Service Providers: this term includes contracted persons, volunteers, interns, temporary
employees, or other vendors providing service whose assignment is primarily on the
Department’s premises, e.g., facility or program office.
Sexual Act: contact between the penis and the vagina or the penis and the anus involving
penetration, however slight; contact between the mouth and the penis, vagina, or anus; or
penetration of the vagina or anus of another person by hand, finger, or other object.
Staff Sexual Harassment: repeated statements or comments of a sexual nature to an offender
by an employee, volunteer, contractor, official visitor, or other agency representative; includes
demeaning references to gender or derogatory comments about body or clothing; and repeated
profane or obscene language or gestures.
Staff Sexual Misconduct: Nonconsensual sexual contact or acts directed toward an offender
by an employee, volunteer, contractor, official visitor, or other agency representative,
including completed, attempted, threatened, or requested sexual acts and occurrences of
indecent exposure, invasion of privacy, or staff voyeurism for sexual gratification.
Staff: any health services staff directly responsible for care or services to the offenders, mainly
MD’s, PA’s, NP’s, Nurses, Medical Records personnel, Students, interns, or ancillary staff such
as X-ray techs, CNA’s, or phlebotomists.
IV.
OTHER SPECIFICATIONS
General Requirements
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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1.
Facility Administrator’s, or designees, will immediately respond to allegations of
nonconsensual acts or contact and staff sexual misconduct and harassment, fully
investigate reported incidents in accordance with Human Resources and Wexford
Health Guidelines, pursue disciplinary action, and refer for investigation and
prosecution those who violate the requirements set forth in this guideline.
2.
During intake, staff will communicate to offenders, verbally and in writing, information
about the Department’s zero tolerance of nonconsensual acts and contact and staff
misconduct and harassment and will provide information including this guideline.
3.
Each site has an assigned PREA liaison responsible for the following:
a.
Coordinate facility PREA-related activities with the PREA coordinator;
b.
Ensure facility compliance with training requirements; and
c.
Tracking and reporting
Offender Reporting
1.
Offenders who are victims of or have knowledge of nonconsensual sexual acts or contact
or staff misconduct or harassment should be encouraged to immediately report the
incident by one of the following methods:
a.
Report the incident to medical staff
b.
Report to mental health
c.
Report to security staff
Prevention and Intervention
1.
Staff must be alert to situations in which nonconsensual sexual acts or contact, or staff
sexual misconduct or harassment might occur and be capable of identifying the
following indicators:
a.
Overly friendly behavior of staff and/or offenders
b.
The exchange of money, food, notes or pictures
Victim Services Provided
1.
2.
Victim services to offenders who allege that they are victims of nonconsensual sexual
acts or contact or staff sexual misconduct or harassment, services must include, at
minimum;
a.
Medical examination, documentation, and treatment of injuries; and
b.
Mental health crisis intervention and treatment
The following standards for examination of victims of nonconsensual sexual acts or staff
sexual misconduct will be followed:
a.
If the victim refuses medical or mental health attention, staff will document the
refusal on the Medical Treatment Refusal (ROR) form;
b.
If reported within 72 hours of the incident, employees will, with the victim’s
permission, immediately transport the victim to a medical facility equipped to
evaluate and treat sexual assault/rape victims; and
c.
If reported more than 72 hours after the incident, employees will, with the victim’s
permission, adhere to the following:
i.
Refer victims to in house health care providers responsible for treatment
and follow up care for sexually transmitted or other communicable diseases,
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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completing a patient history, and conducting an examination to document
the extent of physical injury and determine whether referral to another
medical facility is required; and
ii.
Upon request from law enforcement, transport the victim to a community
medical facility for evidence collection.
iii.
Crisis intervention and trauma-specific treatment, for offenders victimized
by nonconsensual sexual acts will be referred to Mental Health for follow
up.
Staff Training
1.
Prior to working with offenders, all Wexford Health staff with direct and/or incidental
contact with offenders must receive documented PREA training during orientation, and
biannually thereafter. Training will include, but is not limited to:
a.
Review of this guideline, the Prison Rape Elimination Act (2003), and any other
applicable state or federal laws;
b.
Prevention, investigation, and prosecution of sexual misconduct;
c.
The Department’s zero tolerance stance;
d.
Recognition of sexual misconduct, predatory offenders, potential victims, and/or
staff involvement;
e.
Facility procedures on sharing confidential information;
f.
Reporting procedures;
g.
An offender’s right to be free from sexual misconduct;
h.
Offender and employee rights to be free from retaliation for reporting sexual
abuse;
i.
The dynamics of sexual abuse in confinement; and
j.
Common reactions of sexual abuse victims.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Respiratory
Respiratory Disorders
Disorders
WEXFORD MILLER
WEXFORD
MILLER 001032
001032
Acute Asthma
ACUTE ASTHMA
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
1
Evaluation of symptoms, chest examination, vital signs, PEF,
and oxygen saturation
Initial Treatment:
1. Inhaled albuterol metered dose inhaler (MDI) with spacer (2 to 8
puffs of 90 micrograms/puff) or nebulization 2.5 to 5 mg of
albuterol up to 3 treatments at 20 minute intervals.
2. Supplemental O2 1-3 L/min via nasal cannula to maintain O2
saturation greater than 90% (greater than 95% in pregnant
women or patients with coronary artery disease)
2
Repeat assessment in 20-60 minutes.
3
Is response
1. Good (Mild Episode)
2. Incomplete (Moderate Episode)
3. Poor (Severe Episode)
4
7
GOOD RESPONSE
(Mild Episode)
10
INCOMPLETE RESPONSE
(Moderate Episode)
5
POOR RESPONSE
(Severe Episode)
11
8
1. No wheezing or dyspnea.
2. PEF greater than 80% predicted or personal
best.
6
MANAGEMENT
1. Continue albuterol MDI 2 to 8 puffs
Q4H for 1-2 days, then PRN.
2. If on inhaled steroids, double dose for 7-10 days.
1. Marked wheezing or dyspnea.
2. PEF less than 50% predicted or personal best.
1. Persistent wheezing or dyspnea.
2. PEF 50-80% predicted or personal best.
12
9
MANAGEMENT
1. Continue albuterol MDIr 2 to 8 puffs every
hour.
2. Oxygen to achieve greater than or equal to 90% saturation
(greater than 95% in pregnant women or patients with
coronary disease).
3. Prednisone PO 60 mg or methylprednisolone 125 mg I.V.
MANAGEMENT
1. Inhaled albuterol 2.5 mg and ipratropium 0.5mg by
nebulization every 20 minutes or continuously for 1 hour.
2. Oxygen to achieve greater than or equal to 90% saturation
(greater than 95% in pregnant women or patients with
coronary artery disease).
3. Prednisone PO 60 mg or methylprednisolone 125 mg I.V.
13
Repeat assessment in 1-3 hours.
Evaluation of symptoms, chest examination,
vital signs, PEF, and oxygen saturation.
14
Is response
1. Good (Mild Episode)
2. Incomplete (Moderate Episode)
3. Poor (Severe Episode)
15
18
GOOD RESPONSE
(Mild Episode)
16
19
1. PEF greater than 70%.
2. No distress with normal examination.
17
21
INCOMPLETE RESPONSE
(Moderate Episode)
MANAGEMENT
1. Prednisone P.O. 40 mg TID for 48 hours
then 60 to 80 mg/day until the PEFR is
70% of predicted or patient’s personal
best before tapering rapidly.
2. Albuterol MDI 2 to 8 puffs
Q4H x2 days.
3. Follow-up in 1-2 days and stage.
POOR RESPONSE
(Severe Episode)
22
1. PEF 50-70%.
2. Mild to moderate symptoms.
20
MANAGEMENT
1. Individualize decision to discharge per
good response.
1. PEF less than 50%.
2. Severe symptoms.
23
MANAGEMENT
1. Seek emergency treatment.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Severity of Asthma Exacerbation
SEVERITY OF ASTHMA EXACERBATION
SYMPTOMS
Dyspnea
Position, preferred
Alertness
MILD
MODERATE
SEVERE
Speaks in Sentences
Can lie down
Normal/agitated
Speaks in phrases
Sitting
Agitated
Speaks in single words
Sits upright
Agitated or drowsy
Normal to 30% above mean
Less than 100 bpm
Normal
None/mild intercostals retractions
End-expiratory wheezing
Less than 10 mm Hg
30-50% above mean
100-120 bpm
Pale
Moderate intercostals retractions,
chest hyperinflation, use of
sternocleidomastoid muscles
Inspiratory and expiratory wheezing
10-25 mm Hg
Greater than 50% above mean
Greater than 120 bpm
Cyanotic
Moderate intercostals retractions;
chest hyperinflations; tracheosternal
retraction during inspiration.
Inaudible breath signs (no wheezing)
Greater than 25 mm Hg
80% of predicted or baseline
50-80% of predicted or baseline
Less than 50% of predicted or baseline
Greater than 95%
91-95%
Less than 91%
PCO2
Less than 43 mm Hg
Less than 42 mm Hg
Greater than 44 mm Hg
PO2 (Room air)
PH
Normal
Greater than 60 mm Hg
Less than 60 mm Hg
Respiratory alkalosis
Pseudo normal
Respiratory acidosis
SIGNS
Respiratory rate
Heart rate
Color
Accessory muscle
use
Auscultation
Pulsus paradoxus
TESTS
PEF
O2 Saturation
PEF, peak expiratory flow
PCO2: partial pressure of carbon dioxide
PO2: partial pressure of oxygen
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Chronic Asthma Severity Classification/Management
The pathways do not replace sound clinical judgment.
Nor are they intended to strictly apply to all patients.
1
NO
•
•
•
SYMPTOMS
Symptoms less than or equal to 2 times a week.
Asymptomatic and normal PEFR between exacerbations.
Exacerbations brief (from a few hours to a few days); intensity
•
NIGHTTIME SYMPTOMS
Less than or equal to 2 times a month.
•
•
LUNG FUNCTION
FEV 1/PEFR greater than or equal to 80% predicted
PEFR variability less than or equal to 20%
may vary.
YES
2
3
NO
•
•
SYMPTOMS
Symptoms greater than 2 times a week but less than 1 time per day.
Exacerbations may affect activity.
•
NIGHTTIME SYMPTOMS
Greater than 2 times a month.
•
•
LUNG FUNCTION
FEV 1/PEFR greater than or equal to 80% predicted
PEFR variability 20% - 30%
INTERMITTENT
See Step 1 Treatment
YES
4
5
•
•
•
•
Daily symptoms.
Daily use of inhaled short -acting beta agonists.
Exacerbations affect activity.
Exacerbations greater than 2 times a week; may last for days.
•
NIGHTTIME SYMPTOMS
Greater than 1 times a week.
•
•
LUNG FUNCTION
FEV 1/PEFR greater than 60% predicted
PEFR variability greater than 30%
NO
MILD PERSISTENT
See Step 2 Treatment
SYMPTOMS
YES
6
MODERATE PERSISTENT
See Step 3 Treatment
7
SYMPTOMS
•
•
•
Continual symptoms.
Limited physical activity.
Frequent exacerbations.
•
Frequent.
•
•
LUNG FUNCTION
FEV 1/PEFR less than or equal to 60% predicted
PEFR variability greater than 30%
YES
NIGHTTIME SYMPTOMS
8
SEVERE PERSISTENT
See Step 4 Treatment
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Chronic Asthma
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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* National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and
Management of Asthma, Full Report 2007 http://www.nhlbi.nih.gov/files/docs/guidelines/01_front.pdf
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Asthma Control: Achieving the Best Outcomes with Medication Use and Targeted Patient
Education
I.
INTRODUCTION
According to National Heart, Blood, and Lung Institute Expert Panel Report 3: Guidelines for the
Diagnosis and Management of Asthma, there are four (4) essential components of asthma care:
medication, patient education, environmental control measures, and management of comorbidities.
While identifying precipitating factors and treating comorbidities are part of the approach to
management, the first two (2) components are critical in achieving success through appropriate
drug selection and patient compliance. Therapy is initiated based on asthma severity, such that
mild intermittent asthma does not require daily use of maintenance medication, but typically only
short-acting bronchodilators or rescue medicine.
II.
HELPFUL GUIDANCE FOR CORRECTIONAL MEDICAL PERSONNEL
It has been recognized in the community that up to 25% of patients may overuse their rescue
inhalers due to poor technique, lack of understanding, and abuse. In corrections, inhalers can be
used to make handcuff keys, to obtain special privileges such as restricted work details or improved
housing units, and to experience secondary side effects. Therefore, it is critical to assess the
patient’s knowledge of asthma and skills in administering inhalers.
III.
INTERMITTENT ASTHMA CONTROL
Rescue inhalers should not be needed more than two (2) days/week in intermittent asthma, and
should be ordered as patient-specific medications and not as stockpiled medications. Because each
canister contains 200 actuations, a typical refill frequency should not exceed 3–6 months, but a
time frame for refills should be clearly specified on all prescriptions.
During the asthma clinic, the word PROFILE should be written on the prescription to ensure that
the patient doesn’t receive any additional drug unless the present supply of the medication is
exhausted and the patient presents an empty inhalation canister during the visit.
Patients with a remote history of asthma typically do not require a prescription for a short-acting
beta agonist. In many situations, an order for albuterol nebulization prn for asthma exacerbations
is sufficient to assure that the patient can obtain necessary treatment in the medical unit in case
of an unexpected asthma attack.
IV.
MILD TO MODERATE PERSISTENT ASTHMA CONTROL
When the asthma is mild to moderate persistent, a daily maintenance medication is typically
needed.
For mild persistent asthma control, leukotriene receptor antagonist (e.g., Singulair) can be used if
the following causes are identified:
▪
Asthma is exercise-induced
▪
Patient has wheezing due to perennial allergic rhinitis or virus
▪
Patient has history of smoking, or is a current smoker
▪
Patient is obese
Ciclesonide (Alvesco) is an inhaled corticosteroid on the Wexford Health Corporate Formulary that
is FDA-approved for asthma management at doses of 80–320 mcg BID based on disease severity
and previous use of corticosteroids.
▪
Practitioners may start with 160 mcg BID in patients with moderate to severe disease.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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▪
Clinical studies have shown efficacy with 160 mcg once daily dosing for mild to moderate
persistent symptoms, which may improve patient compliance.
In general, adherence to asthma medication regimens in the community tends to be very poor, with
reported rates of nonadherence ranging from 30–70%. This may account for poor asthma control
and higher likelihood of complications, ER visits, and long-term hospitalizations. Therefore, in
patients experiencing frequent symptoms, it may be beneficial to order Alvesco as Directly Observed
Therapy (D.O.T.) and/or to utilize a higher dose (e.g., 320 mcg) once daily to ensure patient
adherence.
V.
▪
The patient should be educated that Alvesco is used as a chronic therapy for prevention of
asthma of attacks, and not as a rescue medication.
▪
Alvesco should be ordered as patient-specific drug only and generally not kept as stock in
facilities.
▪
PROFILE should be indicated on all orders to ensure that a new supply is sent only when the
present canister is empty.
o
With BID dosing, the canister will last 30 days and with daily dosing, the canister
should last 60 days.
o
Should the inhaler run out before 30 days or asthma becomes severe, a seven (7)
day course of prednisone may be considered as a clinical option to regain asthma
control along with patient education.
SEVERE PERSISTENT ASTHMA CONTROL
Progression to maximal dose of inhaled corticosteroid and the possible addition of a long-acting beta
agonist or an oral steroid may be necessary in severe asthma.
VI.
REFERENCES
1.
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert
Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report 2007
http://www.nhlbi.nih.gov/files/docs/guidelines/01_front.pdf
2.
Magnussen H, Hofman J, Staleta P et al. “Similar efficacy of ciclesonide once daily versus fluticasone
propionate twice daily in patients with persistent asthma”. J Asthma 2007 Sep; 44(7): 555-63.
3.
Dahl R, Engestatter R, Trebas-Pietras E. “A 24-week comparison of low-dose ciclesonide and fluticasone
propionate in mild to moderate asthma”. Respir Med. 2010 Aug; 104(8) :1121-30.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Summary
Summary of
of Guideline
Guideline
Recommendations
Recommendations for
for Periodic
Periodic
Health
Health Examinations
Examinations
WEXFORD MILLER 001042
Summary of Guideline Recommendations for Periodic Health Examinations
These guideline recommendations describe Wexford Health guidelines for a number of periodic health
interventions for the populations we serve.
These recommendations are provided only as assistance for physicians making clinical decisions
regarding the care of their patients. As such, they cannot substitute for the individual judgment brought
to each clinical situation by the patient’s physician. As with all clinical reference resources, they reflect
the best understanding of the science of medicine at the time of publication, but they should be used with
the clear understanding that continued research may result in new knowledge and recommendations
I.
INTRODUCTION
The Wexford Health Summary of Guideline Recommendations for Periodic Health
Examinations (RPHE) originated in the Wexford Health Medical Advisory Committee.
The starting point for the recommendations is the rigorous analysis of scientific knowledge
available as presented by the United States Preventive Services Task Force (USPSTF) in their
Guide to Clinical Preventive Services, 2nd Edition and ongoing releases of evidence reports
and recommendations from the 3rd Edition.
The recommendations include:
1.
SR: Strongly Recommend: Good quality evidence exists which demonstrates substantial
net benefit over harm; the intervention is perceived to be cost-effective and acceptable
to nearly all patients.
2.
R: Recommend: Although evidence exists which demonstrates net benefit, either the
benefit is only moderate in magnitude or the evidence supporting a substantial benefit
is only fair. The intervention is perceived to be cost-effective and acceptable to most
patients.
3.
NR: No Recommendation Either For or Against: Either good or fair evidence exists of
at least a small net benefit. Cost-effectiveness may not be known or patients may be
divided about acceptability of the intervention.
4.
RA: Recommend Against: Good or fair evidence which demonstrates no net benefit over
harm.
5.
I: Insufficient Evidence to Recommend Either For or Against. No evidence of even fair
quality exists or the existing evidence is conflicting.
6.
I-HB: Healthy Behavior is identified as desirable but the effectiveness of physician’s
advice and counseling is uncertain.
Physicians are encouraged to review not only the needs of individual patients they see, but
also of the populations in the communities they serve to determine which specific population
recommendations need to be implemented systematically in their practices.
The
recommendations contained in this document are for screening and counseling only. They
do not necessarily apply to patients who have signs and/or symptoms relating to a particular
condition.
Where appropriate, specific website URL’s are provided which link directly to the clinical
consideration section of the U.S. Preventive Services Task Force. The clinical consideration
section provides additional information needed to interpret and implement the
recommendations.
These recommendations are provided only as assistance for physicians making clinical
decisions regarding the care of their patients. As such, they cannot substitute for the
individual judgment brought to each clinical situation by the patient’s physician. As with all
clinical reference resources, they reflect the best understanding of the science of medicine at
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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the time of publication, but they should be used with the clear understanding that continued
research may result in new knowledge and recommendations.
State/County directives and guidelines supersede this guideline.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Summary of Guideline Recommendations for Periodic Health Examinations, Table 1: Wexford
Health
Abdominal
Aortic
Aneurysm
Alcohol
Misuse
Wexford Health recommends a one-time screening for abdominal aortic aneurysm (AAA) with
ultrasonography in men ages 65 to 75 years who have ever smoked.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/abdominal-aorticaneurysm-screening
Wexford Health recommends that clinicians screen adults aged 18 years or older for alcohol misuse and
provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to
reduce alcohol misuse.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcoholmisuse-screening-and-behavioral-counseling-interventions-in-primary-care
Wexford Health recommends biennial screening mammography for women aged 50–74 years.
Breast
Cancer
Wexford Health recommends that the decision to start screening mammography in women prior to age 50
years should be an individual one. Wexford Health recognizes that women age 40–49 years with a parent,
sibling, or child with breast cancer are at a higher risk for breast cancer and thus may benefit more than
average-risk women from beginning screening in their 40s. The screening is recommended to occur after
relevant counseling by their clinician regarding the potential risks and benefits of the procedure.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancerscreening1
Wexford Health strongly recommends that a Pap smear be completed for women between the ages of 21
and 65 and then every three (3) years thereafter or as dictated clinically.
Women over the age of 65 do not require a screening as long as they have had an adequate prior screening
and are not otherwise at high risk for cervical cancer.
Cervical
Cancer
Women who have had a hysterectomy with removal of the cervix and do not have a history of high grade
precancerous lesion or cervical cancer will not require further screening.
These recommendations do not apply to women who have received a diagnosis of a high grade
precancerous lesion or cervical cancer, women with in-utero exposure to DES, or women who are
immunocompromised (such as those with HIV).
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancerscreening
Chlamydia
Wexford Health strongly recommends screening for chlamydia in sexually active women age 24 years and
younger and in older women who are at increased risk for infection.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-andgonorrhea-screening
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Colorectal
Cancer
Colorectal
Cancer
High
Risk
Coronary
Heart
Disease
Depression
Diabetes,
Type 2
Gonorrhea
Hepatitis B
Screening
Wexford Health strongly recommends screening for colorectal cancer using fecal occult blood testing in
adults, beginning at age 50 years and continuing until age 75 years.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancerscreening
Wexford Health recommends screening persons at higher risk for colorectal cancer by following the
American Cancer Society Guidelines on Screening and Surveillance for the Early Detection of Colorectal
Adenomas and Cancer in People at Increased Risk or High Risk.
Clinical Considerations:
http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetectio
n/colorectal-cancer-early-detection-acs-recommendations
Wexford Health recommends initiating low-dose aspirin use for the primary prevention of cardiovascular
disease (CVD) in adults aged 50–59 years who have a 10% or greater 10-year CVD risk, are not at
increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose
aspirin daily for at least 10 years.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-preventcardiovascular-disease-and-cancer
Wexford Health recommends screening for depression in the general adult population, including pregnant
and postpartum women.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-inadults-screening1
Wexford Health recommends screening for abnormal blood glucose as part of cardiovascular risk
assessment in adults aged 40–70 years who are overweight or obese. Clinicians should offer patients with
abnormal blood glucose behavioral counseling interventions to promote a healthful diet and physical
activity.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening
-for-abnormal-blood-glucose-and-type-2-diabetes
Wexford Health recommends screening for gonorrhea in sexually active women age 24 years and younger
and in older women who are at increased risk for infection.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-andgonorrhea-screening
Wexford Health recommends screening for the hepatitis B virus (HBV) infection in persons that are at high
risk for infection.
Clinical Consideration:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-b-virusinfection-screening-2014
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Hepatitis B
Vaccination
Hepatitis B
Vaccination
for Diabetes
Hepatitis C
HIV
Infection
Hypertension
Influenza
Vaccine
Wexford Health strongly recommends immunizing persons for hepatitis B who are injection drug users,
persons who have a history of multiple sexual partners in the previous six (6) months, persons who have
recently acquired a sexually transmitted disease, and the recipients of certain drug products.
Clinical Considerations:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
Wexford Health strongly recommends that all previously unvaccinated adults aged 19–59 years with
diabetes mellitus (type 1 and type 2) be vaccinated against hepatitis B as soon as possible after a diagnosis
of diabetes is made.
Clinical Considerations:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm
Wexford Health recommends screening for the hepatitis C virus (HCV) infection in persons that are at high
risk for infection. Wexford Health also recommends offering a 1-time screening for HCV infection to adults
born between the years of 1945 and 1965. Wexford Health will follow state and county recommendations
for HCV screening in the regions we serve.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-c-screening
Wexford Health strongly recommends that clinicians screen for the HIV infection in adolescents and adults
aged 15–65 years. Younger adolescents and older adults who are at increased risk should also be
screened.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/humanimmunodeficiency-virus-hiv-infection-screening
Wexford Health strongly recommends that Wexford Health physicians screen adults aged 18 and older for
high blood pressure.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/high-blood-pressurein-adults-screening
Wexford Health strongly recommends a routine annual influenza vaccination for all persons who do not
have contraindications. Optimally, a vaccination should occur before the onset of influenza activity in the
community. Health care providers should offer a vaccination by October, if possible. The vaccination should
continue to be offered as long as influenza viruses are circulating. Priority should focus on immunizing adults
for influenza who are residents of chronic care facilities, or ones that suffer from chronic cardiopulmonary
disorders, metabolic disease (including diabetes mellitus), hemoglobinopathies, immunosuppression, and
renal dysfunction.
Clinical Consideration:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
Wexford Health strongly recommends screening for lipid disorders with either a fasting or a non-fasting lipid
profile l in males age 35 and older, and females age 45 and older.
Lipid
Disorders
Wexford Health recommends screening men aged 20–35 for lipid disorders if they are at increased risk for
coronary heart disease and screening women aged 20–45 for lipid disorders if they are at increased risk for
coronary heart disease.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/lipiddisorders-in-adults-cholesterol-dyslipidemia-screening
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Obesity
Osteoporosis
Wexford Health recommends screening all adults for obesity. Clinicians should offer or refer patients with a
body mass index (BMI) of 30 kg/m2 or higher to intensive behavioral interventions. Intensive counseling
may be delivered by primary care physicians, NPs, PAs, nurses or by other qualified professionals including
dietitians and nutritionists.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adultsscreening-and-management
Wexford Health recommends screening for osteoporosis in women aged 65 years and older and in younger
women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no
additional risk factors.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosisscreening
Wexford Health recommends pneumococcal vaccinations among all adults aged ≥65 years and those
adults aged 19–64 years with underlying medical conditions that put them at greater risk for serious
pneumococcal infection including.
Age less than 65, not severely immunocompromised:
• For those who have not received any pneumococcal vaccine or for those whose vaccination
history is unknown, a single dose of PPSV23 (Pneumovax) vaccine should be considered.
Pneumococcal
Disease
Vaccinations
Age 65 and older, not severely immunocompromised:
• For those who have not received any pneumococcal vaccine or for those whose vaccination
history is unknown, a single dose of PCV13 (Prevnar) vaccine in addition to a single dose of
PPSV23 (Pneumovax) should be considered.
• Timing of vaccines - Patients should be immunized with PCV13 (Prevnar) vaccine first, then
PPSV23 (Pneumovax) vaccine 1 year later.
• If the patient has received PPSV23 (Pneumovax) when less than 65, a minimum interval
of 5 years between doses should be maintained between the PPSV23 Pneumovax vaccines.
Severely immunocompromised patients (e.g. chronic renal failure, malignancy, HIV, organ transplant,
congenital immunodeficiency, sickle cell disease):
• For those who have not received any pneumococcal vaccine or for those whose vaccination
history is unknown, a single dose of PCV13 (Prevnar) vaccine in addition to a single dose of
PPSV23 (Pneumovax) should be provided.
• Timing of vaccines – Patients should be immunized with PCV13 (Prevnar) first then PPSV23
(Pneumovax) vaccine at least 8 weeks after receiving the PCV13 (Prevnar) vaccine.
• If the patient has received PPSV23 (Pneumovax) when less than 65, a minimum interval
of 5 years between doses should be maintained between the PPSV23 Pneumovax vaccines.
Clinical Considerations:
https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Prostate
Cancer
Sexually
Transmitted
Diseases
Counseling
Skin
Cancer
Counseling
Syphilis
Tetanus
Tobacco
Use
Wexford Health concludes that routine screening for prostate cancer using prostate specific antigen (PSA)
is not recommended due to the significant potential harm and very small potential benefit. This
recommendation applies to men in the general U.S. population, regardless of age. The recommendation
does not include the use of the PSA test for surveillance after diagnosis or treatment of prostate cancer.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancerscreening
Wexford Health recommends behavioral counseling for all sexually active adolescents and for adults who
are at increased risk for sexually transmitted infections (STIs).
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/sexually-transmittedinfections-behavioral-counseling1
Wexford Health recommends counseling adolescents, and young adults aged 10 to 24 years who have fair
skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancercounseling
Wexford Health strongly recommends that clinicians screen persons at an increased risk for syphilis
infection including all pregnant women.
Clinical Consideration:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infectionscreening
Wexford Health strongly recommends immunizing adults for tetanus by completing the Td vaccine series if
the primary series hasn’t been received. Boosters should be given every ten (10) years or at least at age
50.
Clinical Considerations:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm
Wexford Health strongly recommends that clinicians ask all adults (including all pregnant females) about
tobacco use, advise them to stop using tobacco, and provide behavioral interventions.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-inadults-and-pregnant-women-counseling-and-interventions1
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Summary of Guideline Recommendations for Periodic Health Examinations, Table 2: Wexford
Health– Pregnant Females
Alcohol
Misuse
Wexford Health recommends screening and behavioral counseling interventions to reduce alcohol misuse
by adults, including pregnant women, in primary care settings.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcoholmisuse-screening-and-behavioral-counseling-interventions-in-primary-care
Wexford Health strongly recommends screening for asymptomatic bacteriuria with a urine culture for
pregnant women at 12–16 weeks' gestation or at their first prenatal visit, if later.
Bacteriuria
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/asymptomaticbacteriuria-in-adults-screening
Wexford Health recommends structured breastfeeding education and behavioral counseling programs to
promote breastfeeding where allowable by the DOC/county authority.
Breastfeeding
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breastfeedingcounseling
Wexford Health recommends screening all asymptomatic pregnant females age 24 years or younger and
other women that are at increased risk for chlamydia infection.
Chlamydia
Gestational
Diabetes
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-andgonorrhea-screening
Wexford Health recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant
women after 24 weeks of gestation.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestationaldiabetes-mellitus-screening
Wexford Health recommends screening for gonorrhea in sexually active women age 24 years and younger
and in older women who are at increased risk for infection.
Gonorrhea
Hepatitis B
Virus
Screening
HIV
Infection
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-andgonorrhea-screening
Wexford Health strongly recommends screening for hepatitis B virus (HBV) infection in pregnant women
at their first prenatal visit.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-b-inpregnant-women-screening
Wexford Health strongly recommends that clinicians screen all pregnant women for HIV, including those
who present in labor who are untested and whose HIV status is unknown.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/humanimmunodeficiency-virus-hiv-infection-screening
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Neural
Tube
Defects
Prevention
Preeclampsia
Rh (D)
Incompatibility
Testing
Rh (D)
Incompatibility
Unsensitized
Rh (D) - negative
Wexford Health strongly recommends prescribing 0.4−0.8 mg/day of folic acid supplementation from a
least one (1) month prior to conception through the first trimester of pregnancy to women planning to
become pregnant who have not had a previous pregnancy affected by a neural tube defect.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/folic-acid-toprevent-neural-tube-defects-preventive-medication
Wexford Health recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12
weeks of gestation in women who are at high risk for preeclampsia.
Clinical Consideration:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/low-dose-aspirinuse-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication
Wexford Health strongly recommends Rh (D) blood typing and antibody testing for all pregnant women
during their first visit for pregnancy-related care.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/rh-dincompatibility-screening
Wexford Health recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative
women at 24–28 weeks' gestation.
Clinical Considerations:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/rh-dincompatibility-screening
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Transgender Guidelines
Transgender
Guidelines
WEXFORD MILLER
WEXFORD
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Medical Management of Transgender Patient Guideline
These guideline recommendations summarize the Wexford Health guidelines for transgender patients or
those patients experiencing gender dysphoria.
These recommendations are provided only as assistance for clinicians making clinical decisions regarding
the care of their patients. As such, they cannot substitute for the individual judgment brought to each
clinical situation by the patient’s clinician. As with all clinical reference resources, they reflect the best
understanding of the science of medicine at the time of publication, but they should be used with the
clear understanding that continued research may result in new knowledge and recommendations.
I.
DEFINITIONS
Asexual: Refers to a person not attracted to either sex.
Bisexual: Refers to a person attracted to both sexes.
Endocrine Society:
problems.
Using clinical guidelines, offers evidence-based solutions to clinical
Female-to-Male (FtM): Refers to a biological female who identifies as, or desires to be, a
member of the male gender. The term transgender male or trans male, is used to refer to the
gender identity of a person who is FtM.
Gender: A biopsychological construct used to classify a person as male, female, both, or
neither. Gender encompasses all relational aspects of social identity, psychological identity,
and human behavior.
Gender-affirming Hormones: Hormonal therapy utilized to facilitate biological change(s)
during transition. The term cross-sex hormones is often utilized in the medical literature.
Gender Conformity: Behavior and appearance that adheres to the social expectations of a
particular gender.
Gender Dysphoria (GD): The condition of feeling that one’s emotional and psychological
identity as male or female is different from one’s biological sex. By definition, GD implies that
there is a state of distress or anxiety directly related to this conflict.
Gender Expression: Includes mannerisms, clothing, hair style, and choice of activities that
individuals use to express their gender identity.
Gender Identity: Individuals’ own sense of their gender, which they may choose to
communicate to others by means of gender expression.
Gender Nonconformity: Behavior or appearance that does not match the societal roles or
expectations for one’s assigned gender.
Intersex: Refers to a person whose sexual/reproductive anatomy or chromosomal pattern
does not seem to fit the typical biological definition of male or female.
Male-to-Female (MtF): Refers to a biological male who identifies as, or desires to be, a
member of the female gender. The term transgender female or trans female is used to refer
to the gender identity of a person who is MtF.
Real-life Experience: When individuals live as the gender with which they identify.
Sex Reassignment Surgery: The surgical component of an individual’s transition; also
referred to as gender-affirming or gender confirmation surgery.
Transgender (TG): A general term used for individuals whose gender identity does not
conform to the typical expectations associated with the gender they were assigned at birth.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Transition: The period during which TG individuals change their physical, social, and legal
characteristics to the gender with which they identify. Transition may also be regarded as an
ongoing process of physical change and psychological adaptation.
World Professional Association for Transgender Health (WPATH): Professional
organization devoted to the understanding and treatment of GD based in East Dundee Illinois.
II.
SPECIAL CONSIDERATIONS
Suicidality: Transgender adults with GD are at an increased risk of suicidal ideation and
suicide prior to initiation of their gender transition, regardless of the clinical endpoint of their
transition. The end point may be living as the psychologically identified gender, hormone
therapy, cosmetic treatments, breast augmentation/removal, and/or sex reassignment
surgery. The risk of suicide may decrease after receiving the appropriate, individual
treatment.
Co-morbid Conditions:
III.
1.
Anxiety/depression
2.
Increased risk of being HIV (+) – particularly in MtF persons
INTERACTING WITH TRANSGENDER INDIVIDUALS
Respect and trust are essential to the clinician-client relationship.
Gender-neutral forms of address (e.g., Patient Smith, Offender Roberts, etc.) should be used.
IV.
MULTIDISCIPLINARY TREATMENT APPROACH
Recommended for managing issues associated with the incarceration of TG individuals, including
providing medical treatment when indicated.
V.
INTAKE SCREENING
Based on the Prison Rape Elimination Act, individuals will be assessed during intake for risk
of sexual victimization, including those individuals who are known or perceived to be gay,
lesbian, bisexual, TG, intersex, or gender nonconforming.
If an individual identifies as transgender, a mental health referral will be initiated.
Any patient who is receiving hormonal medication at the time of intake should be continued
on the hormonal medication, provided that:
VI.
1.
The hormones represent an established treatment that has been prescribed under the
supervision of a qualified physician.
2.
The patient cooperates in obtaining written records or other necessary confirmation of
his/her previous treatment.
3.
The medical provider determines that the hormones are medically necessary and not
contraindicated for any reason.
PROBLEM LIST
To provide appropriate medical treatment and management, all individuals who identify as
TG – whether or not they are receiving treatment, will have the appropriate diagnosis entered
on the problem list. This will ensure that the appropriate evaluations are completed in a
timely fashion. The treatment of TG patients needs to be individualized and consideration of
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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the individual’s presentation and preferences, and attention to safety and security needs of
the individual, while keeping in mind the safe and orderly operations of the facility.
The problem list will be updated as needed.
VII.
GENDER DYSPHORIA CRITERIA
An individual identifying as transgender is not necessarily diagnosed with gender dysphoria.
Screening for GD in TG individuals is essential.
Untreated or under-treated GD is associated with increased morbidity and mortality.
Treatment modalities may include:
1.
Psychotherapy.
2.
Hormone therapy, if indicated.
3.
Other treatment as determined to be medically necessary.
If indicated, hormone therapy may improve GD, mental health co-morbidities, and overall
quality of life.
A diagnosis of GD will be recorded in the problem list, and referral to a mental health
professional for co-management of GD is recommended.
VIII. MULTIDISCIPLINARY APPROACH TO THE ASSESSMENT AND MANAGEMENT OF THE TG INDIVIDUAL
Patient requests for hormonal therapy or other necessary medical treatment will be forwarded on to the
Health Services Administrator who will initiate the GD evaluation process by contacting mental health for
a mental health evaluation.
Step 1: Mental Health Assessment
Transgender status is based on an individual’s self-report.
1.
The history or subjective component of the evaluation serves as the primary source for
identifying a person as TG.
Mental health assessment will include:
1.
History of gender identity and screening for GD.
2.
Screening for other mental health disorders related to autism, eating, mood, personality,
psychosis and substance abuse.
3.
Identifying history of abuse or neglect and any current or past self-harm ideations or
attempts.
4.
Performing an assessment of affective, cognitive, and psychosocial functioning, if
indicated.
5.
Psychosocial treatment recommendations, if indicated.
6.
Medical referral, if indicated.
Diagnostic Assessment:
1.
Presenting problems/symptoms
a.
Outline the individual’s concerns, including who made the referral and when.
Relevant historical information:
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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1.
This psychosocial history may include:
a.
Review of the individual’s development history (including gender identity).
b.
Sexual history (including sexual predation or victimization).
c.
Trauma.
d.
Mental health history.
e.
Suicide attempts or self-harm.
f.
Criminal history.
g.
Educational experience and progress.
h.
Family dynamics.
i.
Peer relations.
j.
Social support expected upon release.
Diagnostic formulation
1.
List diagnostic impressions, if applicable.
Care level formulation
1.
Discussion of the individual’s ongoing need for mental health services and assign a care
level based on need.
If the individual desires medical intervention, the mental health staff refer the individual for
evaluation by the medical staff.
Step 2: Medical Assessment
Done upon referral from mental health staff after diagnosis of GD.
Includes:
1.
Review of the mental health assessment.
2.
Assessment of overall health, including OB/GYN as indicated.
3.
Review of sexual activity, sexual orientation, and gender identity.
4.
Assessment of previous treatment (hormonal therapy, surgery, etc.).
5.
Evaluation of co-occurring medical disorders.
6.
HIV/STI testing.
Essential due to risks from hormonal therapy.
Informed consent:
1.
Individuals must be counseled on the risks and long-term effects of hormonal therapy.
a.
Use of gender-affirming hormones in the management of TG individuals is
considered off-label use and does not currently have FDA approval.
b.
Due to the irreversibility of some of the treatment options and the side effects, the
individual’s informed consent is required before initiating treatment and must be
documented within the medical record.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Step 3: Agency/Regional Level Consultation
Upon completion of the mental health and medical evaluations, if the patient/offender meets
the criteria for transgender therapy, the clinician will:
1.
Discuss with the Regional Medical Director.
2.
Review the case during collegial review.
3.
Review case with the agency medical director or the Transgender Committee, if
applicable.
Step 4: Individualized Treatment
Treatment and management for the TG individual required individualized care guided by
treatment goals to allow for successful transition through:
1.
Education.
2.
Counseling.
3.
Real-life experience.
4.
Medical evaluation.
5.
Hormone treatment.
6.
Other medical treatment as necessary.
7.
Due to the limitations of incarceration, a real-life experience.
One year of continuous hormone therapy and living in the desired gender role is expected
before initiating genital surgical treatment.
IX.
MENTAL HEALTH TREATMENT CONSIDERATIONS
Individual’s understanding/expectations of treatment options.
1.
Before starting treatment, medical and mental health staff will discuss the individual’s
outcome expectations to identify realistic goals.
Psychotherapy
1.
Can be used to learn about and treat an individual’s moods, thoughts, or behaviors.
2.
Can be supportive to individuals experiencing distressing thoughts or feelings.
Mental health services
X.
1.
Individuals may be referred to psychiatry for mental health concerns or medication
management of other mental illnesses in conjunction with GD.
2.
A mental health consult is not necessary for a diagnosis of GD.
CRITERIA FOR STARTING TREATMENT
Persistent, well documented gender dysphoria/gender incongruence.
Capacity to make a well-informed decision.
Relevant medical or mental health issues are well controlled.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XI.
HORMONE TREATMENT: ELIGIBILITY, GOALS, OVERVIEW
Important part of transitional treatment for many transgender individuals.
1.
Goals of hormone treatment: To suppress the endogenous hormones and the physical
characteristics of the birth sex.
2.
Supplement hormones and enhance characteristics of the preferred gender, utilizing
principles of hormone replacement therapy for hypogonadal individuals of the TG
individual’s identified gender.
Eligibility and Readiness for Gender-affirming Hormone Therapy
1.
WPATH Criteria:
a.
2.
XII.
Gender dysphoria that is persistent and documented:
i.
Current medical and/or mental health conditions are well controlled.
ii.
Legal age of majority (18 in most states, 19 in Alabama and Nevada).
iii.
Informed consent.
Endocrine Societal Criteria:
a.
Also includes criterial for transsexualism as an alternate criterion for GD and
requires three (3) months of documented real-life experience of psychotherapy.
b.
Describes readiness criteria to include further consolidation of the preferred
gender identity and progress in the gender transition, including a willingness and
ability to take hormones as prescribed.
HORMONE THERAPY FOR MALE-TO-FEMALE (MTF)
More complex of the two (2) gender-affirming regimens.
May consist of a single medication or a combination of anti-androgen and an estrogen, with
a potential progestin adjunct.
1.
Androgen suppression alone may be used for individual’s desiring a more androgynous
appearance.
Individuals should have a realistic expectation of the treatment results as well as the timeline
of when to expect them.
Realistic expectations can avoid any attempts to self-increase the dosage in hopes of speeding
up results.
Most treatment results are reversible upon cessation of treatment, but breast growth is
permanent, and infertility may be irreversible.
XIII. GOAL LEVELS OF TREATMENT MTF
Serum estradiol < 200 pg/ml (premenopausal level)
1.
Should not exceed those of a premenopausal female, but doses used to achieve an
adequate level may be significantly higher than those used in hormone replacement
therapy in menopausal women.
2.
Not everyone requires estradiol as a part of their hormone therapy and do well on antiandrogen therapy alone.
3.
Use the lowest effective hormone dose.
Testosterone < 55 ng/dl
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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1.
Some individuals do poorly with testosterone levels < 35 ng/dl.
2.
Ideal level is 35 – 55 ng/dl.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001059
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Medical Guidelines
Region: New Mexico
XIV. MEDICATIONS FOR MTF INDIVIDUALS
Goal levels for MtF: Serum estradiol <200 pg/mL and serum testosterone <55 ng/dL
Anti-androgen
drugs*
Spironolactone
(1st Line)
Dose
Mode of Action
• Starting: 25–50
mg BID
• Typical: 50mg BID
• Max: 200mg BID
Potassium-sparing
antihypertensive that directly
inhibits testosterone
secretion and androgen
binding to the androgen
receptor
Adverse Effects
• Mild diuretic
• Hyperkalemia
• Excretion of sodium,
calcium, and chloride
• Decreased libido
Contraindications
• Renal insufficiency
• Potassium > 5.5 mmol/L
• Avoid after orchiectomy
Interactions
•
•
•
•
Digoxin
ACE inhibitors
ARBs
Potassium-sparing
diuretics
Notes/Monitoring
• Baseline labs: BMP
• Follow-up labs: BMP in 1
week, monthly x 3 months,
and Q 3 months during the
first year.
• When stable, BMP Q 6 to
12 months
Finasteride
(2nd Line)
• Low: 1 mg daily
• High: 5–10 mg
daily
5a reductase inhibitor, which
blocks the conversion of
testosterone to the more
active 5a
dihydrotestosterone
Sexual dysfunction
None pertinent
Antiretrovirals and diltiazem
may increase finasteride
levels
• High dose: unable to take
spironolactone
• Low dose: Treatment of
male pattern baldness
• Use in combo with
spironolactone for rate
individuals not achieving
desired effects
• May be used after
orchiectomy if hirsutism or
male pattern baldness are
present
Progesterone;
• Starting 2.5 mg
Medroxyprogesterone
daily
(2nd Line)
• Typical: 5–10 mg
daily
• Max: 20 mg daily
• Anti-androgen effect at
high doses
• May help breast
development at cellular
level
•
•
•
•
•
Increased CV risk
Weight gain
Edema
Mood disorder
Increased facial/body hair
Same as estrogen
Antiretrovirals
• Not as effective as
spironolactone
• Adjunct for individuals on
maximum estrogen doses
with unsatisfactory effects
• Monitoring: Same as
estrogen
*Anti-androgen medications are no longer needed after orchiectomy
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 001060
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Medical Guidelines
Region: New Mexico
XV.
ESTROGENS
Goal levels for MtF: Serum estradiol <200 pg/mL and serum testosterone <55 ng/dL
Estrogen
Estradiol
(1st Line)
Estradiol
Valerate
(Progynova)
(2nd Line)
Dose
• Starting: 2–3 mg
daily
• Typical: 4 mg daily
• Max: 8 mg daily
• 5–20 mg IM Q 2
weeks
Adverse Effects
Common:
• Increase in weight
• VTE
• Dyslipidemia
• Insulin resistance
• Prolactin levels
• Edema
• N/V
• Migraine
Less Common:
• LFT abnormalities
• Increase in CV events
especially in those over 50
taking progesterone with
estrogens
• Increased triglycerides in
those taking oral estrogens
• Increased risk of pancreatitis,
cholelithiasis, diabetes
mellitus, hypertension,
hyperkalemia (in
spironolactone users)
Contraindications
Absolute:
• Estrogen-dependent cancer
Precautions:
• History of VTE
• CAD
• Hyperlipidemia
• Diabetes mellitus
• Cigarette smoking
• Highly sedentary lifestyle
• Migraine
• Seizure disorder
• Retinopathy
• Heart failure
• Valvular heart disease
• Family history of estrogendependent tumor
Notes
•
•
•
•
•
•
•
Monitoring
Interactions:
CYP3A4, 1A2 inhibitors/inducers
Transdermal formulations better for
older individuals or those with risk
factors for VTE
Stop estrogens 2 weeks prior to
surgery or immobilizing event.
Restart after mobilization or one week
after surgery.
Consider adding aspirin therapy to
those at high risk for VTE
Individuals who enter the facility on
conjugated estrogen should be
switched to a different form of
estrogen due to inability to monitor
estrogen levels with this preparation
IM injections cause greater peaks and
troughs in estrogen levels making oral
preparations preferable
• Baseline: lipids, CMP, CBC, BP,
weight, serum estradiol, serum
testosterone, CBC, prolactin, PT/PTT
(when DVT risk exists)
• Every 3 months after starting
estrogen during first year: Serum
testosterone, estradiol, CBC, lipids,
CMP, weight, BP.
• Every 6-12 months after first year of
therapy: CBC, CMP, lipids, BP, weight,
serum testosterone, estradiol, prolactin
• Routine prostate and breast cancer
screening
Rare or plausible but have not
been observed:
• Liver damage
• Prolactinoma
• Breast cancer (compared to
men never exposed to
estrogen)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
WEXFORD MILLER 001061
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Medical Guidelines
Region: New Mexico
XVI. TABLE 1: MTF DRUG EFFECTS TIMELINE
Initial Effects
1 – 3 months
3 – 6 months
6 – 12 months
Variable
Changes
•
•
•
•
•
•
•
•
•
Decreased libido and spontaneous erections
Redistribution of body fat
Decrease in muscle mass and strength
Softening and decreased oiliness of skin
Breast growth
Decreased testicular volume
Decrease in terminal hair growth
Male sexual dysfunction
Decreased sperm production
Maximum Effect
3 – 6 months
1 – 3 years
> 3 years
Variable
Voice changes do not occur with hormone treatments
XVII. TABLE 2: MTF DRUG RISKS
Very high risk of serious adverse outcomes
• Thromboembolic disease
Moderate to high risk of adverse outcomes
• Macroprolactinoma
• Breast cancer
• Severe liver dysfunction (transaminases >3x
upper limits of normal)
• CAD
• Cerebrovascular disease
• Severe migraine headaches
XVIII. HORMONE THERAPY FOR FEMALE-TO-MALE (FTM)
Less complex of the two (2) gender-affirming regiments
Consists mainly of testosterone supplementation
Individuals should have a realistic expectation of the treatment results as well as the timeline
of when to expect them
Uterine bleeding should cease within a few months of high-dose testosterone therapy, but
treatments such as gonadotropin-releasing hormone (GnRH) agonists, medroxyprogesterone,
and endometrial ablation may be used to stop menses prior to starting testosterone therapy
or decrease estrogen levels.
Most effects are reversible upon cessation of treatment, but changes to hair, voice depth, and
fertility may be irreversible.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIA.
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Medical Guidelines
Region: New Mexico
XIX. MEDICATIONS FOR FTM INDIVIDUALS
Goal levels for FtM: Serum estradiol <50 pg/ml and serum testosterone 320 – 1000 ng/dl
Drug
Dose
• Testosterone • Starting: 50-100
Cypionate
mg Q 2 weeks
IM
or 25 – 50 mg
weekly
• Testosterone
Enanthate
• Typical: 200mg
IM
Q 2 weeks or
100mg/week
• Max: 400mg Q
2 weeks or 200
mg/week
Adverse Effects
Contraindications
Notes
Monitoring
Common:
• Increased weight
• Oily skin
• Acne
• Male pattern
baldness
• Vaginal atrophy
• Infertility
• Dyslipidemia
• Mood changes
• Skin irritation with
patch
• Risk of exposing
partners or children
with topical
testosterone
Less Common:
• Increase in edema,
BP,
aggressiveness
• Erythrocytosis
• Abnormal LFTs
• Sleep apnea
Rare or plausible but
not observed:
• Increased risk of
CV disease,
breast/ovarian
cancer,
endometrial
hyperplasia
Absolute:
• Pregnancy
• Breast cancer
• Breastfeeding
Precautions:
• Erythrocytosis
• Cardiac, hepatic,
renal, or vascular
disease with
edema or risk of
edema
• Sleep apnea or
high risk of sleep
apnea due to
obesity or chronic
lung disease
• Dyslipidemia
• Interactions:
Warfarin
Cyclosporine
Insulin
• Causes drop in
blood glucose in
DM patients
• May notice cyclic
variation in mood
with IM dosing Q
2-4 weeks. Use a
lower, more
frequent dose, or
transdermal
• Transdermal
reaches same
levels as IM but in
a longer timeframe
• Menses typically
stop in early
months of
treatment, but may
persist when using
transdermal
USE IN
CORRECTIONS:
• Injectable
testosterone is
the preferred
formulation in the
correctional
environment due
to potential risk
of abuse and/or
diversion.
• Testosterone is a
DEA controlled
substance
• Baseline-Lipids, BMP,
CBC, BP, weight, serum
testosterone, BMD (if
osteoporosis risk exists)
• Every 3 months after
starting testosterone for
first year-Serum
testosterone, estradiol (for
6 months after cessation
of menses), BP, CBC,
lipids, CMP, weight
• Every 6-12 months after
1st year of therapy—CBC,
CMP, lipids, BP, weight,
serum testosterone
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
When to check specific
formulations:
IM:
• Testosterone levels just
prior to next dose. Adjust
to mid-normal range of
350-800 ng/dl
Patch:
• Testosterone levels after
1 week
• Continue screenings for
cervical and breast
cancer if tissue is still
present
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Region: New Mexico
XX.
TABLE 4: DRUG EFFECT TIMELINE FOR FTM MEDICATIONS
Initial Effects
Within first 3 months
Within first 6 months
Within 6 – 12 months
•
•
•
•
•
•
•
•
•
•
Changes
Fat redistribution
Cessation of menses
Clitoral enlargement
Vaginal atrophy
Increased skin oiliness
Acne
Increased facial/body hair
Scalp hair loss
Increase muscle mass and strength
Deepening of the voice
Maximum Effect
1 – 2 years (may take up to 5 years)
XXI. TABLE 5: FTM MEDICATIONS: DRUG RISKS
Very high risk of serious adverse outcomes
•
•
Moderate-to-high risk of adverse outcomes
Breast or uterine cancer
Erythrocytosis (Hct > 50%)
•
Severe liver dysfunction (transaminases > 3 x
upper limit of normal)
XXII. GENDER-AFFIRMING (SEX REASSIGNMENT) SURGERY
Considered on a case-by-case basis.
Criteria
1.
In addition to the eligibility and readiness criteria for hormone therapy, general criteria
for consideration of surgery include:
a.
At least 12 months of successful use of hormone therapy.
b.
Participation in psychotherapy as clinically indicated.
c.
Full-time real-life experience in their preferred gender.
d.
Consolidation of gender identity.
The patient must request consideration for and demonstrate via informed consent a practical
understanding of gender-affirming surgery including but not limited to:
1.
Permanence.
2.
Potential complications.
3.
Short and long-term treatment plans.
Requests for surgery are submitted to the Regional Medical Director for initial review and
recommendation to the medical director, who is the approving authority.
Each referral should include:
1.
Comprehensive medical and mental health summaries.
2.
Comprehensive psychosocial assessment (by a licensed clinical social worker).
3.
Criminal history.
4.
Institutional adjustment report.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
XXIII. FUTURE CONSIDERATIONS
MtF will need to be monitored for prostate cancer.
FtM will need to be monitored for breast and cervical cancer.
FtM with history of PCOS will need monitored for insulin resistance and the development.
XXIV. PATIENT EDUCATION AND INFORMED CONSENT
Crucial to the treatment process.
Must be documented in the medical record.
XXV. REFERENCES
1.
Deutsch, B. & Feldman, J. (2019). Primary Care of Transgender Individuals. Retrieved from UpToDate
2.
Federal Bureau of Prisons (2016). Medical Management of Transgender Patients. Retrieved from
http://www.bop.gov/resources/health_care_mngmt.jsp
3.
Illinois Department of Corrections (2013). Evaluations of Offenders with Gender Identification Disorders.
4.
Pennsylvania Department of Corrections (2016). Diagnosis and Treatment of Gender Dysphoria. [13.2.1
Section 19]
5.
Safer, J. & Tangpricha, V. (2018). Transgender Women: Evaluation and Management. Retrieved from
UpToDate
6.
U.S. Department of Justice (2018). Transgender Offender Manual [Policy 5200.04 CN-1]
7.
West Virginia Division of Corrections & Rehabilitation (2019). Gender Nonconforming Inmate/Residents.
Policy Directive [Policy 411.00]
XXVI. ATTACHMENTS
Feminizing Gender-affirming Hormone Treatment for Transgender Patients: Consent and Counseling Form
Masculinizing Gender-affirming Hormone Treatment for Transgender Patients: Consent and Counseling Form
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Feminizing Gender-affirming Hormone Treatment for Transgender Patients- CONSENT to TREATMENT
Feminizing Gender-affirming Hormone Treatment for
Transgender Patients
Consent and Counseling Form
Facility Name:
Patient Name:
ID#:
You want to take estrogen and other medications to feminize your body. Once you start these medications, some of them will
need to be taken for the rest of your life in order to maintain their effects. Before using these medications, you need to know more
about how they might affect you, including possible benefits, side effects, risks, and warning signs. We have listed them here for
you. It is important that you understand all of this information before you start. We are happy to answer any questions you might
have, so please ask!
What are the Different Medications that Can Help Feminize You?
Estrogen is the female gender-affirming hormone, and there are different types of estrogen that can help you appear more like a
woman. There are also medications, called androgen antagonists, or anti-androgens, or androgen blockers, that can help you
appear less like a man. Androgen is the male gender-affirming hormone.
WARNING – Who should NOT take estrogen?
It should not be used by anyone who has a history of:
• An estrogen-dependent cancer
• Blood clots that could or did travel to the lungs
It should be used WITH CAUTION and only after a full discussion of risks, by anyone who:
• Has a strong family history of breast cancer of other cancers that grow faster when estrogens are present
• Has diabetes
• Has eye problems such as retinopathy
• Has heart disease, heart valve problems, or a tendency to have easily clotted blood
• Has hepatitis
• Has high cholesterol
• Has kidney or liver disease
• Has migraines or seizures
• Is obese
• Smokes cigarettes
Please review and initial each statement to show you understand the benefits, risks, and changes that may occur from taking
these medications. At the end of the document, indicate your preference regarding hormone therapy. Then sign and date the
form.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Feminizing Gender-affirming Hormone Treatment for Transgender Patients- CONSENT to TREATMENT
Feminizing Effects
I know that estrogen or anti-androgens, or both, may be prescribed to help me appear less like a man and more like a woman.
I know that it can take several months or longer for the effects to become noticeable. I know that no one can predict how fast, or how
much, change will happen.
I know that if I am taking estrogen, I will probably develop breasts.
•
•
•
•
•
I know it can take several years for breasts to get to their full size.
I know the breasts will remain, even if I stop taking estrogen.
I know I should examine my breasts for irregularities as soon as they start growing. I should also have a clinician examine them
every year.
I know I might have a milky discharge from my nipples (Galactorrhea). If I do, I know I should have it evaluated by my clinician
because it could be caused by the estrogen or by something else.
I know that no one knows if taking estrogen increases the risk of breast cancer.
I know that the following changes are usually not permanent – they are likely to go away if I stop taking the medicines:
•
•
•
•
•
I know my body hair will become less noticeable and will grow more slowly, but it won’t stop completely, even if I take the
medicines for years.
I know I will probably have less fat on my abdomen and more on my buttocks, hips, and thighs. It will be redistributed to a more
female shape, changing from an “apple” shape to more of a “pear” shape.
I know that if I already have male pattern baldness, it may slow down, but will probably not stop completely. It is also unlikely
that hair that has been lost will grow back.
I know I may lose muscle and strength in my upper body.
I know my skin may become softer.
I know that my body will make less testosterone. Upon release, this may affect my sex life in different ways and my future ability to
cause a pregnancy.
•
•
•
•
•
•
I know my sperm may no longer reach maturity. This could make me less able to cause a pregnancy. I also know I might never
produce mature sperm again, but I know that it’s also possible that my sperm could still mature. So, I know that I might get
someone pregnant if we have vaginal intercourse and we don’t use birth control. The options for sperm banking have been
explained to me.
I know my testicles may shrink down to half their size. Even so, I know that I will need regular checkups for them.
I know it is likely that my penis won’t be hard in the morning as often as it has been before. It is also likely that I will have fewer
spontaneous erections.
I know I may lose the ability to obtain an erection for intercourse.
I know I may have less sex drive.
I know this treatment may (but is not assured to) make me permanently unable to make a woman pregnant.
I know that some parts of my body will not change much by using these medicines.
•
•
•
•
I know the hair of my beard and moustache may grow more slowly than before. It may become less noticeable, but it will not go
away.
I know the pitch of my voice will not rise, and my speech patterns will not become more like a woman’s.
I know my Adam’s apple will not shrink.
Although these medicines can’t make these changes happen, there are other treatments that may be helpful.
Risks of Taking Feminizing Medications
_____ I know that the side effects and safety of these medications are not completely known. There may be long-term risks that are not yet
known.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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_____ I know that I should not go to take more medicine than I am prescribed. I know it increases health risks. I know that taking more
than I am prescribed won’t make changes happen more quickly or more significantly. I know my body can convert extra estrogen into
testosterone, and that can slow down or stop my appearing more womanly.
_____ I know these medicines may damage the liver and may lead to liver disease. I know I should be checked for possible liver damage
as long as I take them.
_____ I know these medicines cause changes that other people will notice. Some transgender people have experienced harassment,
discrimination, and violence because of this. Others have lost the support of loved ones. I know I can reach out to psychology
services to help me find support resources. I also know that the facility does not tolerate harassment, discrimination, and violence in
any circumstances. If I feel I am the recipient of any of these actions, I will notify a facility staff member.
Risks of Taking Estrogen
_____ I know that taking estrogen increases the risk of blood clots that can result in:
•
•
•
•
Chronic problems with veins in the legs
Heart attack
Pulmonary embolism (blood clot to the lungs) which may cause permanent lung damage or death
Stroke, which may cause permanent brain damage or death
_____ I know that the risk of blood clots is much worse if I smoke cigarettes, especially if I am over 40. I know the danger is so high that I
should stop smoking completely if I start taking estrogen and that I should not start to smoke again when I am released from the
facility.
_____ I know that taking estrogen can increase the deposits of fat around my internal organs. This can increase my risk for diabetes and
heart disease.
_____ I know that taking estrogen can raise my blood pressure. I know that if my blood pressure goes up, my clinician can work with me to
try and control it with diet, lifestyle changes, and/or medication.
_____ I know that taking estrogen increases my risk of getting gallstones. I know that I should talk with my clinician if I get severe or longlasting pain in my abdomen.
_____ I know that estrogen can cause nausea and vomiting. I know that I should talk with my clinician if I have long-lasting nausea or
vomiting.
_____ I know that estrogen can cause headaches or migraines. I know I should talk with my clinician if I have headaches or migraines
often, or if the pain is unusually severe.
_____ I know that it is not yet known if taking estrogen increases the risk of prolactinomas. These are non-cancerous tumors of the pituitary
gland. I know they are not usually life-threatening, but they can damage vision and cause headaches. I know this possibility needs
to be checked periodically by a clinician for at least 3 years after I start taking estrogen.
_____ I know that I am more likely to have dangerous side effects if:
•
•
•
•
•
•
I smoke
I am overweight
I am over 40 years old
I have a history of blood clots
I have a history of high blood pressure
My family has a history of breast cancer
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Risks of Taking Androgen Antagonists
_____ I know that spironolactone affects the balance of water and salts in the kidneys, which may:
•
•
•
•
Increase the amount of urine I produce, making it necessary to urinate more frequently.
Increase thirst
Reduce blood pressure
Cause (although rarely) high levels of potassium in the blood, possibly leading to changes in the heart rhythms that may be lifethreatening.
_____ I know that some androgen antagonists make it more difficult to evaluate test results for cancer of the prostate. I know that if I am
over 50, I should have my prostate evaluated every year with a prostate-specific antigen test, as applicable.
Prevention of Medical Complications
_____ I agree to take feminizing medications as prescribed, and I agree to tell my clinician if I have any problems or if I am unhappy with
the treatment.
_____ I know that the dose and type of medication that is prescribed for me may not be the same as for someone else.
_____ I know that I need periodic physical exams and blood tests to check for any side effects.
_____ I know that feminization medications can interact with other drugs and medicines – including alcohol, diet supplements, herbs, and
other hormones, and street drugs – causing complications. I know that I need to prevent complications because they can be lifethreatening. That’s why I need to be honest with my clinician about whatever else I take or use. I also know that this will not
interfere with my getting medical care; I will continue to get medical care here no matter what information I share about what I take.
_____ I know that it can be risky for anyone with certain conditions to take feminizing medicines. I agree to be evaluated if my clinician
thinks I may have such a condition. Then, we will decide if it’s a good idea for me to start or continue using these medications.
_____ I know that I should stop taking estrogen two weeks before any surgery or when I may be immobile for a long time. This will lower
the risk of getting blood clots. I know that I can start taking estrogen again a week after I’m back to normal or when my clinician says
it’s okay.
_____ I know that using these medicines to appear more womanly is an “off-label” use. I know that this means that using these medicines
for this purpose is not approved by the Food and Drug Administration (FDA). I know that the medicine and dose that is
recommended for me is based on the judgment and experience of the clinician.
_____ I know that I can choose to stop taking medicines at any time. I know that if I decide to do that, I should do it with the help of my
clinician. This will help me make sure there are no negative reactions. I also know that my clinician may suggest that I cut the dose or
stop taking it altogether if certain conditions develop. This may happen if the side effects are severe or if there are health risks that
cannot be controlled.
My Signature Below Confirms That:
•
•
My clinician has talked with me about:
o The benefits and risks of taking feminizing medication.
o The possible or likely consequences of hormone therapy.
o Potential alternative treatments.
o I understand the risks that may be involved.
o I know that the information in this form includes the known effects and risks. I also know that there may be unknown long-term
effects or risks.
o I have had enough opportunity to discuss treatment options with my clinician.
o All of my questions have been answered to my satisfaction.
o I believe I know enough to take, refuse, or postpone therapy with feminizing medications.
I am 18 years of age or older.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Based on All of this Information:
_____ I want to begin taking estrogen.
_____ I want to begin taking androgen antagonists (e.g., spironolactone).
_____ I do not wish to begin taking feminizing medication at this time.
Patient’s Signature
Date
Prescribing Clinician’s Signature
Date
Your health is important to us. If you have any questions or concerns, please submit a sick call request.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Masculinizing Gender-affirming Hormone Treatment for Transgender Patients- CONSENT to TREATMENT
Masculinizing Gender-affirming Hormone Treatment for
Transgender Patients
Consent and Counseling Form
Facility Name:
Patient Name:
ID#:
You have expressed a desire to take testosterone to masculinize your body. Before beginning treatment, there are several details
about treatment that you need to be familiar with, including the possible advantages, disadvantages, risks, warnings, and
alternatives. These topics are covered below. It is important that you understand all of this information before initiating treatment.
We are happy to answer any questions you might have. So just ask.
What is Testosterone?
Testosterone is the hormone responsible for male features. It builds muscle, causes the development of facial hair, and is
responsible for the deepening of a person’s voice during puberty. Testosterone also may increase sex-drive.
How is Testosterone Taken?
Testosterone is usually injected every 1 – 4 weeks. It is not used as a pill because the body may not absorb it properly, and it
can cause liver problems. Some people use skin creams and patches, but these are not used in the correctional environment.
The doses used for injections differ from products to product and from patient to patient. Doses may range from 100 mg to 400
mg. The injections are given into a large muscle to slow the release of the hormone. There can be unwanted swings in hormone
levels. This can be controlled by changing how often the dose is given, how much of a dose is given, or by changing formulations.
Warning – Who Should NOT Take Testosterone?
Testosterone should NOT be used by anyone who is pregnant or has uncontrolled coronary artery disease. It should be used
with caution and only after a full discussion of risks by anyone who has acne, family history of heart disease or breast cancer,
blood clot history, high levels of cholesterol, liver disease, or high red blood cell count. Caution should also be used in obese
patients and persons who smoke.
Monitoring
Periodic blood tests to check on the effects of the hormone will be required for treatment. Routine breast exams and pelvic exams
with pap tests should be continued, if applicable.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Benefits and Risks of Testosterone Treatment
Benefits
• Appearing more like a man:
o Larger clitoris*
o Coarser skin
o Deeper voice*
o Increased body/facial hair*
o Increased muscle mass
o Increase strength
o Elimination of menstrual periods
• Increased physical energy
• Protection against bone thinning (osteoporosis)
*Permanent changes
Risks
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acne (may permanently scar)
Blood clots
Emotional changes
Headache
High blood pressure
Increased red blood cell count
Infertility
Inflamed liver
Interaction with drugs for diabetes and blood
thinners
Male pattern baldness
Increased abdominal fat
Increased risk of heart disease
Swelling of hands, feet, and legs
Weight gain
Please review and initial each statement to show that you understand the benefits, risks, and changes that may occur from taking
these medications. At the end of the document, indicate your preference regarding hormone therapy, then sign and date it.
Masculinizing Effects of Testosterone
_____ I know that testosterone may be prescribed to make me appear less like a woman and more like a man.
_____ I know that it can take several months or longer for the effects to become noticeable.
_____ I know that no one can predict how fast or how much change will take place.
_____ I know that the changes may not be complete for 2 – 5 years after starting testosterone.
_____ I know the following changes are likely to be permanent, even if I stop taking testosterone:
•
•
•
•
•
Bigger clitoris (typically about half an inch to a little more than an inch).
Deeper voice.
Growth of facial hair (moustache and beard).
Hair loss at the temples and crown of the head and the possibility of becoming completely bald.
More, thicker, and coarser hairs on abdomen, arms, back, chest, and legs.
_____ I know that the following changes are usually not permanent and will likely go away if I stop taking testosterone:
•
•
•
•
•
•
Acne (but the scars will be permanent)
Elimination of menstrual periods (typically stop 1 – 6 months after starting testosterone)
Increased abdominal fat (redistribution of fat to a more masculine shape)
Decreased fat on buttocks, hips, and thighs
More muscle mass and strength
Vaginal dryness
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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_____ I know that the effects of testosterone on fertility are unknown. I have been told that I may or may not be able to get pregnant even if
I stop taking testosterone. I know I might still get pregnant even after testosterone stops my menstrual periods. I know my birth
control options upon release (if applicable). I know I cannot take testosterone if I am pregnant.
_____ I know that some aspects of my body will not be changed:
•
•
Losing some fat may make my breasts appear slightly smaller, but they will not shrink very much.
Although my voice may deepen, other aspects of the way I speak will not change.
Risks of Testosterone
_____ I know that the medical effects and safety of testosterone are not completely known. There may be long-term risks that are not
known yet.
_____ I know not to take more testosterone than prescribed. I know this would be a risk to my health. I know that taking more testosterone
than I am prescribed will not make changes happen more quickly or more significantly. I know that my body can convert extra
testosterone into estrogen, which can slow down or reverse the progress of my transition.
_____ I know that testosterone can cause changes that increase my risk of heart disease. I know these changes include:
•
•
•
Less good cholesterol (HDL), which is needed to protect against heart disease, and more bad cholesterol (LDL), which may
increase the risk of heart disease.
Higher blood pressure
Increased deposits of fat around my internal organs
_____ I know that my risk of heart disease is higher if people in my family have had heart disease, if I am overweight, or if I smoke.
_____ I know that I should have periodic heart-health checkups for as long as I take testosterone. I know I must watch my weight and
cholesterol levels and have them checked by my clinician.
_____ I know that testosterone can damage the liver and possibly lead to liver disease. I know I should be checked periodically for possible
liver damage for as long as I take testosterone.
_____ I know that testosterone can increase my red blood cell count and hemoglobin. I know the increase is usually only to the level that is
normal for a man. I know normal levels would have no health risks; however, higher increases can cause problems that can be lifethreatening. These problems include stroke or heart attack. As such, I know I need to have periodic blood checks for as long as I
take testosterone.
_____ I know that taking testosterone can increase my risk for diabetes. It may decrease my body’s response to insulin, cause weight gain,
and increase deposits of fat around my internal organs. I know I should have periodic checks of my blood glucose for as long as I
take testosterone.
_____ I know that my body can turn testosterone into estrogen. I know that no one knows if this could increase the risk of cancers of the
breast, ovaries, or uterus.
_____ I know that taking testosterone can thin the tissues of my cervix and the walls of my vagina. This can lead to tears or abrasions
during vaginal intercourse. I know it does not matter if my partner is a man or a woman. This raises my risk of getting a sexually
transmitted infection, including HIV. I know I should speak frankly with my provider regarding the best ways to prevent and check for
infections. I am aware that sex between patients, or between patients and staff, is not permitted within the facility.
_____ I know that testosterone can give me headaches or migraines. I know it is best to talk with my clinician if I get them frequently or if
the pain is unusually severe.
_____ I know that testosterone can cause emotional changes. For example, I could become more irritable, frustrated, or angry. I know my
provider can help me find resources to explore and cope with these changes.
_____ I know that testosterone causes changes that other people will notice. Some transgender people have experienced harassment,
discrimination, and violence because of this. Others have lost the support of loved ones. I know I can reach out to psychology
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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services to help me find support resources. I also know that in the facility, harassment, discrimination, and violence are not tolerated
under any circumstances. If I feel I am the recipient of any of these actions, I will notify a facility staff member.
Prevention of Medical Complications
_____ I agree to take testosterone as prescribed, and I agree to tell my clinician if I have any problems or am unhappy with the treatment.
_____ I know that the dose and type of medication prescribed for me may not be the same as it is for someone else.
_____ I know that I need periodic physical exams and blood tests to check for any side effects.
_____ I know that testosterone can interact with other drugs and medicines, including alcohol, diet supplements, herbs, and other hormone,
and street drugs. This kind of interaction can cause complications. I know that I need to prevent complications because they can be
life-threatening. I need to be honest with my clinician about other items I am taking. I also know that this will not interfere with my
getting medical care; I will continue to get medical care here no matter what information I share about what I take.
_____ I know that it can be risky for anyone with certain conditions to take testosterone. I agree to be evaluated if my clinician thinks I may
have one of these conditions. Then, we will decide if it is a good idea to start or continue using testosterone.
_____ I know that using testosterone to appear more masculine is an “off-label” use. I know this means it is not approved by the Food and
Drug Administration (FDA) for this purpose. I know the medicine and dose recommended for me is based on the judgement and
experience of the clinician.
_____ I know that I can choose to stop taking testosterone at any time. I know if I decide to stop, I should discontinue with the help of my
clinician to ensure there are no negative reactions. I know my clinician may suggest I cut the dose of stop taking it altogether if
certain medical conditions develop. This may happen if the side effects are severe or if there are health risks that cannot be
controlled.
My Signature Below Confirms That:
•
•
•
•
•
•
•
My clinician has talked with me about:
o The benefits and risks of taking testosterone.
o The possible or likely consequences of hormone therapy.
o Potential alternative treatments.
I understand the risks that may be involved.
I know that the information in this form includes the known effects and risks. I also know that there may be unknown long-term effects
or risks.
I have had enough opportunity to discuss treatment options with my clinician.
All of my questions have been answered to my satisfaction.
I believe I know enough to take, refuse, or postpone testosterone therapy.
I am 18 years of age or older.
Based on All of This Information:
_____ I want to begin taking testosterone.
_____ I do not wish to begin taking testosterone at this time.
Patient’s Signature
Date
Prescribing Clinician’s Signature
Date
Your health is important to us. If you have any questions or concerns, please submit a sick call request.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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«gy Wextior
SOURCES
INCORPORATED
NCORPOR
Urology
Urology Guidelines
Guidelines
WEXFORD MILLER
WEXFORD
MILLER 001075
001075
Medical Guidelines
Region: New Mexico
Urology Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Benign Prostatic Hyperplasia
(BPH)
Consider: Education of the patient.
The selection of therapy, or the
decision to initiate therapy, should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment and
the response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Benign prostatic hyperplasia (BPH)
increases in prevalence as men age.
Urinary symptoms include increased
frequency of urination, nocturia,
hesitancy, urgency, and weak urinary
stream.
Lifestyle modifications — Lifestyle
modifications and behavioral
interventions are typically first-line
treatments for most patients.
Lifestyle modifications include:
• Limiting fluid intake before
bedtime or prior to transport
• Limiting intake of mild diuretics
(e.g., caffeine)
• Limiting intake of bladder
irritants (e.g., highly seasoned or
irritative foods)
• Avoiding constipation
• Increasing activity, including
regular strenuous exercise
• Weight control
Additional behavioral interventions
include:
• Kegel exercises at time of urinary
urgency.
• Timed voiding regimens – In
patients who exhibit obstructive
complaints (i.e., decreased force
of stream) or who are noted to
carry a high post-void residual,
instructing them to attempt to
empty their bladder based on a
time interval rather than by the
usual sensations can be effective
in reducing lower urinary tract
symptoms (LUTS). Requesting
that they urinate “by the clock”
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
(every 90 to 120 minutes during
the daytime) can be effective.
• Double-voiding techniques –
Similarly, men who complain of
obstructive symptoms may
benefit by following one
urination by a second attempt at
emptying (the double void)
within a minute or two of the
initial void.
Medications:
• Hypotension is an important
potential side effect of
medications.
• Terazosin - Because of this,
terazosin will generally need to
be initiated at bedtime (to
reduce postural lightheadedness
soon after starting the
medication), and the dose then
titrated up over several weeks.
• Tamsulosin - Has a lower risk of
hypotension.
Epididymal
Cyst/Spermatocele
Consider: Evaluation and education of
the patient.
An epididymal cyst is generally
asymptomatic and palpated as a soft
round mass in the head of the
epididymis.
Epididymal cysts and spermatoceles
do not generally require treatment,
but spermatoceles may, at rare
instances, necessitate surgical excision
because of chronic pain.
An epididymal cyst that is larger than
2 cm is called a spermatocele.
Epididymitis or
Epididymo-orchitis
Acute epididymitis is the most
common cause of scrotal pain in
adults.
N. gonorrhoeae and C. trachomatis
are the most common organisms
responsible for acute epididymitis in
men under the age of 35.
Consider: Evaluation and education of
the patient. The selection of therapy
should be individualized and based
upon consideration of the extent of
disease, patient’s risk of an STD, and
treatment availability, and the
response to any previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
At the discretion of the clinician
depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
E. coli and Pseudomonas species are
more frequent in older men, often in
association with obstructive
uropathy from benign prostatic
hyperplasia.
The clinical features of acute
epididymitis include localized
testicular pain with tenderness and
swelling on palpation of the affected
epididymis, which is located adjacent
to the testis. More advanced cases
present with secondary testicular
pain and swelling (epididymoorchitis).
1. Patients under the age of 35 or
who are at risk of sexually
transmitted infections.
Consider coverage for N.
gonorrhoeae and C. trachomatis with:
ceftriaxone (500 mg intramuscular
injection in one dose, or 1 g if patient
weighs 150 kg or greater) plus
doxycycline (100 mg orally twice a day
for 10 days).
For patients unable to tolerate
doxycycline, a single azithromycin
dose (1 g orally) is an alternative
option.
For patients unable to tolerate
ceftriaxone due to cephalosporin
allergy, a single 240 mg intramuscular
dose of gentamicin plus a single 2 g
oral dose of azithromycin is an option.
2. Patients 35 years of age or
older and who are at low risk
for sexually transmitted
infections.
Consider coverage for enteric
pathogens with levofloxacin 500 mg
orally once daily for 10 days.
3. Patients of any age who
participate in insertive anal
intercourse.
Consider coverage for N.
gonorrhoeae, C. trachomatis, and
enteric pathogen infections with
ceftriaxone (500 mg intramuscular
injection in one dose, or 1 g if patient
For patients who are unable to take
fluoroquinolones, trimethoprimsulfamethoxazole (one doublestrength tablet twice a day for 10
days) is a good alternative.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
weighs 150 kg or greater) plus a
fluoroquinolone (levofloxacin 500 mg
orally once daily for 10 days).
Foreskin
1. Balanitis
Balanitis is defined as inflammation
of the glans penis. Balanitis has a
wide range of causes, but most cases
are related to inadequate hygiene in
uncircumcised men. When the
foreskin is not routinely retracted
and the glans is not cleansed in an
appropriate fashion, buildup of
sweat, debris, exfoliated skin, and
bacteria or fungi can occur, resulting
in inflammation. Predisposing factors
include diabetes mellitus, trauma
(e.g., zipper injury), obesity, and
edematous conditions (e.g.,
congestive heart failure, cirrhosis,
nephrotic syndrome).
Of cases with identifiable etiologies,
infection is the with Candida is the
most common.
Phimosis
Phimosis, an abnormal constriction
of the opening in the foreskin that
precludes retraction over the glans
penis, results from chronic
inflammation and edema of the
foreskin. Development of a phimosis
often complicates sexual function,
voiding, and hygiene.
Consider: Evaluation and education of
the patient. The selection of therapy
should be individualized and based
upon consideration of the
presentation, extent of disease, and
previous treatment tried.
At the discretion of the clinician
depending on the clinical
scenario
Attention to genital hygiene is the
most important approach for most
men with balanitis. Retraction of the
foreskin with thorough genital
cleansing can be both preventive and
therapeutic. Twice-daily cleansing of
the affected area should be
encouraged.
Empiric Treatment for candidal
infection with clotrimazole 1% cream
or miconazole 2% cream twice daily
for 7 to 14 days can be helpful.
For those who have no improvement
on antifungal therapy, a trial of
hydrocortisone 1% cream or ointment
twice daily for seven days for
nonspecific dermatitis may be helpful.
The selection of therapy should be
individualized and based upon
consideration of the presentation,
extent of disease, and previous
treatment tried.
At the discretion of the clinician
depending on the clinical
scenario
Foreskin manipulation/stretching
exercises for patients:
• Apply a thin layer of a medium
to high potency steroid cream
around the entire foreskin. The
patient should be instructed to
apply the cream all the way
around from the area of the
penis tip down to where the
foreskin meets the skin lower on
the penis shaft.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001079
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
• The patient should gently
massage the cream into the
foreskin, rubbing the foreskin
tissue slowly until the cream has
been fully absorbed into the skin.
• Advise the patient to carefully try
to pull the foreskin back,
stopping when they start feeling
discomfort or pain. Advise
applying some cream to the tip
of the penis, once it’s exposed
enough.
• Advise the patient to repeat
these steps 2 to 4 times a day
until they can fully retract their
foreskin without any pain or
discomfort.
• This can take anywhere from 4 to
8 weeks and sometimes longer,
so the patient should be
instructed to not be concerned if
their foreskin doesn’t budge
after a few days.
Hydrocele
Consider: Education of the patient.
A hydrocele is a collection of
peritoneal fluid between the parietal
and visceral layers of the tunica
vaginalis, which directly surrounds
the testis and spermatic cord.
Hydrocele fluid in the scrotal sac
transilluminates well, which
differentiates the process from a
possible hematocele, hernia, or solid
mass.
Idiopathic hydrocele, the most
common type, generally arises over a
long period of time. Inflammatory
conditions of the scrotal contents
(epididymitis, torsion, appendiceal
torsion) can produce an acute
reactive hydrocele, which often
resolves with treatment of the
underlying condition.
Most hydroceles do not require
intervention.
At the discretion of the clinician
depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001080
432
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Incontinence (Urinary)
Consider: Education of the patient.
The selection of therapy, or the
decision to initiate therapy, should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment,
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Urinary incontinence is the
involuntary leakage of urine.
1. Male
Men are more likely to experience
urinary incontinence as they get
older.
Urge urinary incontinence is the
most common type of incontinence
among men, it manifests as a sudden
and compelling desire to pass urine
that is difficult to defer and is
accompanied by involuntary leakage.
Stress urinary incontinence (SUI)
occurs in the absence of a bladder
contraction and is due to inadequate
urethral sphincter function, either
from mechanical damage to the
urethral sphincter or from
physiologic effects that limit
sphincter function.
Depending on the patient a workup
may include review of potentially
causative medications, U/A, urine
C&S, and a PSA.
Lifestyle modification: Weight loss in
obese men has many benefits,
including improvement of urinary
incontinence symptoms. Other
lifestyle modifications may include
avoiding excessive fluid consumption,
caffeine reduction and avoiding
constipation.
Pelvic floor muscle exercises and
bladder training may assist patients
depending on the cause.
Medications: Duloxetine, an SNRI, is
approved for the treatment of SUI in
many European countries. In the
United States, there are no
medications approved for SUI but
there have been studies showing
effectiveness in some patients.
Female
Estimates of prevalence vary
depending on the population
studied, the measurement period
(e.g., daily or weekly) and the
instruments used to assess severity.
Overall prevalence of urinary
incontinence among non-pregnant
women age 20 years and above has
been reported to range from 10 to
53 percent.
Consider: The selection of therapy
should be individualized. Initial
treatments for most types of
incontinence (stress, urgency, or
mixed) include lifestyle modifications
and pelvic floor muscle exercise,
along with bladder training in women
with urgency incontinence and in
some women with stress
incontinence.
Depending on the patient a workup
may include review of potentially
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Both the prevalence and severity of
urinary incontinence increase with
age.
causative medications, U/A, and a
urine C&S.
Obesity is a strong risk factor for
incontinence. Obese women have a
nearly threefold increased odds of
urinary incontinence compared with
non-obese women.
Increasing parity is a risk factor for
urinary incontinence and pelvic
organ prolapse.
Prostatitis
1. Acute Prostatitis
The clinical presentation of acute
prostatitis is generally not subtle.
Patients are typically acutely ill, with
spiking fever, chills, malaise, myalgia,
dysuria, irritative urinary symptoms
(frequency, urgency, urge
incontinence), pelvic or perineal pain,
and cloudy urine. Men may also
complain of pain at the tip of the
penis. Swelling of the acutely
inflamed prostate can cause voiding
symptoms, ranging from dribbling
and hesitancy to acute urinary
retention.
Acute prostatitis can occur in the
setting of cystitis, urethritis, or other
urogenital tract infections. Thus,
underlying conditions such as
functional or anatomical anomalies
(e.g., urethral strictures), that
predispose to other urogenital
infections can increase the risk of
prostatitis.
Prostate infections following
urogenital instrumentation, including
chronic indwelling bladder
catheterization, intermittent bladder
catheterization, and prostate biopsy
are well documented
Offsite Care to Consider
Lifestyle modification: Weight loss in
obese women has many benefits,
including improvement of urinary
incontinence symptoms. Other
lifestyle modifications may include
avoiding excessive fluid consumption,
caffeine reduction and avoiding
constipation.
Consider: The selection of therapy
should be individualized depending
on the presumptive cause and the
patient’s presentation and clinical
status.
At the discretion of the clinician
depending on the clinical
scenario
The presence of typical symptoms of
prostatitis should generally prompt
digital rectal exam, and the finding of
an edematous and tender prostate on
physical exam in this setting usually
establishes the diagnosis of acute
bacterial prostatitis.
Labs to consider: U/A and urine C&S.
Medications: A variety of
antimicrobials may be used for the
treatment of acute prostatitis, which
should be treated empirically pending
culture results.
Empiric antibiotic therapy should
adequately treat gram-negative
organisms unless a study is available
that suggests an alternate bacterial
cause.
For patients with acute prostatitis who
can take oral medications, consider
trimethoprim-sulfamethoxazole (one
double-strength tab orally every 12
hours) or a fluoroquinolone
(ciprofloxacin 500 mg orally every 12
hours or levofloxacin 500 mg orally
once daily) as empiric therapy.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001082
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Patients under the age of 35 or who
are at risk of sexually transmitted
infections: Consider coverage for N.
gonorrhoeae and C. trachomatis with:
ceftriaxone (500 mg intramuscular
injection in one dose, or 1 g if patient
weighs 150 kg or greater) plus
doxycycline (100 mg orally twice a day
for 10 days).
Chronic Bacterial Prostatitis
The presentation of chronic bacterial
prostatitis can be quite subtle.
Classically, men present with
symptoms of recurrent urinary tract
infection (frequency, dysuria,
urgency, perineal discomfort, and
perhaps a low-grade fever) with
repeated isolation of the same
organism from the urine. However,
this presentation is reported by the
minority of patients. Most patients
have only one or some of these
features.
Chronic bacterial prostatitis is often
presumptively diagnosed and
empirically treated with
antimicrobials when men present
with chronic (e.g., longer than three
months) or recurrent urogenital
symptoms, particularly if bacteriuria
is also present.
Chronic Prostatitis/Chronic Pelvic
Pain Syndrome
Chronic prostatitis/chronic pelvic
pain syndrome (CP/CPPS) is a clinical
syndrome in men defined by pain or
discomfort in the pelvic region, often
accompanied by urologic symptoms
or sexual dysfunction. Despite the
use of the term "prostatitis," it is
unclear to urologists what degree
Consider: Education of the patient.
The selection of therapy, or the
decision to initiate therapy, should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment,
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Prolonged antibiotic therapy (e.g., at
least six weeks) with an agent that has
good penetration into the prostatic
tissue is generally necessary for
treatment of chronic bacterial
prostatitis. Nevertheless, the infection
frequently recurs.
Trimethoprim-sulfamethoxazole twice
daily is generally the drug of choice
for both initial and recurrent episodes,
if organism susceptibility and patient
tolerance allow. Treatment is typically
for 2-3 months. Doxycycline and
Fluoroquinolones (Ciprofloxacin &
Levaquin) are also alternative
regimens.
Consider: Education of the patient.
The selection of therapy, or the
decision to initiate therapy, should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment,
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
the prostate is the source of
symptoms.
Generally, patients should be
evaluated for a possible bacterial
infection, including acute or chronic
bacterial prostatitis, cystitis, urethritis,
or epididymitis.
The diagnosis of chronic
prostatitis/chronic pelvic pain
syndrome (CP/CPPS) is based on the
presence of characteristic symptoms
of pain or discomfort in the pelvic
region, often accompanied by
urologic symptoms or sexual
dysfunction, for at least three of the
preceding six months, after exclusion
of other causes of these symptoms.
Testicular Cancer
Testicular cancer, while relatively
rare, is the most common solid
tumor in men between the ages of
18 and 40.
Offsite Care to Consider
A urinalysis should typically be
performed in all patients, with urine
culture as indicated.
There are a variety of pharmacological
and non-pharmacological therapies
that may be tried and treatment
should be individualized.
Consider: Evaluation and education of
the patient.
Consider: Scrotal ultrasound is
the typical diagnostic test of
choice to evaluate a concerning
testicular nodule or mass.
Referral to Urology should be
considered for patients with a
suspicious or concerning
ultrasound.
It usually presents as a painless mass
discovered by the patient or clinician,
although rapidly growing germ cell
tumors may cause scrotal pain from
hemorrhage and infarction. On
physical examination, testicular
cancer is usually a firm, nontender
nodule or mass that does not
transilluminate.
Some patients with germ cell tumors
may have associated gynecomastia,
typically associated with elevated
levels of beta-hCG.
Urethritis
1. Male
Urethritis, or inflammation of the
urethra, is a common manifestation
of sexually transmitted infections
among males.
Dysuria, or discomfort with urination,
is usually the chief complaint in
males with urethritis and is reported
in the majority of males with
gonorrhea and over half of patients
with nongonococcal urethritis (NGU).
Consider: U/A and testing for
Gonorrhea and Chlamydia.
Patients presenting with sexually
transmitted infections or risk factors
should also routinely be offered
screening for syphilis and HIV
infection.
At the discretion of the clinician
depending on the clinical
scenario
The initial antimicrobial treatment of
urethritis is typically empiric at the
point-of-care and should be offered
to males with suspected or confirmed
urethritis.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001084
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Recurrent or persistent symptoms
are common following therapy for
urethritis. Possible causes include
poor adherence to the regimen,
reinfection, antimicrobial resistance
(particularly in the case of N.
gonorrhoeae), and involvement of
other organisms inadequately
treated by the empiric regimen (in
particular, M. genitalium or in men
who have sex with women [MSW],
Trichomonas).
The preferred regimen for gonococcal
infections is a single intramuscular
dose of ceftriaxone (500 mg for
individuals <150 kg or 1 g for
individuals ≥150 kg).
Female
Consider: U/A, urine C&S, and testing
for Gonorrhea and Chlamydia.
Evaluation for urethritis is warranted
in sexually active women with
dysuria, particularly those with pyuria
on urinalysis but no bacteriuria.
Causes of urethritis in women
include chlamydia, gonorrhea,
trichomoniasis, Candida species,
herpes simplex virus, and
noninfectious irritants.
UTI (Urinary Tract Infection)
Offsite Care to Consider
If testing results for C. trachomatis are
not available at the time of treatment,
presumptive therapy for chlamydia
co-infection is also indicated. In such
cases, consider adding doxycycline
100 mg twice daily for 7 days.
The selection of therapy, or the
decision to initiate therapy, should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment,
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
See the breakdown below:
Urinary tract infections (UTIs) include
cystitis (infection of the
bladder/lower urinary tract) and
pyelonephritis (infection of the
kidney/upper urinary tract).
Clinical manifestations of cystitis
consist of dysuria, urinary frequency,
urgency, and/or suprapubic pain.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001085
437
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
1. Male - Uncomplicated
Consider: U/A and urine C&S.
Acute Uncomplicated UTI = Simple
Cystitis in men is uncommon.
The selection of therapy should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment,
treatment availability and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
The term acute simple cystitis is used
to refer to an acute urinary tract
infection (UTI) that is presumed to be
confined to the bladder.
For empiric antimicrobial treatment
one of the first-line regimens
recommended include:
• Nitrofurantoin (Macrobid, 100
mg orally twice daily for 7 days)
• Trimethoprim-sulfamethoxazole
(TMP-SMX, one double-strength
tablet [160 mg TMP/800 mg
SMX] orally twice daily for 7
days)
Follow-up urine cultures are not
typically needed in men with acute
simple cystitis whose symptoms
resolve on antimicrobials.
Male - Complicated
Consider: U/A and urine C&S.
Acute Complicated UTI =
pyelonephritis - infections that have
signs or symptoms that suggest an
infection extending beyond the
bladder, which include:
The selection of therapy including the
decision to send patients to the ER
should be individualized. The decision
is generally based upon potential
urinary tract obstruction,
consideration of the extent of the
condition and symptoms, patient
factors, treatment availability and the
response to previous treatments.
If empiric therapy is chosen generally
broad-spectrum IV antibiotics are
chosen.
• Fever
• Other signs or symptoms of
systemic illness (including chills
or rigors, significant fatigue or
malaise beyond baseline)
• Flank pain
At the discretion of the clinician
depending on the clinical
scenario
• Costovertebral angle (CVA)
tenderness.
Female – Uncomplicated
Acute simple cystitis should be
suspected in women who have acute
symptoms of dysuria, urinary
Consider: Urinalysis can be performed
either by microscopy or by dipstick.
Urine culture and susceptibility testing
is considered optional in most women
At the discretion of the clinician
depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001086
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
frequency or urgency, and/or
suprapubic pain, particularly in the
absence of vaginal symptoms (e.g.,
vaginal pruritus or discharge).
with acute simple cystitis, but may be
performed in patients who are at risk
for infection with a resistant organism.
The probability of cystitis is greater
than 50 percent in women with any
of these symptoms and greater than
90 percent in women who have
dysuria and frequency without
vaginal discharge or irritation.
Offsite Care to Consider
For empiric antimicrobial treatment
there are numerous first-line
regimens recommended including:
• Nitrofurantoin (Macrobid, 100
mg orally twice daily for 5 days)
• Trimethoprim-sulfamethoxazole
(TMP-SMX, one double-strength
tablet [160 mg TMP/800 mg
SMX] orally twice daily for 3
days)
• Amoxicillin-clavulanate (500 mg
twice daily) for 5 days.
Female - Complicated
Consider: U/A and urine C&S.
Acute Complicated UTI =
pyelonephritis - infections that have
signs or symptoms that suggest an
infection extending beyond the
bladder, which include:
The selection of therapy including the
decision to send patients to the ER
should be individualized. The decision
is generally based upon potential
urinary tract obstruction,
consideration of the extent of the
condition and symptoms, patient
factors, treatment availability and the
response to previous treatments.
• Fever
• Other signs or symptoms of
systemic illness (including chills
or rigors, significant fatigue or
malaise beyond baseline)
• Flank pain
At the discretion of the clinician
depending on the clinical
scenario
If empiric therapy is chosen generally
broad-spectrum IV antibiotics are
chosen.
• Costovertebral angle (CVA)
tenderness
Pregnancy – UTIs and
asymptomatic bacteriuria in the
Pregnant Patient
The incidence of bacteriuria in
pregnant women is approximately
the same as that in nonpregnant
women, however, recurrent
bacteriuria is more common during
pregnancy.
Consider: U/A and urine C&S.
The selection of therapy should be
individualized and based upon
consideration of the extent of the
condition and symptoms, potential
adverse effects of the treatment on
the mother and the fetus, treatment
availability and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical
scenario
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001087
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
For empiric antimicrobial treatment
one of the first-line regimens
recommended include:
• Nitrofurantoin (Macrobid, 100
mg orally twice daily for 5- 7
days). This medication is
generally avoided during the first
trimester and at term if other
options are available. This
medication also does not achieve
therapeutic levels in the kidneys
so should not be used if
pyelonephritis is suspected.
• Amoxicillin 500 mg orally every 8
hours or 875 mg orally every 12
hours for 5-7 days
• Trimethoprim-sulfamethoxazole
(TMP-SMX, one double-strength
tablet [160 mg TMP/800 mg
SMX] orally twice daily for 3
days) – This medication is
generally avoided during the first
trimester and at term.
Follow-up urine cultures are generally
suggested in pregnant patients. The
C&S is generally performed a week
after completion of therapy for
asymptomatic bacteriuria and a UTI.
Varicocele
Consider: Education of the patient.
A varicocele, which is present in 15
to 20 percent of post-pubertal males,
is caused by dilatation of the
spermatic veins. It is generally leftsided, may first appear at puberty,
and may become larger over time.
Most varicoceles do not require
intervention.
At the discretion of the clinician
depending on the clinical
scenario
Varicocele is diagnosed by its
characteristic physical findings, which
range from minimal left-sided scrotal
fullness to a large, soft, left-sided
scrotal mass ("bag of worms") that
decompresses and disappears in the
recumbent position.
Clinical pathways do not replace sound clinical judgment nor are intended to apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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SOURCES
INCORPORATED
Vascular Disorders
Vascular
Disorders
WEXFORD MILLER
WEXFORD
MILLER 001089
001089
Medical Guidelines
Region: New Mexico
Vascular Surgery Guidelines
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Abdominal Aortic Aneurysm
(AAA) (Asymptomatic)
Consider: Patient education about
the condition. The selection of
therapy, or the decision to initiate
therapy, should be individualized and
based upon consideration of the
extent of the condition and
symptoms, patient’s history and
examination, testing completed,
potential adverse effects of the
treatment and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical scenario.
Associated History: Risk factors for
atherosclerosis include aging and
hypertension. AAAs have a tendency
to run in families.
Associated Exam Findings: Pulsatile
abdominal mass in midline of
abdomen, usually just above
umbilicus. May have femoral or
popliteal aneurysms which show up
as pulsatile masses either in the groin
or behind the knees.
Consider: For patients with
asymptomatic AAA who do not have
indications for elective repair,
medical treatment is aimed at
reducing the risk for future
cardiovascular events and limiting
the rate of aortic expansion.
Consider: Cardiovascular risk
reduction strategies, which may
include medical therapy (antiplatelet
therapy, statin therapy,
antihypertensive therapy), smoking
cessation and aerobic exercise to
reduce the risk of future
cardiovascular events.
For asymptomatic patients, the risk of
AAA rupture generally exceeds the
risk associated with elective AAA
repair when aneurysm diameter
exceeds 5.5 cm.
Earlier repair may benefit patients
with well-documented rapid
aneurysm expansion (>5 mm in six
months or 10 mm per year) on serial
imaging studies performed by the
same modality.
Consider: The optimal surveillance
schedule for patients who are not
undergoing AAA repair has not been
clearly defined so clinician discretion
is advised, especially for AAAs with a
greater expansion rate.
Consider: The Society for Vascular
Surgery (SVS) support longer
surveillance intervals for small AAAs
and suggest the following
surveillance schedule:
• Initial ultrasound screening
aortic diameter >2.5 cm but <
3.0 cm, rescreening after 10
years.
• For AAA 3.0 to 3.9 cm, imaging
at 3-year intervals.
• For AAA 4.0 to 4.9 cm, imaging
at 12-month intervals.
• For AAA 5.0 to 5.4 cm, For
imaging at 6-month intervals
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001090
442
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Abdominal Aortic Aneurysm
(AAA), (Symptomatic)
Consider: The selection of a
treatment plan should be
individualized and based upon
consideration of the extent of the
condition and symptoms, patient’s
known history and examination, and
testing completed.
At the discretion of the clinician
depending on the clinical scenario
recognizing that each case is unique.
Associated Symptoms: Symptomatic
abdominal aortic aneurysm (AAA)
refers to any of a number of
symptoms (e.g., abdominal pain, limb
ischemia, back/flank pain,
hypotension) that can be attributed
to the aneurysm.
Consider: In cases where the
diagnosis is unknown and the patient
is hemodynamically stable, then an
urgent abdominal ultrasound or AAA
ultrasound or abdominal CT scan.
Associated History: Known
abdominal aneurysm.
Associated Exam Findings: Tender,
pulsatile abdominal mass, and
possible flank ecchymosis.
Carotid
Bruit/Stenosis/Occlusion,
(Asymptomatic)
Asymptomatic refers to the presence
of carotid atherosclerosis in
individuals with no history of
ipsilateral carotid territory ischemic
stroke or transient ischemic attack
(TIA) within the preceding six
months.
Associated History: Risk, factors for
atherosclerosis, no TIA or prior
stroke.
Possible Exam Findings: Cervical
bruit auscultated with stethoscope.
Occlusion — There is no role for
revascularization to prevent recurrent
stroke in the setting of complete
carotid chronic occlusion. Intensive
medical therapy is indicated.
Consider: In cases with hemodynamic
instability or suspicious
symptoms/signs, the patient is
typically referred to the ER
emergently.
Consider: Patient education about
the condition. The selection of
therapy, or the decision to initiate
therapy, should be individualized and
based upon consideration of the
extent of the condition and
symptoms, patient’s history and
examination, testing completed,
potential adverse effects of the
treatment and the response to
previous treatments.
Intensive medical therapy lowers the
risk of stroke in patients with
asymptomatic carotid stenosis and
therapy may include medical therapy
(antiplatelet therapy, statin therapy,
antihypertensive therapy), glycemic
control, smoking cessation, weight
management and aerobic exercise to
reduce the risk of future
cardiovascular events.
At the discretion of the clinician
depending on the clinical scenario.
Annual duplex ultrasonography: Most
patients with asymptomatic carotid
stenosis should be followed with
noninvasive vascular imaging of the
carotid artery, particularly if they may
be candidates for revascularization.
Carotid revascularization: Optimal
patient selection for carotid
revascularization is controversial
given the periprocedural risk relative
to the low absolute risk reduction
associated with revascularization.
Stenosis 70 to 99 percent: Per
UpToDate, for medically stable
patients with asymptomatic carotid
atherosclerotic disease at baseline
who have a life expectancy of at least
five years and have a severe (70 to 99
percent) carotid artery stenosis,
either intensive medical therapy
alone or intensive medical therapy
plus carotid revascularization may be
considered.
Stenosis of 80 to 99 percent: Per
UpToDate, many vascular surgeons
have adopted a more conservative
approach and would only consider
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001091
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Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Offsite Care to Consider
carotid revascularization for a patient
with a more severe stenosis of 80 to
99 percent.
Carotid Bruit or Stenosis,
(Symptomatic)
Associated Symptoms: Strokeweakness or numbness of one side of
body, facial drooping, blindness in
one eye, and/or slurred speech of
over 24 hours duration. Transient
ischemic attach (TIA) – above
symptoms of less than 24 hours
duration which disappear completely.
Associated History: Prior stroke or
TIA, risk factors for atherosclerosis.
Potential Exam Findings: Cervical
bruit, abnormal neurologic exam.
Diagnostic studies: Carotid duplex
scan and may need CT scan or MRI.
Duplex scan with >70% stenosis
portends a significant risk for CVA
(especially when associated with TIA
and ipsilateral findings for amaurosis
fugax).
Claudication
Claudication is defined as a
reproducible discomfort of a defined
group of muscles that is induced by
exercise and relieved with rest.
The symptoms result from an
imbalance between the supply and
demand for blood flow due to
peripheral artery disease (PAD).
Symptoms: Calf, thigh, or buttock
pain, on walking relieved by rest.
Associated History: Risk factors for
PAD are similar to those that
promote the development of
coronary atherosclerosis including
Consider: The selection of the
treatment plan should be
individualized and based upon
consideration of the extent of the
condition and the associated signs
and symptoms, patient’s history and
examination, testing completed, and
the response to previous treatments
or interventions.
At the discretion of the clinician
depending on the clinical scenario.
But generally, any patient with
symptoms/signs consistent with
acute symptomatic stenosis should
generally be referred urgently or
emergently for evaluation & work-up
based on the individual patient’s
scenario.
Treatment of symptomatic
extracranial carotid atherosclerotic
disease includes intensive medical
management and may or may not
include carotid revascularization with
carotid endarterectomy (CEA) or
carotid artery stenting (CAS).
Optimal medical therapy includes
antithrombotic therapy, statin
therapy, glycemic control and other
risk factor modification including
smoking cessation. It is
recommended for all patients with
atherosclerotic carotid artery stenosis
in any location and regardless of
symptoms.
Consider: Patient education about
the condition. The selection of
therapy, or the decision to initiate
therapy, should be individualized and
based upon consideration of the
extent of the condition and
symptoms, patient’s history and
examination, testing completed,
potential adverse effects of the
treatment and the response to
previous treatments.
At the discretion of the clinician
depending on the clinical scenario.
Continue to advise the patient on the
importance of stopping smoking and
an escalating exercise program
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001092
444
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
older age, cigarette smoking,
diabetes, high blood pressure, and
high cholesterol.
(walking: 30-60 min. per day, 5 days
per week).
Potential Exam Findings: Diminished
or absent lower extremity pulses,
pallor of distal extremity on leg
elevation, cool skin temperature,
trophic changes (e.g., hair loss,
muscle atrophy) and non-healing
ulcer.
Offsite Care to Consider
Medications to consider:
Cilostazol (Pletal) 100 mg twice daily
should be taken a half hour before or
two hours after eating, because highfat meals markedly increase
absorption. Cilostazol is
contraindicated in heart failure of any
severity.
Consider: Medications for
cardiovascular risk modification.
Swollen Leg (Acute)
Consider: See Wexford’s guideline,
“Approach to the Patient with an
Acutely Swollen Leg.”
Consider: See Wexford’s guideline,
“Approach to the Patient with an
Acutely Swollen Leg.”
Swollen Leg (Chronic)
Consider: Patient education about
the condition. The selection of
therapy, or the decision to initiate
therapy, should be individualized and
based upon consideration of the
extent of the condition and
symptoms patient’s history and
examination, potential adverse
effects of the treatment and the
response to previous treatments.
At the discretion of the clinician
depending on the clinical scenario.
Symptoms: Edema of leg(s), pain in
legs while ambulatory.
Associated History: Chronic swelling,
prior trauma or DVT, varicose veins,
prior surgery of leg.
Bilateral: If both legs are involved
may be systemic in nature, i.e.,
congestive heart failure, kidney
failure, or liver failure.
Unilateral: Swelling more likely to be
a focal process such as DVT,
infection, etc.
Ulcer (PAD associated)
Ischemic ulcers associated with
peripheral arterial disease (PAD)
often begin as minor traumatic
wounds and then fail to heal because
the blood supply is insufficient to
meet the increased demands of the
healing tissue.
Symptoms: Ulceration or infected
tissue, present on toe(s), usually over
area or bony prominence, painful.
Consider: Leg elevation, exercise,
compression stockings and weight
management
Consider patient education about a
goal of normalizing the BMI.
Consider: Patient education about
the condition.
At the discretion of the clinician
depending on the clinical scenario.
The selection of therapy should be
individualized and based upon
consideration of the extent of the
condition and symptoms, the history
of the wound, patient’s history and
examination, testing completed,
potential adverse effects of the
treatment and the response to
previous treatments.
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
MILLER 001093
445
Medical Guidelines
Region: New Mexico
Diagnosis
Onsite Care to Consider
Associated History: Slow onset,
usually with a prior history of arterial
occlusive disease, claudication, or
diabetes. May present with fever.
Patient feels better when leg is in
dependent position.
Consider: Cardiovascular risk
reduction strategies, which may
include medical therapy (antiplatelet
therapy [either aspirin or clopidogrel
(Plavix) are appropriate choices],
statin therapy, antihypertensive
therapy), smoking cessation, diabetes
control [if applicable] and exercise to
reduce the risk of future
cardiovascular events.
Possible exam findings: Extremity
may show signs of occlusive disease
(see claudication, or ischemic
extremities). Ulcer typically occurs on
the toes or lateral aspect of foot or
ankle. May have gangrenous changes
with tenderness, and cyanosis around
ulcer.
Offsite Care to Consider
Ongoing wound care including ulcer
debridement: Wound debridement is
an important component of the
management of ulcers related to PAD
and should be guided/performed by
clinicians familiar with wound
debridement.
Off-loading of the affected area
should be considered as an approach
to assist with wound healing by
keeping shoes or boots from
potentially rubbing against the ulcer.
Ulcer (Venous)
Ulceration or infected tissue,
excessive limb swelling, presence
chronic (longstanding) chronic
venous insufficiency in nature.
Associated History: Conditions that
may precede venous ulceration may
include chronic venous insufficiency,
varicose veins, prior trauma or DVT in
leg, chronic leg swelling, or ulcers in
the past that have healed.
Possible Exam Findings: Edema, Pain
(dull ache, burning or cramping pain),
ulceration usually on medial aspect
of ankle, stasis dermatitis or brawny
or woody change to surrounding
skin.
Consider: Patient education about
the condition.
At the discretion of the clinician
depending on the clinical scenario.
The selection of therapy should be
individualized and based upon
consideration of the extent of the
condition and symptoms, the
wound’s history, patient’s history and
examination, testing completed,
potential adverse effects of the
treatment and the response to
previous treatments.
General patient education to
consider to manage symptoms of
chronic venous insufficiency include
avoidance of prolonged standing, leg
elevation, exercise, smoking and
encourage appropriate skin care. Offloading of the affected area should
be considered as an approach to
assist with wound healing by keeping
shoes or boots from potentially
rubbing against the ulcer.
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Diagnosis
Onsite Care to Consider
Offsite Care to Consider
Treatment to consider: Wound care
that may include, Dome paste
bandage (or zinc gelatin) or Unna
boot must be placed directly on skin
and wrapped from toes to just under
knee with Kerlix or Kling wrap placed
over this.
Unna boot should be changed
typically every 7−10 days, and skin
and ulcer washed.
May take 8−12 weeks or longer to
heal ulcer depending on size. If
infected, often need IV Antibiotics,
bed rest, dressing changes.
Ulcer debridement: Wound
debridement is an important
component of the management of
venous ulcers and should be
performed by clinicians familiar with
wound debridement.
Compression therapy: Static
compression therapy is an essential
component in the treatment of
chronic venous disease.
Medications to consider: aspirin and
Trental (pentoxifylline).
Varicose Veins
Enlarged superficial veins on lower
extremities, that generally cause
cosmetic problems but may be very
painful especially if thrombosed.
Consider: Patient education about
the condition.
At the discretion of the clinician
depending on the clinical scenario.
Consider: Leg elevation, exercise
compression stockings and weight
management.
Associated History: Family history,
pregnancy, trauma, or prior DVT in
leg.
Exam: One to multiple engorged
veins on lower leg, usually medial
aspect.
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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JNC8 Hypertension Management Algorithm
The 2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP,
diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and
CCB, calcium channel blocker. ACEIs and ARBs should not be used in combination. If blood pressure
fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual
therapeutic plan.
Clinical pathways do not replace sound clinical judgment, nor are they intended for all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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I.
REFERENCE
1.
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure, JAMA. 2014; 311(5):507-520
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Vascular Surgery Guidelines
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Table 1: Classification of Blood Pressure for Adults
JNC 6 Parameters
JNC 7 Parameters
JNC 8 Parameters
SBP/DBP
Optimal
<120/80
Normal
120−129/80−84
Borderline
II.
Normal
Normal
Prehypertension
Normal
Hypertension if patient
has diabetes, renal
failure, or has no
diabetes with age less
than 60 years.
If patient has no
diabetes and is 60 years
or older, the goal is
<150/90
130−139/85−89
Hypertension
>140/90
Hypertension
Stage 1
Stage 2
Stage 3
140−159/90−99
160−179/100−109
>180/100
Stage 1
Stage 2
Staging system has
been abandoned in
the newest guidelines.
REFERENCES
1.
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Arch Intern Med 1997;157:2413-46.
2.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure. Arch Intern Med 2003;289:2560-71.
3.
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure, JAMA. 2014;311(5):507-520
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Table 2: Causes for Lack of Responsiveness to Therapy
Causes for Lack of Responsiveness to Therapy
Nonadherence to Therapy
•
•
•
•
•
•
•
Cost of medication
Instructions not clear and/or not given to the patient in writing
Inadequate or no patient education
Lack of involvement of the patient in the treatment plan
Side effects of medication
Organic brain syndrome (e.g., memory deficit)
Inconvenient dosing
Drug-Related Causes
•
•
•
•
Doses too low
Inappropriate combinations (e.g., two centrally acting adrenergic inhibitors)
Rapid inactivation (e.g., hydralazine)
Drug interactions:
➢ Nonsteroidal anti-inflammatory drugs
➢ Oral contraceptives
➢ Sympathomimetics
➢ Antidepressants
➢ Adrenal steroids
➢ Nasal decongestants
➢ Licorice-containing substances (e.g., chewing tobacco)
➢ Cocaine
➢ Cyclosporine
➢ Erythropoietin
Associated Conditions
•
•
•
•
•
•
•
•
•
Increasing obesity
Alcohol intake more than 1 oz of ethanol per day
Smoking
Sleep apnea
Insulin resistance or hypersinsulinemia
Anxiety-induced hyperventilation or panic attacks
Chronic pain
Intensive vasoconstriction (arteritis)
Organic brain syndrome
Secondary Hypertension
•
•
•
•
•
•
Renal insufficiency
Renovascular hypertension
Pheochromocytoma
Hyperparathyroidism
Aortic coarctation
Cushing syndrome
Pseudoresistance
•
•
•
“White-coat hypertension” or office elevations
Pseudohypertension in older patients
Use of regular cuff on a very obese arm
Volume Overload
•
•
•
•
Inadequate diuretic therapy
Excess sodium intake
Fluid retention from reduction of blood pressure
Progressive renal damage
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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JNC 8 GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION IN ADULTS
In any adult 18 years of age or older diagnosed with hypertension, the first strategy is to implement
lifestyle modification and set blood pressure goal, followed by initiation of blood pressure lowering
medications based on the following algorithm.
In the general population, pharmacologic treatment is recommended to be initiated when blood pressure
is 150/90 mm Hg or higher in adults 60 years and older, or 140/90 mm Hg or higher in adults younger
than 60 years.
In patients with hypertension and diabetes, pharmacologic treatment may be initiated when blood
pressure is 140/90 mm Hg or higher, regardless of age.
Initial antihypertensive treatment in a general non-black population should include either:
1. Thiazide diuretic (e.g., HCTZ or Dyazide)
2. Calcium channel blocker - CCB (e.g., amlodipine, diltiazem)
3. ACE inhibitor (e.g., lisinopril), or
4. ARB (e.g., losartan)
If the target blood pressure is not reached within one month after initiating therapy, consider increasing
the dosage of the initial medication or adding a second medication.
III.
DRUGS IN SPECIAL POPULATIONS
When initiating therapy in patients of African descent the without chronic kidney disease the
guidelines suggest using CCBs and thiazides instead of ACEIs.
Per guidelines, CCBs and thiazide-type diuretics are recommended to be used instead of ACEIs and
ARBs in patients over the age of 75 with impaired kidney function due to the risk of hyperkalemia,
increased creatinine, and further renal impairment
IV.
DRUG NO LONGER RECOMMENDED AS PRIMARY CHOICES PER GUIDELINES
The following agents demonstrated inferior cardiovascular outcomes when compared with the four
(4) main recommended classes of drugs:
1. Beta-blockers (e.g. atenolol, metoprolol)
2. Alpha-blockers (e.g. terazosin)
3. Alpha1/beta-blockers (eg, carvedilol)
4. Central alpha2-adrenergic agonists (e.g. clonidine)
5. Direct vasodilators (e.g. hydralazine)
6. Loop diuretics (e.g. furosemide)
7. Aldosterone antagonists (e.g., spironolactone)
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Drug Treatment Considerations for Hypertension2
Patient Characteristics
Preferred Drugs
Demographic Characteristics
African-American
Thiazide diuretic, calcium channel blocker
Concomitant Diseases
V.
Post-myocardial infarction
Beta-blocker; ACE inhibitor, ARB
Congestive heart failure
Diuretic; +Beta-blocker +ACE inhibitor/ARB,+ spironolactone
High CVD risk
Thiazide diuretic; Beta-blocker; ACE inhibitor, CCB
Renal insufficiency
ACE inhibitor/ARB
Diabetes mellitus
Thiazide diuretic; ACE inhibitor/ARB, CCB
Recurrent stroke prevention
Thiazide diuretic; ACE inhibitor
REFERENCES
4.
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Arch Intern Med 1997;157:2413-46.
5.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure. Arch Intern Med 2003;289:2560-71.
6.
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure, JAMA. 2014;311(5):507-520
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Table 3: Risk Stratification Factors
Target Organ Disease
•
Heart diseases
➢ LVH
➢ Angina/Prior MI
➢ Prior coronary artery bypass graft
➢ Heart failure
•
Stroke or transient ischemic attach
•
Nephropathy
•
Peripheral arterial disease
•
Hypertensive retinopathy
Major Risk Factors
•
Smoking
•
Dyslipidemia
•
Diabetes mellitus
•
Gender
➢ Men
➢ Postmenopausal women
•
Family history
➢ Women <age 65 years
➢ Men <age 55 years
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medications on the Wexford Health Corporate Formulary Used to Treat Hypertension
24 HR INITIAL DOSE
24 HR MAX DOSE
SIDE EFFECTS*
Enalapril (Vasotec®)
2.5 mg
40 mg
Headache, fatigue, syncope, diarrhea, nausea, abdominal pain, dry cough
Lisinopril (Zestril®)
Angiotensin II Blockers
Losartan (Cozaar)
Alpha Adrenergic Blockers
10 mg
40 mg
Dizziness, headache, hypotension, syncope
50 mg
100 mg
Dizziness, headache, abdominal pain, diarrhea, nausea, cough, sinusitis, edema
Terazosin (Hytrin®)
1 mg
20 mg
Asthenia, dizziness, headache, peripheral edema, syncope, blurred vision, nasal
congestion, nausea, dyspnea
Clonidine (Catapres®)
0.1 mg
2.4 mg
Fatigue, sedation, malaise, depression, orthostatic hypertension, nausea, diarrhea,
urine retention, rash
Beta Andrenergic Blockers
Atenolol (Tenormin®)
50 mg
100 mg
Metoprolol (Lopressor®)
100 mg
450 mg
5 mg
10 mg
Verapamil SR (Calan SR®)
240 mg
480 mg
Diltiazem XR (Dilacor XR®)
120 mg
540 mg
ACE Inhibitors
Alpha Adrenergic Agonist
Calcium Channel Blockers
Amlodipine (Norvasc)
Fatigue, lethargy, dizziness, bradycardia, nausea, diarrhea, dyspnea, bronchospasm
Fatigue, dizziness, depression, bradycardia, nausea, diarrhea, dyspnea,
bronchospasm, rash
Peripheral edema, headache, fatigue, occasional palpitations
Asthenia, dizziness, headache, bradycardia, AV block, peripheral edema,
constipation, nausea, elevated liver enzymes
Headache, somnolence, irritability, hypertension, photophobia, nausea, diarrhea,
dysgeusia, anorexia, nocturia
Diuretics
Vertigo, headache, paresthesia, blurred vision, nausea, diarrhea, anorexia,
dermatitis, anemia
Headache, drowsiness, confusion, ataxia, diarrhea, gastritis, urticaria, breast
Spironolactone
25 mg
200 mg
tenderness
Dizziness, headache, paresthesia, anorexia, nausea, diarrhea, abdominal pain,
Hydrochlorothiazide
6.25 mg
25 mg
dermatitis, hyperuricemia
* Not all side effects listed are seen with different dosage forms. The listed side effects occur with a greater than 3% incidence.
Furosemide
20 mg
160 mg
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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SOURCES
INCORPORATED
Warfarin Management
Warfarin
Management
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Warfarin Management
VI.
PURPOSE
All patients receiving Warfarin therapy will be managed safely, effectively, and methodically.
Patients for whom Warfarin is prescribed should be followed either in Cardiovascular Chronic Clinic
or General Medical Chronic Clinic. They do not need a separate “Anticoagulation Chronic Clinic.”
As discussed in these materials under ‘Principles of Warfarin Administration,’ once a patient’s
anticoagulation has been deemed stable, the INR value should be monitored every 2−4 weeks.
Documentation of INR for patients on Warfarin therapy will be entered on the included ‘Warfarin
Facility Tracking Log’ and ‘Warfarin patient Flow sheet.’ These forms will be reviewed during either
the Cardiovascular Chronic Clinic or General Medical Chronic Clinic.
VII.
GOALS
To effectively track all patients on Warfarin within each correctional facility utilizing the
Wexford Health Warfarin Facility Tracking Log
To effectively manage each patient on Warfarin utilizing the Wexford Health Warfarin Patient
Flow Sheet
To provide educational material to each patient utilizing the Wexford Health Warfarin Patient
Information Fact Sheet
To provide educational materials to site clinicians by way of the Wexford Health Warfarin Drug
Monograph
To convert to Jantoven as the Wexford Health formulary choice as a Warfarin product
VIII. PROCESS
Each Regional Medical Director will be expected to implement, track, and monitor compliance with
these components.
IX.
PROCEDURE
All patients identified on Warfarin within the facility are entered onto the Warfarin Facility
Tracking Log.
Each patient will have an individual flow sheet placed in the medical record. It is
recommended that the flow sheet be placed immediately behind the Master Problem List.
Patients identified at intake on Warfarin should be scheduled to see a physician or physician
extender within 3–5 days. An INR should be drawn within the first 24 hours of intake.
Review of the initial INR, initiation of the flow sheet, and documentation on the Master
Problem List should be completed at this encounter.
The Patient Information Fact Sheet should be reviewed with the patient at this encounter.
The site medical authority will develop a system with the responsible nurse or pharmacy
technician to effectively populate, track, and manage the Warfarin Tracking Log.
The Warfarin Drug Monograph should be placed in the Wexford Health Pharmacy Guidelines
manual as appropriate and be readily available for all clinical staff.
X.
ASSOCIATED FORMS AND RESOURCES
Warfarin
Warfarin
Warfarin
Warfarin
Facility Tracking Log
Patient Flow Sheet
Patient Information Fact Sheet
Drug Monograph.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Warfarin Drug Monograph
XI.
INTRODUCTION
Warfarin is an extremely “high risk” medication. It has a narrow therapeutic index, which is
compounded by significant side effects associated with both underdosing and overdosing. Patient
compliance is therefore a critical issue with Warfarin administration. Warfarin is rarely a Keep On
Person Medication (KOP). All Warfarin administration should be Directly Observed Therapy (DOT).
Medication refusal should be reported to the responsible physician or designee upon a patient
missing even a single dose. A patient who misses a dose due to a court appearance (or other reason
that renders them unavailable) should be sought out and given their medication.
Warfarin is the generic name for two commercial products Coumadin® and Jantoven®® is on the
approved Wexford Health formulary. Jantoven® is available in all the same strengths as Coumadin®
1, 2, 2.5, 3, 4, 5, 6, 7.5, and 10mg tablets. The tablets have the same color coding as Coumadin®
and the tablets are scored for splitting and dosage titration.
XII.
WARFARIN MONITORING
Warfarin is monitored using a calculated value called the International Normalized Ratio (INR). The
INR formula is the patient’s PT in seconds divided by the reference lab’s mean PT in normal range.
The target INR for most patients should be between 2.0−3.0. The target INR range for patients with:
mechanical heart valves, antiphospholipid syndrome, or to prevent a recurrent Ml in an aspirin
intolerant patient should be between 2.5−3.5.
A patient’s lNRs may fluctuate for no easily apparent reason. Practitioners should be aware of the
potential drug and food interactions, as well as compliance issues, which may cause this to occur.
XIII. PRINCIPLES OF WARFARIN ADMINISTRATION
A loading dose of Warfarin is not clinically indicated.
The typical starting dose is 5 mg p.o. q.d. (expect a therapeutic INR by day 4−5).
Higher doses of 7.5−10 mg q.d. may be given if there is a particular urgency to reach a
therapeutic level.
Low doses of 2.5 mg q.d. should be used as a starting point in the elderly, those with liver
disease or for those with a high risk of bleeding.
Concurrent initial administration of Heparin or Low Molecular Weight Heparin is indicated in
thrombophilic states (Protein C deficiency) and thromboembolism.
Warfarin has an initial paradoxical procoagulant effect; therefore Heparin and LMWH require
at least a four- to five-day overlap with Warfarin to achieve a therapeutic intensity of
anticoagulation.
Warfarin may be started alone for chronic stable atrial fibrillation.
INR should be monitored every 2−4 weeks when stable.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XIV. GUIDELINE FOR ADJUSTING WARFARIN DOSAGES
INR less than 2: increase weekly Warfarin dose by
5−20%
INR 3−3.5: decrease weekly Warfarin dose by
5−15%.
INR 3.6−5. 0: consider withholding one dose, and
decrease weekly dose by 10−15%
INR 5−10: withhold 1−2 doses, decrease weekly
dose by 10−20%
Example: Patient with an INR of 3.5 who is currently taking
Warfarin 5 mg/day p.o..
Reduce weekly dose 10% (35.0 mg−3.5 mg = 31.5mg)
New weekly dose 31.5mg/week divided by 7 = 4.5 mg/day
Solution: Pt. takes a 2.5mg tab plus a 2.0mg tab each day
OR
4mg tab day alternate with a 5 mg tab day 2
(Continue alternating thereafter)
INR >10: hold Warfarin, Vitamin K 3−5 mg p.o.
one dose, anticipate significantly lower INR in 24−48 hours
In cases of significant bleeding, patients will need to receive Vitamin K by slow infusion and
Fresh Frozen Plasma (FFP) in an inpatient setting.
XV.
WARFARIN GUIDELINES FOR PATIENTS WITH CHRONIC ATRIAL FIBRILLATION
Presence of valvular heart disease
Presence of one or more major risk factor(s):
Prior TIA or CVA
HTN
CHF and/or LV dysfunction
Age >75
Presence of 2 minor risk factors
1.
DM
2.
CAD
Aspirin alone may be used when patients have one minor risk factor, are greater than 60
years of age, and/or have structural heart disease. No treatment is indicated when patients
are less than 60 years of age with no structural heart disease.
XVI. WARFARIN GUIDELINES FOR DVT OR PE
Risk Group
First event, reversible risk,* age <60 years
First event, reversible risk,* age >60 years
Or first event with idiopathic cause
Duration
3−6 months
3−6 months
Recurrent event of first event with nonreversible risk factor**
12 months – lifetime
* Surgery, trauma, transient immobility
** Cancer, inhibitor deficiency, antiphospholipid syndrome or factor V Leiden
Ref: AMJ Respiratory Critical Care Medicine 1999; 159: 1−14
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XVII. PERIOPERATIVE MANAGEMENT OF A PATIENT ON WARFARIN
Orthopedic and gynecologic surgeries: Orthopedic and gynecologic surgeries have a low
risk of bleeding and lowering the Warfarin dose to achieve an INR of 1.3−1.5 before surgery is
appropriate, restarting at the regular dose post-operatively.
Dental procedures: Warfarin typically does not cause serious bleeding during routine
cleaning or drilling of teeth when the INR is in the therapeutic range. A root canal procedure
or an extraction of a tooth involves deeper tissues supplied by blood vessels. For root canal or
extractions the dentist should be aware the patient is taking Warfarin. The dentist and
cardiologist (or surgeon) should evaluate whether it is advisable to temporarily stop Warfarin
prior to dental procedures. Patients may be able to safely stop Warfarin for short periods of
time. (Example: Patients taking chronic Warfarin for prevention of venous thrombosis or
stroke probably have little risk in stopping for a few days). Many heart valve patients can stop
Warfarin for a few days, under supervision of a treating cardiologist or surgeon. Some patients
will require an alternative anticoagulant regimen during the time that Warfarin is withheld.
Increased Bleeding Tendency
Inhibit Platelet
Aggregation
Inhibit Procoagulant
Factors
Ulcerogenic Drugs
Cephalosporins
Antimetabolites
Adrenal
lopidogrel
Quinidine
Corticosteroids
Dipyridamote
Quinine
lndomethacin
Indomethacin
Saticylates
Potassium products
Penicillin, parenteral
Salicylates
Salicylates
Sulflinpyrazone
Ticlopidine
Use of these agents withoral anticoagutants may increase the chances of
hemorrhage
d.
Contraindications
INR Ranges Based Upon Indication
Targeted INR Range Targeted INR
Indication
Acute myocardial infarction with risk factor
1
Hemorrhagic tendencies
2.0 - 3.0
2.5
Blood dyscrasias
Recurrent myocardial infarction
2.5 - 3.5
3.0
Atrial fibrillation (moderate- to high-risk patients)
2.0 - 3.0
2.5
Pregnancy
Valvular heart disease
2.0 - 3.0
2.5
Tissue heart valves
2.0 - 3.0
2.5
Recent or potential surgery of CNS or eye
Hypersensitivity to warfarin
Prevention of venous thromboembolism (High risk surgery)
2.0 - 3.0
2.5
Cerebrovascular hemorrhage
Treatment of venous thrombosis
2.0 - 3.0
2.5
Aneurysms
Treatment of pulmonary embolism
2.0 - 3.0
2.5
Bileaflet mechanical heart valve
2.0 - 3.0
2.5
Pericarditis and perieardial effusion
Mechanical heart valve (caged ball, caged disk)
2.5 - 3.5
3.0
1
Up to 3 months of therapy following heparin or LMWH in patients with anterior Q-wave infarction, severe left
ventricular dysfunction, mural thrombus on 2D echo, atrial fibrillation., history of systemic or pulmonary
embolism, congestive heart failure.
For complete discussion, Chest, 2001, 119 (Suppl): 1S-370S
Bacterial endocarditis
Malignant hypertension
Traumatic surgery resulting in large open surfoce
Bleeding tendencies of GI, GU, Resp tract
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
WEXFORD
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Medical Guidelines
Region: New Mexico
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Non-Vitamin K Oral Anticoagulant (NOAC) Guidelines for Utilization
I.
BACKGROUND
Non-vitamin K oral anticoagulants (NOAC) are alternatives for antithrombotic therapy for
nonvalvular atrial fibrillation, venous thromboembolism (VTE) disease, and venous
thromboembolism prophylaxis. Current NOACs available on the market include rivaroxaban
(Xarelto), apixaban (Eliquis), dabigatran (Pradaxa) which are approved for use in nonvalvular atrial
fibrillation to prevent stroke and systemic embolism, treatment of deep vein thrombosis (DVT) and
pulmonary embolism (PE), and prevention of recurrence of DVT and PE. Additionally, rivaroxaban
and apixaban are approved for postoperative DVT prophylaxis in hip and knee replacement surgery,
while dabigatran is approved for DVT prophylaxis in hip replacement surgery. Edoxaban (Savaysa)
is another NOAC which is only approved for prevention of stroke and systemic embolism in
nonvalvular atrial fibrillation and treatment of DVT and PE follow 5 to 10 days of initial treatment
with a parenteral anticoagulant.
While NOACs are approved for the indications above, warfarin (Coumadin) provides a clinically
effective and more cost effective option for anticoagulation. Warfarin is appropriate for use in
nonvalvular and valvular atrial fibrillation to prevent stroke or embolism as well as treatment and
prevention of DVT and/or PE. Warfarin is also effective at providing anticoagulation in other
indications which include mechanical heart valve replacement, antiphospholipid syndrome and
thromboprophylaxis following hip or knee replacement surgery or hip fracture surgery. Appropriate
monitoring of the international normalized ratio (INR) is recommended and the INR range is
individualized to the indication for warfarin use. Warfarin is the preferred anticoagulant on
formulary and is considered the first line anticoagulant agent unless there is appropriate clinical
rationale as to why its use is contraindicated.
II.
RECOMMENDED THERAPEUTIC RANGE FOR WARFARIN BASED ON INDICATION
Indication
Target INR Range
Atrial Fibrillation
Anterior MI
Cardioembolic Stroke
Hypercoagulable State
Left Ventricular Dysfunction
with previous thromboembolism or LV thrombus
Thromboembolism (DVT,PE)
Thromboembolism prevention
Valvular Atrial Fibrillation
Valve Replacement: Bioprosthetic
• Atrial
• Mitral
Aortic Valve Replacement: Mechanical
• Bileaflet, St. Jude
• Bileaflet or current generation tilting disk
• Older generation valves: Ball & cage, Caged disk
Mitral Valve Replacement: Mechanical
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.0-3.0
2.5-3.5
2.5-3.5
Because warfarin is the preferred anticoagulant on formulary, use of a NOAC beyond 30 days of
therapy within the correctional facility will need to be accompanied by rationale as to why the NOAC
is preferred. Warfarin therapy is NOT considered to be a failure due to noncompliance with the
medication, unwillingness/inability to have PT/INR monitored or dietary changes in vitamin K
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
intake. Medication adherence as well as appropriate monitoring should be achievable in a
correctional facility. Inability to achieve a therapeutic INR in a patient on warfarin should be closely
examined to determine if other factors such as diet or concomitant medications are impacting
warfarin dosing. Any requests due to warfarin failure will need appropriate documentation as to
why the patient failed warfarin therapy.
III.
ALGORITHM FOR NOAC TRANSITION TO WARFARIN
•
Assessment of order for NOAC (rivaroxaban, apixaban, dabigatran, edoxaban) should include
the following
o
Drug requested
o
Dose requested
o
Indication for use
o
Appropriateness of therapy
▪
Is the dose requested appropriate for the indication for use?
•
Indication for use will determine how to approach therapy:
o
Nonvalvular Atrial fibrillation
▪
If the nonvalvular atrial fibrillation is new onset, then patient should be started on
warfarin therapy. Low molecular weight heparin (LMWH) should be used as bridging
therapy and should be continued for a minimum of 5 days AND until the INR is
therapeutic for at least 24 hours.
•
Enoxaparin (Lovenox) is a LMWH that can be used for bridging therapy
o
Dosing:
▪
Creatinine Clearance (CrCl) ≥ 30 ml/min: 1 mg/kg/dose SQ every
12 hours OR 1.5 mg/kg/dose once daily
▪
Creatinine Clearance (CrCl) < 30 ml/min: 1 mg/kg/dose SQ once
daily
▪
Patient’s current length of stay in the correctional facility is less than 30 days, the
ordered NOAC should be continued.
▪
Patient’s current length of stay in the correctional facility is greater than 30 days,
then the patient should be converted to warfarin UNLESS THERE IS A
DOCUMENTED WARFARIN FAILURE IN THE PAST.
•
The documented reason why the patient failed warfarin in the past should be
clearly documented on the non-formulary request form.
o
New onset Venous Thromboembolism (VTE)
▪
New onset VTE should be treated with warfarin therapy. LMWH should be used as
bridging therapy and should be continued for a minimum of 5 days AND until the
INR is therapeutic for at least 24 hours.
o
Current therapy for VTE on NOAC
▪
Patient’s length of stay is anticipated to be less than 30 days OR if the patient has a
DOCUMENTED WARFARIN FAILURE IN THE PAST, the NOAC should be continued.
▪
Patient does not meet the above criteria; the length of therapy the patient has
received prior to being incarcerated should be assessed.
▪
Less than 6 months of therapy with NOAC
•
The patient should be transitioned to warfarin therapy
▪
Greater than 6 months of therapy with NOAC
•
Assess indication for use
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
o
o
IV.
Patient has recurrent unprovoked or provoked VTE in the past; patient
should be switched to warfarin therapy.
Patient has history of single episode of VTE
▪
Review length of therapy:
o
Does patient need to continue anticoagulation therapy?
o
Does patient have any risk factors for bleeding?
▪
History of GI bleed?
▪
Intravenous drug/ETOH abuse?
▪
Fall risk?
▪
Comorbidities?
▪
Concomitant medications?
o
Does patient have risk factors for recurrent VTE?
o
Above questions should be assessed for each case
o
If provider makes assessment that anticoagulation should
continue, the patient should be transitioned to warfarin.
CONVERSION OF NOAC TO WARFARIN
•
Switching from Xarelto (rivaroxaban) or Eliquis (apixaban) to warfarin
o No clinical trial data are available to guide converting patients from Xarelto or Eliquis to
warfarin.
o INR measurements are affected by both Xarelto and Eliquis, so INR measurements made
during coadministration with warfarin may not be useful for determining the appropriate
dose of warfarin.
o One approach is to discontinue Xarelto or Eliquis and begin both a parenteral
anticoagulant (LMWH) and warfarin at the time the next dose of Xarelto or Eliquis would
have been taken.
o Parenteral anticoagulation should be discontinued once the INR is within the therapeutic
range.
•
Switching from Pradaxa (dabigatran) to warfarin
o When converting from Pradaxa to warfarin, adjust the starting time of warfarin based on
creatinine clearance as follows:
▪ For CrCl ≥50 mL/min, start warfarin 3 days before discontinuing PRADAXA.
▪ For CrCl 30-50 mL/min, start warfarin 2 days before discontinuing PRADAXA.
▪ For CrCl 15-30 mL/min, start warfarin 1 day before discontinuing PRADAXA.
▪ For CrCl <15 mL/min, no recommendations can be made.
o Because Pradaxa can increase INR, the INR will better reflect warfarin’s effect only after
Pradaxa has been stopped for at least 2 days.
•
Switching from Savaysa (edoxaban) to warfarin
o
Oral option: For patients taking 60 mg of Savaysa, reduce the dose to 30 mg andbegin
warfarin concomitantly. For patients receiving 30 mg of Savaysa, reduce the dose of
Savaysa to 15 mg and begin warfarin concomitantly. INR must be measured at least
weekly and just prior to the daily dose of Savaysa to minimize the influence of Savaysa
on INR measurements. Once a stable INR≥ 2.0 is achieved, Savaysa should be
discontinued and the warfarin continued.
o
Parenteral option: Discontinue Savaysa and administer a parenteral anticoagulant and
warfarin at the time of the next scheduled Savaysa dose. Once a stable INR ≥ 2.0 is
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
achieved, the parenteral anticoagulant should be discontinued and the warfarin
continued.
V.
ATTACHMENT
Algorithm for Non-vitamin K Oral Anticoagulant Use
VI.
REFERENCES
1.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE Disease. Chest Guideline and Expert Panel Report. Chest
2016;149(2):315-352.
2.
Lip GYH, Hull RH. “Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism”,
www.uptodate.com, accessed December 26, 2017.
3.
Rivaroxaban (Xarelto) Prescribing Information. https://www.xareltohcp.com/shared/product/xarelto/prescribinginformation.pdf, Accessed December 27, 2017.
4.
Apixaban (Eliquis) Prescribing Information. https://packageinserts.bms.com/pi/pi_eliquis.pdf, Accessed December
27,2017.
5.
Dabigatran (Pradaxa) Prescribing Information. http://docs.boehringer-
ingelheim.com/Prescribing%20Information/PIs/Pradaxa/Pradaxa.pdf, Accessed December 27, 2017
6.
Edoxaban (Savaysa) Prescribing Information. http://dsi.com/prescribing-informationportlet/getPIContent?productName=Savaysa&inline=true, Accessed December 27, 2017.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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Medical Guidelines
Region: New Mexico
Algorithm for Non-vitamin K Oral Anticoagulant Use
Therapy ordered
for NOAC*
Nonvalvular Atrial fibrillation
If LOS < 30
days, then
continue NOAC
New onset Venous
Thromboembolism (VTE)
Indication for Use
New Onset:
LMWH bridging to warfarin
LMWH bridging
to warfarin
If LOS > 30 days, then
convert to warfarin
therapy UNLESS
DOCUMENTED
WARFARIN FAILURE
Currently on NOAC
for VTE
If LOS < 30 days OR IF
DOCUMENTED
WARFARIN FAILURE,
then continue NOAC
Length of therapy with
NOAC?
Less than 6 months of therapy
Greater than 6 months of therapy
Indication for Use
Switch to warfarin therapy
History of single episode of VTE
*NOAC: Non-vitamin K oral anticoagulant
(rivaroxaban, apixaban, dabigatran, edoxaban)
Recurrent
unprovoked/provoked VTE
Review length of therapy:
• Does patient need to
continue therapy?
• Does patient have risk
factors for bleeding?
• Does patient have risk
factors for recurrent VTE?
Switch to warfarin
therapy
LOS: Length of Stay
LMWH: Low molecular weight heparin
If anticoagulation to continue,
transition to warfarin
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all patients.
Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 1/5/2023 The Wexford Companies. PROPRIETARY and CONFIDENTIAL
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