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Corporate Policies & Procedures

March 07 , 2018

From the office of Jon Popowich, Chief Quality & Privacy Office

New Corporate Policies and Procedures

  • Glycemic Management Policy
  • Hyperglycemic Management Procedure
  • Hypoglycemic Management Procedure

Revised Corporate Policies and Procedures

  • Therapy/Recreational Aid and Toy Cleaning
  • Compensation for Out of Scope Employees

PLEASE NOTE: You can view the policies/procdures (with the changes highlighted) on the Medical Staff Portal under "New/Updated Corporate Policies".

VII-B-460, Glycemic Management Policy
VII-B-465, Hyperglycemic Management: Mangement & Treatment of Adult Patients
VII-B470, Hypoglycemic Management: Mangement & Treatment of Adult Patients

  • The Glycemic Management Policy outlines expectations and recommended strategies for glycemic management of adult patients including information about blood glucose ranges. monitoring and testing requirements, and appropriate assessment and treatment. The Hyperglycemic and Hypoglycemic procedure provide detail with regard to assessment and treatment of glycemic levels.
  • Blood Glucose Target Ranges have been identified as the following:
  1. For the majority of non-critically ill patients, random blood glucose should be in the target range of 5 - 10 mmol/L (five to ten millimoles per litre), as long as these targets can be safely achieved.

    Exceptions include, but may not be limited to diabetes in pregnancy (where the individualized target range may be modestly lower);
  2. For criticall ill patients, or patients with multiple co=morbidities, blood glucose target range is 8 - 10 mmol/L.
  3. Patients with a guarded diagnosis (i.e., end of life); those who have been identified to have hypoglycemia unawareness; the individualized target range may be modestly higher (i.e. blood glucose target range is 5 - 12 mmol/L).
  4. For frail elderly patients, blood glucose target range is 5 - 12 mmol/L
  5. For patients whose blood glucose is anticipated to be outside of the recommended range, the most responsible health practitioner should identify the target range on the patient's health record.

NOTE: These new corporate policies and procedures supersede and replace any previous site policies on this topic including, but not limited to, Edmonton Acute Care policies # VII-G-10, Hypoglycemia Treatment, and VII-G-5, Blood Glucose Monitoring.

INFO: If you have any questions specific to these policies and procedures, please contact Carrie Waggot, Corporate Manager, Clinical Learning by phone at 780.735.2680, or email her.

VI-5, Therapy/Recreational Aid and Toy Cleaning

  • This policy provides recommendations for cleaning toys and/or recreational aids in healthcare facilities and waiting rooms. It also provides guidance in selecting appropriate therapy/recreational aids.
  • Point 2.10 was added to this revised document.

NOTE: This new corporate policy and procedure supersedes and replaces and previous site policies on this topic.

INFO: If you have any questions specific to this policy and procedure, please contact your Infection Prevention and Control respresentative.

II-5, Compensation for Out of Scope Employees

  • This policy outlines the elements of Covenant Health's compensation program for mangement and exempt employees.
  • Covenant Health will apply the principles of fairness, consistency and equity in setting and administering out of scope salaries and will be mindful of the need to maintain internal salary equity with the need to compete successfully in the external labour market.
  • Significant content changes have been made to this policy.

NOTE: This revised corporate policy supersedes and replaces any previous versions.

INFO: If you have any questions specific to this policy and procedure, please contact your Human Resources representative.

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