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| ==Pre-hospital/Surge Plans==
| | #REDIRECT[[Harbor:Main]] |
| *[[Harbor:Disasters|Harbor Surge Plan/Disasters]]
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| *[[Harbor:ORCHID Downtime|ORCHID Downtime]]
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| *[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]
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| *[[Harbor:Screening EMS Patients|Screening EMS Patients]]
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| ==[[Harbor:Labs|Labs]]==
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| ==Radiology==
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| *[[Harbor:ED Radiology Specs|ED Radiology Specs]]
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| *[[Harbor:Rules for Performing ED Ultrasounds|Rules for Performing ED Ultrasounds]]
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| *[[Harbor:STAT MRI|STAT MRI]]
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| *[[Harbor:Discrepancy Review Process|Discrepancy Review Process]]
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| ==[[Harbor:Occupational exposure|Occupational Exposure]]==
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| ==Other Testing==
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| *[[Harbor:EKG STEMI Screening|ECG STEMI screening]]
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| *[[Harbor:Non-Occupational Exposure|Non-Occupational Exposure]]
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| *[[Harbor:Industrial Accident (IA)|Industrial or On-the-Job Accidents (IA)]]
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| ==EQUIPMENT==
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| *[[Harbor:Equipment|Equipment (AED/RME)]]
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| *[[Harbor:Equipment and supplies (peds)|Equipment (peds)]]
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| *[[Harbor:DME|Durable Medical Equipment (DME)]]
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| ==Patient Disposition==
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| ===[[Harbor:Discharge|Discharging a Patient]]===
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| *[https://gallery.mailchimp.com/9d46ba488168336ff904bf5e2/files/f3e83cc1-58eb-404b-99c7-5c1a5542ddaf/ED_followup_flowchart_3_7_18.pdf ED follow up flow chart]
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| *[[Harbor: ED Follow-Up Options|ED Follow-Up]]
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| *[[Harbor:Coumadin clinic|Coumadin clinic]]
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| *[[Harbor:Expedited workup clinic|Expedited workup clinic]]
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| *[[Harbor:Prescribing|Prescribing]]
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| ===[[Harbor:Admitting a patient|Admitting a patient]]===
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| *[[Harbor:Observation placement|Observation placement]]
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| *[[Harbor:CORE|CORE placement]]
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| *[[Harbor:Admission and consultation guidelines|Who goes to what service (Admission and consultation guidelines)]]
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| **[[Harbor:Right level of care|Right level of care]]
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| **[[Harbor:Internal Medicine Admissions|Internal Medicine Admissions]]
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| **[[Harbor:C-Team|C-Team Admissions]]
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| **[[Harbor:Who Goes to Family Medicine|Who Goes to Family Medicine]]
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| *[[Harbor:Paging|Paging consultants]]
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| ===Other===
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| *[[Harbor:Deceased patients|Deceased patients]]
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| *[[Harbor:Transferring a patient|Transferring a patient]]
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| **[[Harbor:Transferring to psych ER|Transferring to psych ER]]
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| ==ADMISSIONS==
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| ===Orders on Admitted Patients===
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| Recently we had problems in the care of a patient due to both the emergency physician and the admitting team writing non-emergent orders on the patient at the same time.
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| Please do not write orders an admitted patient unless it is an emergency. If you do write an order on the an admitted patient, please communicate this as soon as reasonably possible to the admitting team. If nursing staff request that you write non-emergent orders on an admitted patient, please direct them to call the admitting team.
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| Admission officially occurs at the time you place the order "Request for Admit", and only after you've communicated with the admitting team about admission (or made a reasonable attempt to do so)
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| Dir OPS 5/5/15
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| ===Boarding Patients Sent from Clinic===
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| Just a reminder to the seniors in the Emergency Department running the board: the correct procedure for patients admitted from clinic who do not need a monitored bed, especially when the clinic is closing, is for the clinic to contact the patient flow facilitator to assist in locating a bed in the hospital, and only contact the emergency department to board the patient if the flow facilitator cannot make other arrangements.
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| Monitored bed patients can be sent from the clinic to the emergency department to board when we are out of monitored beds. If it does not sound like the patient needs a monitored bed, please talk to the ED attending.
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| (Dir. OPS, February 03, 2015)
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| ===[[Harbor:Direct Admission after Hours|Direct Admission after Hours]]===
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| ===Insurance Problems===
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| # For issues with insurance, refer patients to the CA Dept of Managed Healthcare: https://www.dmhc.ca.gov/
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| ==[[Harbor:Incoming transfers|Incoming transfers]]==
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| ==Physicians==
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| ===[[Harbor:Phone numbers|Harbor phone numbers]]===
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| ===[[Harbor:Forms|Forms]]===
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| ===[[Harbor:PC Cheat Sheet|PC Cheat Sheet]]===
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| ===[[Harbor:Paging|Contacting the Attending On-Call]]/Problems with On-Call Physicians===
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| When you need to urgently contact the attending on a consulting or admitting service I would suggest your follow this approach, assuming the resident or fellow on the service hasn’t been able or willing to reach their attending and have them call you:
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| #Check AMION to see if the attending’s pager, cell-phone, and home phone numbers are listed. If so, try those numbers, in that order;
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| #If no information listed on AMION allows you to reach the attending, then call the hospital operator and ask the operator to contact the physician via his or her home number. (They may not release the number to you - in that case they should dial it for you.)
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| #If you still have no luck, and it is a true emergency then please text Roger Lewis’ cell at 310-720-1661. You can also call Dr. Lewis but texting gives a better record of the issue and makes it easier to respond and address.
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| A true emergency is something in which a delay in care is likely to permanently affect outcome (e.g., STEMI, testicular torsion, SDH);
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| DEM Chair, Dir OPS 5/18/15
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| ===[[Harbor:ED attending on call plan|ED attending on call plan]]===
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| ===Trauma Activations===
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| In addition to the standard trauma activation criteria published on a badge card that everyone should carry and refer to, the Trauma Service can be activated in patients not meeting trauma criteria to help in several ways:
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| #Getting CT scans READ quickly (Trauma will read them)
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| #Getting lots of extra hands to do whatever needs to be done for the patient.
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| #Getting surgical decisions made more quickly.
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| You can even activate the trauma service if you have a non-trauma patient that needs emergent surgical intervention.
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| All of these decisions are covered under "ED Judgment"
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| (Dir OPS 7/15)
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| ===[[Harbor:Code STEMI|STEMI Activation]]===
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| ===[[Harbor:Code stroke|Code Stroke]]===
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| ===Scheduled Dialysis Patients in ED===
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| #The router will place them on the pre-arrivals each AM (M/W/F)
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| #HD times should be 5-9a and 930-130p
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| #They will receive a MSE at triage – if they decline the MSE and only want their scheduled HD, please document that “the patient declined a MSE and no emergent medical condition exists at this time” in the MSE note and we are done from the ED perspective
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| #If the patient appears unstable, please discuss with one of the AED attendings to determine if they need to be on an AED team or simply need dialysis with a call to the nephrologist for urgent evaluation.
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| #Once the MSE is performed, they will be taken to one of our HD rooms – preferentially Gold 29, then RME 19, then Acute 15 (likely a max of 2 rooms at a time).
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| #They will be cared for by the nephrologist (typically Dr. Anuja Shah) who will place the discharge orders (so these patients should NOT be placed on AED teams).
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| #If for some reason Dr. Shah is unable to evaluate the patient prior to discharge, the FastTrack NP (not resident) will briefly evaluate the patient when ready for discharge - documenting vitals, heart, lung, and lower extremity exam, and page Dr. Shah to clear for dispo and subsequently print the discharge instructions (“HEMODIALYSIS” patient education).
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| #The NP will forward the chart to Dr. Shah, not ED R4 or Attending.
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| DIR RME 12-1-17
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| ==Documentation==
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| ===[[Harbor:Attending documentation|Attending Documentation]]===
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| *For all patients physically present in the department at change of shift (whether dispositioned or not) attendings should write and save one note (ED Attending Note), to be modified by the subsequent attending as needed for that episode of care. This note will include all attending documentation, including language regarding admission or change in status (observation or CORE). Attendings should make sure notes are completed prior to leaving the ED.
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| *For patients seen only on your shift and that depart prior to the end of your shift: attendings have the option of modifying the residents note with an attending note OR completing a separate attending note. These notes can be completed within the 72 hour documentation completion timeline.
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| *Interqual documentation will always be in a separate note, called "Interqual Override Note".
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| (T. Horezcko 7/7/15, Clarification 9/28/15, Dir OPS 9/28/15)
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| ====Minimum Content for Attending Notes====
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| *For patients ADMITTED or PLACED ON OBSERVATION OR CORE STATUS
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| **Acute problem list (should justify the need for Admission/OBS/CORE)
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| **Brief history supporting admission/OBS/CORE required only if problem list does not support your decision
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| **Care Level (ICU/PCU/Tele/Ward, etc.)
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| **Admitting Service
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| (Note should be placed prior to or as close to the time of the order for this activity (Admission/OBS/CORE) as possible.)
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| *For patients STILL ON THE TRACKING BOARD at time of sign out (INCLUDING discharged patients still on board)
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| **Acute problem list
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| **Brief plan, if known
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| **Disposition, if already determined or discussed with housestaff, that the attending would feel comfortable with without further involvement of the oncoming attending.
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| *For all DISCHARGED patients (NOT left over on TRACKING BOARD - but departed ED during your shift)
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| **Documentation is at the discretion of the attending. No specific or minimum documentation (other than a signature on the housestaff H&P.) is required. If documentation is desired, it can be made either as an addendum to the H&P or in a separate Attending Note
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| (Faculty Agreement 11/16)
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| ===Resident Documentation===
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| *1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. Attending".
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| *2. If you are a senior seeing and discharging a patient independently and discharge without presenting the patient, please use the phrase "Seen under supervision of Dr. Attending".
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| *3. When working with an intern or NP, its always important that you independently confirm the key elements of the intern or NP's history and physical. When documenting involvement, residents should:
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| **a) Have the intern submit the chart to you for SIGNATURE, not just REVIEW
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| **b) Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM
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| **c) Your ADDENDUM must at a minimum state what you did independently.
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| **d) Remember, medical student patients require a completely separate and complete H & P.
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| *4. Try not to put raw data into your note that exists elsewhere in the EHR. Instead, you should comment on your interpretation of that data.
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| *5. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.
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| ===E-Prescribing===
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| *Ask patient if they would like to pick it up at Harbor - convenient, low cost to patient, saves county $$$
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| **Pharmacy hours M-F 7a - 10p, Weekend and Holidays 8a - 6p
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| **x5434, 5433 - Call if discharging pt <1 hour from closing time so they know to fill the Rx
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| ***When selecting location ("send to"), choose "find pharmacy" instead of the default printer
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| ***In Pharmacy name, type "HUMC" and select "LA CO HUMC OPD" then sign and it is on its way to being filled before you even discharge the patient
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| * If OOP, patients seen in the ED, clinics, or post-hospital discharge may fill their prescriptions at Harbor pharmacies, but they will have to pay out of pocket.
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| *Changing a prescription that has already been transmitted:
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| **1. If a pharmacy calls asking for the script to be sent elsewhere, tell them to cancel the rx they received. If you receive the call from the patient, you will need to call the pharmacy. Cancelling in ORCHID does not retract the prescription once it has been transmitted.
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| **2. Use the “Cancel and Reorder” function in ORCHID to rewrite the prescription to the new pharmacy.
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| ===CODES===
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| ====CODE ASSIST====
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| *Physicians are NOT part of the ED Code Assist Team. The ED Code Assist team is comprised of nurses.
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| *The ED Code Assist Team covers the first floor and basement, but NOT 1 South.
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| *The rest of the hospital and 1 South are covered by the Inpatient Code Assist Team.
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| (Hosp Policy 375B 9/16)
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| ====CODE BLUE====
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| *All Code Blues are run by the Inpatient Code Blue Team (Not the ED).
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| *ED will respond to manage airway only when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.
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| (Hosp Policy 375B 9/16)
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| ====CODE WHITE====
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| *All Code Whites are run by the Inpatient Code White Team (Not the ED).
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| *Anesthesia will be primary airway management for all Code Whites.
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| *ED will also respond when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.
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| ===CODE GREEN See "LEGAL"===
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| ===CODE GOLD See "LEGAL"===
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| ====AIRWAY MANAGEMENT TEAM====
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| *What Does the Airway Management Team Respond To
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| **The airway management team is responsible FOR THE AIRWAY ONLY and will respond to:
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| #All Airway Management Team Pages
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| #All Code Blues (If already intubated - please check tube placement)
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| #All Code Whites
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| #*Anesthesia primary always
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| #*ED will also respond when on airway management call
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| =====Airway Coverage Times=====
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| ED - '''Sunday 7 AM to Wednesday 7 PM'''
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| *Anesthesia - Wednesday 7 PM to Sunday 7 AM
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| *Whoever has the pager around time of handoff will respond
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| *Who Responds
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| **Purple Attending, Purple Senior (PGY 3/4) (if available), and ED Pharmacist (if available).
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| **The Purple Attending may ask the Green Attending or the Peds Attending for assistance at the Purple Attending's discretion.
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| **The Purple Attending may take another senior resident (PGY 3/4) if the Purple Senior is not available.
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| *Pager Handoff
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| **Pick Up: Purple Senior gets from OR front desk at 6:50 AM on Sunday.
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| **Drop Off: Purple Senior to OR front desk at 6:50 PM on Wednesday.
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| **The pager cases for anesthesia (extra - not tied to phones) are in the purple doctor's box clipped to the boxes for the McGrath blades.
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| *Equipment
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| **The airway management team bags - purple doc box in the drawers under the pager. There are two bags.
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| **BVM/PPE/MAPS - plastic bags to the right of the drawers. There are two bags.
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| **'''Please replace the ED airway tray with one from the crash cart on the floor where it was used '''
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| *Keys
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| **The Purple Attending, Green Attending, Purple Senior, Green Senior and ED Pharmacist have keys to the drawers.
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| *Medications
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| **Each bag in top compartment:
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| ***Rocuronium
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| ***Succinylcholine
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| ***Etomidate
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| **Pharmacy will check each day.
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| **Residents are also responsible for checking the medications and logging this in the log kept in the drawer for pharmacy.
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| **Replacement of Meds
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| ***Return the box to the pharmacist with a patient sticker for new box
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| ***If no pharmacist take used box with a patient sticker to the trauma nurse for new box
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| *Restock and Bag Check
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| **Whoever uses the bag is responsible for restocking it.
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| **The bags will be checked by the Purple Senior as part of the 5S process.
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| **Zip tie after restocking.
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| **If zip tie is in place, no need to open
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| =====Documentation=====
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| *When you return to the ED:
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| #Search for patient using magnifying glass in top right corner of Firstnet
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| #Click “Ad-Hoc” button at top and complete “ED Procedures” form as usual (This will give you procedure log credit)
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| #Start a new note
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| #Right-click field at the top that says “Type:”
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| #Choose “Document Type List” à “Personal”
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| #Choose “Rapid Response/Code Blue Records”
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| #If you have not added this Document Type to your personal list, choose “Complete” to see entire list | |
| #Use the “.edairwayteam” autotext to add the template
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| ===Templates===
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| [[Harbor: Macros and Autotext]]
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| ==RME/TRIAGE==
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| ===RME Phones===
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| *Triage Resident x23223
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| *Triage NP (9a) x23209
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| *FT NP (6a/6p) x23203
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| *FT NP #2 x23222
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| *FT R2 x23210
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| *FT R4 x23213
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| *RME Charge x23930
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| *RME 1 EKG Tech x23922
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| *Chest Pain Triage RN x23909
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| *USA M-F 7a-11p x29737; pgr 501-2047 (Francisco 7a-3p, Reuben 3p-11p)
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| *Lori x23972; Martee x23973
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| *'''Triage Printer in registration cubby (10.107.132.219; PH011E16RX)'''
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| Chappell 10/2017
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| ===RME Patient Flow===
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| # Goals of Triage
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| ## Identify the sick patients and get them to the AED quickly
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| ## Get patient to the most appropriate location for care (UCC, Gyn, Psych)
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| ## Initiate the diagnostic workup that will help expedite throughput (labs, imaging) so when you see the patient as the definitive provider, all you have to do is make the disposition decision (this may include IV abx, IVF, and occasional add-on labs and testing, but if we do a good job up front, <25% of the patients will need additional tests)
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| ## Make people feel better – PO Zofran, Tylenol, motrin, maalox
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| # Patient arrival → router who assign triage priority (cardiac, high, normal) and quick reg so orders can be placed
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| # Team Triage → VS by RN with required questions, MSE by Physician/NP
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| ## Designate patient end location
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| ### '''R12''': either next to AED (notify RME charge x23930) or cannot go back to WR due to IV (for CT, etc); task then place in RME 12
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| #### RME 12 is the internal waiting room for patients who are too sick to be in the lobby. They should be next for AED and assigned to Purple/Green teams.
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| #### They may be individually evaluated in R11.
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| #### If there are empty chairs in RME12, patients with an IV simply for CT contrast should stay in R12 until cleared by a provider to remove the IV (i.e., CT resulted)
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| ### '''No designation''': plan for AED, stable to go to AWR; task then AED/AWR
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| #### '''If the patient is ESI 4/5, or ESI 3 with high likelihood of discharge after completed workup, they should be placed on the ORANGE team''' (then designated as "FT ROOM" for immediate discharge once the workup is complete and negative)
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| ### '''FT ROOM''': ready for d/c, just needs to be typed up ... Rx, work note, CCC/referral (e-consult)
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| ### '''FLU''': No testing needed; move immediately to FT rooms for rapid DC unless triggered RIPT and needs XR
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| #### Note: ILI is defined as fever + cough OR sore throat
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| #### Empirically treat with Tamiflu if high-risk (<2, >65, preg, COPD, immunosuppressed) and symptoms <48hr. Send Viral Resp Panel PCR if admitted.
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| ## '''If arrival to triage is >60 minutes, an additional RN should assist with triage (and provider should be pulled from FastTrack if needed to keep up with the screening)'''
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| # Bring Back Now
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| ## Notify the RME Charge (x23930) to identify an immediately available bed
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| ## Call the AED charge (x23910) to determine which team is getting the patient if going to the trauma bays (otherwise based on geographic assignment)
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| ## Call the Purple (x23202) or Green (x23206) Attending to notify them of the case and location of the patient
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| # Registration (behind Triage 3)
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| ## Patients sit in chairs in the hall until seen by registration staff; if no staff, then registration will be done in the back
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| ## At a minimum, the "financial screening" to determine DHS eligibility will occur, but if slow arrival flow of patients, can perform complete registration at this point
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| ### 2nd reg clerk to come to Triage 2 if >2 patients waiting for registration
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| #### If Triage 2 is being used clinically, the tasking nurse or USA should take the patient to the ED lobby registration window after tasking is completed
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| #### Alternately, the registration clerks can take patients to the main registration window and return them to RME 5
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| #### If Registration is still overwhelmed, bypass ESI 2&3 and they can receive full registration in the main ED
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| # Tasking
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| ## USA/NA to assist with patient movement to AED, FT, UCC, AWR
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| # Reassessment
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| ## 30 min for IM/IV pain meds, 60 min for PO pain meds (CAP)
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| ## 2 hours for ESI 2
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| ## 4 hours for ESI 3-5
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| # Critical Results
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| ## It does not matter who ordered the lab, imaging study, or EKG - if you are notified of a critical result, deal with it as soon as possible
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| ### If a concerning EKG, notify an attending
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| ### If a lab or imaging finding that upgrades the patient's urgency to be seen, notify the RME charge (consider BBN or RME 12)
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| # Room Assignments
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| ## Triage 2 - flex room for overflow triage > providers for discharge > 2nd registration clerk
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| ## RME 1 = EKG
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| ## Triage 1, RME 2, RME 3, RME 4 = provider rooms (with one chair outside of each room for "next patient")
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| ## RME 11 = flex room for evaluation of patient in R12 (AED internal WR) and additional FT room
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| ## RME 5, RME 6 = Tasking internal WR
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| ## RME 7 Phlebotomy; RME 8, RME 9 tasking
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| ## RME 10 - pain reassessment
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| ## RME12 = next back, IV for CT, etc.
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| ===FastTrack===
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| # If patient is eligible for UCC (ESI 4-5 with green DHS or MHLA logo), the tasking LVN should let the patient know they are eligible to be seen at the Urgent Care which will likely be a shorter wait, and if they say yes, then the USA or NA can take them over
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| ## If patient declines or "no UCC" on tracking board, to AWR until labeled as R11 or open room/chair in FT
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| # There are 4 rooms available: Tri1, R2, R3, R4
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| ## Additionally, there is 1 chair outside of each room for "next up" (labeled with the corresponding patient room) and 2 discharge/tasking chairs (patient location labeled as R5)
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| ### R11 is a flex room - primarily used to evaluate patients from R12, but can also be used by FastTrack providers for evaluation and discharge
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| ### Due to the 4:1 RN ratio, if discharging a patient out of R11, you are responsible to discharge your own patient
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| ## '''Patients labeled "FT ROOM" (ready for discharge) on the ORANGE Team are eligible for placement in FT rooms Tri1, R2, R3, or R4'''
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| ## Once a patient is in each room, the next patient should be brought on deck to the chair
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| ## When FT RN present, patients ready for discharge MAY be placed in the DC chairs by providers for paperwork and instructions
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| ## When no FT RN
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| ### RME Charge RN should help keep the chairs full and assist with discharges as time allows
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| ### Providers will place patients back in the tasking queue (RME5) for additional workup items and will discharge their own patients
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| ## From 11pm to 11am (unless there are still several FT providers), the RME charge should assign 2 FT rooms to the Purple and Green Teams and keep patients cycling into them (no chairs at night)
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| # '''ORANGE TEAM AT NIGHT'''
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| ## If a slow PED night shift or AED is boarded up, look at the "orange team" filter for easily dischargeable patients
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| ### When seeing adults in PED
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| #### Patients should be discharged by 6:45 AM
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| #### PED Attending should discuss placing patients in PED with the PED Charge RN
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| #### PED Attending will label the desired patients on the "orange team" list - "OK to PED"
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| #### The PED Charge RN will pull the patients from AWR and place into PED rooms, and move their location on the tracking board
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| #### Maximum of 4 adult patients at a time in PED
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| #### If it appears that the patient will require a more extensive work-up or admission then the adult charge nurse should be made aware so the patient can be moved when a bed opens up.
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| #### Purple or Green teams may use PED rooms to see more patients from the AED
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| ##### This must first be cleared with the charge nurse on pediatrics
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| ##### These patients are the responsibility of the purple/green team not the PED team
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| ##### Each team may use a max of 2 rooms at a time
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| ##### These patients should be able to be discharged by 7 am
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| ##### The AED attending can indicate which patients by placing "Peds – purple" or "Peds - green" in the nursing comments after they have discussed this with the PED Attending AND PED Charge RN
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| ##### Once the patient is roomed on the Pediatric side, the charge nurse will place them on either the purple or green team filter
| |
| ##### If it seems as if the patient will need admission or a longer stay than anticipated, the PED Charge RN should immediately notify the AED charge nurse so the patient can be moved to the AED when a bed becomes available
| |
| # FastTrack Nurse Role and Responsibilities
| |
| ## Assignment: Tri1, R2, R3, R4
| |
| ### Patients eligible for FastTrack: ESI 4 & 5, or ESI 3 with completed workups that are expected to be discharged after final provider evaluation
| |
| #### If a patient is seen in FT and requires obs or admission and no rooms are available, they should be moved to R12 until a room is available
| |
| #### If a bed is available, care of patient should be transferred to a member of the Purple or Green Teams
| |
| ## Flow
| |
| ### Team triage --> RME-Reg --> R5 --> FT rooms or chairs (or AWR if no empty chairs)
| |
| #### Keep 4 patients in the FT rooms, and 4 additional patients waiting in the FT chairs outside the FT rooms
| |
| #### Based on longest LOS if there are multiple “R11” patients labeled on the tracking board in the RN comments column
| |
| #### If unclear, communicate with the FT Providers for preference of patients
| |
| ## Nursing Tasks
| |
| ### Perform for any additional workup needs (meds, labs, etc.)
| |
| ### Place any needed IV’s for medication or studies and remove the IV once cleared by provider
| |
| ### If you give a pain medication, you should re-check pain at the appropriate 30 (IM or IV) to 60 (PO) minute timeframe
| |
| ### Chaperone providers for any genital exams
| |
| #### If a patient needs a pelvic exam, help patient undress in the exam room and setup equipment for provider
| |
| ###Send off collected specimens to lab (wet mount, ascitic fluid, etc.)
| |
| ### Discharge
| |
| #### Repeat Vital Signs prior to discharge and notify provider of abnormalities
| |
| #### Coordinate with clerk to make follow-up appointments
| |
| #### Re-iterate discharge instructions and follow-up plan, answer any additional patient questions prior to discharge (should have been done already by providers), get signatures
| |
| #### Remove patients from tracking board after discharge
| |
| # ED R4 Fast Track Note
| |
| ## Label as R4 Ind Note
| |
| ## Forward to Green attending unless staffed with someone else
| |
| | |
| Chappell 1/2018
| |
| | |
| ===Triaging Clinic Patients===
| |
| Because we have a large volume of patients waiting at any given time, many of whom are quite ill, we support independent medical decision-making about whether a patient coming from a clinic needs immediate attention or can safely wait to be triaged.
| |
| | |
| We do ask however that when triaging clinic patients, you follow the same protocol we use for ambulance patients. Specifically, should a resident decide that a clinic patient is stable to go wait in the waiting room, they discuss it with the attending and document that decision in the medical record. You can use the same autotext you'd use for an ambulance patient.
| |
| | |
| If you decide that the patient is not stable to go to triage/waiting room, please keep them in the AED.
| |
| | |
| === Direct to Back ===
| |
| * IF beds in the AED are wide open (> 3-4 open beds including Trauma), still perform team triage, but:
| |
| ** RN
| |
| ***takes vitals
| |
| ***asks the necessary triage questions (RIPT, etc)
| |
| ***documents the triage form
| |
| ** PROVIDER
| |
| ***screens for critical patients,
| |
| ***click MSE note,
| |
| ***assign ESI,
| |
| ***assign to FT Team if low acuity
| |
| ***If critical let the receiving team know.
| |
| **PATIENT REGISTERED
| |
| **PLACE IN ROOM
| |
| ***FT room if low acuity, assign to team if no FT provider
| |
| ***Do not send patients to UCC/GYN UCC
| |
| ***EXCEPTION: RME charge may direct to UCC/GYN UCC if no FT rooms and wait less than 1 hour in UCC/GYN UCC
| |
| ***Tasking done in FT/AED room by that room's nurse
| |
| ***EXCEPTION: RME Charge may have patient stop at tasking if AED busy
| |
|
| |
| Peterson 7/23/18
| |
| | |
| ===Criteria for an immediate transfer to Chest Pain Room===
| |
| *Router RN identifies patient with Triage Priority "Cardiac" based on:
| |
| *# Age >35 AND chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
| |
| *# Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
| |
| *# Age >65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
| |
| *# Clinical concern for myocardial ischemia exists despite absence of 1-3.
| |
| *Router RN calls CP Triage RN x23909 and handoff patient to CP Triage RN at RME 1; 2 chairs available if another patient is currently getting EKG
| |
| **CP Triage RN orders EKG, call EKG Tech x23922 if not in RME 1, and notifies the triage provider if they are not already present (x23223 7a-11p [physician], x23203 11p-7a [NP])
| |
| *** Coming March 2018 - auto-EKG order with cardiac priority patients from router
| |
| ***EKG Tech will hand the EKG to a R4 or Attending (NP ok if interpretation is "sinus rhythm")
| |
| ****If STEMI:
| |
| *****Notify Charge RN x23910 to determine which team will be assigned and what room is available
| |
| *****Triage provider should immediately notify the appropriate attending (Purple x23202, Green x23206)
| |
| *****The AED team is responsible for activating the cath lab and speaking with interventional cardiology
| |
| ***If no other patients are waiting for EKG, MSE can be performed in RME 1; otherwise, patient with completed EKG should be taken back to a triage room for MSE while additional patients are getting EKG
| |
| ***Patient then gets financial screening and should be moved to RME 5/6 for Tasking
| |
| ***Once tasking is completed, they should be moved to the appropriate location based on the "RN Comments" column notation
| |
| | |
| Chappell 4/2017
| |
| | |
| | |
| {{Harbor EKG screening}}
| |
| | |
| ===Patient Transfers to other areas of the hospital===
| |
| | |
| ====Psych ED====
| |
| # If the patient has a primary psychiatric complaint and wishes to be seen in the Psych ED, and the triage provider feels the patient is medically stable for psychiatric evaluation without any further testing needed, the Triage RN should call the psych ED for verbal handoff and escort the patient to the psych ED
| |
| # Triage provider will complete an MSE note in ORCHID
| |
| # If any further clarification is needed, the triage provider should discuss the case with the psych resident
| |
| # If there is any concern for safety, the Sheriffs are available to chaperone the escort from triage to the psych ED
| |
| | |
| ====Gyn UCC====
| |
| # Must be DHS Eligible (or MHLA)
| |
| # Check HCG and H/H
| |
| # Have RME clerk make same-day (typically available until 1pm) or next day appointment depending on the complaint
| |
| # Only requires MSE note unless unable to schedule appointment
| |
| | |
| ====Urgent Care====
| |
| =====Transfer of Low Acuity Patients from ED to UCC=====
| |
| *UCC Charge RN: x8111, 8110; RME Charge x23930
| |
| ** Starting 12/3/18. 7:45am phone huddle to discuss volume, flow, staffing shortages, etc.
| |
| ** Once patient has been triaged/received MSE and designated as ESI 4-5, they will be financially screened by registration for DHS eligibility and then placed in RME 5-6
| |
| *** If the patient is eligible for UCC (as designated by the green DHS or MHLA logo), the patient should be offered the opportunity to be seen at UCC as it will likely be a shorter wait; if the patient declines, they will remain in FastTrack
| |
| **** Eligible patients include DHS, MHLA, and SELF PAY
| |
| **** '''EXCLUDED PATIENTS''': chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, any trauma to the cervical spine, pregnant/vag bleeding, or psych care
| |
| | |
| ****Financial Screening - once financial screening is done, the patient will be assigned the green "DHS" logo or the orange "OOP" icon (meaning they must stay in the ED); NOTE: the golden key will not disappear when only the financial screen has been performed (only when full registration is complete); if golden key still present at time of discharge, please discharge to the registration window
| |
| ***UCC hours of transfer are:
| |
| ****Monday to Friday 8am - 8pm with the exception of no transfers Tuesdays 8am to 12:30
| |
| ****Saturday and Sunday 8am - 1pm
| |
| # Once the patient is taken to UCC, they need to be moved in Orchid to UCWR
| |
| # UCC Nuances
| |
| ## There is no maximum number on the subjective pain scale that precludes transfer to UCC
| |
| ## Pain meds should be given prior to sending to UCC; the patient will be re-assessed upon arrival at UCC by their intake provider
| |
| ## It is ok to transfer a patient who has received an MSE and work-up has been initiated (i.e., x-rays ordered/performed); any orders that have not been completed may be canceled by the definitive provider in UCC
| |
| ## UCC is unable to do CCC but can request e-consult
| |
| ## The UCC has full access to ortho via the cast room
| |
| ## The ability to do simple laceration repair is provider dependent, so please call prior to transferring such patients
| |
| # Despite best efforts to properly screen the patients, if it is later determined that a patient is OOP, they will still be seen in UCC and not returned to the ED simply for financial concerns in the spirit of patient-centered care.
| |
| | |
| =====Pausing Patient Flow from ED to UCC=====
| |
| # UCC physician should assess the current volume of patients in UCC WR as well as current and expected coverage (not counting discharged patients in UCC10)
| |
| ## If greater than the expected disposition ratios (NP: 2/hr, Attending 3/hr), discuss with the UCC Medical Director
| |
| ## If there is any concern about patient safety, call the UCC Medical Director
| |
| ## If UCC Medical Director agrees, they will discuss with RME Medical Director the options of slowing or stopping flow and RME Medical Director will instruct the RME Charge RN based on the joint medical directors' decision
| |
| ### If either UCC or RME Medical Director is unable to contact the other director, they will use their best judgment and call the RME Charge RN (x23930) with directives
| |
| | |
| =====Transfer of Patients from UCC to ED=====
| |
| # Patients presenting to the UCC with the following complaints may be immediately transferred to the ED upon presentation without ever being seen by an UCC provider simply based on stated complaint: chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, pregnant/vag bleeding, or psych care
| |
| # If the decision is made to transfer a patient back to the ED, there must be a physician to physician conversation as to why the patient’s workup cannot be completed in the UCC; call Triage physician x23223 prior to sending back to the ED; Green team attending x23206 or Purple team attending x23202 are alternates
| |
| # The UCC nurse will transition care to the Triage reassessment RN who will then determine the most appropriate next step for the patient (immediate triage by team, WR queue for triage, etc)
| |
| | |
| | |
| | |
| Chappell 7/2017
| |
| | |
| ===FastTrack Roles===
| |
| #NP
| |
| ## from SW
| |
| ## LBTC f/ups after 7a screening resident comes
| |
| #R4
| |
| ## from SW
| |
| #R2
| |
| ## from SW
| |
| | |
| | |
| ===NP Independent Workup Guidelines===
| |
| * NPs may independently order any x-rays deemed appropriate.
| |
| ** Consider XR above and below the injured joint
| |
| * In Chest Pain pts, obtain a brief history and present to an attending or R4 if signs or symptoms of cardiac ischemia or an EKG read that is not “normal sinus rhythm”
| |
| * NPs should NOT provide care to employees with occupational exposures
| |
| *Trauma
| |
| ** ED NP's are not involved in the care of Trauma Team Activation patients. Our NP's may perform the initial medical screening exam of walk-in patients with minor injuries in Triage, but the care of all trauma patients will be performed by a physician that is ATLS certified.
| |
| ** If, in the course of evaluating a patient with a minor trauma, it is determined that the patient meets trauma team activation criteria, care of the patient should immediately be turned over to an AED team.
| |
| ** If it is determined that a patient with an isolated injury needs admission for surgical repair, the care of the patient will be transferred to an AED Team and Trauma Team consulted prior to admission. (Putnam, 2/2017)
| |
| | |
| * Select advanced imaging listed below may be ordered independently when the pertinent decision rules are applied. All other advanced imaging studies (ultrasound, CT, or MRI) must be discussed with an attending physician (not senior resident) prior to ordering.
| |
| ** Non-contrast CT of the brain:
| |
| *** For symptoms of “sudden onset” headache or “worst headache of life”
| |
| **** Consider CTA Brain for aneurysm if the patient is unwilling to have lumbar puncture (discuss CTA with attending)
| |
| *** For patients who have minor head trauma
| |
| **** Follow the ACEP Clinical Policy Statement:
| |
| ***** Loss of consciousness or post-traumatic amnesia PLUS one of the following: headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication).
| |
| ***** Consider if no loss of consciousness but presence of focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
| |
| **** OR the Canadian Guidelines:
| |
| ***** Presenting within 24 hours of closed head injury with initial GCS 13-15 and LOC, confusion, or amnesia to event
| |
| ****** Excludes minimal trauma with no LOC, anticoagulation use, focal neuro deficit, and post-injury seizure
| |
| ***** CT if GCS <15 two hours post-injury, suspected open or depressed skull fracture, signs of basilar skull fracture (CSF otorrhea/rhinorrhea, battle signs, raccoon eyes), >2 episodes of vomiting post trauma, age>65, retrograde amnesia>30 min to event, mechanism (ejection from vehicle, MVA vs pedestrian, fall >3 feet or 5 stairs)
| |
| ** CT brain with IV contrast
| |
| *** Patients being evaluated for mass/tumor or those with HIV and new onset headache
| |
| ** Non-contrast CT of cervical spine
| |
| *** If any of the NEXUS criteria is present: Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
| |
| ** Right upper quadrant ultrasound
| |
| *** Patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
| |
| ** Non-contrast CT of the abdomen/pelvis
| |
| *** Patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
| |
| *** If previous CT confirms stone, consider renal ultrasound to evaluate for hydronephrosis
| |
| ** Pelvic ultrasound
| |
| *** Patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding
| |
| **Risk Stratification for DVT
| |
| ***Well’s Criteria: Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous [[DVT]](+1), and alternative diagnosis as likely (-2)
| |
| ****If low-risk Well’s (score of 0-1), order d-dimer
| |
| ****If score greater than 1, order formal (not bedside) Lower Extremity Doppler US and d-dimer
| |
| **Risk Stratification for PE
| |
| ***If low pre-test probability and PERC negative, no further testing for [[PE]] necessary
| |
| ****PERC measures: Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks
| |
| ***If patient falls out of PERC, then apply Well’s criteria:
| |
| ****Clinical signs and symptoms of [[DVT]](+3), [[PE]] #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
| |
| *****If score 4 or less, order d-dimer
| |
| *****If Score >4, CTA or VQ scan (if contra-indication to CTA)
| |
| *****If pregnant, discuss with attending
| |
| | |
| Chappell 7/2017, rev 12/2018
| |
| | |
| ===Being Seen by Consultants Prior to ED Evaluation===
| |
| *ED Policy 3.3
| |
| **A consultant may request from RME/AED attending or senior resident to see or take a patient to clinic
| |
| **Once the specialty evaluation is completed, documentation of both exam and assessment/plan should be in ORCHID and communicated to the ED provider
| |
| **ED to disposition the patient after evaluating for any other needs (full chart)
| |
| *Alternately, if the patient has already been evaluated in the ED and found to have an isolated problem that is best cared for by the consulting specialist, care of the patient should be transferred from the ED to the specialist who should discharge them from clinic unless there are extenuating circumstances
| |
| | |
| Chappell 4/2017
| |
| | |
| ===NP Consultation Guidelines===
| |
| *Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult
| |
| # If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.
| |
| # If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and alpha-page the consult service.
| |
| *Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending
| |
| *Please obtain the vital signs of the eyes prior to consultation (visual acuity, PERRLA, EOMI, quadrantopia, IOP, US for detachment if pertinent)
| |
| **If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation
| |
| | |
| Chappell 4/2017
| |
| | |
| ===NP Consultation with the Attending Physician===
| |
| As defined in the Standardized Procedures:
| |
| # Patient has unstable vital signs.
| |
| # There is an acute focal neurological deficit.
| |
| # The diagnosis/problem is not covered by the standardized procedures list.
| |
| # There is an emergent condition requiring prompt medical intervention.
| |
| # Patient and/or family requests to be seen by a physician.
| |
| | |
| *Any case requiring admission, observation, or going directly to the OR should be staffed with an attending. All admissions performed by an NP require an Attending Admission Note (see "Admit Process" for contents of note)
| |
| *If an NP wishes to disposition any patient they have consulted an attending physician on (even if the patient's condition is on the independent disposition list), the attending MUST sign the chart.
| |
| **NPs will refer all such charts to the attending for signature.
| |
| *It is expected that on any case that an attending has been consulted, the NP will discuss the disposition of the patient with the attending before actual disposition.
| |
| **It is at the discretion of the attending whether or not to personally evaluate the patient, however the attending physician will be responsible for the care delivered to the patient.
| |
| **Patients who are under the care of an NP but have been discussed with an attending physician may have the attending's name placed in the attending column but should NOT be given a team color unless requested by the attending.
| |
| | |
| Chappell 4/2017
| |
| | |
| ===NP Independent Discharge Guidelines===
| |
| * A physician is always immediately available in the ED. NPs may independently discharge the following patients as long as they feel physician consultation is not warranted:
| |
| ** General:
| |
| *** Any patients with a triaged Emergency Severity Index (ESI) score of 4 or 5
| |
| *** Allergic reactions (without signs of anaphylaxis)
| |
| *** Hyperglycemia (asymptomatic, no DKA/HHS)
| |
| *** Medication refills
| |
| *** Psychiatric Patients without psychosis, homicidal ideation, or suicidality may not be independently dispositioned by a NP, but a NP may provide the medical screening exam and transfer these patients directly to the Psychiatric ED if it is deemed no additional medical workup is necessary prior to psychiatric evaluation
| |
| ** Dermatology Conditions:
| |
| *** Breast Complaints
| |
| *** Burns: Superficial (1st) and Partial Thickness (2nd) which do not meet Burn Center Referral Criteria (3rd degree, 2nd degree with greater than 10% total body surface area, burns of eyes, face, hands, feet, perineum, electrical injuries, inhalation injuries)
| |
| *** Cellulitis or simple abscess
| |
| *** Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury)
| |
| *** Rash (no petechiae/purpura)
| |
| ** Neurological Conditions:
| |
| *** Bell’s Palsy with complete unilateral facial paralysis (upper and lower) and no other focal neurological deficits
| |
| *** Dizziness consistent with Peripheral Vertigo (normal HINTS exam, no cerebellar findings, stable gait)
| |
| *** Seizures (known disorder, no new trauma)
| |
| ** HEENT Conditions
| |
| *** Conjunctivitis
| |
| *** Dental complaints without signs of necrotizing or deep space infection
| |
| *** Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin)
| |
| *** Pharyngitis without signs of peritonsillar abscess or epiglottitis
| |
| *** Minor head or facial trauma
| |
| *** Ocular complaints (no significant acute vision changes, no trauma)
| |
| ** Cardiovascular Conditions:
| |
| *** Chest pain (low risk) as evidenced by the patient having NONE of the following factors: HEART Score >4, age > 30, syncope, persistent dyspnea, IV drug use history, significant family history of early cardiac disease or sudden death, persistent tachycardia, abnormal EKG/arrhythmia
| |
| *** Hypertension (asymptomatic)
| |
| *** Palpitations without arrhythmia noted on EKG
| |
| ** Respiratory Conditions:
| |
| *** Asthma exacerbation that responds to Albuterol, not immune compromised
| |
| *** URI
| |
| ** Gastrological/Genitourinary Conditions:
| |
| *** Abdominal pain that is now resolved in patients <45 years old (with a negative pregnancy test in females)
| |
| *** Constipation without signs/symptoms of obstruction
| |
| *** Dysfunctional uterine bleeding without active hemorrhage and with stable hemoglobin
| |
| *** Hemorrhoids (non-thrombosed)
| |
| *** Nausea and vomiting without significant abdominal pain
| |
| *** Simple UTI in non-pregnant patient
| |
| *** Sexually transmitted infection
| |
| ** Musculoskeletal
| |
| *** Low back pain without associated fever or neurologic deficits
| |
| *** Musculoskeletal pain/injuries
| |
| *** Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
| |
| **** Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks
| |
| **** Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week
| |
| **** Humerus:
| |
| ***** Proximal: non-displaced; sling, ortho in 1 week
| |
| ***** Shaft: non-displaced; sugar tong/sling, ortho 1 week
| |
| **** Radius:
| |
| ***** Non-displaced distal or shaft; volar splint, ortho 2 weeks
| |
| ***** Non-displaced head with good ROM: sling, ortho in 2 weeks
| |
| **** Ulna: non-displaced; volar splint, ortho 2 weeks
| |
| **** Occult Scaphoid: thumb spica splint, ortho in 3 weeks
| |
| **** Metacarpal: non-displaced shaft and neck
| |
| ***** MCP 4&5: Ulnar gutter splint, ortho 3 weeks
| |
| ***** MCP 2&3: Radial gutter splint, ortho 3 weeks
| |
| **** PIP/DIP dislocations: simple, no fracture; buddy tape with padding between digits/splint, ortho 1 week
| |
| **** Hand: Distal Phalanx - buddy tape/alumiform splint, ortho in 3 weeks
| |
| **** Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks
| |
| **** Foot: non-displaced phalanx fracture - buddy tape, ortho in 2 weeks
| |
| **** Chronic or non-healing fracture: CCC for e-consult (call ortho if needs closer follow-up)
| |
| ** Exclusion:
| |
| *** Any cases not specifically listed on the inclusion list
| |
| *** Prior to discharge of any patient with a persistent vital sign abnormality needs consultation with a physician.
| |
| **** Temp >38F
| |
| **** HR > 110 or <50
| |
| **** RR> 20, PO2 <92% on room air (or patient’s home oxygen dose)
| |
| **** SBP >210 or <100, DBP >120 or <50
| |
| | |
| Chappell 4/2017, rev 12/2018
| |
| | |
| ===Rapid Discharge Procedure===
| |
| #If patient needs an appointment (stress test, CCC, etc), this must be done by the clerk first
| |
| #Ensure IV has been removed
| |
| #If vital signs have not been recorded in the past 4 hours, these need to be repeated and recorded prior to discharge
| |
| #Include CHC referral sheet (at RME clerk computer) if patient has no PCP
| |
| #SIGN and TIME paper discharge instruction sheet
| |
| #option#1: Give ED copy of the signed discharge papers to the RN/LVN who can discharge them with the appropriate timestamp to accurately capture LOS
| |
| #option#2: When completing the admit/discharge screen, click the bottom box (yellow highlight) "patient demonstrates understanding of instructions given"
| |
| ##click the "discharge" button
| |
| ##Enter discharge disposition: "home"
| |
| ##Enter discharge date
| |
| ##Enter discharge time
| |
| ##Click complete
| |
| ##Give signed discharge papers to the patient's nurse or place in bottom slot of black divider at RME Clerk desk
| |
| | |
| ===RIPT===
| |
| # Read CXR - if negative can DC airborne precautions (unless patient immunocompromised/HIV - need more detailed Hx/PE)
| |
| # Place wet read in system
| |
| # DC Airborne precautions by right clicking on order under "Review Orders" - usu. its the very last order on the page
| |
| # Document a note using .edript dotphrase
| |
| # Important points
| |
| ##Precautions are only discontinued if the lung fields are completely normal; if not the patient should receive a more complete history and physical prior to discontinuing precautions.
| |
| ##NPs do not read the chest x-rays themselves, but can act on a chest x-ray that's been read by a radiologist.
| |
| | |
| M. Peterson DIR OPS 6/8/18
| |
| | |
| ===Discharge to Chairs===
| |
| *Pilot Starting 2/5/18
| |
| ** We often have patients in rooms waiting final lab result or radiology interpretation prior to discharge. This process is intended to decrease the room turnover time by '''having the room cleaned while the patient is awaiting final discharge''', allowing for immediate turnover once the patient is discharged.
| |
| **Criteria:
| |
| ***A & O x 4
| |
| ***Ambulatory
| |
| ***Clear plan for disposition
| |
| ***Able to sit in chair without assistance
| |
| ***No fall risk
| |
| **Provider:
| |
| ***Place comment in comment section “chair for DC”
| |
| ***Patient should not be expected to sit in the chair for greater than 30 mins
| |
| **Patient Nurse/Charge Nurse
| |
| ***Ensure patient meets above criteria
| |
| ***Notify EVS to clean the room
| |
| ***Help remind provider when the pending test result is completed
| |
| | |
| ===LBTC FOLLOW-UPS===
| |
| The 6am NP should f/up on LBTC patients from the previous 24 hours once the 7am physician is settled into triage
| |
| # Log into FirstNet
| |
| # Click on “HAR Lookup” – teal tab at the top of the tracking board
| |
| # Change filter to discharged within 36 hours
| |
| # Sort by “Disposition” column
| |
| # Scroll down to “Left – LBTC after MSE”
| |
| # Review Labs
| |
| # Review imaging – for plain films, right click the 1/1/0, left click the blue + sign, click negative, and then click ok (this will send radiology the wet read so they know to contact us if there is a discrepancy
| |
| # If there are any concerning labs or imaging, call the patient back and enter a note entitled “Patient Call-back Note”
| |
| # If unable to contact the patient, then ask the clerk for a telegram form, fill it out, and have the clerk send it
| |
| # If there is nothing of concern, write “reviewed” in the comment column so the next person knows where to start
| |
| # Staff any questions with the R4 only or Attending
| |
| | |
| | |
| | |
| Chappell 4/2017
| |
| | |
| ==LEGAL==
| |
| | |
| ===AB 2760: Naloxone for patients at risk for opioid overdose===
| |
| Requires providers to offer a prescription for naloxone (or other reversal agent) when
| |
| #Prescribing ≥90 morphine milligram equivalents/day (for example, 9 Norco 10/325 tabs/day) Here is a link to the CDC tool for daily opioid dose calculations: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf, or
| |
| #When co-prescribing an opiate with a benzodiazepine.
| |
| #''''''Even when not prescribing opioids if the patient just has a history of overdose or substance use disorder''',''' or if the patient is at risk for returning to a high dose of opioid medication to which he or she is no longer tolerant. Cal/ACEP is looking further into this latter provision but for now, it’s the law.
| |
| *At Harbor, we have '''naloxone intranasal''' on formulary. Further, if a prescription for naloxone (or other reversal agent) is given, the p'''rovider must educate the patient''' (or someone designated by the patient) on overdose prevention and how to use naloxone (or other reversal agent). To help you with that requirement, below is a link to a sample patient education handout, which includes naloxone information. [https://gallery.mailchimp.com/e35e5fa1ba46b6de2508eeb46/files/917ffb95-8676-4a7d-be20-bba0f996b22b/Patient_Education_on_Overdoses_and_Naloxone.pdf?utm_source=CA+Providers+%28ED%2C+Hospitalists+%26+ICU%29+ICs%2BAPCs&utm_campaign=01cf5a6775-EMAIL_CAMPAIGN_2018_12_28_08_49&utm_medium=email&utm_term=0_4c468cb1a3-01cf5a6775-157632935 Patient Handout]. We are working making this flyer available at each clerk’s station and in the doc boxes, and there are similar naloxone instructions in ORCHID.
| |
| | |
| ===SB 1152 - New California homeless patient discharge planning law===
| |
| Bottom line,
| |
| #Consult social work as early as possible once you have identified a homeless patient ("HL" icon). Social work wants to be consulted for EVERY homeless patient.
| |
| #Infectious disease (ID) screening and vaccinations are now mandated by law, so based on current ID concerns, please document that you offered Hep A vaccine to those that qualify since there is an ongoing Hep A outbreak.
| |
| #If medically appropriate, please order a meal prior to discharge.
| |
| | |
| Details:
| |
| *New definition of homeless:
| |
| **Lack fixed and regular nighttime residence
| |
| **Primary nighttime residence in supervised area or area not designed for living/sleeping
| |
| **Examples: Car, shelters, tent, hotel, street, beach, park, abandoned building, bus/train station, etc.
| |
| *Offer meal - please order of medically appropriate: Provider and RN
| |
| *Offer weather appropriate clothing - SW and RN
| |
| *Discharge meds or prescriptions - Provider
| |
| *Referral for follow up care - Provider
| |
| *Offer infectious disease screening and vaccinations: Currently, Hep A vaccine to address local outbreak. Provider and RN.
| |
| *Offer transportation: bus tokens from social work, House Supervisor, Registration
| |
| *Screening for affordable healthcare coverage: Patient Financial Services (PFS), Registration
| |
| *Identify post-discharge destination: SW
| |
| *Communicate discharge needs to receiving entity: SW
| |
| | |
| More info: https://californiaacep.site-ym.com/page/Legislation_Implementation
| |
| | |
| ===INVOLUNTARY HOLDS, CODE GOLD, COLD GREEN===
| |
| | |
| *'''Psychiatric reason:'''
| |
| **5150 (5585 for Peds) only for a '''mental health disorder.'''
| |
| **Voluntary patients usually not placed on a 5150/5585, but can be.
| |
| **Non-psychiatric medical personnel can detain anyone who meets criteria until they can be evaluated by a psychiatrist.
| |
| **'''5150 can be placed by''':
| |
| *** '''Psychiatrist ONLY INSIDE''' MAIN HOSPITAL BUILDING
| |
| *** '''Sheriff ANYWHERE OUTSIDE''' MAIN HOSPITAL BUILDING, including rest of hospital grounds
| |
| ****Sheriff has independent authority to place the 5150 or not
| |
| | |
| *'''Medical reason:'''
| |
| **Patients who '''lack capacity''' and are a danger to themselves or others for non-psychiatric reasons. Do not need psych consult to determine capacity when restraining patient for a medical reasons, and psych cannot override decision to restrain a patient for non-psychiatric reasons. DO NOT REFER TO THIS AS A "HOLD" AS THIS MAY LEAD LAW ENFORCEMENT TO BELIEVE THE PATIENT IS ON A 5150.
| |
| **If they try to elope you can detain/restrain, if they become violent or aggressive, call a CODE GOLD (see below).
| |
| **These patients can be held against their will for their own safety no 5150 is required or applies (5150 for psych issues only).
| |
| ** No specific legal form for restraining medical patients - document reasons in chart. Use '''restraint form''' for restraints.
| |
| | |
| *'''Code GOLD:'''
| |
| **For all patients who become physically aggressive, either for psychiatric or medical reasons.
| |
| **They will be placed in '''hard restraints''' by CODE GOLD team
| |
| **Call x111.
| |
| **'''No requirement''' patient be placed or already on 5150
| |
| **LASD (Sheriff) responds but is not part of team, only assists if detect or to prevent criminal activity by patient (assault)
| |
| **Behavioral Response Team leader (BRT) should ID themselves on arrival and ED physician or nurse in charge of patient should brief them.
| |
| **BRT leader has option of turning over situation to LASD as needed.
| |
| | |
| *'''Code GREEN:'''
| |
| **'''Already on or eligible for a 5150/5585''' and attempting to, or have physically left the department.
| |
| **Call x3311 LASD(Sheriff)
| |
| **'''On a 5150 hold''' - LASD will return patient
| |
| **'''NOT on 5150 hold'''
| |
| ***'''Inside''' Hospital Building - LASD can only convince patient to return - can't forcibly return. '''Only Psych''' can place 5150 inside hospital building
| |
| ***'''Outside''' Hospital Building - LASD makes independent determination to place patient on 5150
| |
| ****Physician or nurse in charge of patient should brief LASD if patient on 5150 or if not, indication for 5150
| |
| **If LASD decides not to place patient on 5150, document Code Green in chart and officers involved
| |
| | |
| *'''Code GRAY'''
| |
| **'''ANYONE''' (patient, visitor, staff) who is combative or assaultive and it is not felt due to a medical or psychiatric reason
| |
| | |
| *'''Above vetted by Law Enforcement, Psychiatry, Behavioral Response Team, ED Leadership, and Nursing leadership'''
| |
| *Additional References
| |
| **436 Procedures in Cases To Be Reported to Are Investigated by Law Enforcement Authorities
| |
| **301 Discharge Policy, Procedures, and Guidelines Including Elopement and AMA
| |
| **138 Law Enforcement Use of Force on Harbor-UCLA Campus
| |
| **347A The Use of Restraints Including Seclusion
| |
| **346 Involuntary Holds on and on Psychiatric Units and Emergency Medical Department
| |
| **379 Safety Attendant (Continuous in Person Monitoring)
| |
| **453 Patients in Police Custody
| |
| **347B Code Gold-Behavioral Response Team
| |
| **620 Consent for Medical Treatment for Patient Lacking the Capacity to Provide Consent
| |
| **Sheriff "Cheat Sheet" for Code Green and Code Gold
| |
| | |
| * Public Health
| |
| ** (213) 745-0800 (Tb)
| |
| ** 213-974-1234 after hours
| |
| | |
| Dir OPS 10/15/18
| |
| Dir AED, 10/28/16
| |
| | |
| ===Mandatory Reporting of Adverse Events===
| |
| | |
| There are events which we must report to the state in a timely fashion or face being penalized by State Licensing. Below are some general guidelines for what to report. Please make sure that the ED attending is aware of these events and documents their involvement in the record (HUMC Policy 612B).
| |
| | |
| Events must be reported within 4 hours to both of the following:
| |
| # Immediate supervisor
| |
| # SI (Safety Intelligence System entry)
| |
| # Risk Management x2168
| |
| | |
| Events to be Reported
| |
| # Procedure performed on a wrong body part, patient, or the wrong procedure all together.
| |
| # Death or disability from any medication error, blood product incompatibility, hypoglycemia, intravascular air embolus, falls, or burns that occur while in the ED
| |
| # Patient death or serious disability through any actions or errors which are not an expected part of the patients medical condition or treatment, including elopement of an incompetent individual or minor, abduction, or assault (physical or sexual).
| |
| # Retention of a foreign object (e.g. central line guidewire)
| |
| # Patient suicide or serious injury from suicide attempt while in the ED
| |
| # Visitor or staff death or severe disability while on hospital grounds for any reason.
| |
| # An infant discharged to the wrong person.
| |
| # A maternal death or serious disability within 42 days post delivery
| |
| # Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
| |
| | |
| (Ref: Reporting Form – Adverse Events -Julie Rees)
| |
| | |
| (Hospital policies 612A, 612B 5/14, CMO 7/2017)
| |
| | |
| ===Prescriptions===
| |
| | |
| ====Lost Triplicate Prescriptions====
| |
| | |
| If you find that your providers are missing prescriptions or are contacted from a pharmacy regarding suspected fraudulent prescriptions please do the following as required by the Department of Justice,.If you are unsure if you are missing any individual prescriptions, please assume that they have been stolen and report.
| |
| | |
| #The loss or theft must be reported by the physician to local law enforcement. The physician should take note of the law enforcement agency report number.
| |
| #The loss or theft must be reported by the physician to the Department of Justice Controlled Substance Utilization Review and Evaluation System (CURES) program. A law enforcement agency report number is required when submitting a report of lost or stolen prescription forms to CURES.
| |
| #The physician should notify the California State Board of Pharmacy.
| |
| #The physician should notify the Medical Board of California.
| |
| #In addition, to the above 4 steps please email Dr. Harrington at dharrington@dhs.lacounty.gov.
| |
| | |
| D. Harrington, 11/3/16
| |
| | |
| ====Safe Pain Medication Prescribing Guidelines====
| |
| We will be shortly launching the implementation of the Safe Pain Medication Prescribing Guidelines, a Los Angeles county-wide project to decrease inappropriate opioid prescriptions from the ED and other settings. Patients will receive upon discharge a color pamphlet (English or Spanish) explaining the project, including messages about how stolen prescriptions need to be reported to the police, that the ED does not refill pain pills and that pain pills for chronic pain should really come from a single, continuity provider. Residents, NPs, and nursing staff got some in-depth lectures about this.
| |
| (Dir Adult ED 10/14/14)
| |
| | |
| | |
| | |
| {{Triaging Ambulance Patients}}
| |
| | |
| {{Harbor follow up}}
| |
| | |
| | |
| | |
| | |
| | |
| {{Family Viewing of Deceased Patients}}
| |
| | |
| {{Harbor Law Enforcement Escorting Patients Out Of the Emergency Department}}
| |
| | |
| | |
| | |
| {{Harbor Ebola precautions}}
| |
| | |
| {{Contacting attending consultant}}
| |
| | |
| {{Harbor Elective Transfers to MLK Hospital}}
| |
| | |
| ===Weapons in ED===
| |
| *As a general rule, no patients should have weapons on them (INCLUDING PEACE OFFICERS), even if they have concealed weapons permit.
| |
| *No visitors should have weapons. The only exception to visitors carrying weapons are active peace officers.
| |
| *We are working with hospital administration to make this hospital policy for campus grounds.
| |
| *If you encounter issues, call the Sheriffs Department for assistance.
| |
| | |
| A.Wu, Dir AAED, LASD, Dir OPs 12/9/16
| |
| | |
| ===ILLICIT DRUGS/MARIJUANA IN ED===
| |
| * Marijuana less than an ounce (plant) or 8 gms (concentrate) and patient at least 21 years old - keep with patient belongings
| |
| * Marijuana quantity more than above (or not sure), or possessed by person under 21 - Call Sheriff
| |
| * All other illicit drugs (or suspect as illicit) - Call Sheriff
| |
| | |
| Dir OPS 2/27/18
| |
| | |
| ===OBSERVERS IN THE ED===
| |
| *There can never be an observer of any type in the ED without the prior permission of hospital administration or the chair, or one of the vice-chairs in the department.
| |
| *Observers must be introduced to any patient whose care they observe and the patient must be given the opportunity, in a non-coercive and open manner, to not have the observer present during their care.
| |
| *Observers must never be present during sensitive parts of medical care (e.g., genital exams, during history taking regarding abuse or sexual assault, etc.).
| |
| *Observers must wear a clearly visible name tag that provides their first and last name and identifies them as an “Observer” or using a more descriptive label (e.g., “Medical Student” or “Residency Candidate”).
| |
| | |
| Chair, EM 9/2017
| |
| | |
| ==Social Work==
| |
| | |
| ===Social Work Consultation Guidelines===
| |
| | |
| Generally, please call Social Work early if you anticipate any issues so they can get things during business hours and get to families before they leave. Consult by placing a social work order in Orchid (documents consult time).
| |
| | |
| ====1. SW Order Indications====
| |
| | |
| Choose the indication that best fits your clinical need/question. Special instructions are helpful.
| |
| | |
| ======Lack of Resources======
| |
| | |
| Those who need help connecting with resources (financial, placement, housing, food, transportation, etc)
| |
| *Community resources - food banks, gov benefits
| |
| *Disability - how to apply for disability (not for filling out application itself)
| |
| *'''Discharge planning/placement''' - when a patient needs placement to a facility of lower acuity than an acute care hospital (not to be used if homeless)
| |
| *'''Homeless''' - for housing/resources. If patient has chronic physical and mental health problems, ask for patient to be signed up for Housing for Health.
| |
| *Hospice - still need to place a home-health order (only if going home on hospice, not a care facility)
| |
| *Transportation - transportation home or to appointments, see section 1.2
| |
| *'''Crisis/Trauma''' - SW is consulted automatically for all TTAs. Ask for referral to Violence Prevention program if victim of violent crime (shooting/stabbing, etc)
| |
| | |
| ======Poor judgement/Substance Abuse======
| |
| | |
| *Behavioral issues
| |
| *'''EtOH related trauma''' - SW provides a screening & brief intervention
| |
| *Non-compliance
| |
| *Poor communication
| |
| *'''Positive toxicology screen''' - mainly used in peds
| |
| *Refusal of treatment
| |
| *'''Substance abuse''' - SW will provide screening & brief intervention
| |
| | |
| ======Psychosocial Support======
| |
| | |
| This category has a lot of overlap with psychiatry.
| |
| | |
| *'''Adjustment to illness''' - for psychosocial assessment by SW, help provide coping skill
| |
| *Anxiety
| |
| *Crisis/trauma - see above
| |
| *Depression
| |
| *'''End-of-life issues''' - for family or patient, help with GOC discussions
| |
| *Family conflict
| |
| *'''Grief/bereavement'''
| |
| *HI
| |
| *'''Mental health''' - SW can provide more resources than just the DMH list, provide full assessment of patient's financial abilities and other social factors
| |
| *New diagnosis - overlaps with Adjustment to Illness
| |
| *Poor coping
| |
| *SI
| |
| *'''Teenage pregnancy''' - provide resources & support
| |
| | |
| ======Regulatory/Legal Issues======
| |
| | |
| *Adoption
| |
| *Advanced directive
| |
| *AMA
| |
| *'''Domestic Violence'''
| |
| *'''Reportable pressure ulcer''' - Stage 3+ ulcers upon presentation. SW will contact adult protective services (if coming from home) or ombudsman (if coming from a health care facility).
| |
| *'''Suspect child abuse'''
| |
| *'''Suspect elder/dependent elder abuse'''
| |
| *'''Unidentified person'''
| |
| | |
| ======Nonspecific======
| |
| | |
| *Other
| |
| *Assessment
| |
| | |
| J Singh 7/7/17
| |
| | |
| ====2. Transportation home:====
| |
| | |
| *bus:
| |
| #during day 8-4:30 - send to s/w office / page s/w for bus fare voucher
| |
| #nights/wkends/holidays - call nursing's supervisor @ x3434 to approve bus token and then pt can pick it up from ER registration
| |
| | |
| * taxi:
| |
| #If pt is UNINSURED - limited number of vouchers - if MEDICALLY necessary (ie can't take bus for medical reason) - s/w can help with this
| |
| #If pt is INSURED (including medi-cal) - some insurance companies will pay for taxi (pt may have to wait a few hours) - consult s/w and they can help figure it out
| |
| | |
| * ambulance: for patient's that have a medical necessity (cannot ambulate, here w/o wheel chair, etc) and medically cannot take a taxi
| |
| #If pt is INSURED (including medi-cal) - the insurance company will pay for an ambulance home
| |
| ##UR can help with insurance specific contact info for coordination of ambulance
| |
| ##May be limited by patient's home location (i.e. LA vs Torrance, etc)
| |
| #If pt is UNINSURED (including restricted medi-cal) - use county transport to get an ambulance home
| |
| ##If pt lives outside of LA County, call nursing supervisor or SW as they may need further authorization
| |
| | |
| J Singh 5/9/17
| |
| | |
| *kids without car seats: For kids who arrive (usually by ambulance) w/o a car seat, we do not have car seats available. however, options are:
| |
| # take the bus home (no need for car seat)
| |
| # have someone bring a car seat and pick them up or go home in a taxi with the car seat that is brought
| |
| # if a. or b. will not work, can try arranging for ambulance (see section above)
| |
| | |
| ====3. Patient who are homeless:====
| |
| | |
| a. Homeless Task Force - looking for patients with chronic illness (HTN, diabetes, psych, etc) who have had 2+ visits. Put in s/w consult and choose "Homeless" under reason for consult, NOT "Discharge planning/placement". If eligible - they will help sign up the patient - however, they may be on a waitlist for days to months. If an potentially eligible patient is stable for discharge, you may refer them to contact the Homeless Task Force with the following number: 310-848-3325.
| |
| | |
| b. Patients discharged overnight who are not safe to go out into the night CANNOT wait in the ED lobby. However, they can wait in the main hospital lobby in front of the social work offices to speak with social work for resources on housing in the AM. However, please try to consult SW during the ED visit if possible as there is overnight staff available.
| |
| | |
| J Singh 7/15/17
| |
| | |
| ====5. Patients whom family is no longer able to take care of====
| |
| | |
| Please page social work asap - before family leaves - s/w will work with them to see if:
| |
| | |
| a. IN HOME SUPPORT SERVICES (IHSS) - Medi-Cal program - can either be started or have hours increased (to help with supervision, cooking, bathing, grocery shopping, other ADLs)
| |
| | |
| b. other community resources are available
| |
| | |
| c. help family brainstorm other ideas
| |
| | |
| d. if family dumps patient and doesn't respond, s/w may file an adult protective services report
| |
| | |
| e. if the patient truly needs to be placed and resources and strategies of a/b/c do not work, per Dr. Wu, please place in obs and the inpatient team will work on placement from there
| |
| | |
| ====6. Pt/family not happy with current skilled nursing facility (SNF)====
| |
| | |
| a. generally, this is not an appropriate use of the ED - the family needs to work with the SNF s/w to facilitate transfer to another SNF, exception point c. below
| |
| | |
| b. if actual abuse, s/w at Harbor can help with ombudsman report
| |
| | |
| c. APPROPRIATE if pt needs a HIGHER level of care b/c of medical needs - then s/w at Harbor can help
| |
| | |
| d. Different levels of care are outlined in slides (attached) - shelter vs respite vs board and care vs SNF vs ?
| |
| | |
| ====7. Clothing rack / clothing for patients====
| |
| | |
| a. s/w has a small stash in ED - consult/page to get access
| |
| *Located behind double doors in ambulance bay. NA-7 key for access.
| |
| | |
| b. volunteers office has another stash but only open 8-5 M-F
| |
| | |
| ED stash is in need of donations for men's pants, flip flops, sweat pants, sweat shirts
| |
| | |
| J Singh 5/9/17
| |
| | |
| ====8. Patients who need PT/OT for placement====
| |
| | |
| a. place the patient in obs for placement and PT/OT evaluation - this way the hospitalist can then admit the patient from obs if they cannot get PT/OT (which they more likely than not cannot) - this is needed to document the need for PT/OT so we can get resources (it shows how many avoidable admissions there can be as the ED hospitalists are collecting this data manually).
| |
| | |
| | |
| ===Whole Person Care===
| |
| '''For ANY Medi-Cal patients (including OOP) (not just DHS)'''
| |
| *'''Substance Abuse Referrals''' Wants to stop drug or ETOH use
| |
| ** ORCHID Message/Call/Text/Email Lelalee Vicedo - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral. (213) 572-9895 OR lvicedo@dhs.lacounty.gov. She will respond M-F 9:00-4:30 pm but you can call/text/email/ORCHID message anytime.
| |
| ** OR
| |
| ** Call Whole Person Care Intake Line (24/7) and put patient on phone with intake specialist: 844-804-5200
| |
| *** AND place order in ORCHID:
| |
| **** Consult to Social Work: reason for referral = substance abuse, comments = WPC
| |
| * '''Re-entry''' (released from prison <6 months with medical, mental health, substance abuse, or social needs) 844.804.5200 (24/7) and put patient on phone.
| |
| * '''Medically Complex''' Transitions of care (includes 3 visits to ED in past year)
| |
| ** ORCHID Message/Call/Text/Email Lelalee Vicedo - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral. (213) 572-9895 OR lvicedo@dhs.lacounty.gov. She will respond M-F 9:00-4:30 pm but you can ORCHID message/call/text/email anytime.
| |
| *** AND place order in ORCHID:
| |
| **** Consult to Social Work: reason for referral = other, free text WPC TOC
| |
| * '''Perinatal''' (high-risk pregnant mothers - homeless, mental health, substance abuse, domestic violence, no food) 844.376.2627
| |
| * '''Homeless''' ... social work can help facilitate housing
| |
| ** Refer to Social Work
| |
| *** Place order in ORCHID
| |
| **** Consult to Social Work: reason for referral: homeless, free text WPC
| |
| * Disabled and needs disability benefits (SSI)
| |
| ** Refer to Social Work
| |
| *** Place Order in ORCHID
| |
| **** Consult to Social Work: reason for referral: disability benefits, free text WPC
| |
| * '''Mental Health'''
| |
| ** Residential & Bridging Care (transition from mental health institution to community) 213.738.4775
| |
| ** Intensive Service Recipients (mental health with 2 or more admissions in year, recent DC from psych hospital) 844.804.5200
| |
| | |
| ==Core Measures==
| |
| | |
| * Door to Doc: Door to diagnostic evaluation by a qualified medical personnel
| |
| * Fracture to analgesia: Median time to pain management for long bone fractures
| |
| * Door to Discharge: Median time from ED arrival to ED departure for discharged ED patients
| |
| * Door to Admission: Median time from ED arrival to ED departure for admitted patients
| |
| ** Admit decision time to ED departure for admitted patients
| |
| | |
| * Stroke Head Imaging: Head CT or MRI within 45mins of ED arrival for stroke patients
| |
| | |
| * Sepsis
| |
| ** Overall performance
| |
| ** Initial lactate 6hrs prior to 3hrs after presentation
| |
| ** Blood culture 48hrs prior to 3hrs after presentation
| |
| ** Broad spectrum IV antibiotic administration 24hrs prior to 3hrs after presentation
| |
| ** Antibiotic selection post presentation
| |
| ** Repeat lactate within 6hrs of presentation
| |
| ** IV fluid resuscitation 30ml/kg minimum after septic shock presentation
| |
| ** IV vasopressor administration within 6hrs of septic shock presentation (informational only)
| |
| ** Repeat focused exam after IV fluid initiation and within 6hrs of septic shock
| |
| | |
| ===SEPSIS Core Measure Guidelines===
| |
| *Joint Commission/Center for Medicare & Medicaid Services (CMS) determined national standard of quality: early management bundle for severe sepsis and septic shock patients
| |
| *Time sensitive management and documentation requirements must be met
| |
| *Compliance has financial implications, publicly reported
| |
| *Clock starts when patient meets criteria for severe sepsis or septic shock
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| *Inclusion:
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| '''**Age 18 and older'''
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| *Exclusion:
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| **Comfort care
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| **Transferred from another acute care facility
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| **Expire within 3 hrs of severe sepsis presentation or 6 hrs of septic shock presentation
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| **Received IV antibiotics more than 24 hrs prior
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| **Documented treatment refusal
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| *Systemic Inflammatory Response Syndrome (SIRS) definition
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| **Fever (temperature >38.3 C or >100.9 F) or hypothermia (temperature <36 C or 96.8 F)
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| **HR >90
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| **RR >20
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| **WBC >12 or <4 or >10% bands
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| *Sepsis definition (not included in Core Measure)
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| **At least 2/4 SIRS + Infection Source
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| '''*Severe Sepsis''' (included in Core Measure)
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| **'''Sepsis + acute organ dysfunction'''
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| **Acute organ dysfunction = 1 or more of the following:
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| ***Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40
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| ***Acute respiratory failure (Sat <92% without oxygen)
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| ***Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg/hr
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| ***DIC: PLT < 100, INR > 1.5
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| ***Hepatic dysfunction: bilirubin > 2
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| ***Lactate > 2
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| **Actions required for severe sepsis:
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| ***Use the ED Sepsis Orderset, and .sepsisseveresepsis autotext for documentation
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| ***Start 30ml/kg IVF bolus and the below required actions
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| ***'''3 hour bundle:'''
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| ****Draw initial lactate
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| ****Obtain blood cultures prior to antibiotics
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| ****Administer broad spectrum antibiotics targeted at source
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| ***'''6 hour bundle''':
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| ****'''Repeat lactate if initially 2 or greater'''
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| *'''Septic Shock''' (included in Core Measure)
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| **'''Severe sepsis + persistent hypotension despite 30ml/kg IVF bolus''' OR,
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| **'''Lactic acid > 4'''
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| **Actions required for septic shock:
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| ***Use the ED Sepsis Orderset, and .sepsissepticshock autotext for documentation
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| ***'''3 hour bundle:''' (in addition to the above requirements of sending initial lactate, blood cultures, and antibiotic administration within 3 hours)
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| ****Start 30ml/kg IVF bolus (order needs to include duration over which IVF were given, so use the order in the ED Sepsis Order Set, which has this prefilled for you)
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| ****Currently no exclusion for fluid overloaded patient, but use your clinical judgement, and document accordingly.
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| ***'''6 hour bundle:'''
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| ****Start vasopressors if no improvement
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| ****Perform '''repeat focused exam of “volume status & tissue perfusion assessment” within 1 hour after giving 30/ml IVF bolus'''
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| *****Option 1 (most used): Must include all elements below
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| ******Vital signs: Must include actual Temp, HR, RR, BP. In the 'reexamination/reevaluation' section of your provider note, in the 'vital signs' area, click on 'results included from flowsheet' to automatically drop in a selected set of vitals
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| ******Heart exam: RRR, Irregular, S3, S4
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| ******Lung exam: Clear, wheezes, crackles, diminished
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| ******Pulses: 2+, 1+
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| ******Cap Refill: <2 sec, >2 sec
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| ******Skin: Must include color. Mottled, not mottled, pale, pink
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| *****Option 2: Need 2 of the following
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| ******Central line: CVP, SCVO2
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| ******Bedside ultrasound cardiovascular/volume assessment (such as IVC, systolic function, pulmonary edema, etc.)
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| ******Passive leg raise or fluid challenge
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| **'''If you see the SIRS/Sepsis screening icon or think your patient may have severe sepsis or septic shock, ''use the ED Sepsis Order Set'''''. Has recommended antibiotics based on source of infection, labs, and IVF orders with duration times, etc. Also has some informational text about definitions and management.
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| **Use the .sepsis autotext phrases for documentation (.sepsisseveresepsis, and .sepsissepticshock)
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| === Sepsis Abx ===
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| *Cefepime 2g should be restricted to:
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| **febrile neutropenia
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| **HCAP for patient who weighs > 120kg, for others he'd suggest 1g iv q8h over 2g iv q12h based on time-dependent pharmacokinetic of the beta-lactam class
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| **Meningitis that may involve hospital acquired organism, e.g. patient with VP shunt
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| *Meropenem
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| **Severe sepsis, septic shock, over cefepime as there is trend for ESBL in ~ 20% of klebsiella pneumonia and E. Coli based on cultures
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| A.Wu AED Director 6/13/16
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| ==[[Harbor:ED policy manual|Harbor ED policy manual]]==
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| ==See Also==
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| *[[Harbor: Main]]
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| *[[Harbor:Code STEMI]]
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| ==References==
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| <references/>
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| [[Category:Admin]]
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