During an emergency certain policies, guidelines and scope of service may change.
These documents still require certain elements required for Patient Safety and dissemination of knowledge.

Document Requirements

Name of the Document:Begin all documents with COVID-19 then the Title

Purpose: Why is this document different from current policies, guidelines in place?

 Scope: Please ensure that an individual can tell immediately who the document refers to such as inpatient, outpatient, adult, pediatrics – acute care, ED, ICU

Approved: Who reviewed the document and approved these temporary documents 

Date: Make sure that every version has a current date.


COVID-19: Pediatric Outpatient Antibiotic Prescribing Guidelines
Purpose: Includes the process for choosing on-site vs. telehealth options for Acute Otitis Media, Pharyngitis, Pneumonia, bronchiolitis, or any respiratory distress, UTI, Gastroenteritis
Scope: Outpatient Pediatrics
Approved: Reviewed by the CMT, Strategic Initiative Team (SIT)
Date: 3/23/2020


Identify need for a change in policy, guideline related to an emergent situation.(Resource allocation, supplies, staffing, etc.)

Gather team of experts to create new guideline 

Send the new guideline to the Command Center:Safety Section 

Safety Section reviews and approves document

  • Document should be sent to DPSQ

  • DPSQ will review for regulations required (even in an emergent situation) and patient safety

  • DPSQ will identify any current document related to the newly created emergent document and add the following statement in PolicyStat, “This Guideline HAS changed due to implementation of our Emergency Management Plan.Please go to COVID-19 Surge Plan on the Coronavirus subsite.” 

Approved document sent to Operations 

Operations will ensure education is provided to all relevant staff and will post the document on the Coronavirus subsite. 

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