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| ==ADULT ACUTE ED==
| | #REDIRECT[[Harbor:Main]] |
| {{Harbor EKG screening}}
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| {{Harbor Surge plan}}
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| ===iSTAT Tests===
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| EG7:
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| Na,
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| K,
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| Ca,
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| Hgb/Hct,
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| Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)
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| CG4:
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| Lactate,
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| Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)
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| {{Admitting a patient}}
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| {{Admission Guidelines}}
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| ===Mandatory Reporting of Adverse Events===
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| 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.
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| Events must be reported within 4 hours to both of the following:
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| #PSN (Patient Safety Net)
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| #Risk Management x2168
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| Events to be Reported
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| #Procedure performed on a wrong body part, patient, or the wrong procedure all together.
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| #Retention of a foreign object (e.g. central line guidewire)
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| #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, or an assault.
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| #Visitor or staff death or severe disability while on hospital grounds for any reason.
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| #An infant discharged to the wrong person.
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| #A maternal death or serious disability within 42 days post delivery
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| #Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
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| #Any abduction or sexual assault of anyone on hospital grounds.
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| (Ref: Reporting Form – Adverse Events -Julie Rees)
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| (Hospital policies 612A, 612B 5/14)
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| ===Safe Pain Management Program===
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| 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.
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| (Dir Adult ED 10/14/14)
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| ===Boarding===
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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 doesn't sound like the patient needs a monitored bed, please talk to the ED attending.
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| ====Triaging Clinic Patients====
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| 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.
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| We do ask however that when triaging clinic patients, you follow the same protocol we use for ambulance patients (see below 1.9.2). 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.
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| Regarding sending the patient to RME: we have no workflow that allows a patient to be placed directly into RME - please don't ask the nursing staff to do this. If you decide that the patient is not stable to go to the waiting room and be triaged, then please keep them in the AAED.
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| (Dir. OPS, February 03, 2015)
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| {{Triaging Ambulance Patients}}
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| {{Harbor follow up}}
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| {{Family Viewing of Deceased Patients}}
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| {{Harbor Law Enforcement Escorting Patients Out Of the Emergency Department}}
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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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| {{Harbor Ebola precautions}}
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| {{Contacting attending consultant}}
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| {{Harbor Elective Transfers to MLK Hospital}}
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| ===On Call Plan - Emergency Department Attending Physicians===
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| When it becomes clear for any reason that an Attending Physician in the Adult or Pediatric ED will be unable to cover a scheduled shift due to illness or personal emergency, that physician should:
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| #Send out a group wide email in an attempt to find coverage, as time permits. | |
| #Outside business hours, contact the attending on duty in emergency department, who will notify involved physicians that the shift extension backup plan is in effect (see section 5 below). Contact information for all ED physicians is available on our intranet website http://www.emedharbor.edu/private/
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| #During business hours, call the Department Offices at 310 222-3500 and inform Maria Figueroa, or if unavailable, Juno Chen. Maria (or Juno) will contact the Chair, or in his absence, one of the Vice Chairs, who will initiate an e-mail attempt to arrange coverage. If no coverage is found, the Chair or Vice Chairs will notify the attending in the emergency department to activate the shift extension backup plan.
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| #Part time hourly physicians and volunteer physicians are not obligated under this plan, but will be compensated for their time per their usual agreement should they decide to cover additional hours under this plan.
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| #Shift Extension Back-up Plan: When no coverage can be found - the physicians working the shifts before and after the missed shift will extend their shifts to 12 hours to cover the missed shift. AAED A-team physicians are responsible to cover A-team absences and AAED B-Team for B-Team absences, and PED team physicians cover PEDS team absences.
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| #In the event one of the covering physicians is a part-time physician and unable to extend their shift, the physician from the opposite team should extend their shift to 12 hours to help cover the missed shift.
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| #A full-time faculty member or Fellow will generally be responsible for making up the first 2 shifts missed from any single incident. At the discretion of the Chair, the requirement to make up subsequent shifts may be waived.
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| #*Faculty will not be required to pay back specific individuals who worked their missed shifts. Shift pay back will be accomplished through the regular scheduling process.
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| #*Faculty working extra to cover missed shifts should notify the scheduler to ensure appropriate credit is given.
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| (Dir of OPS 6/2/15)
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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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| ==RME/TRIAGE==
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| ===Criteria for an immediate transfer to Chest Pain Room===
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| *Router RN identifies patient with Triage Priority CP
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| *Router RN calls CP Triage RN.
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| *CP Triage RN performs assessment to determine if patient meets criteria for ECG:
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| *#Chest, arm, neck, jaw, upper back, or epigastric, pain/pressure/heaviness/discomfort concerning for a cardiac etiology, in a patient > 30 yrs old.
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| *#Shortness of breath, weakness, or arm/hand numbness, in a patient > 30 yrs old, concerning for a cardiac etiology and without another explanation
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| *#Nausea, lightheadedness, “indigestion”, or "dizziness" in any diabetic OR elderly patient (>65 yrs) concerning for a cardiac etiology and without another explanation
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| *#Syncope with age > 30 yrs
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| *#If clinical concern persists despite absence of 1-4
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| TRANSFER TO CHEST PAIN ROOM, PERFORM IMMEDIATE ECG, AND THEN NOTIFY NP, x23219.
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| ===NP Consultation with the Attending Physician===
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| Nurse Practitioners working in the RME or Emergency Department should seek consultation with an Attending Physician as is outlined in the Physician Consultation Guidelines.
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| All admissions performed by an NP require an Attending Admission Note (see "Admit Process" for contents of note).
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| 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 he 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.
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| 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.
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| 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. The NP should leave their name on the patient on the track.
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| (Dir OPS 7/15)
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| ===Designation of Patients in Rapid Medical Screening Exam (RME) Area===
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| Nurse Practitioners (NPs) in RME, the RME Charge Nurse, or the ED Attending can designate patients in RME as belonging to an AAED team. In order to do this, the patient should be assigned a team color on the usual rotating basis, have the NP's name removed from the resident/attending/or intern columns, and place the patient in a designated AAED bed.
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| Once a patient has been placed on an AAED team, NPs should not write any more orders for that patient. Any further orders will be written by the AAED team.
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| 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. The NP should leave their name on the patient. The nurse practitioner should forward the documentation for attending signature.
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| (ALL MDS/NPS/NURSING DIRECTOR ED 7/14)
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| ===EKG Screening by NPs===
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| #CP patient from Triage needs an ECG in RME 11 CP room.
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| #ECG tech hands ECG to NP.
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| #NP does the electronic ECG screen in ORCHID for ECGs that say “Normal Sinus Rhythm.”
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| #For ECGs that say anything else, if the ECG is already uploaded into ORCHID, the NP screening chest pain patients can just call the ED attending (x23202 or 23206) for the electronic ECG screen. Otherwise if the ECG is not yet uploaded, the NP will have to walk over the ECG to an ED attending. If there is an RME physician, then that physician can perform the electronic ECG screen.
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| ===Bed Huddles – RME===
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| Every morning at 7:30 am and every evening at 7:30 pm A bed huddle between the RME nurse practitioners and RME nursing staff should occur.. The charge nurse should initiate by gathering nursing staff and NPs into the NP room. The following should be done during the huddle:
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| #Identify the charge nurse for RME that day and write his/her phone on the white board
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| #Find out from charge if we are short staffed
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| #Find out who your staff is for RME beds, and room 12
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| #Let them know which NP is the screening /chest pain NP. If you are short that day also let them know.
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| #Remind them how chest pain process should run
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| (Lead NP 5/15)
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| ===Attending Sign Out of RME Patients===
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| Occasionally the physician working in RME may need to sign out a patient to the AAED in attending if no RME attending a scheduled for the following shift. In the instance where the RME physician saw a patient outside the NP scope, we are asking that the RME physician sign out the plan to both the NP and the AAED attending. That way if the NP has any questions, or if any issues come up, they can have an attending to get guidance from that already knows the patient.
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| ==EMS==
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| ===Responding to a Helicopter Landing===
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| *Requires 2-3 trained individuals, does NOT require a physician, though one may elect to go.
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| *Only individuals with helicopter safety training should respond to a helicopter landing.
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| *Must wear following (available in radio room):
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| **Eye protection
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| **Gloves
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| **Ear plugs
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| *FOR SAFETY:
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| **Secure loose equipment, they may become a projectile.
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| **Face shields are not permitted.
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| **Stethoscopes are not to be worn around the neck.
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| **Items are not to be left on top of the gurney
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| ===Closing to EMS (ALS) Ambulances===
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| The decision to close to ALS ambulances should be made as a joint decision by the AED charge nurse and the ED attending. Although looking at the NEDOCS score can be a helpful indicator of the level of congestion, it does not need to be the only factor that goes into determining the need to close to ALS ambulances. With our recent adjustment of the equation to calculate the NEDOCS score (we now have the accurate ED bed count in the equation) - you may find at times that you need to close at lower NEDOCS scores.
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| As always, the decision to close should be carefully considered, as it results in longer transport times for potentially critically ill patients.
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| ==FINANCE==
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| ===Billing Credit for Attending Staff===
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| Attending credit should be given based on documentation in following order:
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| #First to the attending who writes an addendum on the resident's the H&P
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| #If there is no attending addendum on the H&P, then credit goes next to first attending who writes the appropriate "Supervisory Review Note".
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| #If there is no attending addendum on the H&P or a separate Supervisory Review note or other separate attending note, then credit will be given to the attending who signed the H&P.
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| #For procedures-the attending specified in the procedure note will get credit for procedure billing, even if a different attending gets credit for the patient visit (E&M code).
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| (Dir OPS 11/13/14)
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| ==ORCHID (CERNER)==
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| {{Harbor attending documentation}}
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| {{Downtime}}
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| ==HARBOR ED POLICY MANUAL==
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| ===3.0 Admissions and Consultations===
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| ====3.4: Guidelines for Flow of patients between the Psychiatric and Adult Emergency Departments====
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| * Ambulatory Patients: Patients presenting with abnormal behavior WITHOUT prior psych diagnoses or with acute ALOC are initially evaluated in the adult ED
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| * Patients with a known psych history and behavior consistent with their previous diagnosis, without apparent acute medical condition requiring intervention, are initially evaluated by the Psych ED
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| * Patients arriving by ambulance with psych complaints but not under a 5150 should be triaged by a physician in the adult ED then directed to appropriate location
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| * Psychiatric Consultations in the ED: patients requesting voluntary evaluation by a psychiatrist are transferred to the psych ED after medical clearance for evaluation and should be transferred to the psych ED as soon as there is space available; ED physician to psych physician discussion should occur prior to transfer
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| * All patients on a 5150 hold
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| # With ETOH>200, delirium, complicated alcohol withdrawal, drug overdose, or acute medical problems should be evaluated in the adult ED
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| # Require psych evaluation prior to discharge or transfer to medical unit; this should be done within 30 minutes of request for consult
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| * Patients in the psych ED that require medical evaluation (or re-evaluation) should be transferred to the adult ED as soon as a bed is available; prior to the transfer, the psych physician should discuss the case with the ED physician; exceptions will be made on a case-by-case basis
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| * Patients in the Psych ED who require treatment with sedatives and are deemed to be at risk for significant oxygen desaturation should be transferred to a monitored bed in the adult ED; these patients are co-managed by the physicians from both areas
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| * Psychiatric patients with chronic disorders who require placement are managed in the Psych ED
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| Approved June 2015, Chappell 2/22/16
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| ===21.3 Respiratory Isolation Patient Protocol===
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| *All adult patients presenting to the DEM will be screened at the time of triage by a RN for risk factors, symptoms or complaints of respiratory/tuberculosis (TB) using the RIPT criteria in the EHR; five points or greater indicates the need for immediate initiation of the RIPT procedure.
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| # A mask will be placed on the patient and PA/Lateral chest x-ray will be ordered by the triage nurse with a DEM Attending on duty as ordering physician.
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| # The patient will be escorted to the radiology waiting area, and the triage nurse will hand off communication to the Area Charge Nurse (ACN).
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| # On completion of the chest x-ray, the ACN will follow-up with the R-3 or Attending Physician for interpretation of the chest x-ray. The decision to release the patient back to the waiting area or continue isolation in a designated isolation room will be made by the provider at that time.
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| Approved June 2015, Chappell 2/22/16
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| ===21.4 Care of Potential Myocardial Ischemia Patient in Triage===
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| * All adult patients presenting to the DEM triage area with a chief complaint suggestive of myocardial ischemia will be screened rapidly by the Router RN to determine the need for immediate intervention using the following criteria:
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| # Age >35 AND chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
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| # Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
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| # Age > 65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
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| # Clinical concern for myocardial ischemia exists despite absence of 1-3
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| * If the patient meets the above criteria the Router RN will assign a triage priority of cardiac and notify the triage RN via phone; the patient will be placed in room 11 in the RME area
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| # The triage nurse performs the complete focused assessment and appropriately orders the EKG under the DEM Attending on duty
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| # Once the ECG has been completed, the triage nurse will notify the RME provider who will review the EKG
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| Approved June 2015, Chappell 2/22/16
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| ===21.5 Medications in Triage: Standardized Procedure===
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| * Administration of medications in triage (MIT) is to provide timely treatment for patients arriving to the ED in pain, with fever, with dyspepsia, or N/V. Patients in pain should be offered oral analgesia at the time of triage/assessment and reassessment.
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| * DEM Triage RN's have received additional training in giving medications in triage and may administer medications (Acetaminophen, Ibuprofen, Aluminum hydroxide and Magnesium hydroxide antacid [Mag-Al Plus], or Ondansetron) to patients when indicated by the specific requirements of this procedure unless contra-indicated.
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| ** PAIN: All patients who arrive to the ED Triage area will have their level of pain assessed and documented in the EMR. The pain scales used are FLACC, Numeric, and Faces, depending upon the age of the patient. Dosages for fever and/or pain shall be as follows:
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| *** Child < 12 years of age – Acetaminophen 15mg/kg PO x 1 (max 650 mg)
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| *** Child ≥ 12 years of age – Acetaminophen 15mg/kg PO x 1 (max 650 mg)
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| *** Child > 6 months of age – Ibuprofen 10mg/kg PO x 1 (max 400 mg)
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| *** Adult – Acetaminophen 650 mg PO x 1
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| *** Adult – Ibuprofen 400 mg PO x 1
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| ** FEVER: All patients who present to the ED Triage area will have their temperatures taken and documented in the electronic medical record. All patients who present with a temperature > 100.4º F (38º C) [can be axillary, rectal, or oral temperature] shall be offered acetaminophen or ibuprofen. If a previous antipyretic has been given (either at home or in triage), an alternate antipyretic will be given if temperature >100.4º F (38º C). Rectal temperatures must be obtained for all of the following pediatric patients: Infants less than 2 months old, Children less than 2 years old with the exception of children presenting with minor trauma, & Active seizure patients up to 3 years old
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| ** DYSPEPSIA: Patients with a history of heartburn, gastritis, GERD, or dyspepsia or who complain of epigastric pain consistent with those conditions (e.g. burning epigastric pain that is relieved by food or antacids and worsened by spicy foods) shall be offered aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus). Dosages shall be as follows:
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| *** Child 3 – 11 years of age – 0.5 ml/kg (maximum 30ml)
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| *** Child ≥ 12 years of age and Adult – 30ml PO
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| ** NAUSEA: Patients with a complaint of nausea or vomiting will be offered Ondansetron orally. Dosages shall be as follows: Ondansetron ODT (oral disintegrating tab), oral solution, or IV form orally
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| *** Child 6 months to 3 years of age – 2mg PO
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| *** Child 4 – 11 years of age – 4mg PO
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| *** Child 12 years of age to Adult – 4mg PO
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| * Reassessment and Repeat Dosing
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| ** Assessment of the patient’s symptoms (pain, fever, gastritis symptoms, nausea and/or vomiting) should be reassessed within 1 hours of the medication given in triage.
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| ** Patients who after reassessment of pain (within one hour of receiving the 1st dose of acetaminophen or ibuprofen) continue to complain of pain and desire further analgesic treatment will then be offered acetaminophen or ibuprofen alternating from the previous medication administration.
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| **Patients who continue to complain of pain and/or fever may have a repeat dose of acetaminophen 4 hours after the initial dose, and/or a repeat dose of ibuprofen 6 hours after the initial dose.
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| **Patients who continue to complain of dyspepsia may have a repeat dose of aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) 6 hours after the initial dose.
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| * A nurse practitioner or physician provider will be notified of any patient that:
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| ** The triage nurse assesses to require more analgesia than oral acetaminophen or ibuprofen or aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) can provide
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| ** Develops any signs and/or symptoms of adverse reaction to acetaminophen, ibuprofen, aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus), or ondansetron
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| **Any medication error that occurs shall be brought to the attention of the Attending overseeing the patient and the nurse who administered the medication. The patient and/or caretaker will be informed of the error. Standard procedures will be followed, as is the Department’s policy for other medication errors.
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| Approved November 2015, Chappell 2/22/16
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| ==See Also==
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| *[[Harbor: Main]]
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| [[Category:Admin]]
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