Harbor:Operations manual

Pre-hospital/Surge Plans

Radiology

Other Testing

EQUIPMENT

Patient Disposition

Other

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)

Direct Admission after Hours

If a patient who appears stable presents to the ED stating they are a direct admission, they should be sent to ED registration
- ED registration will confirm with bed control/patient flow that the appropriate paperwork has been completed
  - If the patient was inadvertently registered prior to discovering they were a direct admit, they can be removed ("registration in error")
- If the paperwork has not been completed, ED registration will attempt to contact the admitting physician to complete the process
- If they are unable to contact an admitting physician, the patient should be directed back to the router for entry into the ED process
Patients may be directly placed in CORE by cardiology without ED evaluation
All patients going to Observation must be evaluated in the ED with an ED Chart completed (no direct placements on Observation by clinics, etc.)
Any inpatient direct admissions presenting before 8pm on Weekdays: admitting physician directly contacts Bed Control (x2185) for Ward Beds or Patient Flow (x3434) for Tele/PCU beds
If after 8pm on weekdays, or weekends and holidays: Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from ED registration window x2075/2076/2078 or Bed Control)

Admitting physician provides a copy of the request to ER Registration and they create a pre-admit FIN
Admitting physician provides a copy of the request to Bed Control/informs location of patient to release bed (ER)
1. UR (x3226) financially clears patient or calls to obtain authorization (if OOP) and informs Bed Control of approval or denial
  1. If the patient is denied, UR informs the admitting physician and Bed Control of denial
  2. Admitting physician then must decide whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment
  3. If patient is DHS (approved), admitting physician inputs the admitting order on the pre-admit FIN
ER Physician will document the patient's presence in AWR/ED as a Pre-arrival with name and patient location (AWR or room #) with brief note with admitting service and physician to contact for questions (pager #)
1. Stable patients should be placed in one of the internal waiting rooms and until the upstairs bed is available; reassessment should occur per nursing protocol (q2 hours for ESI 2-3)
2. If a patient is in any way unstable or requires immediate intervention or cardiac monitoring, they should be registered and seen as an ED patient and the admitting team should be notified of the change in patient status as soon as possible
The Scheduled Admission Office (x2137) is open from 530am until 8pm, and admitting physicians should take stable patients there while awaiting a bed. If no bed is obtained by 8pm, then the admitting physician will be contacted and their service should take the patient to the ED to wait until a bed is obtained. They should be held in the WR and placed on the tracking board as a pre-arrival, but not registered in the ED as they already have admission orders.
1. If the hospital capacity is limited, it is important that orders are placed as PLANNED, NOT ACTIVE, so they can be activated in any hospital location (this will allow a pre-admission that is boarded in the ED to have orders such as antibiotics completed while waiting for a bed)

Chappell 7/2016

Insurance Problems

For issues with insurance, refer patients to the CA Dept of Managed Healthcare: https://www.dmhc.ca.gov/

Incoming transfers

Physicians

Important Numbers

Purple Team: Att 23202, Senior 23204, Junior 23205, Intern 23372
Green Team: Att 23206, Senior 23207, Junior 23208, Intern

Printable FORMS

Work Notes

Work Excuse http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Work%20Excuse.pdf
Family Work Excuse http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Family%20Work%20Excuse.pdf

Clinics

Health Care Options (HCO), where unempaneled MediCal patient can go to choose a PCP: https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/HCO%20FLYER%20ENG_SPAN.pdf
CHC Clinics http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/CHC.pdf
South Bay Public Health Clinics (STI, vaccines) http://publichealth.lacounty.gov/chs/SPA8/index.htm
Dental Clinics http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Dental%20Clinics.pdf
Breast Diagnostic Center (Radiology Imaging) Referral Form http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Breast%20Clinic%20Referral.pdf
Women's (Gyn) Clinics List http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Womens%20Clinics.pdf
Pediatric Same-Day Clinic http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Pediatric%20Same%20Day%20Clinic%20at%20Harbor.pdf
Adult Mental Health Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Psych%20Referrals.pdf
Pediatric Mental Health Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Peds%20Psych%20Referrals.pdf
Shelter Resources for the Homeless http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Shelter%20Resources.pdf
Substance Abuse Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Substance%20Abuse%20Referral.pdf

Clinical Forms

Interventional Radiology http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Interventional%20Radiology.pdf
Heparin Infusion http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Heparin%20Infusion%20Adult.pdf
Peripheral Pressor Extravasation (pages 5-6) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Extravasation%20Management.pdf
Cytology Request Form https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Cytology%20Request%20Form.pdf
Pathology Tissue Report http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Path%20Form.pdf
Pediatric Tylenol/Motrin Dosing http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Tylenol%20Motrin%20Peds%20Dosing.pdf

Legal Forms

General Consent (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/General%20Consent-English.pdf
General Consent (Spanish)http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/General%20Consent-Spanish.pdf
Telegram http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Telegram.pdf
DMV Form http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/DMV%20LOC%20Form.pdf
OK to Book http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/OK%20to%20Book.pdf
AMA (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/AMA%20English.pdf
AMA (Spanish) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/AMA%20Spanish.pdf
PHI Release http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/PHI%20Release.pdf
Imaging Request http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Imaging%20Request%20Form.pdf
Photo Consent http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Photo%20Consent.pdf
POLST (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/POLST-English.pdf
POLST (Spanish) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/POLST-Spanish.pdf
Dog Bite Reporting (PDF | Online Form)

Resident Procedures Direct Observation Forms

PC CHEAT SHEET

Paging
For consults:
- Place order for consult in quick orders tab; these orders are located in the right hand column of the quick orders page
  - Auto-page consults: enter your callback number
  - No auto-page consults: after placing order, enter your page through the Harbor Alpha Page link on the intranet home page
Order Sets
Within the quick orders tab, use the "Search for new order" bar at the top of the third column
- ED focused order sets generally start with "ED "
  - i.e., "ED Chest Pain," "ED Trauma," "ED Intubation"
  - ICU Therapeutic Hypothermia Targeted Temperature Management
  - ICU Vasopressors Subphase
  - ICU Anti-Hypertensive Medications
  - Med TB Sputum AFB Bundle
  - Med Insulin One Time Dose
  - Med or Ped Med/Surg IV Fluid Subphase
  - ED Holding orders: Don’t forget you can write holding orders for admitted patients past the 2 hour window.
  - ED Sepsis Screening and Management Bundle: Has recommended antibiotics based on source of infection, labs, and IVF orders. Don’t forget to use the .sepsis autotext phrases as well for documentation requirements.
- Select "Modify order" and select the components of the order set you need

Bedside US
Place order for study from within the quick orders page
- Located at the bottom of the second column
  - Orders titled "ED US __"
Open the US machine, end the current study and select "New patient"
Select "Update" from the list of tabs along the bottom of the screen (this may take a minute to appear)
Select your patient from the list
Perform POCUS study, freeze and save images with necessary measurements
Review images and delete inadequate or poor quality images prior to placing US machine back in charging dock
Select "New patient/End Study" to end the current study and automatically upload images
Placing in Obs
Place order for interqual request to initiate utilization review process of evaluation for possible transfer
When green "Met" icon appears on tracking list indicating able to place on observation:
Write the patient's name and MRN in the aluminum Obs binder next to the AED Clerk, in the next available time slot that has not yet passed
Page the ED hospitalist at 310-204-9753
Complete the "Place in Observation" order, with "Emergency Department" for Location, and "Observation" for Service.
Admitting
Place order for interqual request to initiate utilization review process of evaluation for admission vs transfer
When green "Met" icon appears on tracking list indicating able to admit to Harbor:
Write the patient's name and MRN in the aluminum Admissions binder next to the AED Clerk, in the next available time slot that has not yet passed
Page the admitting resident at the number provided
Inpatient hospitalists admit on Tuesdays and Saturdays, this information is also in the aluminum binder
Transfers
EMTALA form
Transport patient between facilities

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:

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;
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.)
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

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:

Send out a group wide email in an attempt to find coverage, as time permits. The address backup@emedharbor.edu will reach all ED faculty, fellows, and adult and pediatric clinical attendings as well as Becki McKenzie and Veronica Lopez.
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/
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.
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.
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.
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.
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, Upheld by Fulltime Faculty Vote on 5/10/16)

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)

STEMI Activations

Harbor - UCLA is a STEMI Center, with 24/7 cardiac catheterization availability. STEMI activations are often called in from the field. If a STEMI activations is called in from the field or from another hospital (IFT) please ask the providers to advance transmit the field ECG for review. This ECG should be downloaded by the MICN and brought to the Attending physician. Per the request of our colleagues in Interventional Cardiology, you should get the report from the MICN, paramedics, or transferring Emergency physician, review the transmitted ECG and if you agree with the STEMI interpretation have the clerk/MICN page the STEMI out. The Interventional Cardiologist on-call will review the ECG as well and cancel the STEMI activation if they disagree. If you cannot access the transmitted field or outside hospital ECG, you may call the Cardiology Fellow or Attending to access (if available). However, if the transferring hospital or reporting paramedic does not advance transmit the ECG, you should delay activation until the patient arrives in the emergency department and you have a chance to review the field or outside hospital ECG, or have performed one in our emergency department.

Not all hospitals in our area are STEMI receiving centers; a hospital that is not a STEMI Center may call you in the emergency department to inform you that they are transferring a STEMI via 9-1-1 activation. This countywide protocol allows hospitals that are not STEMI centers to call 911 to emergently transfer a patient in their Emergency Department (not inpatients) to a STEMI Center without a formal transfer process. We generally accept these without question. You should ONLY accept these calls on the recorded line in the Radio Room at (310) 328-1800. This is for your (and Harbor’s) protection, as these transfers are considered complex EMTALA matters and are being monitored closely by the County. If you receive a call regarding STEMI transfer to your Spectra (cordless) phone, please ask the caller to call the Radio Room and go there to answer. If you do not remember the number there, ask them to call the AED clerk (main number) and state that they are calling for a STEMI transfer (IFT). The clerks are aware of this process and should be able to transfer the call to the Radio Room. This is not necessary if the call is coming through the MAC (which records all calls).

More information on STEMI patients and Interfacility Transfer of STEMI patients can be found on the Harbor-UCLA Intranet under DEM Policies and Procedures.

(See also "TRANSFERS")

Dir OPS 1/9/17

CODE STROKE

Code Stroke Neurology Spectralink 23369
Code Stroke Pager -0921

Timeline Goals
1. 10 minutes from arrival: ED MD evaluation
2. 15 minutes from arrival: Neurology evaluation
3. 20 minutes from arrival: CT head noncontrast obtained
4. 45 minutes from arrival: CT head read by radiologist
5. 60 minutes from arrival: TPA given for appropriate candidates
6. 20 minutes from Neuro IR discussion: If have IR capacity at Harbor
7. 120 minutes from arrival: LVO with no IR capacity at Harbor --> transfer to Comprehensive Stroke Center
8. 45 minutes from Neuro IR activation: LVO with IR capacity at Harbor

CODE STROKE Procedure
1. INCLUSION: age 18 years or older, new focal neurological deficit for <24 hours
2. Rooming:
  1. From Triage: BBN and call charge RN to place in AED room immediately
  2. By Ambulance: room immediately
  3. **If no room available: RN to start IVs, obtain POC and labs; Initial ED MD evaluation then proceed directly to CT
3. EVALUATION:
  1. Initial ED MD evaluation within 10 minutes
  2. Stabilize ABCs
  3. Last known well time (LKWT), patient’s age, and deficit (consider deferring complete NIHSS until after activated)
4. ACTIVATE CODE STROKE: notify ED clerk to page with information above: “code stroke, name/MRN if available, location, age, M/F, deficits/NIHSS, LKWT”
  1. p0921: Batch page to Neurology (chief and attending, resident on call), lab, CT tech, radiology/IR, ED pharmacist, patient flow coordinator
  2. Neurology to bedside to evaluate patient w/in 15min
5. Prior to CT, in AED room
  1. Complete ED MD evaluation/orders: Perform full NIHSS exam, and use order set “ED Suspected Stroke TPA Intervention Candidate Initial Orders”
  2. Automatic Imaging: CT head, CTA head and neck, CT cerebral perfusion study (can cancel later if a bleed on non-contrast CT)
  3. Labs/Studies
    1. Automatic: CBC, BMP, PT/PTT, POC glucose, POC chemistry for Cr
    2. Consider: EKG, troponin, T&S, CXR, Upreg, U/A, Utox (NOT in order set)
    3. RN: obtain POC glucose and chemistry (including Cr), place 2 large bore IVs, send blood work to lab
6. Go to CT
  1. Always CT head non-contrast
  2. Complete NIHSS if not already done so
  3. IF high risk of Large Vessel Occlusion with NIHSS ≥ 6 obtain CT Perfusion and CTA Head and Neck at the same time [regardless of if Cr on POC testing]
7. Back to AED room from CT
  1. RN to obtain weight from scale on bed, EKG/CXR and other studies as needed
  2. Further history as needed (including TPA contraindications https://www.wikem.org/wiki/Thrombolysis_in_Acute_Ischemic_Stroke_(tPA), await CT results
8. CT Head result – Radiology calls Neurology Spectralink 23369 with read (back up ED clerk transferred to resident Spectralink)
  1. Intracranial hemorrhage
    1. Neurosurgery consult, if subarachnoid hemorrhage consider IR intervention; admit neurosurgery ICU
  2. No intracranial hemorrhage
    1. <4.5 hours from LKWT, 18+ years old = possible TPA Candidate
      1. TPA Candidate (no ICH, symptoms <4.5 hours). Use “ED Ischemic Stroke/TIA” order set
        Manage BP to goal SBP <180, DBP <105
        IV labetalol, Nicardipine drip (in order set); if still uncontrolled, no TPA
        
        If not IR candidate as below and no contraindications to TPA Neurology consents patient, discuss with neurology ED team; Neurology orders TPA (alteplase), ED as backup if Neurology unable
        TPA protocol per neurology/ED pharmacist (in order set): 0.9 mg/kg IV (max 90mg) total with 10% as bolus and remainder over 60 min
        
        Admit to neuro ICU
        Q15 minutes neuro checks for first 2 hours
        
        No anticoagulation/antiplatelets for 24 hours
        
        No foley catheter or NG tube placement after TPA
        
        Consider ordering MRI brain with DWI (non-contrast), MRA head and neck with and without contrast
    2. <6 24 hours from LKWT, NIHSS ≥ 6, CTA findings of large vessel obstruction = possible IR thrombectomy candidate
      1. IR Thrombectomy candidate (<6 hours with LVO on CTA, up to 24 hours in some cases – DAWN trial); Neurology will activate stroke IR batch page
        Yes IR Capacity --> obtain CT cerebral perfusion --> IR thrombectomy; admit to neurology ICU
        
        No IR Capacity --> give TPA if candidate as above; Neurology coordinates transfer to Comprehensive Stroke Center (Long Beach 562-480-3487 or Little Co of Mary, Torrance 310-4-STROKE. Do not use MAC, the accepting comprehensive stroke center arranged their own transport)
    3. 4.5-24 hours from LKWT without suspicion for LVO = Not TPA or IR Candidate
      1. Not TPA Candidate, no evidence of LVO
        Give aspirin, permissive HTN (only treat for SBP >220, DBP >120), glucose control (60-180), early swallow evaluation by RN
        
        Admit to neurology on telemetry for further workup/management

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

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)

Minimum Content for Attending Notes

For patients ADMITTED or PLACED ON OBSERVATION OR CORE STATUS
- Acute problem list (should justify the need for Admission/OBS/CORE)
- Brief history supporting admission/OBS/CORE required only if problem list does not support your decision
- Care Level (ICU/PCU/Tele/Ward, etc.)
- Admitting Service

(Note should be placed prior to or as close to the time of the order for this activity (Admission/OBS/CORE) as possible.)

For patients STILL ON THE TRACKING BOARD at time of sign out (INCLUDING discharged patients still on board)
- Acute problem list
- Brief plan, if known
- Disposition, if already determined or discussed with housestaff, that the attending would feel comfortable with without further involvement of the oncoming attending.
For all DISCHARGED patients (NOT left over on TRACKING BOARD - but departed ED during your shift)
- Documentation is at the discretion of the attending. No specific or minimum documentation (other than a signature on the housestaff H&P.) is required. If documentation is desired, it can be made either as an addendum to the H&P or in a separate Attending Note

(Faculty Agreement 11/16)

Resident Documentation

1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. Attending".
2. If you are a senior seeing and discharging a patient independently and discharge without presenting the patient, please use the phrase "Seen under supervision of Dr. Attending".
3. When working with an intern or NP, its always important that you independently confirm the key elements of the intern or NP's history and physical. When documenting involvement, residents should:
- a) Have the intern submit the chart to you for SIGNATURE, not just REVIEW
- b) Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM
- c) Your ADDENDUM must at a minimum state what you did independently.
- d) Remember, medical student patients require a completely separate and complete H & P.
4. Try not to put raw data into your note that exists elsewhere in the EHR. Instead, you should comment on your interpretation of that data.
5. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.

E-Prescribing

Ask patient if they would like to pick it up at Harbor - convenient, low cost to patient, saves county $$$
- Pharmacy hours M-F 7a - 10p, Weekend and Holidays 8a - 6p
- x5434, 5433 - Call if discharging pt <1 hour from closing time so they know to fill the Rx
  - When selecting location ("send to"), choose "find pharmacy" instead of the default printer
  - In Pharmacy name, type "HUMC" and select "LA CO HUMC OPD" then sign and it is on its way to being filled before you even discharge the patient
If OOP, patients seen in the ED, clinics, or post-hospital discharge may fill their prescriptions at Harbor pharmacies, but they will have to pay out of pocket.
Changing a prescription that has already been transmitted:
- 1. If a pharmacy calls asking for the script to be sent elsewhere, tell them to cancel the rx they received. If you receive the call from the patient, you will need to call the pharmacy. Cancelling in ORCHID does not retract the prescription once it has been transmitted.
- 2. Use the “Cancel and Reorder” function in ORCHID to rewrite the prescription to the new pharmacy.

CODES

CODE ASSIST

Physicians are NOT part of the ED Code Assist Team. The ED Code Assist team is comprised of nurses.
The ED Code Assist Team covers the first floor and basement, but NOT 1 South.
The rest of the hospital and 1 South are covered by the Inpatient Code Assist Team.

(Hosp Policy 375B 9/16)

CODE BLUE

All Code Blues are run by the Inpatient Code Blue Team (Not the ED).
ED will respond to manage airway only when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.

(Hosp Policy 375B 9/16)

CODE WHITE

All Code Whites are run by the Inpatient Code White Team (Not the ED).
Anesthesia will be primary airway management for all Code Whites.
ED will also respond when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.

CODE GREEN See "LEGAL"

CODE GOLD See "LEGAL"

AIRWAY MANAGEMENT TEAM

What Does the Airway Management Team Respond To
- The airway management team is responsible FOR THE AIRWAY ONLY and will respond to:

All Airway Management Team Pages
All Code Blues (If already intubated - please check tube placement)
All Code Whites
- Anesthesia primary always
- ED will also respond when on airway management call

Airway Coverage Times

ED - Sunday 7 AM to Wednesday 7 PM

Anesthesia - Wednesday 7 PM to Sunday 7 AM
Whoever has the pager around time of handoff will respond

Who Responds
- Purple Attending, Purple Senior (PGY 3/4) (if available), and ED Pharmacist (if available).
- The Purple Attending may ask the Green Attending or the Peds Attending for assistance at the Purple Attending's discretion.
- The Purple Attending may take another senior resident (PGY 3/4) if the Purple Senior is not available.

Pager Handoff
- Pick Up: Purple Senior gets from OR front desk at 6:50 AM on Sunday.
- Drop Off: Purple Senior to OR front desk at 6:50 PM on Wednesday.
- The pager cases for anesthesia (extra - not tied to phones) are in the purple doctor's box clipped to the boxes for the McGrath blades.

Equipment
- The airway management team bags - purple doc box in the drawers under the pager. There are two bags.
- BVM/PPE/MAPS - plastic bags to the right of the drawers. There are two bags.
- Please replace the ED airway tray with one from the crash cart on the floor where it was used

Keys
- The Purple Attending, Green Attending, Purple Senior, Green Senior and ED Pharmacist have keys to the drawers.

Medications
- Each bag in top compartment:
  - Rocuronium
  - Succinylcholine
  - Etomidate
- Pharmacy will check each day.
- Residents are also responsible for checking the medications and logging this in the log kept in the drawer for pharmacy.
- Replacement of Meds
  - Return the box to the pharmacist with a patient sticker for new box
  - If no pharmacist take used box with a patient sticker to the trauma nurse for new box

Restock and Bag Check
- Whoever uses the bag is responsible for restocking it.
- The bags will be checked by the Purple Senior as part of the 5S process.
- Zip tie after restocking.
- If zip tie is in place, no need to open

Documentation

When you return to the ED:

Search for patient using magnifying glass in top right corner of Firstnet
Click “Ad-Hoc” button at top and complete “ED Procedures” form as usual (This will give you procedure log credit)
Start a new note
Right-click field at the top that says “Type:”
Choose “Document Type List” à “Personal”
Choose “Rapid Response/Code Blue Records”
If you have not added this Document Type to your personal list, choose “Complete” to see entire list
Use the “.edairwayteam” autotext to add the template

Templates

Harbor: Macros and Autotext

RME/TRIAGE

RME Phones

Triage Resident x23223
Triage NP (9a) x23209
FT NP (6a/6p) x23203
FT NP #2 x23222
FT R2 x23210
FT R4 x23213

RME Charge x23930
RME 1 EKG Tech x23922
Chest Pain Triage RN x23909
USA M-F 7a-11p x29737; pgr 501-2047 (Francisco 7a-3p, Reuben 3p-11p)
Lori x23972; Martee x23973

Triage Printer in registration cubby (10.107.132.219; PH011E16RX)

Chappell 10/2017

RME Patient Flow

Goals of Triage
1. Identify the sick patients and get them to the AED quickly
2. Get patient to the most appropriate location for care (UCC, Gyn, Psych)
3. Initiate the diagnostic workup that will help expedite throughput (labs, imaging) so when you see the patient as the definitive provider, all you have to do is make the disposition decision (this may include IV abx, IVF, and occasional add-on labs and testing, but if we do a good job up front, <25% of the patients will need additional tests)
4. Make people feel better – PO Zofran, Tylenol, motrin, maalox
Patient arrival → router who assign triage priority (cardiac, high, normal) and quick reg so orders can be placed
Team Triage → VS by RN with required questions, MSE by Physician/NP
1. Designate patient end location
  1. R12: either next to AED (notify RME charge x23930) or cannot go back to WR due to IV (for CT, etc); task then place in RME 12
    1. RME 12 is the internal waiting room for patients who are too sick to be in the lobby. They should be next for AED and assigned to Purple/Green teams.
    2. They may be individually evaluated in R11.
    3. If there are empty chairs in RME12, patients with an IV simply for CT contrast should stay in R12 until cleared by a provider to remove the IV (i.e., CT resulted)
  2. No designation: plan for AED, stable to go to AWR; task then AED/AWR
    1. If the patient is ESI 4/5, or ESI 3 with high likelihood of discharge after completed workup, they should be placed on the ORANGE team (then designated as "FT ROOM" for immediate discharge once the workup is complete and negative)
  3. FT ROOM: ready for d/c, just needs to be typed up ... Rx, work note, CCC/referral (e-consult)
  4. FLU: No testing needed; move immediately to FT rooms for rapid DC unless triggered RIPT and needs XR
    1. Note: ILI is defined as fever + cough OR sore throat
    2. Empirically treat with Tamiflu if high-risk (<2, >65, preg, COPD, immunosuppressed) and symptoms <48hr. Send Viral Resp Panel PCR if admitted.
2. If arrival to triage is >60 minutes, an additional RN should assist with triage (and provider should be pulled from FastTrack if needed to keep up with the screening)
Bring Back Now
1. Notify the RME Charge (x23930) to identify an immediately available bed
2. Call the AED charge (x23910) to determine which team is getting the patient if going to the trauma bays (otherwise based on geographic assignment)
3. Call the Purple (x23202) or Green (x23206) Attending to notify them of the case and location of the patient
Registration (behind Triage 3)
1. Patients sit in chairs in the hall until seen by registration staff; if no staff, then registration will be done in the back
2. At a minimum, the "financial screening" to determine DHS eligibility will occur, but if slow arrival flow of patients, can perform complete registration at this point
  1. 2nd reg clerk to come to Triage 2 if >2 patients waiting for registration
    1. If Triage 2 is being used clinically, the tasking nurse or USA should take the patient to the ED lobby registration window after tasking is completed
    2. Alternately, the registration clerks can take patients to the main registration window and return them to RME 5
    3. If Registration is still overwhelmed, bypass ESI 2&3 and they can receive full registration in the main ED
Tasking
1. USA/NA to assist with patient movement to AED, FT, UCC, AWR
Reassessment
1. 30 min for IM/IV pain meds, 60 min for PO pain meds (CAP)
2. 2 hours for ESI 2
3. 4 hours for ESI 3-5
Critical Results
1. It does not matter who ordered the lab, imaging study, or EKG - if you are notified of a critical result, deal with it as soon as possible
  1. If a concerning EKG, notify an attending
  2. If a lab or imaging finding that upgrades the patient's urgency to be seen, notify the RME charge (consider BBN or RME 12)
Room Assignments
1. Triage 2 - flex room for overflow triage > providers for discharge > 2nd registration clerk
2. RME 1 = EKG
3. Triage 1, RME 2, RME 3, RME 4 = provider rooms (with one chair outside of each room for "next patient")
4. RME 11 = flex room for evaluation of patient in R12 (AED internal WR) and additional FT room
5. RME 5, RME 6 = Tasking internal WR
6. RME 7 Phlebotomy; RME 8, RME 9 tasking
7. RME 10 - pain reassessment
8. RME12 = next back, IV for CT, etc.

FastTrack

If patient is eligible for UCC (ESI 4-5 with green DHS or MHLA logo), the tasking LVN should let the patient know they are eligible to be seen at the Urgent Care which will likely be a shorter wait, and if they say yes, then the USA or NA can take them over
1. If patient declines or "no UCC" on tracking board, to AWR until labeled as R11 or open room/chair in FT
There are 4 rooms available: Tri1, R2, R3, R4
1. Additionally, there is 1 chair outside of each room for "next up" (labeled with the corresponding patient room) and 2 discharge/tasking chairs (patient location labeled as R5)
  1. R11 is a flex room - primarily used to evaluate patients from R12, but can also be used by FastTrack providers for evaluation and discharge
  2. Due to the 4:1 RN ratio, if discharging a patient out of R11, you are responsible to discharge your own patient
2. Patients labeled "FT ROOM" (ready for discharge) on the ORANGE Team are eligible for placement in FT rooms Tri1, R2, R3, or R4
3. Once a patient is in each room, the next patient should be brought on deck to the chair
4. When FT RN present, patients ready for discharge MAY be placed in the DC chairs by providers for paperwork and instructions
5. When no FT RN
  1. RME Charge RN should help keep the chairs full and assist with discharges as time allows
  2. Providers will place patients back in the tasking queue (RME5) for additional workup items and will discharge their own patients
6. From 11pm to 11am (unless there are still several FT providers), the RME charge should assign 2 FT rooms to the Purple and Green Teams and keep patients cycling into them (no chairs at night)
ORANGE TEAM AT NIGHT
1. If a slow PED night shift or AED is boarded up, look at the "orange team" filter for easily dischargeable patients
  1. When seeing adults in PED
    1. Patients should be discharged by 6:45 AM
    2. PED Attending should discuss placing patients in PED with the PED Charge RN
    3. PED Attending will label the desired patients on the "orange team" list - "OK to PED"
    4. The PED Charge RN will pull the patients from AWR and place into PED rooms, and move their location on the tracking board
    5. Maximum of 4 adult patients at a time in PED
    6. If it appears that the patient will require a more extensive work-up or admission then the adult charge nurse should be made aware so the patient can be moved when a bed opens up.
    7. Purple or Green teams may use PED rooms to see more patients from the AED
      1. This must first be cleared with the charge nurse on pediatrics
      2. These patients are the responsibility of the purple/green team not the PED team
      3. Each team may use a max of 2 rooms at a time
      4. These patients should be able to be discharged by 7 am
      5. The AED attending can indicate which patients by placing "Peds – purple" or "Peds - green" in the nursing comments after they have discussed this with the PED Attending AND PED Charge RN
      6. Once the patient is roomed on the Pediatric side, the charge nurse will place them on either the purple or green team filter
      7. If it seems as if the patient will need admission or a longer stay than anticipated, the PED Charge RN should immediately notify the AED charge nurse so the patient can be moved to the AED when a bed becomes available
FastTrack Nurse Role and Responsibilities
1. Assignment: Tri1, R2, R3, R4
  1. Patients eligible for FastTrack: ESI 4 & 5, or ESI 3 with completed workups that are expected to be discharged after final provider evaluation
    1. If a patient is seen in FT and requires obs or admission and no rooms are available, they should be moved to R12 until a room is available
    2. If a bed is available, care of patient should be transferred to a member of the Purple or Green Teams
2. Flow
  1. Team triage --> RME-Reg --> R5 --> FT rooms or chairs (or AWR if no empty chairs)
    1. Keep 4 patients in the FT rooms, and 4 additional patients waiting in the FT chairs outside the FT rooms
    2. Based on longest LOS if there are multiple “R11” patients labeled on the tracking board in the RN comments column
    3. If unclear, communicate with the FT Providers for preference of patients
3. Nursing Tasks
  1. Perform for any additional workup needs (meds, labs, etc.)
  2. Place any needed IV’s for medication or studies and remove the IV once cleared by provider
  3. If you give a pain medication, you should re-check pain at the appropriate 30 (IM or IV) to 60 (PO) minute timeframe
  4. Chaperone providers for any genital exams
    1. If a patient needs a pelvic exam, help patient undress in the exam room and setup equipment for provider
  5. Send off collected specimens to lab (wet mount, ascitic fluid, etc.)
  6. Discharge
    1. Repeat Vital Signs prior to discharge and notify provider of abnormalities
    2. Coordinate with clerk to make follow-up appointments
    3. Re-iterate discharge instructions and follow-up plan, answer any additional patient questions prior to discharge (should have been done already by providers), get signatures
    4. Remove patients from tracking board after discharge
ED R4 Fast Track Note
1. Label as R4 Ind Note
2. Forward to Green attending unless staffed with someone else

Chappell 1/2018

Triaging Clinic Patients

Because we have a large volume of patients waiting at any given time, many of whom are quite ill, we support independent medical decision-making about whether a patient coming from a clinic needs immediate attention or can safely wait to be triaged.

We do ask however that when triaging clinic patients, you follow the same protocol we use for ambulance patients. Specifically, should a resident decide that a clinic patient is stable to go wait in the waiting room, they discuss it with the attending and document that decision in the medical record. You can use the same autotext you'd use for an ambulance patient.

If you decide that the patient is not stable to go to triage/waiting room, please keep them in the AED.

Direct to Back

IF beds in the AED are wide open (> 3-4 open beds including Trauma), still perform team triage, but:
- RN
  - takes vitals
  - asks the necessary triage questions (RIPT, etc)
  - documents the triage form
- PROVIDER
  - screens for critical patients,
  - click MSE note,
  - assign ESI,
  - assign to FT Team if low acuity
  - If critical let the receiving team know.
- PATIENT REGISTERED
- PLACE IN ROOM
  - FT room if low acuity, assign to team if no FT provider
  - Do not send patients to UCC/GYN UCC
  - EXCEPTION: RME charge may direct to UCC/GYN UCC if no FT rooms and wait less than 1 hour in UCC/GYN UCC
  - Tasking done in FT/AED room by that room's nurse
  - EXCEPTION: RME Charge may have patient stop at tasking if AED busy

Peterson 7/23/18

Criteria for an immediate transfer to Chest Pain Room

Router RN identifies patient with Triage Priority "Cardiac" based on:
1. Age >35 AND chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
2. Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
3. Age >65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
4. Clinical concern for myocardial ischemia exists despite absence of 1-3.
Router RN calls CP Triage RN x23909 and handoff patient to CP Triage RN at RME 1; 2 chairs available if another patient is currently getting EKG
- CP Triage RN orders EKG, call EKG Tech x23922 if not in RME 1, and notifies the triage provider if they are not already present (x23223 7a-11p [physician], x23203 11p-7a [NP])
  - Coming March 2018 - auto-EKG order with cardiac priority patients from router
  - EKG Tech will hand the EKG to a R4 or Attending (NP ok if interpretation is "sinus rhythm")
    - If STEMI:
      - Notify Charge RN x23910 to determine which team will be assigned and what room is available
      - Triage provider should immediately notify the appropriate attending (Purple x23202, Green x23206)
      - The AED team is responsible for activating the cath lab and speaking with interventional cardiology
  - If no other patients are waiting for EKG, MSE can be performed in RME 1; otherwise, patient with completed EKG should be taken back to a triage room for MSE while additional patients are getting EKG
  - Patient then gets financial screening and should be moved to RME 5/6 for Tasking
  - Once tasking is completed, they should be moved to the appropriate location based on the "RN Comments" column notation

Chappell 4/2017

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

Patient Transfers to other areas of the hospital

Psych ED

If the patient has a primary psychiatric complaint and wishes to be seen in the Psych ED, and the triage provider feels the patient is medically stable for psychiatric evaluation without any further testing needed, the Triage RN should call the psych ED for verbal handoff and escort the patient to the psych ED
Triage provider will complete an MSE note in ORCHID
If any further clarification is needed, the triage provider should discuss the case with the psych resident
If there is any concern for safety, the Sheriffs are available to chaperone the escort from triage to the psych ED

Gyn UCC

Must be DHS Eligible (or MHLA)
Check HCG and H/H
Have RME clerk make same-day (typically available until 1pm) or next day appointment depending on the complaint
Only requires MSE note unless unable to schedule appointment

Urgent Care

Transfer of Low Acuity Patients from ED to UCC

UCC Charge RN: x8111, 8110; RME Charge x23930
- Starting 12/3/18. 7:45am phone huddle to discuss volume, flow, staffing shortages, etc.
- Once patient has been triaged/received MSE and designated as ESI 4-5, they will be financially screened by registration for DHS eligibility and then placed in RME 5-6
  - If the patient is eligible for UCC (as designated by the green DHS or MHLA logo), the patient should be offered the opportunity to be seen at UCC as it will likely be a shorter wait; if the patient declines, they will remain in FastTrack
    - Eligible patients include DHS, MHLA, and SELF PAY
    - EXCLUDED PATIENTS: chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, any trauma to the cervical spine, pregnant/vag bleeding, or psych care

- - - Financial Screening - once financial screening is done, the patient will be assigned the green "DHS" logo or the orange "OOP" icon (meaning they must stay in the ED); NOTE: the golden key will not disappear when only the financial screen has been performed (only when full registration is complete); if golden key still present at time of discharge, please discharge to the registration window
  - UCC hours of transfer are:
    - Monday to Friday 8am - 8pm with the exception of no transfers Tuesdays 8am to 12:30
    - Saturday and Sunday 8am - 1pm

Once the patient is taken to UCC, they need to be moved in Orchid to UCWR
UCC Nuances
1. There is no maximum number on the subjective pain scale that precludes transfer to UCC
2. Pain meds should be given prior to sending to UCC; the patient will be re-assessed upon arrival at UCC by their intake provider
3. It is ok to transfer a patient who has received an MSE and work-up has been initiated (i.e., x-rays ordered/performed); any orders that have not been completed may be canceled by the definitive provider in UCC
4. UCC is unable to do CCC but can request e-consult
5. The UCC has full access to ortho via the cast room
6. The ability to do simple laceration repair is provider dependent, so please call prior to transferring such patients
Despite best efforts to properly screen the patients, if it is later determined that a patient is OOP, they will still be seen in UCC and not returned to the ED simply for financial concerns in the spirit of patient-centered care.

Pausing Patient Flow from ED to UCC

UCC physician should assess the current volume of patients in UCC WR as well as current and expected coverage (not counting discharged patients in UCC10)
1. If greater than the expected disposition ratios (NP: 2/hr, Attending 3/hr), discuss with the UCC Medical Director
2. If there is any concern about patient safety, call the UCC Medical Director
3. If UCC Medical Director agrees, they will discuss with RME Medical Director the options of slowing or stopping flow and RME Medical Director will instruct the RME Charge RN based on the joint medical directors' decision
  1. If either UCC or RME Medical Director is unable to contact the other director, they will use their best judgment and call the RME Charge RN (x23930) with directives

Transfer of Patients from UCC to ED

Patients presenting to the UCC with the following complaints may be immediately transferred to the ED upon presentation without ever being seen by an UCC provider simply based on stated complaint: chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, pregnant/vag bleeding, or psych care
If the decision is made to transfer a patient back to the ED, there must be a physician to physician conversation as to why the patient’s workup cannot be completed in the UCC; call Triage physician x23223 prior to sending back to the ED; Green team attending x23206 or Purple team attending x23202 are alternates
The UCC nurse will transition care to the Triage reassessment RN who will then determine the most appropriate next step for the patient (immediate triage by team, WR queue for triage, etc)

Chappell 7/2017

FastTrack Roles

NP
1. from SW
2. LBTC f/ups after 7a screening resident comes
R4
1. from SW
R2
1. from SW

NP Independent Workup Guidelines

NPs may independently order any x-rays deemed appropriate.
- Consider XR above and below the injured joint
In Chest Pain pts, obtain a brief history and present to an attending or R4 if signs or symptoms of cardiac ischemia or an EKG read that is not “normal sinus rhythm”
NPs should NOT provide care to employees with occupational exposures
Trauma
- ED NP's are not involved in the care of Trauma Team Activation patients. Our NP's may perform the initial medical screening exam of walk-in patients with minor injuries in Triage, but the care of all trauma patients will be performed by a physician that is ATLS certified.
- If, in the course of evaluating a patient with a minor trauma, it is determined that the patient meets trauma team activation criteria, care of the patient should immediately be turned over to an AED team.
- If it is determined that a patient with an isolated injury needs admission for surgical repair, the care of the patient will be transferred to an AED Team and Trauma Team consulted prior to admission. (Putnam, 2/2017)

Select advanced imaging listed below may be ordered independently when the pertinent decision rules are applied. All other advanced imaging studies (ultrasound, CT, or MRI) must be discussed with an attending physician (not senior resident) prior to ordering.
- Non-contrast CT of the brain:
  - For symptoms of “sudden onset” headache or “worst headache of life”
    - Consider CTA Brain for aneurysm if the patient is unwilling to have lumbar puncture (discuss CTA with attending)
  - For patients who have minor head trauma
    - Follow the ACEP Clinical Policy Statement:
      - Loss of consciousness or post-traumatic amnesia PLUS one of the following: headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication).
      - Consider if no loss of consciousness but presence of focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
    - OR the Canadian Guidelines:
      - Presenting within 24 hours of closed head injury with initial GCS 13-15 and LOC, confusion, or amnesia to event
        Excludes minimal trauma with no LOC, anticoagulation use, focal neuro deficit, and post-injury seizure
      - CT if GCS <15 two hours post-injury, suspected open or depressed skull fracture, signs of basilar skull fracture (CSF otorrhea/rhinorrhea, battle signs, raccoon eyes), >2 episodes of vomiting post trauma, age>65, retrograde amnesia>30 min to event, mechanism (ejection from vehicle, MVA vs pedestrian, fall >3 feet or 5 stairs)
- CT brain with IV contrast
  - Patients being evaluated for mass/tumor or those with HIV and new onset headache
- Non-contrast CT of cervical spine
  - If any of the NEXUS criteria is present: Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
- Right upper quadrant ultrasound
  - Patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
- Non-contrast CT of the abdomen/pelvis
  - Patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
  - If previous CT confirms stone, consider renal ultrasound to evaluate for hydronephrosis
- Pelvic ultrasound
  - Patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding
- Risk Stratification for DVT
  - Well’s Criteria: Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous DVT(+1), and alternative diagnosis as likely (-2)
    - If low-risk Well’s (score of 0-1), order d-dimer
    - If score greater than 1, order formal (not bedside) Lower Extremity Doppler US and d-dimer
- Risk Stratification for PE
  - If low pre-test probability and PERC negative, no further testing for PE necessary
    - PERC measures: Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks
  - If patient falls out of PERC, then apply Well’s criteria:
    - Clinical signs and symptoms of DVT(+3), PE #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
      - If score 4 or less, order d-dimer
      - If Score >4, CTA or VQ scan (if contra-indication to CTA)
      - If pregnant, discuss with attending

Chappell 7/2017, rev 12/2018

Being Seen by Consultants Prior to ED Evaluation

ED Policy 3.3
- A consultant may request from RME/AED attending or senior resident to see or take a patient to clinic
- Once the specialty evaluation is completed, documentation of both exam and assessment/plan should be in ORCHID and communicated to the ED provider
- ED to disposition the patient after evaluating for any other needs (full chart)
Alternately, if the patient has already been evaluated in the ED and found to have an isolated problem that is best cared for by the consulting specialist, care of the patient should be transferred from the ED to the specialist who should discharge them from clinic unless there are extenuating circumstances

Chappell 4/2017

NP Consultation Guidelines

Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult

If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.
If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and alpha-page the consult service.

Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending
Please obtain the vital signs of the eyes prior to consultation (visual acuity, PERRLA, EOMI, quadrantopia, IOP, US for detachment if pertinent)
- If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation

Chappell 4/2017

NP Consultation with the Attending Physician

As defined in the Standardized Procedures:

Patient has unstable vital signs.
There is an acute focal neurological deficit.
The diagnosis/problem is not covered by the standardized procedures list.
There is an emergent condition requiring prompt medical intervention.
Patient and/or family requests to be seen by a physician.

Any case requiring admission, observation, or going directly to the OR should be staffed with an attending. All admissions performed by an NP require an Attending Admission Note (see "Admit Process" for contents of note)
If an NP wishes to disposition any patient they have consulted an attending physician on (even if the patient's condition is on the independent disposition list), the attending MUST sign the chart.
- NPs will refer all such charts to the attending for signature.
It is expected that on any case that an attending has been consulted, the NP will discuss the disposition of the patient with the attending before actual disposition.
- It is at the discretion of the attending whether or not to personally evaluate the patient, however the attending physician will be responsible for the care delivered to the patient.
- Patients who are under the care of an NP but have been discussed with an attending physician may have the attending's name placed in the attending column but should NOT be given a team color unless requested by the attending.

Chappell 4/2017

NP Independent Discharge Guidelines

A physician is always immediately available in the ED. NPs may independently discharge the following patients as long as they feel physician consultation is not warranted:
- General:
  - Any patients with a triaged Emergency Severity Index (ESI) score of 4 or 5
  - Allergic reactions (without signs of anaphylaxis)
  - Hyperglycemia (asymptomatic, no DKA/HHS)
  - Medication refills
  - Psychiatric Patients without psychosis, homicidal ideation, or suicidality may not be independently dispositioned by a NP, but a NP may provide the medical screening exam and transfer these patients directly to the Psychiatric ED if it is deemed no additional medical workup is necessary prior to psychiatric evaluation
- Dermatology Conditions:
  - Breast Complaints
  - Burns: Superficial (1st) and Partial Thickness (2nd) which do not meet Burn Center Referral Criteria (3rd degree, 2nd degree with greater than 10% total body surface area, burns of eyes, face, hands, feet, perineum, electrical injuries, inhalation injuries)
  - Cellulitis or simple abscess
  - Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury)
  - Rash (no petechiae/purpura)
- Neurological Conditions:
  - Bell’s Palsy with complete unilateral facial paralysis (upper and lower) and no other focal neurological deficits
  - Dizziness consistent with Peripheral Vertigo (normal HINTS exam, no cerebellar findings, stable gait)
  - Seizures (known disorder, no new trauma)
- HEENT Conditions
  - Conjunctivitis
  - Dental complaints without signs of necrotizing or deep space infection
  - Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin)
  - Pharyngitis without signs of peritonsillar abscess or epiglottitis
  - Minor head or facial trauma
  - Ocular complaints (no significant acute vision changes, no trauma)
- Cardiovascular Conditions:
  - Chest pain (low risk) as evidenced by the patient having NONE of the following factors: HEART Score >4, age > 30, syncope, persistent dyspnea, IV drug use history, significant family history of early cardiac disease or sudden death, persistent tachycardia, abnormal EKG/arrhythmia
  - Hypertension (asymptomatic)
  - Palpitations without arrhythmia noted on EKG
- Respiratory Conditions:
  - Asthma exacerbation that responds to Albuterol, not immune compromised
  - URI
- Gastrological/Genitourinary Conditions:
  - Abdominal pain that is now resolved in patients <45 years old (with a negative pregnancy test in females)
  - Constipation without signs/symptoms of obstruction
  - Dysfunctional uterine bleeding without active hemorrhage and with stable hemoglobin
  - Hemorrhoids (non-thrombosed)
  - Nausea and vomiting without significant abdominal pain
  - Simple UTI in non-pregnant patient
  - Sexually transmitted infection
- Musculoskeletal
  - Low back pain without associated fever or neurologic deficits
  - Musculoskeletal pain/injuries
  - Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
    - Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks
    - Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week
    - Humerus:
      - Proximal: non-displaced; sling, ortho in 1 week
      - Shaft: non-displaced; sugar tong/sling, ortho 1 week
    - Radius:
      - Non-displaced distal or shaft; volar splint, ortho 2 weeks
      - Non-displaced head with good ROM: sling, ortho in 2 weeks
    - Ulna: non-displaced; volar splint, ortho 2 weeks
    - Occult Scaphoid: thumb spica splint, ortho in 3 weeks
    - Metacarpal: non-displaced shaft and neck
      - MCP 4&5: Ulnar gutter splint, ortho 3 weeks
      - MCP 2&3: Radial gutter splint, ortho 3 weeks
    - PIP/DIP dislocations: simple, no fracture; buddy tape with padding between digits/splint, ortho 1 week
    - Hand: Distal Phalanx - buddy tape/alumiform splint, ortho in 3 weeks
    - Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks
    - Foot: non-displaced phalanx fracture - buddy tape, ortho in 2 weeks
    - Chronic or non-healing fracture: CCC for e-consult (call ortho if needs closer follow-up)
- Exclusion:
  - Any cases not specifically listed on the inclusion list
  - Prior to discharge of any patient with a persistent vital sign abnormality needs consultation with a physician.
    - Temp >38F
    - HR > 110 or <50
    - RR> 20, PO2 <92% on room air (or patient’s home oxygen dose)
    - SBP >210 or <100, DBP >120 or <50

Chappell 4/2017, rev 12/2018

Rapid Discharge Procedure

If patient needs an appointment (stress test, CCC, etc), this must be done by the clerk first
Ensure IV has been removed
If vital signs have not been recorded in the past 4 hours, these need to be repeated and recorded prior to discharge
Include CHC referral sheet (at RME clerk computer) if patient has no PCP
SIGN and TIME paper discharge instruction sheet
option#1: Give ED copy of the signed discharge papers to the RN/LVN who can discharge them with the appropriate timestamp to accurately capture LOS
option#2: When completing the admit/discharge screen, click the bottom box (yellow highlight) "patient demonstrates understanding of instructions given"
1. click the "discharge" button
2. Enter discharge disposition: "home"
3. Enter discharge date
4. Enter discharge time
5. Click complete
6. Give signed discharge papers to the patient's nurse or place in bottom slot of black divider at RME Clerk desk

RIPT

Read CXR - if negative can DC airborne precautions (unless patient immunocompromised/HIV - need more detailed Hx/PE)
Place wet read in system
DC Airborne precautions by right clicking on order under "Review Orders" - usu. its the very last order on the page
Document a note using .edript dotphrase
Important points
1. Precautions are only discontinued if the lung fields are completely normal; if not the patient should receive a more complete history and physical prior to discontinuing precautions.
2. NPs do not read the chest x-rays themselves, but can act on a chest x-ray that's been read by a radiologist.

M. Peterson DIR OPS 6/8/18

Discharge to Chairs

Pilot Starting 2/5/18
- We often have patients in rooms waiting final lab result or radiology interpretation prior to discharge. This process is intended to decrease the room turnover time by having the room cleaned while the patient is awaiting final discharge, allowing for immediate turnover once the patient is discharged.
- Criteria:
  - A & O x 4
  - Ambulatory
  - Clear plan for disposition
  - Able to sit in chair without assistance
  - No fall risk
- Provider:
  - Place comment in comment section “chair for DC”
  - Patient should not be expected to sit in the chair for greater than 30 mins
- Patient Nurse/Charge Nurse
  - Ensure patient meets above criteria
  - Notify EVS to clean the room
  - Help remind provider when the pending test result is completed

LBTC FOLLOW-UPS

The 6am NP should f/up on LBTC patients from the previous 24 hours once the 7am physician is settled into triage

Log into FirstNet
Click on “HAR Lookup” – teal tab at the top of the tracking board
Change filter to discharged within 36 hours
Sort by “Disposition” column
Scroll down to “Left – LBTC after MSE”
Review Labs
Review imaging – for plain films, right click the 1/1/0, left click the blue + sign, click negative, and then click ok (this will send radiology the wet read so they know to contact us if there is a discrepancy
If there are any concerning labs or imaging, call the patient back and enter a note entitled “Patient Call-back Note”
If unable to contact the patient, then ask the clerk for a telegram form, fill it out, and have the clerk send it
If there is nothing of concern, write “reviewed” in the comment column so the next person knows where to start
Staff any questions with the R4 only or Attending

Chappell 4/2017

LEGAL

AB 2760: Naloxone for patients at risk for opioid overdose

Requires providers to offer a prescription for naloxone (or other reversal agent) when

Prescribing ≥90 morphine milligram equivalents/day (for example, 9 Norco 10/325 tabs/day) Here is a link to the CDC tool for daily opioid dose calculations: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf, or
When co-prescribing an opiate with a benzodiazepine.
'Even when not prescribing opioids if the patient just has a history of overdose or substance use disorder', or if the patient is at risk for returning to a high dose of opioid medication to which he or she is no longer tolerant. Cal/ACEP is looking further into this latter provision but for now, it’s the law.

At Harbor, we have naloxone intranasal on formulary. Further, if a prescription for naloxone (or other reversal agent) is given, the provider 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. Patient Handout. We are working making this flyer available at each clerk’s station and in the doc boxes, and there are similar naloxone instructions in ORCHID.

SB 1152 - New California homeless patient discharge planning law

Bottom line,

Consult social work as early as possible once you have identified a homeless patient ("HL" icon). Social work wants to be consulted for EVERY homeless patient.
Infectious disease (ID) screening and vaccinations are now mandated by law, so based on current ID concerns, please document that you offered Hep A vaccine to those that qualify since there is an ongoing Hep A outbreak.
If medically appropriate, please order a meal prior to discharge.

Details:

New definition of homeless:
- Lack fixed and regular nighttime residence
- Primary nighttime residence in supervised area or area not designed for living/sleeping
- Examples: Car, shelters, tent, hotel, street, beach, park, abandoned building, bus/train station, etc.
Offer meal - please order of medically appropriate: Provider and RN
Offer weather appropriate clothing - SW and RN
Discharge meds or prescriptions - Provider
Referral for follow up care - Provider
Offer infectious disease screening and vaccinations: Currently, Hep A vaccine to address local outbreak. Provider and RN.
Offer transportation: bus tokens from social work, House Supervisor, Registration
Screening for affordable healthcare coverage: Patient Financial Services (PFS), Registration
Identify post-discharge destination: SW
Communicate discharge needs to receiving entity: SW

More info: https://californiaacep.site-ym.com/page/Legislation_Implementation

INVOLUNTARY HOLDS, CODE GOLD, COLD GREEN

Psychiatric reason:
- 5150 (5585 for Peds) only for a mental health disorder.
- Voluntary patients usually not placed on a 5150/5585, but can be.
- Non-psychiatric medical personnel can detain anyone who meets criteria until they can be evaluated by a psychiatrist.
- 5150 can be placed by:
  - Psychiatrist ONLY INSIDE MAIN HOSPITAL BUILDING
  - Sheriff ANYWHERE OUTSIDE MAIN HOSPITAL BUILDING, including rest of hospital grounds
    - Sheriff has independent authority to place the 5150 or not

Medical reason:
- Patients who lack capacity and are a danger to themselves or others for non-psychiatric reasons. Do not need psych consult to determine capacity when restraining patient for a medical reasons, and psych cannot override decision to restrain a patient for non-psychiatric reasons. DO NOT REFER TO THIS AS A "HOLD" AS THIS MAY LEAD LAW ENFORCEMENT TO BELIEVE THE PATIENT IS ON A 5150.
- If they try to elope you can detain/restrain, if they become violent or aggressive, call a CODE GOLD (see below).
- These patients can be held against their will for their own safety no 5150 is required or applies (5150 for psych issues only).
- No specific legal form for restraining medical patients - document reasons in chart. Use restraint form for restraints.

Code GOLD:
- For all patients who become physically aggressive, either for psychiatric or medical reasons.
- They will be placed in hard restraints by CODE GOLD team
- Call x111.
- No requirement patient be placed or already on 5150
- LASD (Sheriff) responds but is not part of team, only assists if detect or to prevent criminal activity by patient (assault)
- Behavioral Response Team leader (BRT) should ID themselves on arrival and ED physician or nurse in charge of patient should brief them.
- BRT leader has option of turning over situation to LASD as needed.

Code GREEN:
- Already on or eligible for a 5150/5585 and attempting to, or have physically left the department.
- Call x3311 LASD(Sheriff)
- On a 5150 hold - LASD will return patient
- NOT on 5150 hold
  - Inside Hospital Building - LASD can only convince patient to return - can't forcibly return. Only Psych can place 5150 inside hospital building
  - Outside Hospital Building - LASD makes independent determination to place patient on 5150
    - Physician or nurse in charge of patient should brief LASD if patient on 5150 or if not, indication for 5150
- If LASD decides not to place patient on 5150, document Code Green in chart and officers involved

Code GRAY
- ANYONE (patient, visitor, staff) who is combative or assaultive and it is not felt due to a medical or psychiatric reason

Above vetted by Law Enforcement, Psychiatry, Behavioral Response Team, ED Leadership, and Nursing leadership
Additional References
- 436 Procedures in Cases To Be Reported to Are Investigated by Law Enforcement Authorities
- 301 Discharge Policy, Procedures, and Guidelines Including Elopement and AMA
- 138 Law Enforcement Use of Force on Harbor-UCLA Campus
- 347A The Use of Restraints Including Seclusion
- 346 Involuntary Holds on and on Psychiatric Units and Emergency Medical Department
- 379 Safety Attendant (Continuous in Person Monitoring)
- 453 Patients in Police Custody
- 347B Code Gold-Behavioral Response Team
- 620 Consent for Medical Treatment for Patient Lacking the Capacity to Provide Consent
- Sheriff "Cheat Sheet" for Code Green and Code Gold

Public Health
- (213) 745-0800 (Tb)
- 213-974-1234 after hours

Dir OPS 10/15/18 Dir AED, 10/28/16

Mandatory Reporting of Adverse Events

There are events which we must report to the state in a timely fashion or face being penalized by State Licensing. Below are some general guidelines for what to report. Please make sure that the ED attending is aware of these events and documents their involvement in the record (HUMC Policy 612B).

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

Immediate supervisor
SI (Safety Intelligence System entry)
Risk Management x2168

Events to be Reported

Procedure performed on a wrong body part, patient, or the wrong procedure all together.
Death or disability from any medication error, blood product incompatibility, hypoglycemia, intravascular air embolus, falls, or burns that occur while in the ED
Patient death or serious disability through any actions or errors which are not an expected part of the patients medical condition or treatment, including elopement of an incompetent individual or minor, abduction, or assault (physical or sexual).
Retention of a foreign object (e.g. central line guidewire)
Patient suicide or serious injury from suicide attempt while in the ED
Visitor or staff death or severe disability while on hospital grounds for any reason.
An infant discharged to the wrong person.
A maternal death or serious disability within 42 days post delivery
Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

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

(Hospital policies 612A, 612B 5/14, CMO 7/2017)

Prescriptions

Lost Triplicate Prescriptions

If you find that your providers are missing prescriptions or are contacted from a pharmacy regarding suspected fraudulent prescriptions please do the following as required by the Department of Justice,.If you are unsure if you are missing any individual prescriptions, please assume that they have been stolen and report.

The loss or theft must be reported by the physician to local law enforcement. The physician should take note of the law enforcement agency report number.
The loss or theft must be reported by the physician to the Department of Justice Controlled Substance Utilization Review and Evaluation System (CURES) program. A law enforcement agency report number is required when submitting a report of lost or stolen prescription forms to CURES.
The physician should notify the California State Board of Pharmacy.
The physician should notify the Medical Board of California.
In addition, to the above 4 steps please email Dr. Harrington at dharrington@dhs.lacounty.gov.

D. Harrington, 11/3/16

Safe Pain Medication Prescribing Guidelines

We will be shortly launching the implementation of the Safe Pain Medication Prescribing Guidelines, a Los Angeles county-wide project to decrease inappropriate opioid prescriptions from the ED and other settings. Patients will receive upon discharge a color pamphlet (English or Spanish) explaining the project, including messages about how stolen prescriptions need to be reported to the police, that the ED does not refill pain pills and that pain pills for chronic pain should really come from a single, continuity provider. Residents, NPs, and nursing staff got some in-depth lectures about this. (Dir Adult ED 10/14/14)

Template:Triaging Ambulance Patients

Template:Harbor follow up

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 is 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. The House Supervisor should also be notified (x3434) before involving law enforcement. 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 AED 5/26/16

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
1. UR can help with insurance specific contact info for coordination of ambulance
2. 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
1. If pt lives outside of LA County, call nursing supervisor or SW as they may need further authorization

J Singh 5/9/17

kids without car seats: For kids who arrive (usually by ambulance) w/o a car seat, we do not have car seats available. however, options are:

take the bus home (no need for car seat)
have someone bring a car seat and pick them up or go home in a taxi with the car seat that is brought
if a. or b. will not work, can try arranging for ambulance (see section above)

3. Patient who are homeless:

a. Homeless Task Force - looking for patients with chronic illness (HTN, diabetes, psych, etc) who have had 2+ visits. Put in s/w consult and choose "Homeless" under reason for consult, NOT "Discharge planning/placement". If eligible - they will help sign up the patient - however, they may be on a waitlist for days to months. If an potentially eligible patient is stable for discharge, you may refer them to contact the Homeless Task Force with the following number: 310-848-3325.

b. Patients discharged overnight who are not safe to go out into the night CANNOT wait in the ED lobby. However, they can wait in the main hospital lobby in front of the social work offices to speak with social work for resources on housing in the AM. However, please try to consult SW during the ED visit if possible as there is overnight staff available.

J Singh 7/15/17

5. Patients whom family is no longer able to take care of

Please page social work asap - before family leaves - s/w will work with them to see if:

a. IN HOME SUPPORT SERVICES (IHSS) - Medi-Cal program - can either be started or have hours increased (to help with supervision, cooking, bathing, grocery shopping, other ADLs)

b. other community resources are available

c. help family brainstorm other ideas

d. if family dumps patient and doesn't respond, s/w may file an adult protective services report

e. if the patient truly needs to be placed and resources and strategies of a/b/c do not work, per Dr. Wu, please place in obs and the inpatient team will work on placement from there

6. Pt/family not happy with current skilled nursing facility (SNF)

a. generally, this is not an appropriate use of the ED - the family needs to work with the SNF s/w to facilitate transfer to another SNF, exception point c. below

b. if actual abuse, s/w at Harbor can help with ombudsman report

c. APPROPRIATE if pt needs a HIGHER level of care b/c of medical needs - then s/w at Harbor can help

d. Different levels of care are outlined in slides (attached) - shelter vs respite vs board and care vs SNF vs ?

7. Clothing rack / clothing for patients

a. s/w has a small stash in ED - consult/page to get access

Located behind double doors in ambulance bay. NA-7 key for access.

b. volunteers office has another stash but only open 8-5 M-F

ED stash is in need of donations for men's pants, flip flops, sweat pants, sweat shirts

J Singh 5/9/17

8. Patients who need PT/OT for placement

a. place the patient in obs for placement and PT/OT evaluation - this way the hospitalist can then admit the patient from obs if they cannot get PT/OT (which they more likely than not cannot) - this is needed to document the need for PT/OT so we can get resources (it shows how many avoidable admissions there can be as the ED hospitalists are collecting this data manually).

Whole Person Care

For ANY Medi-Cal patients (including OOP) (not just DHS)

Substance Abuse Referrals Wants to stop drug or ETOH use
- ORCHID Message/Call/Text/Email Lelalee Vicedo - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral. (213) 572-9895 OR lvicedo@dhs.lacounty.gov. She will respond M-F 9:00-4:30 pm but you can call/text/email/ORCHID message anytime.
- OR
- Call Whole Person Care Intake Line (24/7) and put patient on phone with intake specialist: 844-804-5200
  - AND place order in ORCHID:
    - Consult to Social Work: reason for referral = substance abuse, comments = WPC
Re-entry (released from prison <6 months with medical, mental health, substance abuse, or social needs) 844.804.5200 (24/7) and put patient on phone.
Medically Complex Transitions of care (includes 3 visits to ED in past year)
- ORCHID Message/Call/Text/Email Lelalee Vicedo - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral. (213) 572-9895 OR lvicedo@dhs.lacounty.gov. She will respond M-F 9:00-4:30 pm but you can ORCHID message/call/text/email anytime.
  - AND place order in ORCHID:
    - Consult to Social Work: reason for referral = other, free text WPC TOC
Perinatal (high-risk pregnant mothers - homeless, mental health, substance abuse, domestic violence, no food) 844.376.2627
Homeless ... social work can help facilitate housing
- Refer to Social Work
  - Place order in ORCHID
    - Consult to Social Work: reason for referral: homeless, free text WPC
Disabled and needs disability benefits (SSI)
- Refer to Social Work
  - Place Order in ORCHID
    - Consult to Social Work: reason for referral: disability benefits, free text WPC
Mental Health
- Residential & Bridging Care (transition from mental health institution to community) 213.738.4775
- Intensive Service Recipients (mental health with 2 or more admissions in year, recent DC from psych hospital) 844.804.5200

Core Measures

Door to Doc: Door to diagnostic evaluation by a qualified medical personnel
Fracture to analgesia: Median time to pain management for long bone fractures
Door to Discharge: Median time from ED arrival to ED departure for discharged ED patients
Door to Admission: Median time from ED arrival to ED departure for admitted patients
- Admit decision time to ED departure for admitted patients

Stroke Head Imaging: Head CT or MRI within 45mins of ED arrival for stroke patients

Sepsis
- Overall performance
- Initial lactate 6hrs prior to 3hrs after presentation
- Blood culture 48hrs prior to 3hrs after presentation
- Broad spectrum IV antibiotic administration 24hrs prior to 3hrs after presentation
- Antibiotic selection post presentation
- Repeat lactate within 6hrs of presentation
- IV fluid resuscitation 30ml/kg minimum after septic shock presentation
- IV vasopressor administration within 6hrs of septic shock presentation (informational only)
- Repeat focused exam after IV fluid initiation and within 6hrs of septic shock

SEPSIS Core Measure Guidelines

Joint Commission/Center for Medicare & Medicaid Services (CMS) determined national standard of quality: early management bundle for severe sepsis and septic shock patients
Time sensitive management and documentation requirements must be met
Compliance has financial implications, publicly reported
Clock starts when patient meets criteria for severe sepsis or septic shock
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

Home Page → Policies and Procedures → HUMC → HUMC Policies and Procedures

3.0 Admissions and Consultations

21.4 Care of Potential Myocardial Ischemia Patient in Triage

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:

Age >35 AND chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
Age > 65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
Clinical concern for myocardial ischemia exists despite absence of 1-3

If the patient meets the above criteria the Router RN will assign a triage priority of cardiac, order an EKG, and notify the triage RN via phone; the patient will be placed in RME1 for immediate EKG

Once the ECG has been completed, the triage nurse will notify the RME provider who will review the ECG

Approved June 2015, Chappell 2/22/16

21.5 Medications in Triage: Standardized Procedure

Administration of medications in triage (MIT) is to provide timely treatment for patients arriving to the ED with pain, fever, dyspepsia, or nausea and vomiting at the time of triage/assessment and reassessment. Available medications include Acetaminophen, Ibuprofen, Maalox, or Ondansetron.
- 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.
- 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
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.
- 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.
- 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.
- 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.
A nurse practitioner or physician provider will be notified of any patient that:
- 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

Consent

PD Blood ETOH draws: patient must be registered, police sign written consent form
- ED staff will draw samples if the patient submits to the test, but will NOT attempt to obtain blood if physical force is required (by staff or law enforcement) to obtain the test
- persons under arrest are only deemed to have given implied consent if they are unconscious or cannot refuse a test for other reasons

Approved November 2015, Chappell 2/22/16

References

Authors:

Harbor:Operations manual

Pre-hospital/Surge Plans

Labs

Radiology

Occupational Exposure

Other Testing

EQUIPMENT

Patient Disposition

Discharging a Patient

Admitting a patient

Other

ADMISSIONS

Orders on Admitted Patients

Boarding Patients Sent from Clinic

Direct Admission after Hours

Insurance Problems

Incoming transfers

Physicians

Important Numbers

Printable FORMS

PC CHEAT SHEET

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

On Call Plan - Emergency Department Attending Physicians

Trauma Activations

STEMI Activations

CODE STROKE

Scheduled Dialysis Patients in ED

Attending Documentation

Minimum Content for Attending Notes

Resident Documentation

E-Prescribing

CODES

CODE ASSIST

CODE BLUE

CODE WHITE

CODE GREEN See "LEGAL"

CODE GOLD See "LEGAL"

AIRWAY MANAGEMENT TEAM

Airway Coverage Times

Documentation

Templates

RME/TRIAGE

RME Phones

RME Patient Flow

FastTrack

Triaging Clinic Patients

Direct to Back

Criteria for an immediate transfer to Chest Pain Room

ECG Screening by Providers

Patient Transfers to other areas of the hospital

Psych ED

Gyn UCC

Urgent Care

Transfer of Low Acuity Patients from ED to UCC

Pausing Patient Flow from ED to UCC

Transfer of Patients from UCC to ED

FastTrack Roles

NP Independent Workup Guidelines

Being Seen by Consultants Prior to ED Evaluation

NP Consultation Guidelines

NP Consultation with the Attending Physician

NP Independent Discharge Guidelines

Rapid Discharge Procedure

RIPT

Discharge to Chairs

LBTC FOLLOW-UPS

LEGAL

AB 2760: Naloxone for patients at risk for opioid overdose

SB 1152 - New California homeless patient discharge planning law

INVOLUNTARY HOLDS, CODE GOLD, COLD GREEN

Mandatory Reporting of Adverse Events

Prescriptions

Lost Triplicate Prescriptions

Safe Pain Medication Prescribing Guidelines

Family Viewing of Deceased Patients

Family Bereavement Resources

Law Enforcement Escorting Patients Out Of the Emergency Department

Weapons in ED

ILLICIT DRUGS/MARIJUANA IN ED

OBSERVERS IN THE ED