Harbor:Administrative resident

Background

ED Administrative Resident Orientation (Team A Resident)

First and foremost, the point of having R2’s begin performing the administrative resident role in the emergency department before the end of the year, is so you can ask questions of the current R3’s about how to do things. Many of the finer points of being the administrative resident is not known to the attending physicians. Ask R3’s lots of questions!

Things to Do Before Starting Rounds

1. Get everyone together to do 5S for a strict 5 minutes. Document on the 5S sheet.
2. Team B (Green team) R3: Prep airway equipment in the trauma bay
3. Page the ED hospitalist and ED pharmacist and ask them to join rounds - they are part of the emergency department team and should be with us during rounds, and can answer many questions that come up about meds, boarding patients and general internal medicine.

Patient Safety

• Your most important job is to make sure that all patients in emergency department have at least been eyeballed, and if needed have orders written, especially for pain medicine. Although each team is responsible for screening its own patients, you may have to screen the opposite team’s patients while they are in rounds.
• Ambulance patients are the responsibility of the Team B Resident to screen. Usually, the charge RN will overhead page you to go see the patient. Sometimes, they will call your phone (x23207). Patients will show up on the trackboard under ATri (on the 'Acute, Trauma, RME HAR track)
• If you are sending the patient to MSE or Psych, use the 'notes' function in FirstNet to document your exam and history. The preset template is ".edambutriage". You need to present the case to an attending (on either team). Note that attending’s name on the template. When in doubt, keep the patient in the back. If the nurses give you a hard time, talk with your attending.
• Another problem area we've noticed with ambulance patients in the middle of the room is that sometimes they sit there a long time with no care whatsoever, either waiting for the nurse to screen them, or waiting for an ED bed after the nurse has screened them. It's your responsibility to keep an eye on all these patients. If you notice an ambulance patient has been sitting awhile and no one has begun caring for the patient, screen the patient and find out what's going on from the charge nurse. If the patient is to stay in the treatment area, make sure a team gets assigned by the charge nurse and someone starts caring for the patient.
• In general, all patients should be screened within approximately 20 minutes. If you're getting really behind, talk to your attending to get some assistance.
  • If the patient you've screened is really sick, make sure a physician starts seeing them right away if you cannot. All the members on your team work for you, and it's your prerogative to reprioritize them to a higher priority task when you need them to!
  • When you screen a patient, you can indicate this on FirstNet by completing the 'MSE' note. Not only does this count for measuring the “time to first provider”, but it also keeps any one else from duplicating your effort.
  • As a general rule, you (or the other R3 if you designate them) should screen all ED Traumas to make sure they do not meet higher level Trauma criteria. Look at the card!

Patient Flow

• Keep an eye on overall flow in the room. The better the flow, the safer the emergency department is and more patients get seen. There are several ways you can do this:
  • Orders: make sure orders are being written in timely fashion for patients who are admitted or on observation. Holding orders should be written for all Non-ICU patients when 2 hours have elapsed after the order “Admit to inpatient”, “Observation Status in ED” or “Core Status” has been entered in Wellsoft, and you have notified the admitting team you are writing the orders. Use Wellsoft “Auto page” to document this call (use it for all calls actually.)
  • Consults: although these will be much less common with the new admission procedure keep an eye on how long consults are taking. If you think the consult is taking too long, ask your attending for assistance. Always ask a consultant for an estimated time of arrival, so you know if they are overdue.
  • Downgrades – One of the best ways to move patients along is to get boarders downgraded as soon as possible. Whenever getting signout on a “follow”, know the (usually) single reason why that patient needs the PCU or ICU bed, and an idea of when that requirement will go a way. Most of these patients are medicine patients, and if unclear why they still need that higher level of care, call the ED hospitalist. They are supposed to assist with all medicine service downgrades. Go over possible downgrades with the ED hospitalist at rounds.
  • Interqual - Make sure that requests for Interqual are made as soon as you think the patient might be admitted - don't have to wait until the final decision is made. This means any IQ difficulties are more likely to come up during your shift rather than having the next resident deal with them and second it ensures that the patient can be admitted here before you use up an admission slot. Sometimes the actual insurance is different from the original registration info so you can't just rely on the red box that pops up. This does a lot to help flow and limit wasted admits.
  • Short Call - Get admits in before 11:30 or so to make sure we don't miss using all the medicine short call spots! Similarly, one long call resident finishes admitting mid-evening so these spots should be used before they are lost if possible.
  • Help your team to avoid time-consuming activities:
    • Consults - consults often take many, many hours. Do you really need that consult? Would a clinic visit suffice?
    • CTs/Ultrasounds - same goes for these. By policy all CT and US orders need to be approved by an ED attending
    • Surge Plan- Although we don't interact with this too often, be aware of what is in the Surge Plan. You're likely to encounter one wherever you end up after residency.
    • Transfers out to other facilities - don't try to do these yourself, they're very time-consuming, except for maybe Kaiser patients. If the patient has been admitted, the transfer should be carried out by the admitting team. If the patient is being transferred for a medical (not surgical) reason, the ED hospitalist should carry out the transfer. This includes Rancho Los Amigos transfers. No transfer should sit for more than an hour or two in the emergency department waiting to find out if the receiving facility has a bed. If no bed can be found within one or two hours, the patient should be admitted and wait on the inpatient side for transfer. Even if you do decide that you want to transfer a patient yourself, if the patient has been seen by a specialist, that specialist should talk to the receiving physician about their findings and plan of care.
  • Clinic patients-
    • These are not technically "transfers" - the clinic physician can send us patients whenever they want without an acceptance. You can however discuss the case with the clinic doctor and let them know what you think the patient needs. For example, if the problem is asymptomatic hypertension, let the clinic doctor know that you don't anticipate any specific therapy in emergency department. In the end, the clinic doctor gets to decide what he/she wants to do.
    • I always let the clinic physician know how long the patient will likely wait to be seen. You can give them a rough idea by looking in Wellsoft at how long it is taking patients to get back in the treatment area, and how long it's taking them to see the nurse practitioner in the MSE area. Encourage them to inform the patient of this, so they can make rational decisions about coming to the emergency department.
    • For on campus clinics, if the patient sounds stable, you can direct the clinic to have the patient go straight to triage instead of coming a sitting first in the middle of the big room.
    • Stable Harbor clinic patients should not be sent to the emergency department for admission. The clinic doctor should use the direct admission process. If there are no beds in the hospital, stable patients can wait in clinic until a bed is found. If the clinic is about to close, they need to contact the Patient Flow Facilitator (PFF) who will either find them a bed, find them additional nursing staff to watch the patient in clinic, or direct them to send the patient to the emergency department. Only patients who need monitoring, or patients approved by the PFF, should come to the ED to await admission.
    • For all patients that you take calls about coming to the ED - create a record in Wellsoft. Place the room as "A-Trg" and the status as "Enroute" (don't put them in an actual room or "MOR" or another status or Wellsoft thinks the patient has actually arrived and starts the visit timer.) Place a note in the Provider Notes section (NOT "Messages" section) describing the reason the patient is coming to the ED. It is helpful if your note includes:
      • Sending Doctors Name
      • Sending Doctors Contact Info
      • If another physician at Harbor was involved in the approval for transfer - put their name and contact info as well.

Patient Care

• Sad that this is last, but that's part of being an administrative leader in the emergency department. Your job is to make sure that the environment is safe and working well so that everyone else in the emergency department can care for as many patients as possible.
• That being said, you're here to learn how to care for patients. You just have to find the balance between how many patients you can care for and how many you can follow and still get your first two priorities met. A couple of tips:
  • try to see patients either with either the intern or the medical student so they can do most of the work
  • try not to overload yourself with too many complex or sick patients
  • when you have a patient with a procedure, do everything except the procedure, and get help from the intern or medical student to suture, etc. Tell them "I did all the scut work, and left the best part for you". They’ll love you.
• It's important to note that one R3 duty that you do not assume until you are actually an R3 is the Tier 2 Airway. This is by agreement with the Trauma Service. You can run the Tier 2 resuscitation, just not the airway. (Don't worry, you'll still get 12 months of Tier 2 airways as an R3! It all works out the same!) So for Tier 2 traumas the R3 must be with you until it is clear that the airway is secured.

Other Administrative Duties

• Callbacks: you're responsible for taking calls from lab and radiology for situations where follow-up is needed. If you're not sure what to do, ask one of the R3’s or attendings. Always make sure you document what you do in the Provider Notes on Wellsoft! (Make sure you document on the right visit for the patient, as the patient may have had multiple visits.) This is very important medicolegally.
  • Remember to check WellSoft to determine that the patient you are being called about is an Emergency Department patient. This includes patients in the waiting room/MSE. If the patient was discharged from the ED, you also need to take the read/report. If the patient was admitted, even if the patient has since been discharged from the admitting service, whoever's calling needs to call the admitting team. Especially be careful with Nighthawk radiology, as they will try to give you reports on outpatient or inpatient studies; you are not obligated to take these calls for non-ED patients.
  • To document follow-up in Wellsoft:
    • Look up the patient in Wellsoft: <Find> <MRUN> Make sure you have the right visit if there are multiple visits!
    • Click on the record, should pull up patients record for that visit
    • Document in “Provider Notes.”
• How to Follow-up Correctly
• Call the patient- Look in the patient demographics section of Wellsoft for the patient's phone number. Call patient and give appropriate follow-up information. If you are not sure what kind of follow-up advice to give the patient - ask your attending (and document that you discussed the follow-up with your attending). Document your attempt to call.
• Mail notification - If the patient is not available to speak with - send a mail notification. This is true even if you leave a message (either on an answering machine or with another person), as there is no guarantee the patient will ever receive that message! Make sure any messages are HIPPA compliant.
  • To do a mail notification fill out the "telegram form" (available on our website) and give it to the clerk. The message should say something like "We have test results from your recent visit to the ER at Harbor that we need to discuss with you (right away/as soon as possible/etc.) Please call 310 222-3500 and tell the clerk you were informed to call back the ER and need to speak to the doctor." Mail notifications may take several days or longer. Document that you submitted a mail notification.
• Welfare Check - if the patient can not be reached and the timing of the follow-up is critical (especially in light of mail notification which takes several days) - call the police department in the city where the patient's address is to request the police perform a "Welfare Check". This is where the police actually go to the patients home. Explain the dispatcher how important it is that patient return to the ER and the timeframe. (The police do not need to know or have a right to know the specifics of the patient's medical condition - but its important they know the danger the patient may be in.) Record the name and badge number of the officer you speak to in Wellsoft. The police may or may not perform the check - it's their decision based on their workload, but taking their info may help them take responsibility.
• Calls you SHOULD take
  • Clinics/Physicians wishing to send patients to the ED
  • Radiology results of patients discharged from ED
    • If they were admitted please ask them to notify admitting team
    • If pt is currently in ED please notify specific resident taking care of pt.
  • Pharmacy calls ONLY IF prescription written in ED and that physician is not currently working
    • Please check Wellsoft to verify (Urgent Care & MSE don’t qualify)
    • Otherwise please refer to appropriate resident/MSE/Urgent Care (call back when UCC open)
• Call that generally AREN'T your reponsibility:
  • Lab calls (hemolysis, critical value)
    • Should go to the nurse
  • Radiology reports for patients who are still in the ED
    • Should go to the specific resident taking care of the pt
    • Admitted patients - should go to the admitting team - if urgent you should assist with this process
  • Family member calls
    • Should be screened by nurse first. May request appropriate resident afterwards.
  • Calls unrelated to direct patient care provided in ED
    • Medical advice (notify we don’t provide this service)
    • Calls about clinic schedules, call schedules or medicine admission status
• Transfers from other hospitals: generally the Medical Alert Center (MAC) should not be contacting us directly, but should be going through the Patient Flow Facilitator, who will contact us to see if we have the space to accept a transfer. These transfers generally have already been accepted by a specialty service in the hospital. Ask your attending if you are open to transfers. We want to make sure that not only do we have space in emergency department, but there is an inpatient bed that the patient can go to from the emergency department. Any calls coming in from outside hospitals for transfers should be directed to the Medical Alert Center unless it is a critical emergency. At times, other hospitals considering a 911 STEMI transfer will call for advice. Get your attending involved. Enter them on the track in Wellosft
• Calls from Psych ED: Generally if the psych ED thinks a patient should be in the Medical ED, we should accept. They should never have really medically sick patients there – that’s not what they do. It also helps smooth out transfers in the other direction as well, which is what we want. You can always offer to just see the patient in the psych ED if you think its appropriate (be sure to use Wellsoft Psych/AED consult process so the patient shows up on our board), but if they really want us to take the patient we should. You can always get input from the attending if you’re not sure what to do. Make sure someone gets assigned in the consult column to take care of the patient while they are in Psych. (You are now a consultant!)
• “Follows” – or admitted patients should have moment to moment management by their admitting service. The only exception is medicine, for which the ED hospitalist is responsible. You should not write any but the most emergent orders on admitted patients. Please encourage nurses not to ask you for the “quick” order for this or that; it’s bad coordination of care, and may lead to dangerous duplication of orders. If there is an emergency however, we should step in until the admitting team can take over. Always call the admitting team ASAP to inform them of what you are doing. They may have important additional information. That being said, at signout you should get a detailed problem list and any baseline exam info (GCS, etc) or info about unstable issues which you might need to know if the patient does have an emergency. Pass off a PROBLEM LIST, it's much easier to remember and pass on with accuracy.
• Working with the ED Hospitalist – The ED Hospitalist was hired in large part to take workload of the ED physicians. Know what they are here to do and use them! Some of their responsibilities:
  • Manage all boarding Medicine patients in the ED
  • Manage all Observation status patients in the ED
  • Perform transfers of all patients out of the ED through MAC
  • When the night hospitalist is more than 2 patients behind, the ED hospitalist is supposed to assist in seeing and admitting patients
  • Can help arranging follow-up for a medicine patient being discharged
  • Can answer IM related questions on ED patients (Hospitalist Consult)
  • Perform medical clearance when needed urgently on any ED patients (e.g. for surgery)
  • Performs H and P’s for any patients being transferred to Rancho
• Working with Nursing
  • I can’t put this any better than Stephanie Donald, a past resident, did:

“Emphasize that they [the residents]should actively work on their leadership skills and establishing a positive working relationship with the charge nurse, and not be afraid to use the charge nurse to help facilitate patient safety and flow, and see themselves as 2 on the same team. Their goal is for the charge RN to see them as the leader of the department and one she/he can work with instead of just the triage person and she/he does their own thing in terms of flow, etc.”

• • Carry your phone and encourage nurses and clerks to contact you on it, as well as forward your calls to it. Have him or her call you to let you know when runs are on their way before the patient shows up
  • And finally – as the leader of the healthcare team in the ED, YOU set the tone for the department. Even if it doesn’t always seem like it, other housestaff, the nurses (most, anyway), clerks, nursing attendants, CT Techs, and even the housekeepers look up to you. If you are grumpy, everyone is, if you are positive and up beat, it’s contagious. “Do with a smile what you have to do anyway”

Source

ED Administrative Resident - Running the Board- Orientation 3-18-14