|
|
| (59 intermediate revisions by 3 users not shown) |
| Line 1: |
Line 1: |
| ==Pre-hospital/Surge Plans==
| | #REDIRECT[[Harbor:Main]] |
| *[[Harbor:Disasters|Harbor Surge Plan/Disasters]]
| |
| *[[Harbor:ORCHID Downtime|ORCHID Downtime]]
| |
| *[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]
| |
| *[[Harbor:Screening EMS Patients|Screening EMS Patients]]
| |
| | |
| ==[[Harbor:Labs|Labs]]==
| |
| | |
| ==Radiology==
| |
| *[[Harbor:ED Radiology Specs|ED Radiology Specs]]
| |
| *[[Harbor:Rules for Performing ED Ultrasounds|Rules for Performing ED Ultrasounds]]
| |
| *[[Harbor:STAT MRI|STAT MRI]]
| |
| *[[Harbor:Discrepancy Review Process|Discrepancy Review Process]]
| |
| | |
| ==[[Harbor:Occupational exposure|Occupational Exposure]]==
| |
| | |
| ==Other Testing==
| |
| *[[Harbor:EKG STEMI Screening|ECG STEMI screening]]
| |
| *[[Harbor:Non-Occupational Exposure|Non-Occupational Exposure]]
| |
| *[[Harbor:Industrial Accident (IA)|Industrial or On-the-Job Accidents (IA)]]
| |
| | |
| ==EQUIPMENT==
| |
| *[[Harbor:Equipment|Equipment (AED/RME)]]
| |
| *[[Harbor:Equipment and supplies (peds)|Equipment (peds)]]
| |
| *[[Harbor:DME|Durable Medical Equipment (DME)]]
| |
| | |
| ==Patient Disposition==
| |
| ===[[Harbor:Discharge|Discharging a Patient]]===
| |
| *[https://gallery.mailchimp.com/9d46ba488168336ff904bf5e2/files/f3e83cc1-58eb-404b-99c7-5c1a5542ddaf/ED_followup_flowchart_3_7_18.pdf ED follow up flow chart]
| |
| *[[Harbor: ED Follow-Up Options|ED Follow-Up]]
| |
| *[[Harbor:Coumadin clinic|Coumadin clinic]]
| |
| *[[Harbor:Expedited workup clinic|Expedited workup clinic]]
| |
| *[[Harbor:Prescribing|Prescribing]]
| |
| | |
| ===[[Harbor:Admitting a patient|Admitting a patient]]===
| |
| *[[Harbor:Observation placement|Observation placement]]
| |
| *[[Harbor:CORE|CORE placement]]
| |
| *[[Harbor:Admission and consultation guidelines|Who goes to what service (Admission and consultation guidelines)]]
| |
| **[[Harbor:Right level of care|Right level of care]]
| |
| **[[Harbor:Internal Medicine Admissions|Internal Medicine Admissions]]
| |
| **[[Harbor:C-Team|C-Team Admissions]]
| |
| **[[Harbor:Who Goes to Family Medicine|Who Goes to Family Medicine]]
| |
| *[[Harbor:Paging|Paging consultants]]
| |
| | |
| ===Other===
| |
| *[[Harbor:Deceased patients|Deceased patients]]
| |
| *[[Harbor:Transferring a patient|Transferring a patient]]
| |
| **[[Harbor:Transferring to psych ER|Transferring to psych ER]]
| |
| | |
| ==ADMISSIONS==
| |
| | |
| ===Orders on Admitted Patients===
| |
| 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.
| |
| | |
| 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.
| |
| | |
| 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)
| |
| | |
| Dir OPS 5/5/15
| |
| | |
| | |
| ===Boarding Patients Sent from Clinic===
| |
| 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.
| |
| | |
| 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.
| |
| | |
| (Dir. OPS, February 03, 2015)
| |
| | |
| ===[[Harbor:Direct Admission after Hours|Direct Admission after Hours]]===
| |
| | |
| ===Insurance Problems===
| |
| # For issues with insurance, refer patients to the CA Dept of Managed Healthcare: https://www.dmhc.ca.gov/
| |
| | |
| ==[[Harbor:Incoming transfers|Incoming transfers]]==
| |
| | |
| ==Physicians==
| |
| ===[[Harbor:Phone numbers|Harbor phone numbers]]===
| |
| | |
| ===[[Harbor:Forms|Forms]]===
| |
| | |
| ===[[Harbor:PC Cheat Sheet|PC Cheat Sheet]]===
| |
| | |
| | |
| ===[[Harbor:Paging]]===
| |
| | |
| ===[[Harbor:ED attending on call plan|ED attending on call plan]]===
| |
| | |
| ===Trauma Activations===
| |
| 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:
| |
| #Getting CT scans READ quickly (Trauma will read them)
| |
| #Getting lots of extra hands to do whatever needs to be done for the patient.
| |
| #Getting surgical decisions made more quickly.
| |
| | |
| You can even activate the trauma service if you have a non-trauma patient that needs emergent surgical intervention.
| |
| | |
| All of these decisions are covered under "ED Judgment"
| |
| | |
| (Dir OPS 7/15)
| |
| | |
| | |
| ===[[Harbor:Code STEMI|STEMI Activation]]===
| |
| | |
| ===[[Harbor:Code stroke|Code Stroke]]===
| |
| | |
| ===Scheduled Dialysis Patients in ED===
| |
| #The router will place them on the pre-arrivals each AM (M/W/F)
| |
| #HD times should be 5-9a and 930-130p
| |
| #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
| |
| #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.
| |
| #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). | |
| #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).
| |
| #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).
| |
| #The NP will forward the chart to Dr. Shah, not ED R4 or Attending.
| |
| DIR RME 12-1-17
| |
| | |
| ==Documentation==
| |
| ===[[Harbor:Attending documentation|Attending Documentation]]===
| |
| | |
| ===[[Harbor:Resident documentation|Resident documentation]]===
| |
| | |
| | |
| ===[[Harbor:Prescribing|Prescribing]]===
| |
| | |
| ===[[Harbor:Codes|Codes]]===
| |
| | |
| ===[[Harbor:Airway management team|Airway management team]]===
| |
| | |
| ===[[Harbor: Macros and Autotext|Macros and Autotext]]===
| |
| | |
| ==[[Harbor:RME & TRIAGE|RME & TRIAGE]]==
| |
| | |
| ==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)
| |
| | |
| ===[[Harbor:Prescribing|Prescribing]]===
| |
| | |
| {{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).
| |
| | |
| | |
| ===[[Harbor:Whole person care|Whole person care]]===
| |
| | |
| ==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
| |
| *Inclusion:
| |
| '''**Age 18 and older'''
| |
| *Exclusion:
| |
| **Comfort care
| |
| **Transferred from another acute care facility
| |
| **Expire within 3 hrs of severe sepsis presentation or 6 hrs of septic shock presentation
| |
| **Received IV antibiotics more than 24 hrs prior
| |
| **Documented treatment refusal
| |
| | |
| *Systemic Inflammatory Response Syndrome (SIRS) definition
| |
| **Fever (temperature >38.3 C or >100.9 F) or hypothermia (temperature <36 C or 96.8 F)
| |
| **HR >90
| |
| **RR >20
| |
| **WBC >12 or <4 or >10% bands
| |
| | |
| *Sepsis definition (not included in Core Measure)
| |
| **At least 2/4 SIRS + Infection Source
| |
| | |
| '''*Severe Sepsis''' (included in Core Measure)
| |
| **'''Sepsis + acute organ dysfunction'''
| |
| **Acute organ dysfunction = 1 or more of the following:
| |
| ***Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40
| |
| ***Acute respiratory failure (Sat <92% without oxygen)
| |
| ***Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg/hr
| |
| ***DIC: PLT < 100, INR > 1.5
| |
| ***Hepatic dysfunction: bilirubin > 2
| |
| ***Lactate > 2
| |
| **Actions required for severe sepsis:
| |
| ***Use the ED Sepsis Orderset, and .sepsisseveresepsis autotext for documentation
| |
| ***Start 30ml/kg IVF bolus and the below required actions
| |
| ***'''3 hour bundle:'''
| |
| ****Draw initial lactate
| |
| ****Obtain blood cultures prior to antibiotics
| |
| ****Administer broad spectrum antibiotics targeted at source
| |
| ***'''6 hour bundle''':
| |
| ****'''Repeat lactate if initially 2 or greater'''
| |
| | |
| *'''Septic Shock''' (included in Core Measure)
| |
| **'''Severe sepsis + persistent hypotension despite 30ml/kg IVF bolus''' OR,
| |
| **'''Lactic acid > 4'''
| |
| **Actions required for septic shock:
| |
| ***Use the ED Sepsis Orderset, and .sepsissepticshock autotext for documentation
| |
| ***'''3 hour bundle:''' (in addition to the above requirements of sending initial lactate, blood cultures, and antibiotic administration within 3 hours)
| |
| ****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)
| |
| ****Currently no exclusion for fluid overloaded patient, but use your clinical judgement, and document accordingly.
| |
| ***'''6 hour bundle:'''
| |
| ****Start vasopressors if no improvement
| |
| ****Perform '''repeat focused exam of “volume status & tissue perfusion assessment” within 1 hour after giving 30/ml IVF bolus'''
| |
| *****Option 1 (most used): Must include all elements below
| |
| ******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
| |
| ******Heart exam: RRR, Irregular, S3, S4
| |
| ******Lung exam: Clear, wheezes, crackles, diminished
| |
| ******Pulses: 2+, 1+
| |
| ******Cap Refill: <2 sec, >2 sec
| |
| ******Skin: Must include color. Mottled, not mottled, pale, pink
| |
| *****Option 2: Need 2 of the following
| |
| ******Central line: CVP, SCVO2
| |
| ******Bedside ultrasound cardiovascular/volume assessment (such as IVC, systolic function, pulmonary edema, etc.)
| |
| ******Passive leg raise or fluid challenge
| |
| | |
| **'''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.
| |
| **Use the .sepsis autotext phrases for documentation (.sepsisseveresepsis, and .sepsissepticshock)
| |
| | |
| === Sepsis Abx ===
| |
| *Cefepime 2g should be restricted to:
| |
| **febrile neutropenia
| |
| **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
| |
| **Meningitis that may involve hospital acquired organism, e.g. patient with VP shunt
| |
| *Meropenem
| |
| **Severe sepsis, septic shock, over cefepime as there is trend for ESBL in ~ 20% of klebsiella pneumonia and E. Coli based on cultures
| |
| | |
| | |
| A.Wu AED Director 6/13/16
| |
| | |
| ==[[Harbor:ED policy manual|Harbor ED policy manual]]==
| |
| | |
| ==See Also==
| |
| *[[Harbor: Main]]
| |
| *[[Harbor:Code STEMI]]
| |
| | |
| ==References==
| |
| <references/>
| |
| | |
| [[Category:Admin]]
| |
