Download - Welcome to the ED Orientation on-line module
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MOST OF THE INFORMATION YOU ARE AB OUT TO READ WILL BE A REVIEW OF THE
IN-PERSON ORIENTATION THAT YOU ALREADY ATTENDED.
IT IS IMPORTANT TO BE FAMILIAR WITH THESE ED PROCESSES AND PROCEDURES
PRIOR TO YOUR FIRST SHIFT.
Welcome to the ED Orientation on-line module
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PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT CARE IN THE ED FROM THE
MOMENT THEY START THEIR ROTATION
Goal of this Orientation
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Objectives of this Orientation
Logistics of working in the ED Your ED team Observations vs. Admission EPIC details
Admission/ Discharge Note completion
High- Yield Emergency Medicine Topics Cardiac Chest Pain
ACS: STEMI vs. NSTEMI Low/ Moderate risk CP
Anaphylaxis Trauma
Backboard clearance C-spine precautions and clearance E-FAST exam
Intoxicated Patient Psychiatric Patient
Medical Clearance
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LOGISTICS OF WORKING IN THE ED
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ED Layout
Section A: Highest Acuity- open 24/7 2 resident teams
Green: 9 beds +2 resuscitation bays Purple: 10 beds + 2 resuscitation bays
Staffing: 2 attendings 9am-1am (1 attending 1am-9am) Senior Resident Supervision
Trauma: All trauma patients that go to resuscitation bays are designated as “full” or “modified” trauma Off-service residents are not responsible for taking care of “modified” or “full” trauma Off-service residents are responsible for trauma patients that don’t meet “modified” or
“full” trauma criteria Section B+C: Lower Acuity- open 24/7 (as of July 2014)
May still get trauma patients that are not “full” or “modified” traumas Staffing
At least 3 resident/PA teams Supervised by an attending
TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK
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ED Layout- Other areas of Interest
Patient entrances/ triage/ registration areas: Ambulance Waiting Room
Central Communications Desk (a.k.a. “the bubble”) Located at the ambulance entrance All calls/ faxes Location of Medtronic Pacemaker interrogation equipment
Intoxication Observation Unit (IOU) Located in hallway behind Section C Staffed by an ED tech
Crisis Intervention Unit (CIU) = Psychiatric ED Separate unit staffed by psychiatry residents, attendings, nurses,
techs Chest Pain Center (CPC)
Separate ED observation unit for low/moderate chest pain patients Staffed by B-side attending, PA (during working hours), nurse, tech
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Your team:
Attendings Supervise multiple teams simultaneously 24/7 in-house coverage for every section of ED (when
open)Senior ED Resident
Only during high volume times (Mondays daytime)ED NurseED TechnicianBusiness Associate (BA)
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Your ED shift: Arrival and Sign-out
Arrival: at least 5 min. prior to scheduled time B+ C sides: divide patient beds equally between available
providers (podiatry and dental residents do not get bed assignments)
Sign-out: 2-part process Off-going senior resident or attending presents patients in
bed-order to the on-coming team Part one: at the computer- all the details (including labs, social
issues, Ddx) Part two: at the bedside- off-going attending introduces the in-
coming team Patient is made aware of the work-up progress, pending studies
and reason for why s/he is still in the ED, and approximate timeline
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Your ED shift: Seeing patients
All patients assigned to your bed assignment are YOUR patients See them within the first 5 minutes of arrival in section A
or 15min. in section B&C See patients in parallel: essential EM skill
Present your patients as soon as you saw them To senior and/or attending Do not pile up patients to present in bulks
Enter all lab orders ASAP Notify your nurse of the plan as soon as you know it
Charts must be completed by the time patient leaves the department
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Your ED shift: Disposition
Important to notify the patient and nurse as soon as the decision is made
NEVER discharge the patient prior to making the ATTENDING AWARE that the patient is being discharged
All PMDs need to be notified that their patient was in the ED Especially for high-risk CC: HA, CP, AP, BP Document all communication in chart
AMA discharge: ALWAYS alert the attending ASAP Document capacity to make decision
Can not be: intoxicated, mentally retarded, cognitively impaired Give appropriate discharge instructions and prescriptions AMA form must be signed by patient Encourage return to the ED
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Your ED shift: Admission vs. Observation
Reasoning: patients who have normal vital signs, normal lab results, normal imaging may not meet criteria by insurance companies to pay for a full hospital admission These patients may still require medical care not
reflected by the criteriaLogistics: most of the time, the ED attending
will be able to determine admit vs. obs Care Coordinators are specially trained in making the
decision Will sometimes ask you to change the admitobs or
obsadmit booking Always make the attending aware of the change
The attending makes the final decision
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Your ED Shift: Medical Admission
Enter order in EPIC: “ED Admit” Observation vs. Admission Medical vs. Non-medical
For medical, pick team: Hospitalist =patient’s PMD is on hospitalist team All other medical admits =no PMD or PMD doesn’t admit to
hospitalist YED attending= CPC PCC/ generalist= patient goes to PCC Goodyear =cardiology complaint without Cardiologist or University
Cardiology General cardiology =cardiology complaint with Non-University
Cardiologist Klatskin =ESLD ESRD Donaldson = HIV/AIDS
Fill out the rest of the booking (specify tele vs. floor)
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Your ED Shift: Admission to an ICUStep 1: notify Bed ManagerStep 2: Call appropriate team for sign-out. Get name
of admitting attending. CCU: page CCU fellow MICU: page MICU admission team SDU: page SDU resident SICU: the surgical team is responsible for getting SICU attending
aproval NICU: don’t need to page anyone b/c you are admitting to a team
that should already be involved in patient careStep 3: Attending- to- attending sign-out.YNHH admission policy: the ED attending makes the final decision where a patient is admitted
Please let your senior resident and/or attending aware of any push-back you get from the admitting team.
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Your ED shift: Admission to CPC
CPC or in-hospital ROMI Both:
low/ moderate risk chest pain patients who need a ROMI Observation, telemetry admission Not for ACS patients
No nitro drips, no heparin drips CPC: patient will get Stress Test at the end of their admission
Your role Place appropriate EPIC order:
• ED chest pain place in CPC observation EPIC Note:
• Smartphrase: “.edobsadmit” Order all out-patient medications
In-Hospital ROMI: most will NOT get a stress test Patient had a stress in the past year Patient with other diagnoses possible (other than CAD) Patient needs isolation Patient morbidly obese (will not fit stress table) Patient can not self-transfer (onto stress table)
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Your ED shift: Admission of hip fractures
For isolated hip fractures No other traumatic injuries Mechanical cause (i.e. not syncope that needs to be worked-up)
Orthopedic team evaluates patient (as all other ortho consultations)
Computer orders: Admit to: Hospitalist Service: Medicine Unit type: free-text ortho/ hospitalist 7-7
Page hospitalist at 766-7416 to give verbal sign-out NO DICTATION NEEDED WHEN VERBAL SIGNOUT
DONE
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Other ED Pearls
COMMUNICATION IS CRITICAL Team-work is essential to surviving in the ED (both
patient and resident): greatest off-service resident pitfall is not communicating with the nurses and attending/senior
Let your senior/ attending know: Patient seems to be sicker…
than triaged than last time seen than signed out
You are feeling overwhelmed and are falling behind You need a break (nourishment/ bodily functions)
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Navigating EPIC in the ED
Log in and pick correct department: YNH EMERGENCY ADULT
Sign inPick your work area
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Navigating EPIC in the ED
Typical day in ED: this is what the board looks like…
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ED Notes in EPIC
Double click patient name My note TAB is open
Pick My Note buttonYou are responsible for…
HPI: add chief complain Complete by clicking Add free-text in “comments”
ROS: “All Other Systems Negative” must be clicked off PE: “VS Reviewed” and “Nursing Note reviewed” must be clicked
offIf you did procedures (e.g. EKG)
EKG: change the “provider” from your name to your attending
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ED Notes in EPIC
To view your full note click on NotesBellow PE and above Proceduresfree-text Assessment and Plan
MDM What was done/ found in ED Disposition
Also, free-text PMD/ consultants called (name and time)
DO NOT WRITE IN THE ED COURSE SECTION
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ED Notes in EPIC
When finished documenting: ShareRefresh Note after “clinical impression” and
“disposition” is complete (after you admitted or discharged the patient in EPIC)
When an attending has signed the note, the system will only let you Sign Pick your attending to Co-sign Feel free to edit as many times as needed to complete
the note until the patient leaves the department
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Admitting Patient in EPIC
Double click patient name to open patient chart Open Admit Tab
Navigate through sections Clinical Impression= diagnosis Manage Orders= “ED admit”… Disposition= admit
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Discharging Patient in EPIC
Double click name to open patient chart Open Discharge Tab
Navigate through sections Disposition= discharge Follow-up= pick appropriate MD/ interval of follow-up Clinical Impression= diagnosis Orders= Discharge prescriptions Discharge instructions= diagnosis/ symptoms
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Discharging Patient in EPIC
When patient ready to leave, open Discharge Tab
Pick Preview/ Print SectionClick PrintHand Instructions to nursewith signed prescriptions
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EPIC PEARLS (feel free to print this page)
Every note MUST have the following elements complete HPI: CC filled in
All click boxes that are applicable filled ROS
“All other systems negative” clicked PE
“Nursing note reviewed” clicked “Vital signs reviewed” clicked
Disposition filled Clinical Impression filled
Note must be refreshed before you sign it
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I H AV E R E A D T H R O U G H T H E E D O R I E N TAT I O N O N L I N E M O D U L E I N C LU D I N G T H E I N S T R U C T I O N S O N H O W T O N AV I G AT E T H R O U G H E P I C ( N O T E S , A D M I S S I O N S, D I S C H A R G E ) P R I O R T O M Y F I R S T S H I F T I N T H E E D. I A M A B L E T O P E R F O R M T H E F U N C T I O N S T H AT A R E D E TA I L E D I N T H E O N -L I N E O R I E N TAT I O N M O D U L E . S H O U L D I H AV E A N Y Q U E S T I O N S A B O U T A N Y I N F O R M AT I O N D E S C R I B E D I N T H E M O D U L E , I K N O W T O C O N TA C T T H E E D C H I E F R E S I D E N T S O R T H E E D O F F- S E R V I C E R E S I D E N T D I R E C T O R .
P L E A S E S I G N Y O U R N A M E A N D T H E D E PA R T M E N T Y O U A R E F R O M .
Now that you have read and understand the module, please copy and paste the following statement into an e-mail and address it to:
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A LI NA TS Y R U L N I KA SS I S TA N T R E S I D E NC Y D I R E C T ORO F F- S E RV I C E R E S I D E NT D I R E C TO R
C LI N I C A L I NS TR U C TO RD E PA RT ME NT O F E M E R G E N C Y ME D I C I N EYA LE U N I V E R S I TY S C H OO L O F M E D I C I N E
A L I N A . T S Y R U L N I K @ Y A L E . E D U
THANK YOU FOR YOUR ATTENTION