Harbor:Operations manual

ADULT ACUTE ED

ECG Screening by Providers

  • CP patients from Triage get ECG in RME 1.
  • ECG tech hands ECG to Provider.
  • Who can sign ECG's electronically:
    • ED Attendings and PGY-4's can sign electronically ("No STEMI Activation")
    • NP's can sign electronically in ORCHID only for ECGs that say “Normal Sinus Rhythm.”
      • For ECGs that say anything else, if the ECG is already uploaded into ORCHID, the NP can call an ED attending (x23202 or 23206) for the electronic ECG screen
      • If the ECG is not yet uploaded, the NP need to hand to an ED attending who will perform the electronic ECG screen.
    • PGY 1-3's can only visually review the ECG but then must hand off to or call an Attending or R4 to sign electronically

Chappell 4/2017

Template:Harbor Surge plan

iSTAT Tests

EG7: Na, K, Ca, Hgb/Hct, Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

CG4: Lactate, Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

Admitting a Patient

We have admitting privileges to all hospital services. Once a patient is admitted by us, the service has two hours to write admitting orders or the ED will do it for them. We should hold services to the two-hour time limit as closely as possible in order to expedite ED flow.

If you are not sure if a patient needs to be admitted, you may always consult the service instead. Please make sure that the residents make it clear to the service that they are either admitting or consult on a patient.

When admitting patients, please follow the "Admission and Consultation Guidelines" as closely as possible to determine which service to admit to. If not listed, emergency department determines the admitting service.

The admission process steps below should be followed in strict order to avoid admission errors.

  1. Place an 'Interqual Request' to begin Utilization Review (UR) process.
  2. Resident or nurse practitioner in RME must discuss the case with the attending, who must agree with the admission.
  3. The attending must write a note in the orchid specifying the following three things:
    • Service to admit to (if to the general surgical service, It should be listed as "Acute-Care Surgery" for the admitting service, even though the trauma service officially does all of our consults in the emergency department. Observation patients are not technically admitted, for these put "OBS", and for CORE patients put "CORE".
    • Reason for admission: if the service itself made the decision to admit, then put "at request of ______ (Service). Otherwise note the brief medical indication for admission. "Placement" may be used as a reason to place the patient observation service; we do not admit placement patients to the hospital. You may put a more detailed justification in your attending note.
    • Level of care (Ward, PCU, ICU, Tele)
  4. Once the admission note is placed by the attending, then the resident may contact the service to inform them of the admission. At this time the service can discuss the admission with emergency physician if they feel the admission is not justified or the patient should be admitted to another service. It is especially helpful if they have other information about the patient which may be important for a disposition decision. The final decision rests with emergency physicians, but if there is significant disagreement the ED attending should be involved in the discussion.
  5. Once the service has been informed, the ED resident should place the order "Request for Admit", which defines the time of admission decision. From this time the admitting service has two hours to disposition the patient. They may discharge the patient, write admitting orders for the patient, or transfer the patient to another service. ED department physicians should not be involved in these transfers; once the patient has been transferred to a new service, that service must contact the ED at which time a new two-hour period is established. The admitting service is responsible for the care of the patient once the "Request for Inpatient Bed" order is placed
  6. if the admitting service does not write admitting orders within the two-hour timeframe, the ED resident should contact the admitting service, or if unable, have made a reasonable effort to contact it makes service to inform them that the ED is going to write admitting orders. The ED resident then should proceed to write a brief admitting order set. ED attendings need to encourage the writing of admission order sets by the ED as soon after the two-hour time limit is up in order to expedite flow.

Admitting a patient

OBS/CORE

Admit Guidelines

ED Hospitalist Duties

Short summary of some of the ED Hospitalist duties:

  1. Serves as a point of contact for all patients boarding in the AAED or Gold unit that are admitted to internal medicine.
  2. Provides consultations to assist with admission decisions on any emergency department patient. The examiner patient and document encounter in record when requested.
  3. Assists inpatient Hospitalist with admissions at night on a regular basis.
  4. Performs transfers of all internal medicine patients being transferred out of emergency department.
  5. Reviews all boarding patients on a regular basis for discharges and bed downgrades.
  6. Manages all observation patients
  7. Touches base with senior EM resident or attending every one to two hours.

(ER Hospitalist Job Description - EM Intranet Website- 3/13)

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.

Events must be reported within 4 hours to both of the following:

  1. PSN (Patient Safety Net)
  2. Risk Management x2168
  1. Procedure performed on a wrong body part, patient, or the wrong procedure all together.
  2. Retention of a foreign object (e.g. central line guidewire)
  3. 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.
  4. Visitor or staff death or severe disability while on hospital grounds for any reason.
  5. An infant discharged to the wrong person.
  6. A maternal death or serious disability within 42 days post delivery
  7. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
  8. Any abduction or sexual assault of anyone on hospital grounds.

(Ref: Reporting Form – Adverse Events -Julie Rees)

(Hospital policies 612A, 612B 5/14)

Safe Pain Management Program

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)

Boarding

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 doesn't sound like the patient needs a monitored bed, please talk to the ED attending.

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 (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.

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.

(Dir. OPS, February 03, 2015)

Triaging Ambulance Patients

We have no requirement that ambulance patients get an AAED room immediately, since often we have sicker patients waiting in the waiting room. Patients may be triaged out to the waiting room after arriving by ambulance, but the following procedure should be followed

  1. An RN performs the initial triage and if the patient obviously needs a room the nurse should room the patient
  2. If the nurse believes the patient is stable to be triaged normally, a resident should evaluate the patient. The attending is not required initially. This is the responsibility of the A Team Senior Resident.
  3. If the resident feels the patient is stable to go to triage - they go to triage ONLY after discussion with the attending and a note documents this decision.

(Dir. OPS, February 03, 2015)

Follow-up in CCC

The CCC is for patients who do not have insurance and are not assigned to a provider in the County system (empanelled), and need follow-up by either a NP or FP/IM physician, or by a subspecialist but not within the following two weeks. For specialist follow-up within two weeks, call the subspecialty service directly. CCC does not provide long term follow-up for patients, except by helping them get empanelled if they are eligible.

Please note:

  1. Just like when we filled out the MLK referral form, patients who are being referred for elective cholecystectomy or hernia repair need a BMI in the chart. This determines which service will perform the surgery. I know we don't always weigh our patients, but you can ask and manually put in the weight. Ideally for these patients, the CCC staff can just put in the eConsult without having to bring the patient back for an in-person appointment and having all the relevant information easily at hand in the chart.
  2. Please don't use CCC to obtain stress testing. Keep in mind that the CCC needs at least 2 business days to complete an action.
  3. Be very careful about your messaging to the patient. Do not write that they will be contacted or seen within 1-2 days, as CCC needs a little more flexibility than that. Lidia Asato from the PED is the main RN on this. Trust me, she is very diligent and thorough, your patients will not fall through the cracks.

Jen Chen, Dir AAED, Mar 29, 2015 / M. Peterson, Dir of OPs, Jun 1, 2015

Family Viewing of Deceased Patients

If you have a death in the ED, please don't direct family to the morgue and don't promise body viewing. If the death is potentially a coroner's case, with an unclear cause of death or concerns for possible criminal activity (violence, hit and run, etc.), the family may not be allowed near the body for concerns of evidentiary integrity. For any death that we will be disclosing to the family, the ED social worker should be present to handle the details of discussing body and funeral preparations with the family.

Family Bereavement Resources

How to access the bereavement packet if needed.

  • Go to home page for Harbor/UCLA and click on Departments/Site pages
  • Once the page comes up, look in the second column for Patient Education
  • Click on Patient Education
  • Once the page comes up, look for Patient Handouts
  • Click on Patient Handouts
  • Once page comes up, scroll down to Bereavement packet; it is available in English, Spanish, and Korean.

Law Enforcement Escorting Patients Out Of the Emergency Department

Because of the potential conflicts with EMTALA law, it important that a physician be involved in any decision to remove any patient or potential patient from the emergency department. For this reason, any time law enforcement is either requested by nursing staff, or decides on its own, to escort a patient from the emergency department (including the waiting room), an attending physician should be notified and agree with (and document) the decision. Documentation should specifically state that the patient has had a medical screening exam and does not have an emergency medical condition, or if there is an emergency medical condition that it has been appropriately stabilized. Obviously, it should also be safe for the patient to be removed from the emergency department.

Dir OPS 5/5/15

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

EBOLA PRECAUTIONS

  1. Never enter a room with a PUI patient without full Ebola level PPE.
  2. The definition of a PUI (Person Under Investigation) is simple - possible exposure to Ebola and subjective complaints consistent with Ebola infection (basically viral syndrome symptoms or abdominal pain or bleeding). No fever or other visible findings are required to classify the patient as a PUI patient.
  3. Currently countries identified as travel locations we should be concerned about are coded into the "ID Risk Screen" the routers perform and you can find on Cerner under "Provider Notes"
  4. There are other ways to be exposed to Ebola virus: including sexual intercourse with a patient who has recovered from an Ebola infection.
  5. As soon as the patient is identified as a PUI - they should go straight into isolation (in AAED or PED, not RME); all further evaluation is done there.
  6. Residents should not be in a room with a PUI patient - only attendings and fellows acting as attendings should be involved in wearing PPE and entering a PUI room
  7. Notify the infectious disease service that you have a PUI patient in the emergency department - they will guide further screening to determine if the patient can be cleared or not.
  8. PUI patients are not allowed to use the sink or toilet. Mechanical should bring a porta-potty for patient use.
  9. The policy of the County of Los Angeles is that any provider may decline to care for a PUI patient. Nursing has a list of nurses who have volunteered to care for PUI patients.
  10. Extreme care should be taken in any situation where a PUI patient may undergo a procedure that aerosolizes body fluids - the best PPE in this case is a PAPR unit - which is a helmet with a positive pressure fan. We will receive additional training on these in the future.
  11. There is a cart in the AAED that contains all of the PPE equipment to care for a PUI patient. It is currently across from the B side desk in the AAED, and looks like all the other yellow PPE carts. We are in the process of having it marked with a large "E" to distinguish it from the other PPE carts.
  12. In the top drawer of the Ebola PPE cart is a binder that has step by step instructions for getting into and out of PPE for both the treating provider and that provider's "buddy". We will plan more training to refresh everyone on this.
  13. The instruction book also contains a log to record who goes in and out of a PUI room.
  14. UCLA Medical Center in Westwood will be our referral center for patients who cannot be cleared in a reasonable timeframe' or become confirmed Ebola patients. The decision for the timing of transfer will be made in conjunction with the infectious disease consultant.
  15. EMS has a special unit to transport such patients - make sure they're aware that you have a PUI or confirmed case of Ebola.

M. Peterson 5/8/15

Contacting the Attending On-Call/Problems with On-Call Physicians

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:

  1. 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;
  2. 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.)
  3. 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.

A true emergency is something in which a delay in care is likely to permanently affect outcome (e.g., STEMI, testicular torsion, SDH);

DEM Chair, Dir OPS 5/18/15

Transfers

Elective Transfers to MLK Hospital

Harbor has been asked to help MLK hospital achieve accreditation by directly admitting some ward-level patients to them. They need 30 admissions and then they can invite Joint Commission to come accredit them.

Our wonderful UR nurses will be trained in identifying appropriate patients for possible direct admission to MLK. They will then let you know. In brief, patients who need a medicine ward type admission that you expect to exceed 2 midnights, and who are uninsured or have Medi-Cal/Medicare FFS plans, can go to MLK if you think they are stable for transfer. MLK currently has general internists, some medicine subspecialties (cardiology, nephrology, GI), urology, and OB/GYN. Same transfer paperwork, Orchid process, etc. otherwise as other transfers to community hospitals. The accepting physician would be the MLK hospitalist, who you will need to have an MD to MD conversation with, of course.

This will start this week sometime. Sorry for the last minute notice. While 30 admissions is not that much, I anticipate we will continue to transfer patients long-term to MLK for direct admission, so it behooves us to get this process right/smooth now. Thanks!

Jennifer Chen, Adult ED Director, 6/1/15

On Call Plan - Emergency Department Attending Physicians

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:

  1. Send out a group wide email in an attempt to find coverage, as time permits.
  2. 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/ Password: harbordem
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
    • 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.
    • Faculty working extra to cover missed shifts should notify the scheduler to ensure appropriate credit is given.

(Dir of OPS 6/2/15)

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:

  1. Getting CT scans READ quickly (Trauma will read them)
  2. Getting lots of extra hands to do whatever needs to be done for the patient.
  3. 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 decision are covered under "ED Judgment"

(Dir OPS 7/15)

RME/TRIAGE

Criteria for an immediate transfer to Chest Pain Room

  • Router RN identifies patient with Triage Priority CP
  • Router RN calls CP Triage RN.
  • CP Triage RN performs assessment to determine if patient meets criteria for ECG:
    1. Chest, arm, neck, jaw, upper back, or epigastric, pain/pressure/heaviness/discomfort concerning for a cardiac etiology, in a patient > 30 yrs old.
    2. Shortness of breath, weakness, or arm/hand numbness, in a patient > 30 yrs old, concerning for a cardiac etiology and without another explanation
    3. Nausea, lightheadedness, “indigestion”, or "dizziness" in any diabetic OR elderly patient (>65 yrs) concerning for a cardiac etiology and without another explanation
    4. Syncope with age > 30 yrs
    5. If clinical concern persists despite absence of 1-4

TRANSFER TO CHEST PAIN ROOM, PERFORM IMMEDIATE ECG, AND THEN NOTIFY NP, x23219.

NP Consultation with the Attending Physician

Nurse Practitioners working in the RME or Emergency Department should seek consultation with an Attending Physician as is outlined in the Physician Consultation Guidelines.

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 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.

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. The NP should leave their name on the patient on the track.

(Dir OPS 7/15)

Designation of Patients in Rapid Medical Screening Exam (RME) Area

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 placed in a bed designated as an AAED bed, assigned a team color on the usual rotating basis, have the NP's name removed from the patient on the tracking board.

Once it has been decided to designate a patient as an AAED patient, NPs should not write any more orders for that patient. Any further orders will be written by the AAED team.

(Dir OPS 7/15)

Designation of Patients in Rapid Medical Screening Exam (RME) Area

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.

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.

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.

(ALL MDS/NPS/NURSING DIRECTOR ED 7/14)

EKG Screening by NPs

  1. CP patient from Triage needs an ECG in RME 11 CP room.
  2. ECG tech hands ECG to NP.
  3. NP does the electronic ECG screen in ORCHID for ECGs that say “Normal Sinus Rhythm.”
  4. 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.

Bed Huddles – RME

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:

  1. Identify the charge nurse for RME that day and write his/her phone on the white board
  2. Find out from charge if we are short staffed
  3. Find out who your staff is for RME beds, and room 12
  4. Let them know which NP is the screening /chest pain NP. If you are short that day also let them know.
  5. Remind them how chest pain process should run

(Lead NP 5/15)

Attending Sign Out of RME Patients

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.

EMS

Responding to a Helicopter Landing

  • Requires 2-3 trained individuals, does NOT require a physician, though one may elect to go.
  • Only individuals with helicopter safety training should respond to a helicopter landing.
  • Must wear following (available in radio room):
    • Eye protection
    • Gloves
    • Ear plugs
  • FOR SAFETY:
    • Secure loose equipment, they may become a projectile.
    • Face shields are not permitted.
    • Stethoscopes are not to be worn around the neck.
    • Items are not to be left on top of the gurney

FINANCE

Billing Credit for Attending Staff

Attending credit should be given based on documentation in following order:

  1. First to the attending who writes an addendum on the resident's the H&P
  2. If there is no attending addendum on the H&P, then credit goes next to first attending who writes the appropriate "Supervisory Review Note".
  3. 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.
  4. 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).

(Dir OPS 11/13/14)

ORCHID (CERNER)

Attending Documentation

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.

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.

Interqual documentation will always be in a separate note, called "Interqual Override Note".

(T. Horezcko 7/7/15, Clarification 9/28/15, Dir OPS 9/28/15)

See Also

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