UM Guidelines
Private Duty Nurse Calculator, Pediatric

Home Health Care
BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®
BCBST modification effective September 27, 2007*
 
Shift
Shift 1: 7am - 3pm
Shift 2: 3pm - 11pm
Shift 3: 11pm - 7am
Demographic factors
Weight
Ongoing Assessments:
Minimal ( < daily)
Moderate (Hands on q 4-6 hrs.)
Frequent visual monitoring < 2 hrs.
VS/GLU/NEURO/RESP Assessment*
Number of assessments per shift:
Assess q 4 - 6 hours
Assess q 1 - 2 hours
Complicated med schedule q 2 hrs or more frequent
Present
Central Line/Groshong catheter/Port-a-cath
Present
w/ TPN
I.V. pain medicines
Regular blood draws/IV/Peripheral site
Regular blood draws IV central
Oxygen Therapy
Nasal canula/Face Mask/ Trach Mask @ >= 2 l/m or 40% FIO2
Humidification
Ventilator
On Ventilator
Total Assist
CPAP/IMV < q 12 hrs.
CPAP/IMV > q 12 hrs.
Standby
CPT or Neb Tx <= 1 q 4 hrs.*
CPT or Neb Tx > q 4 hrs.* ( = 2x/8 hr period)
CPT/Neb Tx > q 2 hrs.
Transition from ventilator to Oxygen
Aspiration precautions
Suctioning <= q 2 hrs
Suctioning > q 2 hrs
Tracheostomy (routine care)
Apnea Monitor
Continuous Pulse Oximeter
Wound Care
Decubitus Dressing Changes - Complicated
Surgical Site Dressing Changes - Complicated
Burn Site Dressing Changes - Complicated
Nutrition
Eats with slight assistance
Simple tube feeding q 4hrs or longer
Occasional Reflux
Gastrostomy/PEG tube (Routine Care)
Gastrostomy/PEG medications >= 2 hrs
Gastrostomy/PEG tube feeding pump q 2-4 hrs
Stoma Care
Bowel Training (abnormal for age group)
Bladder Training (abnormal for age group)
Intermittent straight catheter
Uncontrolled Incontinence (abnormal for age group)
Peritoneal dialysis
Foley catheter
NEURO
Abnormal Reflexes
Communication deficit (abnormal for age group)
Cognitive Developmental Problems (abnormal for age group)
Development delay - Motor Skills
Disorientation/combative
(Strikes out, attempts to hurt self)
Grand Mal Seizures
Req minimum intervention
Frequency <= 4 x day
Frequency 4 - 6 x day
Severe Seizure > 6 x day
Moderate sleep disturbance (awake/turned < q 2hrs)
Severe sleep disturbance (awake/turned > 2hrs.)
Quadraplegia
Paraplegia
MUSCULOSKELETAL
Joint Deformities
Spinal Deformities
Fracture or casted limb
Body cast
Decreased ROM
Traction (skeletal, skin, etc)
Requires Appliance/Special Equipment (ambulate/mobility)
Medical Management
Requires periodic medical specialty consultation
Requires multidisciplinary team approach
Primary Caregivers
Other caregivers available outside of home by arrangement
No other caregivers available
Wage Earner
At least 2 responsible adults in the home and primary caregiver contributes to wage earnings or is primary wage earner.
Primary caregiver may or may not be primary wage earner. Only one responsible adult in the home.
Family Constellation
1 - 3 dependants with moderate medical or emotional needs
Greater than 3 dependants in the home with intense medical or emotional needs.
Problem Solving Skills
Patient/family requires assistance in identifying problem/problem solving
Patient/family requires extensive assistance to recognize problems and identify solution.
Coping
Patient/family needs encouragement to follow through on recommendations. Inconsistent in keeping appointments.
Patient/family follows through on recommendations only with extensive support and assistance.
Support Systems
Support system present but needs encouragement to utilize.
Support systems absent.
Stressors
History of mental illness or behavior problems among family members.
Current diagnosis of mental illness and/or behavior problems.
Psychological Stressors
History of custody issues, abuse/violence, or divorce/death in family greater than 12 months ago.
History of custody issues, abuse/violence, or divorce/death in family within past 12 months.
Finances
Family finances are inadequate, barely meets its needs for security and physical survival. Able to buy only necessities.
Family does not meet it's needs for security and physical survival. Unable to buy the necessities.
Resourse Utilization and/or Private Insurance
Requires assistance in identification and utilization of resourses.
Requires intensive assistance to identify and utilize resources.
Safety/Shelter
Family needs assistance to correct safety and health hazards.
Home inadequate to meet minimum safety and health standards
ADL's
Inconsistent in meeting ADL's
ADL's not met
Shift
PDN Acuity
PDN Psychosocial
PDN Grand Totals
 
Summary:
 
 
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* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines.  The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material.  Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.
The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.