Replenish by NomadMD – Protocols and Procedures

Policy 1.0 Greeting The Replenish Patient
    1.1 Always greet the Replenish client upon entry with kind and welcoming words.
        1.1.1a When answering the phone say: "Thank you for calling Replenish, how may I help you?"
            1.2 We do not want to overwhelm the client; we want them to feel at home, relaxed and without                                         apprehension.
    1.3 The initial introduction should take place at front desk or in the waiting room area:
                      1.3.1 Introduce yourself and welcome the individual or group to Replenish (“Welcome to  Replenish! How may we help you?”)
           1.3.2 Ask if patient has been to Replenish before.
                1.3.2a    If yes, find their chart in the dr.chrono program and add a new appointment chart;
                               1.3.2b    If no, start the OnPatient Program for patient, hand pt an iPad and have patient sign the consent and Hippa forms electronically and start a new client chart         
                       1.3.3 Provide brochures detailing our services and Membership program. Offer assistance in answering any questions. If patient decides to sign up for a membership, have them sign the membership consent form on OnPatient app. and at time of payment add them to the membership recurring payment app. 
             1.4  Ask if the patient would prefer a private room or semi-private with a TV
        1.4.1 Offer patient a blanket, eye mask and a beverage (coffee/tea/water)
        1.4.2 Ask patient if they need to use the restroom first and then escort patient to their room
                             1.4.3 If there is a wait, inquire about their need to use restroom and then have patient sit in waiting room
Policy 2.0  Ascertaining Patient Suitability
            2.1 Upon patient’s completion of initial medical charting the Replenish provider needs to ascertain if  the patient is a viable candidate for treatment.
        2.1.1 Taking vital signs.  The guidelines regarding vital signs are as follows:
              2.1.1a    BP:  between 180/110 & 95/50
              2.1.1b    Temperature: 95.5 to 100.4 degrees F
               2.1.1c     Pulse:  between 50-110.
                         2.1.2  Provider must verbally double check with the patient regarding pregnancy status as indicated on chart
                         2.1.3  Double check past medical history of patients to confirm that the patient does not suffer from cardiac, respiratory, kidney or liver disorders that could be affected by fluid overload or inhibit metabolism of the vitamins and/or  medications.
                         2.1.4  Provider must verbally double check with the patient regarding known latex and medicinal allergies, specifically those associated with Replenish medications.
                         2.1.5  Confirm if patient took any NSAIDs (ibuprofen, naprosyn) within 6 hours prior to arrival. If  "yes" then you may not administer toradol to them. (contraindication!)
                       2.1.6  Based upon the provider’s experience and expertise with patients, if there are any “red flags”  (for example: appearing obviously intoxicated and unable to speak clearly or walk without assistance, appears high or under the influence of an illicit substance or issues regarding the patient behavior (aggressiveness, psychotic)) call the upper level medical provider. If unable to reach CMO, refuse treatment.
                        2.1.7  If the provider ascertains for any reason that the patient is not suitable for treatment the following will occur:
    2.1.7a    If the issue is medical and the provider feels immediate medical attention is necessary, advise the patient and offer to call 911 or call an emergency contact.
    2.1.7b    If the issue is one of security, advise the patient that Replenish will be unable to provide treatment and ask the individual(s) to leave.  If they refuse, immediately call the proper authorities (police).
    2.1.8  When the provider is confident and comfortable with patient behavior, medical chart and vital signs then treatment can begin.
Policy 3.0 Patient Decision for Treatment
             3.1 It is the job of the provider to ascertain the level of treatment Replenish will provide to the patient.
             3.2 The medic will offer assistance to help determine the patient treatment selections.
             3.3 The medic will ask individuals about their current physical state as it relates to our medications:
                   3.3.1  For Toradol: “Are you experiencing any head or body aches?”
                  3.3.2  For Zofran: “Are you experiencing any nausea?”
                  3.3.3  For Pepcid: “Are you experiencing any upset stomach, acid reflux or heartburn?”
                  3.3.4  For Vitamin B12:  “Are you feeling a lack of energy or run-down physically?”
                  3.3.5  For Vitamin B Complex: “Do you have any anxiety, depression or fatigue?”
                 3.3.6 For Vitamin C: “are you feeling like you’re starting to get a cold or fatigued?”
    3.5. Headache Protocol:
        3.5.1 Do NOT treat new onset severe headaches. Consult Medical Physician or PA on call
                            3.5.2 If headache associated with a hangover or menstrual cycle and no contraindications exist treat per protocol
                            3.5.3 If patient presents with headache and has a history of migraines with this being exactly the same in character and intensity treat per protocol. Consult Medical professional on call. Make sure to document this information in the patient chart
            3.6 After patient and medic decide upon appropriate treatment the medic excuses himself or herself to prepare the therapy.


Policy 4.0 Medic Preparation for Treatment
    4.1 All medication prep will be done in the med room and brought to patient room.
            4.2 Toradol, Zantac, Pepcid,  Zofran,  Minerals and Vitamins (except Glutathione) will be injected into Lactated Ringers or Normal Saline bag for patient treatment via IV.
                        4.2.1 The doctor’s standing order is that these medications can be mixed in the LR.and NS. If  patient is pregnant ONLY use Normal Saline
4.2.2 Glutathione will be given through port on tubing or through ultrasite port (use this method if patient is ONLY getting glutathione) . Push over 10 minutes (1cc every 2min). If pt is receiving Vitamin treatment as well, wait to infuse vitamin treatment until the Glutathione treatment has been completed. After pushing 1 cc every 2 min, you can flush the port with either normal saline flush or, if vitamin bag is attached, can infuse a little of the bag and then stop it again. 
    4.3 Vitamin B12 and Vitamin B Complex can be given IM or introduced into Lactated Ringer/NS bag.
                         4.3.1 Vitamin B12 and Vitamin B Complex must be given in two different injections if patient chooses the arm for injection location.
                             4.3.2 Vitamin B12 and Vitamin B Complex can be given in one injection (the two may be                       combined in the same syringe) if patient chooses the hip for injection location.
                       4.3.3 Vitamin B12 and Vitamin B Complex can be mixed in the lactated ringer with all previously  mentioned medications.
            4.4 Prior to medication introduction in LR/NS, provider will spike the bag utilizing 10gtts set and prime the line
    4.5 Prior to drawing up medication from vials that have already been opened:
        4.5.1 check expiration date and clarity of vial contents (should be clear)
        4.5.2 thoroughly cleanse top with alcohol swab
           4.6 Each medication should be drawn up in their own syringe and needle. (see mixing protocol for more detail)
                        4.6.1 If this is a newly opened vial of medication, affix tape to the vial and write the current date on it
           4.7 Cleanse port of LR/NS with alcohol prep between each medication.
           4.8 Inject each medication into the LR/NS.
           4.9 Affix tape to LR/NS bag and indicate by writing with permanent marker on tape what medications have been introduced for treatment.
           4.10 NEVER write medications that have been introduced directly onto the LR/NS bag. This ensures there is no chance for erasure or rubbing off
           4.11 Double check the administration set and the drip line in the med room so no air bubbles are in  line.
           4.12 Place LR/NS with admin. set and make way to treatment room.
Policy 5.0 Patient Treatment Start Interaction
    5.1 Each provider will prepare for treatment in the following way:
        5.1.1 Providers will either wash their hands or use hand sanitizer between each patient
        5.1.2 Gloves will be worn at all times
        5.1.3 Providers will choose from 18g, 20g and 22g IV needle will be utilized for all patients
            5.2 Keep patients as comfortable and relaxed as possible (offer a blanket, beverage, assistance with                      reclining chair, or changing the television)
               5.3 Verbally make them aware of any and all potential issues that may arise so there are no surprises:
                       5.3.1 Instruct patients that they must ask providers for assistance before moving or standing with IV in order to avoid line back ups and fall risk reduction. 
                          5.3.2 Tell them that the LR/NS bag should never be lowered below the heart in order to eliminate the chance of back flow. However if there is a little back flow of blood this is not abnormal and not to worry. 
                          5.3.3 Let the patient know that there may be a small amount of pain with IV insertion and some small amount of bruising may occur over the next few days, but it can be avoided by applying pressure for 5 minutes after treatment.
                      5.3.4 Inform them they may feel a warmth or slight cold burn sensation if magnesium or calcium is administered. 
                         5.3.5 Instruct patient to inform provider immediately of any signs or symptoms of an allergic reaction...itching, rash, swelling of tongue, throat, shortness of breath, burning, redness, swelling or pain around IV site.
      5.4 Explain the factors that may cause a slow IV line:
              5.4.1 Small veins, bend of the elbow, smaller needle, etc.
            5.5 Alert that there may be a small amount of blood with the initial catheter stick and let the patient know this is normal.
           5.6 Alert that there can be a small amount of back flow into tubing from catheter.  This is rare but there is no need to be alarmed.
            5.7 For patient satisfaction, try to prevent black flow of blood into the line . If it is busy in the                   clinic, slow down the rate of the flow so the bags can be checked regularly so this does not occur.
    5.8 Be very clear that if the patient has any questions or concerns that they can ask at any time.
            5.9 With every patient, always make them aware that if they feel uncomfortable, need to leave for any reason or want to end the treatment session it can be done at any time.
Policy 6.0 Treatment Procedure
    6.1 Providers make sure you’re comfortable when performing/beginning the treatment.
     6.2 Ask the patient in which arm they would prefer to have the treatment.
         6.3 Open and lay out all equipment.
            6.4 Choose, large, well anchored vein. The larger the vein, the faster the fluid will flow and the less painful for the client. First choice is at the AC site of either arm. Only if necessary, inspect and place an IV more peripherally towards hands. Do NOT put an IV in a patient's foot or neck. 
        6.4.1 Check that the patient is not allergic to latex. If so, use a non-latex tourniquet.
            6.4.1a  Apply tourniquet and cleanse the site with at least 2 alcohol preps
    6.4.1b  If using topical anesthetic: apply after cleansing site with alcohol and do not touch site after application
    6.5 Open IV catheter and loosen catheter hub.
    6.6 Initiate venipuncture.
                        6.6.1 Inspect the cannula before insertion to ensure the needle is fully inserted into the plastic cannula and that the tip is not damaged. **Do not touch the shaft or tip of the cannula
        6.6.2 Ensure that the bevel of the cannula is facing upwards
        6.6.3 Anchor the site with the less dominant thumb. Insert needle into vein  at a 45 degree angle. 
                        6.6.4 When flash is received advance the needle and catheter slightly further and continue to advance the catheter only, making sure the catheter advances and the needle is not pulled  back.
        6.6.5 The catheter should advance smoothly and without resistance.
    6.7 Release the tourniquet, apply pressure above the catheter site to occlude vein and withdraw the needle.
    6.8 Attach ultrasite cap
    6.9 Screw tubing connection into cap tightly.
    6.10 Turn the dial flow wide open and ensure flow is smooth
    6.11 Watch for infiltration (pain, coolness, swelling blanching, burning around site) and poor fluid flow
            6.12 Monitor for pain at IV site, any signs and symptoms of allergic reaction (redness, swelling, rash, sob, itching) 
    6.13 Continue to monitor client every 7 minutes.
          6.14 If patient is receiving 2 bags of fluids: Do NOT let the first bag empty completely before stopping the line and attaching the 2nd bag. Make sure there is still IV solution in the line before re-starting the drip. Do NOT restart the drip if there is air in the line! If this situation does a new line and attach it to IV catheter
          6.15 If the clinic is busy and you may not be able to watch all the lines carefully, attach the connector cap     directly to the IV and then attach the line to the cap. This way if the 1st bag empties completely you can unhook the line from the cap and re-prime the line with the 2nd bag before attaching it to the IV.
6.16 Use pressure bag ONLY if:
6.16a Re-confirmation that patient has no lung, kidney, heart disease that would be affected by  overload
6.16b Have a good IV in place
6.16b Replenish is not too busy and you can closely monitor flow
6.16c Make note not to apply pressure past 300mmHg (do not want to break bag)
    6.17 Instructions on catheter removal and discharge:
6.17a Explain the process to the patient
        6.17b Use hand sanitizer and/or wash your hands and put on gloves.
         6.17.c Close the IV tubing.
6.17d Loosen and remove the transparent dressing and/or tape holding the IV tubing in place.
                        6.17e Grasp one edge of the transparent dressing, and slowly peel it back from and off of the skin in the direction of hair growth. Hold the cannula in place with the thumb of your other hand.
6.17f  Place 2 x 2 gauze over the insertion site as you smoothly remove the cannula.
        6.17g  Hold pressure for one minute.
6.17h Inform the patient that to decrease the potential for bruising, pressure should be applied for up to five (5) minutes.
        6.17i Lift the gauze briefly to confirm that bleeding has stopped.
        6.17j Look for signs of allergic reaction (redness, swelling)
        6.17k Secure the gauze in place with tape.
        6.17l  Additional Tips & Warnings:
            6.17l.1 Peel the transparent dressing back from the skin as opposed to pulling it up.
            6.17l.3 Always have the 2 x 2 gauze ready to be placed over the insertion site.
                                   6.17l.4 Choose a gentle tape to hold the gauze in place. The area may be uncomfortable and the skin already irritated.
          6.17m Dispose of IV material in biohazard containers
                        6.17n Review with and give discharge card to patient. Mark on chart that discharge instructions were given
        6.17o Complete patient chart on DR. CHRONO
                             6.17p Escort patient to front desk for payment.  If busy, then take payment on iPad at patients current location


Policy 7.0 Procedure for allergic and anaphylactic reactions
    7.1 Allergic reaction and anaphylaxis has a potential to occur with all medications provided at Replenish
    7.2 Any adverse reactions to Lactated Ringers, Vitamin B Complex and Vitamin B12 are extremely rare.
          7.3 Reactions to Toradol, Zofran and Pepcid are more common.
    7.4 Symptoms of ALLERGIC REACTION:
        7.4.1 Urticaria (raised red rashes)
        7.4.2 Pruritus (itchiness of skin)
        7.4.3 Angioedema (swelling of lips and eyelids)
        7.4.4 Localized reaction/ reddening around site of injection and up arm
        7.4.5 Nausea, vomiting, abdominal cramps or diarrhea.
        7.4.6 Subjective shortness of breath without wheeze (and SOB with wheeze)
        7.4.6 All symptoms may occur gradually during treatment
    7.5 Symptoms of ANAPHYLACTIC REACTION:
                        7.5.1 Shortness of breath with either wheezing or silent breath sounds on chest auscultation or stridor (high pitched audible respirations)
        7.5.2 Altered mental status
        7.5.3 Rapid onset of signs and symptoms
        7.5.4 Tachycardia
        7.5.5 Urticaria, Pruritus, Angioedema (swelling of lips and eyelids)
        7.5.6 flushing, chills, anxiety, throbbing in ears
                        7.5.7 It the duty of the MEDIC or provider to decide if patient is stable (allergic reaction) or unstable (anaphylaxis).
    7.6. IF STABLE:
        7.6.1 Stop administration of medications and flow of IV keeping IV line intact
        7.6.2 Administer Benadryl (Diphenhydramine) liquid 25mg PO or 50mg IV and Pepcid (20mg)
        7.6.3 Assess vital signs and recommend evaluation at Emergency Department    
    7.7 IF UNSTABLE (signs/symptoms of anaphylactic reaction):
        7.7.1 Instruct someone to call 911 immediately
        7.7.2 Stop IV treatment, but keep IV access
        7.7.3 Administer 50mg IV of Benadryl and Pepcid (20mg)
        7.7.4 Prepare epi-‐pen auto-‐injection and administer to lateral thigh
                        7.7.5 Provide patient chart and inform 911 and/or arriving medics of all medications administered to client prior to transport to Emergency Room.
Policy 8.0: Infiltration
            8.1 After IV placement check for signs and symptoms of Infiltration (leakage of fluids/meds into surrounding tissue)
    8.2 Signs/Symptoms:
        8.2.1 Pain or burning at catheter site
        8.2.2 swelling around site
        8.2.3 skin blanching
        8.2.4 skin coolness, feeling of tightness
    8.3 **Patient should NEVER have pain around IV site after IV placement
    8.4 If you suspect Infiltration:
        8.4.1 Stop infusion and remove IV catheter
    8.4.2 check radial pulse and for good capillary refill and sensation (document findings in pt chart). Contact medical director IMMEDIATELY if patient does not have a good pulse, sensation or cap refill
        8.4.3 apply warm compress to area
                            8.4.4 if sensation, vascular intact then can find a new and different IV site and continue with treatment

Policy 9.0:  Air Embolism Prevention
    9.1 Signs/symptoms: respiratory distress, unequal breath sounds, weak pulse, confusion,  LOC
    9.2 Treatment:  Immediately call 911!  
        9.2.1 stop IV infusion
        9.2.2 place patient in Trendelenburg position but on left side (head down, feet up)
             9.3.  If we have oxygen, administer high percentage oxygen for both venous and arterial air embolism to counteract ischemia and accelerate bubble size reduction.
    9.4 Precautions to minimize the risk of larger amounts of air entering the system:
                        9.4.1 When hanging a new bag on an existing line, check to make sure the previous fluid has not run down the line leaving a large airspace.
        9.4.2 Expel any air from syringes of IV meds, vitamins, etc. that you are about to administer.
                    9.4.3 If air is introduced into the IV line, fill a syringe with fluid from the bag
        9.4.4 When priming a new IV line, first invert the bag of fluids so you are spiking it from above.
                        9.4.5 Insert administration set into bag of fluids open the roller clamp and gently squeeze the bag expelling all the air from the top of the IV bag into the giving set.
        9.4.6 Keep squeezing until the fluid from the bag is pushed up into the drip chamber.
        9.4.7 Invert the bag back into its normal position and continue to prime the IV line.

Policy 10.0:  Fluid Overload
10.1 Per previous evaluation patient does not have history of congestive heart failure and/or renal disease which would increase risk of fluid overload
10.2 Overload symptoms:
10.1a  headache
10.1b high blood pressure
10.1c anxiety
10.1d trouble breathing
10.1.e circulatory overdose (neck vein distention or engorgement, respiratory distress, lung crackles)

If any one experiences these symptoms STOP the IV flow and call Chief Medical Officer. If unable to  reach CMO or patient is having trouble breathing call 911

Policy 11.0:  Needle Stick
            11.1 In the event of an inadvertent needle stick by a provider refer to the Exposure Control Plan-                                   Bloodborne Pathogens Manual

Policy 12: Fall Reduction
    12.1 IV lines can increase fall risk
    12.2 to prevent risk, verbally inform patient to not get up during the treatment unless they alert provider prior
    12.3 if patient needs to get up, stop the infusion. remove line from ultrasite cap and then allow patient to get up
    12.4 once patient sits back down, the line can be reattached and infusion restarted

Policy 13: Safety at House Calls
    13.1 You have a right to refuse a house call if you feel unsafe
    13.2 If this occurs, contact the manager immediately 

Policy 14.0: Medication and Vitamin/Mineral Information
    14.1 Toradol (Ketorolac Tromethamine)
        14.1.1  NSAID
        14.1.2 Indication: Mild to moderate pain relief
        14.1.3 Contraindications:
            14.1.3a  Allergy to Aspirin or other NSAIDS
            14.1.3b  Pregnancy
            14.1.3c  NSAID use within 6 hours prior
        14.1.4 Dose: 30mg/1ml IVP
        14.1.5 Side Effects:
            14.1.5a Slight Drowsiness
            14.1.5b Headache dizziness
            14.1.5c Sweating
            14.1.5d Vomiting (rare)
        14.1.6 Precautions:  History of Asthma that worsens with NSAIDs
        14.1.7 Onset: 30 minutes
        14.1.8 Peak: 1-‐2 hours
        14.1.9 Duration:  4-‐6  hours
        14.1.10 Policy for administration:
            14.1.10a Client is to be Awake/Alert/Oriented
            14.1.10b Heart Rate < 120bpm
            14.1.10c Blood Pressure <180/110
            14.1.10d  If these conditions are not met, including contraindications, inform the client that Toradol will not be an option for treatment and suggest evaluation by Primary Care Physician or Emergency  Department.
        14.1.11 Procedure for drawing up Toradol:
            14.1.11a Chose proper needle and syringe combo
            14.1.11b Open Toradol vial, open syringe package
14.1.11c Cleanse top with alcohol if vial has been previously used
            14.1.11d Draw up 1cc of air into syringe,
            14.1.11e Turn vial upside down insert needle syringe into vial
            14.1.11f  Displace air into vial then draw fluid into syringe, confirm concentration and dose
        14.1.12 Procedure for administration of Toradol via medication port:
            14.1.12a Cleanse medication port with alcohol prep      
            14.1.12b Inject needle or screw syringe into port
            14.1.12c Pinch off IV tubing going to client aspirating an additional 1-‐ 2cc’s of LR (dilution)
            14.1.12d Pinch off IV tubing away from client and slowly administer over 30 seconds.
    14.2 Zofran  (Ondansetron)
        14.2.1 Anti-‐emetic
        14.2.2 Indication: Prevent and control nausea and vomiting
         14.2.3 Contraindications:  Severe hypotension
        14.2.4 Dose: 4mg/2ml IVP
        14.2.5 Side Effects:
            14.2.5a Hypotension
            14.2.5b Headache
            14.2.5c Diarrhea
            14.2.5d Anxiety
            14.2.5e Dizziness
            14.2.5f Shivering
        14.2.6 Precautions:  May cause syncope if pushed too fast.
        14.2.7 Onset:  Rapid
        14.2.8 Peak: 15-‐30 min
        14.2.9 Duration:  4-‐8 hours
        14.2.10 Does not typically cause sedation.
        14.2.11 Safe during pregnancy.
        14.2.12 Policy for administration:
            14.2.12a Client is to be Awake/Alert/Oriented
            14.2.12b Heart Rate < 120bpm
            14.2.12c Blood Pressure < 180/110
            14.2.12d If these conditions are not met, inform the client that Zofran will not be an option for treatment and suggest evaluation by Primary Care Physician or Emergency Department.
        14.2.13 Procedure for drawing up Zofran:
            14.2.13a Chose proper needle and syringe combo
            14.2.13b Open Zofran vial, open syringe package
            14.2.13c Draw up 1cc of air into syringe,
            14.2.13d Turn vial upside down insert needle syringe into vial
                                           14.2.13e  Displace air into vial then draw fluid into syringe, confirm concentration and dose
        14.2.14 Procedure for administration of Zofran via medication port:
                14.2.14a Cleanse medication port with alcohol prep  
                14.2.14b Inject needle or screw syringe into port
                14.2.14c Pinch off IV tubing going to client aspirating an additional 1-‐ 2cc’s of LR (dilution)
                14.2.14d Pinch off IV tubing away from client and slowly administer over 30 seconds.
    14.3 Antacids
14.3.1 Zantac (ranitidine hydrochloride)
            14.3.1a Indication: Gastric burning, acid reflux
            14.3.1b Contraindications: 
                14.31.b1Allergy to Pepcid (Famotidine), 
                14.3.1.b2 hypersensitivity to drug or other histamine 2-receptor antagonists
                14.3.1.b3 Alcohol intolerance
            14.3.1c Dose: 50mg/2ml
            14.3.1.d Side Effects:
                14.3.1d1  Nausea, vomiting, diarrhea, constipation
                 14.3.1.d2  Dry mouth
                14.3.1.d3  Dizziness, weakness, mood changes; 
14.3.1.d4 Headache
        Muscle cramps, joint pain.
               14.3.1e Precautions:  Allergy to Zantac (ranitidine hydrochloride) other H2 blockers such as cimetidine,  ranitidine
               14.3.1f  Onset: Rapid
               14.3.1g Peak: 0.5-‐3 hours
               14.3.1h Duration: 8-‐15 hours
14.3.2 Pepcid (famotidine)
14.3.2a Indication: Gastric burning, acid reflux
14.3.2b Contraindications:
14.3.2b1 Allergy to any H2 receptor antagonist
14.3.2b2 Allergy to benzyl alcohol
14.3.2b3 Patients with renal insufficiency
14.3.2c Dose: 20mg
14.3.2d Side Effects:
14.3.2d1 Headache
14.3.2d2 dizziness
14.3.2d3 Constipation or diarrhea
14.3.2e Onset: rapid
14.3.2f Peak: 0.5 hours
14.3.2g Duration: 10-12 hours

14.3.3 Policy for administration of Zantac or Pepcid:
            14.3.3a Chose either Zantac or Pepcid, NOT both!
14.3.3b Client is to be Awake/Alert/Oriented
14.3.3c Heart Rate < 120bpm
            14.3.3d Blood Pressure < 180/110
            14.3.3e If these conditions are not met, inform the client that Zantac or Pepcid will not be  an option for treatment and suggest evaluation by Primary Care Physician or   Emergency  Department.
        14.3.4 Procedure for drawing up Zantac and Pepcid
            14.3.4a Chose proper needle and syringe combo
            14.3.4b Open Zantac or Pepcid vial, open syringe package
            14.3.4c Draw up 1cc of air into syringe,
            14.3.4d Turn vial upside down insert needle syringe into vial
            14.3.4e Displace air into vial then draw fluid into syringe, confirm concentration and   dose
14.3.4f  Dispose of needle/syringe in sharps container
        14.3.5 Procedure for administration of Zantac or Pepcid via medication port: 
            14.3.5a Cleanse medication port with alcohol prep   
            14.3.5b Inject needle or screw syringe into port
            14.3.5c Pinch off IV tubing going to client aspirating an additional 1-‐ 2cc’s of LR (dilution)
            14.3.5d Pinch off IV tubing away from client and slowly administer over 30 seconds.
    14.4 Magnesium
        14.4.1 Indication: see replenish menu
        14.4.2 Contraindications:
            14.4.2a avoid in pregnant women, heart, renal disease
            14.4.2b those taking daily magnesium supplements
        14.4.3 Side effects: 
            14.4.3a flushing, sweating
            14.4.3b abdominal cramping, diarrhea
                                           14.4.3c lowered blood pressure
                                           14.5.3d respiratory depression
14.4.4 Administer directly into LR/NS bag
          14.5 Vitamin C (Ascorbic Acid)
          14.5.1 Indication: see replenish menu
          14.5.2 Contraindications: 
              14.5.2a avoid in pregnant women (too much vit C can cause diarrhea which can lead to dehydration)
            14.5.2b chemotherapy users (can affect certain types of chemo)
        14.5.3 Side effects:
            14.5.3a diarrhea, abdominal cramps, GI upset
14.5.4 Administer directly into LR bag
    14.6  B Complex 100
        14.6.1 Indication: see replenish menu
        14.6.2 Contraindications: sensitivity to ingredients. Avoid in pregnancy
        14.6.3 Side effects:
            14.6.3a diarrhea
            14.6.3b feeling of swelling of entire body
14.6.4  Benefits of Vitamin B Complex:
             14.6.4a Responsible for the proper functioning of the most important processes in the body:
            14.6.4b Cell growth and division
            14.6.4c The health of the skin
            14.6.4d The normal development of the immune and nervous system
            14.6.4e The metabolic process.
14.6.5 Administer directly into LR bag

    14.7  Vitamin B5 (pantothenic acid)
         14.7.1 Indication: see replenish menu
         14.7.2 Contraindications:
         14.7.2a avoid in pregnant women
          14.7.3 Side effects:
          14.7.3a Diarrhea
          14.7.4 Administer directly into LR bag
    14.8 Vitamin B6 (pyridoxine)
        14.8.1 Indication: see replenish menu
        14.8.2 Contraindication: sensitivity to ingredients (chlorobutanol anhydrous)
        14.8.3 Safe in Pregnancy
        14.8.4 Side effects:
            14.8.4a may lower blood pressure
            14.8.4b may affect glucose levels
            14.8.4c may increase bleeding
            14.8.4d GI upset
            14.8.4e paresthesia
14.8.5 Administer directly into LR bag
    14.9 Vitamin B12 (Hydroxycobalamin) 
        14.9.1 Indication: energy, endurance. Avoid in Pregnancy
        14.9.2 Side effects:
            14.9.2a diarrhea
            14.9.2b itching
            14.9.2c feeling of swelling of entire body
14.9.3 Benefits of vitamin B12:
            14.9.3a Combats fatigue
            14.9.3b Increases stamina
            14.9.3c Decreases the effects of allergens
            14.9.3d Essential for energy production
14.9.4 Vitamin B12 is not to be administered more than once per week. Check patient history in folder and/or in software system.
14.10 Calcium
        14.10.1 Indication: see replenish menu
        14.10.2 Contraindication: 
            14.102a avoid in pregnant women
         14.10.3 Side effects:
            14.10.3a may lower blood pressure
            14.10.3b arrhythmias
            14.10.3c tingling sensations, heat waves
            14.10.3d Constipation
            14.10.3e GI upset
            14.10.3f  local burning sensation
14.10.4 Administer directly into LR bag
    14.11 Folic Acid
        14.11.1 Indication: see replenish menu
        14.11.2. Contraindications: Allergy to folic acid. Avoid in Pregnancy (injection has aluminum)
14.11.3  Side effects: 
        14.11.2a nausea, abdominal distention
14.11.4 Administer directly into LR bag
    14.12 Glutathione
        14.12.1 Indication: see replenish menu
        14.12.2 Contraindication: 
            14.12.2a Sulfa Allergy
            14.12.2b avoid in pregnancy
            14.12.2c use caution with asthmatics
        14.12.3 Side effects: 
            14.12.3a can increase some asthma symptoms. 
14.12.4 Administer into medication port on line or through cap
14.12.4a Cleanse port with alcohol swab
14.12.4b Insert needle or twist onto cap
14.12.4c Pinch off IV tubing away from the client to stop flow/dilution. 
14.12.4d Slowly push over 10min  

    14.13 Procedure for Administration of  Intramuscular Injections
         14.13.1 Procedure for all Intramuscular Injections: (B12, B complex, Toradol, Zofran)
            14.4.1a administer only 3cc max in buttock, 1 cc max in deltoid
        14.13.2 Wash hands thoroughly or use hand sanitizer.
        14.13.3 Wear gloves.
        14.13.4 Determine the injection site.
        14.13.5 Swab the site you are injecting with an alcohol wipe.
        14.13.6 Remove the protective cap from the needle.
        14.13.7 Grasp the syringe between your thumb and middle finger.
        14.13.8 Place your index finger at the top of the plunger. This provides you with greater control.
        14.13.9 Pinch the skin at the injection site so it is nipped upward.
        14.13.10 Insert the entire needle at a 45 degree angle.
        14.13.11 Let the pinched skin go.
        14.13.12 Plunge the syringe to inject the medication or vitamin
            14.13.12a  Go slowly to avoid any burning sensation.
         14.13.13 Remove the needle when the medication or vitamin is entirely dispensed.
        14.13.14 Apply pressure with a clean cotton ball to any bleeding and then apply a bandage.
        14.13.15 Place syringe in sharps container.
        14.13.16 For B12 and B complex:
                14.13.16a If injected into the arm, B12 and B complex must be administered in different  arms, separately (1cc max in each injection)                                                 
               14.13.16b If injected into the hip, Vitamin B12 and Vitamin B Complex can be mixed  together and administered with a single injection.  
    1.0  Specialized vitamin treatments require manual mixing into either an LR or NS bag
    2.0 Follow instructions on ingredients of each treatment hanging in med room. 
    3.0 Wash hands prior to mixing and put on gloves
    4.0 For newly opened vials
            4.1 tape open date on vial
            4.2 chart in medication log: open date, expiration date, clarity, etc
            4.3 With a NEW sterile 18 gauge needle/10cc syringe draw up desired amount
    5.0 For MDV (multiple dose vials) that have already been opened:
            5.1 check expiration date and vial liquid clarity (should have no residue)
            5.2 thoroughly cleanse top with alcohol prior to puncture
            5.3 Always use a NEW sterile needle every time you puncture vial
    6.0 For SDV (single dose vials):
                          6.1 if doing multiple treatment mixes at once: open vial and with a new and sterile 18gauge needle and 10cc                                        syringe, pull out maximum amount needed for total number of treatments to fill syringe. Can keep needle in                                    vial and reattach a new sterile syringe if the content needed is more than 10cc.  Then add desired dose to                                      each IV bag
                          6.2 After vial has been used once, throw it away

             7.0 For Mixing Multiple vitamins/minerals into a Treatment (i.e vitamin drip):
                          7.1 Designate a NEW sterile needle and syringe for each vial (can attach a piece of tape to the syringe with name                                of vitamin/mineral)
                          7.2 pull out amount of ingredient needed for treatment (if mixing multiple treatments at once, then pull out total number of treatments) in the designated syringe
                  7.3 wipe NS/LR bag opening with alcohol and then inject ingredient into bag
             8.0 The key is to reduce number of times the MDVs are punctured! 
             9.0 Make sure to return the refrigerated Vitamins/Minerals back to the fridge!



Policy 12.0 Preparation and Cleanup
              12.2 Every attempt should be made to empty garbage receptacles in treatment rooms after each patient             treatment.
          12.4 All treatment trays and chairs must be cleaned/wiped down with disposable disinfectant wipes or other bleach compound after each and every treatment is complete.  This will kill both HIV and hepatitis  B virus.
    12.5 Each tray will be prepared individually or for each group.
    12.6 New trays will be prepared for each new individual or group.
            12.7 Syringes, drip-‐sets, nasal cannulas/masks and all other items being utilized for treatment will never  be placed on anything (chairs, stools, tables, etc.) other than treatment trays.
    12.8 Gloves (latex or nitrile) must be worn at all time during treatment.
        12.8.1 Avoid tearing your gloves on equipment or sharp objects.
        12.8.2 Torn gloves should be replaced immediately.
    12.9 Gloves must be changed and hand sanitizer applied after each patient treatment.
    12.10 Use disposable towels or towels to clean up any blood.
            12.11 There must be no blood droplets on anything.  This includes but is not limited to chairs, walls, floor,   alcohol preps, etc.  If you see any blood droplets clean it immediately and/or throw away any disposable items.
            12.12 After each treatment is complete all arms of chairs and couches and tables will be cleaned with disposable disinfectant wipes.
            12.13 Thoroughly inspect the floor and furniture after each treatment.  No blood or fluids on any furniture   or floors will be acceptable.
            12.14 If necessary, use mop to clean any blood or fluids on floors.  After cleaning, promptly disinfect mops  and any other cleaning equipment, otherwise, it can spread potential  viruses to other areas.
            12.15 Put all contaminated towels and waste in the Red Bag or other appropriate sealed, labeled  (Biohazard symbol or label), leak-‐proof container. This is regulated waste.


Policy 13.0 Punctuality:
    13.1 Lateness without a plausible excuse is not acceptable.
            13.2 Providers are required to arrive at Replenish 15 minutes prior to beginning of shift for preparation. 

Policy 14.0 Sharps and Trash Collection and Disposal:
            14.1 When providing injections to patients or injecting medications into lactated ringers/NS all needles  should be removed from syringes and disposed of in the biohazard bag.
        14.1.1 Needles are placed in sharps containers
        14.1.2 Syringes are placed with other non-medical garbage.
    14.2 Garbage should be consolidated whenever there is down time during a shift.
    14.3 At all times medics will maintain a clean and sterile appearance within Replenish.
    14.4 All medical waste should be disposed of in red bag location or in medical waste containers. 
            14.5 Sharps containers should never reach more than two-thirds of capacity.  Once this level has been reached the sharps containers should be closed, sealed and placed in medical waste / red bag containers.

Policy 15.0 Charting
    15.1 Charting on DR CHRONO for each patient must be complete after each patient

Policy 16.0 End of Shift:
             16.1 ALL garbage must be removed to the dumpster at the completion of each shift without exception.                  16.1.1 The policy includes all trash receptacles: All patient treatment rooms, front desk, offices,                                          restroom, med room and waiting area.  Any exceptions will be under the discretion of manager on duty.
    16.2 Supplies must be restocked in med room from storeroom. 
            16.3 If supplies are low, notify manager via email or text AND write what is low on re-order form sheet in med room
    16.4 All charting must be completed on DRCHRONO.

Policy 17.0 Initiating House Call
17.1 Client calls into Replenish and requests a house call
17.2 Input client initial information in the DRCHRONO computer system

Policy 18.0 When On-Call
18.1 Provider must be available to be reached and take calls from 8am until 5pm
18.2 Provider must be within a 30min drive to an inside the perimeter destination
18.3 Provider must wear uniform and name tag
18.4 Provider must call client before arrival to confirm address and destination time

Policy 19.0 House Call Supplies
19.1  If already at the Replenish Shop...mix bags prior to leaving for destination
19.2  If  not at to take to house call:
19.2a Lactated Ringers/Normal Saline (bring 2 bags in case patient wants 2)
19.2b Medications (Toradol, Zofran, Pepcid or Zantac) 
19.2c Vitamins/Minerals
19.3  Contents of house call bag:
19.3a   gloves
19.3b   hand sanitizer
19.3c   alcohol swabs
19.3d   gauze
19.3e   tape
19.3f    multiple IV catheters (18, 20, 22)
19.3g   IV transparent dressing
19.3h   tourniquet (latex and non-latex)
19.3i    pressure bag
19.3j    18 gauge needle
19.3k   syringes
19.3l    22 gauge needle
19.3m  towels
19.3n   biohazard container
19.3o   trash bag
19.3p   blood pressure cuff
19.3q   thermometer
19.3r    patient chart
19.3s    pen
19.3t    sissors
19.3u   IV pole

20.0 House Call Procedure
20.1 Greet the client and introduce yourself and your title
20.2 Assess whether patient is suitable for treatment
20.2a  Take vital signs
20.2b Reconfirm past medical history and allergies
20.2c Assess if they need emergency treatment (are they too sick? If so, call 911)
20.3 If patient is suitable for treatment:
20.3a Have patient sit or lay down in a comfortable place...ideally a couch in a public                     room
20.3b Set up IV Pole
20.3c Prepare IV administration:
- Lay out supplies, place towel under patient's arms, hang IV bag with pressure            bag
- Use hand sanitizer
- Mix medicine/vitamins/minerals as directed by above protocols into bag if     haven't already mixed them at the shop. Make sure to clean each top with     alcohol swab before drawing out
20.3d Use hand sanitizer again
20.3e Put on gloves
20.3f Apply tourniquet
20.3g Cleanse IV site with alcohol swab
20.3h Insert catheter and then cover with transparent dressing
20.3i Attach line to catheter and let it flow. Use pressure bag if appropriate
20.3j Watch for signs of infiltration or allergic reaction
20.3k Attach 2nd liter of fluids (before 1st liter runs out to ensure no air is in tubing) if              requested
20.3l At end of treatment:
-stop the flow on the tubing
-put on gloves
-gently remove catheter and apply pressure to area with gauze for 5min
-throw needles, catheter into biohazard box
-place tubing and IV bags in trash bag  (You MUST take all trash with          you when you leave)
-re-assess patient for adverse reactions
-give patient discharge instructions
-make sure chart on DRCHRONO is complete