Harbor:Main: Difference between revisions
 
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''This is the main page for Harbor-UCLA emergency department; See [[Harbor:Pediatric ED (main)|Pediatric ED]] for the main Harbor pediatric page.''
''This is the main page for Harbor-UCLA emergency department; See [[Harbor:Pediatric ED (main)|Pediatric ED]] for the main Harbor pediatric page.''
==Admin Updates==
==Admin Updates==
* Frequently used resources
** [[Harbor:Admission_and_consultation_guidelines|Admission Guidelines]]
** [[Harbor:ED_follow-up_options|Discharging to Clinics]]
*** [https://lacounty.sharepoint.com/:w:/s/medicineoutpatientspecialtycare/ESLCad7IJDxCjklxFLNfWwIB1hRf_HGr2t2n8u6MvqNHfw?e=4%3AFvJCKk&fromShare=true ED to Specialty Clinic DC - please check instructions for each specific clinic prior to making an appointment]
*** [https://lacounty.sharepoint.com/:w:/t/EDOperations-HUCLA/ES3s8sXJdKBLpukbDXsHZfoBwhQCS17ogqrR8mC2TVNvcQ?e=xp82nc Ortho Consult Criteria]
** [https://wikem.org/wiki/Harbor:Expedited_Work-up_Clinic_(EWC) Expedited Workup Clinic]
** [https://wikem.org/wiki/Harbor:Placement_patients Placement Patients]
** [[Harbor:STAT_MRI|Ordering a MRI]]
** [https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis Breast Abscess]
** [https://www.wikem.org/wiki/Harbor:Admission_and_consultation_guidelines#Breast_mass.2Fmalignancy Breast Mass]
** [https://wikem.org/wiki/Harbor:ED_follow-up_options#ORTHO Ortho:  Splint vs Consult]
** [https://wikem.org/wiki/Harbor:Psych_patients Psych:  OSA, Covid, & Exodus]
** [https://wikem.org/wiki/Harbor:Infectious_Disease_Threats#Treatment Covid Treatment Options]
** [https://wikem.org/wiki/Harbor:QR_for_Staff QR Code:  Equipment issues, Prehospital problems, Med Student evals, Resident Shout-outs]
** [[Harbor:Surge_plan|Surge Criteria/Plan]]


*  When discharging Homeless patients but still waiting for Social WOrk:
** ED Provider drop house and fill out the Homeless Discharge Form in the depart process (offered a meal, Hep A or COVID vaccines, weather appropriate clothing, outpatient medical and/or mental health resources, prescriptions, etc.)
** ED RN: discharges and departs patient off the track, places a patient sticker on a paper log at the Router Desk for SW/HTF
** SW/HTF will assess patient, explore placement opportunities and give resources as available for patient.


OLD TOPICS
* '''ED Request for Specialty Appointment''' order is live 7/25/2023!  No more black star in the depart menu. 
** [https://lacounty.sharepoint.com/:w:/s/medicineoutpatientspecialtycare/ESLCad7IJDxCjklxFLNfWwIB1hRf_HGr2t2n8u6MvqNHfw?e=4%3AFvJCKk&fromShare=true Referral Guidance Summary Sheet]
** [[Harbor:ED_follow-up_options|Details for Specific Clinics ]]
** How to Make an Appointment:  [[:File:ED Request for Specialty Appointment Hot Sheet 7-25-2023.pdf]]


* StatRad Hours
* Happy July 4th:  [[Harbor:Replantation_Patients|Hand Replant Transfers to LAG]]
** '''All studies Fri 4p-Mon 8a''' and county holidays with expected TAT<4 hrs
*** '''Code Strokes after 4p daily'''
*** Available 24/7 as-needed - ED attending call radiology resident (p5814) to request StatRad read


* [[Harbor:ED_follow-up_options#ORTHO|Ortho Follow-up Guidelines (5-2023)]]


*Ortho - who to splint and schedule for f/up without consulting
* '''QR Code Resources'''
** [[Harbor:ED_follow-up_options#ORTHO|Harbor Ortho Follow-up]]
** [[Harbor:QR_for_Staff|For Staff (Equipment, EMS, Med Student Evals)]]
** [[Harbor:QR_for_Patients|For Patients]]


* Hyperbaric treatment for CO
** Options - UCLA Westwood, Long Beach Memorial, UCSD,  '''NOT MAC to Catalina''' (only for dive injuries)
** UR coordinates the acceptance
** Transfers:  UR should help coordinate the transfer - ELTC/HLOC - needs to occur <1-2 hrs
*** Sending facility is supposed to arrange transfer
*** If UR not able to get transfer in a timely manner --> MAC (CDO) - must be approved by house supervisor & Joy; BLS/ALS/CC transport
**** Medics can call the radio for online base medical direction/orders


*  '''COVID VACCINES AVAILABLE to ALL PATIENTS 12 and older with ORCHID MRN''': 
** '''Pfizer ONLY''';  now available in ED on the Quick Order page "Med Immunization COVID Subphase"
** https://wikem.org/wiki/Harbor:Infectious_Disease_Threats#Vaccines
*** 2nd dose: 
**** Empaneled: pt calls PAC at 66500
**** Unempaneled but DHS eligible:  CCC
**** Unempaneled Kids:  to Lomita Clinic


*New Expedited Work up Clinic referral process: https://www.wikem.org/wiki/Harbor:Expedited_Work-up_Clinic_(EWC)
*New asthma guidelines
**The preferred DHS controller medication is Symbicort (formeterol – long-acting B-agonist + budesonide – inhaled corticosteroid), 2nd line is Advair (salmeterol + fluticasone). 
**If seeing the patient in the ED for an asthma exacerbation, please be sure to refill their controller medication AND the albuterol (if needed).  We fall out if they fill more albuterol Rx’s in a year than their controller medication, so we need to make sure they get both when seen in the ED.  If prescribing albuterol, do not give refills (you get 200 puffs!).
*Sepsis – remember to do the required components of the sepsis core measure w/in 3 hrs (30ml/kg, bcx, abx), document using the auto text (use “auto text copy utility” to get Brad Chappell’s “ .harsepsis” to go through the reminder guidance text and exclusions for IVF 30ml/kg. Communicate to the admitting team if they need to repeat the lactate and perform the sepsis reassessment exam with time stamp (w/in 6 hrs). 
*If UR is suggesting a transfer to Rancho Los Amigos (RLA), then place the ‘consult to Transfer Center’ order. The Transfer Center is a county entity that helps transfer patients between county facilities. 


* '''No CCC for specialty e-consult'''
*Synapse got a new look. See link for details. A [https://lacounty.sharepoint.com/:b:/s/dhs-eci/ESN8ppJYxPZGhUcV9ZGyWYMB8do8sVnRqmBWuNyKG5x-7A?e=RpdAsg one-page intro guide] are available on [https://lacounty.sharepoint.com/sites/dhs-eci/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Deci%2FShared%20Documents%2FRadiology%2FPACS%205%2E7%20Upgrade%2FGuides%2FQuick%20Start%20Tutorial&p=true&originalPath=aHR0cHM6Ly9sYWNvdW50eS5zaGFyZXBvaW DHS SharePoint]
** DHS:  message PCP for anything urgent
**Alt+C still works to compare studies.
** OOP:  return to PCP
**Open the PowerJacket (folder icons) and then you can pull up the read on 'reports'. Click the dropdown to switch from 'report' to 'notes' to find a free text prelim read.
** '''NOT EMPANELED DHS ELIGIBLE''':  NERF for PCP who can submit e-consult
**Change your default settings to what PowerJacket looks like and select ‘Notes’ and ‘Reports’ to always open so you can see prelim and final reads, respectively.
** CCC:  still available for non-empaneled DHS eligible patients with urgent follow-up needs (eg., uncontrolled DM)
*Patient Relations Representatives (PRR) 3p-2a, 7days a week – call Registration for PRR who can help empanel into DHS or change empanelment/network in real time in the ED. PRR can come to bedside to meet with patient or send patient to Registration Windows. During business hours, send patient to Patient Relations Office in Rm 1-B-1.
** Goal:  Reduce number of CCC referrals solely for e-consults to ZERO by September 2021


* [[Harbor:Infectious_Disease_Threats#Wuhan_Coronavirus_.28nCoV-2019.29|Coronavirus (COVID-19) Info]]
* '''Harbor's COVID page''' [[Harbor:Infectious_Disease_Threats#Wuhan_Coronavirus_.28nCoV-2019.29|Coronavirus (COVID-19) Info]]
** [https://lacounty.sharepoint.com/sites/DHS-COVID19/ExpectedPractices/Forms/Newest%20on%20Top.aspx?id=%2Fsites%2FDHS%2DCOVID19%2FExpectedPractices%2FDHS%20COVID%20Visitation%2Epdf&parent=%2Fsites%2FDHS%2DCOVID19%2FExpectedPractices DHS Visitor Policy 6/15/21]
** Paxlovid, Remdesivir, etc ... [[Harbor:Infectious_Disease_Threats#Treatment|COVID Treatment Options]]
*** Signage posted at the entrances (no individual screening)
**** In the last 24 hours, have you had a temperature of ≥100.4 ̊F and/or thought you had a fever?
**** In the last 24 hours, have you had a cough, shortness of breath, difficulty breathing, chills, muscle or body aches, new loss of taste or smell?
**** If you have not been vaccinated against COVID-19, have you had any contact with someone who had a confirmed case of COVID-19/coronavirus in the past 14 days?
***** If Positive screen, ok if with PED or patient who needs assistance (but the visitor must be masked)
****** Parents who have recently been exposed to COVID-19 may still come into building if they have received and are two weeks beyond all required doses of the COVID-19 vaccination and can show proof of vaccination.
*** '''MUST wear a facility-provided face mask at all times while in the hospital'''
**** Patients who refuse to wear a mask will be required to remain outside of building until the time of appointment at which time only the patient (no visitors) will be directly escorted to the appointment site
**** Failure of a visitor to mask will result in being asked to immediately leave the hospital; must stay in the patient’s room for the entire visit except as noted below
*** '''2 visitors in the ED'''
**** Visitors may be required to wear appropriate PPE, per Nursing instructions based on isolation precautions. In some circumstances,  visitors may only be able to view the patient from outside of the room.


* '''Interqual criteria''' [[Harbor:Interqual_Criteria_Tips|Interqual Criteria Tips]]


* '''STEMI transfer''' during cath lab remodel
* '''Monkeypox'''
** '''911 IFT''' - 30 min from door to transfer (unless there happens to be a county ALS unit in our ED ready to go)
** See [[Monkeypox]] for medical information  &  [[Harbor:Infectious_Disease_Threats#Monkeypox|Harbor Monkeypox Plan]]
** Clerk fax EKG, copies face sheet and
** Educational Material
** Call LCM Torrance on radio, fill out STEMI transfer out form
*** [http://publichealth.lacounty.gov/acd/Monkeypox.htm LA County Monkeypox]
** EMTALA form from patient
*** [http://publichealth.lacounty.gov/media/monkeypox/docs/Monkeypox_IntimateContact.pdf LAC DPH Monkeypox]
** MICN contact 911
*** http://publichealth.lacounty.gov/media/monkeypox/resources.htm#reduce
** If patient on pressors, sedation for vent, antiarrhythmic gtt --> OCN will find RN/MICN to go with pt (and likely Triage/FT or PED resident)
*** [https://www.cdc.gov/poxvirus/monkeypox/resources/print.html CDC Monkeypox]




* Eye drops (vanco & tobra) and HIV prophylaxis (raltegravir and Truvada) for home - coming soon ~6/7/21
* '''Active Threat in the ED'''
** For patients needing glaucoma or corneal ulcer meds from pharmacy, there is a new process to order from pharmacy and allow the patient to legally take the meds home
** Situational awareness
*** '''Daytime Outpatient Pharmacy Hours''' (M-F 7a-10p, S/S 8a-6p): 
*** Stand between door and patient
**** 1 - Place typical order and in comments section write "'''ok to use home med in ED'''"
*** Ensure patient is gowned
**** 2 - E-Rx as usual
*** Be aware of long stethoscope, lanyard, long hair, etc
**** Process:
*** Panic buttons at nursing stations/router
***** RN to call outpatient pharmacy to notify med need immediately
*** Run & scream for help
***** Pharmacy calls RN when Rx and med info sheets are ready
** Hospital Codes
***** USA picks up med in med box, gives to bedside RN
*** Gold x111 - combative/agitated patient
***** RN signs pickup slip and USA returns to pharmacy
*** Gray x64450 - combative/agitated NON-patient
*** '''After Outpatient Pharmacy Hours''':
*** Silver x111 - weapon, active shooter, hostage
**** 1 - Place typical order for meds
**** 2 - E-Rx and add comment "'''dispensed by ED Pharmacist'''"


==General Administrative==
==General Administrative==
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***Exodus should call Psych ED about transfer, not Med ED
***Exodus should call Psych ED about transfer, not Med ED
***Med ED will do MSE
***Med ED will do MSE
===[[Harbor:Screening EMS Patients|Screening EMS Patients]]===
*DEM AOD [[Harbor:DEM_Admin_on_Duty_(AOD)|DEM Admin on Duty (AOD)]]
* [[Harbor:Resident responsibilities and transitions of responsibility|Resident Responsibilities]]
 
===[[Harbor:Screening EMS Patients|Ambulance (EMS) Triage]]===
 
===Administrative duties===
===Administrative duties===
**[[Harbor:Administrative resident|Administrative resident directions]]
**[[Harbor:Administrative resident|Administrative resident directions]]
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**[[Harbor:EKG screening|EKG Screening]]
**[[Harbor:EKG screening|EKG Screening]]
**[[Harbor:5S|Pre-shift: 5S]]
**[[Harbor:5S|Pre-shift: 5S]]
**Airway Bag [[https://www.wikem.org/wiki/Harbor:Airway_management_team]]
**Airway Bag [[Harbor:Airway_management_team]]
***Missing or low on equipment such as McGrath blades or batteries - inform the overall charge nurse (more in nursing office)
***PURPLE SENIOR - use the laminated checklist to stock AT EACH SHIFT CHANGE on on-call days
***Locks let you know which compartments to check
***ED pharmacists help with meds BUT SENIORS should double check.
***TURN OFF McGRATH AFTER USE!
*** Can use new “GlideScope Go” with a MAC 3 & 4 blade, but bring it back. (It’s not  part of bag).
Wu 11/2019)


===Administrative resources===
===Administrative resources===
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**[[Harbor:Direct Admission after Hours]]
**[[Harbor:Direct Admission after Hours]]
**[[Harbor:Core Measures|Core Measures]]
**[[Harbor:Core Measures|Core Measures]]
**[[Harbor:Crown Checks in PED|Crown Checks in PED]]
===[[Harbor:ED policy manual|Harbor ED policy manual]]===
===[[Harbor:ED policy manual|Harbor ED policy manual]]===
**[[Harbor:ED attending on call plan|ED attending on call plan]]
===[[Harbor:ED attending on call plan|ED attending on call plan]]===
 
===[[Harbor:Legal|Harbor Legal]]===
===[[Harbor:Legal|Harbor Legal]]===
**[[Harbor:Ophtho abbreviation dictionary]]


==Managing your Patient==
==Managing your Patient==
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====[[Harbor:Paging|Paging consultants]]====
====[[Harbor:Paging|Paging consultants]]====
*[[Harbor:Ophtho abbreviation dictionary]]
====[[Harbor:Phone numbers|Phone numbers]]====
====[[Harbor:Phone numbers|Phone numbers]]====
====[[Harbor:Radiology directory|Radiology directory]]====
====[[Harbor:Radiology directory|Radiology directory]]====
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===Tests & Orders===
===Tests & Orders===
*[[Harbor:Labs|Labs]]
*[[Harbor:Labs|Labs]]
====Radiology Hours====
** StatRad
*** All studies Fri 4p-Mon 8a with expected TAT<4 hrs
*** Code Strokes after 4p daily
*** Available 24/7 as-needed - ED attending call radiology resident (p5814) to request StatRad read
*** Reports go directly into FirstNet
*** Faxing prelim during downtime
**** Can also directly login to their website:  [https://clients.statrad.com/Account/Login?ReturnUrl=%2f StatRad]  --> Main tab --> review exams & images --> can search by name or MRN
***** Call Dr. Chappell for login information
** Fortino
*** All X-rays  M-F 8a-5p
** Radiology resident
*** Mon – Thursday 4p - 8a
*** Prelim reads on ED CT, US, MRI
*** Call resident for any XR questions overnight (prelim read), otherwise enter an ED PRELIM and Fortino will over-read in the AM
*** '''For any XR or CT disagreements overnight, the ED attending can request radiology resident send to StatRad for a final attending read'''
**** The radiology resident will ask for your name and call-back spectralink and push the radiology study to StatRad


====[[Harbor:Entering Prelim Radiology Read|Enter Prelim Rads Read]]====
 
===Radiology===
====[[Radiology Hours]]====
[[https://wikem.org/wiki/Harbor:Radiology_directory#Radiology_Directory| Radiology Directory]]
 
====US & QPathE====
* [https://dhsqpath.qpath.cloud '''QPathE Login link''']
** Login using e# and associated password
** Double-click the exam
** Click "edit" at the top of the page
** Enter MRN in the "patient ID" box
** in "comments" enter trauma FAST
** Click save at top of screen
 
 
*Ultrasound
*Ultrasound
**[[Harbor:Ordering a Formal Ultrasound|Ordering a Formal Ultrasound]]
**[[Harbor:Ordering a Formal Ultrasound|Ordering a Formal Ultrasound]]
**[[Harbor:Ultrasound Approval List|Ultrasound approval list]]
**[[Harbor:Rules for Performing ED Ultrasounds|Formal & ED Ultrasounds]]
**[[Harbor:Rules for Performing ED Ultrasounds|Formal & ED Ultrasounds]]
**Cleaning Endocavitary Probes
**[[Endocavitary Probes]]
***Place in Red Bag (above probe cabinet in clean utility room)
*[[Harbor:Entering Prelim Radiology Read|Enter Prelim Rads Read]]
***Place patient sticker on bag
***Give to area charge nurse
***Once cleaned, probe comes back in clear bag
***T. Jang 8/2019
 
*[[Harbor:Example text for a discrepancy e-mail|Example text for a discrepancy e-mail]]
*[[Harbor:Example text for a discrepancy e-mail|Example text for a discrepancy e-mail]]
*CT
*CT
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**[[Harbor:ED Radiology Specs|CT Specs]]
**[[Harbor:ED Radiology Specs|CT Specs]]


*Oral contrast
====Contrast====
**No more gastrograffin, replaced by omnipaque. Must place an order for it. If you need to obtain a retrograde urethrogram, order a KUB.
* [[Creatinine_screening_prior_to_IV_contrast|IV Contrast]]
**Below is the suggested/usual volume of omnipaque used for certain indication sent to us by Dr. Putnam:
** [https://lacounty.sharepoint.com/sites/dhs-harbor-pharm/PrePrinted%20Forms/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dharbor%2Dpharm%2FPrePrinted%20Forms%2FExtravasation%20Management%20Provider%20Order%20Form%20P294%20%2810%2E6%2E20%29%2Epdf&parent=%2Fsites%2Fdhs%2Dharbor%2Dpharm%2FPrePrinted%20Forms| Hyaluronidase for IV Contrast Extravasation order Form]
***For use in bowel obstruction, a volume of 100cc of Omnipaque 300 is used.
* [[Oral contrast for abdominal and pelvic CT|Oral Contrast]]
***For use in tube contrast studies, a volume anywhere between 50-200cc of Omnipaque 300 would likely be used.
***For a CT with po contrast, the order is for 30cc of Omnipaque 300 in 970cc of water.


==== Outpatient IR ====
==== [[Urgent Outpatient IR]] ====
* Interventional Radiology (IR) - outpatient - for items such as stenosed/thrombosed dialysis catheter, etc
** For '''DHS/MHLA''' patients who require an urgent IR procedure, and have no other indication to be admitted, then the patient will be accommodated in the IR schedule to get their procedure done '''within 24-48 hours as outpatient'''.
** ED provider will '''discuss with the IR resident on call x64747, p5423'''
*** '''IR Business hours''':
**** If request for outpatient urgent IR procedure happens during the hours that IR clerk is available, then the providers can discuss with IR if the procedure can be done the next day or day after.
**** The ED provider will need to fill out the grey IR paper form which will need to be delivered to IR in 2 West, Room 40 (copies are in the hanging folders in doc boxes)
**** Patient will need CBC, chem 7, POC INR, and COVID test
*** '''Afterhours''':
**** If request is approved by on call IR attending/resident, but the clerk is not there, then the plan should be to do the procedure not the next day, but the day after, to give time to create the appointment and FIN.
**** Fill out the electronic [https://teams.microsoft.com/l/file/F3A9ABA8-DF16-4F6E-B5DD-C30845F3EDF0?tenantId=07597248-ea38-451b-8abe-a638eddbac81&fileType=docx&objectUrl=https%3A%2F%2Flacounty.sharepoint.com%2Fteams%2FHarborEDProviderscopy%2FShared%20Documents%2FGeneral%2F1-%20IR%20Consultation%20Form%20afterhours.docx&baseUrl=https%3A%2F%2Flacounty.sharepoint.com%2Fteams%2FHarborEDProviderscopy&serviceName=teams&threadId=19:dbce6612063346aba3d3ea1775478494@thread.skype&groupId=5ca89281-2ef3-4fb4-a828-2e9df7660b86 IR Form] for after hours and email it to the following:
***** Juliana Castel
***** Shontay Hysaw
***** Anton Mlikotic
**** Subject: ED IR REQUEST
**** The request will be processed at the beginning of the following business day. 
**** '''Patient will be contacted by the IR schedulers for exact appointment time and be told to go to OR second floor surgery registration area to get check in to be registered therefore  do not need to come back to ED on the day of procedure'''.
***'''For OOP patients''':
**** ED providers can call UM to see if patient can be transferred to in-network hospital, or an urgent appointment with patient's PCP or specialist can be made. If patient's care cannot be safely transferred to in-network, then we can request for an authorization to admit the patient, given that procedure will be done the next day.


====[[Harbor:STAT MRI|STAT MRI]]====
====[[Harbor:STAT MRI|STAT MRI]]====
*[[Harbor:ED Radiology Specs|MRI Specs]]
*[[Harbor:ED Radiology Specs|MRI Specs]]
*Other orders
**[[Harbor:Ordering Blood Products|Blood products]]
**Antibiotics


====[[Harbor:Antibiogram|Antibiogram]]====
====Upload Outside Films to PACS====
**[[Harbor:Antibiotics in Sepsis|Harbor antibiotics in sepsis]]
***[[Harbor:Sepsis core measures|Sepsis core measures]]
*Buprenorphine/Opiate Withdrawal Treatment
**[[Harbor:Opiate Withdrawal/MAT/BUP|Opiate Withdrawal/MAT/BUP]]
 
==== Upload Outside Films to PACS====
*Get form from clerk
*Get form from clerk
*Put patient sticker on Form
*Put patient sticker on Form
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**Check "Export"
**Check "Export"
**Write time frame on form you want studies from
**Write time frame on form you want studies from
===[[Harbor:Ordering Blood Products|Blood products]]===
===[[Harbor:Antibiogram|Antibiogram]]===
**[[Harbor:Antibiotics in Sepsis|Harbor antibiotics in sepsis]]
***[[Harbor:Sepsis core measures|Sepsis core measures]]


===Finding Equipment/DME===
===Finding Equipment/DME===
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*[[Harbor:DME|Durable Medical Equipment (DME)]]
*[[Harbor:DME|Durable Medical Equipment (DME)]]


====[[Harbor:ED supplies A-Z|E supplies A-Z]]====
====[[Harbor:ED supplies A-Z|ED supplies A-Z]]====


===Procedures===
===Procedures===
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==Special patient types==
==Special patient types==
===[[Harbor:Whole person care|Whole Person Care]]===
===[[Harbor:Social work|Social Work]]===
===[[Harbor:Codes|Code Activations]]===
===[[Harbor:Codes|Code Activations]]===
*[[Harbor:Involuntary holds|Involuntary Holds]]
*[[Harbor:Involuntary holds|Involuntary Holds]]
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*[[Harbor:Code STEMI|STEMI Activation]]
*[[Harbor:Code STEMI|STEMI Activation]]
*[[Harbor:Trauma activations|Trauma Activations]]
*[[Harbor:Trauma activations|Trauma Activations]]
===[[Harbor:PE Response Team|PE Response Team]]===
===[[Harbor:Social work|Social Work]]===
===[[Harbor:Opiate Withdrawal/MAT/BUP|Opiate Withdrawal/MAT/BUP]]===
===[[Harbor:Alcohol Use Disorder/Withdrawal Treatment]]===
===[[Harbor:Stimulant Use Disorder Treatment]]===
===[[Harbor:Baby Safe Surrender Program|Baby Safe Surrender Program]]===
===[[Harbor: Reporting to DCFS|Reporting to DCFS]]===
===[[Harbor:Placement patients|'''Placement patients''']]===
===[[Harbor: Identifying Jane/John Doe, finding next of kin tips]]===
===[[Harbor:Psych patients|Psych Patients (& Exodus)]]===
===[[Harbor:Scheduled dialysis patients in ED|Scheduled dialysis patients in ED]]===
===[[Harbor:NFL Injured Player/Staff Protocol|NFL Injured Player/Staff Protocol]]===
===Sepsis===
===Sepsis===
*[[Harbor:Antibiotics in Sepsis|Harbor antibiotics in sepsis]]
*[[Harbor:Antibiotics in Sepsis|Harbor antibiotics in sepsis]]
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*[[Harbor:Industrial Accident (IA)|Industrial or On-the-Job Accidents (IA)]]
*[[Harbor:Industrial Accident (IA)|Industrial or On-the-Job Accidents (IA)]]
==='''[[Harbor:Non-Occupational Exposure|Sexual Assault/STI Exposure (SART)]]'''===
==='''[[Harbor:Non-Occupational Exposure|Sexual Assault/STI Exposure (SART)]]'''===
*[[Harbor:PE Response Team|PE Response Team]]
 
*[[Harbor:Psych patients|Psych Patients (Exodus)]]
===[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]===
*[[Harbor: Identifying Jane/John Doe, finding next of kin tips]]
*[[Harbor:Infectious_Disease_Threats#Coronavirus_.28COVID-19.29|'''COVID''']]
===Others===
*[[Harbor:AVF/graft complications|AVF/graft complications]]
*[[Harbor:Respiratory isolation|Respiratory isolation]]
===[[Harbor:Scheduled dialysis patients in ED|Scheduled dialysis patients in ED]]===
*[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]
===[[Harbor:Infectious_Disease_Threats#Coronavirus_.28COVID-19.29|'''COVID''']]===
*[[Harbor:Ebola|Suspected Ebola protocol]]
*[[Harbor:Ebola|Suspected Ebola protocol]]
*[[Harbor:Replantation Patients|Replantation Patients]]
*[[Harbor:Infectious_Disease_Threats#Monkeypox\Monkeypox]]
*[[Harbor:XRT|XRT transfers]]


==Patient Disposition==
==Patient Disposition==
===Discharge===
===Discharge===
====[[Harbor: ED Follow-Up Options|'''ED Follow-Up Options''']]====
*[[Harbor:Prescribing|Prescribing]]
*[[Harbor:Prescribing|Prescribing]]
*[[Harbor: ED Follow-Up Options|ED Follow-Up]]


===='''[[Harbor: ED Follow-Up Options|ED Follow-Up Clinics]]'''====
====[[DC with meds in ED]]====
*'''[[Harbor:Forms|Forms]]'''
* Eye drops (vanco & tobra) and STI prophylaxis for home
* HIV prophylaxis for sexual assault patients (raltegravir and Truvada)


====DC with meds in ED====
* Eye drops (vanco & tobra) and STI prophylaxis for home - starting 6/7/21
** For patients needing glaucoma or corneal ulcer meds from pharmacy, there is a new process to order from pharmacy and allow the patient to legally take the meds home
*** '''Daytime Outpatient Pharmacy Hours''' (M-F 7a-10p, S/S 8a-6p): 
**** 1 - Place typical order and in comments section write "'''ok to use home med in ED'''"
**** 2 - E-Rx as usual
**** Process:
***** RN to call outpatient pharmacy to notify med need immediately
***** Pharmacy calls RN when Rx and med info sheets are ready
***** USA picks up med in med box, gives to bedside RN
***** RN signs pickup slip and USA returns to pharmacy
*** '''After Outpatient Pharmacy Hours''':
**** 1 - Place typical order for meds
**** 2 - E-Rx and add comment "'''dispensed by ED Pharmacist'''"




*Follow-up of out patient labs/imaging
*'''[[Harbor:Forms| Paper Forms]]'''
**Any imaging or labs requested by a consultant in the ED that will NOT be resulted during the patient's stay in the ED should be ordered by the consultant making the request. Follow-up of outpatient tests can be either performed by the consultant OR by the CCC (Peterson 11/19)


*[[Harbor:Coumadin clinic|Coumadin clinic]]
*[[Harbor:Coumadin clinic|Coumadin clinic]]
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*[[Harbor:Home hospice from ED]]
*[[Harbor:Home hospice from ED]]


===Transportation Needs===
====[[Transportation Needs]]====
*BUS/METRO TAP CARDS:
**8a-5p - send to Social Work Office
**Nights/weekends/holidays - ED RN can get from the House Supervisor x65620 or spectra 23721 who will deliver the voucher to the ED


* TAXI VOUCHERS: Must have a place to go with keys/someone home, or a shelter where patient is already accepted
** Daytime - call Social Work to facilitate
** Night/Weekend/Holidays - call house supervisor x65620 or spectra 23721 who will deliver the voucher to the ED
*** RN calls taxi - must notify taxi if needs wheelchair accessibility (Yellow Cab @ 310-533-6800)
*** RN takes the patient to the hospital nursing office; taxi driver comes to nursing office to sign paperwork and pick up the patient


* UBER/LYFT:
====[[Social EM resources]]====
**Similar to above Taxi Vouchers
**Available to patient's without insurance who do not have other transportation options
 
* AMBULANCE:  for patients that have a medical necessity (cannot ambulate, here w/o wheel chair, etc) and medically cannot take a taxi
* ED RN & area clerk to coordinate with insurance (if applicable)
* If patient is UNINSURED (including restricted Medi-Cal) - use county transport to get an ambulance home
** UR & SW can get involved if issues
** If patient lives outside of LA County, call nursing supervisor or SW as they may need further authorization
*** Joy Lagrone can authorize county transport as a last resort
 
*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 in
# If either of above options is not possible, may try arranging for ambulance (see section above)
 
===Social EM resources===
*[https://www.wikem.org/wiki/Harbor:Social_work Harbor Social Work]
**24/7 Auto page in house social worker p1735 for various issues including: homelessness, discharge planning, sexual assault, crisis/grief, suspected elder/child abuse, recoup care, disability benefits (SSI),  etc.
*Homeless Task Force, in person during business hours 730a-4p Mon-Fri pager # is (310) 501-0637 and their phone number is (310) 413-8871
*[[Harbor:Opiate Withdrawal/MAT/BUP|Opiate Withdrawal/MAT/BUP]]
*[[Harbor:Medical Legal Partnership|Medical Legal Partnership]]
*[[Harbor:Immigration Legal Assistance|Immigration Assistance]]
*[[Harbor:Hospital Based Violence Intervention Program and Trauma Recovery Center|Hospital Based Violence Intervention Program (HBVIP) and Trauma Recovery Center (TRC)]]
*[[Harbor:Whole person care|Whole Person Care (WPC)]] autopage in Cerner (p0145), refer 24/7.
**[[Harbor:Substance Use Disorder|Substance Use Disorder (SUD)]]
***Available SUD counselor in-person Mon 8a-5p, T-F 8a-12:30a, Sat 4p-12:30a.
***Otherwise will follow up next business day via phone call. Need good contact phone number. Ensure patient knows you put a referral and someone will be contacting them.
***On discharge, include the WPC discharge instructions (“Whole Person Care Harbor-UCLA”, also available in Spanish) from ORCHID
**Medically Complex Transitions of care (includes 3 visits to ED in past year)
***1) ORCHID Message/Call/Text Rosario Aliviado - Social Work Supervisor. Please include MRN, pt phone number, and reason for referral. (213) 294-8908. She will respond M-F 9:00-4:30 pm but you can ORCHID message/call/text/email anytime.
***AND 2) place order in ORCHID "Consult to Whole Person Care". Reason for Consult Freetext: "Substance Abuse", "MAT", or "TOC" and any relevant details.
*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.
*Food Pharmacy, free fruits and vegetables every Wednesday 9a-1p outside front entrance of S/E building
*Free cell phones:
**Lifeline free phones: Outside of PCDC building 8a-6p (Mon-Fri), Wednesday only they outreach in front of the SE building to catch patients participating in the Food Pharmacy program.
***[https://www.assurancewireless.com/lifeline-services/how-qualify Assurance Wireless]
**Social work has a limited number
*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
*Perinatal (high-risk pregnant mothers - homeless, mental health, substance abuse, domestic violence, no food) Mama's Program (844) 376-2627


===Admission===
===Admission===
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*[[Harbor:Admitting a patient|Admitting a patient]]
*[[Harbor:Admitting a patient|Admitting a patient]]
*[[Harbor:Who Goes to Family Medicine|Who Goes to Family Medicine]]
*[[Harbor:Who Goes to Family Medicine|Who Goes to Family Medicine]]
====[[Harbor:Interqual Criteria Tips|Interqual Criteria Tips]]====
====[[Harbor:Interqual Override Notes|Interqual Override Notes]]====
====[[Harbor:Interqual Override Notes|Interqual Override Notes]]====


====[[Harbor:Right level of care|Right level of care]]====
====[[Harbor:Right level of care|Right level of care]]====
*[[Harbor:Internal Medicine Admissions|Internal Medicine Admission Template]]
*Admitting to Medicine - use MS Teams (no more clipboard)
*[[Harbor:Post-admission management|Post-admission management/Orders on Admitted Patients]]
*[[Harbor:Post-admission management|Post-admission management/Orders on Admitted Patients]]
*[[Harbor:Direct Admission after Hours|Direct Admission after Hours]]
*[[Harbor:Direct Admission after Hours|Direct Admission after Hours]]
===OBS & CORE===
===OBS & CORE===
*[[Harbor:Observation placement|Observation placement]]
*[[Harbor:Observation placement|Observation placement]]
*[[Harbor:CORE|CORE placement]]
*[[Harbor:CORE|CORE placement]]
*Observation Patients Direct from UCC
 
**Do not need an ED MSE - can go direct to OBS
**If no OBS beds available in GOLD - should be made Direct Admits to the Hospital
Peterson 8/2019


===[[Harbor:Scheduled_dialysis_patients_in_ED|Dialysis in the ED]]===
===[[Harbor:Scheduled_dialysis_patients_in_ED|Dialysis in the ED]]===
Line 346: Line 269:
*'''[[Harbor:Death Packet Checklist|Death Packet Checklist]]
*'''[[Harbor:Death Packet Checklist|Death Packet Checklist]]
* [[Harbor:Deceased patients|Deceased patients]]
* [[Harbor:Deceased patients|Deceased patients]]
*[[Harbor:Transferring a patient|Transferring a patient]]
===[[Harbor:Transferring a patient|Transferring a patient]]===
**[[Harbor:Transferring to psych ER|Transferring to psych ER]]
*[[Harbor:Transferring to psych ER|Transferring to psych ER]]
**[[Harbor:XRT|XRT transfers]]
*[[Harbor:Exodus|Exodus Psych transfers]]
**[[Harbor:Replantation Patients|Replantation patient transfer]]
*[[Harbor:Transfer to L&D|Transfer to L&D]]
*[[Harbor:Transfer/Discharge to Specialty Clinic|Transfer/Discharge to Specialty Clinic]]
*[[Harbor:911 STEMI out|911 STEMI out]]
*[[Harbor:MAC Transfer Burn or Replant|MAC Transfer Burn or Replant]]
*[[Harbor:Replantation_Patients|Hand Replant]]
*[[Harbor:Transfer to Comprehensive Stroke Center|Transfer to Comprehensive Stroke Center]]
*[[Harbor:XRT|XRT transfers]]
*[[Harbor:_Hyperbaric_Transfers|Harbor: Hyperbaric Transfers]]


==Documentation==
==Documentation==
Line 365: Line 295:
*[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]
*[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]
**[[Harbor:Ebola|Suspected Ebola protocol]]
**[[Harbor:Ebola|Suspected Ebola protocol]]
* Environmental Exposure:
** Ask Hazmat Response team or Incident Commander what decon has occurred on scene
** [https://www.atsdr.cdc.gov/toxprofiledocs/index.html CDC Tox Profile Lookup]


==Resident Education==
==Resident Education==

Latest revision as of 21:15, 11 April 2024

This is the main page for Harbor-UCLA emergency department; See Pediatric ED for the main Harbor pediatric page.

Admin Updates


OLD TOPICS

  • Hyperbaric treatment for CO
    • Options - UCLA Westwood, Long Beach Memorial, UCSD, NOT MAC to Catalina (only for dive injuries)
    • UR coordinates the acceptance
    • Transfers: UR should help coordinate the transfer - ELTC/HLOC - needs to occur <1-2 hrs
      • Sending facility is supposed to arrange transfer
      • If UR not able to get transfer in a timely manner --> MAC (CDO) - must be approved by house supervisor & Joy; BLS/ALS/CC transport
        • Medics can call the radio for online base medical direction/orders


  • New Expedited Work up Clinic referral process: https://www.wikem.org/wiki/Harbor:Expedited_Work-up_Clinic_(EWC)
  • New asthma guidelines
    • The preferred DHS controller medication is Symbicort (formeterol – long-acting B-agonist + budesonide – inhaled corticosteroid), 2nd line is Advair (salmeterol + fluticasone).
    • If seeing the patient in the ED for an asthma exacerbation, please be sure to refill their controller medication AND the albuterol (if needed). We fall out if they fill more albuterol Rx’s in a year than their controller medication, so we need to make sure they get both when seen in the ED. If prescribing albuterol, do not give refills (you get 200 puffs!).
  • Sepsis – remember to do the required components of the sepsis core measure w/in 3 hrs (30ml/kg, bcx, abx), document using the auto text (use “auto text copy utility” to get Brad Chappell’s “ .harsepsis” to go through the reminder guidance text and exclusions for IVF 30ml/kg. Communicate to the admitting team if they need to repeat the lactate and perform the sepsis reassessment exam with time stamp (w/in 6 hrs).
  • If UR is suggesting a transfer to Rancho Los Amigos (RLA), then place the ‘consult to Transfer Center’ order. The Transfer Center is a county entity that helps transfer patients between county facilities.
  • Synapse got a new look. See link for details. A one-page intro guide are available on DHS SharePoint
    • Alt+C still works to compare studies.
    • Open the PowerJacket (folder icons) and then you can pull up the read on 'reports'. Click the dropdown to switch from 'report' to 'notes' to find a free text prelim read.
    • Change your default settings to what PowerJacket looks like and select ‘Notes’ and ‘Reports’ to always open so you can see prelim and final reads, respectively.
  • Patient Relations Representatives (PRR) 3p-2a, 7days a week – call Registration for PRR who can help empanel into DHS or change empanelment/network in real time in the ED. PRR can come to bedside to meet with patient or send patient to Registration Windows. During business hours, send patient to Patient Relations Office in Rm 1-B-1.


  • Active Threat in the ED
    • Situational awareness
      • Stand between door and patient
      • Ensure patient is gowned
      • Be aware of long stethoscope, lanyard, long hair, etc
      • Panic buttons at nursing stations/router
      • Run & scream for help
    • Hospital Codes
      • Gold x111 - combative/agitated patient
      • Gray x64450 - combative/agitated NON-patient
      • Silver x111 - weapon, active shooter, hostage

General Administrative

Ambulance (EMS) Triage

Administrative duties

Administrative resources

RME & triage

Harbor ED policy manual

ED attending on call plan

Harbor Legal

Managing your Patient

General

On shift (PC) Cheat Sheet

Paging consultants

Phone numbers

Radiology directory

Tests & Orders


Radiology

Radiology Hours

[Radiology Directory]

US & QPathE

  • QPathE Login link
    • Login using e# and associated password
    • Double-click the exam
    • Click "edit" at the top of the page
    • Enter MRN in the "patient ID" box
    • in "comments" enter trauma FAST
    • Click save at top of screen


Contrast

Urgent Outpatient IR

STAT MRI

Upload Outside Films to PACS

  • Get form from clerk
  • Put patient sticker on Form
  • Check "Import"
  • Sign

Get Images on Disc (For DC or Transfer)

  • Same as upload EXCEPT
    • Check "Export"
    • Write time frame on form you want studies from

Blood products

Antibiogram

Finding Equipment/DME

ED supplies A-Z

Procedures

Special patient types

Code Activations

PE Response Team

Social Work

Opiate Withdrawal/MAT/BUP

Harbor:Alcohol Use Disorder/Withdrawal Treatment

Harbor:Stimulant Use Disorder Treatment

Baby Safe Surrender Program

Reporting to DCFS

Placement patients

Harbor: Identifying Jane/John Doe, finding next of kin tips

Psych Patients (& Exodus)

Scheduled dialysis patients in ED

NFL Injured Player/Staff Protocol

Sepsis

Sepsis core measures

Occupational Exposure

Sexual Assault/STI Exposure (SART)

Infectious Disease Threats

Patient Disposition

Discharge

ED Follow-Up Options

DC with meds in ED

  • Eye drops (vanco & tobra) and STI prophylaxis for home
  • HIV prophylaxis for sexual assault patients (raltegravir and Truvada)


Transportation Needs

Social EM resources

Admission

Admission Guidelines

Interqual Criteria Tips

Interqual Override Notes

Right level of care

OBS & CORE


Dialysis in the ED

Other Disposition

Transferring a patient

Documentation

Disaster & Surge

Resident Education

See Also

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