OVMC:ED: Difference between revisions
 
(446 intermediate revisions by 8 users not shown)
Line 1: Line 1:
''WikEM OVMC:ED is meant as a guide to providers working in the ED at Oliveview UCLA Medical Center.  It is only a guide.  Management of the patient is always at the discretion of the ED provider.''   
''WikEM OVMC:ED is meant as a guide to providers working in the ED at Oliveview UCLA Medical Center.  It is only a guide.  Management of the patient is always at the discretion of the ED provider.''   


==Wiki of the Day==
==OVMC Observed Procedure Checklist and Evaluation Form==
*Epinephrine
[https://uclahs.az1.qualtrics.com/jfe/form/SV_3IuVbdiEI2r877E Procedure Checklist and Evaluation Form]
**1:1,000 = 1mg/ml
**1:10,000= 0.1mg/ml


==Phone Numbers==
==OVMC Administration Master Phone List==
===ED===
[[Media:OVMC Administration Master List.jpg|OVMC Administration Master List]]
*MD Room ED 1A Attendings 73648, 73649
 
*MD Room ED 1A Residents 73907, 74732, 73645, 74720 (phones running in direction of ED1 to ED2)
==DEM Master Backup Supply List==
*MD Room ED 4/5 74936, 74937, 74938, 74939
https://lacounty.sharepoint.com/:x:/r/sites/dhs-ov-nursing/_layouts/15/Doc.aspx?sourcedoc=%7B897E3F6F-0F9F-477F-91D7-7508A46AC03E%7D&file=DEM%20Master%20Supply%20List%2011.2020.xlsx&action=default&mobileredirect=true&cid=098fcb59-1f0b-4860-9c35-cc726dd19469
*Hospitalist Room 74930
 
*ED 1A/Clerk: 74324    (PR1,PR2,15,24,25)
==RSV Bronchiolitis and Other Peds Respiratory Illnesses==
*ED 1B: 74865  (16-23)
===Waiting Room===
*ED 2A: 74321 (1-7)
*HR and Pulse ox will be obtained on all QR kids with respiratory complaints;  completed by NA or ICN
*ED 2B: 74280 (8-14)
*ED 4 Attending is responsible for monitoring how many Peds patients waiting to be seen;  ED 4 Attending will tell ED residents when they need to start picking up patients.  RME NP will help be the eyes/ears and let the ED4 Attending know if kids start to back up to ensure ED residents are engaged on seeing them too.
*ED 3: 74976 (43-49)
===Treatment===
*ED 4/RME Unit: 74974 (34-41)
*Suction Snot!!
*ED 5: 74970 (26-33)
*Remember, beta agonists and steroids have not been shown to helpful for kids with bronchiolitis.
*ED Fax: 74298
===Admissions===
*Charge/Resource Nurse: 74324
*Pediatrics will try to keep more kids here at OVMC on HFNC.  Will be evaluated on case by case basis. Will likely want the child to be observed in ED on HFNC to see if they are stabilizing.
*ICN/Router: 73440
===Transfers===
*Triage 1: 65658
*If it's determined a child does need to be transferred:
*Triage 2: 65661
**Utilize MAC for dhs-responsible; if MAC is unable to find a bed, UM can assist by calling other hospitals with pediatric monitored/ICU beds.
*Triage 3: 65662
**Utilize UM for OOP patients;  if UM unable to find a bed through the health plan, engage MAC to help find a bed
*Triage 4/RME: 65697
**If no beds are available anywhere, and child still requires a Higher Level of Care transfer, utilize ''Emergent Transfer Request'' or ELTC to MAC and notify MOD on-call. 
*Triage 7: 75709
**Our OVMC Critical Care Team CCT is not certified to take children;  If a child needs critical care transport, and MAC (which also utilizes CHLA transport team) is unable to provide transportation in a timely manner, may need to decide to use one of our ED providers for transportation. 
*ED Lab 74977
===Discharges===
*ED Xray tech 75496
*Autotext/dotphrase for URI and bronchiolitis discharge instructions can be found under Maureen McCollough auto text
*ED CT scan tech 74968
*Bulb syringes will be made available to give to parents
*ED Ultrasound tech 74940, 74945
 
*ED Reading Room 74969, 74971
==MONKEYPOX==
*ED Pharmacy 75530
===ACEP Monkeypox Field Guide:  https://www.acep.org/monkeypox-field-guide/cover-page/===
*Psych ED 74340, 74341
===How Transmitted?===
*UR 74890, 74891
*Transmitted via direct contact and respiratory droplet;  wear appropriate PPE.
*PFS 65228
*Place suspects in a room with closed door and 'special precautions' sign
*TFU 74825
===How to Test?===
*ED North Annex 73107
*Use same swab used for COVID testing (UTM or VTM);  use one swab to sample 1-3 lesions of the same type, preferably from different locations on the body
**if different appearing lesions, collect additional swabs from several more lesions
**limit 2 swabs per patient
*Order is in Place Orders page (left side scroll down) = Monkeypox Virus DNA Qual RT PCR-SO  (if possible, try to unroof the lesion to swab)
*Have low threshold for also testing for HIV
*If you are also swabbing for other things such as HSV, varicella or GC/Chlamydia, make sure you send separate swabs for the other tests
===When will results return?===
*Tests are send-outs with results taking 3+ days to return
*LA Public Health is notified of all positive results and will follow up with patient for contact tracing and isolation. 
DHS also has a centralized process to follow up on positive results and contact patient for consideration of Tecovirimat. 
*Consider TFU if you are sending other tests, or if you would like patient notified of negative result
===Who to Notify?===
*For '''SUSPECTED''' cases, contact OVMC Infectious Disease and Prevention x73624; after hours, leave message with patient's name, MRUN, birthdate and verified contact information
===What about Treatment?===
*Cases treated once confirmed positive; treatment will be handled by OVMC Infectious Disease and Prevention
===Discharge Instructions===
*Discharge ALL SUSPECTED cases with the LA County Dept of Public Health monkeypox home isolation guidelines
*LA County DPH monkeypox home isolation guidelines now available in Cerner...Patient Education...Departmental...Monkeypox, english and spanish versions available.
*Hard copies of the isolation guidelines also located in ED1A Provider Room
*ED1A clerks have original copies of handouts
===How to keep track of staff exposures?===
*Nursing will keep track by placing a log sheet outside the patient's room.  Names of any staff who enter the room should be added to the log.
===What if I have an occupational exposure?===
*Monkeypox is not as highly contagious as COVID and many other infections.  However, if you come into direct skin contact with any lesions, or are in proximity to an aerosol generating procedure (intubation, swabbing of unroofed lesions) without N-95 mask and face covering then it could be a high risk exposure. 
*OV Employee Health has monkeypox vaccine for high risk occupational exposures.  You can contact them at x73403
 
==COVID-19==
===PPE===
*All patients should be wearing a mask and presumed contagious even if asymptomatic.
*Visitors should be minimized to one visitor maximum, and only for pediatrics, elderly/disabled in need of assistance, or end of life. 
*All staff should wear a mask at all times.  Staff who may become involved in aerosolizing procedure may wear an N95 mask throughout shift, at their own discretion.  Eye protection should be worn for all patient interactions.
*Patients with fever and/or respiratory symptoms will be moved into an ED room or another care venue after ICN.  Those deemed possible COVID suspects will be placed in droplet and contact precautions while in ED.
*Mask, eye protection, gown, and gloves for all COVID-suspect patient interactions.  N95 or CAPR/PAPR required if aerosol generation.
*CAPR face shields re-used: clean with purple top wipes; Used N-95 masks in designated white bins to reprocess if not visibly contaminated.
===Oxygen Therapy===
*Regular nasal cannula or simple/NRB facemask are not aerosol-generating, use first-line (leave paper mask on patient over cannula)
*AVOID CPAP and BiPAP as these are aerosol-generating
*High-flow nasal cannula may be used in with a simple mask over the nose/mouth in patients requiring >10 L/min O2.  Limit flow rate to 30 L/min or less. These patients should be placed in airborne isolation.
*Intubation/mechanical ventilation should be considered early enough to allow for careful, planned procedure
 
===Intubation===
*N95 with eye protection or CAPR/PAPR.  Minimize personnel in room (RN, RT, and 2 MDs).  Use negative pressure rooms.
*RSI without bagging whenever possible; If bagging needed, put viral filter (from RT) and place LMA to minimize aerosol generation
*Senior resident or attending to perform.  Use Glidescope whenever possible to reduce exposure
*McGrath in the black airway toolbox is only for attending intubation in 2F
*Consider additional protective barrier such as clear sheet if available
*Patients in cardiac arrest: Prioritize intubation over chest compressions if no shockable rhythm. 
*Use lung protective vent settings, 6 cc/kg tidal volume with escalating  PEEP  needed to maintain oxygenation. Simple vent mode (AC)
===Treatment of Bronchospasm===
*Avoid nebulized therapy as this is aerosol-generating
*In addition to MDI’s, consider sub cut. epinephrine (0.3 mg) or terbutaline (0.25 mg), or IV magnesium
*Steroids should be used as needed; do not withhold based on COVID concerns.
===Admission===
*Only for persistent oxygen requirement, or some other physiologic derangement (e.g. sepsis). Document PUI for interqual purposes.
*No Observation beds now; Try to dispo with 6-8 hrs (e.g., Asthma, CHF exacerb, CP w neg trops w/o need for risk strat); Otherwise admit.
*Notify hospitalist of COVID suspect.  They will coordinate bed choice with ID attending (You do not need to call ID.)
*ANO/patient flow should be contacted for prolonged boarding issues at x73170.
*Consider ICU for patients:
**on ventilator
**requiring >6L/min of oxygen
**requiring pressor support
**with three or more of: AMS, uremia, tachypnea >30, multilobar infiltrate, age >55
*Cover for CAP as appropriate.  Other therapy is at discretion of IM/ID/Pulm/ICU teams
*Labs: CBC, CMP, phosphorus, magnesium, LDH, troponin, CK, CRP, ferritin, procalcitonin, PT/PTT, d-dimer.
*Imaging: portable CXR only unless high suspicion of PE or other life-threatening concern besides COVID
 
===COVID and PEDIATRICS===
*Any child under age 1 with fever more than 4-5 days (even in the ABSENCE of any Kawasaki’s symptoms/criteria) should be considered a suspect and should be sent for COVID testing, CBC, ESR, and CRP and consider specialty consult with Peds ID/Immune/Cards.
*Any child >1 year of age and up to 18 years of age with fever more than 4-5 days AND any other Kawasaki’s symptom(s)/criteria should be evaluated as above.
 
===COVID Testing Reminders===
*'''Admissions''' - ordered as Symptomatic or Asymptomatic - all done rapidly (rapidly = a few hours)
 
*'''Psychiatric''' - see below
 
*'''Outpatient - Symptomatic, CAN'T Isolate''' - Do NOT discharge until COVID result is back.  Should be used rarely for those living in group homes, SNFs, board&cares.  Living with Grandpa doesn't qualify. 
**There are hotels/shelters that can be arranged for the rare COVID+ who cannot isolate at home.  Can be arranged through social work Mon-Fri business hours.  Or patients can be given the DPH number  (833) 596-1009 to call themselves. 
 
*'''Outpatient - Symptomatic, CAN Isolate''' -  These patients should be sent home. Results are sent in a daily report from the lab to our ED COVID RESULTS TEAM.  No need to flag anything.  Results will be followed up by the team.  Including peds cases. 
**Make sure we have the correct address and phone number in Cerner.   
**Results take 3-5 days.  NEGATIVE results will receive a letter in the mail.  POSITIVE results will get a phone call. 
**Patients can call 747-210-3110, Mon-Fri 8am-4pm, if they have questions.  Do NOT refer to TFU.   
**Use COVID OVMC Awaiting Testing Results patient handout in the Departmental folder, English and Spanish.   
 
*'''Asymptomatic or just COVID exposures''' - Do NOT send tests on these.  We do not have the staff to follow these up.  Refer to L.A. City website.  Coronavirus.lacity.org/testing  See new handout in Departmental Folder.  COVID OVMC Testing Sites.  English and Spanish available.
 
*'''Access Center''' (on the ED Post Visit Plan page) gets the SYMPTOMATIC COVID+ or PUI patient a follow-up phone call with a DHS doctor in about 3 days.  This is to find patients who may be getting worse at home.  For DHS empaneled or DHS eligible.  NOT OOP or MHLA.  Check contact phone number in Cerner. 
 
*'''HOMELESS''': For symptomatic patients experiencing homelessness who are going to be placed in a COVID-19 shelter by Social Worker, order as "Outpatient CAN self isolate".  These will be held as lower priority as SW will send patient to a shelter where patient will self-isolate while test is pending.
*'''CONGREGATE LIVING, symptomatic patients''': e.g. group home, SNF.  Order as "Outpatient CANNOT self-isolate". These will be given priority as discharge may depend upon test results. 
*'''DHS Healthcare Workers:'''  Refer to employee health for testing to x73403.  They will get an appt for drive-thru testing 1-3pm weekdays.
 
===Psych Patients and Testing===
UPDATED 6-3-2021
*'''If medically cleared from triage or ambulance bay''', and asymptomatic, then no covid testing needed prior to going to psych.  If symptomatic, order covid. 
 
*'''If in an ED bed and medical clearance occurring/waiting for psych to see patient''', order the covid test on ALL psych patients.    If asymptomatic AND psych has a place to hold the patient awaiting test results, patient can be sent to psych before test results are back.  If they don't have a place to hold the patient, then we need to wait until results are back.
 
===Safer at Home/Home O2 and Pulse Oximeter Program UPDATED 12-1-2020===
*Candidate for Home O2:
**Should be considered for any suspected COVID-19 patient when:  
***Diagnosis of COVID-19 (+) or PUI for COVID-19
***Room air O2 sat < 93%  with no history of chronic lung disease
***O2 requirement are 0-3L NC to keep SaO2 >/= 94% or improving clinical trajectory with SaO2 >/= 92%, and without accessory muscle use
***No other medical issues necessitate inpatient care
***Patient has to have access to electrical plug for oxygen concentrator.
 
*Step 1:   Call Resp Therapy. ED RT x75581 (Supervisor RT x75038 Mon-Fri 8am-8pm-ish); RT will coordinate with oxygen vendor for oxygen and concentrator. 
**Patient must remain in ED until oxygen and concentrator arrive from oxygen vendor. 
**CalOx Home Health 323-255-5175
**Supercare Health 855-621-5929
*Step 2:   ALL STAFF:  Verify address and phone number in Cerner
*Step 3:   ALL STAFF:    Notify ED Clerk to obtain pulse ox ;  ED clerk will log patient in the Home O2 binder. 
*Step 4:   Provider orders DME for Home Oxygen and Home Oximeter Device
**Home Oxygen: Concentrator;  continuous flow 1-3 Lpm;  interface – nasal cannula; Est need in months – 1; diagnosis – suspected coronavirus.
**Home Oximeter:  Pulse ox;  hypoxia/coronavirus
*Step 5:  Nursing:  Have all prescription sent to the ED
*Step 6:  RT will educate patient on oxygen cylinders and concentrator when they arrive. 
*Step 7:  Provider adds COVID discharge instructions
**COVID OVMC Home O2/Safer at Home Discharge Instructions
**COVID OVMC Self-Proning positions Eng/Span
*Step 8:  Provider adds Access Center to depart process.  This allows patient to have a follow-up call by PCP or CCC within 3 days.  OOP patients should be told to call their PCP.
*Step 9:  Next Day - ED Clerk assigns NP to call ED patients for 1st follow-up call.  Patient will also receive follow-up call 3 days later by PCP or CCC via Access Center.    NPs do NOT call Obs or Admitted patients sent home on O2. 
*Step 10:  NPs document short note after discussion with patient.  Message can be left with patient to call ED with questions.    No other follow-up calls will be made. 
*For any problems, call or text Dr. McCollough 310-614-5306


===Psych ED===
===Discharge Handouts including Department of Public Health===
*74340
*Prone Positioning https://lacounty.sharepoint.com/:b:/s/dhs-ov-emergencymedicine/ESvTpwAfVz1FllL55FBMVNABobW54lHuSSzUAW83ok2e0A?e=uBf5CV
*74341
*Home Care Instructions - Respiratory Symptoms, Not Tested, English


===Inpatient===
*Home Care Instructions - Respiratory Symptoms, Not Tested, Spanish
*ICU


===Radiology===
*Isolation Instructions - Exposed Household Members, English
*Main Radiology 74059
 
*ED Xray tech 74591
*Isolation Instructions - Exposed Household Members, Spanish
*ED CT scan tech 74968
*ED Ultrasound tech 74940
*ED Reading Room 74971
*MRI tech 73862
*MRI front desk 73535
*ED Reading 74971
*MRI Body Reading 73770
*Neuro and MRI Neuro Reading 74082
*MSK/General Reading 65145
*UTZ Reading 74177
*CT Reading 74791, 74792, 66078
*Interventional Radiology 74554
*Interventional Radiology Scheduling 73686
*USC Radiology Overnight Attending 323-409-6679  (M-F 11p-7a and Weekends/Holidays 7p-7a)
**USC Radiology General ER Radiology 323-409-6688
**USC Radiology resident VOIP 323-409-1673 (in case above two phone numbers don't work)


===Lab===
===General Information on COVID-19, Department of Public Health, LA County===
*Lab - ED 74977
*General Information
*Lab - Processing 66033
Updated info to be added
*Lab - Blood Gas 73314
*Lab - Micro 66045
*Lab - Pathology 73532
*Lab - Blood Bank 74062


===Pharmacy===
===CDC Webinar===
*ED Pharmacist 75011(Monday-Friday 8am-4pm)
*CDC Webinar with Micheal Bundesmann, who took care of the ~50 patients with severe COVID-19 in the Kirkland, WA, cluster. He gives a nice case series and his own perspectives with management. Waleed Alhazzani, who chaired the Surviving Sepsis Campaign’s (which may be a dirty word to some out there) position paper on the management of COVID-19 patients. He gives a lot of historical context for some of the management we are exploring with patients with severe COVID-19.  
**ED Pharmacist lives in fishbowl near Radiology
https://emergency.cdc.gov/coca/calls/2020/callinfo_040220.asp
*Pharmacy Outpt 73070
**Monday - Friday 7:30am-8:00pm;  Sat, Sun, Holidays 8:30am-4:30pm
**Prescription drop-off times:  Mon-Friday until 6:30pm;  Sat, Sun, Holidays until XXX
**Eprescribing "cut-off" times:  Mon-Friday 7:00pm; Sat, Sun, Holidays 3:30pm
*Pharmacy Inpt 73059, 573061
*EPCS Electronic Prescribing of Controlled Substances
**EPCS video:  http://myladhs.lacounty.gov/collaboration/epmo/Projects/ORCHID/ORCHID%20Project%20Status/Electronic%20Prescribing%20of%20Controlled%20Substances/EPCS%20video.mp4


===Nursing===
===Donning and Doffing===
*ED Charge Nurse  74324
*CDC Donning and Doffing PDF
*ICN/Router: 75235, 75236
https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
*ED Nursing Supervisor Office (near bed #8) 74850
*HIPPOED Donning and Doffing Video (4th and 5th videos)
*Triage 1: 75658
https://covid.hippoed.com/#watch
*Triage 2: 75661
 
*Triage 3: 75662
===MAXAIR CAPRS===
*Triage 4/RME: 75697
https://www.maxair-systems.net/ProductTrainingVideos/Helmet_Basics/Helmet_Basics_A.html
*ED 1A/Clerk: 74323, 74324
 
*ED 1B: 74865
===Guidelines for Safe Intubation (Life in the Fastlane)===
*ED 2A: 74321
*https://litfl.com/wp-content/uploads/2020/03/COVID-19-3-step.pdf
*ED 2B: 74280
 
*ED 3: 74976
===McGrath Video Laryngoscope===
*ED 4/RME Unit: 74974
*How to use the McGrath video laryngoscope
*ED 5: 74970
https://hcpresources-en.medtronic.ca/intubation/mcgrathtm-mac-video-laryngoscope-mac-3-instruction
*Hospital Nursing Administration 73001
 
===Ultrasound and COVID===
*youtube videos cannot link to WikEM.
 
==The Joint Commission TJC==
*Attending Privileges - OVMC GME http://ovweb2.ovmc.net/util/Program/Physician.aspx
*Housestaff/Resident Competencies - OVMC GME Site
*TJC Blast Email PDFs
**Environment of Care:  https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FENVIRONMENT%20OF%20CARE%20%2D%2002%2E17%2E2020%5FEC%5FEOC%20TIP%20SHEET%20GET%20READY%20STAY%20READY%5FEC%20GROUP%5F02%2E17%2E2020%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**Medication Management for Nursing:   https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FMEDICATION%20MANAGEMENT%20%2D%2002%2E03%2E2020%2DMM%5FMedication%20Safety%20Guide%20for%20Nursing%20Final%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**Medication Management for Providers:   https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FMEDICATION%20MANAGEMENT%20%2D%2002%2E03%2E2020%2DMM%5FPROVIDER%20Cheat%20Sheet%20JM%20rev%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**National Patient Safety Goals:  https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FNATIONAL%20PATIENT%20SAFETY%20GOALS%20%2D02%2E24%2E2020%2DNPSG%5F2020%20National%20Patient%20Safety%20Goals%20%28BW%29%5F02%2E25%2E2020%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**Provisions of Care:  https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FPROVISION%20OF%20CARE%20%2D%2002%2E10%2E2020%20%2DProvision%20of%20Care%20Weekly%20Tip%20Sheet%202%2010%202020%2DBB%2DLP%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**Quality Improvement and Patient Experience: https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FQUALITY%2DPERFORMANCE%20IMPROVEMENT%20%2D%2003%2E09%2E2020%20%2D%20QUALITY%20%2DTJC%20Readiness%20Gude%20%2D%20QI%5Fv2%5FDunham%2DAM%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission
**Record of Care:  https://lacounty.sharepoint.com/sites/dhs-ov-administration/Joint%20Commission/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission%2FRECORD%20OF%20CARE%20%2D03%2E09%2E2020%5FRC%2DTJC%5FRecord%20of%20Care%20Tip%20Sheet%202020%5F03%2E09%2E2020%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Dadministration%2FJoint%20Commission


===Clinics===
==Phone Numbers==
{| {{table}}
===ED===
| align="center" style="background:#f0f0f0;"|'''Urgent Care Clinic and CCC'''  74312
*MD Room ED 1A Attendings 73648, 73649
| align="center" style="background:#f0f0f0;"| Open Mon-Sat
*MD Room ED 1A Residents 73907, 74732, 73645, 74720 (phones running in direction of ED1 to ED2)
|-
*MD Room ED 4/5 74936, 74937, 74938, 74939
| '''Clinic A'''  73125||Derm, Endo, Renal, Primary Care
*Hospitalist Room 74930
|-
*ED 1A/Clerk: 74324    (PR1,PR2,15,24,25)
| '''Clinic B'''  73129, 73131, 73132||Breast, Chest, Gen Surg, Peds Urology, Plastic Hand, Plastic Surg, Proctology, Thoracic Surg, Urology, Vasc Surg
*ED 1B: 74865  (16-23)
|-
*ED 2A: 74321 (1-7)
| '''Clinic C'''  73133||Cardio, Endo, GI, Heme, ID, MDA, Neuro, Oncology, Pulm
*ED 2B: 74280 (8-14)
|-
*ED 3: 74976 (43-49)
| '''Clinic D'''  73137||Gyn After Care, Gyn, Gyn Onc, Urogyn, Gyn Endo, Memory
*ED 4/RME Unit: 74974 (34-41)
|-
*ED 5: 74970 (26-33)
| '''Clinic E'''  73676 ||Interventional Rads, Ortho, Podiatry, Rheum
*ED Fax: 74298
|-
*Charge/Resource Nurse: 74324
| '''Clinic M'''  74301||Primary Care
*ICN/Router: 73440
|-
*Triage 1: 65658
| '''Clinic P'''  74990||Primary Care
*Triage 2: 65661
|-
*Triage 3: 65662
| '''ENT/Ophtho'''  75630||
*RME 1: 73789
|-
*RME 2:
| '''Peds'''  73144||
*Triage 7: 75709
|-
*ED Lab 74977
| '''Ortho Tech'''  818-529-5135, 818-529-5509||
*ED Xray tech 74951
|}
*ED CT scan tech 74968
 
*ED Ultrasound tech 74940, 74945
===Operator===
*ED Reading Room 74969, 74971
*"0" then "5" then "5"
*ED Pharmacy 75011
*Psych ED 74340, 74341
*UR 74890, 74891
*PFS 65228
*TFU 74825
*ED North Annex 73107


===Other===
===Translator Phones in Room===
*ANO 75526
*PR 1 x60400
*Appointment Center 747-210-8000
*PR 2 x60401
*Bed Control 75959, 73179
*Bay 1 x60346
*Central Supply 65946
*Bay 2 x60347
*IT Info Technology 74522, 72644, 323-409-8000
*Bay 3 x60348
*OR 74364
*Bay 4 x60349
*PFS (Patient Financial Screening/Registration) 65228
*Bay 5 x60350
*Medical Administration 73025
*Bay 6 x60351
*Medical Records (problems with Cerner notes) 73934
*Bay 7 x60352
*Physical Therapy 74245
*Exam Rm 8  x60353
*Psych ED 74340, 74341
*Exam Rm 9 x60354
*Resp Therapy RT office 74422, pager 4055...1392...enter callback number
*Exam Rm 10 x60355
*Sheriff XXXX
*Exam Rm 11 x60356
*Social Work
*Exam Rm 12 x60357
**Consult to Social Work now working in Cerner
*Exam Rm 13 x60358
**If no answer,
*Exam Rm 14 x60359
***Social Work 7am-7:30pm pager 818-313-1759
*Exam Rm 15 x60360
***Social Work 7:30p-7am (off campus) 818-313-1637
*Exam Rm 16 x60361
***Social Work Office 74236
*Exam Rm 17 x60362
*Exam Rm 18 x60363
*Exam Rm 19 x60364
*Exam Rm 20 x60365
*Exam Rm 21 x60366
*Exam Rm 22 x60367
*Exam Rm 23 x60368
*Exam Rm 24 x60369
*Exam Rm 25 x60370
*Exam Rm 26 x60371
*Exam Rm 27 x60372
*Exam Rm 28 x60373
*Exam Rm 29 x60374
*Exam Rm 30 x60375
*Exam Rm 31 x60376
*Exam Rm 32 x60377
*Exam Rm 33 x60378
*Exam Rm 34 x60379
*Exam Rm 35 x60380
*Exam Rm 36 x60381
*Exam Rm 37 x60382
*Exam Rm 38 x60383
*Exam Rm 39 x60384
*Exam Rm 40 x60385
*Exam Rm 41 x60386
*Exam Rm 42 x60387
*Exam Rm 43 x60388
*Exam Rm 44 x60389
*Exam Rm 45 x60390
*Exam Rm 46 x60391
*Exam Rm 47 x60392
*Exam Rm 48 x60393
*Exam RM 49 x60394


===USC===
===Anesthesiology/Airway===
*Teleradiology Night Reads 323-409-6679 
*Pager: 818-529-0372
*ED Resusc 323-409-6667
*VOIP Phone: 75112
*ED Resusc Attending 323-409-1610
 
*ED Peds Attending 323-409-1650
===Psych ED===
*Psych ED Front Desk 74340
*Psych ED Doctor Room 73950


===MAC===
===Inpatient===
*866-940-4401; press "1" for emergent, or press "3" for DHS facility
*ICU


===Kaiser EPRP===
===Radiology Techs===
*800-447-3777
*Main Radiology 74059
*ED Xray tech 74951
*ED CT scan tech 74968
*ED Ultrasound tech 74940
*ED Reading Room 74971
*MRI tech 73862
*MRI front desk 73535
*Interventional Radiology Scheduling 73686


==ED Administration==
===Radiology Reading Rooms===
===ED Admin Gurus===
*ED Reading 74971
*Matt - Neurology, Neurosurgery, Infection Control, EMS, and Disaster
*MRI Body Reading 73770
*Pam - Ob/gyn and Residency
*Neuro and MRI Neuro Reading 74082
*Maureen - Pediatrics, Cerner and supplies/equipment
*MSK/General Reading 65145
*Alan - Radiology
*UTZ Reading 74177
*Fred - Psych
*CT Reading 74791, 74792, 66078
*Amir - Medicine and ICU
*Interventional Radiology 74554
*Tomer - Pharmacy and P&T (pharmacy and therapeutics committee)
*Overnight read hours:  Monday-Friday 11pm-7am, Sat/Sun/Holidays 7pm-7am
*Breena - IRB, Invasive Procedures and Language assistance (interpreter issues, video phone issues…)
*Overnight Reads:  USROC (utz, plain films) 866-448-7762 
*Jorge - QI/Peer Review, Surgical subspecialties including general surgery, ophtho, ENT, plastics, ortho, podiatry, urology
*Overnight Reads:  StatRad 858-546-3800
*Steven - Residency
*On-call schedules for Radiologists and Tech Supervisor: https://lacounty.sharepoint.com/sites/dhs-ov-radiology/Radiology%20On%20Call%20Schedules/Forms/AllItems.aspx
*Luis - Cerner
 
===Lab===
*Lab - ED Phlebotomy 74977, 74978
*Lab - Processing 66033
*Lab - Results 66033
*Lab - Blood Gas 73314
*Lab - Micro 66045
*Lab - Pathology 73532
*Lab - Blood Bank 74062


==ED Throughput==
===Pharmacy===
===RME Unit===
*ED Pharmacist 75011
*Monday - Sunday, 8am to 8pm
**ED Pharmacist lives in fishbowl near Radiology
*ED 4:  34,35,36,37,38,39,40,41
*Pharmacy Outpt 73070
*ED 31/Procedure/Discharge Room will be left open and used for slit lamp exams and ENT procedures as needed, consults and discharge patients home as needed.
**Monday - Friday 7:30am-8:00pm;  Sat, Sun, Holidays 8:30am-4:30pm
*Staffing: two NPs, two RNs, one NA
**Prescription drop-off times:  Mon-Friday until 6:30pm;  Sat, Sun, Holidays until XXX
*Responsible for ESI level 4 and 5 patients
**Eprescribing "cut-off" times: Mon-Friday 7:00pm; Sat, Sun, Holidays 3:30pm
*Responsible for overall turnover of rooms by discharging patients and bringing in new patients to be seen
*Pharmacy Inpt 73059, 573061
*NP and RN will pair up and take 4 rooms each, 34-37 and 38-41
*EPCS Electronic Prescribing of Controlled Substances
*RME Unit rooms will be set up with gurney against the wall and a chair in center of room in which patients will be placed.
**EPCS video:  http://myladhs.lacounty.gov/collaboration/epmo/Projects/ORCHID/ORCHID%20Project%20Status/Electronic%20Prescribing%20of%20Controlled%20Substances/EPCS%20video.mp4
*Patients who remain in the ED 4 from the nightshift will either be discharged or moved to another area as soon as is possible for nursing staff.    Night shift staff will attempt to move these patients at 6am.  Dayshift stay will continue moving patients held over from the night shift.  
 
*In the morning when ED 4/RME Unit rooms are empty, Triage RN will place ESI level 4 or 5 patients directly into empty ED 4/RME Unit rooms; when these rooms are finally full, the responsibility for room turnover will shift to the staff in the RME Unit.
===Respiratory Therapy===
*In the morning, when ED 4/RME Unit beds have been filled by the Triage RN, additional ESI 4 and 5 patients can continue to be placed into other ED beds in ED 1,2,3 or 5 if ESI 1-3 patients do not take precedent.
*RT Supervisor 75038
*NP provider will sign up for the patient in the Res/ML column
*DEM RT 75581
*RN will not sign up for the patient on the Tracking Board.  The RN, however, will be responsible for patients who are under the care of the NP with which they are paired.   
*RT Lead Therapist 75331
*RN is not required to complete an assessment on every RME Unit patient.  If medications given, etc, then a reassessment should be completed.    If RME Unit patients are on the track more than 4 hours, a reassessment must be done by the RME Unit RN in the waiting room.
*RT Pager 818-542-1156
*RME Unit Nursing (RN/NA) responsibilities: visual acuities, drawing blood, obtaining urine samples, sending patients needing plain films to PWR, calling Radiology about patients need utz or CT scan, anticipating procedures such as lac repairs or gyn exams and moving carts to the room, moving patients to and retrieving patients from the waiting room, etc.    
*Any patient placed in RME Unit who is subsequently deemed too complicated for RME Unit will have an RME documented, their ESI level changed to 3, orders placed as needed, and patient moved either back to the waiting room or when possible to ED 1, 2, 3, or 5.  Responsibility for these patients should also move to the ED provider and nursing staff in those areas.  If moved back to the waiting room, responsibility falls back to the Triage and Reassessment RNs. 
*Patients requiring plain films will be sent down to PWR/Radiology WR to wait for their imaging. RN or Provider will change the bed assignment to PWR.   Radiology tech will then look on the tracking board, find the patient in PWR, complete the plain film imaging and then tell the patient to return to the RME Unit/ED 4 Nursing Station.  The RME Unit RNs will then change the bed assignment to TR4 and send patient to waiting room to wait for imaging results.
**ONLY RME Unit patients requiring plain films will be sent to PWR/Radiology WR. 
*Patients who are waiting for laboratory testing results, imaging such as utz or CT, plain film imaging results, or consultations by subspecialits can be moved to the waiting room.  Bed assignment will be changed to TR4 in order to keep them visually separate from the other waiting room patients.  These patients will remain the responsibility of their providers while they are in the WR awaiting results.
*Patients moved to the waiting room (TR4) or ED 31/Procedure/Discharge Room will not be counted toward the nurse/patient ratios because they will need limited nursing interventions. 
*Patients who need to receive discharge instructions will be discharged in their ED room assigned or in ED 31/Procedure/Discharge Room.  
*RN will notify housekeeping when a room needs to be cleaned; RN will choose a new ESI level 4 or 5 patient from the WR to fill the room.
*At 7pm the night shift RNs assigned to RME Unit will assume care for the day shift RN’s patients and continue working with the NP per the above guidelines.
*At 8pm, the RME Unit will close, and patients who are still in progress of being cared for by the RME Unit team will be signed out by the day shift NPs to one of the night shift residents.  The night shift RNs assigned to EDs 4 continue to care for the patient until discharge. 
*At 8pm, ED 4 will be used along with ED 1,2,3 and 5 beds for a variety of patients. Triage RN will be responsible for assigning patients to those beds. 
*If the RME Unit is successful, we may extend hours to 8pm-8am when a night shift Nurse Practitioner has been hired.    We may also extend the RME Unit, as needed, to include additional ED beds and other ED nursing and provider staff.


==Nursing==
===Nursing===
===MIT Meds in Triage===
*ED Charge Nurse/Throughput RN in ED1A  75333
*Triage RNs are able to administer acetaminophen, ibuprofen, ondansetron or mylanta under a Medication in Triage Protocol
*ICN/Router: 75235, 75236
*Applies to adults and children
*ED Nursing Supervisor Office (near bed #8)  74850
*One time dose only
*Triage 1: 75658
*If patient has already been RME'd and requests pain medication, then MIT protocol does not apply and provider will be asked to order medication
*Triage 2: 75661
*Triage 3: 75662
*Triage 4/RME: 75697
*ED 1A/Clerk: 74323, 74324
*ED 1B: 74865
*ED 2A: 74321
*ED 2B: 74280
*ED 3: 74976
*ED 4/RME Unit: 74974
*ED 5: 74970
*Hospital Nursing Administration 73001


==Admission Guidelines==
===Clinics===
===Medicine Admissions UPDATE March 2017===
{| {{table}}
*ED Provider contacts Hospitalist and discusses case (''ONE PHONE CALL'')
| align="center" style="background:#f0f0f0;"|'''Urgent Care Clinic and CCC 2A105'''  74312
*Hospitalist has one hour to see patient and obs vs admit, level of care, admission team
| align="center" style="background:#f0f0f0;"| Open Mon-Sat
*If hospitalist desires discharge or transfer, hospitalist will recontact ED providers and discuss
|-
*Hospitalist will place order for Request for Admit '''(Red circle)'''
| '''Clinic A'''  73125||
*Hospitalist will contact the Admitting Team and tell them about the case
|-
*Admitting Team will write inpatient Admission Orders '''(Hospital icon)'''
| '''Clinic B''' 73129, 73131, 73132||Breast, Chest, Gen Surg, Peds Urology, Plastic Hand, Plastic Surg, Proctology, Thoracic Surg, Urology, Vasc Surg
*If Admitting Team desires more information, Admitting Team will contact ED provider
|-
| '''Clinic C''' 73133||Primary Care, GI, HIV/Positive Health, Cardio, Heme, ID, MDA, Neuro, Oncology
|-
| '''Clinic D'''  73137||Gyn After Care, Gyn, Gyn Onc, Urogyn, Gyn Endo, Memory
|-
| '''Clinic E'''  73064 ||ENT, Interventional Rads, Ortho, Podiatry, Rheum
|-
| '''Clinic M'''  74546||Respiratory Urgent Care
|-
| '''Clinic P'''  73700||Primary Care, Derm, Endo, Pulm, Renal, Women's Health
|-
| '''Ophtho'''  75630||
|-
| '''Peds Clinic in 4C'''   73144||
|-
| '''Ortho Tech'''   818-529-5135, 818-529-5509||
|}
 
===Operator===
*"0" then "5" then "5"


===Medicine Admissions Upgrades, Downgrades, ICU Admits co-managed===
===Other===
*Inpatient teams are required to write inpatient admission orders (hosp icon) within 2 hours of Order to Admit (red circle)
*ANO 75526
*Once inpatient admission orders are written (hosp icon),both Attending and Resident column on Tracking board can be changed to ''Inpatient Attending'' and ''Inpatient Resident''
*Appointment Center 747-210-8000
*ED Admissions to Ward, Tele, Stepdown are managed by inpatient Medicine team once hospital icon appears
*Bed Control 75959, 73179
*ED Admissions to ICU are managed by ED with ICU consultation
*Central Supply 65946
*Ward, Tele, Stepdown ''then upgraded to ICU'' are co-managed by original medicine inpatient service and ICU team
*IT Info Technology  74522, 72644, 323-409-8000
*ICU ''then downgraded to Ward, Tele, Stepdown'' are managed by the inpatient medicine team;  ED should give report to Medicine
*OR 74364
*PFS (Patient Financial Screening/Registration) 65228
*Medical Administration 73025
*Medical Records (problems with Cerner notes) 73934
*Physical Therapy 74245, room 1D120
*Psych ED 74340, 74341
*Resp Therapy RT office 74422, pager 4055...1392...enter callback number
*Sheriff
*Social Work 74236
*Social Work pager 818-313-1759
*Social Work after hours for emergencies like deaths, 818-313-1637
*SUD Counselor 74773
 
===USC===
*ED Resusc 323-409-6667
*ED Resusc Attending 323-409-1610
*ED Peds Attending 323-409-1650


===Observation===
===MAC===
*Observation unit upstairs has 8 beds all with tele capabilities
*866-940-4401; press "1" for emergent, or press "3" for DHS facility
*Request for Interqual not needed
*Order "Place in Observation"
*Once patient is admitted (Request for Admit placed/red circle on tracking board), provider cannot cancel the admission and place in Observation.  Decision for observation has to be made prior. 
*If the status of an Observation patient changes/worsens, can be changed to a full admission (Request for Admit) by the Observation team.
*Apparently, on occasion, Gyn has been allowed by Medicine to obs gyn patients in the Obs unit.  Primary service would be Gyn.


===Chest Pain Admission Guidelines===
===Kaiser EPRP===
*'''High Risk = Any of the following''':
*800-447-3777
**Objective signs of myocardial infarction/ischemia or new LV dysfunction:
 
***Diagnostic ST/T changes or new LBBB on EKG
==ED Administration==
***Abnormal Troponin result
===ED Admin Gurus===
***Symptoms associated with dynamic EKG changes
*Matt - Neurology, Neurosurgery, Infection Control, EMS, and Disaster
***Signs of CHF or cardiogenic shock
*Pam - Ob/gyn and Residency
***Malignant dysrhythmias
*Maureen - Pediatrics, Cerner, Substance Use Disorders, ED High Utilizers, and supplies/equipment
**Typical symptoms known to be ischemic and:
*Alan - Radiology
***Recent (<12 month) PCI
*Fred - Psych
***Recurrent/refractory despite anti‐anginal therapy
*Amir - Medicine and ICU
**Management:
*Tomer - Pharmacy and P&T (pharmacy and therapeutics committee)
***Anti‐platelet, anti‐thrombotic, and anti‐anginal therapy
*Breena - IRB, Invasive Procedures and Language assistance (interpreter issues, video phone issues…)
***Cardiology consult for possible urgent invasive therapy
*Steven - Residency
***Repeat troponin q3h x3 unless urgent invasive therapy already planned
*Kellie - Residency
***Admit to SDU or ICU bed
*Luis - Cerner
*'''Intermediate Risk = No High Risk Features, but one or more of the following''':
 
**Abnormal but non‐diagnostic EKG, cannot exclude ischemia:
==ED In Person Translation Service for Hard of Hearing, Deaf, Deaf Blind, and non-ASL speakers, see Social Work section==
***LVH with strain
***Digoxin effect
***Ventricular‐paced rhythm
**New, typical angina symptoms in a patient with:
***Known CAD
***Age>70
***Inability to complete outpatient ETT
***Intermediate Score on Risk Estimation Tool (e.g., TIMI 3 or higher)
**Management:
***ASA; anti‐anginal therapy as needed
***Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
***Observation or Telemetry admit (in consultation with Hospitalist and/or Cardiologist) for risk stratification prior to discharge, unless already performed in past 12 months.
*'''Low Risk = No High or Intermediate Risk feature, plus'''
**TIMI 0-2
**Highly atypical symptoms
**Recent negative objective study (e.g. angiogram, nuclear imaging, CCTA, ETT with Duke score 9 or greater)
**Management:
***ASA
***Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
***Refer for expedited (<72h) outpt. risk stratification if not already done in past 12 months
***Refer for primary care to assess and manage vascular risk factors


===Tele Admission Guidelines===
==ED Throughput==
*Based on AHA/ACC guidelines, see reference at: http://circ.ahajournals.org/content/110/17/2721.full
===RME Unit===
*'''Class I (Valid for 72 hours)'''
*Monday - Sunday, 8am to 8pm
**CONSIDER SDU OR ICU LEVEL OF CARE, IF INDICATED
*ED 4: 34,35,36,37,38,39,40,41
**Mild – moderate heart failure (Requiring IV Diuretics BID, not PRN)
*ED 31/Procedure/Discharge Room will be left open and used for slit lamp exams and ENT procedures as needed, consults and discharge patients home as needed.
**Hemodynamically stable arrhythmia (HR > 45 and < 150 bpm):
*Staffing: two NPs, two RNs, one NA
***atrial fibrillation/flutter
*Responsible for ESI level 4 and 5 patients
***non-sustained ventricular tachycardia
*Responsible for overall turnover of rooms by discharging patients and bringing in new patients to be seen
***other non-sustained SVT
*NP and RN will pair up and take 4 rooms each, 34-37 and 38-41
**Following percutaneous coronary intervention (PCI)/cardiac cath
*RME Unit rooms will be set up with gurney against the wall and a chair in center of room in which patients will be placed.
**QTc prolongation (> 460 msec in women, > 450 msec in men)
*Patients who remain in the ED 4 from the nightshift will either be discharged or moved to another area as soon as is possible for nursing staff.    Night shift staff will attempt to move these patients at 6am.  Dayshift stay will continue moving patients held over from the night shift. 
**Hemodynamically stable (HR > 45 bpm) atrioventricular block (consider higher level of care for 3rd deg)
*In the morning when ED 4/RME Unit rooms are empty, Triage RN will place ESI level 4 or 5 patients directly into empty ED 4/RME Unit rooms; when these rooms are finally full, the responsibility for room turnover will shift to the staff in the RME Unit.
**Drug overdose with arrhythmic potential (e.g. Digitalis, Tricyclic antidepressants, Phenothiazines, Antiarrythmics)
*In the morning, when ED 4/RME Unit beds have been filled by the Triage RN, additional ESI 4 and 5 patients can continue to be placed into other ED beds in ED 1,2,3 or 5 if ESI 1-3 patients do not take precedent.
 
*NP provider will sign up for the patient in the Res/ML column
*'''Class II (Valid for 48 hours)''':
*RN will not sign up for the patient on the Tracking Board.  The RN, however, will be responsible for patients who are under the care of the NP with which they are paired.  
**Transfer from ICU or SDU after Acute Coronary Syndrome (STEMI/NSTEMI) or cardiac/respiratory arrest
*RN is not required to complete an assessment on every RME Unit patient.   If medications given, etc, then a reassessment should be completed.    If RME Unit patients are on the track more than 4 hours, a reassessment must be done by the RME Unit RN in the waiting room.
**Chest pain requiring inpatient evaluation (troponin < 0.8, no significant ECG changes)
*RME Unit Nursing (RN/NA) responsibilities: visual acuities, drawing blood, obtaining urine samples, sending patients needing plain films to PWR, calling Radiology about patients need utz or CT scan, anticipating procedures such as lac repairs or gyn exams and moving carts to the room, moving patients to and retrieving patients from the waiting room, etc. 
**Stroke
*Any patient placed in RME Unit who is subsequently deemed too complicated for RME Unit will have an RME documented, their ESI level changed to 3, orders placed as needed, and patient moved either back to the waiting room or when possible to ED 1, 2, 3, or 5.  Responsibility for these patients should also move to the ED provider and nursing staff in those areas.  If moved back to the waiting room, responsibility falls back to the Triage and Reassessment RNs. 
**Syncope (true loss of consciousness)
*Patients requiring plain films will be sent down to PWR/Radiology WR to wait for their imaging.  RN or Provider will change the bed assignment to PWR.  Radiology tech will then look on the tracking board, find the patient in PWR, complete the plain film imaging and then tell the patient to return to the RME Unit/ED 4 Nursing Station.  The RME Unit RNs will then change the bed assignment to TR4 and send patient to waiting room to wait for imaging results.
**Post-operative patients with presumptive or confirmed obstructive sleep apnea
**ONLY RME Unit patients requiring plain films will be sent to PWR/Radiology WR.  
**Cardiac contusion, myocarditis or pericarditis
*Patients who are waiting for laboratory testing results, imaging such as utz or CT, plain film imaging results, or consultations by subspecialits can be moved to the waiting room.  Bed assignment will be changed to TR4 in order to keep them visually separate from the other waiting room patients.  These patients will remain the responsibility of their providers while they are in the WR awaiting results.
**Initiation/adjustment of antiarrhythmic medications
*Patients moved to the waiting room (TR4) or ED 31/Procedure/Discharge Room will not be counted toward the nurse/patient ratios because they will need limited nursing interventions. 
*Patients who need to receive discharge instructions will be discharged in their ED room assigned or in ED 31/Procedure/Discharge Room.
*RN will notify housekeeping when a room needs to be cleaned; RN will choose a new ESI level 4 or 5 patient from the WR to fill the room.
*At 7pm the night shift RNs assigned to RME Unit will assume care for the day shift RN’s patients and continue working with the NP per the above guidelines.
*At 8pm, the RME Unit will close, and patients who are still in progress of being cared for by the RME Unit team will be signed out by the day shift NPs to one of the night shift residents.  The night shift RNs assigned to EDs 4 continue to care for the patient until discharge. 
*At 8pm, ED 4 will be used along with ED 1,2,3 and 5 beds for a variety of patients. Triage RN will be responsible for assigning patients to those beds. 
*If the RME Unit is successful, we may extend hours to 8pm-8am when a night shift Nurse Practitioner has been hired.    We may also extend the RME Unit, as needed, to include additional ED beds and other ED nursing and provider staff.


*'''Class III (Valid for 24 hours)''':
==Nursing==
**Electrolyte abnormality requiring cardiac monitoring but not requiring higher level of care due to underlying process such as diabetic ketoacidosis
===MIT Meds in Triage===
**Following pacemaker placement or cardioversion
*Triage RNs are able to administer acetaminophen, ibuprofen, ondansetron or mylanta under a Medication in Triage Protocol
**Asthma/COPD exacerbation with hypoxemia (spO2 less than or equal to 95%) despite high flow O2 treatment
*Applies to adults and children
*One time dose only
*If patient has already been RME'd and requests pain medication, then MIT protocol does not apply and provider will be asked to order medication
 
==Admission Guidelines==
===Medicine Admissions UPDATE March 2017===
*ED Provider contacts Hospitalist and discusses case  (''ONE PHONE CALL'')
*Hospitalist has one hour to see patient and obs vs admit, level of care, admission team
*If hospitalist desires discharge or transfer, hospitalist will recontact ED providers and discuss
*Hospitalist will place order for Request for Admit '''(Red circle)'''
*Hospitalist will contact the Admitting Team and tell them about the case
*Admitting Team will write inpatient Admission Orders '''(Hospital icon)'''
*If Admitting Team desires more information, Admitting Team will contact ED provider


===Surgical Subspecialty Admission Guidelines===
===Medicine Admissions Upgrades, Downgrades, ICU Admits co-managed===
*DATE: October 22, 2014
*Inpatient teams are required to write inpatient admission orders (hosp icon) within 2 hours of Order to Admit (red circle)
*TO: Faculty and Housestaff,  Departments of Surgery, Medicine, Ob/Gyn, Pediatrics, and Emergency Medicine
*Once inpatient admission orders are written (hosp icon),both Attending and Resident column on Tracking board can be changed to ''Inpatient Attending'' and ''Inpatient Resident''
*FROM: Robert Bennion, M.D., Chief, Department of Surgery;  Soma Wali, M.D., Chief, Department of Medicine;  Christine Holschneider, MD, Chief, Department of Obstetrics & Gynecology;  Shannon Thyne, MD, Chief, Department of Pediatrics;  Greg Moran, M.D., Chief, Department of Emergency Medicine
*ED Admissions to Ward, Tele, Stepdown are managed by inpatient Medicine team once hospital icon appears
**Re: Emergency Department Hospital Admission Guidelines:  IIn order to optimize patient care, housestaff supervision, expedite the admission process, and minimize conflicts regarding admission decisions, this document will clarify how the decision is made to admit emergency department (ED) patients to various inpatient services, and provide guidelines as to what types of patient diagnoses are most appropriately admitted to a specific inpatient service and hospital ward or unit.
*ED Admissions to ICU are managed by ED with ICU consultation
**Decision to Admit an ED Patient to the Hospital & Resolving Disputes:  The decision as to whether a patient can be managed as an outpatient or requires more intensive observation and therapy in the hospital can be critically important. Therefore, the service chiefs have decided that after input from the admitting housestaff, the decision regarding admission ultimately must be made by attending physicians, which is consistent with community standards of care.
*Ward, Tele, Stepdown ''then upgraded to ICU'' are co-managed by original medicine inpatient service and ICU team
**The Department of Emergency Medicine attending physician will make the decision on the need for an ED patient to be admitted. This decision will be made after reasonable evaluation and consultation to determine a presumptive diagnosis, admission service, and level of care. To avoid misunderstandings and delays, consulting residents should, upon completing their evaluation, clearly communicate their recommendations with the ED resident caring for the patient prior to leaving the ED. Patients will not be transferred from the ED to the floor until there is notification and confirmed acceptance by the admitting resident or attending, which should be indicated in the ED patient tracking system.
*ICU ''then downgraded to Ward, Tele, Stepdown'' are managed by the inpatient medicine team;  ED should give report to Medicine
**If, once notified, the admitting service resident disagrees with the recommendation of the ED staff, the resident should contact his/her senior/chief resident or attending physician to review the case. All disputes should be resolved first by ED resident discussion with the admitting service senior/chief resident, and, if necessary, by discussion between the ED and the admitting service attending physicians.
 
**'''Diagnosis-Specific Guidelines for Appropriate Admission Service'''
===Observation - updated May 28, 2021 ===
**The service chiefs expect that patients with certain designated illnesses will be admitted to the appropriate service, in accordance with the preceding section. Patients with disorders appropriate for surgical admission may not require an acute surgical procedure (e.g., abdominal pain with possible ischemic bowel admitted for observation). Patients with potential surgical diagnoses but who have significant concomitant medical problems (e.g., diabetes out-of-control) may be best managed on the Medicine service, with close consultation.
*We can page hospitalist for Obs admissions or overrides up to 11pm. 
**For patients seen in the ED who are within 30-days from their operation and for whom admission is being considered, the operative service (general surgery, urology, GYN, etc) should be the primary consulting service and in most cases the admitting service.
*If we have a patient who is still in interqual process and/or still awaiting some parts of the workup, but for whom we already know they will not be going home, we should contact the hospitalist before 11pm.  With discussion, they can be put on the list for the Night Admitting Resident to be admitted or placed in Obs after 11pm. The goal is to allow discussion with hospitalist before ED resident and attending signout to the overnight ED team. (Most of the time we should wait until we have the essential workup done to call the hospitalist)
{| {{table}}
*DEM will continue to keep patients who do not meet interqual in the ED overnight and manage them. We will NOT place the Obs order on these patients, and they will remain under ED care. Put a "ED OBS" comment in the MD column so we can identify them.
| align="center" style="background:#f0f0f0;"|'''General Surgery & Subspecialties'''
*In the morning those who cannot be discharged within a few hours should be discussed with the hospitalist for override or Obs placement under medicine. It's a good idea for the overnight attending to call the hospitalist around 7:15 to discuss them before signout, if the hospitalist has not already called or come by.
| align="center" style="background:#f0f0f0;"|'''Medicine/Pediatrics/Ob/Gyn'''
 
|-
===Chest Pain Admission Guidelines===
| ||
*'''High Risk = Any of the following''':
|-
**Objective signs of myocardial infarction/ischemia or new LV dysfunction:
| Acute abdominal pain - potential underlying surgical etiology (e.g., possible ischemic bowel), complicated diverticulitis ([[abscess]] or microperforation)- non-pregnant (General Surgery)||Acute abdominal pain – unclear but possible medical/ non-surgical etiology (e.g., colitits, gastroparesis, uncomplicated diverticulitis) (Medicine)
***Diagnostic ST/T changes or new LBBB on EKG
|-
***Abnormal Troponin result
| ||Pregnant women and non-pregnant women with acute abdominal pain likely to have gynecologic etiology (Ob/Gyn with General Surgery consultation)
***Symptoms associated with dynamic EKG changes
|-
***Signs of CHF or cardiogenic shock
| ||
***Malignant dysrhythmias
|-
**Typical symptoms known to be ischemic and:
| Gallstone pancreatitis (including presumed cases), acute cholecystitis, cholangitis, [[choledocholithiasis]] with gallbladder, symptomatic biliary colic with PO intolerance  (General Surgery)||Alcoholic and other non-gallstone-related pancreatitis, [[choledocholithiasis]] without gallbladder (Medicine)
***Recent (<12 month) PCI
|-
***Recurrent/refractory despite anti‐anginal therapy
| ||Pregnant women with gallstone pancreatitis, acute cholecystitis, choledocholithiasis/cholangitis (Ob with General Surgery consultation)
**Management:
|-
***Anti‐platelet, anti‐thrombotic, and anti‐anginal therapy
| ||
***Cardiology consult for possible urgent invasive therapy
|-
***Repeat troponin q3h x3 unless urgent invasive therapy already planned
| ||Hepatitis and hepatic abscess(es) (Medicine)
***Admit to SDU or ICU bed
|-
*'''Intermediate Risk = No High Risk Features, but one or more of the following''':
| ||
**Abnormal but non‐diagnostic EKG, cannot exclude ischemia:
|-
***LVH with strain
| Mechanical small bowel obstruction - partial or complete (General Surgery)||Small bowel obstruction – partial or complete secondary to prior Ob/Gyn surgery or gynecologic malignancy (Ob/Gyn)
***Digoxin effect
|-
***Ventricular‐paced rhythm
| ||Ileus or colitis – (Medicine)
**New, typical angina symptoms in a patient with:
|-
***Known CAD
| ||
***Age>70
|-
***Inability to complete outpatient ETT
| Abscesses with complex wounds or requiring OR intervention (regardless where drained), necrotizing skin and soft tissue infections, post-operative wound infections, other significant skin/soft tissue infections involving specific areas (Surgical sub-specialty, e.g., significant head and neck infections to Head & Neck Surgery, excluding Plastic Surgery, see below)||Cellulitis/lymphangitis, abscesses that can drained in the ER with predominant cellulitis, and other skin infections with significant concomitant medical problems (e.g., diabetes out-of-control)  (Medicine)
***Intermediate Score on Risk Estimation Tool (e.g., TIMI 3 or higher)
|-
**Management:
| ||
***ASA; anti‐anginal therapy as needed
|-
***Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
| Infections or injuries distal to the elbow requiring immediate operation (Plastic Surgery)||Infections or injuries distal to the elbow, not requiring immediate operation, or in patients with significant/unstable medical problems. (Medicine with Plastics consultation)
***Observation or Telemetry admit (in consultation with Hospitalist and/or Cardiologist) for risk stratification prior to discharge, unless already performed in past 12 months.
|-
*'''Low Risk = No High or Intermediate Risk feature, plus'''
| ||Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
**TIMI 0-2
|-
**Highly atypical symptoms
| ||
**Recent negative objective study (e.g. angiogram, nuclear imaging, CCTA, ETT with Duke score 9 or greater)
|-
**Management:
| ||
***ASA
|-
***Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
| Obstructing ureteral stone or malfunctioning stent and hydronephrosis with documented fever (> 38o C) and pyuria, or uncontrollable pain, or bilateral hydronephrosis from ureteral stones and renal insufficiency or solitary kidney in adults; acute prostatitis (fever, chills, toxic appearing, severe obstructive voiding symptoms), or with severe hydronephrosis; scrotal [[abscess]] requiring OR intervention and/or admission for IV antibiotics (Urology, also see specific inter-departmental guideline)||Urinary tract infection without significant anatomical obstruction (Medicine/Pediatrics), pregnancy (Ob) or gynecologic malignancy (Gyn)
***Refer for expedited (<72h) outpt. risk stratification if not already done in past 12 months
|-
***Refer for primary care to assess and manage vascular risk factors
| ||Significant tract infection with anatomical obstruction, with or without infection, in stable pediatric patients (Pediatrics with Urology consultation)
|-
| ||Urolithiasis with infection, no obstruction, patient toxic appearing or high risk for complications, or indwelling ureteral stent in appropriate position and no hydronephrosis or mild hydronephrosis; epididymitis requiring admission for IV antibiotics; urologic problem in patient with any complicated medical problem (e.g., diabetes out of control, severe sepsis) (Medicine with Urology consultation); pregnancy (Ob), or gynecologic malignancy (Gyn)
|-
| ||Acute gastrointestinal bleeding (Medicine or Pediatrics)
|-
| ||Ankle and foot fractures (Medicine with Podiatry consultation)
|-
| All patients with post-operative surgical problems within 15 days of discharge requiring admission - to specific operating service (with Medicine/Pediatrics consultation as necessary)||
|}
**'''Admission Orders''' Admission orders must be written by the responsible inpatient service housestaff who are available to floor nursing in order to direct inpatient management.  For cases in which the admitting diagnosis is established (e.g., CT-confirmed appendicitis), an inpatient bed is available, and the admitting service residents are unavailable for > 2 hours (e.g., in the OR), the ED resident will contact the admitting service senior/chief resident in order to seek verbal approval for the admission.  The ED physician will then write holding admission orders on the standard admit form and transfer the patient to a hospital bed.  If the admitting senior/chief resident is also unavailable or the admission cannot be approved, then the ED attending may contact the admitting service attending physician to facilitate the admission. Admission holding orders should include pain medications, intravenous fluids, and antibiotics (if recommended by the admitting service), and contact information (resident name and pager number) for the admitting service if a nurse needs new orders or to notify a physician about any change in patient status
**'''Patient Transfers'''  All patients considered for transfer from Olive View-UCLA must be reviewed and evaluated by the ED attending physician.  For pediatric patients, the pediatric attending physician on-call should be notified prior to patient transfer.
 
===Admissions from the Clinic, How to===
*Clinic staff places order for "UR Consult"
*Once UR approves admission through Interqual, UR will contact PFS for a new FIN number to be created
*UR will then fax admission info and new FIN number to Bed Control
*Bed Control then contacts clinic staff to give them the new FIN number so admission orders can be placed
*Clinic staff or inpatient team must write Admission Orders in order for Bed Control to secure a bed
*For admissions to Obs Unit, clinic staff should contact Hospitalist on-call


==Follow Up Guidelines==
===Tele Admission Guidelines===
*Based on AHA/ACC guidelines, see reference at: http://circ.ahajournals.org/content/110/17/2721.full
*'''Class I (Valid for 72 hours)'''
**CONSIDER SDU OR ICU LEVEL OF CARE, IF INDICATED
**Mild – moderate heart failure (Requiring IV Diuretics BID, not PRN)
**Hemodynamically stable arrhythmia (HR > 45 and < 150 bpm):
***atrial fibrillation/flutter
***non-sustained ventricular tachycardia
***other non-sustained SVT
**Following percutaneous coronary intervention (PCI)/cardiac cath
**QTc prolongation (> 460 msec in women, > 450 msec in men)
**Hemodynamically stable (HR > 45 bpm) atrioventricular block (consider higher level of care for 3rd deg)
**Drug overdose with arrhythmic potential (e.g. Digitalis, Tricyclic antidepressants, Phenothiazines, Antiarrythmics)


===Future OVMC Clinic Appointments already scheduled===
*'''Class II (Valid for 48 hours)''':
*Future OVMC appointments can be found on the Patient Summary (Discharge Instructions).  Click Depart.  Page that appears is the Patient Summary.  Scroll down to Future Appointments.
**Transfer from ICU or SDU after Acute Coronary Syndrome (STEMI/NSTEMI) or cardiac/respiratory arrest
 
**Chest pain requiring inpatient evaluation (troponin < 0.8, no significant ECG changes)
===Future Orders - Outpatient studies ordered by the ED===
**Stroke
*When you order a future outpatient study, it will automatically print on the Patient Summary (discharge instructions)
**Syncope (true loss of consciousness)
*Phone numbers for Radiology, Cardiology Lab, Neurology Lab and TFU automatically print out on the Patient Summary (discharge instructions)
**Post-operative patients with presumptive or confirmed obstructive sleep apnea
*Patients ''MUST'' call to schedule their own outpatient study.  Patient should then call TFU afterwards to get the results of the study
**Cardiac contusion, myocarditis or pericarditis
*Outpatient CTs, ultrasounds and MRIs are generally booked 4-6 weeks out.  PLEASE do NOT tell the patient to schedule the appointment within a few days
**Initiation/adjustment of antiarrhythmic medications
*If you think the patient needs the outpatient radiology appointment sooner, you will need to get overbook approval from Radiology during business hours and type the name of the approving Radiologist in the future order radiology request in Cerner.  Obviously this is going to be harder to do overnight or on weekend shifts.
*Cerner orders:
**Echocardiogram = CV Transthoracic Echocardiogram
**Exercise Stress Test = CV Treadmill Stress Test or CV Exercise ECG Stress Test
**Holter monitor = CV Holter Monitor
**Barium Enema = RF Barium Enema
**Upper GI = RF Upper GI
**Mammogram = MG Mammogram Digital Diagnostic (indicate left, right or bilateral)
**Breast ultrasound = US Breast
**EMG = EMG 1 Extremity Request
**EEG = EEG


===OOP (Out of Plan)===
*'''Class III (Valid for 24 hours)''':
*Orange OOP on Tracking Board indicates out of plan insurance.  Patient should be referred back to their health plan and PCP.
**Electrolyte abnormality requiring cardiac monitoring but not requiring higher level of care due to underlying process such as diabetic ketoacidosis
*Info on health plan and PCP found on Patient Summary (Discharge Instructions), Demographics and Utilization Review tabs.
**Following pacemaker placement or cardioversion
*Do not refer OOP patients to subspecialty care at OVMC
**Asthma/COPD exacerbation with hypoxemia (spO2 less than or equal to 95%) despite high flow O2 treatment
*OOP Health Plan and/or clinic name will print automatically on the Patient Summary (Discharge Instructions).
*'''URGENT FOLLOWUP''': To arrange urgent followup with PCP for OOP patients, call '''Outpatient Service Coordinator (OPSC) x74556'''. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc).  Make sure contact info is correct in Cerner.  OPSC coordinators will help expedite a followup appt with the PCP.  Remember,outside health plans usually require patients to see their PCP ''before'' being referred to a subspecialist.


===DHS Empaneled===
===Surgical Subspecialty Admission Guidelines===
*To find out if a patient is empaneled to a DHS provider, look at the banner bar on the patient's chart. Look right hand side "Emp Prov". Name of PCP will be written there.
*DATE: February 14, 2023
*If empaneled, DHS or community clinic name can be found listed under ''Additional Patient Information'' on ED Summary page.
*TO: Faculty and Housestaff,  Departments of Surgery, Medicine, Ob/Gyn, Pediatrics, and Emergency Medicine
*'''URGENT FOLLOWUP''': To arrange urgent followup with PCP for OOP patients, call '''Outpatient Service Coordinator (OPSC) x74556'''. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc). Make sure contact info is correct in Cerner. OPSC coordinators will help expedite a followup appt with the PCP. Remember,outside health plans usually require patients to see their PCP before being referred to a subspecialist.
*FROM: Jane Yang, M.D., Interim Chief, Department of Surgery;  Soma Wali, M.D., Chief, Department of Medicine;  Christine Holschneider, MD, Chief, Department of Obstetrics & Gynecology;  Shannon Thyne, MD, Chief, Department of Pediatrics;  Greg Moran, M.D., Chief, Department of Emergency Medicine
 
**Re: Emergency Department Hospital Admission Guidelines:  IIn order to optimize patient care, housestaff supervision, expedite the admission process, and minimize conflicts regarding admission decisions, this document will clarify how the decision is made to admit emergency department (ED) patients to various inpatient services, and provide guidelines as to what types of patient diagnoses are most appropriately admitted to a specific inpatient service and hospital ward or unit.
===MHLA (My Health LA)===
**Decision to Admit an ED Patient to the Hospital & Resolving Disputes:  The decision as to whether a patient can be managed as an outpatient or requires more intensive observation and therapy in the hospital can be critically important. Therefore, the service chiefs have decided that after input from the admitting housestaff, the decision regarding admission ultimately must be made by attending physicians, which is consistent with community standards of care.
*Indicated by green MHLA icon on tracking board
**The Department of Emergency Medicine attending physician will make the decision on the need for an ED patient to be admitted. This decision will be made after reasonable evaluation and consultation to determine a presumptive diagnosis, admission service, and level of care. To avoid misunderstandings and delays, consulting residents should, upon completing their evaluation, clearly communicate their recommendations with the ED resident caring for the patient prior to leaving the ED. Patients will not be transferred from the ED to the floor until there is notification and confirmed acceptance by the admitting resident or attending, which should be indicated in the ED patient tracking system.
*Not an insurance plan but gives patient access to primary care clinic and provider (PCP)
**If, once notified, the admitting service resident disagrees with the recommendation of the ED staff, the resident should contact his/her senior/chief resident or attending physician to review the case. All disputes should be resolved first by ED resident discussion with the admitting service senior/chief resident, and, if necessary, by discussion between the ED and the admitting service attending physicians.
*MHLA patients receive all SPECIALTY care at OVMC or other DHS facilities
**'''Diagnosis-Specific Guidelines for Appropriate Admission Service'''  
*OK to refer MHLA patients to subspecialty care at OVMC either through Message Pool or econsult.
**The service chiefs expect that patients with certain designated illnesses will be admitted to the appropriate service, in accordance with the preceding section. Patients with disorders appropriate for surgical admission may not require an acute surgical procedure (e.g., abdominal pain with possible ischemic bowel admitted for observation). Patients with potential surgical diagnoses but who have significant concomitant medical problems (e.g., diabetes out-of-control) may be best managed on the Medicine service, with close consultation.
 
**For patients seen in the ED who are within 30-days from their operation and for whom admission is being considered, the operative service (general surgery, urology, GYN, etc) should be the primary consulting service and in most cases the admitting service.
===NERF (New Empanelment Referral Form)===
{| {{table}}
*Used to enroll patients with significant PMH who have no primary care or health plan
| align="center" style="background:#f0f0f0;"|'''General Surgery & Subspecialties'''
*Patient must have at least one of a specific list of diagnoses
| align="center" style="background:#f0f0f0;"|'''Medicine/Pediatrics/Ob/Gyn'''
*Only about 1/3 of patients will actually receive a PCP through the NERF process. Because of that, give patient a clinic list upon discharge so he/she can find a PMD on their own.
|-
*To enroll in NERF program, click '''NERF''' while completing Depart process. Check off diagnoses that apply. Click green arrow. Clerk will complete on-line NERF form.
| ||
 
|-
===TFU (Telephone Follow Up)===
| Acute abdominal pain - very likely underlying surgical etiology (e.g., ischemic bowel), complicated diverticulitis likely to require surgery - non-pregnant (General Surgery)||Acute abdominal pain – unclear but possible medical/ non-surgical etiology (e.g., colitits, gastroparesis, uncomplicated diverticulitis) (Medicine)
*818-364-4825  (STAFFED ONLY 2 DAYS PER WEEK!!!)     '''DO NOT USE TFU FOR ANYTHING URGENT or EMERGENT!!!'''
|-
*Used for follow-up of culture or GC/chlamydia results and for patients to call for outpatient Radiology imaging results
| ||Pregnant women and non-pregnant women with acute abdominal pain likely to have gynecologic etiology (Ob/Gyn with General Surgery consultation)
*To refer to TFU, click '''ED Post Visit Plan''' while completing Depart process, choose '''ED-TFU-OVM''' and indicate what needs to be followed up
|-
*Ensure we have a correct phone number on the patient
| ||
*If patient has already been discharged from the ED and you want to refer to TFU
|-
**Step 1: Find patient on the '''Look Up track''' (only good for 7 days after discharge)
| Acute cholecystitis, Cholangitis, Choledocholithiasis in patient with gallbladder, symptomatic biliary colic with PO intolerance  (General Surgery)||Gallstone pancreatitis in patient with or without a gallbladder, Alcoholic and other non-gallstone-related pancreatitis, Choledocholithiasis without gallbladder (Medicine)
**Step 2: Choose patient on the Look Up track, click Modify Events.....Request Event......Post Visit ED TFU
|-
**Step 3: Open patient's chart......Depart.....now fill out ED Post Visit Plan form
| ||Pregnant women with gallstone pancreatitis, acute cholecystitis, choledocholithiasis/cholangitis (Ob with General Surgery consultation)
**If you do not follow these steps, TFU will not be flagged to follow-up the patient
|-
| ||
|-
| ||Hepatitis and hepatic abscess(es) (Medicine)
|-
| ||
|-
| Mechanical small bowel obstruction requiring NG tube (General Surgery)||Small bowel obstruction – secondary to prior Ob/Gyn surgery or gynecologic malignancy (Ob/Gyn)
|-
| ||SBO not requiring NG tube, or if not surgical candidate – (Medicine)
|-
| ||
|-
| Abscesses with complex wounds or requiring urgent OR intervention, necrotizing skin and soft tissue infections, post-operative wound infections, other significant skin/soft tissue infections involving specific areas needing urgent surgery (General Surgery, Head & Neck Surgery, Plastic Surgery for hand)
||Cellulitis/lymphangitis, abscesses that do not require urgent OR intervention, and other skin infections with significant concomitant medical problems (e.g., diabetes out-of-control)  (Medicine with surgical consult as needed); Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
|-
| ||Vulvar abscess (Gyn);
|-
| ||Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
|-
| Kidney stones with uncontrollable pain, with or without obstruction, without infection; Bilateral hydronephrosis from ureteral stones and renal insufficiency or solitary kidney; Acute prostatitis, with severe obstructive voiding symptoms, or with severe hydronephrosis; Scrotal abscess requiring OR intervention (Urology)||Urinary tract infection (Medicine), UTI with pregnancy (OB) or UTI with gynecologic malignancy (Gyn)
|-
| ||UTI requiring admission, with kidney stone or indwelling ureteral stent, with or without obstruction
|-
| ||Acute prostatitis (fever, chills, toxic appearing);
|-
| ||Epididymitis requiring admission for IV antibiotics;
|-
| ||Scrotal abscess not requiring OR but needs IV abx;
|-
| ||Urologic problem in patient with any complicated medical problem (e.g., diabetes out of control, severe sepsis) (Medicine with Urology consultation); pregnancy (OB), or gynecologic malignancy (Gyn)
|-
| ||
|-
| ||Acute gastrointestinal bleeding (Medicine or Pediatrics)
|-
| ||
|-
| Injuries distal to the elbow requiring urgent operation (Plastic Surgery)||Ankle and foot fractures (Medicine with Podiatry consultation)
|-
| All patients with post-operative surgical problems within 15 days of discharge requiring admission - to specific operating service (with Medicine consultation as necessary)||
|}
**'''Admission Orders''' Admission orders must be written by the responsible inpatient service housestaff who are available to floor nursing in order to direct inpatient management. 
***For cases in which the admitting diagnosis is established (e.g., CT-confirmed appendicitis), an inpatient bed is available, and the admitting service residents are unavailable for > 2 hours (e.g., in the OR), the ED resident will contact the admitting service senior/chief resident in order to seek verbal approval for the admission.  The ED physician will then write holding admission orders on the standard admit form and transfer the patient to a hospital bed. 
***If the admitting senior/chief resident is also unavailable or the admission cannot be approved, then the ED attending may contact the admitting service attending physician to facilitate the admission. Admission holding orders should include pain medications, intravenous fluids, and antibiotics (if recommended by the admitting service), and contact information (resident name and pager number) for the admitting service if a nurse needs new orders or to notify a physician about any change in patient status
**'''Patient Transfers'''
***All patients considered for transfer from Olive View-UCLA must be reviewed and evaluated by the ED attending physician.
***For pediatric patients, the pediatric attending physician on-call should be notified prior to patient transfer.
***For surgical diagnoses the attending surgeon on-call should be notified to approve the transfer.


===CCC (Continuing Care Clinic)===
===Admissions from the Clinic, How to===
*ED Followup Clinic used for complicated patients without primary care or an outside health plan
*Clinic staff places order for "UR Consult"
*Guidelines for CCC: Urgent follow-up of potentially serious internal medicine conditions that might otherwise require hospital admission, ED return visits, or extensive ED workup. The clinic is for patients without any other primary care resource; patients who have insurance and/or an established primary care clinic should be referred back there for follow-up of such conditions. *Consults sent to CCC will be reviewed within a few days by the NP who staffs the clinic; patients who have insurance or who do not meet the referral criteria listed below will not be seen in CCC; they will be referred on for routine primary care.  
*Once UR approves admission through Interqual, UR will contact PFS for a new FIN number to be created
*Our DEM TFU program can also refer patients to CCC, so if a test is pending to determine whether a patient meets criteria, please do not generate a CCC referral; the TFU program can review the test and refer to CCC if appropriate.
*UR will then fax admission info and new FIN number to Bed Control
*The CCC clinic can coordinate work-ups for possible malignancies including ordering additional outpatient imaging and biopsies.  
*Bed Control then contacts clinic staff to give them the new FIN number so admission orders can be placed
**Step 1: Please do not skip this step! Ensure that patient does not have established HMO insurance, other primary care. Do NOT send DHS Empaneled or OOP patients (see DHS Empaneled and OOP).   
*Clinic staff or inpatient team must write Admission Orders in order for Bed Control to secure a bed
**Step 2: Click '''ED Post Visit Plan''' while completing Depart process, choose '''ED-CCC-OVM'''
*For admissions to Obs Unit, clinic staff should contact Hospitalist on-call
**Step 3: Indicate condition requiring urgent CCC visit:
 
***Suspected new or recurrent neoplastic disease
==Follow Up Guidelines==
***Acute medical condition potentially requiring inpatient admission if not followed up promptly
 
***Diabetes out of control (Glucose >500, requiring initiation of insulin therapy, or new end-organ dz.)
===Future OVMC Clinic Appointments already scheduled===
***Severe hypertension (>160/100 at time of ED discharge, new end-organ dz., or refractory to tx.)
*Future OVMC appointments can be found in the Patient's Chart, tabs on the left, Patient Schedule
***Suspected new significant auto-immune disease (SLE, RA, scleroderma, IBD, vasculitis)
*Future OVMC appointments can also be found on the Patient Summary (Discharge Instructions).  Click Depart.  Page that appears is the Patient Summary. Scroll down to Future Appointments.
***Complex or undefined infections requiring further evaluation (FUO, osteo, colitis, fungal/parasite, HIV)
 
***Acute pulmonary disease or exacerbation requiring systemic steroids or antibiotics
===Future Orders - Outpatient studies ordered by the ED===
***Potentially serious lab or imaging findings (anemia, hepatitis, renal insuff., hyperCa++, incidentalomas)  
*When you order a future outpatient study, it will automatically print on the Patient Summary (discharge instructions)
***Endocrine disease requiring advanced workup (hyperthyroidism, thyroid masses, pituitary/adrenal dz)
*Phone numbers for Radiology, Cardiology Lab and TFU automatically print out on the Patient Summary (discharge instructions)
***New congestive heart failure, arrhythmia, or structural cardiac disease not requiring admission
*Patients ''MUST'' call to schedule their own outpatient study.  Patient should then call TFU afterwards to get the results of the study
***Decompensated liver disease requiring diuretics, paracentesis, or workup for occult etiology
*Outpatient CTs, ultrasounds and MRIs are generally booked 4-6 weeks out.   PLEASE do NOT tell the patient to schedule the appointment within a few days
***New or recurrent deep venous thrombosis or other condition requiring anticoagulation
*If you think the patient needs the outpatient radiology appointment sooner, you will need to get overbook approval from Radiology during business hours and type the name of the approving Radiologist in the future order radiology request in Cerner.  Obviously this is going to be harder to do overnight or on weekend shifts.
*If you have questions about a consult, or wish to discuss a case during regular business hours, contact Dennis Chamling, NP, via the Department of Medicine or by pager on the amion.com internal medicine website. (password ov_im)
*Cerner orders:
**Echocardiogram = CV Transthoracic Echocardiogram
**Exercise Stress Test = CV Treadmill Stress Test or CV Exercise ECG Stress Test
**Holter monitor = CV Holter Monitor
**Barium Enema = RF Barium Enema
**Upper GI = RF Upper GI
**Mammogram = MG Mammogram Digital Diagnostic (indicate left, right or bilateral)
**Breast ultrasound = US Breast
**EMG = EMG 1 Extremity Request
**EEG = EEG
 
===Next Day Clinic NDC Appointments===
*Scheduled appointments in Urgent Care Clinic (UCC) within 24-72 hours after an ED visit to avoid inpatient admission for complex medical patients.
*Appointments are Monday through Friday only.
*This is ONLY for DHS empaneled or responsible patients.  '''This is NOT for OOP patients.''' Refer OOP patients back to their health plan or if required, transfer patient with approval from their health plan.  
*Ensure patient requires an URGENT follow-up appointment with an internal medicine provider in UCC.  These appointments should be used to avoid an inpatient admission or observation.  Other follow up pathways still exist including CCC and with the patient's DHS PCP.
*Ensure patient has transportation to the NCD follow up appointment. 
*Ensure we have the correct working phone number of the patient. 
*ED clerks are responsible for scheduling the NDC appointments.  Appointments should be within 24-72 hours after ED discharge.  Once scheduled, the appointment will show up on the ED Patient Discharge Instructions (Patient Summary)under Future Appointments.   
*'''Ensure ED Note is completed before the NDC appointment.'''
*Patient should be instructed to follow up in Urgent Care Clinic on the date/time of the appointment.  '''ED Clerk will give patient handout with date/time and instructions to go to Urgent Care Clinic'''.
'''*If there are no appointments in the next 24-72 hours for APPROPRIATE patients, please page Paul Salama, Director of NDC;  Amion...OV IM....Medicine Subspecialty Consults.....Next Day Clinic;  Ok to page 24/7.'''
 
====Appropriate Diagnoses for NDC====
*SEE BELOW FOR ADDITIONAL SPECIFIC INFO BY DIAGNOSIS
*CHF exacerbations - without hypoxia, or need for IV drips;  give IV diuretic in ED and have patient followup in 24 hrs;  NDC can further titrate meds and arrange for ECHO if needed
*Diabetic foot infection/osteo - without sepsis or necrotizing infection; discussed with podiatry and start antibiotics; NDC can re-consult podiatry and obtain further testing as needed
*AKI without signs of shock or underlying electrolyte abnormalities; discuss with renal, consider trial of IVF in ED;  NDC can repeat labs in 1-2 days and re-consult renal.
*ESBL infection, known or suspected, without sepsis (e.g. well appearing UTI); give one dose Ertapenem or Amikacin in the ED and have pt return in approximately 24 hrs for culture results and further dosing needed.
*Cellulitis without sepsis that may have failed conventional oral antibiotics;  start Linezolid and have patient return in 1-2 days in NDC for a recheck.
*Urgent GI endoscopy for stable patients (must contact GI prior to scheduling NDC appt)
*Cancer, new diagnosis or suspected, or other serious diagnosis/issue requiring urgent follow-up; obtain appropriate imaging in the ED and scheduled for NDC appointment for possible biopsy, and further imaging and testing as needed
*Any other condition that might otherwise be admitted but is suitable for urgent internal medicine follow-up.
 
====NDC EXCLUSION CRITERIA FOR ALL CONDITIONS====
*Lives over 30 minutes away from OV
*Extremely poor social conditions/support based on subjective evaluation
**Must have accessibility to telephone and ability to be contacted reliably
*Not DHS eligible/responsible (must be DHS eligible to be seen in NDC);  '''NO OOP!!!'''
*Any allograft or autologous stem cell transplant recipient
*Immunocompromised
**Primary condition (e.g., HIV with CD4 count <100, neutropenia with ANC<500, active chemotherapy, not that diabetes does not count)
**Iatrogenic (e.g., ≥20mg prednisone equivalents per day x 3 weeks, chemotherapy, biologics)
*Pregnant
*Resides in SNF/ALF
*History of frequent AMA or no-shows to clinics
*ASA IV classification: “severe systemic disease that is a constant threat to life”


===Urgent Referrals for Subspecialty Care/Message Pools===
====Need Help? For Assistance or Guidance for NDC, call the following:====
*Used to refer patients to certain subspecialty clinics for URGENT follow-up appts (<2 weeks)
*NDC Director on-call:  Listed on AMION....OV IM passcode
*Do NOT refer OOP patients or non-urgent complaints through the Message Pool
*Hospitalist on duty: place Consult to Hospital Medicine in Cerner
*For ENT and Ophtho patients, page the on-call resident for approval for the urgent follow-up appt.  Type in the approving resident's name and the follow-up date/time agreed upon. Tell patient to show up at 10am to the clinic.
*ED Interim Chief Scott Lundberg:  cell number posted in ED
*Current Clinics with Message Pools:
 
**OVM Coumadin ED/UC Urgent Follow Up 
====Additional Specific Information by Diagnosis for NDC Appointments====
**OVM Hand Surgery ED/UC Urgent Follow Up 
===== AKI Acute Kidney Injury=====
**OVM Gyn Aftercare ED/UC Urgent Follow Up 
*Inclusion criteria for next day clinic:
**OVM Ophthalmology ED/UC Urgent Follow Up
**Stage 1 AKI (Cr 1.5-1.9 times baseline) or stage 2 AKI (Cr 2.0-2.9 times baseline)
**OVM Orthopedics ED/UC Urgent Follow Up
**If there is suspicion for UTI/pyelo, refer to that algorithm instead
**OVM Otolaryngology (ENT) ED/UC Urgent Follow Up
 
**OVM Pediatrics ED/UC Urgent Follow Up
*Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
**OVM Peds Ortho ED/UC Urgent Follow Up
**Toxic ingestion
**OVM Plastic Surgery ED/UC Urgent Follow Up
**New or worsening oliguria (<0.3cc/kg/hr x 24 hours)
**OVM Podiatry ED/UC Urgent Follow Up
**Anuric for >12 hours
*Note:  USC Peds Ortho ED/UC Urgent Follow Up no longer exists
**Patient presents with clinically significant hypervolemia
**Decompensated cirrhosis
**New or worsening oxygen requirement
**Any of the following laboratory abnormalities: pH<7.30 (if applicable), K>6.0, BUN>50
**UA: Gross hematuria, microscopic hematuria with >5 RBCs/HPF, cellular casts
**New proteinuria >300 mg/dL (worsening proteinuria is acceptable)
**Stage 3 AKI (Cr more than 3.0 times baseline), or if Cr >3.0 with unknown baseline
**New hydronephrosis on imaging
**High suspicion for obstructive stone that may require intervention
**Post-obstructive AKI with PVR greater than 250cc
 
*Treatment in ED
**If any exclusion criteria present on H&P then stop algorithm and deliver care as usual.
**If BMP reveals bicarb <18, then draw VBG.
***If pH < 7.30 then stop algorithm and deliver care as usual.
**If patient has diabetes or there is concern for BPH/obstructive picture, ensure PVR is obtained in ED.
***If PVR >250cc, the stop algorithm and deliver care as usual.
**Ensure a STAT renal ultrasound is obtained in ED unless clear pre-renal picture (e.g. vomiting/diarrhea).
***If new hydronephrosis, then stop algorithm and deliver care as usual.
**Administer 1 to 3 liters of IV crystalloid based on clinical judgment (ideally over 1.5L if safe).
**Schedule for NDC appt for the following day (approx 24hrs)


===Econsult===
=====NDC Cellulitis (excluding diabetic foot infections)=====
*Econsult appointment center for new referrals: 855-521-XXXX
*Inclusion criteria for next day clinic:
*When starting a new econsult, '''ONLY''' enter the '''Orchid MRUN''' (use '''ORCHID MRN field''' and not MRUN) and '''birthdate'''.  All registered patients in the ED can be found in the Econsult system.
**Cellulitis that would typically be admitted (i.e., not usual candidate for oral cephalosporin)
*All ED providers must send econsults using their own log-in username and password.  Do not borrow usernames and passwords from other providers.  Mistakes are sometimes made and it is impossible to then correct the mistake if providers are sharing log-ins. 
**Cellulitis that “failed” oral cephalosporins as outpatient are great candidates
*Used to refer patients to subspecialty clinics for NON-URGENT follow-up appts.  Not all referrals are approved.  In fact, most from the ED are denied.  If approved, appts are likely several months away.
*Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
*Do NOT send econsults on OOP patients
**Diabetic foot infection-- refer to that algorithm instead
*Do NOT send econsults on DHS empaneled patients.  These patients should be referred back to their primary care doctor.
**Necrotizing skin/soft tissue infection
*For outside records to be attached, use the '''Fax-to-Scan form''' on the Econsult.  Print it out.  Patient name and MRUN will be on the fax form.  Attach it to the outside records and give to the clerk to fax.    See job aid.  XXXXX 
**Evidence of sepsis
*For General Surgery gallbladders and hernia referrals, fill out the Cholecystectomy/Hernia form.  Patient must be non-smoker with BMI <35
**Treatment with IV antibiotics of the same site within the prior month
*Do '''NOT''' refer the following:
**Cellulitis of the face, hands, or overlying joints
**Derm - simple skin conditions (must be SEVERE or worrisome for cancer)
**History of limb amputation or complex skin/soft tissue infections in the past
**GI - diverticulitis, undiagnosed abdominal pain, gastritis without minimum of 3 months of PPI or h.pylori treatment
**Severe penicillin allergy (e.g., SJS/TENS), non-severe PCN allergy is okay
**Neuro - simple seizures, headaches
**Urology - stones less than 5mm


==Patient Education==
*Treatment in ED:
===Diabetic Teaching===
**Use sharpie to outline borders of affected area, and follow the appropriate pathway below
*Classes held at OVMC; patients must call to schedule a class, 747-210-3176
**''For Pus/Purulent Infections''
**Classes are 9am-12:30pm
***1. Ensure I&D is performed in ED and sent for culture, and give one of the following antibiotics:
**Appointment is required to attend class; late arrivals will not be allowed to participate
****For standard patients who can be discharged on oral cephalosporins, they do not need NDC follow-up
*Adult Classes English http://myladhs.lacounty.gov/ov/Departments/Education/Documents/CommunityClasses/Diabetes%20Self%20Management%20Group%20Education%20Flyer_English.pdf
****For patients who would normally be admitted, give 600mg Linezolid PO/IV
*Adult Classes Spanish http://myladhs.lacounty.gov/ov/Departments/Education/Documents/CommunityClasses/Diabetes%20Self%20Management%20Group%20Education%20Flyer_Spanish.pdf
*****Discharge with Linezolid 600mg PO BID x7 days
****If contraindication to Linezolid (e.g., SSRI/TCA), give Vancomycin 1g IV (may require renal dosing)unless already given.
*****Discharge with Minocycline 200mg po loading then 100mg BID x7 days (MRSA resistance <10%)
*****Alternatively can use 7d Bactrim 2 DS BID or Doxy 100mg BID, but MRSA resistance >10%
****If concern for compliance, follow-up, drug use, etc., on-call pharmacist can approve 1.2g Oritavancin IV
*****'''Please use sparingly.''' Does not require outpatient antibiotics after Oritavancin.
***2. Proceed to Schedule Follow-up
**''For Animal/Human Bite Infections''
***1. Assuming patient has received Ampicillin-Sulbactam, schedule another 3g dose 4-6 hours after last
****Discharge with Amoxicillin-Clavulanate 500mg q8h x7 days
***1. Proceed to Schedule Follow-up
**''For Non-Purulent Standard Cellulitis''
***1. For standard patients, give 600mg Linezolid PO/IV (if no contraindications)
****Discharge with Linezolid 600mg PO BID x7 days
****If contraindication to Linezolid (e.g., SSRI/TCA), pursue Oritavancin with on-call pharmacist
***If concern for compliance, follow-up, drug use, etc., on-call pharmacist can approve 1.2g Oritavancin IV
****'''Please use sparingly'''. Does not require outpatient antibiotics after Oritavancin
***2.  Proceed to Schedule Follow-up
**Schedule Follow-up
***1. Schedule Next Day Clinic in-person appointment within 24 hours for another dose of IV antibiotics (Linezolid, Vancomycin, Ampicillin-Sulbactam, or Ceftriaxone)
****Schedule NDC in-person appointment in 24 hours, instruct patient to hold oral antibiotics 12 hours prior


==Cardiology==
=====NDC Diabetic Foot Ulcer and/or Osteomyelitis=====
===Code STEMI===
*Inclusion criteria for next day clinic:
*Definite STEMI on EKG and appropriate patient - ACTIVATE Cath Lab per protocol below
**Diabetic foot ulcer with or without concern for osteomyelitis
*Probable STEMI or complex patient - CONSULT Cardiology (digital FAX '''310-496-0160''')
**Lower extremity osteomyelitis with or without overlying skin infection
{| {{table}}
**Any cellulitis in a patient with diabetes that does not meet the exclusion criteria
| align="center" style="background:#f0f0f0;"|'''Oliveview UCLA Medical Center'''
 
| align="center" style="background:#f0f0f0;"|'''Providence Holy Cross'''
*Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
|-
**Concern that patient will require surgical intervention beyond simple bedside debridement
| Mon-Fri 7am-5pm||Nights, weekends, holidays
**Necrotizing skin/soft tissue infection or wet gangrene
|-
**Unstable vitals
| Page Code STEMI via Cerner Consults- Auto Paging (pager 818-226-4502)||Verbally concept patient for transfer
**Evidence of sepsis
|-
**Treatment with IV antibiotics of the same site within the prior month
| Verbally consent patient and family for PCI||Fax the EKG to Holy Cross: 818-496-4495
**Severe penicillin allergy (e.g., SJS/TENS); non-severe PCN allergy is okay
|-
 
| Goal: <30 mins in ED||Call 818-496-7700 (or 7704) for Patient Placement Center to start the Code STEMI transfer                                                                                                                           
*Treatment in ED:
|-
** 1. Use sharpie to outline borders of affected area
| ||***Speak with ED physician at Holy Cross to review the faxed EKG 
** 2. If wound probes to bone OR xray/CT suspicious for osteomyelitis:
|-
*** a. Consult to podiatry for debridement/deep wound culture/bone culture in ED
| ||***Chart accepting MD name
*** b. If podiatry consult unavailable in ED can organize podiatry follow-up from the NDC
|-
*** c. MRI to evaluate for acute/chronic osteomyelitis can be completed in NDC
| ||For updates, call ED direct 818-496-1270
** 3. If wound does not probe to bone:
|-
*** a. Obtain standard wound cultures
| ||Call LAFD 213-847-5340 (or 5360) for Code STEMI transfer       
** 4. If evidence of surrounding necrotic tissue, consult podiatry for ED debridement
|-
*** a. If podiatry unavailable in ED and urgent debridement is necessary, can admit
| ||***Emergency STEMI transfers ONLY
*** b. Otherwise, non-urgent podiatry debridement can be organized in NDC
|-
** 5. If there is no current skin/soft tissue infection, then give no antibiotics (cultures will be followed)
| ||ED Clerk to fax patient registration info to 818-496-7707
*** a. Proceed to Schedule Follow-up
|-
** 6. If there is concurrent skin/soft tissue infection:
| ||Goal: <45 mins in ED before transfer
*** a. Give Ampicillin/Sulbactam 3g IV x1 regardless of if there is purulence
|}
**** ● Discharge with Amox/Clav 875mg pO q12h x7d (dosing must be adjusted for renal impairment unless otherwise specified)
*'''DEFIBRILLATOR DEVICE AT PATIENT BEDSIDE FOR ALL STEMI's'''
**** ● If h/o MRSA, give Minocycline 200mg PO x1 (loading), then discharge with 100mg PO q12h x7d
**ED: Zoll pads package at bedside (apply only if unstable)
***** MRSA has much lower resistance rates to mino than doxy/bactrim, but these can be used as alternatives
**OVMC Cath Lab: Cardiology will bring & apply radiolucent Zoll Pads
** 7. Proceed to Schedule Follow-up
**Transfers: LAFD uses Physio monitor. Pads applied PRN arrhythmia.
 
{| {{table}}
*Schedule Follow-up
| align="center" style="background:#f0f0f0;"|'''Primary Medications'''
**1. If further IV antibiotics needed for cellulitis: Schedule Next Day Clinic in-person appointment within 24 hours
| align="center" style="background:#f0f0f0;"|'''Optional Medications'''
*** Schedule NDC in-person appointment in 24 hours; instruct patient to hold PO antibiotics 12 hours prior.
| align="center" style="background:#f0f0f0;"|'''Nursing Duties'''
** 2. If no further parenteral antibiotics are necessary and no deep wound/bone cultures are needed.
|-
*** Schedule NDC appointment in 1-5 days. Follow-up interval based on severity of infection using clinical judgment. If non-severe, schedule follow-up after cultures expected to result.
| Aspirin 325mg P.O.||Nitroglycerin (SL or patch)||Undress patient
 
|-
=====NDC Gastrointestinal (GI)Urgent Cases=====
| Heparin 5,000 U bolus IV||Morphine IV||Two saline locks
*Gastrointestinal bleeding or suspected bleeding
|-
*Dysphagia or odynophagia
| Defer 2nd anti-platelet drug to cardiology's choice||Ativan IV||Hang one bag saline, slow drip
*Clearly abnormal imaging studies suggestive of malignancy
|-
*Significant, unintentional weight loss not explained by other causes, warranting bidirectional (endoscopy and colonoscopy) in expedited fashion
| AVOID intravenous drips||||At OVMC, ED nurse goes with patient to Cath Lab and brings Code Blue kit
 
|-
*INCLUSION criteria
| ||||For transfers to Holy Cross: call report to 818-496-1270
** 1. No vomiting of bright red blood witnessed during ED stay
|}
** 2. Hemodynamically stable
*'''Plan B Transfer to Northridge'''
** 3. Hemoglobin stable when compared to baseline or near normal limits
**Rare event of Holy Cross closure or 2 simultaneous STEMI, fax EKG to '''818-885-3590''' and then call Northridge ED charge nurse at '''818-885-5396'''
** 4. Patient must not be taking warfarin, NOAC's, or enoxaparin (Lovenox)
** 5. INR level must be <1.5 and platelets >50
** 6. Patients must be tolerating at least liquids; any patient unable to take POs should be admitted
** 7. Patients with evidence of luminal GI obstruction, impending obstruction or food impaction/foreign body obstruction should always be admitted
 
*Management in the ED
** 1. Discuss case with on-all GI fellow or attending who will decide if patient is appropriate for NDC follow-up appointment.  DO NOT SCHEDULE NDC APPT FOR GI WITHOU DISCUSSING WITH ON-CALL GI FELLOW OR ATTENDING.
***GI fellow or attending may be able to schedule an outpatient procedure without a NDC appt; NDC appts are for patients who would otherwise be admitted
***Please confirm with GI fellow or attending that an NDC appt is necessary to expedite the procedure prior to scheduling the NDC appt
***When clerk schedules the NDC appt, please have ED clerk write "endoscopy evaluation" in the field that queries reason for visit
***GI can accommodate Tuesday - Friday AM appointments;  NOT Monday AM appts
***Patient will likely be evaluated by both GI and anesthesiology during the NDC appt;  patient will then be given another appt and instructions to return directly to OPSA for the procedure(s).
 
=====NDC Pyelonephritis or Acute Cystitis=====
* Inclusion criteria for next day clinic:
** Any uncomplicated or complicated UTI (including pyelonephritis) that does not meet the exclusion criteria
** History of MDR organisms (including ESBL) are acceptable
** Frequently recurrent UTIs are acceptable
 
* Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
** New or worsening oliguria (<0.3cc/kg/hr x 24 hours)
** Anuric for >12 hours
** Patient has unstable vitals and/or high suspicion for bacteremia
** Stage 3 AKI (Cr more than 3.0 times baseline)
** Evidence of stones that are a suspected nidus of infection
 
* Treatment in ED for all Pyelonephritis and Cystitis (including history of ESBL)
** 1. For standard cases without complex antimicrobial history, deliver care as usual (e.g., ceftriaxone 1g)
** 2. If ESBL or CRE organisms within prior 12 months, administer amikacin 15 mg/kg IV (renal dosing)
*** a. Can also give if high suspicion for ESBL: recent (within 2-3 months) antibiotic use or prolonged hospitalization, presence of foley, resides in nursing home
** 3. If Cr>1.5 and concern for ESBL, prescribe 1g Ertapenem IV
*** a. Please only use carbapenems in renal impairment given risk of c.diff and PRIME penalties
** 4. For pyelonephritis, discharge with one of the following enteral antibiotics:
*** a. No h/o ESBL: Cefdinir 300mg BID x 14 days (renal dosing)
*** b. H/o Zosyn-sensitive ESBL: Augmentin 875mg BID + cefdinir 300mg BID x 14 days (renal dosing)
**** i. In addition to POs, 100% of these patients will return to NDC for Amikacin/Ertapenem
*** c. H/o fluoroquinolone-sensitive isolates: Ciprofloxacin 500mg BID x 7 days (renal dosing)
*** d. Other difficult susceptibility profiles can be addressed in NDC-- discharge with plans for IV abx
** 5. For acute cystitis, discharge with one of the following enteral antibiotics:
*** a. If creatinine clearance > 60: Nitrofurantoin 100mg BID x 7 days
*** b. If creatinine clearance < 60: Fosfomycin 3g x 1 dose
*** c. If h/o enterococcus: Amoxicillin 500mg PO q6h x7 days (if PCN allergy: Nitrofurantoin 100mg BID)
*** d. Other difficult susceptibility profiles can be addressed in NDC-- discharge with plans for IV abx
** 6. Proceed to Schedule Follow-up
 
* Schedule Follow-up
** 1. If patient presented to the ED with a foley catheter or suprapubic tube in place, replace the catheter
** 2. If clinical judgment suggests additional dose of parenteral antibiotics is necessary (either Amikacin 15mg/kg, Ceftriaxone 1g q24h, or Ertapenem 1g q24h for h/o ESBL)
** 3.  Schedule Next Day Clinic in-person appointment within 24 hours
 
===OOP (Out of Plan)===
*Orange OOP on Tracking Board indicates out of plan insurance.  Patient should be referred back to their health plan and PCP.
*Info on health plan and PCP found on Patient Summary (Discharge Instructions), Demographics and Utilization Review tabs.
*Do not refer OOP patients to subspecialty care at OVMC
*OOP Health Plan and/or clinic name will print automatically on the Patient Summary (Discharge Instructions).
*'''URGENT FOLLOWUP''': To arrange urgent followup with PCP for OOP patients, call '''Outpatient Service Coordinator (OPSC) x74556'''. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc).  Make sure contact info is correct in Cerner.  OPSC coordinators will help expedite a followup appt with the PCP.  Remember,outside health plans usually require patients to see their PCP ''before'' being referred to a subspecialist.
 
 
===DHS Empaneled===
*To find out if a patient is empaneled to a DHS provider, look at the banner bar on the patient's chart. Look right hand side "Emp Prov". Name of PCP will be written there. 
*If empaneled, DHS or community clinic name can be found listed under ''Additional Patient Information'' on ED Summary page.
*'''URGENT FOLLOWUP''': To arrange urgent followup with PCP for OOP patients, call '''Outpatient Service Coordinator (OPSC) x74556'''. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc). Make sure contact info is correct in Cerner. OPSC coordinators will help expedite a followup appt with the PCP. Remember,outside health plans usually require patients to see their PCP before being referred to a subspecialist.
 
===MHLA (My Health LA)===
*Indicated by green MHLA icon on tracking board
*Not an insurance plan but gives patient access to primary care clinic and provider (PCP)
*MHLA patients receive all SPECIALTY care at OVMC or other DHS facilities
*OK to refer MHLA patients to subspecialty care at OVMC either through Message Pool or econsult.


==Dental==
===NERF (New Empanelment Referral Form)===
===Dental Clinics===
*Used to enroll patients with significant PMH who have no primary care or health plan
*No services available at OVMC
*Patient must have at least one of a specific list of diagnoses
*Dental Clinics  https://sslvpn.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/,DanaInfo=myladhs.lacounty.gov+Dental%20Clinics.pdf
*Only about 1/3 of patients will actually receive a PCP through the NERF process. Because of that, give patient a clinic list upon discharge so he/she can find a PMD on their own.
*Dental Clinic Mid-Valley https://sslvpn.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/,DanaInfo=myladhs.lacounty.gov+Dental%20Mid-Valley.pdf
*To enroll in NERF program, click '''NERF''' while completing Depart process. Check off diagnoses that apply. Click green arrow. Clerk will complete on-line NERF form.  '''OR'''. Open patient's chart. Go to Primary Care Information at the bottom of the tabs on the left. Click New Empanelment. Complete form. Unless patient has strong desire to be empaneled to a particular primary care clinic, leave options open.


==Dermatology==
===TFU (Telephone Follow Up)===
===Dermatology Clinic Referral Guidelines===
*818-364-4825  (STAFFED ONLY 2 DAYS PER WEEK!!!)      '''DO NOT USE TFU FOR ANYTHING URGENT or EMERGENT!!!'''
*ONLY refer patients through econsult with SEVERE skin disorder or concern for skin cancer
*Used for follow-up of culture or GC/chlamydia results and for patients to call for outpatient Radiology imaging results
*Referral through econsult MUST include photos
*To refer to TFU, click '''ED Post Visit Plan''' while completing Depart process, choose '''ED-TFU-OVM''' and indicate what needs to be followed up
*Clerk has digital camera and USB cable. Camera icon may take a minute or so to show up on "Computer"
*Ensure we have a correct phone number on the patient
*Please delete any photos from camera or desktop after use
*If patient has already been discharged from the ED and you want to refer to TFU
**Step 1: Find patient on the '''Look Up track''' (only good for 7 days after discharge)
**Step 2: Choose patient on the Look Up track, click Modify Events.....Request Event......Post Visit ED TFU
**Step 3: Open patient's chart......Depart.....now fill out ED Post Visit Plan form
**If you do not follow these steps, TFU will not be flagged to follow-up the patient


==ENT/Head and Neck==
===CCC (Continuing Care Clinic)===
===Hearing Aids===
*ED Followup Clinic used for complicated patients without primary care or an outside health plan
*Econsult to Audiology who will screen patient with audiology testing and refer to ENT if necessary
*Guidelines for CCC:  Urgent follow-up of potentially serious internal medicine conditions that might otherwise require hospital admission, ED return visits, or extensive ED workup. The clinic is for patients without any other primary care resource; patients who have insurance and/or an established primary care clinic should be referred back there for follow-up of such conditions. *Consults sent to CCC will be reviewed within a few days by the NP who staffs the clinic; patients who have insurance or who do not meet the referral criteria listed below will not be seen in CCC; they will be referred on for routine primary care.
*Our DEM TFU program can also refer patients to CCC, so if a test is pending to determine whether a patient meets criteria, please do not generate a CCC referral; the TFU program can review the test and refer to CCC if appropriate.
*The CCC clinic can coordinate work-ups for possible malignancies including ordering additional outpatient imaging and biopsies.
**Step 1: Please do not skip this step! Ensure that patient does not have established HMO insurance, other primary care. Do NOT send DHS Empaneled or OOP patients (see DHS Empaneled and OOP). 
**Step 2: Click '''ED Post Visit Plan''' while completing Depart process, choose '''ED-CCC-OVM'''
**Step 3: Indicate condition requiring urgent CCC visit:
***Suspected new or recurrent neoplastic disease
***Acute medical condition potentially requiring inpatient admission if not followed up promptly
***Diabetes out of control (Glucose >500, requiring initiation of insulin therapy, or new end-organ dz.)
***Severe hypertension (>160/100 at time of ED discharge, new end-organ dz., or refractory to tx.)
***Suspected new significant auto-immune disease (SLE, RA, scleroderma, IBD, vasculitis)
***Complex or undefined infections requiring further evaluation (FUO, osteo, colitis, fungal/parasite, HIV)
***Acute pulmonary disease or exacerbation requiring systemic steroids or antibiotics
***Potentially serious lab or imaging findings (anemia, hepatitis, renal insuff., hyperCa++, incidentalomas)
***Endocrine disease requiring advanced workup (hyperthyroidism, thyroid masses, pituitary/adrenal dz)
***New congestive heart failure, arrhythmia, or structural cardiac disease not requiring admission
***Decompensated liver disease requiring diuretics, paracentesis, or workup for occult etiology
***New or recurrent deep venous thrombosis or other condition requiring anticoagulation
*If you have questions about a consult, or wish to discuss a case during regular business hours, contact Dennis Chamling, NP, via the Department of Medicine or by pager on the amion.com internal medicine website. (password ov_im)


==Gastroenterology==
===Urgent Referrals for Subspecialty Care/Message Pools===
===GI Clinic Referral Guidelines===
*Used to refer patients to certain subspecialty clinics for URGENT follow-up appts (<4 weeks)
*Abdominal pain – do not refer chronic abdominal pain of unclear etiology to GI
*Do NOT refer OOP patients or non-urgent complaints through the Message Pool
*Abnormal imaging
*For Colorectal, ENT and Ophtho patients, page the on-call resident for approval for the urgent follow-up appt. Type in the approving resident's name and the follow-up date/time agreed upon. Tell patient to show up at 8am to the clinic.
**If radiology reading is clearly suspicious for malignancy, refer to GI
*Current Clinics with Message Pools:
**Do not refer patients with studies that “cannot rule out”, “includes possibility of”, etc.
**OVM Colorectal ED/UC Urgent Follow up - needs 24/7 phone call to general surgery
**Do not refer patients simply because radiology wrote “endoscopy is recommended” on final read.   Send patient to PMD or CCC for further interpretation of study results or further imaging
**OVM Coumadin ED/UC Urgent Follow Up
*Anemia - Refer ONLY iron deficiency anemia; send Fe, TIBC, Ferritin; refer to TFU who will place e-consult if labs show iron deficiency
**OVM Hand Surgery ED/UC Urgent Follow Up 
*Barrett’s Esophagus – refer only if documented pathology report can be attached to e-consult
**OVM Gyn Aftercare ED/UC Urgent Follow Up
*BRBPR
**OVM Interventional Radiology ED/UC Urgent Follow Up
**If patient is anemic, refer to GI
**OVM MAT Bridge ED/UC Urgent Follow Up
**If patient is > 40yo, refer to GI
**OVM Ophthalmology ED/UC Urgent Follow Up - needs 24/7 phone call to ophtho
**If patient is < 40yo, Anusol-HC supp qhs x 14 days. Symptoms persist? Follow-up PMD or have pt call TFU for GI referral
**OVM Orthopedics ED/UC Urgent Follow Up
**Do not refer if bloody diarrhea
**OVM Otolaryngology (ENT) ED/UC Urgent Follow Up - needs 24/7 phone call to ENT
*Cirrhosis – Refer ONLY for banding of esophageal varices
**OVM PCC (HIV) ED/UC Urgent Follow Up
*Constipation – treat with osmotic laxative (e.g. sorbitol/miralax/prune juice) and send TSH if applicable
**OVM Pediatrics ED/UC Urgent Follow Up
**If severe (<1 BM per week) or rapid onset, refer to GI
**OVM Peds Ortho ED/UC Urgent Follow Up
*Diarrhea
**OVM Plastic Surgery ED/UC Urgent Follow Up
**Will only see chronic non-infectious diarrhea >8 weeks; send C&S, O&P, C.diff, WBC; refer to TFU who will place e-consult if stool studies negative
**OVM Podiatry ED/UC Urgent Follow Up
*Diverticulitis – do ''NOT'' refer to GI; Pt must be asymptomatic for 2 months before GI will consider colonoscopy
**OVM Procedure Service ED/UC Urgent Follow Up
*Dysphagia
**OVM Urology ED/UC Urgent Follow Up
**If problem is high in throat region, refer to ENT instead If patient does not have weight loss, send barium swallow
**OVM - Trauma Recovery ED/UC Urgent Follow Up
**If patient has weight loss or severe dysphagia, refer to GI
 
*Dyspepsia (i.e. upper GI pain/epig pain >3 months)
===Econsult===
**If patient is > 55yo OR has worrisome symptoms, e.g., weight loss, refer to GI
*eConsult appointment center for new referrals:  747-210-3800
**If patient is < 55yo, order H. pylori test; refer to TFU who will treat with antibiotics if positive
*eConsult is now accessed directly through Cerner from within a patient's chart. There is an eConsult tab available under the Table of Contents Menu (Table of Contents are the grey tabs on the left hand side of the mPage underneath the "ED Summary"). Users no longer have to manually enter patient identifiers to search for a patient. There is no longer a need to maintain a separate username and password for eConsult. 
**If H.pylori test is negative or antibiotic trial fails, try PPI BID for at least 2 months. If that fails, refer to GI for evaluation
*Used to refer patients to subspecialty clinics for NON-URGENT follow-up appts. Not all referrals are approved.  In fact, most from the ED are denied. If approved, appts are likely several months away.
*Family history of colon cancer (must be first-degree relative – mom,dad, sister, brother, child)
*Do NOT send eConsults on OOP patients
**If only one relative, must be < 60 at age of diagnosis or if two or more relatives, age of diagnosis is not important
*Do NOT send eConsults on DHS empaneled patients.  These patients should be referred back to their primary care doctor.
**If patient fulfills above criteria and is either older than 40 or 10 years younger than the age of the relative at diagnosis (whichever is earlier), refer to GI
*For outside records to be attached, use the '''Fax-to-Scan form''' on the Econsult.  Print it out.  Patient name and MRUN will be on the fax form.  Attach it to the outside records and give to the clerk to fax.    See job aid.  XXXXX 
**Otherwise, refer to primary care for fecal occult blood testing.
*For General Surgery gallbladders and hernia referrals, fill out the Cholecystectomy/Hernia form.  Patient must be non-smoker with BMI <35
*GERD (e.g. burning epig/chest pain with acid taste)
*Do '''NOT''' refer the following:
**Do NOT refer to GI – pt must be on maximal therapy x 2months AND have lifestyle changes
**Derm - simple skin conditions (must be SEVERE or worrisome for cancer)
**If patient is not on maximum PPI therapy, change to or increase PPI to BID. Ex: Omeprazole 20 mg BID.
**GI - diverticulitis, undiagnosed abdominal pain, gastritis without minimum of 3 months of PPI or h.pylori treatment
*Hepatitis C - Do NOT refer to GI – treatment reserved for compensated cirrhotics; send to primary care
**Neuro - simple seizures, headaches
*Inflammatory Bowel Disease
**Urology - stones less than 5mm
**If urgent referral needed (moderate flare symptoms), call GI Fellow/Attending on-call; otherwise refer to PMD
 
*Irritable Bowel Syndrome
==Patient Education==
**Only if associated with worrisome symptoms (sudden onset at late age, weight loss), refer to GI
===Diabetic Teaching===
*Occult positive stool only – do not refer from the ED
*Classes held at OVMC; patients must call to schedule a class, 747-210-3176
**Pt must be >50yo, <50 BMI, '''AND''' have CLIA-approved lab occult-positive test NOT from ED to be referred
**Classes are 9am-12:30pm
*Polyps – Do NOT refer to GI unless you can attach endoscopy and pathology reports Ulcer – refer only GASTRIC ulcers that are >5mm; do NOT refer duodenal ulcers
**Appointment is required to attend class; late arrivals will not be allowed to participate
**If concern for malignancy based on outside endocscopy results, call GI for Urgent Consult
*Adult Classes English http://myladhs.lacounty.gov/ov/Departments/Education/Documents/CommunityClasses/Diabetes%20Self%20Management%20Group%20Education%20Flyer_English.pdf
*Urgent Consults
*Adult Classes Spanish http://myladhs.lacounty.gov/ov/Departments/Education/Documents/CommunityClasses/Diabetes%20Self%20Management%20Group%20Education%20Flyer_Spanish.pdf
**Communicate with on-call GI Fellow/Attending AND place e-consult; Note fellow on call CANNOT overbook a clinic visit
 
 
==Cardiology==
==Infectious Disease==
===Code STEMI===
===Reportable Diseases and How To===
*Definite STEMI on EKG and appropriate patient - ACTIVATE Cath Lab per protocol below
*'''HIV''' - if HIV diagnosed at OVMC in our lab, then OVMC ID will take care of reporting positive HIV to LA County Health Department.  Not emergency to report.  ED does not have to report.
*Probable STEMI or complex patient - CONSULT Cardiology (digital FAX '''310-496-0160''')
 
{| {{table}}
==='''Dog Bite''' Reporting Form===
| align="center" style="background:#f0f0f0;"|'''Oliveview UCLA Medical Center'''
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Public%20Health%20-%20Animal%20Bite%20Reporting.pdf
| align="center" style="background:#f0f0f0;"|'''Providence Holy Cross'''
 
|-
===Public Health Confidential Morbidity Report Form ('''Reportable Diseases''')===
| Mon-Fri 7am-5pm||Nights, weekends, holidays
http://publichealth.lacounty.gov/acd/Cdrs.htm
|-
 
| Page Code STEMI via Cerner Consults- Auto Paging (pager 818-226-4502)||Verbally concept patient for transfer
===Public Health '''STD''' Confidential Morbidity Report Form===
|-
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Public%20Health%20-%20STD%20Confidential%20Morbidity%20Report_CMR.pdf
| Verbally consent patient and family for PCI||Fax the EKG to Holy Cross: 818-496-4495
 
|-
===PICC Lines===
| Goal: <30 mins in ED||Call 818-496-7700 (or 7704) for Patient Placement Center to start the Code STEMI transfer                                                                                                                           
*Patients may present with a PICC line in place requesting continued IV antibiotics for an infectious process. Arrangement for on-going antibiotics can only be arranged Monday - Friday (I'm checking this)
|-
**Step 1: XXXX
| ||***Speak with ED physician at Holy Cross to review the faxed EKG 
**Step 2: XXXX
|-
**Step 3: XXXX
| ||***Chart accepting MD name
 
===TB Outpatient Management Guidelines===
*Revised Oct 2014
*The following symptoms, risk factors, and radiographic findings are associated with active TB disease (adapted from Moran et al, Ann Emerg Med, 2009):
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Symptoms'''
| align="center" style="background:#f0f0f0;"|'''Risk factors'''
| align="center" style="background:#f0f0f0;"|'''Radiographic findings'''
|-
|-
| Weight loss (>1 month)||History of homelessness||Cavitary lesion(s)
| ||For updates, call ED direct 818-496-1270
|-
|-
| Cough  (>2 weeks)||History of incarceration||Apical or upper lobe infiltrates
| ||Call LAFD 213-847-5340 (or 5360) for Code STEMI transfer       
|-
|-
| Fever (>2 weeks)||Born outside the U.S.||
| ||***Emergency STEMI transfers ONLY
|-'''Bold text'''
|-
| Night sweats (>1 month)||Prior active TB disease||
| ||ED Clerk to fax patient registration info to 818-496-7707
|-
| ||Goal: <45 mins in ED before transfer
|}
*'''DEFIBRILLATOR DEVICE AT PATIENT BEDSIDE FOR ALL STEMI's'''
**ED: Zoll pads package at bedside (apply only if unstable)
**OVMC Cath Lab: Cardiology will bring & apply radiolucent Zoll Pads
**Transfers: LAFD uses Physio monitor.  Pads applied PRN arrhythmia.
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Primary Medications'''
| align="center" style="background:#f0f0f0;"|'''Optional Medications'''
| align="center" style="background:#f0f0f0;"|'''Nursing Duties'''
|-
| Aspirin 325mg P.O.||Nitroglycerin (SL or patch)||Undress patient
|-
| Heparin 5,000 U bolus IV||Morphine IV||Two saline locks
|-
|-
| Hemoptysis||HIV infection||
| Defer 2nd anti-platelet drug to cardiology's choice||Ativan IV||Hang one bag saline, slow drip
|-
|-
| Malaise (>1 month)||History of TB exposure||
| AVOID intravenous drips||||At OVMC, ED nurse goes with patient to Cath Lab and brings Code Blue kit
|-
|-
| ||History of (+) tuberculin skin test*||*A positive tuberculin skin test alone does not necessitate collection of sputum for active TB disease
| ||||For transfers to Holy Cross: call report to 818-496-1270
|}
|}
*'''EVALUATION OF PATIENTS FOR ACTIVE PULMONARY TB DISEASE IN THE ED'''
*'''Plan B Transfer to Northridge'''
**1. Perform a History and Physical, asking specifically about the symptoms and risk factors noted in the Table above.
**Rare event of Holy Cross closure or 2 simultaneous STEMI, fax EKG to '''818-885-3590''' and then call Northridge ED charge nurse at '''818-885-5396'''
**2. Order chest radiograph.
 
**3. Perform a clinical assessment, taking into account symptoms, risk factors, HIV status, and radiographic findings.
==Dental==
**4. If active pulmonary TB disease is considered possible, order the following tests:
===Dental Clinics===
***1) AFB Culture, other non-sterile, PHL (sputum induced)
*No services available at OVMC
***2) M. tuberculosis PCR with Rifampin Resistance (sputum or expectorated or induced)
*Dental Clinics  https://sslvpn.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/,DanaInfo=myladhs.lacounty.gov+Dental%20Clinics.pdf
***3) HIV antigen/antibody screen (blood)
*Dental Clinic Mid-Valley  https://sslvpn.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/,DanaInfo=myladhs.lacounty.gov+Dental%20Mid-Valley.pdf
****The first specimen should be collected in the ED and should be induced by inhalation of an aerosol (e.g., warm, sterile, 3%–5% hypertonic saline).
 
****Further sputum collection (a total of 3 samples q8 hours recommended) can be collected by Public Health (if discharged) or on the ward (if admitted).
==Dermatology==
****HIV tests will be followed up as an outpatient but will not be performed STAT
===Dermatology Clinic Referral Guidelines===
**5. If discharge is appropriate (see criteria below), the patient must be reported to the TB liaison by phone.
*ONLY refer patients through econsult with SEVERE skin disorder or concern for skin cancer
**6. If patient meets all discharge criteria, educate patient and provide written instructions with appropriate infection control precautions (see below).
*Referral through econsult MUST include photos
*'''DISCHARGE CRITERIA''' (all must be met)
*Clerk has digital camera and USB cable. Camera icon may take a minute or so to show up on "Computer"
**Can be discharged to a stable residence with a verified address and phone number
*Please delete any photos from camera or desktop after use
**WILL NOT be discharged to a shelter, nursing home, single room occupancy hotel or other congregate settings
 
**WILL NOT have significant contact with immunosuppressed individuals or children ≤ 5 yo
==Employee Health - Staff Exposure / Needlestick Cases==
**Is willing and able to follow-up with outpatient care
*Who handles staff exposure cases?
**Is willing and able to comply with home isolation (see below)
**Business hours - refer patient to Employee Health, closes 4:30pm
**''Remember, patient may need a work note''
***When Employee Health is closed, if UCC is open, send to UCC
*'''REPORT TO TB LIAISON'''
***When Employee Health and UCC are closed, staff member to be seen in ED
**Call (818) 364-4590
**Reason patient is seen in the ED at time of exposure is to determine if exposure has high enough risk to warrant presumptive treatment with PEP
**Leave a voicemail with patient name, MRN, patient address AND phone number
*Basic Protocol
**Do '''not''' call the County Operator as the message instructs. The Department of Public Health will attempt to locate the patient and ensure they are evaluated further as an outpatient at a public health clinic
**No paperwork required;  all documentation will be done in Cerner
*'''PATIENT EDUCATION''' - give patient info sheet - located in MD Room or link here https://sslvpn.lacounty.gov/ov/Departments/DEM/Documents/,DanaInfo=myladhs.lacounty.gov+TB%20Patient%20Info%20English.pdf
**Staff member to registered in Cerner;  PAC will use IA billing code to register employee
**DO NOT receive visitors at home, visit others, or go to work until evaluated by Public Health
**ED or UCC provider will use ''.edexposure'' autotext for documentation of exposure episode
**DO NOT care for children ≤ 5 years old
**NO LABS WILL BE DRAWN ON THE STAFF MEMBER FROM THE EMERGENCY DEPARTMENT;  ALL lab testing on staff member will occur in Employee Health (or at UCLA for students/residents/fellows) the next business day even over a long weekend and even if PEP meds are started
**Avoid public areas/ public transportation.
**Source patient will have labs drawn by unit/clinic using the ''Blood and Body Fluid - Source Patient'' order set
**If you are employed DO NOT go to work
*Decision to treat with post-exposure prophylaxis medication
**Cover your mouth and nose when coughing
**For any questions regarding the starting of PEP, Consult Infectious Disease 24/7
**Wear a surgical mask when spending time in a shared space (should be provided to patient upon discharge)
**If PEP is deemed appropriate, ED provider will prescribe the following medications through Cerner (PRINT OUT HARD COPY OF PRESCRIPTION.  DO NOT EPRESCRIBE TO OUR PHARMACY. OK TO PRINT ON WHITE PAPER. GIVE HARD COPY TO ED PHARMACIST WHO WILL GO GET THE MEDICATION):
**Patients will be contacted regarding any positive TB or HIV results
***Truvada 200/200mg tabs one tab QDAY x 30 days
*'''FREQUENTLY ASKED QUESTIONS ABOUT TB'''
***Raltegravir 400mg tabs one tab BID x 30 days
**'''What is the role of the TB liaison at OVMC?'''
*Where do we send for follow-up?
***The primary role of the TB liaison is to assist with patients suspected to have active TB disease, particularly to ensure proper reporting to the Department of Public Health
**OVMC employees should be instructed to followup at Employee Health the next business day;  just walk-in.  No need for appointment.
***Per the new ED policy, the liaison SHOULD be contacted by phone for patients with sputum collected for TB evaluation, but not admitted to the hospital. This is essential to ensure those patients are adequately followed for outpatient evaluation in the public health clinics.
***For OVMC employees:  *Message through Cerner:  Suzanna Mendez-Nasrallah NP that employee was seen in the ED for an exposure. 
***The liaison SHOULD NOT be contacted for patients with latent TB infection (see below) who are not suspected to active TB disease
**For UCLA students:  Refer back to UCLA Student Health.
***The liaison can also provide information regarding patients seen in the ED who are already diagnosed with TB disease, and may be presenting with a related complaint (e.g., intolerance of anti-TB medications)
**For UCLA resident/fellows:  Refer back to UCLA Occupational Health.
***Then liaison is not able to provide clinical consults regarding patient care or decisions to admit/discharge
**No additional paperwork besides ED Discharge Instructions is given to staff member.  All workman's comp paperwork will be completed by Employee Health or UCLA.
**'''How do I contact the TB liaison?'''
 
***The liaison has an office at OVMC, and is available Monday through Friday, 9am-5pm.
==ENT/Head and Neck==
***Call (818) 364-4590; if no one answers, leave a voicemail with the patient’s name and MRUN. VERIFY ADDRESS and PHONE NUMBER ARE CORRECT IN CERNER!
===Hearing Aids===
***If calling outside business hours, just leave a voicemail with above information.
*Econsult to Audiology who will screen patient with audiology testing and refer to ENT if necessary
**'''What should I do with a patient sent to the ED for a positive tuberculin skin test (i.e., PPD) or a positive IGRA (e.g., Quantiferon)?'''
 
***Both of these tests may represent latent TB infection.
==Gastroenterology==
***Patients with a positive test should be evaluated with:
===H. Pylori Testing===
****1. A history and physical - to see if they have any signs or symptoms or active TB disease.
*OVMC has removed the H.pylori BLOOD test;  all H.pylori testing should be STOOL Antigen testing
****2. A chest radiograph - to look for active pulmonary tuberculosis.
 
***If the patient’s overall clinical presentation is very unlikely to represent active pulmonary TB (e.g., normal chest x-ray, not immunosuppressed, no signs or symptoms of TB), then the patient should be referred for possible treatment of latent TB infection.
===GI Clinic Referral Guidelines===
***Preferably, patients should be sent to a primary care provider
*Abdominal pain – do not refer chronic abdominal pain of unclear etiology to GI
***For patients without a primary care provider, they can be sent to public health centers  http://publichealth.lacounty.gov/locator.htm
*Abnormal imaging
***DO NOT contact the TB liaison for patients with latent TB infection; the liaison should only be contacted for patients suspected to have active TB disease
**If radiology reading is clearly suspicious for malignancy, refer to GI
 
**Do not refer patients with studies that “cannot rule out”, “includes possibility of”, etc.
==Neurology==
**Do not refer patients simply because radiology wrote “endoscopy is recommended” on final read.  Send patient to PMD or CCC for further interpretation of study results or further imaging
===Matt's Reminders===
*Anemia - Refer ONLY iron deficiency anemia; send Fe, TIBC, Ferritin; refer to TFU who will place e-consult if labs show iron deficiency
*Please call neurology for ANY questions regarding the management of stroke patients
*Barrett’s Esophagus – refer only if documented pathology report can be attached to e-consult
*All CVAs with symptoms within 8 hours should be discussed with neurology
*BRBPR
*For acute CVAs within a 5 hour window the imaging of choice is CT angiography head with and without contrast
**If patient is anemic, refer to GI
*Admit TIAs to medicine: we don’t send them home
**If patient is > 40yo, refer to GI
*E-mail Matt with any difficult neurosurgery transfers or neurology issues. Matt's cell is posted in ED. Matt has direct contact with USC Neurosurg and is happy to help in the heat of battle
**If patient is < 40yo, Anusol-HC supp qhs x 14 days. Symptoms persist? Follow-up PMD or have pt call TFU for GI referral
**Do not refer if bloody diarrhea
*Cirrhosis – Refer ONLY for banding of esophageal varices
*Constipation – treat with osmotic laxative (e.g. sorbitol/miralax/prune juice) and send TSH if applicable
**If severe (<1 BM per week) or rapid onset, refer to GI
*Diarrhea
**Will only see chronic non-infectious diarrhea >8 weeks; send C&S, O&P, C.diff, WBC; refer to TFU who will place e-consult if stool studies negative
*Diverticulitis – do ''NOT'' refer to GI; Pt must be asymptomatic for 2 months before GI will consider colonoscopy
*Dysphagia
**If problem is high in throat region, refer to ENT instead If patient does not have weight loss, send barium swallow
**If patient has weight loss or severe dysphagia, refer to GI
*Dyspepsia (i.e. upper GI pain/epig pain >3 months)
**If patient is > 55yo OR has worrisome symptoms, e.g., weight loss, refer to GI
**If patient is < 55yo, order H. pylori test; refer to TFU who will treat with antibiotics if positive
**If H.pylori test is negative or antibiotic trial fails, try PPI BID for at least 2 months. If that fails, refer to GI for evaluation
*Family history of colon cancer (must be first-degree relative – mom,dad, sister, brother, child)
**If only one relative, must be < 60 at age of diagnosis or if two or more relatives, age of diagnosis is not important
**If patient fulfills above criteria and is either older than 40 or 10 years younger than the age of the relative at diagnosis (whichever is earlier), refer to GI
**Otherwise, refer to primary care for fecal occult blood testing.
*GERD (e.g. burning epig/chest pain with acid taste)
**Do NOT refer to GI – pt must be on maximal therapy x 2months AND have lifestyle changes
**If patient is not on maximum PPI therapy, change to or increase PPI to BID. Ex: Omeprazole 20 mg BID.
*Hepatitis C - Do NOT refer to GI – treatment reserved for compensated cirrhotics; send to primary care
*Inflammatory Bowel Disease
**If urgent referral needed (moderate flare symptoms), call GI Fellow/Attending on-call; otherwise refer to PMD
*Irritable Bowel Syndrome
**Only if associated with worrisome symptoms (sudden onset at late age, weight loss), refer to GI
*Occult positive stool only – do not refer from the ED
**Pt must be >50yo, <50 BMI, '''AND''' have CLIA-approved lab occult-positive test NOT from ED to be referred
*Polyps – Do NOT refer to GI unless you can attach endoscopy and pathology reports Ulcer – refer only GASTRIC ulcers that are >5mm; do NOT refer duodenal ulcers
**If concern for malignancy based on outside endocscopy results, call GI for Urgent Consult
*Urgent Consults
**Communicate with on-call GI Fellow/Attending AND place e-consult; Note fellow on call CANNOT overbook a clinic visit
 
==Infectious Disease==
===Reportable Diseases and How To===
*'''HIV''' - if HIV diagnosed at OVMC in our lab, then OVMC ID will take care of reporting positive HIV to LA County Health Department.  Not emergency to report.  ED does not have to report.
*If known HIV patient presents to DHS requesting follow-up, check for OOP then Message Pool OVM PCC(HIV) ED/UC Urgent Follow Up
**PCC = Positive Care Clinic
 
==='''Dog Bite''' Reporting Form===
http://www.publichealth.lacounty.gov/vet/docs/Forms/BiteFormVet.pdf


===Code Stroke===
===Public Health Confidential Morbidity Report Form '''Reportable Diseases'''===
*Criteria: Potential new Code Stroke case with ≤8 hours since last know well time.
*Hot Line: (888) 397-3993 
*Code Stroke pager available through through AMION  ('''818-226-4797''')
*Fax Line: (888) 397-3778 of (213) 482-5508
**NOTE: 1/5/2017 - Code Stroke through Consults-Auto Paging OVMC currently not working
http://www.publichealth.lacounty.gov/acd/pubs/reports/CMR-H-794.pdf
*Code Stroke Team:
**Neurology Team
**Stroke Fellow
**ED pharmacist (M-F 8am-4pm)
*Step 1:  Page Code Stroke
**If paging through AMION, include patient's name, MRUN, location/room number and last known well time
*Step 2: Briefly discuss the case with the on-call Neurology Resident. Have the last known well time ready.
*Step 3:  Labs: CBC, BMP (including BUN and creatinine), LFTs, troponin, PT/PTT
*Step 4: Chest x-ray
*Step 5: EKG
*Step 6: Brain imaging to be discussed with Neurology Resident and Stroke Fellow. Generally:
**STAT Non-contrast CT head '''AND''' CT angiogram if there is no contraindication to contrast
*Step 7: Prepare for STAT imaging. Neurology team will coordinate with Radiology to ascertain the most suitable mode and location of imaging, including determining if MRI would be more appropriate.
*Step 8: Neurology Resident will come evaluate the patient. The Stroke Fellow will assist by phone/telemedicine unit until the Resident (who may be off campus) arrives.
*Step 9: Stroke Fellow will handle transfer of any patient (e.g. to UCLA) requiring intra-arterial thrombolysis
**If MRI is requested by Neurology after-hours and tech needs to be called in, see Radiology...MRI After Hours


===Neuro Clinic Referral Guidelines===
===Public Health '''STD''' Confidential Morbidity Report Form===
*Stroke/TIA
http://www.publichealth.lacounty.gov/dhsp/ReportCase/STD_CMR.pdf
**TIA. In general, all patients who present with a history suggestive of TIA should be admitted for risk factor assessment. Due to the high immediate risk of ischemic stroke following a TIA and the inefficiencies of outpatient diagnostic testing, inpatient monitoring and assessment ensures comprehensive evaluation and the potential for timely intervention if indicated.
 
**Hemorrhagic stroke. In the event of a parenchymal, subdural or subarachnoid hemorrhage, a transfer to LAC+USC should be arranged. The only exception is a parenchymal hemorrhage with symptoms already for more than 5 days, in which case admission to Olive View is permissible.
===TB Outpatient Management Guidelines===
**Ischemic Stroke. All ischemic stroke patients should be evaluated by the Neurology Service. The timing of consultation shall be determined by the duration of symptoms.
*Revised Oct 2014
***0-3 hours: Consultation should occur in the Emergency Department to determine eligibility for intravenous tPA.
*The following symptoms, risk factors, and radiographic findings are associated with active TB disease (adapted from Moran et al, Ann Emerg Med, 2009):
***3-6 hours: Consultation should occur in the Emergency Department to determine eligibility for possible transfer to UCLA for intra-arterial tPA.
{| {{table}}
***6-48 hours: Consultation should occur in the Emergency Department to help determine the appropriate level of care for admission.
| align="center" style="background:#f0f0f0;"|'''Symptoms'''
***48-72 hours: Consultation may be sought after admission (unless symptoms have progressed in a stepwise pattern or if the patient has multiple increasing, stereotypic TIA symptoms, in which case consultation should occur in the Emergency Department). Patients should be admitted to the intermediate care unit or standard care telemetry ward for 24 hours of observation/monitoring.
| align="center" style="background:#f0f0f0;"|'''Risk factors'''
***>3 days: Consultation may be sought after admission. The level of care for admission is left to the discretion of the DEM attending.
| align="center" style="background:#f0f0f0;"|'''Radiographic findings'''
**Studies to be obtained prior to Neurology Clinic consultation:
|-
***If old, check for MRA of neck or Doppler, echocardiogram, MRI brain
| Weight loss (>1 month)||History of homelessness||Cavitary lesion(s)
***Labs: RPR, ESR, HbA1c, PT/PTT or INR, homocysteine level
|-
*Seizures
| Cough  (>2 weeks)||History of incarceration||Apical or upper lobe infiltrates
**Patients with established epilepsy do not need consultation following a solitary seizure, if an obvious reason for the breakthrough exists (e.g., non-compliance with meds, concomitant illness). If the patient has had a 20% increase in seizure frequency in the recent past, then a request for an earlier appointment may be submitted if the patient’s scheduled visit to Neurology Clinic is >1 month into the future. Patients who have run out of anticonvulsant medication(s) may be given a supply to cover them until the next scheduled Neurology Clinic visit. If an appointment does not exist, then a 5-month supply should be given and a Request for Outpatient Consultation form submitted. If a patient has a stable seizure disorder (no seizures on anticonvulsant medication with the past half-year or more) there is no clinical necessity that the Neurology Service follow them. Medication may be refilled by Primary Care. Stable seizure patients who cannot obtain Primary Care can be most efficiently followed in one of Neurology’s Nurse Practitioner clinics.
|-
**Studies to be obtained prior to Neurology Clinic consultation:
| Fever (>2 weeks)||Born outside the U.S.||
***Anticonvulsant levels
|-'''Bold text'''
***EEG
| Night sweats (>1 month)||Prior active TB disease||
***Brain MRI
|-
*Headache
| Hemoptysis||HIV infection||
**Patients with established migraine headache who have failed primary-care attempts at management may be referred to the Neurology Clinic. Patients given a new diagnosis of migraine by Primary Care, Medical Walk- In or the DEM, who have not yet had reasonable attempts at management (use of triptans and/or appropriate preventive medications) should be referred to Primary Care prior to seeking specialist care.
|-
**Studies to be obtained prior to Neurology Clinic consultation:
| Malaise (>1 month)||History of TB exposure||
***If DEM referral, the patient should be referred to Primary Care first. If referral from Primary Care, and headache of long duration (>1 year), documentation of prior management attempts.
|-
***Medication history
| ||History of (+) tuberculin skin test*||*A positive tuberculin skin test alone does not necessitate collection of sputum for active TB disease
***If patient > 50 years old, ESR
|}
***Documented neurology examination (to help determine the urgency of the referral).
*'''EVALUATION OF PATIENTS FOR ACTIVE PULMONARY TB DISEASE IN THE ED'''
***If focal findings on neuro exam, neuroimaging results or at least a request submitted for MRI of brain.
**1. Perform a History and Physical, asking specifically about the symptoms and risk factors noted in the Table above.
*Dizziness - In all cases of “dizziness”, Neurology is best equipped to help patients who exhibit vertigo and/or disequilibrium accompanied by focal neurological signs. Episodic light-headedness and chronic dizziness are generally better served by Primary Care, Cardiology, or Head and Neck Surgery.
**2. Order chest radiograph.
*Peripheral neuropathy
**3. Perform a clinical assessment, taking into account symptoms, risk factors, HIV status, and radiographic findings.
**Studies to be obtained prior to Neuromuscular Clinic consultation:
**4. If active pulmonary TB disease is considered possible, order the following tests:
***If painful, medication history
***1) AFB Culture, other non-sterile, PHL (sputum induced)
***Labs: B12, RPR, TSH, HbA1c, ESR, and consider SPEP, ANA
***2) M. tuberculosis PCR with Rifampin Resistance (sputum or expectorated or induced)
***EMG/nerve conduction velocities if available
***3) HIV antigen/antibody screen (blood)
*Muscle Disease
****The first specimen should be collected in the ED and should be induced by inhalation of an aerosol (e.g., warm, sterile, 3%–5% hypertonic saline).
**Studies to be obtained prior to Neuromuscular Clinic consultation:
****Further sputum collection (a total of 3 samples q8 hours recommended) can be collected by Public Health (if discharged) or on the ward (if admitted).
***Labs: CPK, ESR, TSH, ANA
****HIV tests will be followed up as an outpatient but will not be performed STAT
***EMG
**5. If discharge is appropriate (see criteria below), the patient must be reported to the TB liaison by phone.
*Dementia
**6. If patient meets all discharge criteria, educate patient and provide written instructions with appropriate infection control precautions (see below).
**Studies to be obtained prior to Memory Disorders Clinic consultation:
*'''DISCHARGE CRITERIA''' (all must be met)
***Do not refer to General Neurology; refer to Memory Disorders Clinic
**Can be discharged to a stable residence with a verified address and phone number
***Labs: CBC, B12, TSH, RPR, MHA-TP, Ca, Na, ALT, AST, BUN, creatinine, homocysteine, RBS Vitamin D level, lipid panel
**WILL NOT be discharged to a shelter, nursing home, single room occupancy hotel or other congregate settings
***MRI of Brain with Dementia Protocol
**WILL NOT have significant contact with immunosuppressed individuals or children ≤ 5 yo
*Multiple Sclerosis
**Is willing and able to follow-up with outpatient care
**Studies to be obtained prior to Neurology Clinic consultation:
**Is willing and able to comply with home isolation (see below)
***MRI brain and/or spinal cord with contrast if available
**''Remember, patient may need a work note''
***Labs: ANA, B12, RPR, Vit D level, ESR, SSA, SSB, consider HIV
*'''REPORT TO TB LIAISON'''
***LP if available, for oligoclonal bands, IgG, IgG synthesis, and routine protein glucose, cell counts, differential
**Call (747)210-4590
 
**Leave a voicemail with patient name, MRN, patient address AND phone number
===Sleep Study===
**Do '''not''' call the County Operator as the message instructs. The Department of Public Health will attempt to locate the patient and ensure they are evaluated further as an outpatient at a public health clinic
*Econsult Sleep Study
*'''PATIENT EDUCATION''' - give patient info sheet - located in MD Room or link here https://sslvpn.lacounty.gov/ov/Departments/DEM/Documents/,DanaInfo=myladhs.lacounty.gov+TB%20Patient%20Info%20English.pdf
*Do NOT place order for sleep study; econsult should be placed but seriously ask yourself WHY AM I ORDERING THIS FROM THE ED??
**DO NOT receive visitors at home, visit others, or go to work until evaluated by Public Health
 
**DO NOT care for children ≤ 5 years old
===DMV Request for Re-Examination Form===
**Avoid public areas/ public transportation.
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/DMV%20Request%20for%20Reexamination%20Form.pdf
**If you are employed DO NOT go to work
 
**Cover your mouth and nose when coughing
==Neurosurgery==
**Wear a surgical mask when spending time in a shared space (should be provided to patient upon discharge)
===Neurosurgery Transfer Guidelines===
**Patients will be contacted regarding any positive TB or HIV results
*Approved by DEMs at OVMC and LAC, LAC+USC Neurosurgery, OVMC Medical Admin and MAC April 2017
*'''FREQUENTLY ASKED QUESTIONS ABOUT TB'''
*Protocol to streamline ability to transfer patients with intracranial bleeds, spinal cord injuries, etc out of the ED at OVMC
**'''What is the role of the TB liaison at OVMC?'''
*No longer will subsets of patients with intracranial bleeds remain at OVMC
***The primary role of the TB liaison is to assist with patients suspected to have active TB disease, particularly to ensure proper reporting to the Department of Public Health
*If patient is '''OOP but stable, contact UR x4890''' to attempt transfer within the patient's health plan
***Per the new ED policy, the liaison SHOULD be contacted by phone for patients with sputum collected for TB evaluation, but not admitted to the hospital. This is essential to ensure those patients are adequately followed for outpatient evaluation in the public health clinics.
*For '''unstable or DHS/uninsured patients,''' transfers will be made through the '''MAC to LAC+USC neurosurgery'''  (Harbor is no longer an option)
***The liaison SHOULD NOT be contacted for patients with latent TB infection (see below) who are not suspected to active TB disease
*For difficult transfers, it is really important that the OVMC ED attending through MAC contacts the LAC-USC neurosurgery attending to discuss the case
***The liaison can also provide information regarding patients seen in the ED who are already diagnosed with TB disease, and may be presenting with a related complaint (e.g., intolerance of anti-TB medications)
*If the LAC+USC neurosurgery resident refuses the case or '''cannot accept due to lack of beds''', OVMC should '''request an ED Attending to ED Attending transfer to LAC-USC'''
***Then liaison is not able to provide clinical consults regarding patient care or decisions to admit/discharge
*ED to ED transfers can also be used for cases that '''LAC+USC neurosurgery does not want on their service'''
**'''How do I contact the TB liaison?'''
**Neurosurgery must agree to go to the ED and evaluate the patient
***The liaison has an office at OVMC, and is available Monday through Friday, 9am-5pm.
**This also must be communicated to the LAC+USC ED Attending
***Call (747)210-4590; if no one answers, leave a voicemail with the patient’s name and MRUN. VERIFY ADDRESS and PHONE NUMBER ARE CORRECT IN CERNER!
*If problems remain unresolved, contact Dr. Waxman (phone directory in ED1A MD room); he can then contact Dr. Arun Amar at LAC-USC neurosurgery 24/7 for problems
***If calling outside business hours, just leave a voicemail with above information.
**'''What should I do with a patient sent to the ED for a positive tuberculin skin test (i.e., PPD) or a positive IGRA (e.g., Quantiferon)?'''
***Both of these tests may represent latent TB infection. 
***Patients with a positive test should be evaluated with:
****1. A history and physical - to see if they have any signs or symptoms or active TB disease.
****2. A chest radiograph - to look for active pulmonary tuberculosis.
***If the patient’s overall clinical presentation is very unlikely to represent active pulmonary TB (e.g., normal chest x-ray, not immunosuppressed, no signs or symptoms of TB), then the patient should be referred for possible treatment of latent TB infection.
***Preferably, patients should be sent to a primary care provider
***For patients without a primary care provider, they can be sent to public health centers  http://publichealth.lacounty.gov/locator.htm
***DO NOT contact the TB liaison for patients with latent TB infection; the liaison should only be contacted for patients suspected to have active TB disease


==OB-Gyn==
==Neurology==
===Referral Guidelines for Message Pool vs Econsult===
===Matt's Reminders===
*Urgent Followup through Message Pool in Cerner/Orchid
*Please call neurology for ANY questions regarding the management of stroke patients
**These go to NP clinic and will be seen usually within a few days
*All CVAs with symptoms within 8 hours should be discussed with neurology
***First trimester vag bleed
*For acute CVAs within a 5 hour window the imaging of choice is CT angiography head with and without contrast
***Complicated PID that needs GYN followup
*Admit TIAs to medicine: we don’t send them home
***AUBs who are anemic (hgb less than or equal to 9)
*E-mail Matt with any difficult neurosurgery transfers or neurology issues. Matt's cell is posted in ED. Matt has direct contact with USC Neurosurg and is happy to help in the heat of battle
***Post menopausal bleeding
***Bartholyn's cysts
***Labial abscess


*Econsult to GYN
===Acute Stroke Protocol and TeleStroke iPad===
**These go to an MD clinic and will usually be seen in 2-4 weeks
*updated May 2021
***AUBs with stable hemoglobin
*For suspected or presumed stroke with last time known to be at baseline ≤ 8 hrs before presentation
***Ovarian cysts
*Stroke Alert Background:  Intent of this protocol is to create a rapid, collaborative care model for the acute stroke patient. The ED Attending or primary team attending (for non-ED patients) retains ultimate responsibility for the care of the patient and any decision-making regarding that care.
***Chronic pelvic pain
*Stroke Alert Pager number is 818-226-4797. Any physician involved in the patient’s care can activate a Stroke Alert by calling the page operator, requesting a page to the “Stroke Alert Pager,” and provide a call back number. The number can be text paged from www.amion.com or www.myairmail.com (American Messaging). The pager is used to alert appropriate group members to a potential acute stroke in-house or in the ED. The Stroke Alert pager notifies the following staff members:
***Urogyn
**Neurology Resident on-call
**Stroke Fellow
**ED Pharmacist
***please enter the full 10 digit call back number and add *911 or “stroke alert” to note high acuity.
'''ED Actions'''
*Dial 818-226-4797 or text page this number through www.amion.com or www.myairmail.com (American Messaging). 
**Briefly discuss the case with the on-call Neurology Resident.  Have the symptoms and last known well time ready.
*Studies:
**CBC, BMP (including BUN and creatinine), LFTs, troponin, PT/PTT/INR
**Chest x-ray
**EKG
**Brain imaging: Discuss with the Neurology Resident and Stroke Fellow. Generally:
***STAT Non-contrast CT head '''''AND''''' CT angiogram head and neck if there is no contraindication to contrast
***Prepare for STAT imaging.  Neurology team will coordinate with Radiology to ascertain the most suitable mode and location of imaging, including determining if MRI would be more appropriate.
*If patient meets criteria for thrombolytics or thrombectomy, the Neurology Resident will come evaluate the patient.  The Stroke Fellow will assist by phone/telemedicine until the Resident (who may be off campus) arrives.
*The Stroke Fellow will assist arranging for tPA or Transfer, if appropriate.  In these cases, please assist by paging “tPA Case” or “Stroke Transfer,” to 818-226-4797 though www.amion.com.  Texting these messages will mobilize the appropriate team.
*Transfer for mechanical thrombectomy for patients with large vessel occlusion for clinically appropriate candidates:
**Transfers are coordinated by Utilization Review (747-210-4890).  If further assistance is needed, contact MAC center (866-940-4401).
***Holy Cross One-Call Transfer:  818-858-5779 - closest, 1st choice, MOU for inpatients
***UCLA One-Call Transfer: 310-825-0909
***Keck One-Call Transfer: 323-442-6111


===Establishing care at OVMC for pregnant patients===
'''Potential Thrombolytic Case - last at baseline <4.5 hours prior to presentation'''
*Do not refer OOP patients;  refer these back to their health plan
* Text "tPA case" to 818-226-4797 and to stroke fellow, pager 818-226-4885
*For uninsured patients, tell patient to go to Clinc D to request follow-up for pre-natal care, "PK" clinic;  clinic closes at 4pm
*REMEMBER, use Message Pool for an urgent request for pregnant vag bleeds, rule out ectopics getting BHCG checks, etc


===Oral Contraceptive Taper Patient Instructions===
'''Large Vessel Occlusions (LVOs) at OVMC'''
http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_English.pdf
*Mechanical thrombectomy in patients with LVOs are considered in patients presenting with deficits within 24 hours.
http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_Spanish.pdf
*The decision on which patients are candidates for a cerebral angiogram which is the first step in an intervention for an LVO is a complex decision made by the neurology team.
*The OVMC neurology resident decides with the stroke attending and/or stroke fellow if the patient is a candidate for an LVO intervention. This involves the interpretation of the CT perfusion study and CT angiography as well as the patient's presenting symptoms.
*If the patient is a candidate for an LVO intervention the '''stroke neurology team arranges transport with Holy Cross which is contracted with DHS to provide this service to OVMC'''. The '''ED team should ''NOT'' call MAC or the critical care transport team''' for transport to Holy Cross.


===Oral Provera Taper Patient Instructions===
'''Tele Stroke iPAD instructions'''
*Coming soon!!
*When the iPAD is receiving an incoming call, you will hear a tone.
**1. To receive the call, please unlock the home screen (code: 800000)
**2. Click on the blue HipaaBridge icon.
**3. Video should start automatically.
*Receiving a call: iPAD will ring when someone is calling in.
**1. Home screen, unlock by pressing the button (under the finger in the picture)
**2. Press “800000” on the touchscreen to unlock the iPAD
**3. Answer call (green button, under finger)
*Troubleshooting:
**No volume: volume tabs are on your right as you face the screen, towards the top
**Not turning on: ensure iPAD is charged.  Charging port is at the bottom of the iPAD.  Power button is on the top of the device, towards your right. Charging cables are stored behind the device in the locked cabinet where the iPAD is stored.
**If you wish to dial out from the iPAD (generally will not be necessary), in order to log into Hipaabridge, it may ask you for a 4-digit passcode
*If you get to this screen, and absolutely have to log in (not needed to answer a call, only needed for dialing out), press “3104” on the touch screen. DO NOT press “cancel” - this will lock the device out of HipaaBridge and currently for security purposes, only IT personnel can log back in.  They can be reached at x73239 or room 1D132.
*If completely locked out from HipaaBridge and you see a log in screen requesting an e-mail or single sign on, please contact IT at x73239 or room 1D132.  Currently, only they can log back in if the iPAD is completely locked out.


==Orthopedics and Podiatry==
===Neuro Clinic Referral Guidelines===
*Orthopedic Surgery and Podiatry share clinic space and communicate regarding complex lower extremity cases.  
*Stroke/TIA
===Ortho and Podiatry Clinic Referral Guidelines===
**TIA. In general, all patients who present with a history suggestive of TIA should be admitted for risk factor assessment. Due to the high immediate risk of ischemic stroke following a TIA and the inefficiencies of outpatient diagnostic testing, inpatient monitoring and assessment ensures comprehensive evaluation and the potential for timely intervention if indicated.
{| {{table}}
**Hemorrhagic stroke. In the event of a parenchymal, subdural or subarachnoid hemorrhage, a transfer to LAC+USC should be arranged. The only exception is a parenchymal hemorrhage with symptoms already for more than 5 days, in which case admission to Olive View is permissible.
| align="center" style="background:#f0f0f0;"|'''OVMC Orthopedics'''
**Ischemic Stroke. All ischemic stroke patients should be evaluated by the Neurology Service. The timing of consultation shall be determined by the duration of symptoms.
| align="center" style="background:#f0f0f0;"|'''OVMC Podiatry'''
***0-3 hours: Consultation should occur in the Emergency Department to determine eligibility for intravenous tPA.
|-
***3-6 hours: Consultation should occur in the Emergency Department to determine eligibility for possible transfer to UCLA for intra-arterial tPA.
| Patients 16 years of age and older||Majority of foot and ankle fractures are managed by podiatry (5th metatarsal fractures, ankle fractures)
***6-48 hours: Consultation should occur in the Emergency Department to help determine the appropriate level of care for admission.
|-
***48-72 hours: Consultation may be sought after admission (unless symptoms have progressed in a stepwise pattern or if the patient has multiple increasing, stereotypic TIA symptoms, in which case consultation should occur in the Emergency Department). Patients should be admitted to the intermediate care unit or standard care telemetry ward for 24 hours of observation/monitoring.
| High Energy ankle fractures such as a pilon fracture||Diabetic foot including osteomyelitis
***>3 days: Consultation may be sought after admission. The level of care for admission is left to the discretion of the DEM attending.
|-
**Studies to be obtained prior to Neurology Clinic consultation:
| Maisonneuve fractures involving the fibular head||Ankle sprains
***If old, check for MRA of neck or Doppler, echocardiogram, MRI brain
|-
***Labs: RPR, ESR, HbA1c, PT/PTT or INR, homocysteine level
| Lisfranc fractures (tarso-matatasal injury)||Plantar fasciitis
*Seizures
|-
**Patients with established epilepsy do not need consultation following a solitary seizure, if an obvious reason for the breakthrough exists (e.g., non-compliance with meds, concomitant illness). If the patient has had a 20% increase in seizure frequency in the recent past, then a request for an earlier appointment may be submitted if the patient’s scheduled visit to Neurology Clinic is >1 month into the future. Patients who have run out of anticonvulsant medication(s) may be given a supply to cover them until the next scheduled Neurology Clinic visit. If an appointment does not exist, then a 5-month supply should be given and a Request for Outpatient Consultation form submitted. If a patient has a stable seizure disorder (no seizures on anticonvulsant medication with the past half-year or more) there is no clinical necessity that the Neurology Service follow them. Medication may be refilled by Primary Care. Stable seizure patients who cannot obtain Primary Care can be most efficiently followed in one of Neurology’s Nurse Practitioner clinics.
| No acute soft tissue knee injury (non-fracture) greater than age 55||
**Studies to be obtained prior to Neurology Clinic consultation:
|-
***Anticonvulsant levels
| No hip fractures) (Transfer out)||
***EEG
|-
***Brain MRI
| No compartment syndromes (General Surgery)||
*Headache
|-
**Patients with established migraine headache who have failed primary-care attempts at management may be referred to the Neurology Clinic. Patients given a new diagnosis of migraine by Primary Care, Medical Walk- In or the DEM, who have not yet had reasonable attempts at management (use of triptans and/or appropriate preventive medications) should be referred to Primary Care prior to seeking specialist care.
| No Open fractures (Transfer out)||
**Studies to be obtained prior to Neurology Clinic consultation:
|-
***If DEM referral, the patient should be referred to Primary Care first. If referral from Primary Care, and headache of long duration (>1 year), documentation of prior management attempts.
| Tibial plateau and knee fractures||
***Medication history
|-
***If patient > 50 years old, ESR
| Upper extremity injuries proximal to mid-forearm. (Distal to forearm goes to Hand)||
***Documented neurology examination (to help determine the urgency of the referral).
|-
***If focal findings on neuro exam, neuroimaging results or at least a request submitted for MRI of brain.
| No septic arthritis involving history of arthroplasty (prosthetic joint) (Transfer out)||
*Dizziness - In all cases of “dizziness”, Neurology is best equipped to help patients who exhibit vertigo and/or disequilibrium accompanied by focal neurological signs. Episodic light-headedness and chronic dizziness are generally better served by Primary Care, Cardiology, or Head and Neck Surgery.
|-
*Peripheral neuropathy
| Will operate on septic arthritis with fracture hardware (wires, plates)||
**Studies to be obtained prior to Neuromuscular Clinic consultation:
|}
***If painful, medication history
***Labs: B12, RPR, TSH, HbA1c, ESR, and consider SPEP, ANA
***EMG/nerve conduction velocities if available
*Muscle Disease
**Studies to be obtained prior to Neuromuscular Clinic consultation:
***Labs: CPK, ESR, TSH, ANA
***EMG
*Dementia
**Studies to be obtained prior to Memory Disorders Clinic consultation:
***Do not refer to General Neurology; refer to Memory Disorders Clinic
***Labs: CBC, B12, TSH, RPR, MHA-TP, Ca, Na, ALT, AST, BUN, creatinine, homocysteine, RBS Vitamin D level, lipid panel
***MRI of Brain with Dementia Protocol
*Multiple Sclerosis
**Studies to be obtained prior to Neurology Clinic consultation:
***MRI brain and/or spinal cord with contrast if available
***Labs: ANA, B12, RPR, Vit D level, ESR, SSA, SSB, consider HIV
***LP if available, for oligoclonal bands, IgG, IgG synthesis, and routine protein glucose, cell counts, differential


===OVMC Pediatric Orthopedics===
===Sleep Study===
*Emergent Peds Ortho cases less than 16 years old, e.g. open fractures that require OR debridement, should be transferred out via the MAC for uninsured or to the patient's health plan whenever possible
*Econsult Sleep Study
*All other pediatric orthopedic cases should be referred to OVM Peds Ortho via the Message Pool.  All of these cases will be reviewed by Dr. Farrell and he will determine if the case should stay here at OVMC or be referred to Peds Ortho at USC
*Do NOT place order for sleep study; econsult should be placed but seriously ask yourself WHY AM I ORDERING THIS FROM THE ED??
*If the case needs referral to USC Peds Ortho, the Ortho clinic here at OVMC will handle the referral to USC


==Pediatrics==
===DMV Request for Re-Examination Form===
*Pediatric attending should be notified for any pediatric patient transferred out
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/DMV%20Request%20for%20Reexamination%20Form.pdf
*Pediatric patients (non-OOP) can be told to return to the Pediatric Urgent Care clinic for follow-up issues
*For any pediatric patient requiring follow up with a subspecialist (non-OOP), contact the Pediatric Attending on-call as needed for any questions regarding follow-up


===Critical Pediatric Patients===
==Neurosurgery==
*1:  Call MAC for transfer to LAC+USC 866-940-4401  then “3” for DHS facility  (Insurance issues will be worked out later)
===A few pointers===
*2:  For significant delays in acceptance or transportation to LAC+USC:
*All transfers through the MAC are classified as “routine” or “urgent/emergent”.  The language with them really matters. MOST of our transfers are ROUTINE as long as it is not immediately life threatening (e.g. stable subdural hematoma), but routine transfers can sometimes take hours. If you have a transfer from the ED such as a head bleed, and the patient decompensates while the patient is waiting for a bed at LAC-USC, the transfer actually gets easier. You can upgrade the transfer to EMERGENT through MAC and they will get you in touch with the LAC-USC DEM attending who based on our agreement will accept the patient.
**a. call OVMC Peds Attending on-call
*Similarly, for a CRITICAL neurosurgical patient, these transfers should be deemed EMERGENT with MAC and will be readily accepted attending to attending either by the neurosurgery attending or USC DEM attending regardless of bed status.
**b. call OVMC CMO on-call
*For a neurosurgical transfer not going smoothly, MAC is easily able to get the LAC-USC neurosurgery attending on the phone and you can have a magical attending to attending discussion. In our experience this usually results in a satisfactory result, and they do not mind being called.
**c. call CHLA for either help with transportation to LAC+USC or acceptance to CHLA
*Finally, we had a recent attempted neurosurgical transfer to UCLA. Unfortunately, ONLY ACUTE STROKE patients eligible for a mechanical thrombectomy by neurology will be accepted at UCLA from DHS hospitals.  Neurosurgery transfers should go through MAC to a county facility, unless they are out of plan (OOP), in which case we should try to transfer to someplace within their plan.
*CHLA Access and Transfer (Transport Center) 888-631-2452
*Call Maureen with questions anytime 310-614-5306


===Peds patients seen in ED===
===Neurosurgery Transfer Guidelines===
*Peds Resident pager '''818-313-1739'''   Also available through Cerner...Consults Auto Paging OVMC
*Approved by DEMs at OVMC and LAC, LAC+USC Neurosurgery, OVMC Medical Admin and MAC Feb 2018
*Weekdays: 0830am-3:00pm Triage RN should contact Super Track or MSE Attending or NP to screen patient (ESI 3-5) as OK to go to Peds Clinic. MSE note should be completed. Parents are given map and walk over to Peds Clinic. 
*If patient is '''OOP but stable, contact UR x74890''' to attempt transfer within the patient's health plan
**If patient is roomed in the ED, page Peds Resident
*For '''unstable or DHS/uninsured patients,''' transfers will be made through the '''MAC to LAC+USC neurosurgery'''  (Harbor is no longer an option)
*Weekdays: 7am-9pm, page the Peds Resident
*'''Indications for Potential Emergency Transfer:'''
*Weekdays: 9pm-7am, call the Emerg Med Resident assigned to Peds
**ACUTE cerebral hemorrhages, including:
*Overnights, Weekends, Holidays: Pediatric Resident and Emerg Med Resident will share patients
***Subarachnoid hemorrhage (traumatic or spontaneous)
*At 9pm every day and 0830am on Weekends and Holidays, Peds Resident and Emerg Med Resident should discuss how they want to share patients during the shift
***Intracerebral hemorrhage (ICH score >0)
*DEM PROVIDERS SHOULD CALL PEDS EARLY for any pediatric patient that is likely to be admitted
***Subdural or epidural hemorrhage
*For patients seen overnight, Pediatrics would like DEM providers to contact Peds in the morning and let them know about the patients that were seen
**Any lesion with significant mass effect (e.g. midline shift >5mm, hydrocephalus, or increased ICP with risk or concern for herniation)
===Child Maltreatment/Non-Accidental Trauma/Sexual Abuse===
**Acute or subacute spinal cord or cauda equine compression (e.g. abnl exam with sensory level, motor deficit, or MRI evidence of cord compression with CSF block or abnl cord signal)
*Step 1:  Call the Pediatric Attending on-call
*'''Emergency Transfer may NOT be Indicated:'''
*Step 2: Report case to Dept of Children and Family Services;  can be done by SW or provider
**Mild traumatic brain injury (no or trace blood, no fracture, GCS ≥ 14 with stable scan)
**Phone - (800) 540-4000
**Space occupying lesion with minimal mass effect: midline shift <5mm, no concern for herniation or increased ICP
*Step 3: Fill out on-line referral form.  You MUST have the 19-digit Referral Number in order to complete the on-line form.  You will receive the 19-digit Referral Number when you call DCFS.  It may take up to 2 HOURS for the Referral Number to be activated by DCFS. 
**Chronic mild spinal cord compression - no neurological deterioration without cord signal change or CSF block around cord
**On-line form link:  https://mandreptla.org/login.asp?ItemId=test
**Chronic subdural hematoma (no acute blood products, size <7mm, no midline shift, no recent change in size if prior imaging available)
*'''How to Transfer:'''
**Contact LAC+USC Neurosurgery Resident to discuss case via MAC (866-940-4401); if no response, page resident directly through AMION (Logon = LACUSC)
**If no response or disagreement with NS resident, Call LAC Neurosurgery Attending (Amion logon = LACUSC; if no response or disagreement with NS Attending, call Matt Waxman 310-497-7113 or Greg Moran 818-426-1478 or LAC Neurosurgery Service Chief Dr. Arun Amar (pager 213-508-0000) or the LAC CMO of the day via MAC
**If no immediate neurosurgery intervention planned but needs monitoring in Neurocritical Care ICU, contact LAC+USC Neurocritical Care Attending (Gold Service) via MAC (866-940-4401)
**If transfer is delayed, may initiate ED to ED transfer
**If patient acutely demands urgent/emergent transfer but no DHS beds are available, page OVMC CMO on-call @747-210-3000 to obtain approval for transfer to nearest trauma or comprehensive stroke center
**Once transfer is accepted, call Utilization Management (UM) at 74890.  Notify them of the accepting facility and accepting physician.  UM will then take the lead in the transfer process.
*'''How to Handle if Transfer maybe NOT indicated:'''
**Contact LAC Neurosurgery via MAC (866-940-4401) to discuss patient's case
**If no indication for emergent Neurosurgical intervention or ED to ED transfer, may call LAC+USC Neurology Gold Service or Medicine via MAC
**If no indication for emergent transfer to LAC+USC Neurology or Medicine, may undergo initial evaluation and treatment at OVMC
**Re-evaluate transfer if imaging or condition worsens


*Olive View has a Foster Care Clinic called Hub, on 4C.
==OB-Gyn==
**Composed of child abuse specialized pediatricians, social workers, DCFS caseworkers, and nurses.
===Referral Guidelines for Message Pool vs Econsult===
 
*Urgent Followup through Message Pool in Cerner/Orchid
*For pediatric sexual assault, do not perform a detailed history or exam.  History and exam should be brief, just to determine if a medical emergency exists.  Then:
**These go to NP clinic and will be seen usually within a few days
**8 am to 4 pm Monday-Friday: Contact the Peds Attending.  Contact Hub/Dr. Woods for guidance.
***First trimester vag bleed
**After hours: Contact the Peds Attending on call and the police department in the jurisdiction to determine need for forensic exam.
***Complicated PID that needs GYN followup
***If forensic exam not necessary, you can proceed with your normal ED evaluation.
***AUBs who are anemic (hgb less than or equal to 9)
***If forensic exam is necessary, the police department will pick up and take patient to Northridge Hospital (CATS).
***Post menopausal bleeding
***Bartholyn's cysts
*For patients brought in with concerns of other types of abuse:
***Labial abscess
**8 am to 4 pm Mon-Fri: Call Peds attending. Contact Hub clinic for help with the forensic exam and guidance.
 
**After Hours: Call Peds attending on call. See the patient and do a limited exam and history. We do not do forensic exams at OV afterhours. They can be referred to LAC-USC VIP Clinic, open 24/7. Please call the clinic to notify the on-call provider that you are sending a patient over:
*Econsult to GYN
**These go to an MD clinic and will usually be seen in 2-4 weeks
***AUBs with stable hemoglobin
***Ovarian cysts
***Chronic pelvic pain
***Urogyn


*LAC-USC VIP Clinic
===Establishing care at OVMC for pregnant patients===
**Outpatient Department Building (Building B)
*Do not refer OOP patients;  refer these back to their health plan
**2010 Zonal Avenue, 3rd floor, 3P-61
*For uninsured patients, tell patient to go to Clinc D to request follow-up for pre-natal care, "PK" clinic;  clinic closes at 4pm
**Los Angeles CA 90033
*REMEMBER, use Message Pool for an urgent request for pregnant vag bleeds, rule out ectopics getting BHCG checks, etc
**Phone: 323-409-3800


==Psychiatry==
===Oral Contraceptive Taper Patient Instructions===
*x4340
http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_English.pdf
*For patients without medical complaints, medically screen patients at Triage or Ambulance Triage. If medically cleared, provider should call x4340 and speak to Psychiatry MD who should approve patient being sent over to the Psych ED
http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_Spanish.pdf
*If patient is placed into an ED bed and needs emergent psychiatry, order Consult to Psychiatry and call x4340 to speak to Psychiatry MD.
===Psych Urgent Care===
*Oliveview Community Mental Health Urgent Care Center
*operated by LA County Dept of Mental Health
*located down the street, 14659 Oliveview Drive
*818-485-0888
*hours M-F 8am-7pm, Sat 9am-5:30pm, closed Sundays and holidays
*Crisis stabilization 24/7 - can place patients on 5150
*Able to see patients with outside health plans (OOP)


===Can I place a patient on an "8 hour hold" like at UCLA?===
===Oral Provera Taper Patient Instructions===
*No, we cannot use the Calif law 1799 that allows non-LPS designated facilities/hospitals to place psychiatric patients on an 8-24 hour hold until the patient can be evaluate by a psychiatric team that must come from the outside.
*Coming soon!!
*LPS stands for Lanterman-Petris-Short Act which allows psychiatric patients to be placed on involuntary holds for 72 hours, etc (e.g. 5150)
*LPS designated facilities are allowed to receive 5150 patients by EMS, police and accept transfers;  LPS designated facilities have psychiatric providers on-site
*OVMC, Harbor, LAC+USC, Northridge, Glendale Memorial, and others are LPS designated and therefore CANNOT use 1799 to hold patients before psych places them on a hold
*UCLA NPI is a LPS designated facility also
*UCLA RR is technically NOT an LPS designated facility and therefore CAN use the 1779 law to hold patients until psychiatry comes to see them.
*What we can do at OVMC:
**1. If patients are brought in by police, if possible, insist that the police write the hold if the patient said to police "I want to kill myself", police found pt standing with noose around his neck, etc.  Officers are often resistent to writing the 5150s and we need to insist more often that they do.  Blank 5150's are at the charge nurse chair/desk in the forms rack on the left. 
**2.  place 1:1 sitters on patients
**3.  Call psych early
**4.  check in with patient often to update them on the wait for psych
**5.  Feed patients
**6.  Use Xyprexa earlier to decrease chance of patient escalating
**7.  If you are worried a patient may bolt and psych has not seen the patient yet, you can call psych back and state you have a "psych emergency" and you need them "stat".  There is an agreement between the departments that psych will come immediately if we say it's an emergency assuming they are not already dealing with an emergency on there end.  Please use this judiciously.  We don't want the "boy who cried wolf" problem.
**8.  If the patient does leave and you felt the is concern enough for the patient to be on a 5150, call the Sheriff.  They are not allowed to just bring the patient back just because we say so.  They will go look for the patient, engage the patient, and if the patient says or does something that is concerning for SI/HI/gravely disabled, then the Sheriffs can bring them back.  More often than not the patient is brought back.  The Sheriff is very good about engaging these patients well.


==Radiology==
===Ordering Rhogam===
===On-Call and In-House Radiology Coverage Schedule===
*In Cerner, order "RhIG Request"; right click on order to modify order, 300mg,intramuscular, prenatal
*Operator has Radiology on-call schedule and pager numbers
*Also posted on OVMC Website...Departments....Radiology....On-Call Schedules....Radiology Faculty Schedule Current Month
 
====In House Coverage====
*M-F 6 pm-11 pm:  STAT Radiology Attending in-house
*Mon-Fri 11pm-7am: USC Teleradiology coverage  323-409-6679
*Sat, Sun Holidays before 1pm:  General Radiology Attending in-house
*Sat, Sun, Holidays 1p-7 pm Sat:  STAT Radiology Attending in-house
*Sat, Sun and Holidays 7pm-7am: USC Teleradiology coverage 323-409-6679


===USC Coverage for OVMC ED===
==Ophthalmology==
*USC Radiology Overnight Attending 323-409-6679 (M-F 11p-7a and Weekends/Holidays 7p-7a)  
===Ophthalmology Abbreviations===
**USC Radiology General ER Radiology 323-409-6688
AAU: acute anterior uveitis
**USC Radiology resident VOIP 323-409-1673 (in case above two phone numbers don't work)
AFT: artificial tears
AGV: Ahmed glaucoma valve
ARMD or AMD: age-related macular degeneration
DR: diabetic retinopathy
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BULB: bilateral upper lid blepharoplasty
BVS: borderline visually significant
C/D: cup-to-disc ratio
CEIOL: cataract extraction with insertion of intraocular lens
CME: cystoid macular edema
CRAO: central retinal artery occlusion
CRVO: central retinal vein occlusion
CSME: clinically significant macular edema
CS: cortical spoking (cataract)
CSR: central serous retinopathy
DES: dry eye syndrome
DME: diabetic macular edema
DWC: dense white cataract
ED: epithelial defect
EL: endolaser
ERM: epiretinal membrane
FML: focal macular laser
GS: glaucoma suspect
HST: horseshoe tear
HVF: Humphrey visual field
K: cornea
KP: keratic precipitate (inflammatory cellular deposits)
LH/WC/AFTs: lid hygiene, warm compresses, artificial tears
LPI: laser peripheral iridotomy
MMCR: Muller's muscle conjunctival resection
MP: membrane peel
NAION: nonarteritic ischemic optic neuropathy
NCVH: non-clearing vitreous hemorrhage
NPDR: non-proliferative diabetic retinopathy
NS: nuclear sclerosis (cataract)
NTG: normal tension glaucoma
NVG: neovascular glaucoma
NVS: not visually significant
OD: right eye
OHTN: ocular hypertension
OS: left eye
OU: both eyes
POAG: primary open angle glaucoma
PCO: posterior capsular opacity (aka, secondary cataract)
PDR: proliferative diabetic retinopathy
PKP: penetrating keratoplasty (aka corneal transplant)
PPV: pars plana vitrectomy
PRP: pan retinal photocoagulation
PS: posterior synechiae (sequelae of inflammation)
PSC: posterior subcapsular cataract
PTG: pterygium
PVD: posterior vitreous detachment
RRD: rhegmatogenous retinal detachment
RT: retinal tear
SB: scleral buckle
SRD: serous retinal detachment
Trab: trabeculectomy
TRD: tractional retinal detachment
VA: visual acuity
VH: vitreous hemorrhage
VS: visually significant
XT: exotropia
YAG cap: YAG capsulotomy


===Over-Reads===
==Orthopedics and Podiatry==
*'''Urgent or Emergent?'''
*Orthopedic Surgery and Podiatry share clinic space and communicate regarding complex lower extremity cases.
**Radiology to call x3649 or x4938 and report to ED Attending
===Ortho and Podiatry Clinic Referral Guidelines===
**ED Attending shall document in the........TBD
{| {{table}}
 
| align="center" style="background:#f0f0f0;"|'''OVMC Orthopedics'''
*'''Non-Urgent?'''
| align="center" style="background:#f0f0f0;"|'''OVMC Podiatry'''
**Radiology to email patient name, MRUN, date of study, and findings to Ari Orue NP at aorue@dhs.lacounty.gov
|-
 
| Patients 16 years of age and older||Majority of foot and ankle fractures are managed by podiatry (5th metatarsal fractures, ankle fractures)
===Film Copy Request and Outside Film Imaging Upload===
|-
*Film Copy Request
| High Energy ankle fractures such as a pilon fracture||Diabetic foot including osteomyelitis
**Fill out "Film Copy Request" form and take to ED Radiology 2E262
|-
**Film Copy Request Form:  http://myladhs.lacounty.gov/ov/HIM/Documents/Radiology%20Forms/Film%20Copy%20Request%20.pdf
| Maisonneuve fractures involving the fibular head||Ankle sprains
**Form also available on the OVMC Intranet...Departments....Health Information Management...Radiology Forms
|-
*Outside Film Imaging Upload in Cerner
| Lisfranc fractures (tarso-matatasal injury)||Plantar fasciitis
**Fill out "Outside Film Import Request" form and give it to ED clerk along with the imaging CD that needs to be uploaded.  Clerk will take it to 1B114 (HIM) from 8am-11pm Monday through Friday.
|-
**Outside Film Import Request Form:  http://myladhs.lacounty.gov/ov/HIM/Documents/Radiology%20Forms/Outside%20Film%20Import%20request.pdf
| No acute soft tissue knee injury (non-fracture) greater than age 55||
**Form also available on OVMC Intranet...Departments...Health Information Management...Radiology Forms
|-
 
| No hip fractures) (Transfer out)||
===Weight Limits for Imaging===
|-
*ED xray table - 500lbs
| No compartment syndromes (General Surgery)||
*ED CT scanner - 550lbs
|-
*MRI - 350lbs
| No Open fractures (Transfer out)||
*Downey MRI - 600lbs (see MRI Imaging for Large Patients)
|-
*Cath Lab - 500lbs
| Tibial plateau and knee fractures||
*Nuclear Medicine - 300lbs
|-
| Upper extremity injuries proximal to mid-forearm. (Distal to forearm goes to Hand)||
|-
| No septic arthritis involving history of arthroplasty (prosthetic joint) (Transfer out)||
|-
| Will operate on septic arthritis with fracture hardware (wires, plates)||
|}


===Plain Films and No Need for Pregnancy Tests===
===OVMC Pediatric Orthopedics===
*July 2016 - In a discussion with Dr. Patel from Radiology and Mike Ruiz, Sup Rad Tech, it was re-affirmed that women do '''NOT''' require a pregnancy test prior to plain film X-rays
*Emergent Peds Ortho cases less than 16 years old, e.g. open fractures that require OR debridement, should be transferred out via the MAC for uninsured or to the patient's health plan whenever possible
*Under protocol, Radiology techs will ask the patient if she is possibly pregnant and the date of her LMP period (should be within the last 4 weeks). 
*All other pediatric orthopedic cases should be referred to OVM Peds Ortho via the Message Pool.  All of these cases will be reviewed by Dr. Farrell and he will determine if the case should stay here at OVMC or be referred to Peds Ortho at USC
*As per the American College off Radiology and the OVMC Dept of Radiology: ''If a patient can reliably answer that 1) she cannot be pregnant (for example, she is not sexually active, or she is using an effective form of birth control, or she is biologically incapable of conceiving) and that 2) she had a recent complete menstrual period, then it is reasonable to proceed with a medically indicated diagnostic X-ray test of the abdomen or pelvis. The last complete menstrual period should have occurred within the previous 4 weeks.''
*If the case needs referral to USC Peds Ortho, the Ortho clinic here at OVMC will handle the referral to USC
*Prior to CT scans, a pregnancy test should be obtained as the amount of radiation is higher.  If, however, the patient's medical condition could deteriorate and the CT scan is needed emergently (e.g. head CT for AMS), then a pregnancy test may not always be obtained prior to the scan.
 
==Pediatrics==
*Pediatric attending should be notified for any pediatric patient transferred out
*Pediatric patients (non-OOP) can be told to return to the Pediatric Urgent Care clinic for follow-up issues
*For any pediatric patient requiring follow up with a subspecialist (non-OOP), contact the Pediatric Attending on-call as needed for any questions regarding follow-up


===Fluoroscopy===
===Pediatric Subspecialists On-Call===
*On rare occasion, fluoroscopy might be needed to reduce a fracture or fracture/dislocation
====https://lacounty-my.sharepoint.com/:x:/g/personal/mamccollough_dhs_lacounty_gov/EVZYsT1K_UhNjps63dUNSiMBwPnuoa9OERCoCXE8RZv5qw?e=8Dpqhc
*Fluoroscopy is available Mon-Fri 8am-4pm, call Main Radiology x74059
*After hours, availability for fluoroscopy will depend upon hospital tech availability;  talk to ED Radiology tech
*Order in Cerner: RF Fluoroscopy Under 1 hour


===Interventional Radiology===
===Critical Pediatric Patients===
*'''AVAILABLE''' Intervential Radiology '''After Hours''' (Operator has Interventional Radiology on-call schedule.  Also available on OVMC Intranet.  See above under Radiology On-Call Schedule)
*DHS PEDIATRIC CRITICAL CARE TRANSPORT WORKFLOW FOR OLIVE VIEW*
**Percutaneous [[abscess]] drainage
**1. NICU transports (less than 52 weeks from gestation)
**Image-guided paracentesis
***a. Call Pediatrics and contact OVMC NICU to see if infant can be admitted to our OVMC NICU. 
**Image-guided thoracentesis
***b. For transport to Harbor, call the NICU directly 424-306-5608 and they will work to put together a transport team to come to Olive View to get the neonates. MAC does not need to be contacted for these transports (all of the administrative functions such as reserving a bed, financial clearance, passing along information for MD and RN reports are the responsibility Harbor).
**Percutaneous cholecystostomy
***c. For transport to LAC, recommend that LAC+USC mimics the procedure for 1a.
**Percutaneous nephrostomy/nephroureteral stent placement and other urologic intervention as applicable
***d. If Harbor/LAC do not offer needed services (such as cooling/ECMO) refer patient to UCLA or CHLA Transfer Center using their internal transport services
**Transhepatic biliary drainage and other biliary intervention as applicable
***e. All back transports TO Olive View should be coordinated through MAC
**Central venous access including placement of tunneled/non-tunneled catheter
**2. PICU transports
**IVC filter placement
***a. For transports to Harbor and LAC, Olive View to call MAC; MAC will attempt to engage CHLA to transport infant from Olive View to Harbor or LAC
**Transarterial embolization for unremitting hemorrhage refractory to conventional therapy
***b. If CHLA transport team not able to mobilize transport team to take the child to LAC or Harbor within 90 minutes, refer patient to UCLA Transfer Center using their internal transport services
**IR Consultation
***c. All back transports TO Olive View should be coordinated through MAC
*'''NOT AVAILABLE''' Interventional Radiology '''After Hours'''  (Only available Mon-Fri 8am-5pm)
**3. Challenges
**No MSK procedures (e.g. no joint aspirations)
***a. Shannon Thyne and Peter Balingit are available to help troubleshoot any transport issues in real time. PLEASE CALL EARLY to avoid delays in patient care.
**No LPs
***b. Peter, Shannon, and the Olive View CMO are always available for urgent approval for air transport and/or approval for critical care transport to UCLA.
**No G/GJ tube replacement (if tube fell out, place foley temporarily)
*Note that this approach does NOT apply to any non-critical care transports. Do not arrange any BLS transports to DHS facilities without contacting MAC.  For non-critical care transports of stable patients, can go through patient's outside health plan. Engage Utilization Management x74890.
*'''FUTURE ORDERS''' Interventional Radiology from the DEM
**Contact IR physician on-duty to discuss case
**Place an IR request in ORCHID (if given option, make sure to choose Future Order)
**Please include a note on the IR Orchid request about any high risk meds e.g. anticoagulants, DM meds or any other high risk meds
**Instruct the patient to be NPO after midnight except approved meds with sips of water
**Instruct the patient to secure a ride home with family/friends after the procedure
**Instruct the patient to report to Radiology reception at 7:30am on the day of the procedure
**Patient should be instructed to call 747-210-3686 for interventional scheduling and for instructions about home meds to hold the morning of the procedure
*'''ORCHID ORDERS''': AV shunt fistulogram?  Order "IR Angiogram Arteriovenous Shunt”


===MRI After Hours===
===Peds patients seen in ED===
*MRI tech is in-house Mon-Fri 7am to midnight. All other hours are considered off-hours.
*Peds Resident pager '''818-313-1739'''  Also available through Cerner...Consults Auto Paging OVMC
*MRI tech is on-call for emergent cases limited to acute cord compression and rarely acute CVAs if requested by the Neuro Service for patient management (e.g. large CVA that may be considered for transfer to UCLA for intracerebral angio therapy)
*Weekdays: 0830am-3:00pm Triage RN should contact Super Track or MSE Attending or NP to screen patient (ESI 3-5) as OK to go to Peds Clinic. MSE note should be completed. Parents are given map and walk over to Peds Clinic. 
*Findings that suggest acute cord compression include: 
**If patient is roomed in the ED, page Peds Resident
**1. Bladder dysfunction (urinary retention or incontinence)
*Weekdays: 7am-9pm, page the Peds Resident
**2. Bilateral limb weakness
*Weekdays: 9pm-7am, call the Emerg Med Resident assigned to Peds
**3. Sensory abnormalities with a sensory level
*Overnights, Weekends, Holidays: Pediatric Resident and Emerg Med Resident will share patients
**4. Flaccid areflexia with upgoing toes, loss of anal sphincter tone
*At 9pm every day and 0830am on Weekends and Holidays, Peds Resident and Emerg Med Resident should discuss how they want to share patients during the shift
*Some cases may be able to wait until the morning hours such as IVDA, fever and back pain without neuro findings.
*DEM PROVIDERS SHOULD CALL PEDS EARLY for any pediatric patient that is likely to be admitted
*To request an emergent MRI when the tech is not here, first contact the STAT Radiologist in-house Mon-Fri until 11pm and weekends/holidays until 7pm.  If there is no STAT Radiologist in-house (e.g. after 11pm), contact the Neuro Radiologist on standby (on-call).
*For patients seen overnight, Pediatrics would like DEM providers to contact Peds in the morning and let them know about the patients that were seen
**On-call schedule can be found on OVMC Intranet...Departments...Radiology...Radiology Faculty Schedule Current Month.....Neuro/MRI Standby.  Operator has on-call schedule also and pager #s.   
===Child Maltreatment/Non-Accidental Trauma/Sexual Abuse===
**If no STAT radiologist, ED MD pages the Neuro Radiologist on standby (on-call) and requests MRI.
*OVMC HUB/SCAN Clinic
*STAT Radiologist or Neuro Radiology Attending then pages the MRI tech.
**OVMC has its own HUB/DCFS Clinic on campus over in the Women/Children's building.  phone x74680
*For cord compression cases, as much as possible, try to narrow down the level where the possible pathology lies e.g. lumbar vs thoracic.  If this is not possible, a '''"cord compression" MRI protocol''' can be performed that will give a large field of view (sagittal images) that will cover the whole spine in two slabs (cervical through mid-thoracic and mid-thoracic through lumbar), along with axial T2 images through the whole spine. Will not give great detail, but will see gross cord compression or high grade lumbar spinal canal stenosis. Decision about what imaging is performed will be up to the Neuro radiologist on-call.
**This clinic sees children who are victims of both non-accidental trauma and sexual abuse.  
**Staff includes specialized pediatricians, social workers, DCFS case workers, and nurses
**'''OVMC HUB Clinic can see patients regardless of their insurance status, including outside health plans.'''
'''*Monday-Friday, 8am-8pm:  Call the OVMC HUB Clinic x74680'''


===MRI for Large Patients===
'''*After-hours, weekends, holidays''':
*Weight limit at OVMC: 350lbs (same at Harbor and USC)
**Notify the pediatric resident on-call and the Pediatric Attending on-call
*For larger patients, Downey MRI Center, 8515 E. Florence Ave, Downey CA, 90240, 562-904-1340 (weight limit 600lbs)
**Place Consult to Social Work if SW is in-house
*If ED patient, will need County trans to transport patient to Downey and then return to ED
***NOTE - Place consult early so they can be present when the parent/caretaker/child is giving the history; THE PROVIDER (EITHER CLINICAL SOCIAL WORK STAFF OR PHYSICIAN) WHO TAKES THE HISTORY SHOULD BE THE ONE WHO CALLS DCFS TO REPORT THE CASE
*For outpatient, order as Future Order; Patient should call OVMC MRI to schedule and OVMC MRI will then arrange the MRI at Downey
***When Social Worker is not present, they will come in for serious child abuse cases/deaths but most routine cases can be handled by CSW team at the HUB clinic or in the ED the next day. 
**Peds Attending will know who from the Dept of Pediatrics is on call for child abuse cases.
**Peds Attending/HUB Clinic Attending on-call will guide management re: what needs to be done in the ED in regards to labs or imaging and will help get the child scheduled in our HUB Clinic for follow-up.  Peds Attending/HUB clinic attending will decide if case is URGENT or NON-URGENT.
**See below for how to handle URGENT vs NON-URGENT cases


===Barium/Air Enemas for Intussception Cases===
'''URGENT CASES'''
*Surgical resident on-call should be made aware of any pediatric patient who is considered to have a possibility of intussusception
*'''Step 1''': Report case to '''DCFS (Dept of Children and Family Services)''';  can be done by SW or provider
*Patient should have no contraindication to a barium or air enema such as evidence of peritonitis or perforation.
**NOTE - WHOEVER TOOK THE HISTORY SHOULD BE THE ONE TO CALL DCFS;  CALL CLINICAL SOCIAL WORK EARLY TO BE INVOLVED;
*M-F Business Hours:  Peds Radiologist Dr. Chawla usually performs the BEs/AEs
**Phone - (800) 540-4000
*M-F 6 pm-11 pm: STAT Attendings will perform any BEs/AEs during their STAT shift
**You will be given a '''19-digit Referral/Case Number''' that you will need when completing the on-line form. Please document the 19-digit referral/case number in the patient's chart. 
*Sat, Sun Holidays before 1pm:  General Radiology Attending is responsible
*'''Step 2''': Fill out '''on-line SCAR (Suspected Child Abuse Referral) form'''. You MUST have the 19-digit Referral/Case Number in order to complete the on-line SCAR form; it may take up to 2 HOURS for the referral/case # to be activated by DCFS.  After you complete the on-line SCAR form, you will get a 16digit tracking number; please document this in the chart. 
*Sat, Sun, Holidays 1p-7 pm Sat:   STAT attendings will perform any BEs/AEs during their STAT shift
**On-line form link: https://mandreptla.org/cars.web/
*M-F 11 pm- 7am and Sat, Sun, Holidays 7pm-7 am:   General standby call is responsible for performing the BEs/AEs
 
'''NON-URGENT CASES'''
*Step 1: Peds Attending/HUB Clinic Attending can help decide if case is ok for non-urgent reporting.  Use the CARES on line form to report non-urgent cases.  https://mandreptla.org/cars.web/


===UGI for Malrotation/Volvulus Cases in Infants===
*For pediatric sexual assault, do not perform a detailed history or exam. History and exam should be brief, just to determine if a medical emergency exists.
*As per Dr. Andrews of Radiology, we have the ability to do an Upper GI 24/7 to evaluate an infant for malrotation/volvulus
*Contact the ED Radiology tech if a study is required


===Breast Imaging===
'''After Hours:  LAC+USC or Northridge CATS'''  
*''Radiology keeps an extensive database of all patients receiving breast ultrasound to ensure all patients have follow-up with surgeon, PMD or ED''.
*HUB Clinic Attending may say that a child needs to be seen that night or on the weekend. We use LAC+USC HUB Clinic or Northridge CATS clinic. Patient will go with law enforcement. Document law enforcement office name, bade # in the chart.   Law enforcement will often decide which center they will take the patient to.  We encourage LAC because follow-up is easier. ''CALL LAC+USC OR NORTHRIDGE AHEAD OF TIME and DOCUMENT WHO YOU SPOKE WITH.''
*''OK to order UNILATERAL breast ultrasound for these cases. Any significant findings such as a concerning mass on ultrasound will be followed up by radiology and follow-up ensured''.
*''Check insurance when deciding follow-up.''
*'''Breast mass, not concerned about infection, low risk for cancer'''
**Outpatient breast ultrasound (future order)
**eConsult to ''Surgery, Breast'' for follow-up
*'''Breast mass, not concerned about infection, high risk for cancer'''
**High Risk = family history of +BRCA, skin dimpling, nipple retraction, discharge, palpable lymph nodes
**Call surgery consult to expedite follow-up
*'''Breast mass, concerned about infection/abscess, mild case, do not think the patient needs admission or IV antibiotics'''
**M-F 7am-4pm:  Order Breast ultrasound, send to Radiology 1D
**Overnight, weekends, holidays:  Order breast ultrasound (future study). Instruct patient to go to Radiology 1D at 8am the next weekday. If patient does have an [[abscess]] on ultrasound, Radiology staff will call ED and send patient to the ED
*'''Breast mass, concerned about infection/abscess, moderate to severe case, considering surgery consult and/or admission'''
**M-F 7am-4pm:  Order Breast ultrasound, send to Radiology 1D
**Overnight, weekends, holidays: ED ultrasound tech can perform a limited ultrasound to evaluate for abscess. Order breast ultrasound and in comments type "Evaluate for abscess". Consult surgery for evaluation and treatment.
**''If the symptoms have been occurring for >1 week, please consider inflammatory cancer which can look like an [[abscess]] on ultrasound. In these cases, please obtain surgery consult for evaluation and/or expedited follow-up.''


===Joint and Spine Injections===
<small>'''LAC+USC HUB Clinic.''' 323-409-3601. Ask to speak to Peds Attending who will know HUB clinic provider on-call.
*Dr. Raffi Salibian  x75145
*Dr. Catherine Yim  x74082
*'''Joints''':
**Order:  X-ray plain view
**Future Order: US aspirate/injection/biopsy  (use ''Relevant History'' to indicate which joint)
**CBC and Coags if patient is coagulopathic


*'''Lumbar Spine''' (facets and epidurals):
'''Northridge CATS (Center for Assault Treatment Services''') (818) 908-8630 or (818) 908-8632</small>.
**Send Message Center message to Dr. Catherine Yim requesting lumbar spine injection with the name of the ED Attending requesting the procedure.
**Future Order:  MRI lumbar spine (Patient must call to schedule the MRI.  Radiology phone # is pre-printed on ED Patient Summary/Discharge Instructions)
**Future Order:  IR facet inject lumbar  (need kg weight)
**CBC, Coags please
*Radiology will contact the ED TFU Coordinator or Urgent Care TFU Coordinator through the Message Pool with any problems


==Surgery==
==Plastic Surgery==
*For surgical vs medicine admissions, see Surgical Subspecialty Admissions Guidelines under Admission Guidelines.
===Upper Extremity Splinting Recs===
*For ALL surgical transfers out, ED Attending needs to speak to Surgical Subspecialty Attending
[[:Media:OVMC Upper Ext Splinting Recs.pdf|OVMC Upper Ext Splinting Recs.pdf]]


===Surgery Clinic Referral Guidelines===
==Psychiatry==
*Econsult: All hernias and gallbladders need the hernia/chole form filled out - asks about BMI and cigarette smoking
*x74340
*Surgery will not perform hernia repair or cholecystectomy if BMI >35
*For patients without medical complaints, medically screen patients at Triage or Ambulance Triage. If medically cleared, provider should call x4340 and speak to Psychiatry MD who should approve patient being sent over to the Psych ED
*Surgery will not perform hernia repair if patient smokes
*If patient is placed into an ED bed and needs emergent psychiatry, order Consult to Psychiatry and call x4340 to speak to Psychiatry MD.
*For breast cases, see WikEM OVMC:ED....Radiology....Breast imaging
===Psych Urgent Care===
*Oliveview Community Mental Health Urgent Care Center
*operated by LA County Dept of Mental Health
*located down the street, 14659 Oliveview Drive
*818-485-0888
*hours M-F 8am-7pm, Sat 9am-5:30pm, closed Sundays and holidays
*Crisis stabilization 24/7 - can place patients on 5150
*Able to see patients with outside health plans (OOP)


===Cardiothoracic Surgery===
===Can I place a patient on an "8 hour hold" like at UCLA?===
*We have non-cardiac Cardiothoracic Surgery at OVMC.  If you have a case, consult General Surgery who will consult with Cardiothoracic Fellow/Attending
*No, we cannot use the Calif law 1799 that allows non-LPS designated facilities/hospitals to place psychiatric patients on an 8-24 hour hold until the patient can be evaluate by a psychiatric team that must come from the outside.
 
*LPS stands for Lanterman-Petris-Short Act which allows psychiatric patients to be placed on involuntary holds for 72 hours, etc (e.g. 5150)
===Neurosurgery===
*LPS designated facilities are allowed to receive 5150 patients by EMS, police and accept transfers;  LPS designated facilities have psychiatric providers on-site
*See Transfers...Higher Level of Care....Neurosurgery
*OVMC, Harbor, LAC+USC, Northridge, Glendale Memorial, and others are LPS designated and therefore CANNOT use 1799 to hold patients before psych places them on a hold
*UCLA NPI is a LPS designated facility also
*UCLA RR is technically NOT an LPS designated facility and therefore CAN use the 1779 law to hold patients until psychiatry comes to see them.
*What we can do at OVMC:
**1. If patients are brought in by police, if possible, insist that the police write the hold if the patient said to police "I want to kill myself", police found pt standing with noose around his neck, etc.  Officers are often resistent to writing the 5150s and we need to insist more often that they do.  Blank 5150's are at the charge nurse chair/desk in the forms rack on the left. 
**2.  place 1:1 sitters on patients
**3.  If patient will cooperate, have patient change into a gown. If patient bolts out the door, much easier to spot them wearing a gown.  Don't fight the patient on this issue though.  Please avoid agitating the patient. 
**4.  Call psych early
**5.  Check in with patient often to update them on the wait for psych
**6.  Feed patients
**7.  Use Xyprexa earlier to decrease chance of patient escalating
**8.  If you are worried a patient may bolt and psych has not seen the patient yet, you can call psych back and state you have a "psych emergency" and you need them "stat".  There is an agreement between the departments that psych will come immediately if we say it's an emergency assuming they are not already dealing with an emergency on their end.  Please use this judiciously.  We don't want the "boy who cried wolf" problem.
**9. If the patient does leave and you felt the is concern enough for the patient to be on a 5150, call the Sheriff. If you believe the patient was likely to be put on a 5150 hold, make sure the Sheriffs know this. They are not allowed to just bring the patient back just because we say so. They will go look for the patient, engage the patient, and if the patient says or does something that is concerning for SI/HI/gravely disabled, then the Sheriffs can bring them back. More often than not the patient is brought back. The Sheriff is very good about engaging these patients well.


===Vascular Surgery===
==Radiology==
*Jan 2017 Vascular surgery being covered by several part-time vascular surgeons while full-time OVMC vascular surgeon is on maternity leave. Part-time folks have their own practices to cover during the week. At times, may need to transfer vascular patients out as we have more limited coverage during business hours.
===On-Call Radiologist and In-House Radiology Coverage Schedule===
*Operator has Radiology on-call schedule and pager numbers
*Also posted on OVMC Website...Departments....Radiology....On-Call Schedules....Radiology Faculty Schedule Current Month
*https://lacounty.sharepoint.com/sites/dhs-ov-radiology/Radiology%20On%20Call%20Schedules/Forms/AllItems.aspx


==Laboratory==
===On-Call Tech Supervisor Schedule===
===Critical Lab Results on ED patients, ED Boarders (Admitted Patients), and ICU patients===
*Also posted on OVMC Website...Departments....Radiology....On-Call Schedules or Radiology Schedules....current month Supv and Techs On-Call schedule (link below_
*Lab tech will determine if a patient is an ED patient or an ED Boarder prior to calling a critical lab result. Lab techs have a cheat sheet that outlines this process.  
*https://lacounty.sharepoint.com/sites/dhs-ov-radiology/Radiology%20On%20Call%20Schedules/Forms/AllItems.aspx
**ED patients: critical lab report goes to ED provider or attending. Lab tech should contact ED provider in the provider room based on patient location (main ED room or SuperTrack room. Lab has been given a list of ED patient rooms and the MD Room associated. 
**ED Boarder/Admitted patients: Lab tech should call the ED nurse directly based on patient location in the ED. Nurse will forward results to the inpatient team.
**All ICU patients: Lab tech should contact the ED provider directly for all critical labs on ICU patients since ICU boarders are still managed by the ED team.


===Critical Lab Results on Discharged ED Patients===
To be added


===Infrequent Lab Orders - Instructions ===
====In House Coverage====
'''Rapid Strep'''
*M-F 6 pm-10 pm:  STAT OVMC Radiology Attending in-house
*Order as ''Rapid Strep Group A Ag''. Do '''NOT''' order POC Rapid Strep.
*M-F 10pm-06:30am:  STAT RADS or US ROC (see After Hours Coverage)
*Run 24/7 when the test is received in the lab.  General turnaround time 30mins.
*Sat, Sun Holidays before 1pm: General Radiology Attending in-house
*Sat, Sun, Holidays 1p-7 pm Sat:  STAT OVMC Radiology Attending in-house
*Sat, Sun and Holidays 7pm-7am: STAT RADS or US ROC (See After Hours Coverage)


'''Varicella Testing'''
===StatRad Coverage for '''CT and MRI''' Overnight and Weekend Reads Only===
*For Varicella testing,VZV DNA Qaul RT PCR-SO
*StatRad coverage Mon-Fri 10pm - 0630am and Weekends/Holidays 7pm-7am
*StatRad will fax the prelim reads and the tech will scan that into Synapse.  Instead of viewing in the Synapse "Notes" section you view in the "Documents" section in "Technologist Notes".
*If you would like to discuss the case with the Radiologist or you have any problems or concerns with the service, please call their reading room 858-546-3800, press 1.
*If it is not coming through you can log onto the site to check the status at  https://clients.statrad.com
**The first time you log in use the temporary password "Olive" and you will then be prompted to enter a new password.  Hopefully you will not have to use the portal at all.  Only Attendings have log in IDs for now.
** Attending IDs for log-in  https://lacounty.sharepoint.com/:x:/r/sites/dhs-ov-emergencymedicine/_layouts/15/Doc.aspx?sourcedoc=%7B5400E91A-2B4F-44D4-9BAA-3280DEE276BF%7D&file=StatRad%20ED%20Physician%20accounts%20for%20UCLA%20OV.xlsx&action=default&mobileredirect=true
**Website access instructions  https://lacounty.sharepoint.com/sites/dhs-ov-emergencymedicine/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2Fdhs%2Dov%2Demergencymedicine%2FShared%20Documents%2FDocuments%2FStatRad%20Exam%20Status%2Epdf&parent=%2Fsites%2Fdhs%2Dov%2Demergencymedicine%2FShared%20Documents%2FDocuments


'''Influenza Testing'''
===USROC Coverage for '''Ultrasound''' Overnight and Weekend Reads Only===
*Order as ''Influenza A/B & RSV,RNA by PCR''.
* Monday-Friday 10p-06:30am and Weekends/Holidays 7p-7a
*Generally run every 3hrs, starting at 9am,12n,3pm,6pm,9pm.  Tests takes 2 hour turnaround.
* 866-448-7762


'''Chlamydia/Neisseria gonorrhea RNA:'''
===Over-Reads===
*females - urine or cervical (not vaginal)
*'''Urgent or Emergent?'''
*males - urine or urethral
**Radiology to call x3649 or x4938 and report to ED Attending
*urine - yellow tube, fluid level in between black lines
**ED Attending shall document in the........TBD
*cervical/urethral - white swab to clean mucus, blue swab for specimen collection
*don't use Rectal-SO or Throat-SO orderable unless you are specifically checking these sites


'''Malaria/Thin Smear'''
*'''Non-Urgent?'''
*Order as Blood Parasite Exam
**Radiology to email patient name, MRUN, date of study, and findings to Ari Orue NP at aorue@dhs.lacounty.gov


'''Pathology Tissue Request:'''
===Film Copy Request and Outside Film Imaging Upload===
*label prints as soon as the order is signed and cannot easily be printed again.
*Film Copy Request
*printed in MD room on label printer if ordered from computer in MD room
**Tell ED clerk that you need patient films copied onto a CD
*printed in patient room on label printer if ordered from computer in patient room
**ED Clerk will complete the Radiology Request form and handle the request with Radiology
'''Peripheral Smear Exam by Lab:''' usually ordered by non Heme/Onc provider for review by lab tech <br />
***Monday - Friday 8am-11pm:  Release of Information (ROI) Unit, 1B114
***After 11pm, weekends and holidays: ED Radiology
**Request Form also available on the OVMC Intranet...Departments....Health Information Management...Radiology Forms
*Outside Film Imaging Upload in Cerner
**Tell ED clerk that you need patient imaging CD uploaded into Orchid/Cerner;  give ED clerk the CD
**ED Clerk will complete the Radiology Request form and handle the request with Radiology
***Monday - Friday 8am-4:30pm:  General Radiology 2D141
***After 4:30pm, weekends, and holidays: ED Radiology
**Request Form also available on OVMC Intranet...Departments...Health Information Management...Radiology Forms


'''Peripheral Smear for Provider Pickup (Slide Wirght Giemsa):''' usually ordered in consultation with Heme/Onc for MD to personally review<br />
===Plain Films and No Need for Pregnancy Tests===
 
*July 2016 - In a discussion with Dr. Patel from Radiology and Mike Ruiz, Sup Rad Tech, it was re-affirmed that women do '''NOT''' require a pregnancy test prior to plain film X-rays
===Specimen Collection Instructions - OVMC Micro Quick Reference Guide===
*Under protocol, Radiology techs will ask the patient if she is possibly pregnant and the date of her LMP period (should be within the last 4 weeks). 
http://myladhs.lacounty.gov/ov/Pathology/Documents/Microbiology%20Specimen%20Collection.pdf
*As per the American College off Radiology and the OVMC Dept of Radiology: ''If a patient can reliably answer that 1) she cannot be pregnant (for example, she is not sexually active, or she is using an effective form of birth control, or she is biologically incapable of conceiving) and that 2) she had a recent complete menstrual period, then it is reasonable to proceed with a medically indicated diagnostic X-ray test of the abdomen or pelvis. The last complete menstrual period should have occurred within the previous 4 weeks.''
*Prior to CT scans, a pregnancy test should be obtained as the amount of radiation is higher.  If, however, the patient's medical condition could deteriorate and the CT scan is needed emergently (e.g. head CT for AMS), then a pregnancy test may not always be obtained prior to the scan.
 
===Fluoroscopy===
*On rare occasion, fluoroscopy might be needed to reduce a fracture or fracture/dislocation
*Fluoroscopy is available Mon-Fri 8am-4pm, call Main Radiology x74059
*After hours, availability for fluoroscopy will depend upon hospital tech availability;  talk to ED Radiology tech
*Order in Cerner:  RF Fluoroscopy Under 1 hour
 
===Interventional Radiology===
====Protocol for Urgent Interventional Radiology Procedures====
*1. ED Provider contacts IR provider on-duty or on-call to determine the appropriate timing of the requested procedures and determine if the procedure can be done in next few days.   
**a. Weekdays 8am-4:30pm: call x74554/66088/73931 to find the interventionalist on-duty. Also available on OVMC Intranet…..see under Radiology On-Call Schedule.  Also available on Amion...OV IM......All Services
**b. After Hours:  Operator has Interventional Radiology on-call schedule.  Also available on OVMC Intranet….see under Radiology On-Call Schedule.  Also available on Amion....OV IM......All Services
**c. See below for Interventional Radiology procedures available after hours


==Pharmacy==
*2. If patient is on anticoagulant, IR provider on-duty or on-call will determine whether or not anticoagulants need to be held and for how long. 
*ED Pharmacist Mon-Fri 8am-4pm x75490


===Hours===
*3. If procedure can be scheduled for the next business day or two, ED Provider obtains pre-procedure labs/studies including COVID-19 testing as requested by the IR provider on-call .  COVID-19 testing should be ordered as Admit Asymptomatic. 
*Monday - Friday 7:30am-8pm; Sat, Sun, Holidays 8:30am-4:30pm


===Empiric Antibiotic Recommendations OVMC===
*4. ED Provider places an order in Cerner for the desired procedure, indicating FUTURE ORDER:
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Empiric%20Antibiotic%20Recommendation%20Card.pdf


===DHS Formulary Pocket Guide 2017-2018===
{| {{table}}
http://myladhs.lacounty.gov/ov/Departments/DEM/Documents/DHS%20Core%20Formulary%20Pocket%20Guide-%202017-2018%20final.pdf
| align="center" style="background:#f0f0f0;"|'''Issue/Problem'''
| align="center" style="background:#f0f0f0;"|'''Order in Cerner'''
|-
| Dialysis fistula not working/declotting      ||IR angiogram arteriovenous shunt
|-
| Tunneled catheter needed||IR central venous catheter tunneled
|-
| Exchange nephrostomy tube||IR Exchange of nephrostomy catheter
|-
| G-Tube change||IR Gastrointestinal Tube or Catheter Change
|}


===Rhogam Administration===
*5. ED Provider sends a message through ORCHID using new ED to IR message pool. '''OVM Interventional Radiology ED/UCC Urgent Follow Up''' ED Provider will document name of IR Provider who approved procedure and time frame, e.g 1-2 days.  
*Cerner: RhIG Request, click on both Administer and RhIG Request, then Initiate, then Modify both: Administer Intramuscular and RhIG Request 1 vial and reason Prenatal. Then Orders for Signature and Sign.


===Medication Refill Patient Handout===
*6. ED Provider gives patient a Patient Education/Discharge Instructions including NPO after midnight except for medications with sips of water.  Directions regarding anticoagulants should be answered by IR Provider on-duty or on-call.  DC Instructions located in Cerner...Patient Education.....Departmental.....Outpatient Followup Interventional Radiology Procedure
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Pharmacy%20Refills.pdf


===Safe Prescribing and Narcan Handouts===
*7. Patient is to arrange transportation to and from OVMC on the day of the procedure. 
*Safe Prescribing English  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Safe%20Prescribing%20ED%20English.pdf
 
*Safe Prescribing Spanish  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Safe%20Prescribing%20ED%20Spanish.pdf
*8.  IR Provider will tell ED provider when the patient is to show up for the procedure; patient is to report to OSPA 2B-121 on the day of procedure.
*Narcan (Naloxone) English  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Naloxone%20English.pdf
 
*Narcan (Naloxone) Spanish  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Naloxone%20Spanish.pdf
====AVAILABLE and NOT AVAILABLE Interventional Radiology After Hours====  
*(Operator has Interventional Radiology on-call schedule. Also available on OVMC Intranet under Radiology On-Call Schedule. Also available on Amion...OV IM....All Services)
*AVAILABLE
**Percutaneous [[abscess]] drainage
**Image-guided paracentesis
**Image-guided thoracentesis
**Percutaneous cholecystostomy
**Percutaneous nephrostomy/nephroureteral stent placement and other urologic intervention as applicable
**Transhepatic biliary drainage and other biliary intervention as applicable
**Central venous access including placement of tunneled/non-tunneled catheter
**IVC filter placement
**Transarterial embolization for unremitting hemorrhage refractory to conventional therapy
**IR Consultation


===Buprenorphine Administration in the ED===
*NOT AVAILABLE Interventional Radiology After Hours (Only available Mon-Fri 8am-5pm)
*ED Bridge Guide      https://static1.squarespace.com/static/5adf7f1fa2772cb4f86018b2/t/5aff30cf758d46c1c95b5a40/1526673619420/ED-BRIDGE+BUP+GUIDE+-+MAY+2018+%282%29.pdf
**No MSK procedures (e.g. no joint aspirations)
*ED Buprenorphine Algorithm    https://static1.squarespace.com/static/5adf7f1fa2772cb4f86018b2/t/5afce60070a6ad7647ef8893/1526523398244/QUICK+BUP+ALGORITHM+MAY+2018.pdf
**No LPs
*Need help?   
**No G/GJ tube replacement (if tube fell out, place foley temporarily)
**Clinician Consultation Center Advice line phone 855-300-3595  (Monday – Friday 6am to 5pm)
**ED Bridge Office Hours  https://ed-bridge.org/office-hours


==Physical Therapy, Occupational Therapy and Orthotics==
===Dialysis AV Fistula Evaluation===
===Orthopedic Equipment and Hernia Trusses===
*For evaluation for flow, order "US Duplex Hemodialysis Access Flow"
*Crutches, walkers, canes – stored in ED1A and ED5 clean utility rooms
*For de-clotting by IR, order "IR Angiogram Arteriovenous Shunt"
*Hard shoes, wrist braces, ankle splints - stored in Room #43
*Hernia trusses – stored in Room #43
*Other routine orthotics not stocked in EDM: lumbar corsets, etc
**Order Orthotic Equipment in Cerner.  Patient can call Valley Institute of Prosthetics and Orthotics 661-253-1191 to make arrangements to get the equipment.


===Urgent Spinal Bracing - TLSO Brace, Miami J Collar, St. Jude Collar etc===
===MRI After Hours===
*Place order in Cerner: '''Orthotic Equipment'''
*MRI tech is in-house Mon-Fri 7am to midnight.  All other hours are considered off-hours.
**Write "TLSO Brace" under Special Instructions
*MRI tech is on-call for emergent cases limited to acute cord compression and rarely acute CVAs if requested by the Neuro Service for patient management (e.g. large CVA that may be considered for transfer to UCLA for intracerebral angio therapy)
*Call VALLEY INSTITUTE OF PROSTHETICS AND ORTHOTICS (VIPO)
*Findings that suggest acute cord compression include: 
**Cell phone: (661) 319-2777 Mike Nelson, CPO
**1. Bladder dysfunction (urinary retention or incontinence)
***Call 24/7 for URGENT spinal bracing otherwise wait until daytime hours
**2. Bilateral limb weakness
***IPO headquarters: 661-253-1191 or after hours: (800) 439-1005
**3. Sensory abnormalities with a sensory level
**VIPO will come to ED with brace or collar if needed before discharge
**4. Flaccid areflexia with upgoing toes, loss of anal sphincter tone
**Otherwise patient can be sent to our Physical Therapy on T/Th to pickup brace or patient can go to the company headquarters in Santa Clarita
*Some cases may be able to wait until the morning hours such as IVDA, fever and back pain without neuro findings.
*To request an emergent MRI when the tech is not here, first contact the STAT Radiologist in-house Mon-Fri until 11pm and weekends/holidays until 7pm.  If there is no STAT Radiologist in-house (e.g. after 11pm), contact the Neuro Radiologist on standby (on-call).
**On-call schedule can be found on OVMC Intranet...Departments...Radiology...Radiology Faculty Schedule Current Month.....Neuro/MRI Standby.  Operator has on-call schedule also and pager #s. 
**If no STAT radiologist, ED MD pages the Neuro Radiologist on standby (on-call) and requests MRI. 
*STAT Radiologist or Neuro Radiology Attending then pages the MRI tech.
*For cord compression cases, as much as possible, try to narrow down the level where the possible pathology lies e.g. lumbar vs thoracic.  If this is not possible, a '''"cord compression" MRI protocol''' can be performed that will give a large field of view (sagittal images) that will cover the whole spine in two slabs (cervical through mid-thoracic and mid-thoracic through lumbar), along with axial T2 images through the whole spine. Will not give great detail, but will see gross cord compression or high grade lumbar spinal canal stenosis. Decision about what imaging is performed will be up to the Neuro radiologist on-call.


*If Mike Nelson cannot be reached, the following vendors can be tried (all have DHS contracts):
===MRI for Large Patients===
**PERFORMANCE PROSTHETIC AND ORTHOTIC CENTER, INC (310) 829-2322 LERMAN AND SON (310) 659-2290
*Weight limits and gantry (size) limits:  (Note: measure patient at widest width either top to bottom or left to right;  must be able to fit into MRI scanner)
**ALPHA ORTHOPEDIC APPLIANCE COMPANY, INC (323) 721-6706
**'''OVMC''' - 350lbs and 60cm
**HANGER PROSTHETICS & ORTHOTICS (562) 233-4481
**'''LAC+USC''' - 300 lbs and 19inches
**DYNAMIC ORTHOTICS & PROSTHETICS, INC (213) 383-9212 ORTHO ENGINEERING, INC. (310) 559-5996
**'''Harbor'''- one MRI: 350lb and 65cm;  2nd MRI: 450 lbs and 60cm
**PRECISION ORTHOTICS & PROSTHETIC, INC. (213) 388-5847
**'''Downey MRI Center''',  8515 E. Florence Ave, Downey CA, 90240, 562-904-1340 (Open 7 days a week, 0630am-11pm) -   550 lbs and 17inches from top of table to scanner
**'''Garfield Insight Imaging Center''', located at Garfield Medical Center, 555 N. Garfield Ave, Monterey Park CA, 91754, 626-572-0912 (Open Mon-Fri 7am-6pm) - 550 lbs and 74cm. Need to fax patient demographic information and order request for imaging.
*These are the manufacturers weight limits. We have to be mindful and not get too close to the limit, or the table will break
*Harbor should be considered first option if possible as they have a scanner up to 450lbs
*Our MRI techs should help expedite this;  otherwise escalate to the Radiologist
*Call ANO for transportation.  Patient will be sent there via ambulance and then returned via same ambulance.
*If the patient requires sedation, this will be a problem for Downey or Garfield imaging centers.
*Utilization Management can help if the patient has insurance
*Ensure a CD of the imaging is brought back with the patient if sent to Downey or Garfield and if possible have the imaging read by their radiologist also just in case we cannot upload the images
*For imaging done as an outpatient after ED discharge, order as Future Order; Patient should call OVMC MRI to schedule and OVMC MRI will then arrange the MRI at Downey


===Wheelchairs===
===OVMC Weight Limits for Imaging===
*Wheelchairs are kept in the ED1A Clean Utility room, ED5 clean utility room and Roque's closet for after-hours and weekend patients to avoid admissions, e.g. wheelchair-bound patients or patients requiring wheelchair for example bilateral ankle fractures
*ED xray table - 500lbs
*Alternative ordering process:
*ED CT scanner - 550lbs* (*Note - an additional black table located in the ED CT Room can be used and the weight limit is then 650lbs)
**Order DME in Cerner- Do NOT order on OOP patients - must go to Health Plan for wheelchair
*MRI - 350lbs
**Order Physical Therapy Outpatient Future Order also in Cerner
*Downey MRI - 600lbs (see MRI Imaging for Large Patients)
**Patient should be sent to Physical Therapy. Patient will be financially screened. If patient has no insurance to pay for wheelchair through DHS, patient/family will be given list of outside vendors to contact.
*Cath Lab - 500lbs
*Nuclear Medicine - 300lbs
 
===Barium/Air Enemas for Intussception Cases===
*Surgical resident on-call should be made aware of any pediatric patient who is considered to have a possibility of intussusception
*Patient should have no contraindication to a barium or air enema such as evidence of peritonitis or perforation.
*M-F Business Hours:  Peds Radiologist Dr. Chawla usually performs the BEs/AEs
*M-F 6 pm-11 pm:  STAT Attendings will perform any BEs/AEs during their STAT shift
*Sat, Sun Holidays before 1pm:  General Radiology Attending is responsible
*Sat, Sun, Holidays 1p-7 pm Sat:  STAT attendings will perform any BEs/AEs during their STAT shift
*M-F 11 pm- 7am and Sat, Sun, Holidays 7pm-7 am:  General standby call is responsible for performing the BEs/AEs


===Physical Therapy and Occupational Therapy Outpatient===
===UGI for Malrotation/Volvulus Cases in Infants===
*Do NOT send OOP; refer patient to their health plan
*As per Dr. Andrews of Radiology, we have the ability to do an Upper GI 24/7 to evaluate an infant for malrotation/volvulus
*Order as Physical Therapy Outpatient or Occupational Therapy Outpatient Future Order in Cerner
*Contact the ED Radiology tech if a study is required
*Patient should be told to go to PT/OT Office, 1st floor, XXXXX. Patient will be financially screened. If patient has no insurance, patient/family will be given list of outside physical therapy centers to contact.
===='''Guidelines'''====
*'''Physical Therapy'''
**Post-op or acute shoulder injuries
**Neck, trunk, lower extremities
**Face
**Gait, balance, mobility and transfer training
**Conditioning
**Cardiopulmonary
**Lymphedema
**Chronic Wounds
**Neuro conditions (except upper extremity)
*'''Occupational Therapy (in general)'''
**Finger, hand, elbow, wrist injury, fracture, or post-op
**Chronic shoulder issues/pain
**Frozen shoulder
**If patient has difficulty with ADLs, such as bathing, dressing, grooming, feeding
**Neuro conditions that affect the upper extremity
**Fine motor control


===Back Pain Classes===
===Breast Mass and Infection Management and Imaging April 2023===
*Order as Physical Therapy Outpatient Future Order in Cerner;  PT Program: PT Eval and PT Reasons: Back Class as choices in the order
*OOP patients should be referred back to their Health Plan/PCP.   


===For Emergency Calls After Hours===
*RADIOLOGY has protocol in place for breast imaging follow-up.  They will ensure patient receives their results and they will refer patients to Breast Surgery who have concerning findings. All patients require imaging before being sent to Breast Surgery clinic.
*You may call Physical Therapy by having OVMC Operator use the Disaster Fan-Out list to reach Physical Therapy. Joann York will be the first one tried, then other staff within the Physical Therapy Dept.


==Procedure Clinic==
*see attached OVMC ED Breast Complaints algorithm
===Paracentesis, Thoracentesis, Lumbar Puncture===
**[[:media:OVMC ED Breast Complaints April 2023.pdf]]
*'''Medicine Procedure Service''' (sponsored by the Department of Medicine, Division of Pulmonary and Critical Care)
*Send requests to '''''OVM Procedure Service ED/UC Urgent Followup'' Message Pool''' and patients will be contacted with instructions and scheduled for the requested procedure.
*Patients will check into '''Outpatient Special Procedures Area''' on the 2nd floor on day of procedure. (Procedures done in Medicine Procedure Room on 5th floor).
*Ensure patient has good contact phone number in ORCHID.  Appointment will be mailed.
*If patient does NOT have reliable phone number, please page '''Procedure Service Pager 818-313-1733 or x73820 (M-F 8 AM to 4 PM)''' and we will attempt to give a date/time/instructions.
*If lab tests are needed on the specimen, please request this in Orchid message to Lisa Morgan RN
*Patients will be financially cleared prior to scheduled appt.
*Followup appts for those who need procedures such as paracentesis regularly will be arranged by the Medicine Procedure Service.


==Respiratory Therapy==
===Joint and Spine Injections===
*Dr. Raffi Salibian  x75145
*Dr. Catherine Yim  x74082
*'''Joints''':
**Order:  X-ray plain view
**Future Order:  US aspirate/injection/biopsy  (use ''Relevant History'' to indicate which joint)
**CBC and Coags if patient is coagulopathic
 
*'''Lumbar Spine''' (facets and epidurals):
**Send Message Center message to Dr. Catherine Yim requesting lumbar spine injection with the name of the ED Attending requesting the procedure.
**Future Order:  MRI lumbar spine (Patient must call to schedule the MRI.  Radiology phone # is pre-printed on ED Patient Summary/Discharge Instructions)
**Future Order:  IR facet inject lumbar  (need kg weight)
**CBC, Coags please
*Radiology will contact the ED TFU Coordinator or Urgent Care TFU Coordinator through the Message Pool with any problems


===BiPAP, Transporting patients upstairs on portable BiPAP===
==Renal==
*Often we have patients on BiPAP who need to be admitted upstairs.   
===Workflow to Access Dialysis===
*RT currently has 3 BiPAP (V60) machines that have a battery backup so patients can be transported upstairs without turning off the BiPAP
*ED calls on-call Renal Fellow for all HD/PD or potential HD initiation, regardless of reason for admission - e.g., dialysis patient being admitted for cellulitis or elective procedure, etc.   
*Ideally, before placing a patient on BiPAP, we should tell RT that the patient is likely to be admitted so RT can place the patient on a BiPAP machine that has battery backup.
*Fellows review and discuss case and plans for possible transfer with Renal Consult Attending.
*If the patient is already on BiPAP that does not have battery backup AND taking the patient off BiPAP would be detrimental to the patient, ask RT about switching the patient to a unit that has battery backup
*If transfer is deemed necessary, Renal Consult Attending calls and discusses case with Dr. Chi Pham.  
*If absolutely necessary, RT has the option to rent a BiPAP machine which can generally be here within 30-60mins.  
*Dr. Pham will work behind the scene (e.g., discuss with HD service/ANO 74586 to come up with creative/alternative plans if possible).
*RT Supervisor Jim Pratt is always available (RT is able to page him) if a question cannot be answered by RT
*Dr. Pham will then call "ED hotline" to give final plan. ED hotline number:  73648 and 73649
*In the event when Dr. Pham is not available: Renal Consult Attending discusses case and transfer plans with Dr. Jafari. *There will be one week this academic year when both Dr. Pham and Dr. Jafari will be out of town (June 23-28, 2020), in which case, Dr. Kamarzarian will make the final call regarding transfers.


===Home O2, How to obtain===
==Surgery==
*Call Resp Therapy x74422
*For surgical vs medicine admissions, see Surgical Subspecialty Admissions Guidelines under Admission Guidelines.
*If already on oxygen and has moved to L.A., lost insurance, etc, will need to prove need for home O2.  Get pulse ox on room air.  Qualifies if O2 Sat less than 88% on room air.
*For ALL surgical transfers out, ED Attending needs to speak to Surgical Subspecialty Attending
*Resp Therapy will bring a Durable Medical Equipment form that will need to be filled out by the ED provider
*Resp Therapy will contact the company, fax over the form, and arrange for delivery
*O2 TANK CAN BE DELIVERED TO THE ED so patient can leave with O2.  More tanks will be arranged to be sent to patient's home
*On occasion, the company may not have O2 tanks readily available in which case patient needs to be admitted to the hospital
*If patient has an outside health plan (OOP), UR may need to be involved for coordination of care


==Social Work==
===911 Trauma Re-Triage===
===Contacting Social Worker===
*To be used for trauma patients brought in by EMS by mistake or walk-in/drop-off patients with life-threatening traumatic injuries requiring '''EMERGENT''' (aka immediate) surgical intervention that we do not have at OVMC e.g. neurosurgical
*"Consult to Social Work" in Cerner - will send automatic page to SW and fax to the SW office
*Other EMERGENT surgical cases such as stab wounds or GSWs should be evaluated with the consult surgical resident (and Attending as needed) on a case by case basis as many of these such as abdominal trauma may be able to be cared for here at OVMC by the Dept of Surgery
**Social Work 7am-7:30pm pager 818-313-1759
*Please, if possible, ensure the Surgical Attending on-call is aware of the case. We have transferred trauma patients out that could have been taken care of by our Surgery Dept. 
**Social Work 7:30p-7am (off campus) 818-313-1637
*Step 1:  You MUST HAVE an ACCEPTING PHYSICIAN (new EMS policy Sept 2020)
**Social Work ED Office 74930
**Adult Patients
**Social Work 1st floor Office 74236
***Holy Cross, by Trauma Center policy, is OVMC's designated Trauma Center.
***Call Holy Cross, ask for Charge RN and get an accepting physician;  Holy Cross ED # 818-496-3302
**Pediatric Patients, 14 yrs old or younger
***Call Northridge Hospital, ask for Charge RN and get an accepting physician; Northridge ED #818-885-5396
*Step 2:  Call 911 and tell them you have a "Trauma Re-Triage" patient
**Do NOT call the MAC Center
*Copy all records and imaging but do not delay transfer
*Because of the limited scope of practice by the paramedics, if the patient has blood hanging or has any drips, then our OVMC Critical Care Transport team will accompany the patient in the EMS ambulance to Holy Cross.


===Substance Abuse Counselor and SASH Hotline===
*'''County Policy:  9-1-1 Trauma Re-Triage''' – This section applies to injured patients in emergency departments of non-trauma centers whose injuries were initially estimated by EMS to be less serious (under triaged) or patients who self-transported (walk-in) to a non-trauma center, and subsequently assessed by the non-trauma center physician to require immediate trauma center care. The referring facility shall utilize the procedure outlined below to expedite transfer arrangements and rapid transport to the trauma center. This process should be reserved for patients with life-threatening traumatic injuries requiring emergent surgical intervention.
*Contact Tomas Fajardo, Substance Abuse Counselor, through Consult to Social Work
**A. Determine if the injured patient meets any of the following 9-1-1 Trauma Re- Triage criteria:
* SASH Helpline (Substance Abuse Service Helpline) 1-844-804-7500;  24/7;  Patient will speak to a counselor who will ask questions and help patient obtain services for detox and rehab
***1. Persistent signs of poor perfusion
**http://myladhs.lacounty.gov/ov/Departments/DEM/Documents/Substance%20Abuse%20Service%20Hotline%20(SASH).pdf
***2. Need for immediate blood replacement therapy
***3. Intubation required
***4. Glasgow Coma Score less than 9
***5. Glasgow Coma Score deteriorating by 2 or more points during observation
***6. Penetrating injuries to head, neck and torso
***7. Extremity injury with neurovascular compromise or loss of pulses
***8. Patients, who in the judgment of the evaluating emergency physician, have high likelihood of requiring emergent life- or limb-saving intervention within two (2) hours.
**B. '''Contact the designated receiving trauma center or pediatric trauma center if the patient is less than or equal to 14 years of age and transport does not exceed 30 min.''' '''Do not delay transfer by initiating any diagnostic procedures that do not have direct impact on immediate resuscitative measures.'''
**C. Contact 9-1-1 for transportation. '''The paramedic scope of practice (Ref. No. 803) does not include paralyzing agents and blood products.'''
**D. Prepare patient and available medical records for immediate transport. Do not delay transport for medical records which could be sent at a later time.
**E. EMS has no immediate solution if there is refusal by the Trauma Center;  remind them of the EMS 911 Trauma Re-Triage Policy, that they are our receiving facility;  please let McCollough know about any refusals


===Sexual Assault===
===Surgery Clinic Referral Guidelines===
*OVMC does not have an adult Sexual Assault Nurse Examiner (SANE)
*Econsult:  All hernias and gallbladders need the hernia/chole form filled out - asks about BMI and cigarette smoking
*Call police dept in jurisdiction/city where assault occurred
*Surgery will not perform hernia repair or cholecystectomy if BMI >35
*Police must take patient to our closest center for sexual assaults which is Northridge Hospital
*Surgery will not perform hernia repair if patient smokes
*For breast cases, see WikEM OVMC:ED....Radiology....Breast imaging


===Child Maltreatment/Abuse===
===Breast Issues===
*See Pediatrics
*For breast cases, see WikEM OVMC:ED....Radiology....Breast Mass and Infection Management and Imaging


===Transporting patients home===
===Cardiothoracic Surgery===
*For patients without ability to get home (e.g. brought in by EMS), and no family or friends to take them home, first option is to have patients wait in waiting room until bus resumes in morning.
*We have non-cardiac Cardiothoracic Surgery at OVMC.  If you have a case, consult General Surgery who will consult with Cardiothoracic Fellow/Attending
*SOCIAL WORKER DOES NOT HAVE BUS TOKENS
*If more urgent transportation is necessary, County Trans can be used on a case-by-case basis to transport patient home.  Patient must have a key to house/apartment.  County Trans will not transport to shelters.


===Community Resources===
===Neurosurgery===
*Anger Management  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Anger%20Mgmt.pdf
*See Transfers...Higher Level of Care....Neurosurgery
*Bereavement  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Bereavement.pdf
*Community Clinic List  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Community%20clinic%20list%20MHLA.pdf
*Community Clinic List Children & Families  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Community%20Clinics%20Children%20Families.pdf
*Counseling  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Counseling.pdf
*Counseling Children and Families  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Counseling%20Children%20and%20Families.pdf
*Dental Clinics  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Dental%20Clinics.pdf
*Dental Clinic Mid-Valley  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Dental%20Mid-Valley.pdf
*Developmental Delay Services  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Development%20Delay%20Services.pdf
*Domestic Violence Shelters & Services  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Domestic%20Violence%20Shelters%20Services.pdf
*Drug & Alcohol Referrals I  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Drug%20and%20Alcohol%20I.pdf
*Drug & Alcohol Referrals II  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Drug%20and%20Alcohol.pdf
*Food Pantry and Clothing  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Food%20Pantry%20and%20Clothing.pdf
*Homeless Shelters  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/homeless%20shelters.pdf
*Legal Services Spanish  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Legal%20Services%20Spanish.pdf
*Mental Health Community Resources  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Community%20Resources.pdf
*Mental Health Urgent Care http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Urgent%20Care.pdf
*Mental Health Perinatal Depression  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Perinatal%20Depression.pdf
*Smoking Quitting  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Smoking%20Quitting.pdf
*Vision Clinics  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Vision%20Clinics.pdf
*Vision Valley Community Clinic  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Vision%20Valley%20Community.pdf


==Transfers==
===Vascular Surgery===
===MAC phone number 866-940-4401, press 3 for DHS facility===
*No update


===Higher Level of Care Transfers===
==Laboratory==
*Patients who require services that OVMC does not offer may need to be transferred out (e.g. neurosurgery, some emergent orthopedic cases). 
===Critical Lab Results on ED patients, ED Boarders (Admitted Patients), and ICU patients===
*For OOP patients who are clinically stable, every attempt should be made to transfer the patient to their health plan.
*Lab tech will determine if a patient is an ED patient or an ED Boarder prior to calling a critical lab result. Lab techs have a cheat sheet that outlines this process.  
*For uninsured or DHS-empaneled patients, transfer will occur through the MAC.
**ED patients: critical lab report goes to ED provider or attending. Lab tech should contact ED provider in the provider room based on patient location (main ED room or SuperTrack room. Lab has been given a list of ED patient rooms and the MD Room associated.   
*Transfers from the ED via the MAC fall into two categories. This is based on existing DHS policy:
**ED Boarder/Admitted patients: Lab tech should call the ED nurse directly based on patient location in the ED. Nurse will forward results to the inpatient team.
**(1) '''Emergent/Urgent''' e.g. intubated intracranial bleed. MAC will ask minimal questions in order to get transportation to OVMC as quickly as possible.  CMO on-call (ask Operator)should be notified regarding emergent transfer.  Emergent/Urgent patients cannot be refused by Harbor or USC and may end up being transferred to their ED if no inpatient beds are available. Emergent/Urgent transfers should be used on a rare basis for those patients who need to move RIGHT NOW aka emergently.   
**All ICU patients: Lab tech should contact the ED provider directly for all critical labs on ICU patients since ICU boarders are still managed by the ED team.
**(2) '''Non-Urgent''' e.g. open tib/fib fracture or hip fracture. MAC will ask more detailed questions. Patients will be presented to appropriate service at USC or Harbor. Transportation will be arranged after patient has been accepted.
**Remember both USC and Harbor have DHS Cerner and have access to our ED records and imaging
**MAC will '''NOT''' transfer to private hospitals such as transfer of neuro patient to UCLA for intracerebral thrombolysis (exception burn cases) or pediatric patient who is followed by UCLA sub specialist at the OVMC clinics. Transportation of those patients must be arranged by the private hospital or OVMC UR.


===BLS vs ALS vs Critical Care vs Helicopters===
===Critical Lab Results on Discharged ED Patients===
*BLS is staffed by EMTs, limited abilities, can administer oxygen;  cannot push meds and cannot have any hanging IV drips
To be added
*ALS is staffed by paramedics, can take intubated patients, CANNOT take patients with ANY type of IV drip (no heparin, mannitol, norepi, etc) even if those drips are not titratable.  Drips must be shut off. ALS ''IS ABLE'' take maintenance IV with max of KCl 20meq/L.  ETA variable.
*Critical care is staffed by paramedics plus Critical Care RN and/or MD, can take intubated patients with IV drips.  Often ETA of critical care team arrival 4-5 hours away. 
*Helicopter is staffed by paramedics +/- critical care RN, can take intubated patients with IV drips.  Dependent upon weather.  ETA variable. 
*For critically ill or injured patients on a drip that cannot be turned off, if critical care team's ETA is too long, consider sending OVMC ED RN, MD and/or RT as needed in ambulance.  Arrange head of time for same ambulance to bring staff back to OVMC.


===Pediatrics===
===Infrequent Lab Orders - Instructions ===
*The Pediatric attending on-call should be made aware of any higher level of care transfer out
'''Rapid Strep'''
*For OOP pediatric patients, UR should attempt to transfer the patient to the hospital requested by the health plan
*Order as ''Rapid Strep Group A Ag''.  Do '''NOT''' order POC Rapid Strep.
*For uninsured patients, not currently followed by a pediatric sub-specialist, attempts should be made to transfer to USC or Harbor via the MAC
*Run 24/7 when the test is received in the lab. General turnaround time 30mins.
*Patients followed by UCLA Pediatric subspecialties at OVMC may be transferred to UCLA if accepted by UCLA Pediatrics or subspecialist.
**OVMC Pediatric resident will contact UCLA inpatient staff or subspecialty service about transfer with approval by the Pediatric attending on-call
**Once accepted, transportation will depend upon the type of transfer: PICU transfers may transported by the UCLA Transport team;  Ward transfers to UCLA will need to have transportation arranged by OVMC ED UR staff.  
**MAC WILL NOT ARRANGE TRANSPORTATION TO UCLA


===Surgical and surgical subspecialties===
'''Varicella Testing'''
*For all surgical and surgical subspecialties being transferred out for "higher level of care", please contact the Attending of that service prior to transfer out.  ED Attending should speak to Surgical Attending to ensure we do not have the ability to care for the patient here at OVMC
*For Varicella testing,VZV DNA Qaul RT PCR-SO


===Neurosurgery===
'''Influenza Testing'''
*TO BE ADDED
*Order as ''Influenza A/B & RSV,RNA by PCR''.
*Generally run every 3hrs, starting at 9am,12n,3pm,6pm,9pm.  Tests takes 2 hour turnaround.


==Utilization Review (Utilization Management)==
'''Chlamydia/Neisseria gonorrhea RNA:'''
*x4890
*females - urine or cervical (not vaginal)
*Outpatient Service Coordinator OPSC can help with urgent follow-up to primary care for OOP patients (see above Follow-Up...Out of Plan OOP)
*males - urine or urethral
*urine - yellow tube, fluid level in between black lines
*cervical/urethral - white swab to clean mucus, blue swab for specimen collection
*don't use Rectal-SO or Throat-SO orderable unless you are specifically checking these sites
 
'''Malaria/Thin Smear'''
*Order as Blood Parasite Exam


==ED Ultrasound==
'''Pathology Tissue Request:'''
===Link to OVMC Ultrasound website===
*label prints as soon as the order is signed and cannot easily be printed again.
*http://www.uclaemultrasound.org
*printed in MD room on label printer  if ordered from computer in MD room
===Transvaginal Ultrasound===
*printed in patient room on label printer if ordered from computer in patient room
'''Peripheral Smear Exam by Lab:''' usually ordered by non Heme/Onc provider for review by lab tech <br />


==ED Supplies and Equipment==
'''Peripheral Smear for Provider Pickup (Slide Wirght Giemsa):''' usually ordered in consultation with Heme/Onc for MD to personally review<br />
===Clerk ED1A Cabinet===
 
*Alligator Forceps
===Specimen Collection Instructions - OVMC Micro Quick Reference Guide===
*Bolt Cutter
http://myladhs.lacounty.gov/ov/Pathology/Documents/Microbiology%20Specimen%20Collection.pdf
*Doppler
 
*Dremel
==Blood Bank==
*EZ-IO
===Massive Transfusion Protocol===
*Hair Remover
*MTP Recommendations:
*Panoptic
**1 unit plasma for every 1 unit PRBCs
*Ring Cutter  https://www.youtube.com/watch?v=VGE8oYtyR6k&feature=youtu.be
**1 unit of platelets for every 6 unit PRBCs
*Rongeur
**Due to necessity of thawing plasma units, plasma will be given when available
*Stryker  https://wikem.org/wiki/Compartment_pressure_measurement
 
*Tonopen
*'''Step 1''': Call Blood Bank x74062 to activate MTP
''*MUST LEAVE BADGE FOR ANY EQUIPMENT REMOVED FROM CLERK CABINET''
**a. Need Name and MRUN (John Doe name/MRUN from Reg ok)
**b. Need Attending Name


===ED1A MD Room===
*'''Step 2''': Order “Blood Product Pick Up Slip – MTP” in Cerner
*Ultrasound Supplies
**a. MD or RN can do this
**Gel
**b. Clerk prints out pick-up slip
**Probe covers
**c. No co-sign needed
*Angiocaths 3inch
*Headlamp


===Airway Cart in PR Room===
*'''Step 3''': Send runner to blood bank with printed pick-up slip to retrieve blood
*CO2 detectors, ETT
**a. If available, give them:
*CO2 detectors, nasal
***Signed Emergency Blood Release Form
*Nasal Atomizers
***Type and Cross Specimen
*Trach Atomizers
*Endotracheal Tubes
*LMAs


===Room 31===
*'''Step 4''': Blood Bank will send up unmatched Type O or type-specific cross matched units with runner
*Upper Cabinet
**Nosebleed Trays
**Lollicaine Lollipops (lidocaine lollipops)
**Ophtho Micoscope
**Cable for Xenon lamp
**Magnifying Headlamp
*ENT Cart
**OPHTHO
***pH paper taped to pH folder on top of cart
**OROPHARYNGEAL
**NASAL
***Nasal compression device for nose bleeds
***Nasal speculum
***Merocel
***Surgicel 2" x 3"
***Silver nitrate sticks
***Rhino Rocket Slimline - small, medium, large
***Rapid Rhino 5.5cm Rapid Pac
***Rapid Rhino 7.5cm Ant/Posterior with Airway
***Vaseline Petroleum Gauze Strip 1" x 36"
***Denver Nasal Splint
**Wood's Lamp bottom drawer


===Suture Cart===
*'''Step 5''': Send Type and Cross specimen STAT if not already sent
**a. MD to order in Cerner
**b. Specimen to be brought directly to Blood Bank


===Ortho Cart===
*Need more units?
**a. ALWAYS give them “Blood Product Pick Up Slip”
**b. If not yet sent, give them Signed Emergency Blood Release Form


===Gyn Cart===
*Follow-up: Have MD order blood products and transfusion orders for blood products infused
**one blanket order for 6 PRBCs, 6 plasma, 1 platelets, 1 cryo is acceptable. Order can be reconciled later to reflect exact amounts


===Central Line Cart in ED 1A/B hallway===
==Pharmacy==
*ED Pharmacist Mon-Fri 8am-4pm x75490


===Orthopedic supplies in Room 43===
===Hours===
*Soft collars, slings, wrist guards, CAM walkers, hard shoes
*Monday - Friday 7:30am-8pm; Sat, Sun, Holidays 8:30am-4:30pm
*Abdominal binders
*Hernia truss


===Crutches, Walkers, Wheelchairs===
===OVMC Empiric Antibiotic Recommendations 2019-2020===
*Located in ED1A/B Clean Utility Room
http://myladhs.lacounty.gov/ov/DEM/Documents/2019-2020%20Empiric%20Antibiotic%20Recommendation%20Guide.pdf


===Bronchoscope===
===Rhogam Administration===
*Located in storage room near Triage 4. Disposable scopes in cabinet in same room.
*Cerner: RhIG Request, click on both Administer and RhIG Request, then Initiate, then Modify both: Administer Intramuscular  and  RhIG Request 1 vial and reason Prenatal. Then Orders for Signature and Sign.


===Glidescope===
===Medication Refill Patient Handout===
*Located in PR Room - pediatric and adult batons available
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Pharmacy%20Refills.pdf
*Disposable blades located in Glidescope basket
*Extra blades located in cabinets in PR Room
*Wipe down batons after each use


===Unusual Supplies===
===Safe Prescribing and Narcan Handouts===
*Gastrostomy Tubes - ED 1A MD Room "S**T HAPPENS" Cabinet
*Safe Prescribing English  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Safe%20Prescribing%20ED%20English.pdf
*Nephrostomy tubing and bags - try OR
*Safe Prescribing Spanish
*Whitacre Spinal Needles - LP Cart
http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Safe%20Prescribing%20ED%20Spanish.pdf
*Narcan (Naloxone) English  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Naloxone%20English.pdf
*Narcan (Naloxone) Spanish  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Naloxone%20Spanish.pdf


==Disaster Preparedness==
===Buprenorphine Administraton===
*Olive View-UCLA has a robust plan for a number of possible disasters such as earthquakes. All OVMC faculty and residents should review the materials on the hospital homepage under “Disaster Management.” The link is in the center of the screen.  For staff in the ED at the time of a disaster, the important information is as follows.
*See Substance Use Disorder
**1. The ANO (Acting Nursing Officer) is designated as the incident commander and is in the hospital 24/7.
**2. The ANO will set up a command post in Hospital Administration and will contact the charge nurses in each department.
**3. The initial priority is a head count of all staff, and a report on the physical condition of the department.
**4. A physician in the hospital will be designated as a medical officer in the incident command center. At night, this may be OB or Anesthesia as they are also in house and we will be responsible for managing the ED.
**5. All requests for materials, staff, and questions go though the incident command in medical administration.
**6. The ED charge nurse is aware of the location of extra supplies and the hospital wide disaster management plan. 
*Olive View-UCLA has over one week of food, water and medical supplies for an anticipated disaster. There are specific incident commanders and disaster professionals who will be responding, and the emergency physicians on site are not expected to lead the disaster response.


==Downtime Protocols==
==Physical Therapy, Occupational Therapy and Orthotics==
Downtime Documentation
===ED Orthopedic Equipment and Hernia Trusses===
*H&P will be documented on paper using DEM Physician Record (OV1901). Resident and Attending signatures are required.
*Crutches, walkers, canes – stored in ED1A and ED5 clean utility rooms
*MSE - when performed by a separate MSE provider, note should be very brief and be written on the upper portion of the History section of  the paper DEM Physician Record (OV1901). It should include a separate header of MSE NOTE and must be signed.
*Hard shoes, wrist braces, ankle splints - stored in Orthopedic Storage Room
*Hernia trusses – stored in Room #43


Downtime General Orders
===DME Supplies to be ordered as outpatient===
*orders should be written on paper using DEM Physician’s Orders (OV1337) and include a date, time, initials, and signature
*Order supplies such as compression stockings as "DME..."
*orders should be placed in the order bin located at each Nursing Station (ED 1-5, RME) for the Nurse/Clerk to initiate
*Order will ask Diagnosis, length of use, etc.  For compression stockings, use 20-30mmHg
*clerk has all downtime forms, lab slips and Radiology Request forms.
*Instruct patient to go to Physical Therapy room 1D120 to pick up the supply
*Do NOT use for OOP patients;  please send to health plan.
*Link will take you to list of DME supplies:  http://myladhs.lacounty.gov/ov/DEM/Documents/DME%20Supplies.xlsx?Web=1


Downtime Radiology Orders
===Urgent Spinal Bracing - TLSO Brace, Miami J Collar, St. Jude Collar etc===
*order imaging on paper and include a complete paper Radiology Order Form (OV2059). Runner will hand deliver request to the appropriate ED radiology area.
*Place order in Cerner: '''Orthotic Equipment'''
*if ORCHID downtime is isolated, iimages and preliminary results will still be available in Synapse even if not viewable in ORCHID
**Write "TLSO Brace" under Special Instructions
*radiology orders ordered during downtime using the Radiology Request forms do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur).
*Call VALLEY INSTITUTE OF PROSTHETICS AND ORTHOTICS (VIPO)
**Cell phone: (661) 319-2777 Mike Nelson, CPO
***Call 24/7 for URGENT spinal bracing otherwise wait until daytime hours
***IPO headquarters: 661-253-1191 or after hours: (800) 439-1005
**VIPO will come to ED with brace or collar if needed before discharge
**Otherwise patient can be sent to our Physical Therapy on T/Th to pickup brace or patient can go to the company headquarters in Santa Clarita


Downtime Laboratory Orders/Workflow
*If Mike Nelson cannot be reached, the following vendors can be tried (all have DHS contracts):
*clerk/nurse will complete paper lab request slips to accompany specimens sent to the lab. The lab slip should include collector's employee number ("e" or "c" number).
**PERFORMANCE PROSTHETIC AND ORTHOTIC CENTER, INC (310) 829-2322 LERMAN AND SON (310) 659-2290
*lab labels will not print during downtime. All specimens must be labeled with the following information:
**ALPHA ORTHOPEDIC APPLIANCE COMPANY, INC (323) 721-6706
**patient info: patient name, DOB, MRN, FIN
**HANGER PROSTHETICS & ORTHOTICS (562) 233-4481
**collector's info: date/time specimen collected, employee number ("e' or "c" number), collectors signature
**DYNAMIC ORTHOTICS & PROSTHETICS, INC (213) 383-9212 ORTHO ENGINEERING, INC. (310) 559-5996
*lab results will be faxed to the ED at X74298 and hand delivered to the assigned resident or attending for that patient
**PRECISION ORTHOTICS & PROSTHETIC, INC. (213) 388-5847
*POCT orders placed by the providers will be resulted verbally to the ordering provider and also resulted in nursing documentation
*lab will call critical results to the ED
*lab orders ordered during downtime do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur). Results that came back on paper will eventually also be resulted in ORCHID.


Downtime Medication Orders
===Wheelchairs===
*all medication orders should be written on paper using form OV1337
*Wheelchairs are kept in the ED for after-hours and weekend patients to avoid admissions, e.g. wheelchair-bound patients or patients requiring wheelchair for example bilateral ankle fractures
*patient prescriptions should be written on paper and handed to the patient. A copy of each Rx should be kept in the patient’s paper record. Rxs will be scanned into ORCHID once ORCHID comes back up. Rx’s will not be back entered by the provider into ORCHID after a prolonged downtime.  
*Ask RNs where they are kept;  or Use Backup Supply list (top of WikEM) and search where wheelchairs are kept
*when ORCHID is back up, Pharmacy will manually enter all medications that were ordered during downtime
*Alternative ordering process:
**Order DME in Cerner- Do NOT order on OOP patients - must go to Health Plan for wheelchair
**Order Physical Therapy Outpatient Future Order also in Cerner
**Patient should be sent to Physical Therapy. Patient will be financially screened. If patient has no insurance to pay for wheelchair through DHS, patient/family will be given list of outside vendors to contact.


Downtime Blood Bank Orders
===Physical Therapy and Occupational Therapy Outpatient===
*enter required orders on paper (T&S, T&C, transfusion, etc)
*Do NOT send OOP; refer patient to their health plan
*paper blood transfusion indication sheet must be filled out for Adults OV1998 or Peds (OV2015)
*Order as Physical Therapy Outpatient or Occupational Therapy Outpatient Future Order in Cerner
*Patient should be told to go to PT/OT Office, 1st floor, XXXXX. Patient will be financially screened. If patient has no insurance, patient/family will be given list of outside physical therapy centers to contact.
====Guidelines====
*'''Physical Therapy'''
**Post-op or acute shoulder injuries
**Neck, trunk, lower extremities
**Face
**Gait, balance, mobility and transfer training
**Conditioning
**Cardiopulmonary
**Lymphedema
**Chronic Wounds
**Neuro conditions (except upper extremity)
*'''Occupational Therapy (in general)'''
**Finger, hand, elbow, wrist injury, fracture, or post-op
**Chronic shoulder issues/pain
**Frozen shoulder
**If patient has difficulty with ADLs, such as bathing, dressing, grooming, feeding
**Neuro conditions that affect the upper extremity
**Fine motor control


Downtime Specialty Diagnostic Services
===Back Pain Classes===
*complete paper requisition for Echo, Stress Treadmill/Myocardial Perfusion Imaging, Holter and EEG. Call appropriate department for STAT orders
*Order as Physical Therapy Outpatient Future Order in Cerner;  PT Program: PT Eval and PT Reasons: Back Class as choices in the order


Downtime Admissions
===For Emergency Calls After Hours===
*initiate Interqual request by calling UR directly at X74890.
*You may call Physical Therapy by having OVMC Operator use the Disaster Fan-Out list to reach Physical Therapy. Joann York will be the first one tried, then other staff within the Physical Therapy Dept.
*discuss with admitting team
*once an admission is accepted by the admitting team, enter ''Request to Admit'' order on paper and include service, level of care, and the name of the admitting attending and resident.
*admissions during downtime will be tracked by Nursing on a paper log
*certain orders such as Bed Requests and Admit Orders will need to be manually re-entered into ORCHID once ORCHID is back up


Downtime Discharge
==Procedure Clinic==
*complete discharge and aftercare instructions using form OV2014 including discharge impression, recommended follow up, and return precuations. Do not use this form for Rx.  
===Paracentesis, Thoracentesis, Lumbar Puncture===
*Rx should be written on paper Rx pads. Copies should be left in paper chart to be scanned in later.  
*'''Medicine Procedure Service''' (sponsored by the Department of Medicine, Division of Pulmonary and Critical Care)
*discharge order must be signed on paper
*Send requests to '''''OVM Procedure Service ED/UC Urgent Followup'' Message Pool''' and patients will be contacted with instructions and scheduled for the requested procedure.  
*all discharges from the ED during downtime will be tracked by Nursing on a paper log. A separate provider log will be kept for downtime discharges that require future labs, studies, message pools, e-consults, TFU referrals so that they may be entered into ORCHID during recovery.  
*Patients will check into '''Outpatient Special Procedures Area''' on the 2nd floor on day of procedure. (Procedures done in Medicine Procedure Room on 5th floor).  
*Ensure patient has good contact phone number in ORCHID.  Appointment will be mailed.
*If patient does NOT have reliable phone number, please page '''Procedure Service Pager 818-313-1733 or x73820 (M-F 8 AM to 4 PM)''' and we will attempt to give a date/time/instructions.  
*If lab tests are needed on the specimen, please request this in Orchid message to Lisa Morgan RN
*Patients will be financially cleared prior to scheduled appt.
*Followup appts for those who need procedures such as paracentesis regularly will be arranged by the Medicine Procedure Service.


Downtime Recovery - ORCHID Back Online
==Respiratory Therapy==
*LAB/RAD - results will begin to populate via the interface in ORCHID. Lab and imaging orders previously placed on paper should not neeed to be ordered again.  
===Respiratory Therapy contact phone numbers===
*documentation – Provider documentation on paper will be scanned into patient chart.
*RT supervisor x75038
*pharmacy will back-enter enter all medication orders placed on paper during downtime back into ORCHID.  
*RT DEM resp therapist x75581
*physicians must re-enter all other paper orders placed during downtime into ORCHID (admission requests, place in obs, isolation, communication, restraints, holds, consults, etc).
*RT Lead resp therapist x75331
===BiPAP, Transporting patients upstairs on portable BiPAP===
*Often we have patients on BiPAP who need to be admitted upstairs. 
*RT currently has 3 BiPAP (V60) machines that have a battery backup so patients can be transported upstairs without turning off the BiPAP
*Ideally, before placing a patient on BiPAP, we should tell RT that the patient is likely to be admitted so RT can place the patient on a BiPAP machine that has battery backup.
*If the patient is already on BiPAP that does not have battery backup AND taking the patient off BiPAP would be detrimental to the patient, ask RT about switching the patient to a unit that has battery backup
*If absolutely necessary, RT has the option to rent a BiPAP machine which can generally be here within 30-60mins.  
*RT Supervisor Jim Pratt is always available (RT is able to page him) if a question cannot be answered by RT


Downtime Frequent Phone Numbers
===Home O2, How to obtain===
*ED Lab (8:30 am - 10:30pm) : 74977
*Call Resp Therapy x74422
*General Lab: 73476, 74038
*If already on oxygen and has moved to L.A., lost insurance, etc, will need to prove need for home O2.  Get pulse ox on room air.  Qualifies if O2 Sat less than 88% on room air.  
*Microbiology: 76041
*Resp Therapy will bring a Durable Medical Equipment form that will need to be filled out by the ED provider
*Blood Bank: 74062
*Resp Therapy will contact the company, fax over the form, and arrange for delivery
*Phlebotomy: 74555/74039
*O2 TANK CAN BE DELIVERED TO THE ED so patient can leave with O2.  More tanks will be arranged to be sent to patient's home
*ED Xray Tech: 75496
*On occasion, the company may not have O2 tanks readily available in which case patient needs to be admitted to the hospital
*ED US Tech: 74940
*If patient has an outside health plan (OOP), UR may need to be involved for coordination of care
*ED CT Tech: 74968
*MRI Tech: 73535
*ED Radiologist: 74971
*LAC+USC Radiology Nighthawk (11pm–7am): 323-409-6688
*ED UR/Interqual: 74890
*Pharmacy: 73070
*ED1A: 74320
*ED1B: 74865 
*ED2A: 74321
*ED2B: 74280
*ED3: 74976
*ED4: 74974
*ED5: 74970
*SuperTrack Provider Room : 74936/74937
*Main Provider Room: 73645
*DEM Administrative Offices: 73107


==ORCHID/FirstNet==
==Social Work==
===Contacting Social Worker===
*"Consult to Social Work" in Cerner - will send automatic page to SW and fax to the SW office
**Social Work 7am - 7:30pm pager 818-313-1759
**Social Work 7:30p-7am (off campus) 818-313-1637 for emergencies such as deaths, significant child abuse
**Social Work ED Office 74930
**Social Work 1st floor Office 74236


===Logon===
===Sexual Assault===
*logon credentials are the same as your Internet Password
*OVMC does not have an adult Sexual Assault Nurse Examiner (SANE)
*if you need to reset your password go to the Olive View- UCLA Home Page, under the Links Section (toward the bottom), and choose one of the ''Password and Account Management'' links
*Call police dept in jurisdiction/city where assault occurred
*if you still can’t logon, call the Enterprise Help Desk at x74522
*Police must take patient to our closest center for sexual assaults which is Northridge Hospital
*Northridge Hospital ''Center for Assault Treatment Services'' 818-908-8630
 
===Child Maltreatment/Abuse===
*See Pediatrics
 
===Transporting patients home===
*For patients without ability to get home (e.g. brought in by EMS), and no family or friends to take them home, first option is to have patients wait in waiting room until bus resumes in morning.
*SOCIAL WORKER DOES NOT HAVE BUS TOKENS
*If more urgent transportation is necessary, County Trans can be used on a case-by-case basis to transport patient home.  Patient must have a key to house/apartment.  County Trans will not transport to shelters.
 
===Translation Services===
*In Person Translation Services for Hard of Hearing, Deaf, Deaf Blind, and Non ASL Speakers
**For American Sign Language, Tactile, and Certified Deaf, In-Person Interpreter Services: Please contact Accommodating Ideas at (800)257-1783 M-F 8:00am to 10:00pm; for Weekends, Holidays and after above hours, call Heather C. at (818)481-9028.
***They work with contractors and will aim to provide you with an interpreter as soon as one is available.
**Please have Accommodating Ideas form completed and available when you call:
***Always include your P.O. Number: DO-HO-19034844-1 effective 09/25/18 thru 06/31/19
***Your interpreter must be requested for a minimum of 2 hours
***Our ED clerks will email Accommodating Ideas at aiterps@ai-ada.com & always CC: Laura Onofre, CHI at Lonofre@dhs.lacounty.gov for invoicing purposes and verification
**You may reach Laura Onofre, CHI at (747) 210-3411 M-F 8:00 am to 4:30 pm, for any support or clarification of the process
 
===Olive View Trauma Recovery Center===
*We provide mental health and wrap-around case management for victims of crime in the San Fernando and Antelope Valleys.
*Who is eligible for services?
**Anyone who has been a victim of crime in the past 3 years and/or the victim’s family members.
***Has a need for mental health and/or case management.
***Not currently under the care of a mental health professional.
*We aim to serve:
**1. Crime victims who typically are unable to access traditional services, including, but not limited to, victims who are homeless, chronically mentally ill, of diverse ethnicity, members of immigrant and refugee groups, disabled, who have severe trauma-related symptoms or complex psychological issues, or juvenile victims, including minors who have had contact with the juvenile dependency or justice system.
**2. Victims of a wide range of crimes, including, but not limited to, victims of sexual assault, domestic violence, physical assault, shooting, stabbing, human trafficking, and vehicular assault, and family members of victims.
*How do I refer a patient?
**1. From Olive View- In ORCHID, place a social work consult with the reason “Other” and write “Trauma Recovery Center Referral” in the comments.
**2. From outside Olive View- go to our website https://oliveviewtrc.org/ and use the referral form tab.
*FAQs
**1. Do you provide services for children?  Yes
**2. What if the crime happened outside the U.S.?  We can still provide services to the victim.
**3. Does the potential client have to be DHS eligible?  No, we can provide services regardless of insurance plan or lack thereof.
*Email: olvtrc@dhs.lacounty.gov
*Phone: (747)210-4800
*Web: oliveviewtrc.org
*Social: Instagram – @oliveview_trc
 
===Medico-Legal Resources===
Olive View now has a Medical Legal Community Partnership (MLCP) in conjunction with Neighborhood Legal Services. If you have a patient who has legal issues that impact their health (unsafe housing, MediCal issues, immigration, employment, etc) they can now consult with a lawyer on the OV campus through the MLCP. There is a lawyer available by appointment in the social work office on Tuesdays and Thursdays. The way to refer is to put in a social work consult order for the patient with the reason as "other" and in the comments write "request MLCP visit for..." with the reason for the referral. See below flyers for more information about areas where they can help.
*MLCP English: [https://www.scribd.com/document/449824976/MLCP-Info-English]
*MLCP Spanish: [https://www.scribd.com/document/449824975/MLCP-Info-Spanish]


===CheckIn===
===Violence Intervention Programs===
*at the start of a new shift, ORCHID should immediately prompt you to check-in as an available provider.
*https://www.allianceforcommunityempowerment.org/
*in the Provider CheckIn window, select your ''Display Name'', ''Provider Role'' and a ''Default Relation''. Also select the checkboxes for ''Available Provider'' and ''Available Reviewer''.
*https://www.championsinservice.org/
*if you were already checked-in to see patients on that shift, you will not be prompted to check in again.
*https://www.lagryd.org/refer
*if you need to Check In manually, click on the little icon of the provider with the Check Box.


===Patient Sign Up===
===Immigration Resources===
*click once on the patient row then click on the ''Assign Provider'' icon. Your Display Name will appear in the appropriate column.


===Documentation===
The changes to the public charge rule went into effect in February 2020. This has created high levels of fear among our patients because it has the potential to impact future adjustments in immigration status. There is lots of misinformation out there about these changes. For the most part, our patients can continue to obtain healthcare within the DHS without any problem. If a patient has a concern about whether receiving care or signing up for benefits will impact their ability to adjust their immigration status, please give them the attached flyer from the Office of Immigrant Affairs of Los Angeles County. They are available to help answer questions about what these changes mean for specific patients and families.
Selecting a Note Template
Public Charge Information Card: [https://www.scribd.com/document/449824982/OIA-Public-Charge-Info-Card Link to Info Card]
*click ''Provider Notes'' from the tracking list then ''+Add'' in the ''Provider Notes'' band
 
*the ''Note Type'' should default to ''ED Note-Provider'' so that notes are filed in the correct folder and can be viewed by UR and the ED Attending once they are saved. If the ''ED Note-Provider'' option is not available, ''right-click'' on the arrow to select from ''All Note Types''.
*County Policy on Sensitive Locations: http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/LA%20County%20Sensitive%20Locations%20Policy%20-%20October%2019%202017.pdf [https://www.scribd.com/document/423080634/LA-County-Sensitive-Locations-Policy-October-19-2017?secret_password=n3IUGkEbiVWkvOF09FCe Alt Link]
*using the ''Reason For Visit'' tab select a ''Note Template'' to use either by free text search or by using the structured menu (PNED RFV) then hit select ''OK''. Use the checkboxes to select which elements (if any) you would like to import into your note
*Know your Rights flyer:
*colored notepads on the Tracking Board track the progress of your Provider Note (not started, in progress, or signed) during the patient encounter
**English:  http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/Know%20Your%20Rights%20Flyers_English.pdf [https://www.scribd.com/document/423080633/Know-Your-Rights-Flyers-English Alt Link]
Documentation Workflow
**Spanish:  http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/Know%20Your%20Rights%20Flyers_Spanish.pdf [https://www.scribd.com/document/423080632/Know-Your-Rights-Flyers-Spanish Alt Link]
*once saved, notes written using the default ED Note-Provider template, can be viewed by both Utilization Management and the ED Attending. Consultants cannot view provider ED documentation until the note is signed.
**Chinese:  http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/Know%20Your%20Rights%20Flyers_Chinese.pdf[https://www.scribd.com/document/423080630/Know-Your-Rights-Flyers-Chinese Alt Link]
*once you have completed your provider note, click on ''Sign/Submit'' and a new window will pop up. Select ''Request Endorsement'', then click inside the yellow area under Endorser. Select the ''binoculars'' icon to search for the attending you would like to co-sign your chart. Click OK. Under “Type” make sure that ''sign'' is selected (not reviewed). Then click sign to close the window.
*Know your Rights pocket card:
*Attendings: In the ''Message Center'' you can view notes forwarded to you for signature. Choose the ''Correct'' icon to change a note and write an addendum. If you want to write a separate note before the intern/resident has completed their note, use the ''Note'' function (rather than Provider Notes).
**English: http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/OIA%20Know%20Your%20Rights%20Card%20English.pdf[https://www.scribd.com/document/423080616/OIA-Know-Your-Rights-Card-English Alt Link]
*for patients signed out at rounds, the oncoming resident should write a brief note using the ''Notes'' function (not Provider Notes).
**Spanish: http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/OIA%20Know%20Your%20Rights%20Card%20Spanish.pdf[https://www.scribd.com/document/423080617/OIA-Know-Your-Rights-Card-Spanish Alt Link]
Documenting a Re-Evaluation
**Chinese: http://myladhs.lacounty.gov/ov/DEM/PublishingImages/SitePages/EMHome/OIA%20Know%20Your%20Rights%20Card%20Chinese.pdf[https://www.scribd.com/document/423080615/OIA-Know-Your-Rights-Card-Chinese Alt Link]
*below the ''Medical Decision Making'' section of the PowerNote note there is a section to document follow up exams. Choose ''Re-exam/Re-eval'' and enter a ''time'' before entering details of the follow up exam
 
* ''right-clicking'' over the ''Re-exam/Re-eval'' header and selecting repeat allows you to document repeated re-evalautions
===Community Resources===
*Anger Management http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Anger%20Mgmt.pdf [https://www.scribd.com/document/423080610/Anger-Mgmt Alt Link]
*Bereavement  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Bereavement.pdf [https://www.scribd.com/document/423080621/Bereavement Alt Link]
*Community Clinic List  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Community%20clinic%20list%20MHLA.pdf [https://www.scribd.com/document/423080631/Community-Clinic-List-MHLA Alt Link]
*Community Clinic List Children & Families  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Community%20Clinics%20Children%20Families.pdf [https://www.scribd.com/document/423080619/Community-Clinics-Children-Families Alt Link]
*Counseling  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Counseling.pdf [https://www.scribd.com/document/423080622/Counseling Counseling]
*Counseling Children and Families  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Counseling%20Children%20and%20Families.pdf [https://www.scribd.com/document/423080623/Counseling-Children-and-Families Alt Link]
*Dental Clinics  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Dental%20Clinics.pdf [https://www.scribd.com/document/423080627/Dental-Clinics Alt Link]
*Dental Clinic Mid-Valley  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Dental%20Mid-Valley.pdf [https://www.scribd.com/document/423080612/Dental-Mid-Valley Alt Link]
*Developmental Delay Services  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Development%20Delay%20Services.pdf [https://www.scribd.com/document/423080629/Development-Delay-Services Alt Link]
*Domestic Violence Shelters & Services  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Domestic%20Violence%20Shelters%20Services.pdf
*Drug & Alcohol Referrals I  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Drug%20and%20Alcohol%20I.pdf [https://www.scribd.com/document/423080626/Drug-and-Alcohol-I?secret_password=4aem6ZLXeYVFD1Ejq0wJ Alt Link]
*Drug & Alcohol Referrals II  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Drug%20and%20Alcohol.pdf [https://www.scribd.com/document/423080628/Drug-and-Alcohol Alt Link]
*Food Pantry and Clothing  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Food%20Pantry%20and%20Clothing.pdf [https://www.scribd.com/document/423080613/Food-Pantry-and-Clothing Alt Link] Updated List Feb 2020: [https://www.scribd.com/document/449824978/Spa-2-English-Foodpantryplanner-List-Final]
*Heat Relief and Cooling Centers (English) https://ready.lacounty.gov/heat/
*Heat Relief and Cooling Centers (Spanish) https://ready.lacounty.gov/calor/
*Heat Relief and LA's Green New Deal  https://plan.lamayor.org/neighborhood-council/neighborhood_council.html
*Homeless Shelters  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/homeless%20shelters.pdf [https://www.scribd.com/document/423080609/Homeless-Shelters Alt Link]
*Legal Services Spanish  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Legal%20Services%20Spanish.pdf [https://www.scribd.com/document/423080614/Legal-Services-Spanish Alt Link]
*Mental Health Community Resources  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Community%20Resources.pdf [https://www.scribd.com/document/423080608/Mental-Health-Community-Resources Alt Link]
*Mental Health Urgent Care  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Urgent%20Care.pdf [https://www.scribd.com/document/423080611/Mental-Health-Urgent-Care Alt Link]
*Mental Health Perinatal Depression  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Mental%20Health%20Perinatal%20Depression.pdf [https://www.scribd.com/document/423080606/Mental-Health-Perinatal-Depression Alt Link]
*Smoking Quitting  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Smoking%20Quitting.pdf [https://www.scribd.com/document/423080618/Smoking-Quitting Alt Link]
*Vision Clinics  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Vision%20Clinics.pdf [https://www.scribd.com/document/423080620/Vision-Clinics Alt Link]
*Vision Valley Community Clinic  http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Social%20Service%20Resources/Vision%20Valley%20Community.pdf [https://www.scribd.com/document/423080607/Vision-Valley-Community Alt Link]


=== Procedure Consent with iMedConsent ===
==Substance Use Disorders==
*from the FirstNet Tracking List, click on the '''iMedConsent''' link located on the favorite links bar
*OVMC Bridge Website: https://www.ovmcbridge.org/
*logon to iMedConsent using your ORCHID user credentials. This part may be automated if using the Imprivata One Sign system.
===Substance Abuse Counselors in the ED and SASH Hotline===
*perform a manual patient search (MRN based) from within iMedConsent to auto populate the demographic fields in iMedConsent. '''Note: if you skip this step, then the patient information will be blank on the printed consent form, and it will be rejected by the medical records department'''
*Contact Substance Use Disorder Counselor through Consult to Social Work, drop down Substance Use Disorder
*select the appropriate procedure/s that you would like to print for the patient
*Refer DHS patient to MAT Bridge Message Pool
*have the patient read, consent, and wet sign the printed procedure consent form
* SASH Helpline (Substance Abuse Service Helpline) 1-844-804-7500;  24/7;  Patient will speak to a counselor who will ask questions and help patient obtain services for detox and rehab
*place a copy of the wet signed consent in the patient's paper chart. The Health Information Management (HIM) team will scan the consent form into ORCHID after the patient is discharged.
**http://myladhs.lacounty.gov/ov/Departments/DEM/Documents/Substance%20Abuse%20Service%20Hotline%20(SASH).pdf


===Procedure Documentation (ad hoc forms)===
===Opioid Use Disorder Recognition and Treatment/Bridge Program===
*''AdHoc Forms'' are used for specific template driven documentation in the ED. This includes documentation of all ED Procedures. AdHoc forms can be found using the ''AdHoc'' link on the ORCHID Menubar,
Goal is to recognize opioid use disorder and initiate treatment with buprenorphine or methadone while the patient is in the ED or hospitalized.
then finding the ED Forms Folder.
*'''Consult Social Work''' for ALL Opioid Use Disorder patients even if they do not want treatment
*template AdHoc forms include documentation for ED Procedures, ED Bedside Ultrasounds, Central Line (CLIP) documentation, and the NIH Stroke Scale.
**Consult to Social Work......Substance Abuse.....free text OUD
*once completed, these AdHoc forms are signed using the ''Check Mark'' on the Upper Left corner of the screen.
**'''V. Figueroa''' is our Substance Use Coordinator, Mon-Fri, 8am-5pm, 818-792-0407
*'''Medications for Opioid Use Disorder (MOUD) On-call provider 8am-8pm 7 days per week:  818-313-1451'''
**'''Bridge provider on-call''' can help with recognition of OUD, help with buprenorphine or methadone initiation in the ED and MOUD provider will make sure the patient gets follow-up
*'''OVM MAT Bridge ED/UC Urgent Follow Up Message Pool''' to refer DHS patients to Bridge for follow up.
***PLEASE DOUBLE CHECK PATIENT'S CONTACT PHONE NUMBER IN CERNER


===Medicine Admissions===
*Additional Resources:
1) ''Interqual Request Order'' - found on the Quick Orders page under the ''Top Other'' section. A diagnosis is required.
**'''California Poison Control 24/7 access to addiction fellow/attending''' for help with difficult cases: 844-326-2626
*DHS uses Interqual Criteria for Utilization Review (UR). All admissions must be reviewed by UR. The Interqual decision is facilitated by having a note in the chart for UR to review. UR can view ED resident notes as long as they have been saved.
**'''UCSF Substance Use Warmline''', access to help with difficult cases, Monday-Friday 6am-5pm:  855-300-3595
*the Interqual Request is found under the Events tab and the Request Events sub-tab.
**ovmcbridge.org has a lot of education, videos on a variety of SUD topics
*the Interqual review process is tracked with ICONs under the ADT column
**REQ - Requested
**IP - In Progress
**MET - Criteria Met the
2) Contact the admitting team via ''Amion'' to give report
*contact the admitting Hospitalist or Resident. Use auto-paging (see below) to help track the time the admitting service is first paged. Confirm with the Hospitalist the name of the receiving Attending, Resident, Service, and Level of Care
3) Enter the ''Request for Admit''. Enter the admitting resident name in the Special Instructions field. Medicine teams will drop Admission orders in the chart within 2 hours from the time the Request for Admit order is placed.
*Note: Admission orders should NOT be placed on any patient until Bed Control updates their location status to ED Boarders. ED Boarders are easily identifiedin the location field on the Banner Bar and by a slash in the Bed
column on the FirstNet track. If inpatient orders are dropped on a patient before they are changed to an ED Boarder they will have to be re-entered by the Admitting team.
*the ''Hospital'' Icon indicates that the inpatient team has placed Admitting Orders in ORCHID. The Medicine team assumes all responsibility for patient care once Admission orders are placed. Routing questions from Nursing regarding further medical care should be directed to the inpatient provider.


===Changes in Service or Level of Care after Initial Admission===
===Buprenorphine and Methadone Administration in the ED===
*if you need to upgrade/downgrade an ED Boarder after the initial Request for Admit has been submitted, you need to order ''Request for Admit'' again (not Transfer). This is the only way bed control will get the message that a change has been requested. DEM providers will do this if they are still following the patient, however once Admission Orders are written (Hospital Icon), the Admitting Service will re-order the Request for Admit if any upgrade/downgrade must occur.
*For any patient with opioid use disorder, OD, withdrawal or seeking care, please page the '''Meds for Opioid Use Disorder provider on-call 8am-8pm 7 days per week, 818-313-1451
*if the post-admission upgrade/downgrade results in the patient going to a different team, the Inpatient team must notify and give report to the new team since these patients are no longer being followed by the ED.
*Call Dr. McCollough if unable to reach MOUD provider OR anytime 8pm-8am. 310-614-5306 WE WANT TO KNOW ABOUT ALL OF THESE PATIENTS!
*Please also '''Consult to Social Work'''....Substance Use Disorder....OUD in free text
*'''Viviana Figueroa is the Substance Use Navigator''' for the Bridge OUD program - 747-210-5625, pager 818-226-4824, Mon-Fri 8am-5pm
*ED initiation of buprenorphine (Bup) for patients with opiate use disorder has been shown to increase likelihood patients will continue with addiction treatment.  Bup has been shown to decrease mortality. 
*ED Bridge guidelines encourage a higher loading dose of Bup (up to 32mg) which allows patients time to get into an outside addiction treatment program. 
*Buprenorphine may be ordered during the ED visit by ED providers without an X-waiver.  ED providers without an X-Waiver have may treat a patient up to 72 hours (3 contiguous days) in order to bridge the patient to outpatient treatment.  This means the patient must return to the ED if symptoms reoccur.   ED providers WITHOUT an X-waiver cannot prescribe.
*If patient really wants methadone instead, that also can be started in the ED.  Follow-up will be arranged by our Bridge team as patient must go to a licensed methadone clinic.  PLEASE MAKE SURE WE HAVE A CORRECT PHONE NUMBER
*MOUD Providers all have their X-Waiver and can eprescribe buprenorphine to our pharmacy or to an outside pharmacy
*Bridge program (Viviana and staff) will ensure patient gets follow-up PLEASE MAKE SURE WE HAVE A CORRECT PHONE NUMBER.
*'''OVMC Substance Use Disorder Education and Management Website''' http://myladhs.lacounty.gov/ov/Substance_Use_Disorder_Management/SitePages/Home.aspx
*'''ED Bridge Guide'''      https://static1.squarespace.com/static/5adf7f1fa2772cb4f86018b2/t/5aff30cf758d46c1c95b5a40/1526673619420/ED-BRIDGE+BUP+GUIDE+-+MAY+2018+%282%29.pdf
*'''ED Buprenorphine Initiation Algorithm'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc255df2d46c2731a7b366c/1573017059129/CA+Bridge+-+Protocol+-+Bup+Hospital+Quick+Start+-+NOV+2019.pdf
*'''ED Buprenorphine Initiation for Pregnant Patients Algorithm'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc24f6e67488341e241a1c4/1573015410380/CA+Bridge+-+Protocol+-+Bup+Quick+Start+in+Pregnancy+-+NOV+2019.pdf
*'''ED Buprenorphine Initiation after Overdose'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc31217b305036def2229e9/1573065241235/CA+Bridge+-+Protocol+-+Bup+After+Overdose+-+NOV+2019.pdf
*'''Buprenorphine and Acute Pain in the ED'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dce41a3b351797406dacc19/1573798309226/CA+Bridge+-+Protocol+-+Acute+Pain+and+Bup+-+ED+and+Critical+Care+-+NOV+2019.pdf
*'''Buprenorphine and Acute Pain on the Med/Surg Unit'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dce418a59f2dd43d758b7c6/1573798284017/CA+Bridge+-+Protocol+-+Acute+Pain+and+Bup+-+Med-Surg+-+NOV+2019.pdf
*'''Methadone Quick Start'''
https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc2561cd90490301babf7f5/1573017118257/CA+Bridge+-+Protocol+-+Methadone+Hospital+Quick+Start+-+NOV+2019.pdf
*'''Home Start of Buprenorphine Instructions''' http://myladhs.lacounty.gov/ov/Substance_Use_Disorder_Management/PublishingImages/SitePages/Home/NIH%20Simplified%20Buprenorphine%20Home%20Start.pdf
*'''CA Bridge website''' https://www.bridgetotreatment.org/
*Need help?
*'''California Poison Control 24/7 access to addiction fellow/attending''' for help with difficult cases: 844-326-2626
*'''UCSF Substance Use Warmline''', access to help with difficult cases, Monday-Friday 6am-5pm:  855-300-3595
**'''ED Bridge Office Hours'''  https://ed-bridge.org/office-hours


=== Surgery Admissions===
==Transfers==
*the process is similar to the Medicine admission process with the following exceptions:
===MAC phone number 866-940-4401, press 3 for DHS facility===
**the ''Request for Admit'' order is held until the admitting team evaluates the patient in the ED
**the ED resident places the the Request for Admit order once the admitting information is confirmed with the surgery team
**Note: the surgery team should NOT place Admission orders in ORCHID until the Request for Admit is placed and the patient’s location has been updated to an ED Boarder otherwise orders may have to be re-written when the patient goes upstairs


===ED Holding Orders===
===Higher Level of Care Transfers===
*if the inpatient team has already accepted a patient, but there is an unavoidable delay (> 2 hrs.) in placing admission orders, the ED Team can initiate the ''ED Holding Orders'' Order Set for the inpatient setting to either facilitate boarding care in the ED or to facilitate transportation to an available bed upstairs. Make certain the inpatient team is contacted so they are aware ED Holding Orders have been initiated and that the patient may go upstairs.
*Patients who require services that OVMC does not offer may need to be transferred out (e.g. neurosurgery, some emergent orthopedic cases). 
*as with all admissions, do not place ED Holding Orders unless the patient has already entered ED Boarding status (see Med Admissions above).
*For OOP patients who are clinically stable, every attempt should be made to transfer the patient to their health plan.
*For uninsured or DHS-empaneled patients, transfer will occur through the MAC.
*Transfers from the ED via the MAC fall into two categories. This is based on existing DHS policy:
**(1) '''Emergent/Urgent''' e.g. intubated intracranial bleed. MAC will ask minimal questions in order to get transportation to OVMC as quickly as possible.  CMO on-call (ask Operator)should be notified regarding emergent transfer. Emergent/Urgent patients cannot be refused by Harbor or USC and may end up being transferred to their ED if no inpatient beds are available.  Emergent/Urgent transfers should be used on a rare basis for those patients who need to move RIGHT NOW aka emergently. 
**(2) '''Non-Urgent''' e.g. open tib/fib fracture or hip fracture. MAC will ask more detailed questions. Patients will be presented to appropriate service at USC or Harbor. Transportation will be arranged after patient has been accepted.
**Remember both USC and Harbor have DHS Cerner and have access to our ED records and imaging
**MAC will '''NOT''' transfer to private hospitals such as transfer of neuro patient to UCLA for intracerebral thrombolysis (exception burn cases) or pediatric patient who is followed by UCLA sub specialist at the OVMC clinics. Transportation of those patients must be arranged by the private hospital or OVMC UR.


===Observation Patients===
===BLS vs ALS vs Critical Care vs Helicopters===
*the observation unit is used for patients who require additional care after the ED but less than 24 hours of hospital care. The decision to place a patient in the OBS unit should be made in conjunction with the ED Attending and Hospitalist
*BLS is staffed by EMTs, limited abilities, can administer oxygen;  cannot push meds and cannot have any hanging IV drips
*observation patients do not require Interqual
*ALS is staffed by paramedics, can take intubated patients, CANNOT take patients with ANY type of IV drip (no heparin, mannitol, norepi, etc) even if those drips are not titratable. Drips must be shut off. ALS ''IS ABLE'' take maintenance IV with max of KCl 20meq/L.  ETA variable.
*once the patient has been accepted by the Hospitalist for OBS status, order ''Place in Observation'' from the ED Quick Order page (top other section)
*Critical care is staffed by paramedics plus Critical Care RN and/or MD, can take intubated patients with IV drips.  Often ETA of critical care team arrival 4-5 hours away. 
*patients should NEVER be placed in OBS status after a Request for Admit has been ordered
*Helicopter is staffed by paramedics +/- critical care RN, can take intubated patients with IV drips.  Dependent upon weather.  ETA variable. 
*For critically ill or injured patients on a drip that cannot be turned off, if critical care team's ETA is too long, consider sending OVMC ED RN, MD and/or RT as needed in ambulance.  Arrange head of time for same ambulance to bring staff back to OVMC.


===Consultation & Auto Paging===
===Pediatrics===
Consults - No Auto Paging OVMC
*The Pediatric attending on-call should be made aware of any higher level of care transfer out
*consult initiation time can easily be documented by placing the consult order from the ''Other'' Pane on the lower right side of the ''Adult ED Quick Orders'' page.
*For OOP pediatric patients, UR should attempt to transfer the patient to the hospital requested by the health plan
*once the Consult order is signed, a marker is placed on the Events tab. Hovering over this marker will show the duration since the consult was first placed. When the consult is complete, this can be documented by right- clicking over the active order and completing the consult. Once complete it will be removed from the Tracking List.
*For uninsured patients, not currently followed by a pediatric sub-specialist, attempts should be made to transfer to USC or Harbor via the MAC
Consults - Auto Paging OVMC
*Patients followed by UCLA Pediatric subspecialties at OVMC may be transferred to UCLA if accepted by UCLA Pediatrics or subspecialist.
*a selected number of consults also page the provider automatically when the consult is placed. In these Orders, the ''Call Back Phone Number'' is the only required field. The provider receiving the page will NOT see any instructions included in the Special Instructions on their pager but these instructions can still be reviewed on the Review Orders pane.
**OVMC Pediatric resident will contact UCLA inpatient staff or subspecialty service about transfer with approval by the Pediatric attending on-call
*clear pages from the list using the ''red X'' Icon under ''Task''
**Once accepted, transportation will depend upon the type of transfer:  PICU transfers may transported by the UCLA Transport team;  Ward transfers to UCLA will need to have transportation arranged by OVMC ED UR staff.  
*Note: DO NOT click on the close window button to close the ED Paging error will result. Instead use the ''Minimize'' window Icon.
**MAC WILL NOT ARRANGE TRANSPORTATION TO UCLA
===ECGs===
Triage ECGs
*nurse will bring paper Triage ECG to the Attending for review
*ED attending will verbally tell the nurse what to do (STEMI, BRING BACK, or TRIAGE)
*paper EKG stays with Attending as a reminder to document their read in FirstNet ECG Viewing/Documentation
*on the FirstNet track, under the ECG column, double click on the completed EKG ICON
*in the ECG Review Pane, free text either the Triage ECG read (i.e. STEMI, BRING BACK, or TRIAGE), or a more comprehensive read (follow up ECGs)
*save the ED read by selecting “ED Review & Close” into the window then hit ED Review and Close.
*the EKG Icon will now have a checkbox on it
*once EKGs are visible in Cerner and have a ''ED preliminary read'' documented, they can be shredded


Viewing Prior ECGs
===Surgical and surgical subspecialties===
*all ECGs from the current FirstNet encounter are accessible directly from the ECG column
*For all surgical and surgical subspecialties being transferred out for "higher level of care", please contact the Attending of that service prior to transfer out.  ED Attending should speak to Surgical Attending to ensure we do not have the ability to care for the patient here at OVMC
*ECGs from previous ORCHID encounters are available in the ''Flowsheet'' tab under the the ''Cardiology View'' and ''Cardiovascular CV'' Filters
*ECG archives prior to ORCHID are accessible in Tracemaster using the patient’s legacy Affinity MRN. It can be accessed either through Wellsoft or Clinical Workstation.


===Entering ED Provider Radiology Wet Reads===
===Neurosurgery===
*from the Tracking List, ''right-click'' on the ''Rad'' column of any completed imaging order and the Order Info window will open. Click the blue ''+Add'' button to display the ''Wet Read'' window.
*See Neurosurgery
*select ''Positive'' or ''Negative'' and free text your wet read then enter ''OK''
*a red exclamation icon indicates a wet read has already been entered. Click the exclamation mark to view or add another wet read
*wet reads may also be entered from the ''Radiology Results'' section of a Power Note by using the ''Launch Wet Read'' button.


===Medical Students in FirstNet===
==Utilization Review (Utilization Management)==
Documentation
*x74890
*refer to the Documentation section for detailed documentation instructions.
*Outpatient Service Coordinator OPSC can help with urgent follow-up to primary care for OOP patients (see above Follow-Up...Out of Plan OOP)
*initiate and save a note (without signing) early during a patient encounter after taking a history and performing your exam. Next, present to the Attending physician.
*update your note with any follow up including medical decision making, lab/imaging results, and/or patient updates.
*once your note is finalized, hit ''Sign''. A window will pop to “Request Endorsement” of your supervising attending to endorse your note. This request will show up in their Message Center.
*Attendings: medical student notes forwarded to you will show up in your Message Center in a preliminary status. Once reviewed, a brief note documenting supervision should be added, then the note should be signed.
*students who leave the ED must sign out all their patients to either an NP or resident after reviewing the overall plan with their supervising attending.  


Order Entry
==ED Ultrasound==
*after discussing with the Attending, enter proposed orders into ORCHID. '''Medical students cannot use Quick Orders.'''
===Link to OVMC Ultrasound website===
*access the Modular Order Entry Window by going to the Menu pane and select ''+Add'' from the ''Review Orders'' band.
*http://www.uclaemultrasound.org
*enter the name of the Attending you will be proposing orders to for co- signature.
===Transvaginal Ultrasound===
*search for orders individually and enter all required details
*these orders will be forwarded to the attending once you sign them but they won’t become active until co-signed by the Attending. To speed up turn around time, remind the attending verbally that orders are in their Message Center and ready for co-signature.


===Order Entry===
==ED Supplies and Equipment==
Quick Orders
===Tutorial Videos===
*from the Tracking Board choose a patient then select ''Place Orders'' to go to the ''Quick Orders'' page
* Compass® disposable Pressure Monitor for Lumbar punctures https://www.youtube.com/watch?v=Fzcd7ef7N3U
*orders can be added to the green ‘Shopping Cart’ by selecting them off your menu of choice or via the search line in the ''New Order Entry'' widget
* Compass® disposable Pressure Monitor for Central Venous Pressure (CVP):  https://www.youtube.com/watch?v=1zLpLXY5W6E
• once order selection is completed, click on the green shopping cart to ''sign'', save, modify, or cancel all of the selected orders. If additional required details are required you will be prompted to enter them
* Compass® disposable Pressure Monitor for Compartment Pressures:  https://vimeo.com/117488817
• orders can also be entered using the ''Modular Order Entry Window'' which is accessed by hitting ''+Add'' from the ''Review Orders'' menu pane


Required Order Fields
===Clerk ED1A Cabinet===
*many orders in ORCHID cannot be signed without filling out required fields. During order selection on the order pane, required fields are indicated by a blue circle icon with an “X”. Within order details, required fields are indicated with a yellow background, bold-face lettering, or an asterisk
*Alligator Forceps
*use the ''Missed Required Details'' button to rapidly cycle through a long list of orders with required details
*Bolt Cutter
*alternately, multiple orders can be selected together (SHIFT-select) or (CTRL-select) and common fields shared among them can be addressed more easily
*Doppler
*Dremel
*EZ-IO
*Hair Remover
*Panoptic
*Ring Cutter  https://www.youtube.com/watch?v=VGE8oYtyR6k&feature=youtu.be
*Rongeur
*Stryker  https://wikem.org/wiki/Compartment_pressure_measurement
*Tonopen
''*MUST LEAVE BADGE FOR ANY EQUIPMENT REMOVED FROM CLERK CABINET''


Copying Orders
===ED1A MD Room===
*if you would like to repeat an order, right-click on an active order and select '''Copy'''. It will be available for you to sign again.
*Ultrasound Supplies
**Gel
**Probe covers
*Angiocaths 3inch
*Headlamp


Discontinuing Orders
===Airway Cart in PR Room===
*to discontinue any order, ''right-click'' on the active order and select ''Cancel/Discontinue''. Note: Don’t forget to sign after you discontinue an order!
*CO2 detectors, ETT
*CO2 detectors, nasal
*Nasal Atomizers
*Trach Atomizers
*Endotracheal Tubes
*LMAs


===Lab Orders===
===Room 31===
Collection Priorities
*Upper Cabinet
*''Add'' – to add another test to a sample that is already in the lab. Prior to ordering a test with the ''Add'' priority, you must first verbally confirm with the lab that they can run this test with an existing sample.
**Nosebleed Trays
*''Stat'' – all ED labs
**Lollicaine Lollipops (lidocaine lollipops)
*''Timed Stat'' – used when the same ''STAT'' test is ordered and a ''Frequency'' id included (i.e. Troponin q6h). Enter a duration (i.e. 3 times) so that the order will not continue indefinitely. If a Frequency is added to a Stat priority ORCHID will automatically change the Collection Priority to Timed Stat
**Ophtho Micoscope
 
**Cable for Xenon lamp
Nurse Collect:
**Magnifying Headlamp
*“No”: most ED labs should be ordered as Nurse Collect “No.” The lab order is tasked directly to the phlebotomist. Nurses can intercept the order and draw it themselves if desired.
*ENT Cart
*“Yes”: the lab order is specifically tasked to the bedside nurse. If the phlebotomist is available, the nurse can call phlebotomy to perform the draw.
**OPHTHO
*Note: lab orders should never need to be re-ordered simply due to the incorrect selection of the Nurse Collect field.
***pH paper taped to pH folder on top of cart
**OROPHARYNGEAL
**NASAL
***Nasal compression device for nose bleeds
***Nasal speculum
***Merocel
***Surgicel 2" x 3"
***Silver nitrate sticks
***Rhino Rocket Slimline - small, medium, large
***Rapid Rhino 5.5cm Rapid Pac
***Rapid Rhino 7.5cm Ant/Posterior with Airway
***Vaseline Petroleum Gauze Strip 1" x 36"
***Denver Nasal Splint
**Wood's Lamp bottom drawer


===Order Sets===
===Suture Cart===
Order Sets
 
*Order Sets are individual orders grouped together to simplify order entry for common indications or procedures. Commonly used Order Sets for the ED can be found on the Quick Orders page, under the ''Order Sets'' widget. One may also search for Order Sets using the prefix “ED” on any Order search field.
===Ortho Cart===
*all Order Sets are designated by a yellow Icon with multiple geometric shapes. They are designed with some individual orders being pre-selected, however each included order can be selected, modified (right-click) or un-selected prior to order signature


Adding Orders from an Order Set already Initiated
===Gyn Cart===
*Searching/launching an Order Set repeatedly is usually not necessary. If you need to go back into an active Order Set and add or modify something, you can do so without having to reorder the entire Order Set. Go to the ''Review
Orders'' menu, highlight the Order Set under the ''Plans'' section of the ''Order View'' pane, then click the light bulb icon called “View Excluded
Components.” Orders already active will show up indented and checked, and all unordered components will have empty boxes. Select the orders you would like to add or discontinue then sign.


Discontinuing Order Sets
===Central Line Cart in ED 1A/B hallway===
*to discontinue an Order Set, find the active Order Set in the ''Order View'' pane and then right-click to select ''Discontinue''.
*you will be given the option of choosing which orders to ''Keep active'' even though the rest of the Order Set is being discontinued.
*Note: Don’t forget to sign after you discontinue an Order Set!


===Order Favorites===
===Orthopedic supplies in Room 43===
Order Favorites
*Soft collars, slings, wrist guards, CAM walkers, hard shoes
*''right-click'' on any order before signature and select ''Add to Favorites''
*Abdominal binders
*Hernia truss


===Lab Results===
===Crutches, Walkers, Wheelchairs===
*hover over the lab column to rapidly view what lab tests have been ordered. The ''Lab Indicator'' column on the track shows how many labs have been ordered and how many labs are resulted. ''Double-click'' on the Lab Indicator to see a detailed view (Quick View) of lab results. To see full lab results in details click on the ''Vitals/Nursing/Results'' pane
*Located in ED1A/B Clean Utility Room


===Imaging Results===
===Bronchoscope===
*hover over the lab column to rapidly view what lab tests have been ordered. The ''Rad Indicator'' column on the track shows how many imaging tests have been ordered, how many have images available, and how many images have a preliminary read in ORCHID.
*Located in storage room near Triage 4. Disposable scopes in cabinet in same room.
*''double-click'' on the ''Rad Indicator'' to open the ''Quick Flowsheet Radiology'' tab.
*click on the ''Result'' box to open up the ''Document Viewer'' to view the read if available.
*viewing Images: within the Document Viewer, click on the image icon to open a link to Synapse and view the image from within ORCHID. You may have to enter your login credentials to open Synapse.


===Discharge & Follow Up===
===Glidescope===
Discharge Process
*Located in PR Room - pediatric and adult batons available
*select patient from the Tracking List then hit the Admit/Discharge button
*Disposable blades located in Glidescope basket
*open each pane by clicking on the pencil
*Extra blades located in cabinets in PR Room
*fill out the required and optional fields as needed. The Check Marks will help keep track of your progress.
*Wipe down batons after each use
*Diagnosis, Prescriptions, Med Reconciliation
 
*Patient Education - education handouts and Work Excuse notes
===Unusual Supplies===
*Follow Up Date - to communicate follow up with your patient. Note: This does NOT result in actually scheduling appointments!
*Gastrostomy Tubes - ED 1A MD Room "S**T HAPPENS" Cabinet
*ED Post Visit Plan - TFU/CCC referrals (see below)
*Nephrostomy tubing and bags - try OR
*ED NERF - new NERF referrals (see below)
*Whitacre Spinal Needles - LP Cart
*Note: DO NOT SELECT THE DISCHARGE PANE! This is how the nurse removes the patient from the Tracking List.
*Merlin Pacemaker Interrogator - ED 1A Cabinet
* This device interrogates pacers and ICDs made by '''St. Jude or Abbott'''.  The detailed instructions are printed and posted inside of the cabinet door and included below.  It requires cellular data transmission. First interrogate the patient's device at the bedside, then move the unit to the ambulance bay and plug it in there so it can transmit.  The report is subsequently faxed to the ED1 nursing station and is also transmitted to the device reps and our cardiology service.  The device reps are on call for assistance as needed, or you can call Scott Lundberg to try and help.
 
==Disaster Preparedness==
*Olive View-UCLA has a robust plan for a number of possible disasters such as earthquakes. All OVMC faculty and residents should review the materials on the hospital homepage under “Disaster Management.” The link is in the center of the screen.  For staff in the ED at the time of a disaster, the important information is as follows.
**1. The ANO (Acting Nursing Officer) is designated as the incident commander and is in the hospital 24/7.
**2. The ANO will set up a command post in Hospital Administration and will contact the charge nurses in each department.
**3. The initial priority is a head count of all staff, and a report on the physical condition of the department.
**4. A physician in the hospital will be designated as a medical officer in the incident command center. At night, this may be OB or Anesthesia as they are also in house and we will be responsible for managing the ED.
**5. All requests for materials, staff, and questions go though the incident command in medical administration.
**6. The ED charge nurse is aware of the location of extra supplies and the hospital wide disaster management plan. 
*Olive View-UCLA has over one week of food, water and medical supplies for an anticipated disaster. There are specific incident commanders and disaster professionals who will be responding, and the emergency physicians on site are not expected to lead the disaster response.


Follow Up
==Downtime Protocols==
Downtime Documentation
*H&P will be documented on paper using DEM Physician Record (OV1901). Resident and Attending signatures are required.
*MSE - when performed by a separate MSE provider, note should be very brief and be written on the upper portion of the History section of  the paper DEM Physician Record (OV1901). It should include a separate header of MSE NOTE and must be signed.
 
Downtime General Orders
*orders should be written on paper using DEM Physician’s Orders (OV1337) and include a date, time, initials, and signature
*orders should be placed in the order bin located at each Nursing Station (ED 1-5, RME) for the Nurse/Clerk to initiate
*clerk has all downtime forms, lab slips and Radiology Request forms.
 
Downtime Radiology Orders
*order imaging on paper and include a complete paper Radiology Order Form (OV2059). Runner will hand deliver request to the appropriate ED radiology area.
*if ORCHID downtime is isolated, iimages and preliminary results will still be available in Synapse even if not viewable in ORCHID
*radiology orders ordered during downtime using the Radiology Request forms do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur).
 
Downtime Laboratory Orders/Workflow
*clerk/nurse will complete paper lab request slips to accompany specimens sent to the lab. The lab slip should include collector's employee number ("e" or "c" number).
*lab labels will not print during downtime. All specimens must be labeled with the following information:
**patient info: patient name, DOB, MRN, FIN
**collector's info: date/time specimen collected, employee number ("e' or "c" number), collectors signature
*lab results will be faxed to the ED at X74298 and hand delivered to the assigned resident or attending for that patient
*POCT orders placed by the providers will be resulted verbally to the ordering provider and also resulted in nursing documentation
*lab will call critical results to the ED
*lab orders ordered during downtime do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur). Results that came back on paper will eventually also be resulted in ORCHID.
 
Downtime Medication Orders
*all medication orders should be written on paper using form OV1337
*patient prescriptions should be written on paper and handed to the patient. A copy of each Rx should be kept in the patient’s paper record. Rxs will be scanned into ORCHID once ORCHID comes back up. Rx’s will not be back entered by the provider into ORCHID after a prolonged downtime.
*when ORCHID is back up, Pharmacy will manually enter all medications that were ordered during downtime
 
Downtime Blood Bank Orders
*enter required orders on paper (T&S, T&C, transfusion, etc)
*paper blood transfusion indication sheet must be filled out for Adults OV1998 or Peds (OV2015)
 
Downtime Specialty Diagnostic Services
*complete paper requisition for Echo, Stress Treadmill/Myocardial Perfusion Imaging, Holter and EEG. Call appropriate department for STAT orders
 
Downtime Admissions
*initiate Interqual request by calling UR directly at X74890.
*discuss with admitting team
*once an admission is accepted by the admitting team, enter ''Request to Admit'' order on paper and include service, level of care, and the name of the admitting attending and resident.
*admissions during downtime will be tracked by Nursing on a paper log
*certain orders such as Bed Requests and Admit Orders will need to be manually re-entered into ORCHID once ORCHID is back up
 
Downtime Discharge
*complete discharge and aftercare instructions using form OV2014 including discharge impression, recommended follow up, and return precuations. Do not use this form for Rx.
*Rx should be written on paper Rx pads. Copies should be left in paper chart to be scanned in later.
*discharge order must be signed on paper
*all discharges from the ED during downtime will be tracked by Nursing on a paper log. A separate provider log will be kept for downtime discharges that require future labs, studies, message pools, e-consults, TFU referrals so that they may be entered into ORCHID during recovery.
 
Downtime Recovery - ORCHID Back Online
*LAB/RAD - results will begin to populate via the interface in ORCHID. Lab and imaging orders previously placed on paper should not neeed to be ordered again.
*documentation – Provider documentation on paper will be scanned into patient chart.
*pharmacy will back-enter enter all medication orders placed on paper during downtime back into ORCHID.
*physicians must re-enter all other paper orders placed during downtime into ORCHID (admission requests, place in obs, isolation, communication, restraints, holds, consults, etc).
 
Downtime Frequent Phone Numbers
*ED Lab (8:30 am - 10:30pm) : 74977
*General Lab: 73476, 74038
*Microbiology: 76041
*Blood Bank: 74062
*Phlebotomy:  74555/74039
*ED Xray Tech: 75496
*ED US Tech: 74940
*ED CT Tech: 74968
*MRI Tech: 73535
*ED Radiologist: 74971
*StatRad Coverage for CT and MRI Overnight and Weekend Reads Only - 858-546-3800, press 1.
*USROC Coverage for Ultrasound Overnight and Weekend Reads OnlyMonday-Friday 11p-7a and Weekends/Holidays 7p-7a 866-448-7762
*ED UR/Interqual: 74890
*Pharmacy: 73070
*ED1A: 74320
*ED1B: 74865 
*ED2A: 74321
*ED2B: 74280
*ED3: 74976
*ED4: 74974
*ED5: 74970
*SuperTrack Provider Room : 74936/74937
*Main Provider Room: 73645
*DEM Administrative Offices: 73107
 
==ORCHID/FirstNet==
 
===Logon===
*logon credentials are the same as your Internet Password
*if you need to reset your password go to the Olive View- UCLA Home Page, under the Links Section (toward the bottom), and choose one of the ''Password and Account Management'' links
*if you still can’t logon, call the Enterprise Help Desk at x74522
 
===CheckIn===
*at the start of a new shift, ORCHID should immediately prompt you to check-in as an available provider.
*in the Provider CheckIn window, select your ''Display Name'', ''Provider Role'' and a ''Default Relation''. Also select the checkboxes for ''Available Provider'' and ''Available Reviewer''.
*if you were already checked-in to see patients on that shift, you will not be prompted to check in again.
*if you need to Check In manually, click on the little icon of the provider with the Check Box.
 
===Patient Sign Up===
*click once on the patient row then click on the ''Assign Provider'' icon. Your Display Name will appear in the appropriate column.
 
===Documentation===
Selecting a Note Template
*click ''Provider Notes'' from the tracking list then ''+Add'' in the ''Provider Notes'' band
*the ''Note Type'' should default to ''ED Note-Provider'' so that notes are filed in the correct folder and can be viewed by UR and the ED Attending once they are saved. If the ''ED Note-Provider'' option is not available, ''right-click'' on the arrow to select from ''All Note Types''.
*using the ''Reason For Visit'' tab select a ''Note Template'' to use either by free text search or by using the structured menu (PNED RFV) then hit select ''OK''. Use the checkboxes to select which elements (if any) you would like to import into your note
*colored notepads on the Tracking Board track the progress of your Provider Note (not started, in progress, or signed) during the patient encounter
Documentation Workflow
*once saved, notes written using the default ED Note-Provider template, can be viewed by both Utilization Management and the ED Attending. Consultants cannot view provider ED documentation until the note is signed.
*once you have completed your provider note, click on ''Sign/Submit'' and a new window will pop up. Select ''Request Endorsement'', then click inside the yellow area under Endorser. Select the ''binoculars'' icon to search for the attending you would like to co-sign your chart. Click OK. Under “Type” make sure that ''sign'' is selected (not reviewed). Then click sign to close the window.
*Attendings: In the ''Message Center'' you can view notes forwarded to you for signature. Choose the ''Correct'' icon to change a note and write an addendum. If you want to write a separate note before the intern/resident has completed their note, use the ''Note'' function (rather than Provider Notes).
*for patients signed out at rounds, the oncoming resident should write a brief note using the ''Notes'' function (not Provider Notes).
Documenting a Re-Evaluation
*below the ''Medical Decision Making'' section of the PowerNote note there is a section to document follow up exams. Choose ''Re-exam/Re-eval'' and enter a ''time'' before entering details of the follow up exam
* ''right-clicking'' over the ''Re-exam/Re-eval'' header and selecting repeat allows you to document repeated re-evaluations
 
===Getting Rid of Spellcheck===
*Open a patient's chart and start a note
*Click View at the top.....then Customize.....then More......unclick Run Spelling check....click OK
 
===Unable to place Diagnosis?===
*Usually because HLI: Physician Friendly Term box has not been checked
*Step 1:  Type in desired diagnosis and click Binoculars
*Step 2:  Click the 3 dots just to the right of "Terminology"
*Step 3:  Check the box HLI: Physician Friendly Term
*Step 4:  You may have to close the Diagnosis box and re-enter the diagnosis
 
=== Procedure Consent with iMedConsent ===
*iMedConsent is now accessed directly through Cerner from within a patient's chart. There is an iMedConsent tab available under the Table of Contents Menu (Table of Contents are the grey tabs on the left hand side of the mPage underneath the "ED Summary"). Users no longer have to manually enter patient identifiers to search for a patient. There is no longer a need to maintain a separate username and password for iMedConsent.
*select the appropriate procedure/s that you would like to print for the patient
*have the patient read, consent, and wet sign the printed procedure consent form
*place a copy of the wet signed consent in the patient's paper chart. The Health Information Management (HIM) team will scan the consent form into ORCHID after the patient is discharged.
 
===Procedure Documentation (ad hoc forms)===
*''AdHoc Forms'' are used for specific template driven documentation in the ED. This includes documentation of all ED Procedures. AdHoc forms can be found using the ''AdHoc'' link on the ORCHID Menubar,
then finding the ED Forms Folder.
*template AdHoc forms include documentation for ED Procedures, ED Bedside Ultrasounds, Central Line (CLIP) documentation, and the NIH Stroke Scale.
*once completed, these AdHoc forms are signed using the ''Check Mark'' on the Upper Left corner of the screen.
 
===Medicine Admissions===
1) ''Interqual Request Order'' - found on the Quick Orders page under the ''Top Other'' section. A diagnosis is required.
*DHS uses Interqual Criteria for Utilization Review (UR). All admissions must be reviewed by UR. The Interqual decision is facilitated by having a note in the chart for UR to review. UR can view ED resident notes as long as they have been saved.
*the Interqual Request is found under the Events tab and the Request Events sub-tab.
*the Interqual review process is tracked with ICONs under the ADT column
**REQ - Requested
**IP - In Progress
**MET - Criteria Met the
2) Contact the admitting team via ''Amion'' to give report
*contact the admitting Hospitalist or Resident. Use auto-paging (see below) to help track the time the admitting service is first paged. Confirm with the Hospitalist the name of the receiving Attending, Resident, Service, and Level of Care
3) Enter the ''Request for Admit''. Enter the admitting resident name in the Special Instructions field. Medicine teams will drop Admission orders in the chart within 2 hours from the time the Request for Admit order is placed.
*Note: Admission orders should NOT be placed on any patient until Bed Control updates their location status to ED Boarders. ED Boarders are easily identifiedin the location field on the Banner Bar and by a slash in the Bed
column on the FirstNet track. If inpatient orders are dropped on a patient before they are changed to an ED Boarder they will have to be re-entered by the Admitting team.
*the ''Hospital'' Icon indicates that the inpatient team has placed Admitting Orders in ORCHID. The Medicine team assumes all responsibility for patient care once Admission orders are placed. Routing questions from Nursing regarding further medical care should be directed to the inpatient provider.
 
===Changes in Service or Level of Care after Initial Admission===
*if you need to upgrade/downgrade an ED Boarder after the initial Request for Admit has been submitted, you need to order ''Request for Admit'' again (not Transfer). This is the only way bed control will get the message that a change has been requested. DEM providers will do this if they are still following the patient, however once Admission Orders are written (Hospital Icon), the Admitting Service will re-order the Request for Admit if any upgrade/downgrade must occur.
*if the post-admission upgrade/downgrade results in the patient going to a different team, the Inpatient team must notify and give report to the new team since these patients are no longer being followed by the ED.
 
=== Surgery Admissions===
*the process is similar to the Medicine admission process with the following exceptions:
**the ''Request for Admit'' order is held until the admitting team evaluates the patient in the ED
**the ED resident places the the Request for Admit order once the admitting information is confirmed with the surgery team
**Note: the surgery team should NOT place Admission orders in ORCHID until the Request for Admit is placed and the patient’s location has been updated to an ED Boarder otherwise orders may have to be re-written when the patient goes upstairs
 
===ED Holding Orders===
*if the inpatient team has already accepted a patient, but there is an unavoidable delay (> 2 hrs.) in placing admission orders, the ED Team can initiate the ''ED Holding Orders'' Order Set for the inpatient setting to either facilitate boarding care in the ED or to facilitate transportation to an available bed upstairs. Make certain the inpatient team is contacted so they are aware ED Holding Orders have been initiated and that the patient may go upstairs.
*as with all admissions, do not place ED Holding Orders unless the patient has already entered ED Boarding status (see Med Admissions above).
 
===Observation Patients===
*the observation unit is used for patients who require additional care after the ED but less than 24 hours of hospital care. The decision to place a patient in the OBS unit should be made in conjunction with the ED Attending and Hospitalist
*observation patients do not require Interqual
*once the patient has been accepted by the Hospitalist for OBS status, order ''Place in Observation'' from the ED Quick Order page (top other section)
*patients should NEVER be placed in OBS status after a Request for Admit has been ordered
 
===Consultation & Auto Paging===
Consults - No Auto Paging OVMC
*consult initiation time can easily be documented by placing the consult order from the ''Other'' Pane on the lower right side of the ''Adult ED Quick Orders'' page.
*once the Consult order is signed, a marker is placed on the Events tab. Hovering over this marker will show the duration since the consult was first placed. When the consult is complete, this can be documented by right- clicking over the active order and completing the consult. Once complete it will be removed from the Tracking List.
Consults - Auto Paging OVMC
*a selected number of consults also page the provider automatically when the consult is placed. In these Orders, the ''Call Back Phone Number'' is the only required field. The provider receiving the page will NOT see any instructions included in the Special Instructions on their pager but these instructions can still be reviewed on the Review Orders pane.
*clear pages from the list using the ''red X'' Icon under ''Task''
*Note: DO NOT click on the close window button to close the ED Paging error will result. Instead use the ''Minimize'' window Icon.
===ECGs===
Triage ECGs
*nurse will bring paper Triage ECG to the Attending for review
*ED attending will verbally tell the nurse what to do (STEMI, BRING BACK, or TRIAGE)
*paper EKG stays with Attending as a reminder to document their read in FirstNet ECG Viewing/Documentation
*on the FirstNet track, under the ECG column, double click on the completed EKG ICON
*in the ECG Review Pane, free text either the Triage ECG read (i.e. STEMI, BRING BACK, or TRIAGE), or a more comprehensive read (follow up ECGs)
*save the ED read by selecting “ED Review & Close” into the window then hit ED Review and Close.
*the EKG Icon will now have a checkbox on it
*once EKGs are visible in Cerner and have a ''ED preliminary read'' documented, they can be shredded
 
Viewing Prior ECGs
*all ECGs from the current FirstNet encounter are accessible directly from the ECG column
*ECGs from previous ORCHID encounters are available in the ''Flowsheet'' tab under the the ''Cardiology View'' and ''Cardiovascular CV'' Filters
*ECG archives prior to ORCHID are accessible in Tracemaster using the patient’s legacy Affinity MRN. It can be accessed either through Wellsoft or Clinical Workstation.
 
===Entering ED Provider Radiology Wet Reads===
*from the Tracking List, ''right-click'' on the ''Rad'' column of any completed imaging order and the Order Info window will open. Click the blue ''+Add'' button to display the ''Wet Read'' window.
*select ''Positive'' or ''Negative'' and free text your wet read then enter ''OK''
*a red exclamation icon indicates a wet read has already been entered. Click the exclamation mark to view or add another wet read
*wet reads may also be entered from the ''Radiology Results'' section of a Power Note by using the ''Launch Wet Read'' button.
 
===Medical Students in FirstNet===
Documentation
*refer to the Documentation section for detailed documentation instructions.
*initiate and save a note (without signing) early during a patient encounter after taking a history and performing your exam. Next, present to the Attending physician.
*update your note with any follow up including medical decision making, lab/imaging results, and/or patient updates.
*once your note is finalized, hit ''Sign''. A window will pop to “Request Endorsement” of your supervising attending to endorse your note. This request will show up in their Message Center.
*Attendings: medical student notes forwarded to you will show up in your Message Center in a preliminary status. Once reviewed, a brief note documenting supervision should be added, then the note should be signed.
*students who leave the ED must sign out all their patients to either an NP or resident after reviewing the overall plan with their supervising attending.
 
Order Entry
*after discussing with the Attending, enter proposed orders into ORCHID. '''Medical students cannot use Quick Orders.'''
*access the Modular Order Entry Window by going to the Menu pane and select ''+Add'' from the ''Review Orders'' band.
*enter the name of the Attending you will be proposing orders to for co- signature.
*search for orders individually and enter all required details
*these orders will be forwarded to the attending once you sign them but they won’t become active until co-signed by the Attending. To speed up turn around time, remind the attending verbally that orders are in their Message Center and ready for co-signature.
 
===Order Entry===
Quick Orders
*from the Tracking Board choose a patient then select ''Place Orders'' to go to the ''Quick Orders'' page
*orders can be added to the green ‘Shopping Cart’ by selecting them off your menu of choice or via the search line in the ''New Order Entry'' widget
• once order selection is completed, click on the green shopping cart to ''sign'', save, modify, or cancel all of the selected orders. If additional required details are required you will be prompted to enter them
• orders can also be entered using the ''Modular Order Entry Window'' which is accessed by hitting ''+Add'' from the ''Review Orders'' menu pane
 
Required Order Fields
*many orders in ORCHID cannot be signed without filling out required fields. During order selection on the order pane, required fields are indicated by a blue circle icon with an “X”. Within order details, required fields are indicated with a yellow background, bold-face lettering, or an asterisk
*use the ''Missed Required Details'' button to rapidly cycle through a long list of orders with required details
*alternately, multiple orders can be selected together (SHIFT-select) or (CTRL-select) and common fields shared among them can be addressed more easily
 
Copying Orders
*if you would like to repeat an order, right-click on an active order and select '''Copy'''. It will be available for you to sign again.
 
Discontinuing Orders
*to discontinue any order, ''right-click'' on the active order and select ''Cancel/Discontinue''. Note: Don’t forget to sign after you discontinue an order!
 
===Lab Orders===
Collection Priorities
*''Add'' – to add another test to a sample that is already in the lab. Prior to ordering a test with the ''Add'' priority, you must first verbally confirm with the lab that they can run this test with an existing sample.
*''Stat'' – all ED labs
*''Timed Stat'' – used when the same ''STAT'' test is ordered and a ''Frequency'' id included (i.e. Troponin q6h). Enter a duration (i.e. 3 times) so that the order will not continue indefinitely. If a Frequency is added to a Stat priority ORCHID will automatically change the Collection Priority to Timed Stat
 
Nurse Collect:
*“No”: most ED labs should be ordered as Nurse Collect “No.” The lab order is tasked directly to the phlebotomist. Nurses can intercept the order and draw it themselves if desired.
*“Yes”: the lab order is specifically tasked to the bedside nurse. If the phlebotomist is available, the nurse can call phlebotomy to perform the draw.
*Note: lab orders should never need to be re-ordered simply due to the incorrect selection of the Nurse Collect field.
 
===Order Sets===
Order Sets
*Order Sets are individual orders grouped together to simplify order entry for common indications or procedures. Commonly used Order Sets for the ED can be found on the Quick Orders page, under the ''Order Sets'' widget. One may also search for Order Sets using the prefix “ED” on any Order search field.
*all Order Sets are designated by a yellow Icon with multiple geometric shapes. They are designed with some individual orders being pre-selected, however each included order can be selected, modified (right-click) or un-selected prior to order signature
 
Adding Orders from an Order Set already Initiated
*Searching/launching an Order Set repeatedly is usually not necessary. If you need to go back into an active Order Set and add or modify something, you can do so without having to reorder the entire Order Set. Go to the ''Review
Orders'' menu, highlight the Order Set under the ''Plans'' section of the ''Order View'' pane, then click the light bulb icon called “View Excluded
Components.” Orders already active will show up indented and checked, and all unordered components will have empty boxes. Select the orders you would like to add or discontinue then sign.
 
Discontinuing Order Sets
*to discontinue an Order Set, find the active Order Set in the ''Order View'' pane and then right-click to select ''Discontinue''.
*you will be given the option of choosing which orders to ''Keep active'' even though the rest of the Order Set is being discontinued.
*Note: Don’t forget to sign after you discontinue an Order Set!
 
===Order Favorites===
Order Favorites
*''right-click'' on any order before signature and select ''Add to Favorites''
 
===Lab Results===
*hover over the lab column to rapidly view what lab tests have been ordered. The ''Lab Indicator'' column on the track shows how many labs have been ordered and how many labs are resulted. ''Double-click'' on the Lab Indicator to see a detailed view (Quick View) of lab results. To see full lab results in details click on the ''Vitals/Nursing/Results'' pane
 
===Imaging Results===
*hover over the lab column to rapidly view what lab tests have been ordered. The ''Rad Indicator'' column on the track shows how many imaging tests have been ordered, how many have images available, and how many images have a preliminary read in ORCHID.
*''double-click'' on the ''Rad Indicator'' to open the ''Quick Flowsheet Radiology'' tab.
*click on the ''Result'' box to open up the ''Document Viewer'' to view the read if available.
*viewing Images: within the Document Viewer, click on the image icon to open a link to Synapse and view the image from within ORCHID. You may have to enter your login credentials to open Synapse.
 
===Discharge & Follow Up===
Discharge Process
*select patient from the Tracking List then hit the Admit/Discharge button
*open each pane by clicking on the pencil
*fill out the required and optional fields as needed. The Check Marks will help keep track of your progress.
*Diagnosis, Prescriptions, Med Reconciliation
*Patient Education - education handouts and Work Excuse notes
*Follow Up Date - to communicate follow up with your patient. Note: This does NOT result in actually scheduling appointments!
*ED Post Visit Plan - TFU/CCC referrals (see below)
*ED NERF - new NERF referrals (see below)
*Note: DO NOT SELECT THE DISCHARGE PANE! This is how the nurse removes the patient from the Tracking List.
 
Follow Up
*once fully registered, patients who cannot follow up at Olive View should have an Outside Of Plan Icon in their Events column. These patients should be referred elsewhere.
*once fully registered, patients who cannot follow up at Olive View should have an Outside Of Plan Icon in their Events column. These patients should be referred elsewhere.


Message Pools
Message Pools
*only for Urgent Appointment requests to selected clinics, that need to be seen within 2 wks. Many of these clinics previously used the “wallbox" referral system.
*only for Urgent Appointment requests to selected clinics, that need to be seen within 2 wks. Many of these clinics previously used the “wallbox" referral system.
*select a patient on the Tracking List then select Communicate - > Message. Patient Name should Autofill.
*select a patient on the Tracking List then select Communicate - > Message. Patient Name should Autofill.
*TO: Binoculars Icon, Pool filter, search for the correct Message Pool (see list), Add to Send to list, hit OK.
*TO: Binoculars Icon, Pool filter, search for the correct Message Pool (see list), Add to Send to list, hit OK.
*Subject: choose OVM ED/Urgent Care Appt Request from the menu
*Subject: choose OVM ED/Urgent Care Appt Request from the menu
*fill out template, check Patient Needs Appointment box, and Send
*fill out template, check Patient Needs Appointment box, and Send
 
 
TFU/CCC Clinics
TFU/CCC Clinics
*part of the Depart Process. Open the ED Post Visit Plan band and Route to either the Telephone Follow Up Clinic (ED-TFU-OVM) or the Continuity Clinic (ED-CCC- OVM). Specify need for referral and Contact Phone number
*part of the Depart Process. Open the ED Post Visit Plan band and Route to either the Telephone Follow Up Clinic (ED-TFU-OVM) or the Continuity Clinic (ED-CCC- OVM). Specify need for referral and Contact Phone number
*Click on the Check Mark at the Upper left to close this window.
*Click on the Check Mark at the Upper left to close this window.
 
eConsult
*the eConsult referral system should be used for non-urgent outpatient referrals that can wait more than 2 weeks to be processed. eConsults should be entered by the Attending Physician using the eConsult link on the ORCHID menu bar.
 
ED NERF
*patients new to the county that qualify for outpatient primary care (no OOP Icon) can be referred to primary care using the ED NERF tab. Choose as many diagnoses that apply then click on the Check
*Mark at the Upper Left of the referral window.
 
Ordering Outpatient Studies (Future Orders)
*once a patient is sent home from the ED, all pending orders are automatically cancelled unless they are entered as Future Orders. Any labs, tests, or referrals to be completed after ED discharge should be entered as Orders for Future Visit. This includes all outpatient imaging and cardiology tests.
*Physical Therapy: outpatient PT should be ordered using Physical Therapy Evaluation and Treatment Outpatient as a future order.
*Outpatient FNA: outpatient FNAs should be processed as an eConsult by the Attending Physician. The eConsult destination specialty is Pathology - Fine Needle Aspiration. Patients can then show up directly to the lab during regular business hours.
 
== Patient Portal (LA Health Portal) / Giving Medical Records to Patients ==
<gallery>
LA Health Portal.png
Portal QR Code.png|LA Health Portal QR
 
</gallery>
The LADHS Health Portal is an extremely important resource to give our ED patients so they may access their own medical records. This includes labs, imaging, provider notes, and ED discharge instructions. This is the best way to give our "OOP" patients access to records they need to share with outside providers. Patients can access the LA Health Portal via the web or by using the LA Health Portal smartphone app (iOs and Android App Stores).
 
====Enroll Patient in Portal====
See widely distributed recruitment fliers in ED with QR code for patient smartphones. Best workflow is for patient's to use their own smartphones. All the patient needs to enroll is their name, birthdate, and medical record number (preferred) to confirm who they are. An email or text phone number can also be used to confirm who they are, but only if the email or text number is already in their registration information in ORCHID.
 
Alternately patient can use any WOW to enroll, but will likely need assistance in finding the LADHS Health Portal website.
 
Nursing staff are also encouraging LA Health Portal Enrollment for all of our patients.
 
ED Registration staff can assist if phone numbers or email addresses need to be updated, but neither is required for a new enrollment.
 
During regular business hours, the OVMC Health Tech Navigator, Jennifer Vargas, can also assist with complicated Patient Portal enrollments (reset existing passwords, proxy access, etc). Jennifer Vargas x74546 - jvargas4@dhs.lacounty.gov
 
[https://lacounty.sharepoint.com/sites/DHS-lahealthportal LA Health Portal Sharepoint]
 
==Procedure References==
These links should serve as a reference for safe and proper techniques on how to perform many common (and some uncommon) procedures in the ED. For some procedures there may be both a longer video explaining in-depth details if this is your first time (eg med students and interns) and a shorter video if it's been a while and you just want to brush up.
 
====Basics====
Lumbar Puncture:
*NEJM (10:59)  https://www.nejm.org/doi/full/10.1056/NEJMvcm054952
*Mellick (3:14) https://www.youtube.com/watch?v=grpeEDBMrn8
 
Paracentesis:
*NEJM (9:50) https://www.nejm.org/doi/full/10.1056/NEJMvcm062234
 
====Resuscitation====
IO line Placement
*EMRAP (3:12) https://www.youtube.com/watch?v=KHXSfh2ZRDM
 
US-guided IV Placement
*5 Min Sono (5:52) https://www.youtube.com/watch?v=4Znd21vJPb8
 
Central Venous Catheterization
*NEJM (15:28) https://www.nejm.org/doi/full/10.1056/NEJMvcm055053
 
====ENT====
Facial Nerve Blocks
*Inferior Alveolar Nerve Block: FreeDentalEducation (4:48; procedure at 2:15) https://www.youtube.com/watch?v=kmPqV-dMo98
*Infraorbital Nerve Block: Brian Lin (2:00) https://www.youtube.com/watch?v=3nzXe_NYKlg
*Mental Nerve Block: The Dental Box (1:06) https://www.youtube.com/watch?v=hPALXAq9pTo
 
Nasal Foreign Body Removal
*BVM for Complete Occlusion: Robert Dudas (0:51) https://www.youtube.com/watch?v=PacvHiJFhNA
*Katz Extractor for Partial Occlusion: Larry Mellick (3:22) https://www.youtube.com/watch?v=rQpIOdJrYIc
 
====GI====
Balloon Tamponade
*Minnesota: EMRAP (5:08) https://www.youtube.com/watch?v=4FHIiA_doWU
*Blakemore: EMRAP (4:47) https://www.youtube.com/watch?v=NHelCd5Jtp4
 
====Digits====
Digital Block
*CORE EM (2:34) https://www.youtube.com/watch?v=i51y6t1YRNQ
 
Paronychia
*Brian Lin (3:35) https://www.youtube.com/watch?v=G9CBKoKEvRM
 
Subungual Hematoma Drainage
*EMRAP (1:02) https://www.youtube.com/watch?v=G_7eKSYLfxY
 
Rongeurs
*EMRAP (2:30) https://www.youtube.com/watch?v=zBmsrGzPk40
 
==Links==
*http://www.amion.com
*http://www.emergencymedicine.ucla.edu
*http://www.uclaemultrasound.org
*[http://www.emcrc.com OVMC FirstNet Training Website]
 
==OVMC Pages==
{{Special:Prefixindex/OVMC |hideredirects=1}}


eConsult
*the eConsult referral system should be used for non-urgent outpatient referrals that can wait more than 2 weeks to be processed. eConsults should be entered by the Attending Physician using the eConsult link on the ORCHID menu bar.
ED NERF
*patients new to the county that qualify for outpatient primary care (no OOP Icon) can be referred to primary care using the ED NERF tab. Choose as many diagnoses that apply then click on the Check
*Mark at the Upper Left of the referral window.
Ordering Outpatient Studies (Future Orders)
*once a patient is sent home from the ED, all pending orders are automatically cancelled unless they are entered as Future Orders. Any labs, tests, or referrals to be completed after ED discharge should be entered as Orders for Future Visit. This includes all outpatient imaging and cardiology tests.
*Physical Therapy: outpatient PT should be ordered using Physical Therapy Evaluation and Treatment Outpatient as a future order.
*Outpatient FNA: outpatient FNAs should be processed as an eConsult by the Attending Physician. The eConsult destination specialty is Pathology - Fine Needle Aspiration. Patients can then show up directly to the lab during regular business hours.
==Links==
*http://www.amion.com
*http://www.emergencymedicine.ucla.edu
*http://www.uclaemultrasound.org
*[http://www.emcrc.com OVMC FirstNet Training Website]
[[Category:Admin]]
[[Category:Admin]]

Latest revision as of 20:17, 27 March 2024

WikEM OVMC:ED is meant as a guide to providers working in the ED at Oliveview UCLA Medical Center. It is only a guide. Management of the patient is always at the discretion of the ED provider.

OVMC Observed Procedure Checklist and Evaluation Form

Procedure Checklist and Evaluation Form

OVMC Administration Master Phone List

OVMC Administration Master List

DEM Master Backup Supply List

https://lacounty.sharepoint.com/:x:/r/sites/dhs-ov-nursing/_layouts/15/Doc.aspx?sourcedoc=%7B897E3F6F-0F9F-477F-91D7-7508A46AC03E%7D&file=DEM%20Master%20Supply%20List%2011.2020.xlsx&action=default&mobileredirect=true&cid=098fcb59-1f0b-4860-9c35-cc726dd19469

RSV Bronchiolitis and Other Peds Respiratory Illnesses

Waiting Room

  • HR and Pulse ox will be obtained on all QR kids with respiratory complaints; completed by NA or ICN
  • ED 4 Attending is responsible for monitoring how many Peds patients waiting to be seen; ED 4 Attending will tell ED residents when they need to start picking up patients. RME NP will help be the eyes/ears and let the ED4 Attending know if kids start to back up to ensure ED residents are engaged on seeing them too.

Treatment

  • Suction Snot!!
  • Remember, beta agonists and steroids have not been shown to helpful for kids with bronchiolitis.

Admissions

  • Pediatrics will try to keep more kids here at OVMC on HFNC. Will be evaluated on case by case basis. Will likely want the child to be observed in ED on HFNC to see if they are stabilizing.

Transfers

  • If it's determined a child does need to be transferred:
    • Utilize MAC for dhs-responsible; if MAC is unable to find a bed, UM can assist by calling other hospitals with pediatric monitored/ICU beds.
    • Utilize UM for OOP patients; if UM unable to find a bed through the health plan, engage MAC to help find a bed
    • If no beds are available anywhere, and child still requires a Higher Level of Care transfer, utilize Emergent Transfer Request or ELTC to MAC and notify MOD on-call.
    • Our OVMC Critical Care Team CCT is not certified to take children; If a child needs critical care transport, and MAC (which also utilizes CHLA transport team) is unable to provide transportation in a timely manner, may need to decide to use one of our ED providers for transportation.

Discharges

  • Autotext/dotphrase for URI and bronchiolitis discharge instructions can be found under Maureen McCollough auto text
  • Bulb syringes will be made available to give to parents

MONKEYPOX

ACEP Monkeypox Field Guide: https://www.acep.org/monkeypox-field-guide/cover-page/

How Transmitted?

  • Transmitted via direct contact and respiratory droplet; wear appropriate PPE.
  • Place suspects in a room with closed door and 'special precautions' sign

How to Test?

  • Use same swab used for COVID testing (UTM or VTM); use one swab to sample 1-3 lesions of the same type, preferably from different locations on the body
    • if different appearing lesions, collect additional swabs from several more lesions
    • limit 2 swabs per patient
  • Order is in Place Orders page (left side scroll down) = Monkeypox Virus DNA Qual RT PCR-SO (if possible, try to unroof the lesion to swab)
  • Have low threshold for also testing for HIV
  • If you are also swabbing for other things such as HSV, varicella or GC/Chlamydia, make sure you send separate swabs for the other tests

When will results return?

  • Tests are send-outs with results taking 3+ days to return
  • LA Public Health is notified of all positive results and will follow up with patient for contact tracing and isolation.

DHS also has a centralized process to follow up on positive results and contact patient for consideration of Tecovirimat.

  • Consider TFU if you are sending other tests, or if you would like patient notified of negative result

Who to Notify?

  • For SUSPECTED cases, contact OVMC Infectious Disease and Prevention x73624; after hours, leave message with patient's name, MRUN, birthdate and verified contact information

What about Treatment?

  • Cases treated once confirmed positive; treatment will be handled by OVMC Infectious Disease and Prevention

Discharge Instructions

  • Discharge ALL SUSPECTED cases with the LA County Dept of Public Health monkeypox home isolation guidelines
  • LA County DPH monkeypox home isolation guidelines now available in Cerner...Patient Education...Departmental...Monkeypox, english and spanish versions available.
  • Hard copies of the isolation guidelines also located in ED1A Provider Room
  • ED1A clerks have original copies of handouts

How to keep track of staff exposures?

  • Nursing will keep track by placing a log sheet outside the patient's room. Names of any staff who enter the room should be added to the log.

What if I have an occupational exposure?

  • Monkeypox is not as highly contagious as COVID and many other infections. However, if you come into direct skin contact with any lesions, or are in proximity to an aerosol generating procedure (intubation, swabbing of unroofed lesions) without N-95 mask and face covering then it could be a high risk exposure.
  • OV Employee Health has monkeypox vaccine for high risk occupational exposures. You can contact them at x73403

COVID-19

PPE

  • All patients should be wearing a mask and presumed contagious even if asymptomatic.
  • Visitors should be minimized to one visitor maximum, and only for pediatrics, elderly/disabled in need of assistance, or end of life.
  • All staff should wear a mask at all times. Staff who may become involved in aerosolizing procedure may wear an N95 mask throughout shift, at their own discretion. Eye protection should be worn for all patient interactions.
  • Patients with fever and/or respiratory symptoms will be moved into an ED room or another care venue after ICN. Those deemed possible COVID suspects will be placed in droplet and contact precautions while in ED.
  • Mask, eye protection, gown, and gloves for all COVID-suspect patient interactions. N95 or CAPR/PAPR required if aerosol generation.
  • CAPR face shields re-used: clean with purple top wipes; Used N-95 masks in designated white bins to reprocess if not visibly contaminated.

Oxygen Therapy

  • Regular nasal cannula or simple/NRB facemask are not aerosol-generating, use first-line (leave paper mask on patient over cannula)
  • AVOID CPAP and BiPAP as these are aerosol-generating
  • High-flow nasal cannula may be used in with a simple mask over the nose/mouth in patients requiring >10 L/min O2. Limit flow rate to 30 L/min or less. These patients should be placed in airborne isolation.
  • Intubation/mechanical ventilation should be considered early enough to allow for careful, planned procedure

Intubation

  • N95 with eye protection or CAPR/PAPR. Minimize personnel in room (RN, RT, and 2 MDs). Use negative pressure rooms.
  • RSI without bagging whenever possible; If bagging needed, put viral filter (from RT) and place LMA to minimize aerosol generation
  • Senior resident or attending to perform. Use Glidescope whenever possible to reduce exposure
  • McGrath in the black airway toolbox is only for attending intubation in 2F
  • Consider additional protective barrier such as clear sheet if available
  • Patients in cardiac arrest: Prioritize intubation over chest compressions if no shockable rhythm.
  • Use lung protective vent settings, 6 cc/kg tidal volume with escalating PEEP needed to maintain oxygenation. Simple vent mode (AC)

Treatment of Bronchospasm

  • Avoid nebulized therapy as this is aerosol-generating
  • In addition to MDI’s, consider sub cut. epinephrine (0.3 mg) or terbutaline (0.25 mg), or IV magnesium
  • Steroids should be used as needed; do not withhold based on COVID concerns.

Admission

  • Only for persistent oxygen requirement, or some other physiologic derangement (e.g. sepsis). Document PUI for interqual purposes.
  • No Observation beds now; Try to dispo with 6-8 hrs (e.g., Asthma, CHF exacerb, CP w neg trops w/o need for risk strat); Otherwise admit.
  • Notify hospitalist of COVID suspect. They will coordinate bed choice with ID attending (You do not need to call ID.)
  • ANO/patient flow should be contacted for prolonged boarding issues at x73170.
  • Consider ICU for patients:
    • on ventilator
    • requiring >6L/min of oxygen
    • requiring pressor support
    • with three or more of: AMS, uremia, tachypnea >30, multilobar infiltrate, age >55
  • Cover for CAP as appropriate. Other therapy is at discretion of IM/ID/Pulm/ICU teams
  • Labs: CBC, CMP, phosphorus, magnesium, LDH, troponin, CK, CRP, ferritin, procalcitonin, PT/PTT, d-dimer.
  • Imaging: portable CXR only unless high suspicion of PE or other life-threatening concern besides COVID

COVID and PEDIATRICS

  • Any child under age 1 with fever more than 4-5 days (even in the ABSENCE of any Kawasaki’s symptoms/criteria) should be considered a suspect and should be sent for COVID testing, CBC, ESR, and CRP and consider specialty consult with Peds ID/Immune/Cards.
  • Any child >1 year of age and up to 18 years of age with fever more than 4-5 days AND any other Kawasaki’s symptom(s)/criteria should be evaluated as above.

COVID Testing Reminders

  • Admissions - ordered as Symptomatic or Asymptomatic - all done rapidly (rapidly = a few hours)
  • Psychiatric - see below
  • Outpatient - Symptomatic, CAN'T Isolate - Do NOT discharge until COVID result is back. Should be used rarely for those living in group homes, SNFs, board&cares. Living with Grandpa doesn't qualify.
    • There are hotels/shelters that can be arranged for the rare COVID+ who cannot isolate at home. Can be arranged through social work Mon-Fri business hours. Or patients can be given the DPH number (833) 596-1009 to call themselves.
  • Outpatient - Symptomatic, CAN Isolate - These patients should be sent home. Results are sent in a daily report from the lab to our ED COVID RESULTS TEAM. No need to flag anything. Results will be followed up by the team. Including peds cases.
    • Make sure we have the correct address and phone number in Cerner.
    • Results take 3-5 days. NEGATIVE results will receive a letter in the mail. POSITIVE results will get a phone call.
    • Patients can call 747-210-3110, Mon-Fri 8am-4pm, if they have questions. Do NOT refer to TFU.
    • Use COVID OVMC Awaiting Testing Results patient handout in the Departmental folder, English and Spanish.
  • Asymptomatic or just COVID exposures - Do NOT send tests on these. We do not have the staff to follow these up. Refer to L.A. City website. Coronavirus.lacity.org/testing See new handout in Departmental Folder. COVID OVMC Testing Sites. English and Spanish available.
  • Access Center (on the ED Post Visit Plan page) gets the SYMPTOMATIC COVID+ or PUI patient a follow-up phone call with a DHS doctor in about 3 days. This is to find patients who may be getting worse at home. For DHS empaneled or DHS eligible. NOT OOP or MHLA. Check contact phone number in Cerner.
  • HOMELESS: For symptomatic patients experiencing homelessness who are going to be placed in a COVID-19 shelter by Social Worker, order as "Outpatient CAN self isolate". These will be held as lower priority as SW will send patient to a shelter where patient will self-isolate while test is pending.
  • CONGREGATE LIVING, symptomatic patients: e.g. group home, SNF. Order as "Outpatient CANNOT self-isolate". These will be given priority as discharge may depend upon test results.
  • DHS Healthcare Workers: Refer to employee health for testing to x73403. They will get an appt for drive-thru testing 1-3pm weekdays.

Psych Patients and Testing

UPDATED 6-3-2021

  • If medically cleared from triage or ambulance bay, and asymptomatic, then no covid testing needed prior to going to psych. If symptomatic, order covid.
  • If in an ED bed and medical clearance occurring/waiting for psych to see patient, order the covid test on ALL psych patients. If asymptomatic AND psych has a place to hold the patient awaiting test results, patient can be sent to psych before test results are back. If they don't have a place to hold the patient, then we need to wait until results are back.

Safer at Home/Home O2 and Pulse Oximeter Program UPDATED 12-1-2020

  • Candidate for Home O2:
    • Should be considered for any suspected COVID-19 patient when:
      • Diagnosis of COVID-19 (+) or PUI for COVID-19
      • Room air O2 sat < 93% with no history of chronic lung disease
      • O2 requirement are 0-3L NC to keep SaO2 >/= 94% or improving clinical trajectory with SaO2 >/= 92%, and without accessory muscle use
      • No other medical issues necessitate inpatient care
      • Patient has to have access to electrical plug for oxygen concentrator.
  • Step 1: Call Resp Therapy. ED RT x75581 (Supervisor RT x75038 Mon-Fri 8am-8pm-ish); RT will coordinate with oxygen vendor for oxygen and concentrator.
    • Patient must remain in ED until oxygen and concentrator arrive from oxygen vendor.
    • CalOx Home Health 323-255-5175
    • Supercare Health 855-621-5929
  • Step 2: ALL STAFF: Verify address and phone number in Cerner
  • Step 3: ALL STAFF: Notify ED Clerk to obtain pulse ox ; ED clerk will log patient in the Home O2 binder.
  • Step 4: Provider orders DME for Home Oxygen and Home Oximeter Device
    • Home Oxygen: Concentrator; continuous flow 1-3 Lpm; interface – nasal cannula; Est need in months – 1; diagnosis – suspected coronavirus.
    • Home Oximeter: Pulse ox; hypoxia/coronavirus
  • Step 5: Nursing: Have all prescription sent to the ED
  • Step 6: RT will educate patient on oxygen cylinders and concentrator when they arrive.
  • Step 7: Provider adds COVID discharge instructions
    • COVID OVMC Home O2/Safer at Home Discharge Instructions
    • COVID OVMC Self-Proning positions Eng/Span
  • Step 8: Provider adds Access Center to depart process. This allows patient to have a follow-up call by PCP or CCC within 3 days. OOP patients should be told to call their PCP.
  • Step 9: Next Day - ED Clerk assigns NP to call ED patients for 1st follow-up call. Patient will also receive follow-up call 3 days later by PCP or CCC via Access Center. NPs do NOT call Obs or Admitted patients sent home on O2.
  • Step 10: NPs document short note after discussion with patient. Message can be left with patient to call ED with questions. No other follow-up calls will be made.
  • For any problems, call or text Dr. McCollough 310-614-5306

Discharge Handouts including Department of Public Health

  • Home Care Instructions - Respiratory Symptoms, Not Tested, Spanish
  • Isolation Instructions - Exposed Household Members, English
  • Isolation Instructions - Exposed Household Members, Spanish

General Information on COVID-19, Department of Public Health, LA County

  • General Information

Updated info to be added

CDC Webinar

  • CDC Webinar with Micheal Bundesmann, who took care of the ~50 patients with severe COVID-19 in the Kirkland, WA, cluster. He gives a nice case series and his own perspectives with management. Waleed Alhazzani, who chaired the Surviving Sepsis Campaign’s (which may be a dirty word to some out there) position paper on the management of COVID-19 patients. He gives a lot of historical context for some of the management we are exploring with patients with severe COVID-19.

https://emergency.cdc.gov/coca/calls/2020/callinfo_040220.asp

Donning and Doffing

  • CDC Donning and Doffing PDF

https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

  • HIPPOED Donning and Doffing Video (4th and 5th videos)

https://covid.hippoed.com/#watch

MAXAIR CAPRS

https://www.maxair-systems.net/ProductTrainingVideos/Helmet_Basics/Helmet_Basics_A.html

Guidelines for Safe Intubation (Life in the Fastlane)

McGrath Video Laryngoscope

  • How to use the McGrath video laryngoscope

https://hcpresources-en.medtronic.ca/intubation/mcgrathtm-mac-video-laryngoscope-mac-3-instruction

Ultrasound and COVID

  • youtube videos cannot link to WikEM.

The Joint Commission TJC

Phone Numbers

ED

  • MD Room ED 1A Attendings 73648, 73649
  • MD Room ED 1A Residents 73907, 74732, 73645, 74720 (phones running in direction of ED1 to ED2)
  • MD Room ED 4/5 74936, 74937, 74938, 74939
  • Hospitalist Room 74930
  • ED 1A/Clerk: 74324 (PR1,PR2,15,24,25)
  • ED 1B: 74865 (16-23)
  • ED 2A: 74321 (1-7)
  • ED 2B: 74280 (8-14)
  • ED 3: 74976 (43-49)
  • ED 4/RME Unit: 74974 (34-41)
  • ED 5: 74970 (26-33)
  • ED Fax: 74298
  • Charge/Resource Nurse: 74324
  • ICN/Router: 73440
  • Triage 1: 65658
  • Triage 2: 65661
  • Triage 3: 65662
  • RME 1: 73789
  • RME 2:
  • Triage 7: 75709
  • ED Lab 74977
  • ED Xray tech 74951
  • ED CT scan tech 74968
  • ED Ultrasound tech 74940, 74945
  • ED Reading Room 74969, 74971
  • ED Pharmacy 75011
  • Psych ED 74340, 74341
  • UR 74890, 74891
  • PFS 65228
  • TFU 74825
  • ED North Annex 73107

Translator Phones in Room

  • PR 1 x60400
  • PR 2 x60401
  • Bay 1 x60346
  • Bay 2 x60347
  • Bay 3 x60348
  • Bay 4 x60349
  • Bay 5 x60350
  • Bay 6 x60351
  • Bay 7 x60352
  • Exam Rm 8 x60353
  • Exam Rm 9 x60354
  • Exam Rm 10 x60355
  • Exam Rm 11 x60356
  • Exam Rm 12 x60357
  • Exam Rm 13 x60358
  • Exam Rm 14 x60359
  • Exam Rm 15 x60360
  • Exam Rm 16 x60361
  • Exam Rm 17 x60362
  • Exam Rm 18 x60363
  • Exam Rm 19 x60364
  • Exam Rm 20 x60365
  • Exam Rm 21 x60366
  • Exam Rm 22 x60367
  • Exam Rm 23 x60368
  • Exam Rm 24 x60369
  • Exam Rm 25 x60370
  • Exam Rm 26 x60371
  • Exam Rm 27 x60372
  • Exam Rm 28 x60373
  • Exam Rm 29 x60374
  • Exam Rm 30 x60375
  • Exam Rm 31 x60376
  • Exam Rm 32 x60377
  • Exam Rm 33 x60378
  • Exam Rm 34 x60379
  • Exam Rm 35 x60380
  • Exam Rm 36 x60381
  • Exam Rm 37 x60382
  • Exam Rm 38 x60383
  • Exam Rm 39 x60384
  • Exam Rm 40 x60385
  • Exam Rm 41 x60386
  • Exam Rm 42 x60387
  • Exam Rm 43 x60388
  • Exam Rm 44 x60389
  • Exam Rm 45 x60390
  • Exam Rm 46 x60391
  • Exam Rm 47 x60392
  • Exam Rm 48 x60393
  • Exam RM 49 x60394

Anesthesiology/Airway

  • Pager: 818-529-0372
  • VOIP Phone: 75112

Psych ED

  • Psych ED Front Desk 74340
  • Psych ED Doctor Room 73950

Inpatient

  • ICU

Radiology Techs

  • Main Radiology 74059
  • ED Xray tech 74951
  • ED CT scan tech 74968
  • ED Ultrasound tech 74940
  • ED Reading Room 74971
  • MRI tech 73862
  • MRI front desk 73535
  • Interventional Radiology Scheduling 73686

Radiology Reading Rooms

Lab

  • Lab - ED Phlebotomy 74977, 74978
  • Lab - Processing 66033
  • Lab - Results 66033
  • Lab - Blood Gas 73314
  • Lab - Micro 66045
  • Lab - Pathology 73532
  • Lab - Blood Bank 74062

Pharmacy

Respiratory Therapy

  • RT Supervisor 75038
  • DEM RT 75581
  • RT Lead Therapist 75331
  • RT Pager 818-542-1156

Nursing

  • ED Charge Nurse/Throughput RN in ED1A 75333
  • ICN/Router: 75235, 75236
  • ED Nursing Supervisor Office (near bed #8) 74850
  • Triage 1: 75658
  • Triage 2: 75661
  • Triage 3: 75662
  • Triage 4/RME: 75697
  • ED 1A/Clerk: 74323, 74324
  • ED 1B: 74865
  • ED 2A: 74321
  • ED 2B: 74280
  • ED 3: 74976
  • ED 4/RME Unit: 74974
  • ED 5: 74970
  • Hospital Nursing Administration 73001

Clinics

Urgent Care Clinic and CCC 2A105 74312 Open Mon-Sat
Clinic A 73125
Clinic B 73129, 73131, 73132 Breast, Chest, Gen Surg, Peds Urology, Plastic Hand, Plastic Surg, Proctology, Thoracic Surg, Urology, Vasc Surg
Clinic C 73133 Primary Care, GI, HIV/Positive Health, Cardio, Heme, ID, MDA, Neuro, Oncology
Clinic D 73137 Gyn After Care, Gyn, Gyn Onc, Urogyn, Gyn Endo, Memory
Clinic E 73064 ENT, Interventional Rads, Ortho, Podiatry, Rheum
Clinic M 74546 Respiratory Urgent Care
Clinic P 73700 Primary Care, Derm, Endo, Pulm, Renal, Women's Health
Ophtho 75630
Peds Clinic in 4C 73144
Ortho Tech 818-529-5135, 818-529-5509

Operator

  • "0" then "5" then "5"

Other

  • ANO 75526
  • Appointment Center 747-210-8000
  • Bed Control 75959, 73179
  • Central Supply 65946
  • IT Info Technology 74522, 72644, 323-409-8000
  • OR 74364
  • PFS (Patient Financial Screening/Registration) 65228
  • Medical Administration 73025
  • Medical Records (problems with Cerner notes) 73934
  • Physical Therapy 74245, room 1D120
  • Psych ED 74340, 74341
  • Resp Therapy RT office 74422, pager 4055...1392...enter callback number
  • Sheriff
  • Social Work 74236
  • Social Work pager 818-313-1759
  • Social Work after hours for emergencies like deaths, 818-313-1637
  • SUD Counselor 74773

USC

  • ED Resusc 323-409-6667
  • ED Resusc Attending 323-409-1610
  • ED Peds Attending 323-409-1650

MAC

  • 866-940-4401; press "1" for emergent, or press "3" for DHS facility

Kaiser EPRP

  • 800-447-3777

ED Administration

ED Admin Gurus

  • Matt - Neurology, Neurosurgery, Infection Control, EMS, and Disaster
  • Pam - Ob/gyn and Residency
  • Maureen - Pediatrics, Cerner, Substance Use Disorders, ED High Utilizers, and supplies/equipment
  • Alan - Radiology
  • Fred - Psych
  • Amir - Medicine and ICU
  • Tomer - Pharmacy and P&T (pharmacy and therapeutics committee)
  • Breena - IRB, Invasive Procedures and Language assistance (interpreter issues, video phone issues…)
  • Steven - Residency
  • Kellie - Residency
  • Luis - Cerner

ED In Person Translation Service for Hard of Hearing, Deaf, Deaf Blind, and non-ASL speakers, see Social Work section

ED Throughput

RME Unit

  • Monday - Sunday, 8am to 8pm
  • ED 4: 34,35,36,37,38,39,40,41
  • ED 31/Procedure/Discharge Room will be left open and used for slit lamp exams and ENT procedures as needed, consults and discharge patients home as needed.
  • Staffing: two NPs, two RNs, one NA
  • Responsible for ESI level 4 and 5 patients
  • Responsible for overall turnover of rooms by discharging patients and bringing in new patients to be seen
  • NP and RN will pair up and take 4 rooms each, 34-37 and 38-41
  • RME Unit rooms will be set up with gurney against the wall and a chair in center of room in which patients will be placed.
  • Patients who remain in the ED 4 from the nightshift will either be discharged or moved to another area as soon as is possible for nursing staff. Night shift staff will attempt to move these patients at 6am. Dayshift stay will continue moving patients held over from the night shift.
  • In the morning when ED 4/RME Unit rooms are empty, Triage RN will place ESI level 4 or 5 patients directly into empty ED 4/RME Unit rooms; when these rooms are finally full, the responsibility for room turnover will shift to the staff in the RME Unit.
  • In the morning, when ED 4/RME Unit beds have been filled by the Triage RN, additional ESI 4 and 5 patients can continue to be placed into other ED beds in ED 1,2,3 or 5 if ESI 1-3 patients do not take precedent.
  • NP provider will sign up for the patient in the Res/ML column
  • RN will not sign up for the patient on the Tracking Board. The RN, however, will be responsible for patients who are under the care of the NP with which they are paired.
  • RN is not required to complete an assessment on every RME Unit patient. If medications given, etc, then a reassessment should be completed. If RME Unit patients are on the track more than 4 hours, a reassessment must be done by the RME Unit RN in the waiting room.
  • RME Unit Nursing (RN/NA) responsibilities: visual acuities, drawing blood, obtaining urine samples, sending patients needing plain films to PWR, calling Radiology about patients need utz or CT scan, anticipating procedures such as lac repairs or gyn exams and moving carts to the room, moving patients to and retrieving patients from the waiting room, etc.
  • Any patient placed in RME Unit who is subsequently deemed too complicated for RME Unit will have an RME documented, their ESI level changed to 3, orders placed as needed, and patient moved either back to the waiting room or when possible to ED 1, 2, 3, or 5. Responsibility for these patients should also move to the ED provider and nursing staff in those areas. If moved back to the waiting room, responsibility falls back to the Triage and Reassessment RNs.
  • Patients requiring plain films will be sent down to PWR/Radiology WR to wait for their imaging. RN or Provider will change the bed assignment to PWR. Radiology tech will then look on the tracking board, find the patient in PWR, complete the plain film imaging and then tell the patient to return to the RME Unit/ED 4 Nursing Station. The RME Unit RNs will then change the bed assignment to TR4 and send patient to waiting room to wait for imaging results.
    • ONLY RME Unit patients requiring plain films will be sent to PWR/Radiology WR.
  • Patients who are waiting for laboratory testing results, imaging such as utz or CT, plain film imaging results, or consultations by subspecialits can be moved to the waiting room. Bed assignment will be changed to TR4 in order to keep them visually separate from the other waiting room patients. These patients will remain the responsibility of their providers while they are in the WR awaiting results.
  • Patients moved to the waiting room (TR4) or ED 31/Procedure/Discharge Room will not be counted toward the nurse/patient ratios because they will need limited nursing interventions.
  • Patients who need to receive discharge instructions will be discharged in their ED room assigned or in ED 31/Procedure/Discharge Room.
  • RN will notify housekeeping when a room needs to be cleaned; RN will choose a new ESI level 4 or 5 patient from the WR to fill the room.
  • At 7pm the night shift RNs assigned to RME Unit will assume care for the day shift RN’s patients and continue working with the NP per the above guidelines.
  • At 8pm, the RME Unit will close, and patients who are still in progress of being cared for by the RME Unit team will be signed out by the day shift NPs to one of the night shift residents. The night shift RNs assigned to EDs 4 continue to care for the patient until discharge.
  • At 8pm, ED 4 will be used along with ED 1,2,3 and 5 beds for a variety of patients. Triage RN will be responsible for assigning patients to those beds.
  • If the RME Unit is successful, we may extend hours to 8pm-8am when a night shift Nurse Practitioner has been hired. We may also extend the RME Unit, as needed, to include additional ED beds and other ED nursing and provider staff.

Nursing

MIT Meds in Triage

  • Triage RNs are able to administer acetaminophen, ibuprofen, ondansetron or mylanta under a Medication in Triage Protocol
  • Applies to adults and children
  • One time dose only
  • If patient has already been RME'd and requests pain medication, then MIT protocol does not apply and provider will be asked to order medication

Admission Guidelines

Medicine Admissions UPDATE March 2017

  • ED Provider contacts Hospitalist and discusses case (ONE PHONE CALL)
  • Hospitalist has one hour to see patient and obs vs admit, level of care, admission team
  • If hospitalist desires discharge or transfer, hospitalist will recontact ED providers and discuss
  • Hospitalist will place order for Request for Admit (Red circle)
  • Hospitalist will contact the Admitting Team and tell them about the case
  • Admitting Team will write inpatient Admission Orders (Hospital icon)
  • If Admitting Team desires more information, Admitting Team will contact ED provider

Medicine Admissions Upgrades, Downgrades, ICU Admits co-managed

  • Inpatient teams are required to write inpatient admission orders (hosp icon) within 2 hours of Order to Admit (red circle)
  • Once inpatient admission orders are written (hosp icon),both Attending and Resident column on Tracking board can be changed to Inpatient Attending and Inpatient Resident
  • ED Admissions to Ward, Tele, Stepdown are managed by inpatient Medicine team once hospital icon appears
  • ED Admissions to ICU are managed by ED with ICU consultation
  • Ward, Tele, Stepdown then upgraded to ICU are co-managed by original medicine inpatient service and ICU team
  • ICU then downgraded to Ward, Tele, Stepdown are managed by the inpatient medicine team; ED should give report to Medicine

Observation - updated May 28, 2021

  • We can page hospitalist for Obs admissions or overrides up to 11pm.
  • If we have a patient who is still in interqual process and/or still awaiting some parts of the workup, but for whom we already know they will not be going home, we should contact the hospitalist before 11pm. With discussion, they can be put on the list for the Night Admitting Resident to be admitted or placed in Obs after 11pm. The goal is to allow discussion with hospitalist before ED resident and attending signout to the overnight ED team. (Most of the time we should wait until we have the essential workup done to call the hospitalist)
  • DEM will continue to keep patients who do not meet interqual in the ED overnight and manage them. We will NOT place the Obs order on these patients, and they will remain under ED care. Put a "ED OBS" comment in the MD column so we can identify them.
  • In the morning those who cannot be discharged within a few hours should be discussed with the hospitalist for override or Obs placement under medicine. It's a good idea for the overnight attending to call the hospitalist around 7:15 to discuss them before signout, if the hospitalist has not already called or come by.

Chest Pain Admission Guidelines

  • High Risk = Any of the following:
    • Objective signs of myocardial infarction/ischemia or new LV dysfunction:
      • Diagnostic ST/T changes or new LBBB on EKG
      • Abnormal Troponin result
      • Symptoms associated with dynamic EKG changes
      • Signs of CHF or cardiogenic shock
      • Malignant dysrhythmias
    • Typical symptoms known to be ischemic and:
      • Recent (<12 month) PCI
      • Recurrent/refractory despite anti‐anginal therapy
    • Management:
      • Anti‐platelet, anti‐thrombotic, and anti‐anginal therapy
      • Cardiology consult for possible urgent invasive therapy
      • Repeat troponin q3h x3 unless urgent invasive therapy already planned
      • Admit to SDU or ICU bed
  • Intermediate Risk = No High Risk Features, but one or more of the following:
    • Abnormal but non‐diagnostic EKG, cannot exclude ischemia:
      • LVH with strain
      • Digoxin effect
      • Ventricular‐paced rhythm
    • New, typical angina symptoms in a patient with:
      • Known CAD
      • Age>70
      • Inability to complete outpatient ETT
      • Intermediate Score on Risk Estimation Tool (e.g., TIMI 3 or higher)
    • Management:
      • ASA; anti‐anginal therapy as needed
      • Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
      • Observation or Telemetry admit (in consultation with Hospitalist and/or Cardiologist) for risk stratification prior to discharge, unless already performed in past 12 months.
  • Low Risk = No High or Intermediate Risk feature, plus
    • TIMI 0-2
    • Highly atypical symptoms
    • Recent negative objective study (e.g. angiogram, nuclear imaging, CCTA, ETT with Duke score 9 or greater)
    • Management:
      • ASA
      • Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
      • Refer for expedited (<72h) outpt. risk stratification if not already done in past 12 months
      • Refer for primary care to assess and manage vascular risk factors

Tele Admission Guidelines

  • Based on AHA/ACC guidelines, see reference at: http://circ.ahajournals.org/content/110/17/2721.full
  • Class I (Valid for 72 hours)
    • CONSIDER SDU OR ICU LEVEL OF CARE, IF INDICATED
    • Mild – moderate heart failure (Requiring IV Diuretics BID, not PRN)
    • Hemodynamically stable arrhythmia (HR > 45 and < 150 bpm):
      • atrial fibrillation/flutter
      • non-sustained ventricular tachycardia
      • other non-sustained SVT
    • Following percutaneous coronary intervention (PCI)/cardiac cath
    • QTc prolongation (> 460 msec in women, > 450 msec in men)
    • Hemodynamically stable (HR > 45 bpm) atrioventricular block (consider higher level of care for 3rd deg)
    • Drug overdose with arrhythmic potential (e.g. Digitalis, Tricyclic antidepressants, Phenothiazines, Antiarrythmics)
  • Class II (Valid for 48 hours):
    • Transfer from ICU or SDU after Acute Coronary Syndrome (STEMI/NSTEMI) or cardiac/respiratory arrest
    • Chest pain requiring inpatient evaluation (troponin < 0.8, no significant ECG changes)
    • Stroke
    • Syncope (true loss of consciousness)
    • Post-operative patients with presumptive or confirmed obstructive sleep apnea
    • Cardiac contusion, myocarditis or pericarditis
    • Initiation/adjustment of antiarrhythmic medications
  • Class III (Valid for 24 hours):
    • Electrolyte abnormality requiring cardiac monitoring but not requiring higher level of care due to underlying process such as diabetic ketoacidosis
    • Following pacemaker placement or cardioversion
    • Asthma/COPD exacerbation with hypoxemia (spO2 less than or equal to 95%) despite high flow O2 treatment

Surgical Subspecialty Admission Guidelines

  • DATE: February 14, 2023
  • TO: Faculty and Housestaff, Departments of Surgery, Medicine, Ob/Gyn, Pediatrics, and Emergency Medicine
  • FROM: Jane Yang, M.D., Interim Chief, Department of Surgery; Soma Wali, M.D., Chief, Department of Medicine; Christine Holschneider, MD, Chief, Department of Obstetrics & Gynecology; Shannon Thyne, MD, Chief, Department of Pediatrics; Greg Moran, M.D., Chief, Department of Emergency Medicine
    • Re: Emergency Department Hospital Admission Guidelines: IIn order to optimize patient care, housestaff supervision, expedite the admission process, and minimize conflicts regarding admission decisions, this document will clarify how the decision is made to admit emergency department (ED) patients to various inpatient services, and provide guidelines as to what types of patient diagnoses are most appropriately admitted to a specific inpatient service and hospital ward or unit.
    • Decision to Admit an ED Patient to the Hospital & Resolving Disputes: The decision as to whether a patient can be managed as an outpatient or requires more intensive observation and therapy in the hospital can be critically important. Therefore, the service chiefs have decided that after input from the admitting housestaff, the decision regarding admission ultimately must be made by attending physicians, which is consistent with community standards of care.
    • The Department of Emergency Medicine attending physician will make the decision on the need for an ED patient to be admitted. This decision will be made after reasonable evaluation and consultation to determine a presumptive diagnosis, admission service, and level of care. To avoid misunderstandings and delays, consulting residents should, upon completing their evaluation, clearly communicate their recommendations with the ED resident caring for the patient prior to leaving the ED. Patients will not be transferred from the ED to the floor until there is notification and confirmed acceptance by the admitting resident or attending, which should be indicated in the ED patient tracking system.
    • If, once notified, the admitting service resident disagrees with the recommendation of the ED staff, the resident should contact his/her senior/chief resident or attending physician to review the case. All disputes should be resolved first by ED resident discussion with the admitting service senior/chief resident, and, if necessary, by discussion between the ED and the admitting service attending physicians.
    • Diagnosis-Specific Guidelines for Appropriate Admission Service
    • The service chiefs expect that patients with certain designated illnesses will be admitted to the appropriate service, in accordance with the preceding section. Patients with disorders appropriate for surgical admission may not require an acute surgical procedure (e.g., abdominal pain with possible ischemic bowel admitted for observation). Patients with potential surgical diagnoses but who have significant concomitant medical problems (e.g., diabetes out-of-control) may be best managed on the Medicine service, with close consultation.
    • For patients seen in the ED who are within 30-days from their operation and for whom admission is being considered, the operative service (general surgery, urology, GYN, etc) should be the primary consulting service and in most cases the admitting service.
General Surgery & Subspecialties Medicine/Pediatrics/Ob/Gyn
Acute abdominal pain - very likely underlying surgical etiology (e.g., ischemic bowel), complicated diverticulitis likely to require surgery - non-pregnant (General Surgery) Acute abdominal pain – unclear but possible medical/ non-surgical etiology (e.g., colitits, gastroparesis, uncomplicated diverticulitis) (Medicine)
Pregnant women and non-pregnant women with acute abdominal pain likely to have gynecologic etiology (Ob/Gyn with General Surgery consultation)
Acute cholecystitis, Cholangitis, Choledocholithiasis in patient with gallbladder, symptomatic biliary colic with PO intolerance (General Surgery) Gallstone pancreatitis in patient with or without a gallbladder, Alcoholic and other non-gallstone-related pancreatitis, Choledocholithiasis without gallbladder (Medicine)
Pregnant women with gallstone pancreatitis, acute cholecystitis, choledocholithiasis/cholangitis (Ob with General Surgery consultation)
Hepatitis and hepatic abscess(es) (Medicine)
Mechanical small bowel obstruction requiring NG tube (General Surgery) Small bowel obstruction – secondary to prior Ob/Gyn surgery or gynecologic malignancy (Ob/Gyn)
SBO not requiring NG tube, or if not surgical candidate – (Medicine)
Abscesses with complex wounds or requiring urgent OR intervention, necrotizing skin and soft tissue infections, post-operative wound infections, other significant skin/soft tissue infections involving specific areas needing urgent surgery (General Surgery, Head & Neck Surgery, Plastic Surgery for hand) Cellulitis/lymphangitis, abscesses that do not require urgent OR intervention, and other skin infections with significant concomitant medical problems (e.g., diabetes out-of-control) (Medicine with surgical consult as needed); Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
Vulvar abscess (Gyn);
Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
Kidney stones with uncontrollable pain, with or without obstruction, without infection; Bilateral hydronephrosis from ureteral stones and renal insufficiency or solitary kidney; Acute prostatitis, with severe obstructive voiding symptoms, or with severe hydronephrosis; Scrotal abscess requiring OR intervention (Urology) Urinary tract infection (Medicine), UTI with pregnancy (OB) or UTI with gynecologic malignancy (Gyn)
UTI requiring admission, with kidney stone or indwelling ureteral stent, with or without obstruction
Acute prostatitis (fever, chills, toxic appearing);
Epididymitis requiring admission for IV antibiotics;
Scrotal abscess not requiring OR but needs IV abx;
Urologic problem in patient with any complicated medical problem (e.g., diabetes out of control, severe sepsis) (Medicine with Urology consultation); pregnancy (OB), or gynecologic malignancy (Gyn)
Acute gastrointestinal bleeding (Medicine or Pediatrics)
Injuries distal to the elbow requiring urgent operation (Plastic Surgery) Ankle and foot fractures (Medicine with Podiatry consultation)
All patients with post-operative surgical problems within 15 days of discharge requiring admission - to specific operating service (with Medicine consultation as necessary)
    • Admission Orders Admission orders must be written by the responsible inpatient service housestaff who are available to floor nursing in order to direct inpatient management.
      • For cases in which the admitting diagnosis is established (e.g., CT-confirmed appendicitis), an inpatient bed is available, and the admitting service residents are unavailable for > 2 hours (e.g., in the OR), the ED resident will contact the admitting service senior/chief resident in order to seek verbal approval for the admission. The ED physician will then write holding admission orders on the standard admit form and transfer the patient to a hospital bed.
      • If the admitting senior/chief resident is also unavailable or the admission cannot be approved, then the ED attending may contact the admitting service attending physician to facilitate the admission. Admission holding orders should include pain medications, intravenous fluids, and antibiotics (if recommended by the admitting service), and contact information (resident name and pager number) for the admitting service if a nurse needs new orders or to notify a physician about any change in patient status
    • Patient Transfers
      • All patients considered for transfer from Olive View-UCLA must be reviewed and evaluated by the ED attending physician.
      • For pediatric patients, the pediatric attending physician on-call should be notified prior to patient transfer.
      • For surgical diagnoses the attending surgeon on-call should be notified to approve the transfer.

Admissions from the Clinic, How to

  • Clinic staff places order for "UR Consult"
  • Once UR approves admission through Interqual, UR will contact PFS for a new FIN number to be created
  • UR will then fax admission info and new FIN number to Bed Control
  • Bed Control then contacts clinic staff to give them the new FIN number so admission orders can be placed
  • Clinic staff or inpatient team must write Admission Orders in order for Bed Control to secure a bed
  • For admissions to Obs Unit, clinic staff should contact Hospitalist on-call

Follow Up Guidelines

Future OVMC Clinic Appointments already scheduled

  • Future OVMC appointments can be found in the Patient's Chart, tabs on the left, Patient Schedule
  • Future OVMC appointments can also be found on the Patient Summary (Discharge Instructions). Click Depart. Page that appears is the Patient Summary. Scroll down to Future Appointments.

Future Orders - Outpatient studies ordered by the ED

  • When you order a future outpatient study, it will automatically print on the Patient Summary (discharge instructions)
  • Phone numbers for Radiology, Cardiology Lab and TFU automatically print out on the Patient Summary (discharge instructions)
  • Patients MUST call to schedule their own outpatient study. Patient should then call TFU afterwards to get the results of the study
  • Outpatient CTs, ultrasounds and MRIs are generally booked 4-6 weeks out. PLEASE do NOT tell the patient to schedule the appointment within a few days
  • If you think the patient needs the outpatient radiology appointment sooner, you will need to get overbook approval from Radiology during business hours and type the name of the approving Radiologist in the future order radiology request in Cerner. Obviously this is going to be harder to do overnight or on weekend shifts.
  • Cerner orders:
    • Echocardiogram = CV Transthoracic Echocardiogram
    • Exercise Stress Test = CV Treadmill Stress Test or CV Exercise ECG Stress Test
    • Holter monitor = CV Holter Monitor
    • Barium Enema = RF Barium Enema
    • Upper GI = RF Upper GI
    • Mammogram = MG Mammogram Digital Diagnostic (indicate left, right or bilateral)
    • Breast ultrasound = US Breast
    • EMG = EMG 1 Extremity Request
    • EEG = EEG

Next Day Clinic NDC Appointments

  • Scheduled appointments in Urgent Care Clinic (UCC) within 24-72 hours after an ED visit to avoid inpatient admission for complex medical patients.
  • Appointments are Monday through Friday only.
  • This is ONLY for DHS empaneled or responsible patients. This is NOT for OOP patients. Refer OOP patients back to their health plan or if required, transfer patient with approval from their health plan.
  • Ensure patient requires an URGENT follow-up appointment with an internal medicine provider in UCC. These appointments should be used to avoid an inpatient admission or observation. Other follow up pathways still exist including CCC and with the patient's DHS PCP.
  • Ensure patient has transportation to the NCD follow up appointment.
  • Ensure we have the correct working phone number of the patient.
  • ED clerks are responsible for scheduling the NDC appointments. Appointments should be within 24-72 hours after ED discharge. Once scheduled, the appointment will show up on the ED Patient Discharge Instructions (Patient Summary)under Future Appointments.
  • Ensure ED Note is completed before the NDC appointment.
  • Patient should be instructed to follow up in Urgent Care Clinic on the date/time of the appointment. ED Clerk will give patient handout with date/time and instructions to go to Urgent Care Clinic.

*If there are no appointments in the next 24-72 hours for APPROPRIATE patients, please page Paul Salama, Director of NDC; Amion...OV IM....Medicine Subspecialty Consults.....Next Day Clinic; Ok to page 24/7.

Appropriate Diagnoses for NDC

  • SEE BELOW FOR ADDITIONAL SPECIFIC INFO BY DIAGNOSIS
  • CHF exacerbations - without hypoxia, or need for IV drips; give IV diuretic in ED and have patient followup in 24 hrs; NDC can further titrate meds and arrange for ECHO if needed
  • Diabetic foot infection/osteo - without sepsis or necrotizing infection; discussed with podiatry and start antibiotics; NDC can re-consult podiatry and obtain further testing as needed
  • AKI without signs of shock or underlying electrolyte abnormalities; discuss with renal, consider trial of IVF in ED; NDC can repeat labs in 1-2 days and re-consult renal.
  • ESBL infection, known or suspected, without sepsis (e.g. well appearing UTI); give one dose Ertapenem or Amikacin in the ED and have pt return in approximately 24 hrs for culture results and further dosing needed.
  • Cellulitis without sepsis that may have failed conventional oral antibiotics; start Linezolid and have patient return in 1-2 days in NDC for a recheck.
  • Urgent GI endoscopy for stable patients (must contact GI prior to scheduling NDC appt)
  • Cancer, new diagnosis or suspected, or other serious diagnosis/issue requiring urgent follow-up; obtain appropriate imaging in the ED and scheduled for NDC appointment for possible biopsy, and further imaging and testing as needed
  • Any other condition that might otherwise be admitted but is suitable for urgent internal medicine follow-up.

NDC EXCLUSION CRITERIA FOR ALL CONDITIONS

  • Lives over 30 minutes away from OV
  • Extremely poor social conditions/support based on subjective evaluation
    • Must have accessibility to telephone and ability to be contacted reliably
  • Not DHS eligible/responsible (must be DHS eligible to be seen in NDC); NO OOP!!!
  • Any allograft or autologous stem cell transplant recipient
  • Immunocompromised
    • Primary condition (e.g., HIV with CD4 count <100, neutropenia with ANC<500, active chemotherapy, not that diabetes does not count)
    • Iatrogenic (e.g., ≥20mg prednisone equivalents per day x 3 weeks, chemotherapy, biologics)
  • Pregnant
  • Resides in SNF/ALF
  • History of frequent AMA or no-shows to clinics
  • ASA IV classification: “severe systemic disease that is a constant threat to life”

Need Help? For Assistance or Guidance for NDC, call the following:

  • NDC Director on-call: Listed on AMION....OV IM passcode
  • Hospitalist on duty: place Consult to Hospital Medicine in Cerner
  • ED Interim Chief Scott Lundberg: cell number posted in ED

Additional Specific Information by Diagnosis for NDC Appointments

AKI Acute Kidney Injury
  • Inclusion criteria for next day clinic:
    • Stage 1 AKI (Cr 1.5-1.9 times baseline) or stage 2 AKI (Cr 2.0-2.9 times baseline)
    • If there is suspicion for UTI/pyelo, refer to that algorithm instead
  • Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
    • Toxic ingestion
    • New or worsening oliguria (<0.3cc/kg/hr x 24 hours)
    • Anuric for >12 hours
    • Patient presents with clinically significant hypervolemia
    • Decompensated cirrhosis
    • New or worsening oxygen requirement
    • Any of the following laboratory abnormalities: pH<7.30 (if applicable), K>6.0, BUN>50
    • UA: Gross hematuria, microscopic hematuria with >5 RBCs/HPF, cellular casts
    • New proteinuria >300 mg/dL (worsening proteinuria is acceptable)
    • Stage 3 AKI (Cr more than 3.0 times baseline), or if Cr >3.0 with unknown baseline
    • New hydronephrosis on imaging
    • High suspicion for obstructive stone that may require intervention
    • Post-obstructive AKI with PVR greater than 250cc
  • Treatment in ED
    • If any exclusion criteria present on H&P then stop algorithm and deliver care as usual.
    • If BMP reveals bicarb <18, then draw VBG.
      • If pH < 7.30 then stop algorithm and deliver care as usual.
    • If patient has diabetes or there is concern for BPH/obstructive picture, ensure PVR is obtained in ED.
      • If PVR >250cc, the stop algorithm and deliver care as usual.
    • Ensure a STAT renal ultrasound is obtained in ED unless clear pre-renal picture (e.g. vomiting/diarrhea).
      • If new hydronephrosis, then stop algorithm and deliver care as usual.
    • Administer 1 to 3 liters of IV crystalloid based on clinical judgment (ideally over 1.5L if safe).
    • Schedule for NDC appt for the following day (approx 24hrs)
NDC Cellulitis (excluding diabetic foot infections)
  • Inclusion criteria for next day clinic:
    • Cellulitis that would typically be admitted (i.e., not usual candidate for oral cephalosporin)
    • Cellulitis that “failed” oral cephalosporins as outpatient are great candidates
  • Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
    • Diabetic foot infection-- refer to that algorithm instead
    • Necrotizing skin/soft tissue infection
    • Evidence of sepsis
    • Treatment with IV antibiotics of the same site within the prior month
    • Cellulitis of the face, hands, or overlying joints
    • History of limb amputation or complex skin/soft tissue infections in the past
    • Severe penicillin allergy (e.g., SJS/TENS), non-severe PCN allergy is okay
  • Treatment in ED:
    • Use sharpie to outline borders of affected area, and follow the appropriate pathway below
    • For Pus/Purulent Infections
      • 1. Ensure I&D is performed in ED and sent for culture, and give one of the following antibiotics:
        • For standard patients who can be discharged on oral cephalosporins, they do not need NDC follow-up
        • For patients who would normally be admitted, give 600mg Linezolid PO/IV
          • Discharge with Linezolid 600mg PO BID x7 days
        • If contraindication to Linezolid (e.g., SSRI/TCA), give Vancomycin 1g IV (may require renal dosing)unless already given.
          • Discharge with Minocycline 200mg po loading then 100mg BID x7 days (MRSA resistance <10%)
          • Alternatively can use 7d Bactrim 2 DS BID or Doxy 100mg BID, but MRSA resistance >10%
        • If concern for compliance, follow-up, drug use, etc., on-call pharmacist can approve 1.2g Oritavancin IV
          • Please use sparingly. Does not require outpatient antibiotics after Oritavancin.
      • 2. Proceed to Schedule Follow-up
    • For Animal/Human Bite Infections
      • 1. Assuming patient has received Ampicillin-Sulbactam, schedule another 3g dose 4-6 hours after last
        • Discharge with Amoxicillin-Clavulanate 500mg q8h x7 days
      • 1. Proceed to Schedule Follow-up
    • For Non-Purulent Standard Cellulitis
      • 1. For standard patients, give 600mg Linezolid PO/IV (if no contraindications)
        • Discharge with Linezolid 600mg PO BID x7 days
        • If contraindication to Linezolid (e.g., SSRI/TCA), pursue Oritavancin with on-call pharmacist
      • If concern for compliance, follow-up, drug use, etc., on-call pharmacist can approve 1.2g Oritavancin IV
        • Please use sparingly. Does not require outpatient antibiotics after Oritavancin
      • 2. Proceed to Schedule Follow-up
    • Schedule Follow-up
      • 1. Schedule Next Day Clinic in-person appointment within 24 hours for another dose of IV antibiotics (Linezolid, Vancomycin, Ampicillin-Sulbactam, or Ceftriaxone)
        • Schedule NDC in-person appointment in 24 hours, instruct patient to hold oral antibiotics 12 hours prior
NDC Diabetic Foot Ulcer and/or Osteomyelitis
  • Inclusion criteria for next day clinic:
    • Diabetic foot ulcer with or without concern for osteomyelitis
    • Lower extremity osteomyelitis with or without overlying skin infection
    • Any cellulitis in a patient with diabetes that does not meet the exclusion criteria
  • Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
    • Concern that patient will require surgical intervention beyond simple bedside debridement
    • Necrotizing skin/soft tissue infection or wet gangrene
    • Unstable vitals
    • Evidence of sepsis
    • Treatment with IV antibiotics of the same site within the prior month
    • Severe penicillin allergy (e.g., SJS/TENS); non-severe PCN allergy is okay
  • Treatment in ED:
    • 1. Use sharpie to outline borders of affected area
    • 2. If wound probes to bone OR xray/CT suspicious for osteomyelitis:
      • a. Consult to podiatry for debridement/deep wound culture/bone culture in ED
      • b. If podiatry consult unavailable in ED can organize podiatry follow-up from the NDC
      • c. MRI to evaluate for acute/chronic osteomyelitis can be completed in NDC
    • 3. If wound does not probe to bone:
      • a. Obtain standard wound cultures
    • 4. If evidence of surrounding necrotic tissue, consult podiatry for ED debridement
      • a. If podiatry unavailable in ED and urgent debridement is necessary, can admit
      • b. Otherwise, non-urgent podiatry debridement can be organized in NDC
    • 5. If there is no current skin/soft tissue infection, then give no antibiotics (cultures will be followed)
      • a. Proceed to Schedule Follow-up
    • 6. If there is concurrent skin/soft tissue infection:
      • a. Give Ampicillin/Sulbactam 3g IV x1 regardless of if there is purulence
        • ● Discharge with Amox/Clav 875mg pO q12h x7d (dosing must be adjusted for renal impairment unless otherwise specified)
        • ● If h/o MRSA, give Minocycline 200mg PO x1 (loading), then discharge with 100mg PO q12h x7d
          • MRSA has much lower resistance rates to mino than doxy/bactrim, but these can be used as alternatives
    • 7. Proceed to Schedule Follow-up
  • Schedule Follow-up
    • 1. If further IV antibiotics needed for cellulitis: Schedule Next Day Clinic in-person appointment within 24 hours
      • Schedule NDC in-person appointment in 24 hours; instruct patient to hold PO antibiotics 12 hours prior.
    • 2. If no further parenteral antibiotics are necessary and no deep wound/bone cultures are needed.
      • Schedule NDC appointment in 1-5 days. Follow-up interval based on severity of infection using clinical judgment. If non-severe, schedule follow-up after cultures expected to result.
NDC Gastrointestinal (GI)Urgent Cases
  • Gastrointestinal bleeding or suspected bleeding
  • Dysphagia or odynophagia
  • Clearly abnormal imaging studies suggestive of malignancy
  • Significant, unintentional weight loss not explained by other causes, warranting bidirectional (endoscopy and colonoscopy) in expedited fashion
  • INCLUSION criteria
    • 1. No vomiting of bright red blood witnessed during ED stay
    • 2. Hemodynamically stable
    • 3. Hemoglobin stable when compared to baseline or near normal limits
    • 4. Patient must not be taking warfarin, NOAC's, or enoxaparin (Lovenox)
    • 5. INR level must be <1.5 and platelets >50
    • 6. Patients must be tolerating at least liquids; any patient unable to take POs should be admitted
    • 7. Patients with evidence of luminal GI obstruction, impending obstruction or food impaction/foreign body obstruction should always be admitted
  • Management in the ED
    • 1. Discuss case with on-all GI fellow or attending who will decide if patient is appropriate for NDC follow-up appointment. DO NOT SCHEDULE NDC APPT FOR GI WITHOU DISCUSSING WITH ON-CALL GI FELLOW OR ATTENDING.
      • GI fellow or attending may be able to schedule an outpatient procedure without a NDC appt; NDC appts are for patients who would otherwise be admitted
      • Please confirm with GI fellow or attending that an NDC appt is necessary to expedite the procedure prior to scheduling the NDC appt
      • When clerk schedules the NDC appt, please have ED clerk write "endoscopy evaluation" in the field that queries reason for visit
      • GI can accommodate Tuesday - Friday AM appointments; NOT Monday AM appts
      • Patient will likely be evaluated by both GI and anesthesiology during the NDC appt; patient will then be given another appt and instructions to return directly to OPSA for the procedure(s).
NDC Pyelonephritis or Acute Cystitis
  • Inclusion criteria for next day clinic:
    • Any uncomplicated or complicated UTI (including pyelonephritis) that does not meet the exclusion criteria
    • History of MDR organisms (including ESBL) are acceptable
    • Frequently recurrent UTIs are acceptable
  • Illness-specific EXCLUSION criteria for next day clinic (in addition to general exclusion criteria):
    • New or worsening oliguria (<0.3cc/kg/hr x 24 hours)
    • Anuric for >12 hours
    • Patient has unstable vitals and/or high suspicion for bacteremia
    • Stage 3 AKI (Cr more than 3.0 times baseline)
    • Evidence of stones that are a suspected nidus of infection
  • Treatment in ED for all Pyelonephritis and Cystitis (including history of ESBL)
    • 1. For standard cases without complex antimicrobial history, deliver care as usual (e.g., ceftriaxone 1g)
    • 2. If ESBL or CRE organisms within prior 12 months, administer amikacin 15 mg/kg IV (renal dosing)
      • a. Can also give if high suspicion for ESBL: recent (within 2-3 months) antibiotic use or prolonged hospitalization, presence of foley, resides in nursing home
    • 3. If Cr>1.5 and concern for ESBL, prescribe 1g Ertapenem IV
      • a. Please only use carbapenems in renal impairment given risk of c.diff and PRIME penalties
    • 4. For pyelonephritis, discharge with one of the following enteral antibiotics:
      • a. No h/o ESBL: Cefdinir 300mg BID x 14 days (renal dosing)
      • b. H/o Zosyn-sensitive ESBL: Augmentin 875mg BID + cefdinir 300mg BID x 14 days (renal dosing)
        • i. In addition to POs, 100% of these patients will return to NDC for Amikacin/Ertapenem
      • c. H/o fluoroquinolone-sensitive isolates: Ciprofloxacin 500mg BID x 7 days (renal dosing)
      • d. Other difficult susceptibility profiles can be addressed in NDC-- discharge with plans for IV abx
    • 5. For acute cystitis, discharge with one of the following enteral antibiotics:
      • a. If creatinine clearance > 60: Nitrofurantoin 100mg BID x 7 days
      • b. If creatinine clearance < 60: Fosfomycin 3g x 1 dose
      • c. If h/o enterococcus: Amoxicillin 500mg PO q6h x7 days (if PCN allergy: Nitrofurantoin 100mg BID)
      • d. Other difficult susceptibility profiles can be addressed in NDC-- discharge with plans for IV abx
    • 6. Proceed to Schedule Follow-up
  • Schedule Follow-up
    • 1. If patient presented to the ED with a foley catheter or suprapubic tube in place, replace the catheter
    • 2. If clinical judgment suggests additional dose of parenteral antibiotics is necessary (either Amikacin 15mg/kg, Ceftriaxone 1g q24h, or Ertapenem 1g q24h for h/o ESBL)
    • 3. Schedule Next Day Clinic in-person appointment within 24 hours

OOP (Out of Plan)

  • Orange OOP on Tracking Board indicates out of plan insurance. Patient should be referred back to their health plan and PCP.
  • Info on health plan and PCP found on Patient Summary (Discharge Instructions), Demographics and Utilization Review tabs.
  • Do not refer OOP patients to subspecialty care at OVMC
  • OOP Health Plan and/or clinic name will print automatically on the Patient Summary (Discharge Instructions).
  • URGENT FOLLOWUP: To arrange urgent followup with PCP for OOP patients, call Outpatient Service Coordinator (OPSC) x74556. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc). Make sure contact info is correct in Cerner. OPSC coordinators will help expedite a followup appt with the PCP. Remember,outside health plans usually require patients to see their PCP before being referred to a subspecialist.


DHS Empaneled

  • To find out if a patient is empaneled to a DHS provider, look at the banner bar on the patient's chart. Look right hand side "Emp Prov". Name of PCP will be written there.
  • If empaneled, DHS or community clinic name can be found listed under Additional Patient Information on ED Summary page.
  • URGENT FOLLOWUP: To arrange urgent followup with PCP for OOP patients, call Outpatient Service Coordinator (OPSC) x74556. After hours/weekends/holidays, leave message with patient name, MRUN, and reason for urgent followup (e.g. fracture, new lung mass, etc). Make sure contact info is correct in Cerner. OPSC coordinators will help expedite a followup appt with the PCP. Remember,outside health plans usually require patients to see their PCP before being referred to a subspecialist.

MHLA (My Health LA)

  • Indicated by green MHLA icon on tracking board
  • Not an insurance plan but gives patient access to primary care clinic and provider (PCP)
  • MHLA patients receive all SPECIALTY care at OVMC or other DHS facilities
  • OK to refer MHLA patients to subspecialty care at OVMC either through Message Pool or econsult.

NERF (New Empanelment Referral Form)

  • Used to enroll patients with significant PMH who have no primary care or health plan
  • Patient must have at least one of a specific list of diagnoses
  • Only about 1/3 of patients will actually receive a PCP through the NERF process. Because of that, give patient a clinic list upon discharge so he/she can find a PMD on their own.
  • To enroll in NERF program, click NERF while completing Depart process. Check off diagnoses that apply. Click green arrow. Clerk will complete on-line NERF form. OR. Open patient's chart. Go to Primary Care Information at the bottom of the tabs on the left. Click New Empanelment. Complete form. Unless patient has strong desire to be empaneled to a particular primary care clinic, leave options open.

TFU (Telephone Follow Up)

  • 818-364-4825 (STAFFED ONLY 2 DAYS PER WEEK!!!) DO NOT USE TFU FOR ANYTHING URGENT or EMERGENT!!!
  • Used for follow-up of culture or GC/chlamydia results and for patients to call for outpatient Radiology imaging results
  • To refer to TFU, click ED Post Visit Plan while completing Depart process, choose ED-TFU-OVM and indicate what needs to be followed up
  • Ensure we have a correct phone number on the patient
  • If patient has already been discharged from the ED and you want to refer to TFU
    • Step 1: Find patient on the Look Up track (only good for 7 days after discharge)
    • Step 2: Choose patient on the Look Up track, click Modify Events.....Request Event......Post Visit ED TFU
    • Step 3: Open patient's chart......Depart.....now fill out ED Post Visit Plan form
    • If you do not follow these steps, TFU will not be flagged to follow-up the patient

CCC (Continuing Care Clinic)

  • ED Followup Clinic used for complicated patients without primary care or an outside health plan
  • Guidelines for CCC: Urgent follow-up of potentially serious internal medicine conditions that might otherwise require hospital admission, ED return visits, or extensive ED workup. The clinic is for patients without any other primary care resource; patients who have insurance and/or an established primary care clinic should be referred back there for follow-up of such conditions. *Consults sent to CCC will be reviewed within a few days by the NP who staffs the clinic; patients who have insurance or who do not meet the referral criteria listed below will not be seen in CCC; they will be referred on for routine primary care.
  • Our DEM TFU program can also refer patients to CCC, so if a test is pending to determine whether a patient meets criteria, please do not generate a CCC referral; the TFU program can review the test and refer to CCC if appropriate.
  • The CCC clinic can coordinate work-ups for possible malignancies including ordering additional outpatient imaging and biopsies.
    • Step 1: Please do not skip this step! Ensure that patient does not have established HMO insurance, other primary care. Do NOT send DHS Empaneled or OOP patients (see DHS Empaneled and OOP).
    • Step 2: Click ED Post Visit Plan while completing Depart process, choose ED-CCC-OVM
    • Step 3: Indicate condition requiring urgent CCC visit:
      • Suspected new or recurrent neoplastic disease
      • Acute medical condition potentially requiring inpatient admission if not followed up promptly
      • Diabetes out of control (Glucose >500, requiring initiation of insulin therapy, or new end-organ dz.)
      • Severe hypertension (>160/100 at time of ED discharge, new end-organ dz., or refractory to tx.)
      • Suspected new significant auto-immune disease (SLE, RA, scleroderma, IBD, vasculitis)
      • Complex or undefined infections requiring further evaluation (FUO, osteo, colitis, fungal/parasite, HIV)
      • Acute pulmonary disease or exacerbation requiring systemic steroids or antibiotics
      • Potentially serious lab or imaging findings (anemia, hepatitis, renal insuff., hyperCa++, incidentalomas)
      • Endocrine disease requiring advanced workup (hyperthyroidism, thyroid masses, pituitary/adrenal dz)
      • New congestive heart failure, arrhythmia, or structural cardiac disease not requiring admission
      • Decompensated liver disease requiring diuretics, paracentesis, or workup for occult etiology
      • New or recurrent deep venous thrombosis or other condition requiring anticoagulation
  • If you have questions about a consult, or wish to discuss a case during regular business hours, contact Dennis Chamling, NP, via the Department of Medicine or by pager on the amion.com internal medicine website. (password ov_im)

Urgent Referrals for Subspecialty Care/Message Pools

  • Used to refer patients to certain subspecialty clinics for URGENT follow-up appts (<4 weeks)
  • Do NOT refer OOP patients or non-urgent complaints through the Message Pool
  • For Colorectal, ENT and Ophtho patients, page the on-call resident for approval for the urgent follow-up appt. Type in the approving resident's name and the follow-up date/time agreed upon. Tell patient to show up at 8am to the clinic.
  • Current Clinics with Message Pools:
    • OVM Colorectal ED/UC Urgent Follow up - needs 24/7 phone call to general surgery
    • OVM Coumadin ED/UC Urgent Follow Up
    • OVM Hand Surgery ED/UC Urgent Follow Up
    • OVM Gyn Aftercare ED/UC Urgent Follow Up
    • OVM Interventional Radiology ED/UC Urgent Follow Up
    • OVM MAT Bridge ED/UC Urgent Follow Up
    • OVM Ophthalmology ED/UC Urgent Follow Up - needs 24/7 phone call to ophtho
    • OVM Orthopedics ED/UC Urgent Follow Up
    • OVM Otolaryngology (ENT) ED/UC Urgent Follow Up - needs 24/7 phone call to ENT
    • OVM PCC (HIV) ED/UC Urgent Follow Up
    • OVM Pediatrics ED/UC Urgent Follow Up
    • OVM Peds Ortho ED/UC Urgent Follow Up
    • OVM Plastic Surgery ED/UC Urgent Follow Up
    • OVM Podiatry ED/UC Urgent Follow Up
    • OVM Procedure Service ED/UC Urgent Follow Up
    • OVM Urology ED/UC Urgent Follow Up
    • OVM - Trauma Recovery ED/UC Urgent Follow Up

Econsult

  • eConsult appointment center for new referrals: 747-210-3800
  • eConsult is now accessed directly through Cerner from within a patient's chart. There is an eConsult tab available under the Table of Contents Menu (Table of Contents are the grey tabs on the left hand side of the mPage underneath the "ED Summary"). Users no longer have to manually enter patient identifiers to search for a patient. There is no longer a need to maintain a separate username and password for eConsult.
  • Used to refer patients to subspecialty clinics for NON-URGENT follow-up appts. Not all referrals are approved. In fact, most from the ED are denied. If approved, appts are likely several months away.
  • Do NOT send eConsults on OOP patients
  • Do NOT send eConsults on DHS empaneled patients. These patients should be referred back to their primary care doctor.
  • For outside records to be attached, use the Fax-to-Scan form on the Econsult. Print it out. Patient name and MRUN will be on the fax form. Attach it to the outside records and give to the clerk to fax. See job aid. XXXXX
  • For General Surgery gallbladders and hernia referrals, fill out the Cholecystectomy/Hernia form. Patient must be non-smoker with BMI <35
  • Do NOT refer the following:
    • Derm - simple skin conditions (must be SEVERE or worrisome for cancer)
    • GI - diverticulitis, undiagnosed abdominal pain, gastritis without minimum of 3 months of PPI or h.pylori treatment
    • Neuro - simple seizures, headaches
    • Urology - stones less than 5mm

Patient Education

Diabetic Teaching

Cardiology

Code STEMI

  • Definite STEMI on EKG and appropriate patient - ACTIVATE Cath Lab per protocol below
  • Probable STEMI or complex patient - CONSULT Cardiology (digital FAX 310-496-0160)
Oliveview UCLA Medical Center Providence Holy Cross
Mon-Fri 7am-5pm Nights, weekends, holidays
Page Code STEMI via Cerner Consults- Auto Paging (pager 818-226-4502) Verbally concept patient for transfer
Verbally consent patient and family for PCI Fax the EKG to Holy Cross: 818-496-4495
Goal: <30 mins in ED Call 818-496-7700 (or 7704) for Patient Placement Center to start the Code STEMI transfer
***Speak with ED physician at Holy Cross to review the faxed EKG
***Chart accepting MD name
For updates, call ED direct 818-496-1270
Call LAFD 213-847-5340 (or 5360) for Code STEMI transfer
***Emergency STEMI transfers ONLY
ED Clerk to fax patient registration info to 818-496-7707
Goal: <45 mins in ED before transfer
  • DEFIBRILLATOR DEVICE AT PATIENT BEDSIDE FOR ALL STEMI's
    • ED: Zoll pads package at bedside (apply only if unstable)
    • OVMC Cath Lab: Cardiology will bring & apply radiolucent Zoll Pads
    • Transfers: LAFD uses Physio monitor. Pads applied PRN arrhythmia.
Primary Medications Optional Medications Nursing Duties
Aspirin 325mg P.O. Nitroglycerin (SL or patch) Undress patient
Heparin 5,000 U bolus IV Morphine IV Two saline locks
Defer 2nd anti-platelet drug to cardiology's choice Ativan IV Hang one bag saline, slow drip
AVOID intravenous drips At OVMC, ED nurse goes with patient to Cath Lab and brings Code Blue kit
For transfers to Holy Cross: call report to 818-496-1270
  • Plan B Transfer to Northridge
    • Rare event of Holy Cross closure or 2 simultaneous STEMI, fax EKG to 818-885-3590 and then call Northridge ED charge nurse at 818-885-5396

Dental

Dental Clinics

Dermatology

Dermatology Clinic Referral Guidelines

  • ONLY refer patients through econsult with SEVERE skin disorder or concern for skin cancer
  • Referral through econsult MUST include photos
  • Clerk has digital camera and USB cable. Camera icon may take a minute or so to show up on "Computer"
  • Please delete any photos from camera or desktop after use

Employee Health - Staff Exposure / Needlestick Cases

  • Who handles staff exposure cases?
    • Business hours - refer patient to Employee Health, closes 4:30pm
      • When Employee Health is closed, if UCC is open, send to UCC
      • When Employee Health and UCC are closed, staff member to be seen in ED
    • Reason patient is seen in the ED at time of exposure is to determine if exposure has high enough risk to warrant presumptive treatment with PEP
  • Basic Protocol
    • No paperwork required; all documentation will be done in Cerner
    • Staff member to registered in Cerner; PAC will use IA billing code to register employee
    • ED or UCC provider will use .edexposure autotext for documentation of exposure episode
    • NO LABS WILL BE DRAWN ON THE STAFF MEMBER FROM THE EMERGENCY DEPARTMENT; ALL lab testing on staff member will occur in Employee Health (or at UCLA for students/residents/fellows) the next business day even over a long weekend and even if PEP meds are started
    • Source patient will have labs drawn by unit/clinic using the Blood and Body Fluid - Source Patient order set
  • Decision to treat with post-exposure prophylaxis medication
    • For any questions regarding the starting of PEP, Consult Infectious Disease 24/7
    • If PEP is deemed appropriate, ED provider will prescribe the following medications through Cerner (PRINT OUT HARD COPY OF PRESCRIPTION. DO NOT EPRESCRIBE TO OUR PHARMACY. OK TO PRINT ON WHITE PAPER. GIVE HARD COPY TO ED PHARMACIST WHO WILL GO GET THE MEDICATION):
      • Truvada 200/200mg tabs one tab QDAY x 30 days
      • Raltegravir 400mg tabs one tab BID x 30 days
  • Where do we send for follow-up?
    • OVMC employees should be instructed to followup at Employee Health the next business day; just walk-in. No need for appointment.
      • For OVMC employees: *Message through Cerner: Suzanna Mendez-Nasrallah NP that employee was seen in the ED for an exposure.
    • For UCLA students: Refer back to UCLA Student Health.
    • For UCLA resident/fellows: Refer back to UCLA Occupational Health.
    • No additional paperwork besides ED Discharge Instructions is given to staff member. All workman's comp paperwork will be completed by Employee Health or UCLA.

ENT/Head and Neck

Hearing Aids

  • Econsult to Audiology who will screen patient with audiology testing and refer to ENT if necessary

Gastroenterology

H. Pylori Testing

  • OVMC has removed the H.pylori BLOOD test; all H.pylori testing should be STOOL Antigen testing

GI Clinic Referral Guidelines

  • Abdominal pain – do not refer chronic abdominal pain of unclear etiology to GI
  • Abnormal imaging
    • If radiology reading is clearly suspicious for malignancy, refer to GI
    • Do not refer patients with studies that “cannot rule out”, “includes possibility of”, etc.
    • Do not refer patients simply because radiology wrote “endoscopy is recommended” on final read. Send patient to PMD or CCC for further interpretation of study results or further imaging
  • Anemia - Refer ONLY iron deficiency anemia; send Fe, TIBC, Ferritin; refer to TFU who will place e-consult if labs show iron deficiency
  • Barrett’s Esophagus – refer only if documented pathology report can be attached to e-consult
  • BRBPR
    • If patient is anemic, refer to GI
    • If patient is > 40yo, refer to GI
    • If patient is < 40yo, Anusol-HC supp qhs x 14 days. Symptoms persist? Follow-up PMD or have pt call TFU for GI referral
    • Do not refer if bloody diarrhea
  • Cirrhosis – Refer ONLY for banding of esophageal varices
  • Constipation – treat with osmotic laxative (e.g. sorbitol/miralax/prune juice) and send TSH if applicable
    • If severe (<1 BM per week) or rapid onset, refer to GI
  • Diarrhea
    • Will only see chronic non-infectious diarrhea >8 weeks; send C&S, O&P, C.diff, WBC; refer to TFU who will place e-consult if stool studies negative
  • Diverticulitis – do NOT refer to GI; Pt must be asymptomatic for 2 months before GI will consider colonoscopy
  • Dysphagia
    • If problem is high in throat region, refer to ENT instead If patient does not have weight loss, send barium swallow
    • If patient has weight loss or severe dysphagia, refer to GI
  • Dyspepsia (i.e. upper GI pain/epig pain >3 months)
    • If patient is > 55yo OR has worrisome symptoms, e.g., weight loss, refer to GI
    • If patient is < 55yo, order H. pylori test; refer to TFU who will treat with antibiotics if positive
    • If H.pylori test is negative or antibiotic trial fails, try PPI BID for at least 2 months. If that fails, refer to GI for evaluation
  • Family history of colon cancer (must be first-degree relative – mom,dad, sister, brother, child)
    • If only one relative, must be < 60 at age of diagnosis or if two or more relatives, age of diagnosis is not important
    • If patient fulfills above criteria and is either older than 40 or 10 years younger than the age of the relative at diagnosis (whichever is earlier), refer to GI
    • Otherwise, refer to primary care for fecal occult blood testing.
  • GERD (e.g. burning epig/chest pain with acid taste)
    • Do NOT refer to GI – pt must be on maximal therapy x 2months AND have lifestyle changes
    • If patient is not on maximum PPI therapy, change to or increase PPI to BID. Ex: Omeprazole 20 mg BID.
  • Hepatitis C - Do NOT refer to GI – treatment reserved for compensated cirrhotics; send to primary care
  • Inflammatory Bowel Disease
    • If urgent referral needed (moderate flare symptoms), call GI Fellow/Attending on-call; otherwise refer to PMD
  • Irritable Bowel Syndrome
    • Only if associated with worrisome symptoms (sudden onset at late age, weight loss), refer to GI
  • Occult positive stool only – do not refer from the ED
    • Pt must be >50yo, <50 BMI, AND have CLIA-approved lab occult-positive test NOT from ED to be referred
  • Polyps – Do NOT refer to GI unless you can attach endoscopy and pathology reports Ulcer – refer only GASTRIC ulcers that are >5mm; do NOT refer duodenal ulcers
    • If concern for malignancy based on outside endocscopy results, call GI for Urgent Consult
  • Urgent Consults
    • Communicate with on-call GI Fellow/Attending AND place e-consult; Note fellow on call CANNOT overbook a clinic visit

Infectious Disease

Reportable Diseases and How To

  • HIV - if HIV diagnosed at OVMC in our lab, then OVMC ID will take care of reporting positive HIV to LA County Health Department. Not emergency to report. ED does not have to report.
  • If known HIV patient presents to DHS requesting follow-up, check for OOP then Message Pool OVM PCC(HIV) ED/UC Urgent Follow Up
    • PCC = Positive Care Clinic

Dog Bite Reporting Form

http://www.publichealth.lacounty.gov/vet/docs/Forms/BiteFormVet.pdf

Public Health Confidential Morbidity Report Form Reportable Diseases

  • Hot Line: (888) 397-3993
  • Fax Line: (888) 397-3778 of (213) 482-5508

http://www.publichealth.lacounty.gov/acd/pubs/reports/CMR-H-794.pdf

Public Health STD Confidential Morbidity Report Form

http://www.publichealth.lacounty.gov/dhsp/ReportCase/STD_CMR.pdf

TB Outpatient Management Guidelines

  • Revised Oct 2014
  • The following symptoms, risk factors, and radiographic findings are associated with active TB disease (adapted from Moran et al, Ann Emerg Med, 2009):
Symptoms Risk factors Radiographic findings
Weight loss (>1 month) History of homelessness Cavitary lesion(s)
Cough (>2 weeks) History of incarceration Apical or upper lobe infiltrates
Fever (>2 weeks) Born outside the U.S.
Night sweats (>1 month) Prior active TB disease
Hemoptysis HIV infection
Malaise (>1 month) History of TB exposure
History of (+) tuberculin skin test* *A positive tuberculin skin test alone does not necessitate collection of sputum for active TB disease
  • EVALUATION OF PATIENTS FOR ACTIVE PULMONARY TB DISEASE IN THE ED
    • 1. Perform a History and Physical, asking specifically about the symptoms and risk factors noted in the Table above.
    • 2. Order chest radiograph.
    • 3. Perform a clinical assessment, taking into account symptoms, risk factors, HIV status, and radiographic findings.
    • 4. If active pulmonary TB disease is considered possible, order the following tests:
      • 1) AFB Culture, other non-sterile, PHL (sputum induced)
      • 2) M. tuberculosis PCR with Rifampin Resistance (sputum or expectorated or induced)
      • 3) HIV antigen/antibody screen (blood)
        • The first specimen should be collected in the ED and should be induced by inhalation of an aerosol (e.g., warm, sterile, 3%–5% hypertonic saline).
        • Further sputum collection (a total of 3 samples q8 hours recommended) can be collected by Public Health (if discharged) or on the ward (if admitted).
        • HIV tests will be followed up as an outpatient but will not be performed STAT
    • 5. If discharge is appropriate (see criteria below), the patient must be reported to the TB liaison by phone.
    • 6. If patient meets all discharge criteria, educate patient and provide written instructions with appropriate infection control precautions (see below).
  • DISCHARGE CRITERIA (all must be met)
    • Can be discharged to a stable residence with a verified address and phone number
    • WILL NOT be discharged to a shelter, nursing home, single room occupancy hotel or other congregate settings
    • WILL NOT have significant contact with immunosuppressed individuals or children ≤ 5 yo
    • Is willing and able to follow-up with outpatient care
    • Is willing and able to comply with home isolation (see below)
    • Remember, patient may need a work note
  • REPORT TO TB LIAISON
    • Call (747)210-4590
    • Leave a voicemail with patient name, MRN, patient address AND phone number
    • Do not call the County Operator as the message instructs. The Department of Public Health will attempt to locate the patient and ensure they are evaluated further as an outpatient at a public health clinic
  • PATIENT EDUCATION - give patient info sheet - located in MD Room or link here https://sslvpn.lacounty.gov/ov/Departments/DEM/Documents/,DanaInfo=myladhs.lacounty.gov+TB%20Patient%20Info%20English.pdf
    • DO NOT receive visitors at home, visit others, or go to work until evaluated by Public Health
    • DO NOT care for children ≤ 5 years old
    • Avoid public areas/ public transportation.
    • If you are employed DO NOT go to work
    • Cover your mouth and nose when coughing
    • Wear a surgical mask when spending time in a shared space (should be provided to patient upon discharge)
    • Patients will be contacted regarding any positive TB or HIV results
  • FREQUENTLY ASKED QUESTIONS ABOUT TB
    • What is the role of the TB liaison at OVMC?
      • The primary role of the TB liaison is to assist with patients suspected to have active TB disease, particularly to ensure proper reporting to the Department of Public Health
      • Per the new ED policy, the liaison SHOULD be contacted by phone for patients with sputum collected for TB evaluation, but not admitted to the hospital. This is essential to ensure those patients are adequately followed for outpatient evaluation in the public health clinics.
      • The liaison SHOULD NOT be contacted for patients with latent TB infection (see below) who are not suspected to active TB disease
      • The liaison can also provide information regarding patients seen in the ED who are already diagnosed with TB disease, and may be presenting with a related complaint (e.g., intolerance of anti-TB medications)
      • Then liaison is not able to provide clinical consults regarding patient care or decisions to admit/discharge
    • How do I contact the TB liaison?
      • The liaison has an office at OVMC, and is available Monday through Friday, 9am-5pm.
      • Call (747)210-4590; if no one answers, leave a voicemail with the patient’s name and MRUN. VERIFY ADDRESS and PHONE NUMBER ARE CORRECT IN CERNER!
      • If calling outside business hours, just leave a voicemail with above information.
    • What should I do with a patient sent to the ED for a positive tuberculin skin test (i.e., PPD) or a positive IGRA (e.g., Quantiferon)?
      • Both of these tests may represent latent TB infection.
      • Patients with a positive test should be evaluated with:
        • 1. A history and physical - to see if they have any signs or symptoms or active TB disease.
        • 2. A chest radiograph - to look for active pulmonary tuberculosis.
      • If the patient’s overall clinical presentation is very unlikely to represent active pulmonary TB (e.g., normal chest x-ray, not immunosuppressed, no signs or symptoms of TB), then the patient should be referred for possible treatment of latent TB infection.
      • Preferably, patients should be sent to a primary care provider
      • For patients without a primary care provider, they can be sent to public health centers http://publichealth.lacounty.gov/locator.htm
      • DO NOT contact the TB liaison for patients with latent TB infection; the liaison should only be contacted for patients suspected to have active TB disease

Neurology

Matt's Reminders

  • Please call neurology for ANY questions regarding the management of stroke patients
  • All CVAs with symptoms within 8 hours should be discussed with neurology
  • For acute CVAs within a 5 hour window the imaging of choice is CT angiography head with and without contrast
  • Admit TIAs to medicine: we don’t send them home
  • E-mail Matt with any difficult neurosurgery transfers or neurology issues. Matt's cell is posted in ED. Matt has direct contact with USC Neurosurg and is happy to help in the heat of battle

Acute Stroke Protocol and TeleStroke iPad

  • updated May 2021
  • For suspected or presumed stroke with last time known to be at baseline ≤ 8 hrs before presentation
  • Stroke Alert Background: Intent of this protocol is to create a rapid, collaborative care model for the acute stroke patient. The ED Attending or primary team attending (for non-ED patients) retains ultimate responsibility for the care of the patient and any decision-making regarding that care.
  • Stroke Alert Pager number is 818-226-4797. Any physician involved in the patient’s care can activate a Stroke Alert by calling the page operator, requesting a page to the “Stroke Alert Pager,” and provide a call back number. The number can be text paged from www.amion.com or www.myairmail.com (American Messaging). The pager is used to alert appropriate group members to a potential acute stroke in-house or in the ED. The Stroke Alert pager notifies the following staff members:
    • Neurology Resident on-call
    • Stroke Fellow
    • ED Pharmacist
      • please enter the full 10 digit call back number and add *911 or “stroke alert” to note high acuity.

ED Actions

  • Dial 818-226-4797 or text page this number through www.amion.com or www.myairmail.com (American Messaging).
    • Briefly discuss the case with the on-call Neurology Resident. Have the symptoms and last known well time ready.
  • Studies:
    • CBC, BMP (including BUN and creatinine), LFTs, troponin, PT/PTT/INR
    • Chest x-ray
    • EKG
    • Brain imaging: Discuss with the Neurology Resident and Stroke Fellow. Generally:
      • STAT Non-contrast CT head AND CT angiogram head and neck if there is no contraindication to contrast
      • Prepare for STAT imaging. Neurology team will coordinate with Radiology to ascertain the most suitable mode and location of imaging, including determining if MRI would be more appropriate.
  • If patient meets criteria for thrombolytics or thrombectomy, the Neurology Resident will come evaluate the patient. The Stroke Fellow will assist by phone/telemedicine until the Resident (who may be off campus) arrives.
  • The Stroke Fellow will assist arranging for tPA or Transfer, if appropriate. In these cases, please assist by paging “tPA Case” or “Stroke Transfer,” to 818-226-4797 though www.amion.com. Texting these messages will mobilize the appropriate team.
  • Transfer for mechanical thrombectomy for patients with large vessel occlusion for clinically appropriate candidates:
    • Transfers are coordinated by Utilization Review (747-210-4890). If further assistance is needed, contact MAC center (866-940-4401).
      • Holy Cross One-Call Transfer: 818-858-5779 - closest, 1st choice, MOU for inpatients
      • UCLA One-Call Transfer: 310-825-0909
      • Keck One-Call Transfer: 323-442-6111

Potential Thrombolytic Case - last at baseline <4.5 hours prior to presentation

  • Text "tPA case" to 818-226-4797 and to stroke fellow, pager 818-226-4885

Large Vessel Occlusions (LVOs) at OVMC

  • Mechanical thrombectomy in patients with LVOs are considered in patients presenting with deficits within 24 hours.
  • The decision on which patients are candidates for a cerebral angiogram which is the first step in an intervention for an LVO is a complex decision made by the neurology team.
  • The OVMC neurology resident decides with the stroke attending and/or stroke fellow if the patient is a candidate for an LVO intervention. This involves the interpretation of the CT perfusion study and CT angiography as well as the patient's presenting symptoms.
  • If the patient is a candidate for an LVO intervention the stroke neurology team arranges transport with Holy Cross which is contracted with DHS to provide this service to OVMC. The ED team should NOT call MAC or the critical care transport team for transport to Holy Cross.

Tele Stroke iPAD instructions

  • When the iPAD is receiving an incoming call, you will hear a tone.
    • 1. To receive the call, please unlock the home screen (code: 800000)
    • 2. Click on the blue HipaaBridge icon.
    • 3. Video should start automatically.
  • Receiving a call: iPAD will ring when someone is calling in.
    • 1. Home screen, unlock by pressing the button (under the finger in the picture)
    • 2. Press “800000” on the touchscreen to unlock the iPAD
    • 3. Answer call (green button, under finger)
  • Troubleshooting:
    • No volume: volume tabs are on your right as you face the screen, towards the top
    • Not turning on: ensure iPAD is charged. Charging port is at the bottom of the iPAD. Power button is on the top of the device, towards your right. Charging cables are stored behind the device in the locked cabinet where the iPAD is stored.
    • If you wish to dial out from the iPAD (generally will not be necessary), in order to log into Hipaabridge, it may ask you for a 4-digit passcode
  • If you get to this screen, and absolutely have to log in (not needed to answer a call, only needed for dialing out), press “3104” on the touch screen. DO NOT press “cancel” - this will lock the device out of HipaaBridge and currently for security purposes, only IT personnel can log back in. They can be reached at x73239 or room 1D132.
  • If completely locked out from HipaaBridge and you see a log in screen requesting an e-mail or single sign on, please contact IT at x73239 or room 1D132. Currently, only they can log back in if the iPAD is completely locked out.

Neuro Clinic Referral Guidelines

  • Stroke/TIA
    • TIA. In general, all patients who present with a history suggestive of TIA should be admitted for risk factor assessment. Due to the high immediate risk of ischemic stroke following a TIA and the inefficiencies of outpatient diagnostic testing, inpatient monitoring and assessment ensures comprehensive evaluation and the potential for timely intervention if indicated.
    • Hemorrhagic stroke. In the event of a parenchymal, subdural or subarachnoid hemorrhage, a transfer to LAC+USC should be arranged. The only exception is a parenchymal hemorrhage with symptoms already for more than 5 days, in which case admission to Olive View is permissible.
    • Ischemic Stroke. All ischemic stroke patients should be evaluated by the Neurology Service. The timing of consultation shall be determined by the duration of symptoms.
      • 0-3 hours: Consultation should occur in the Emergency Department to determine eligibility for intravenous tPA.
      • 3-6 hours: Consultation should occur in the Emergency Department to determine eligibility for possible transfer to UCLA for intra-arterial tPA.
      • 6-48 hours: Consultation should occur in the Emergency Department to help determine the appropriate level of care for admission.
      • 48-72 hours: Consultation may be sought after admission (unless symptoms have progressed in a stepwise pattern or if the patient has multiple increasing, stereotypic TIA symptoms, in which case consultation should occur in the Emergency Department). Patients should be admitted to the intermediate care unit or standard care telemetry ward for 24 hours of observation/monitoring.
      • >3 days: Consultation may be sought after admission. The level of care for admission is left to the discretion of the DEM attending.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • If old, check for MRA of neck or Doppler, echocardiogram, MRI brain
      • Labs: RPR, ESR, HbA1c, PT/PTT or INR, homocysteine level
  • Seizures
    • Patients with established epilepsy do not need consultation following a solitary seizure, if an obvious reason for the breakthrough exists (e.g., non-compliance with meds, concomitant illness). If the patient has had a 20% increase in seizure frequency in the recent past, then a request for an earlier appointment may be submitted if the patient’s scheduled visit to Neurology Clinic is >1 month into the future. Patients who have run out of anticonvulsant medication(s) may be given a supply to cover them until the next scheduled Neurology Clinic visit. If an appointment does not exist, then a 5-month supply should be given and a Request for Outpatient Consultation form submitted. If a patient has a stable seizure disorder (no seizures on anticonvulsant medication with the past half-year or more) there is no clinical necessity that the Neurology Service follow them. Medication may be refilled by Primary Care. Stable seizure patients who cannot obtain Primary Care can be most efficiently followed in one of Neurology’s Nurse Practitioner clinics.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • Anticonvulsant levels
      • EEG
      • Brain MRI
  • Headache
    • Patients with established migraine headache who have failed primary-care attempts at management may be referred to the Neurology Clinic. Patients given a new diagnosis of migraine by Primary Care, Medical Walk- In or the DEM, who have not yet had reasonable attempts at management (use of triptans and/or appropriate preventive medications) should be referred to Primary Care prior to seeking specialist care.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • If DEM referral, the patient should be referred to Primary Care first. If referral from Primary Care, and headache of long duration (>1 year), documentation of prior management attempts.
      • Medication history
      • If patient > 50 years old, ESR
      • Documented neurology examination (to help determine the urgency of the referral).
      • If focal findings on neuro exam, neuroimaging results or at least a request submitted for MRI of brain.
  • Dizziness - In all cases of “dizziness”, Neurology is best equipped to help patients who exhibit vertigo and/or disequilibrium accompanied by focal neurological signs. Episodic light-headedness and chronic dizziness are generally better served by Primary Care, Cardiology, or Head and Neck Surgery.
  • Peripheral neuropathy
    • Studies to be obtained prior to Neuromuscular Clinic consultation:
      • If painful, medication history
      • Labs: B12, RPR, TSH, HbA1c, ESR, and consider SPEP, ANA
      • EMG/nerve conduction velocities if available
  • Muscle Disease
    • Studies to be obtained prior to Neuromuscular Clinic consultation:
      • Labs: CPK, ESR, TSH, ANA
      • EMG
  • Dementia
    • Studies to be obtained prior to Memory Disorders Clinic consultation:
      • Do not refer to General Neurology; refer to Memory Disorders Clinic
      • Labs: CBC, B12, TSH, RPR, MHA-TP, Ca, Na, ALT, AST, BUN, creatinine, homocysteine, RBS Vitamin D level, lipid panel
      • MRI of Brain with Dementia Protocol
  • Multiple Sclerosis
    • Studies to be obtained prior to Neurology Clinic consultation:
      • MRI brain and/or spinal cord with contrast if available
      • Labs: ANA, B12, RPR, Vit D level, ESR, SSA, SSB, consider HIV
      • LP if available, for oligoclonal bands, IgG, IgG synthesis, and routine protein glucose, cell counts, differential

Sleep Study

  • Econsult Sleep Study
  • Do NOT place order for sleep study; econsult should be placed but seriously ask yourself WHY AM I ORDERING THIS FROM THE ED??

DMV Request for Re-Examination Form

http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/DMV%20Request%20for%20Reexamination%20Form.pdf

Neurosurgery

A few pointers

  • All transfers through the MAC are classified as “routine” or “urgent/emergent”. The language with them really matters. MOST of our transfers are ROUTINE as long as it is not immediately life threatening (e.g. stable subdural hematoma), but routine transfers can sometimes take hours. If you have a transfer from the ED such as a head bleed, and the patient decompensates while the patient is waiting for a bed at LAC-USC, the transfer actually gets easier. You can upgrade the transfer to EMERGENT through MAC and they will get you in touch with the LAC-USC DEM attending who based on our agreement will accept the patient.
  • Similarly, for a CRITICAL neurosurgical patient, these transfers should be deemed EMERGENT with MAC and will be readily accepted attending to attending either by the neurosurgery attending or USC DEM attending regardless of bed status.
  • For a neurosurgical transfer not going smoothly, MAC is easily able to get the LAC-USC neurosurgery attending on the phone and you can have a magical attending to attending discussion. In our experience this usually results in a satisfactory result, and they do not mind being called.
  • Finally, we had a recent attempted neurosurgical transfer to UCLA. Unfortunately, ONLY ACUTE STROKE patients eligible for a mechanical thrombectomy by neurology will be accepted at UCLA from DHS hospitals. Neurosurgery transfers should go through MAC to a county facility, unless they are out of plan (OOP), in which case we should try to transfer to someplace within their plan.

Neurosurgery Transfer Guidelines

  • Approved by DEMs at OVMC and LAC, LAC+USC Neurosurgery, OVMC Medical Admin and MAC Feb 2018
  • If patient is OOP but stable, contact UR x74890 to attempt transfer within the patient's health plan
  • For unstable or DHS/uninsured patients, transfers will be made through the MAC to LAC+USC neurosurgery (Harbor is no longer an option)
  • Indications for Potential Emergency Transfer:
    • ACUTE cerebral hemorrhages, including:
      • Subarachnoid hemorrhage (traumatic or spontaneous)
      • Intracerebral hemorrhage (ICH score >0)
      • Subdural or epidural hemorrhage
    • Any lesion with significant mass effect (e.g. midline shift >5mm, hydrocephalus, or increased ICP with risk or concern for herniation)
    • Acute or subacute spinal cord or cauda equine compression (e.g. abnl exam with sensory level, motor deficit, or MRI evidence of cord compression with CSF block or abnl cord signal)
  • Emergency Transfer may NOT be Indicated:
    • Mild traumatic brain injury (no or trace blood, no fracture, GCS ≥ 14 with stable scan)
    • Space occupying lesion with minimal mass effect: midline shift <5mm, no concern for herniation or increased ICP
    • Chronic mild spinal cord compression - no neurological deterioration without cord signal change or CSF block around cord
    • Chronic subdural hematoma (no acute blood products, size <7mm, no midline shift, no recent change in size if prior imaging available)
  • How to Transfer:
    • Contact LAC+USC Neurosurgery Resident to discuss case via MAC (866-940-4401); if no response, page resident directly through AMION (Logon = LACUSC)
    • If no response or disagreement with NS resident, Call LAC Neurosurgery Attending (Amion logon = LACUSC; if no response or disagreement with NS Attending, call Matt Waxman 310-497-7113 or Greg Moran 818-426-1478 or LAC Neurosurgery Service Chief Dr. Arun Amar (pager 213-508-0000) or the LAC CMO of the day via MAC
    • If no immediate neurosurgery intervention planned but needs monitoring in Neurocritical Care ICU, contact LAC+USC Neurocritical Care Attending (Gold Service) via MAC (866-940-4401)
    • If transfer is delayed, may initiate ED to ED transfer
    • If patient acutely demands urgent/emergent transfer but no DHS beds are available, page OVMC CMO on-call @747-210-3000 to obtain approval for transfer to nearest trauma or comprehensive stroke center
    • Once transfer is accepted, call Utilization Management (UM) at 74890. Notify them of the accepting facility and accepting physician. UM will then take the lead in the transfer process.
  • How to Handle if Transfer maybe NOT indicated:
    • Contact LAC Neurosurgery via MAC (866-940-4401) to discuss patient's case
    • If no indication for emergent Neurosurgical intervention or ED to ED transfer, may call LAC+USC Neurology Gold Service or Medicine via MAC
    • If no indication for emergent transfer to LAC+USC Neurology or Medicine, may undergo initial evaluation and treatment at OVMC
    • Re-evaluate transfer if imaging or condition worsens

OB-Gyn

Referral Guidelines for Message Pool vs Econsult

  • Urgent Followup through Message Pool in Cerner/Orchid
    • These go to NP clinic and will be seen usually within a few days
      • First trimester vag bleed
      • Complicated PID that needs GYN followup
      • AUBs who are anemic (hgb less than or equal to 9)
      • Post menopausal bleeding
      • Bartholyn's cysts
      • Labial abscess
  • Econsult to GYN
    • These go to an MD clinic and will usually be seen in 2-4 weeks
      • AUBs with stable hemoglobin
      • Ovarian cysts
      • Chronic pelvic pain
      • Urogyn

Establishing care at OVMC for pregnant patients

  • Do not refer OOP patients; refer these back to their health plan
  • For uninsured patients, tell patient to go to Clinc D to request follow-up for pre-natal care, "PK" clinic; clinic closes at 4pm
  • REMEMBER, use Message Pool for an urgent request for pregnant vag bleeds, rule out ectopics getting BHCG checks, etc

Oral Contraceptive Taper Patient Instructions

http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_English.pdf http://myladhs.lacounty.gov/ov/Departments/OBGYN/Documents/PtInfoCounseling/GYN_Combined_OCP_taper_Spanish.pdf

Oral Provera Taper Patient Instructions

  • Coming soon!!

Ordering Rhogam

  • In Cerner, order "RhIG Request"; right click on order to modify order, 300mg,intramuscular, prenatal

Ophthalmology

Ophthalmology Abbreviations

AAU: acute anterior uveitis AFT: artificial tears AGV: Ahmed glaucoma valve ARMD or AMD: age-related macular degeneration DR: diabetic retinopathy BRAO: branch retinal artery occlusion BRVO: branch retinal vein occlusion BULB: bilateral upper lid blepharoplasty BVS: borderline visually significant C/D: cup-to-disc ratio CEIOL: cataract extraction with insertion of intraocular lens CME: cystoid macular edema CRAO: central retinal artery occlusion CRVO: central retinal vein occlusion CSME: clinically significant macular edema CS: cortical spoking (cataract) CSR: central serous retinopathy DES: dry eye syndrome DME: diabetic macular edema DWC: dense white cataract ED: epithelial defect EL: endolaser ERM: epiretinal membrane FML: focal macular laser GS: glaucoma suspect HST: horseshoe tear HVF: Humphrey visual field K: cornea KP: keratic precipitate (inflammatory cellular deposits) LH/WC/AFTs: lid hygiene, warm compresses, artificial tears LPI: laser peripheral iridotomy MMCR: Muller's muscle conjunctival resection MP: membrane peel NAION: nonarteritic ischemic optic neuropathy NCVH: non-clearing vitreous hemorrhage NPDR: non-proliferative diabetic retinopathy NS: nuclear sclerosis (cataract) NTG: normal tension glaucoma NVG: neovascular glaucoma NVS: not visually significant OD: right eye OHTN: ocular hypertension OS: left eye OU: both eyes POAG: primary open angle glaucoma PCO: posterior capsular opacity (aka, secondary cataract) PDR: proliferative diabetic retinopathy PKP: penetrating keratoplasty (aka corneal transplant) PPV: pars plana vitrectomy PRP: pan retinal photocoagulation PS: posterior synechiae (sequelae of inflammation) PSC: posterior subcapsular cataract PTG: pterygium PVD: posterior vitreous detachment RRD: rhegmatogenous retinal detachment RT: retinal tear SB: scleral buckle SRD: serous retinal detachment Trab: trabeculectomy TRD: tractional retinal detachment VA: visual acuity VH: vitreous hemorrhage VS: visually significant XT: exotropia YAG cap: YAG capsulotomy

Orthopedics and Podiatry

  • Orthopedic Surgery and Podiatry share clinic space and communicate regarding complex lower extremity cases.

Ortho and Podiatry Clinic Referral Guidelines

OVMC Orthopedics OVMC Podiatry
Patients 16 years of age and older Majority of foot and ankle fractures are managed by podiatry (5th metatarsal fractures, ankle fractures)
High Energy ankle fractures such as a pilon fracture Diabetic foot including osteomyelitis
Maisonneuve fractures involving the fibular head Ankle sprains
Lisfranc fractures (tarso-matatasal injury) Plantar fasciitis
No acute soft tissue knee injury (non-fracture) greater than age 55
No hip fractures) (Transfer out)
No compartment syndromes (General Surgery)
No Open fractures (Transfer out)
Tibial plateau and knee fractures
Upper extremity injuries proximal to mid-forearm. (Distal to forearm goes to Hand)
No septic arthritis involving history of arthroplasty (prosthetic joint) (Transfer out)
Will operate on septic arthritis with fracture hardware (wires, plates)

OVMC Pediatric Orthopedics

  • Emergent Peds Ortho cases less than 16 years old, e.g. open fractures that require OR debridement, should be transferred out via the MAC for uninsured or to the patient's health plan whenever possible
  • All other pediatric orthopedic cases should be referred to OVM Peds Ortho via the Message Pool. All of these cases will be reviewed by Dr. Farrell and he will determine if the case should stay here at OVMC or be referred to Peds Ortho at USC
  • If the case needs referral to USC Peds Ortho, the Ortho clinic here at OVMC will handle the referral to USC

Pediatrics

  • Pediatric attending should be notified for any pediatric patient transferred out
  • Pediatric patients (non-OOP) can be told to return to the Pediatric Urgent Care clinic for follow-up issues
  • For any pediatric patient requiring follow up with a subspecialist (non-OOP), contact the Pediatric Attending on-call as needed for any questions regarding follow-up

Pediatric Subspecialists On-Call

====https://lacounty-my.sharepoint.com/:x:/g/personal/mamccollough_dhs_lacounty_gov/EVZYsT1K_UhNjps63dUNSiMBwPnuoa9OERCoCXE8RZv5qw?e=8Dpqhc

Critical Pediatric Patients

  • DHS PEDIATRIC CRITICAL CARE TRANSPORT WORKFLOW FOR OLIVE VIEW*
    • 1. NICU transports (less than 52 weeks from gestation)
      • a. Call Pediatrics and contact OVMC NICU to see if infant can be admitted to our OVMC NICU.
      • b. For transport to Harbor, call the NICU directly 424-306-5608 and they will work to put together a transport team to come to Olive View to get the neonates. MAC does not need to be contacted for these transports (all of the administrative functions such as reserving a bed, financial clearance, passing along information for MD and RN reports are the responsibility Harbor).
      • c. For transport to LAC, recommend that LAC+USC mimics the procedure for 1a.
      • d. If Harbor/LAC do not offer needed services (such as cooling/ECMO) refer patient to UCLA or CHLA Transfer Center using their internal transport services
      • e. All back transports TO Olive View should be coordinated through MAC
    • 2. PICU transports
      • a. For transports to Harbor and LAC, Olive View to call MAC; MAC will attempt to engage CHLA to transport infant from Olive View to Harbor or LAC
      • b. If CHLA transport team not able to mobilize transport team to take the child to LAC or Harbor within 90 minutes, refer patient to UCLA Transfer Center using their internal transport services
      • c. All back transports TO Olive View should be coordinated through MAC
    • 3. Challenges
      • a. Shannon Thyne and Peter Balingit are available to help troubleshoot any transport issues in real time. PLEASE CALL EARLY to avoid delays in patient care.
      • b. Peter, Shannon, and the Olive View CMO are always available for urgent approval for air transport and/or approval for critical care transport to UCLA.
  • Note that this approach does NOT apply to any non-critical care transports. Do not arrange any BLS transports to DHS facilities without contacting MAC. For non-critical care transports of stable patients, can go through patient's outside health plan. Engage Utilization Management x74890.

Peds patients seen in ED

  • Peds Resident pager 818-313-1739 Also available through Cerner...Consults Auto Paging OVMC
  • Weekdays: 0830am-3:00pm Triage RN should contact Super Track or MSE Attending or NP to screen patient (ESI 3-5) as OK to go to Peds Clinic. MSE note should be completed. Parents are given map and walk over to Peds Clinic.
    • If patient is roomed in the ED, page Peds Resident
  • Weekdays: 7am-9pm, page the Peds Resident
  • Weekdays: 9pm-7am, call the Emerg Med Resident assigned to Peds
  • Overnights, Weekends, Holidays: Pediatric Resident and Emerg Med Resident will share patients
  • At 9pm every day and 0830am on Weekends and Holidays, Peds Resident and Emerg Med Resident should discuss how they want to share patients during the shift
  • DEM PROVIDERS SHOULD CALL PEDS EARLY for any pediatric patient that is likely to be admitted
  • For patients seen overnight, Pediatrics would like DEM providers to contact Peds in the morning and let them know about the patients that were seen

Child Maltreatment/Non-Accidental Trauma/Sexual Abuse

  • OVMC HUB/SCAN Clinic
    • OVMC has its own HUB/DCFS Clinic on campus over in the Women/Children's building. phone x74680
    • This clinic sees children who are victims of both non-accidental trauma and sexual abuse.
    • Staff includes specialized pediatricians, social workers, DCFS case workers, and nurses
    • OVMC HUB Clinic can see patients regardless of their insurance status, including outside health plans.

*Monday-Friday, 8am-8pm: Call the OVMC HUB Clinic x74680

*After-hours, weekends, holidays:

    • Notify the pediatric resident on-call and the Pediatric Attending on-call
    • Place Consult to Social Work if SW is in-house
      • NOTE - Place consult early so they can be present when the parent/caretaker/child is giving the history; THE PROVIDER (EITHER CLINICAL SOCIAL WORK STAFF OR PHYSICIAN) WHO TAKES THE HISTORY SHOULD BE THE ONE WHO CALLS DCFS TO REPORT THE CASE
      • When Social Worker is not present, they will come in for serious child abuse cases/deaths but most routine cases can be handled by CSW team at the HUB clinic or in the ED the next day.
    • Peds Attending will know who from the Dept of Pediatrics is on call for child abuse cases.
    • Peds Attending/HUB Clinic Attending on-call will guide management re: what needs to be done in the ED in regards to labs or imaging and will help get the child scheduled in our HUB Clinic for follow-up. Peds Attending/HUB clinic attending will decide if case is URGENT or NON-URGENT.
    • See below for how to handle URGENT vs NON-URGENT cases

URGENT CASES

  • Step 1: Report case to DCFS (Dept of Children and Family Services); can be done by SW or provider
    • NOTE - WHOEVER TOOK THE HISTORY SHOULD BE THE ONE TO CALL DCFS; CALL CLINICAL SOCIAL WORK EARLY TO BE INVOLVED;
    • Phone - (800) 540-4000
    • You will be given a 19-digit Referral/Case Number that you will need when completing the on-line form. Please document the 19-digit referral/case number in the patient's chart.
  • Step 2: Fill out on-line SCAR (Suspected Child Abuse Referral) form. You MUST have the 19-digit Referral/Case Number in order to complete the on-line SCAR form; it may take up to 2 HOURS for the referral/case # to be activated by DCFS. After you complete the on-line SCAR form, you will get a 16digit tracking number; please document this in the chart.

NON-URGENT CASES

  • Step 1: Peds Attending/HUB Clinic Attending can help decide if case is ok for non-urgent reporting. Use the CARES on line form to report non-urgent cases. https://mandreptla.org/cars.web/
  • For pediatric sexual assault, do not perform a detailed history or exam. History and exam should be brief, just to determine if a medical emergency exists.

After Hours: LAC+USC or Northridge CATS

  • HUB Clinic Attending may say that a child needs to be seen that night or on the weekend. We use LAC+USC HUB Clinic or Northridge CATS clinic. Patient will go with law enforcement. Document law enforcement office name, bade # in the chart. Law enforcement will often decide which center they will take the patient to. We encourage LAC because follow-up is easier. CALL LAC+USC OR NORTHRIDGE AHEAD OF TIME and DOCUMENT WHO YOU SPOKE WITH.

LAC+USC HUB Clinic. 323-409-3601. Ask to speak to Peds Attending who will know HUB clinic provider on-call.

Northridge CATS (Center for Assault Treatment Services) (818) 908-8630 or (818) 908-8632.

Plastic Surgery

Upper Extremity Splinting Recs

OVMC Upper Ext Splinting Recs.pdf

Psychiatry

  • x74340
  • For patients without medical complaints, medically screen patients at Triage or Ambulance Triage. If medically cleared, provider should call x4340 and speak to Psychiatry MD who should approve patient being sent over to the Psych ED
  • If patient is placed into an ED bed and needs emergent psychiatry, order Consult to Psychiatry and call x4340 to speak to Psychiatry MD.

Psych Urgent Care

  • Oliveview Community Mental Health Urgent Care Center
  • operated by LA County Dept of Mental Health
  • located down the street, 14659 Oliveview Drive
  • 818-485-0888
  • hours M-F 8am-7pm, Sat 9am-5:30pm, closed Sundays and holidays
  • Crisis stabilization 24/7 - can place patients on 5150
  • Able to see patients with outside health plans (OOP)

Can I place a patient on an "8 hour hold" like at UCLA?

  • No, we cannot use the Calif law 1799 that allows non-LPS designated facilities/hospitals to place psychiatric patients on an 8-24 hour hold until the patient can be evaluate by a psychiatric team that must come from the outside.
  • LPS stands for Lanterman-Petris-Short Act which allows psychiatric patients to be placed on involuntary holds for 72 hours, etc (e.g. 5150)
  • LPS designated facilities are allowed to receive 5150 patients by EMS, police and accept transfers; LPS designated facilities have psychiatric providers on-site
  • OVMC, Harbor, LAC+USC, Northridge, Glendale Memorial, and others are LPS designated and therefore CANNOT use 1799 to hold patients before psych places them on a hold
  • UCLA NPI is a LPS designated facility also
  • UCLA RR is technically NOT an LPS designated facility and therefore CAN use the 1779 law to hold patients until psychiatry comes to see them.
  • What we can do at OVMC:
    • 1. If patients are brought in by police, if possible, insist that the police write the hold if the patient said to police "I want to kill myself", police found pt standing with noose around his neck, etc. Officers are often resistent to writing the 5150s and we need to insist more often that they do. Blank 5150's are at the charge nurse chair/desk in the forms rack on the left.
    • 2. place 1:1 sitters on patients
    • 3. If patient will cooperate, have patient change into a gown. If patient bolts out the door, much easier to spot them wearing a gown. Don't fight the patient on this issue though. Please avoid agitating the patient.
    • 4. Call psych early
    • 5. Check in with patient often to update them on the wait for psych
    • 6. Feed patients
    • 7. Use Xyprexa earlier to decrease chance of patient escalating
    • 8. If you are worried a patient may bolt and psych has not seen the patient yet, you can call psych back and state you have a "psych emergency" and you need them "stat". There is an agreement between the departments that psych will come immediately if we say it's an emergency assuming they are not already dealing with an emergency on their end. Please use this judiciously. We don't want the "boy who cried wolf" problem.
    • 9. If the patient does leave and you felt the is concern enough for the patient to be on a 5150, call the Sheriff. If you believe the patient was likely to be put on a 5150 hold, make sure the Sheriffs know this. They are not allowed to just bring the patient back just because we say so. They will go look for the patient, engage the patient, and if the patient says or does something that is concerning for SI/HI/gravely disabled, then the Sheriffs can bring them back. More often than not the patient is brought back. The Sheriff is very good about engaging these patients well.

Radiology

On-Call Radiologist and In-House Radiology Coverage Schedule

On-Call Tech Supervisor Schedule


In House Coverage

  • M-F 6 pm-10 pm: STAT OVMC Radiology Attending in-house
  • M-F 10pm-06:30am: STAT RADS or US ROC (see After Hours Coverage)
  • Sat, Sun Holidays before 1pm: General Radiology Attending in-house
  • Sat, Sun, Holidays 1p-7 pm Sat: STAT OVMC Radiology Attending in-house
  • Sat, Sun and Holidays 7pm-7am: STAT RADS or US ROC (See After Hours Coverage)

StatRad Coverage for CT and MRI Overnight and Weekend Reads Only

USROC Coverage for Ultrasound Overnight and Weekend Reads Only

  • Monday-Friday 10p-06:30am and Weekends/Holidays 7p-7a
  • 866-448-7762

Over-Reads

  • Urgent or Emergent?
    • Radiology to call x3649 or x4938 and report to ED Attending
    • ED Attending shall document in the........TBD
  • Non-Urgent?
    • Radiology to email patient name, MRUN, date of study, and findings to Ari Orue NP at aorue@dhs.lacounty.gov

Film Copy Request and Outside Film Imaging Upload

  • Film Copy Request
    • Tell ED clerk that you need patient films copied onto a CD
    • ED Clerk will complete the Radiology Request form and handle the request with Radiology
      • Monday - Friday 8am-11pm: Release of Information (ROI) Unit, 1B114
      • After 11pm, weekends and holidays: ED Radiology
    • Request Form also available on the OVMC Intranet...Departments....Health Information Management...Radiology Forms
  • Outside Film Imaging Upload in Cerner
    • Tell ED clerk that you need patient imaging CD uploaded into Orchid/Cerner; give ED clerk the CD
    • ED Clerk will complete the Radiology Request form and handle the request with Radiology
      • Monday - Friday 8am-4:30pm: General Radiology 2D141
      • After 4:30pm, weekends, and holidays: ED Radiology
    • Request Form also available on OVMC Intranet...Departments...Health Information Management...Radiology Forms

Plain Films and No Need for Pregnancy Tests

  • July 2016 - In a discussion with Dr. Patel from Radiology and Mike Ruiz, Sup Rad Tech, it was re-affirmed that women do NOT require a pregnancy test prior to plain film X-rays
  • Under protocol, Radiology techs will ask the patient if she is possibly pregnant and the date of her LMP period (should be within the last 4 weeks).
  • As per the American College off Radiology and the OVMC Dept of Radiology: If a patient can reliably answer that 1) she cannot be pregnant (for example, she is not sexually active, or she is using an effective form of birth control, or she is biologically incapable of conceiving) and that 2) she had a recent complete menstrual period, then it is reasonable to proceed with a medically indicated diagnostic X-ray test of the abdomen or pelvis. The last complete menstrual period should have occurred within the previous 4 weeks.
  • Prior to CT scans, a pregnancy test should be obtained as the amount of radiation is higher. If, however, the patient's medical condition could deteriorate and the CT scan is needed emergently (e.g. head CT for AMS), then a pregnancy test may not always be obtained prior to the scan.

Fluoroscopy

  • On rare occasion, fluoroscopy might be needed to reduce a fracture or fracture/dislocation
  • Fluoroscopy is available Mon-Fri 8am-4pm, call Main Radiology x74059
  • After hours, availability for fluoroscopy will depend upon hospital tech availability; talk to ED Radiology tech
  • Order in Cerner: RF Fluoroscopy Under 1 hour

Interventional Radiology

Protocol for Urgent Interventional Radiology Procedures

  • 1. ED Provider contacts IR provider on-duty or on-call to determine the appropriate timing of the requested procedures and determine if the procedure can be done in next few days.
    • a. Weekdays 8am-4:30pm: call x74554/66088/73931 to find the interventionalist on-duty. Also available on OVMC Intranet…..see under Radiology On-Call Schedule. Also available on Amion...OV IM......All Services
    • b. After Hours: Operator has Interventional Radiology on-call schedule. Also available on OVMC Intranet….see under Radiology On-Call Schedule. Also available on Amion....OV IM......All Services
    • c. See below for Interventional Radiology procedures available after hours
  • 2. If patient is on anticoagulant, IR provider on-duty or on-call will determine whether or not anticoagulants need to be held and for how long.
  • 3. If procedure can be scheduled for the next business day or two, ED Provider obtains pre-procedure labs/studies including COVID-19 testing as requested by the IR provider on-call . COVID-19 testing should be ordered as Admit Asymptomatic.
  • 4. ED Provider places an order in Cerner for the desired procedure, indicating FUTURE ORDER:
Issue/Problem Order in Cerner
Dialysis fistula not working/declotting IR angiogram arteriovenous shunt
Tunneled catheter needed IR central venous catheter tunneled
Exchange nephrostomy tube IR Exchange of nephrostomy catheter
G-Tube change IR Gastrointestinal Tube or Catheter Change
  • 5. ED Provider sends a message through ORCHID using new ED to IR message pool. OVM Interventional Radiology ED/UCC Urgent Follow Up ED Provider will document name of IR Provider who approved procedure and time frame, e.g 1-2 days.
  • 6. ED Provider gives patient a Patient Education/Discharge Instructions including NPO after midnight except for medications with sips of water. Directions regarding anticoagulants should be answered by IR Provider on-duty or on-call. DC Instructions located in Cerner...Patient Education.....Departmental.....Outpatient Followup Interventional Radiology Procedure
  • 7. Patient is to arrange transportation to and from OVMC on the day of the procedure.
  • 8. IR Provider will tell ED provider when the patient is to show up for the procedure; patient is to report to OSPA 2B-121 on the day of procedure.

AVAILABLE and NOT AVAILABLE Interventional Radiology After Hours

  • (Operator has Interventional Radiology on-call schedule. Also available on OVMC Intranet under Radiology On-Call Schedule. Also available on Amion...OV IM....All Services)
  • AVAILABLE
    • Percutaneous abscess drainage
    • Image-guided paracentesis
    • Image-guided thoracentesis
    • Percutaneous cholecystostomy
    • Percutaneous nephrostomy/nephroureteral stent placement and other urologic intervention as applicable
    • Transhepatic biliary drainage and other biliary intervention as applicable
    • Central venous access including placement of tunneled/non-tunneled catheter
    • IVC filter placement
    • Transarterial embolization for unremitting hemorrhage refractory to conventional therapy
    • IR Consultation
  • NOT AVAILABLE Interventional Radiology After Hours (Only available Mon-Fri 8am-5pm)
    • No MSK procedures (e.g. no joint aspirations)
    • No LPs
    • No G/GJ tube replacement (if tube fell out, place foley temporarily)

Dialysis AV Fistula Evaluation

  • For evaluation for flow, order "US Duplex Hemodialysis Access Flow"
  • For de-clotting by IR, order "IR Angiogram Arteriovenous Shunt"

MRI After Hours

  • MRI tech is in-house Mon-Fri 7am to midnight. All other hours are considered off-hours.
  • MRI tech is on-call for emergent cases limited to acute cord compression and rarely acute CVAs if requested by the Neuro Service for patient management (e.g. large CVA that may be considered for transfer to UCLA for intracerebral angio therapy)
  • Findings that suggest acute cord compression include:
    • 1. Bladder dysfunction (urinary retention or incontinence)
    • 2. Bilateral limb weakness
    • 3. Sensory abnormalities with a sensory level
    • 4. Flaccid areflexia with upgoing toes, loss of anal sphincter tone
  • Some cases may be able to wait until the morning hours such as IVDA, fever and back pain without neuro findings.
  • To request an emergent MRI when the tech is not here, first contact the STAT Radiologist in-house Mon-Fri until 11pm and weekends/holidays until 7pm. If there is no STAT Radiologist in-house (e.g. after 11pm), contact the Neuro Radiologist on standby (on-call).
    • On-call schedule can be found on OVMC Intranet...Departments...Radiology...Radiology Faculty Schedule Current Month.....Neuro/MRI Standby. Operator has on-call schedule also and pager #s.
    • If no STAT radiologist, ED MD pages the Neuro Radiologist on standby (on-call) and requests MRI.
  • STAT Radiologist or Neuro Radiology Attending then pages the MRI tech.
  • For cord compression cases, as much as possible, try to narrow down the level where the possible pathology lies e.g. lumbar vs thoracic. If this is not possible, a "cord compression" MRI protocol can be performed that will give a large field of view (sagittal images) that will cover the whole spine in two slabs (cervical through mid-thoracic and mid-thoracic through lumbar), along with axial T2 images through the whole spine. Will not give great detail, but will see gross cord compression or high grade lumbar spinal canal stenosis. Decision about what imaging is performed will be up to the Neuro radiologist on-call.

MRI for Large Patients

  • Weight limits and gantry (size) limits: (Note: measure patient at widest width either top to bottom or left to right; must be able to fit into MRI scanner)
    • OVMC - 350lbs and 60cm
    • LAC+USC - 300 lbs and 19inches
    • Harbor- one MRI: 350lb and 65cm; 2nd MRI: 450 lbs and 60cm
    • Downey MRI Center, 8515 E. Florence Ave, Downey CA, 90240, 562-904-1340 (Open 7 days a week, 0630am-11pm) - 550 lbs and 17inches from top of table to scanner
    • Garfield Insight Imaging Center, located at Garfield Medical Center, 555 N. Garfield Ave, Monterey Park CA, 91754, 626-572-0912 (Open Mon-Fri 7am-6pm) - 550 lbs and 74cm. Need to fax patient demographic information and order request for imaging.
  • These are the manufacturers weight limits. We have to be mindful and not get too close to the limit, or the table will break
  • Harbor should be considered first option if possible as they have a scanner up to 450lbs
  • Our MRI techs should help expedite this; otherwise escalate to the Radiologist
  • Call ANO for transportation. Patient will be sent there via ambulance and then returned via same ambulance.
  • If the patient requires sedation, this will be a problem for Downey or Garfield imaging centers.
  • Utilization Management can help if the patient has insurance
  • Ensure a CD of the imaging is brought back with the patient if sent to Downey or Garfield and if possible have the imaging read by their radiologist also just in case we cannot upload the images
  • For imaging done as an outpatient after ED discharge, order as Future Order; Patient should call OVMC MRI to schedule and OVMC MRI will then arrange the MRI at Downey

OVMC Weight Limits for Imaging

  • ED xray table - 500lbs
  • ED CT scanner - 550lbs* (*Note - an additional black table located in the ED CT Room can be used and the weight limit is then 650lbs)
  • MRI - 350lbs
  • Downey MRI - 600lbs (see MRI Imaging for Large Patients)
  • Cath Lab - 500lbs
  • Nuclear Medicine - 300lbs

Barium/Air Enemas for Intussception Cases

  • Surgical resident on-call should be made aware of any pediatric patient who is considered to have a possibility of intussusception
  • Patient should have no contraindication to a barium or air enema such as evidence of peritonitis or perforation.
  • M-F Business Hours: Peds Radiologist Dr. Chawla usually performs the BEs/AEs
  • M-F 6 pm-11 pm: STAT Attendings will perform any BEs/AEs during their STAT shift
  • Sat, Sun Holidays before 1pm: General Radiology Attending is responsible
  • Sat, Sun, Holidays 1p-7 pm Sat: STAT attendings will perform any BEs/AEs during their STAT shift
  • M-F 11 pm- 7am and Sat, Sun, Holidays 7pm-7 am: General standby call is responsible for performing the BEs/AEs

UGI for Malrotation/Volvulus Cases in Infants

  • As per Dr. Andrews of Radiology, we have the ability to do an Upper GI 24/7 to evaluate an infant for malrotation/volvulus
  • Contact the ED Radiology tech if a study is required

Breast Mass and Infection Management and Imaging April 2023

  • OOP patients should be referred back to their Health Plan/PCP.
  • RADIOLOGY has protocol in place for breast imaging follow-up. They will ensure patient receives their results and they will refer patients to Breast Surgery who have concerning findings. All patients require imaging before being sent to Breast Surgery clinic.

Joint and Spine Injections

  • Dr. Raffi Salibian x75145
  • Dr. Catherine Yim x74082
  • Joints:
    • Order: X-ray plain view
    • Future Order: US aspirate/injection/biopsy (use Relevant History to indicate which joint)
    • CBC and Coags if patient is coagulopathic
  • Lumbar Spine (facets and epidurals):
    • Send Message Center message to Dr. Catherine Yim requesting lumbar spine injection with the name of the ED Attending requesting the procedure.
    • Future Order: MRI lumbar spine (Patient must call to schedule the MRI. Radiology phone # is pre-printed on ED Patient Summary/Discharge Instructions)
    • Future Order: IR facet inject lumbar (need kg weight)
    • CBC, Coags please
  • Radiology will contact the ED TFU Coordinator or Urgent Care TFU Coordinator through the Message Pool with any problems

Renal

Workflow to Access Dialysis

  • ED calls on-call Renal Fellow for all HD/PD or potential HD initiation, regardless of reason for admission - e.g., dialysis patient being admitted for cellulitis or elective procedure, etc.
  • Fellows review and discuss case and plans for possible transfer with Renal Consult Attending.
  • If transfer is deemed necessary, Renal Consult Attending calls and discusses case with Dr. Chi Pham.
  • Dr. Pham will work behind the scene (e.g., discuss with HD service/ANO 74586 to come up with creative/alternative plans if possible).
  • Dr. Pham will then call "ED hotline" to give final plan. ED hotline number: 73648 and 73649
  • In the event when Dr. Pham is not available: Renal Consult Attending discusses case and transfer plans with Dr. Jafari. *There will be one week this academic year when both Dr. Pham and Dr. Jafari will be out of town (June 23-28, 2020), in which case, Dr. Kamarzarian will make the final call regarding transfers.

Surgery

  • For surgical vs medicine admissions, see Surgical Subspecialty Admissions Guidelines under Admission Guidelines.
  • For ALL surgical transfers out, ED Attending needs to speak to Surgical Subspecialty Attending

911 Trauma Re-Triage

  • To be used for trauma patients brought in by EMS by mistake or walk-in/drop-off patients with life-threatening traumatic injuries requiring EMERGENT (aka immediate) surgical intervention that we do not have at OVMC e.g. neurosurgical
  • Other EMERGENT surgical cases such as stab wounds or GSWs should be evaluated with the consult surgical resident (and Attending as needed) on a case by case basis as many of these such as abdominal trauma may be able to be cared for here at OVMC by the Dept of Surgery
  • Please, if possible, ensure the Surgical Attending on-call is aware of the case. We have transferred trauma patients out that could have been taken care of by our Surgery Dept.
  • Step 1: You MUST HAVE an ACCEPTING PHYSICIAN (new EMS policy Sept 2020)
    • Adult Patients
      • Holy Cross, by Trauma Center policy, is OVMC's designated Trauma Center.
      • Call Holy Cross, ask for Charge RN and get an accepting physician; Holy Cross ED # 818-496-3302
    • Pediatric Patients, 14 yrs old or younger
      • Call Northridge Hospital, ask for Charge RN and get an accepting physician; Northridge ED #818-885-5396
  • Step 2: Call 911 and tell them you have a "Trauma Re-Triage" patient
    • Do NOT call the MAC Center
  • Copy all records and imaging but do not delay transfer
  • Because of the limited scope of practice by the paramedics, if the patient has blood hanging or has any drips, then our OVMC Critical Care Transport team will accompany the patient in the EMS ambulance to Holy Cross.
  • County Policy: 9-1-1 Trauma Re-Triage – This section applies to injured patients in emergency departments of non-trauma centers whose injuries were initially estimated by EMS to be less serious (under triaged) or patients who self-transported (walk-in) to a non-trauma center, and subsequently assessed by the non-trauma center physician to require immediate trauma center care. The referring facility shall utilize the procedure outlined below to expedite transfer arrangements and rapid transport to the trauma center. This process should be reserved for patients with life-threatening traumatic injuries requiring emergent surgical intervention.
    • A. Determine if the injured patient meets any of the following 9-1-1 Trauma Re- Triage criteria:
      • 1. Persistent signs of poor perfusion
      • 2. Need for immediate blood replacement therapy
      • 3. Intubation required
      • 4. Glasgow Coma Score less than 9
      • 5. Glasgow Coma Score deteriorating by 2 or more points during observation
      • 6. Penetrating injuries to head, neck and torso
      • 7. Extremity injury with neurovascular compromise or loss of pulses
      • 8. Patients, who in the judgment of the evaluating emergency physician, have high likelihood of requiring emergent life- or limb-saving intervention within two (2) hours.
    • B. Contact the designated receiving trauma center or pediatric trauma center if the patient is less than or equal to 14 years of age and transport does not exceed 30 min. Do not delay transfer by initiating any diagnostic procedures that do not have direct impact on immediate resuscitative measures.
    • C. Contact 9-1-1 for transportation. The paramedic scope of practice (Ref. No. 803) does not include paralyzing agents and blood products.
    • D. Prepare patient and available medical records for immediate transport. Do not delay transport for medical records which could be sent at a later time.
    • E. EMS has no immediate solution if there is refusal by the Trauma Center; remind them of the EMS 911 Trauma Re-Triage Policy, that they are our receiving facility; please let McCollough know about any refusals

Surgery Clinic Referral Guidelines

  • Econsult: All hernias and gallbladders need the hernia/chole form filled out - asks about BMI and cigarette smoking
  • Surgery will not perform hernia repair or cholecystectomy if BMI >35
  • Surgery will not perform hernia repair if patient smokes
  • For breast cases, see WikEM OVMC:ED....Radiology....Breast imaging

Breast Issues

  • For breast cases, see WikEM OVMC:ED....Radiology....Breast Mass and Infection Management and Imaging

Cardiothoracic Surgery

  • We have non-cardiac Cardiothoracic Surgery at OVMC. If you have a case, consult General Surgery who will consult with Cardiothoracic Fellow/Attending

Neurosurgery

  • See Transfers...Higher Level of Care....Neurosurgery

Vascular Surgery

  • No update

Laboratory

Critical Lab Results on ED patients, ED Boarders (Admitted Patients), and ICU patients

  • Lab tech will determine if a patient is an ED patient or an ED Boarder prior to calling a critical lab result. Lab techs have a cheat sheet that outlines this process.
    • ED patients: critical lab report goes to ED provider or attending. Lab tech should contact ED provider in the provider room based on patient location (main ED room or SuperTrack room. Lab has been given a list of ED patient rooms and the MD Room associated.
    • ED Boarder/Admitted patients: Lab tech should call the ED nurse directly based on patient location in the ED. Nurse will forward results to the inpatient team.
    • All ICU patients: Lab tech should contact the ED provider directly for all critical labs on ICU patients since ICU boarders are still managed by the ED team.

Critical Lab Results on Discharged ED Patients

To be added

Infrequent Lab Orders - Instructions

Rapid Strep

  • Order as Rapid Strep Group A Ag. Do NOT order POC Rapid Strep.
  • Run 24/7 when the test is received in the lab. General turnaround time 30mins.

Varicella Testing

  • For Varicella testing,VZV DNA Qaul RT PCR-SO

Influenza Testing

  • Order as Influenza A/B & RSV,RNA by PCR.
  • Generally run every 3hrs, starting at 9am,12n,3pm,6pm,9pm. Tests takes 2 hour turnaround.

Chlamydia/Neisseria gonorrhea RNA:

  • females - urine or cervical (not vaginal)
  • males - urine or urethral
  • urine - yellow tube, fluid level in between black lines
  • cervical/urethral - white swab to clean mucus, blue swab for specimen collection
  • don't use Rectal-SO or Throat-SO orderable unless you are specifically checking these sites

Malaria/Thin Smear

  • Order as Blood Parasite Exam

Pathology Tissue Request:

  • label prints as soon as the order is signed and cannot easily be printed again.
  • printed in MD room on label printer if ordered from computer in MD room
  • printed in patient room on label printer if ordered from computer in patient room

Peripheral Smear Exam by Lab: usually ordered by non Heme/Onc provider for review by lab tech

Peripheral Smear for Provider Pickup (Slide Wirght Giemsa): usually ordered in consultation with Heme/Onc for MD to personally review

Specimen Collection Instructions - OVMC Micro Quick Reference Guide

http://myladhs.lacounty.gov/ov/Pathology/Documents/Microbiology%20Specimen%20Collection.pdf

Blood Bank

Massive Transfusion Protocol

  • MTP Recommendations:
    • 1 unit plasma for every 1 unit PRBCs
    • 1 unit of platelets for every 6 unit PRBCs
    • Due to necessity of thawing plasma units, plasma will be given when available
  • Step 1: Call Blood Bank x74062 to activate MTP
    • a. Need Name and MRUN (John Doe name/MRUN from Reg ok)
    • b. Need Attending Name
  • Step 2: Order “Blood Product Pick Up Slip – MTP” in Cerner
    • a. MD or RN can do this
    • b. Clerk prints out pick-up slip
    • c. No co-sign needed
  • Step 3: Send runner to blood bank with printed pick-up slip to retrieve blood
    • a. If available, give them:
      • Signed Emergency Blood Release Form
      • Type and Cross Specimen
  • Step 4: Blood Bank will send up unmatched Type O or type-specific cross matched units with runner
  • Step 5: Send Type and Cross specimen STAT if not already sent
    • a. MD to order in Cerner
    • b. Specimen to be brought directly to Blood Bank
  • Need more units?
    • a. ALWAYS give them “Blood Product Pick Up Slip”
    • b. If not yet sent, give them Signed Emergency Blood Release Form
  • Follow-up: Have MD order blood products and transfusion orders for blood products infused
    • one blanket order for 6 PRBCs, 6 plasma, 1 platelets, 1 cryo is acceptable. Order can be reconciled later to reflect exact amounts

Pharmacy

  • ED Pharmacist Mon-Fri 8am-4pm x75490

Hours

  • Monday - Friday 7:30am-8pm; Sat, Sun, Holidays 8:30am-4:30pm

OVMC Empiric Antibiotic Recommendations 2019-2020

http://myladhs.lacounty.gov/ov/DEM/Documents/2019-2020%20Empiric%20Antibiotic%20Recommendation%20Guide.pdf

Rhogam Administration

  • Cerner: RhIG Request, click on both Administer and RhIG Request, then Initiate, then Modify both: Administer Intramuscular and RhIG Request 1 vial and reason Prenatal. Then Orders for Signature and Sign.

Medication Refill Patient Handout

http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Pharmacy%20Refills.pdf

Safe Prescribing and Narcan Handouts

http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Safe%20Prescribing%20ED%20Spanish.pdf

Buprenorphine Administraton

  • See Substance Use Disorder

Physical Therapy, Occupational Therapy and Orthotics

ED Orthopedic Equipment and Hernia Trusses

  • Crutches, walkers, canes – stored in ED1A and ED5 clean utility rooms
  • Hard shoes, wrist braces, ankle splints - stored in Orthopedic Storage Room
  • Hernia trusses – stored in Room #43

DME Supplies to be ordered as outpatient

  • Order supplies such as compression stockings as "DME..."
  • Order will ask Diagnosis, length of use, etc. For compression stockings, use 20-30mmHg
  • Instruct patient to go to Physical Therapy room 1D120 to pick up the supply
  • Do NOT use for OOP patients; please send to health plan.
  • Link will take you to list of DME supplies: http://myladhs.lacounty.gov/ov/DEM/Documents/DME%20Supplies.xlsx?Web=1

Urgent Spinal Bracing - TLSO Brace, Miami J Collar, St. Jude Collar etc

  • Place order in Cerner: Orthotic Equipment
    • Write "TLSO Brace" under Special Instructions
  • Call VALLEY INSTITUTE OF PROSTHETICS AND ORTHOTICS (VIPO)
    • Cell phone: (661) 319-2777 Mike Nelson, CPO
      • Call 24/7 for URGENT spinal bracing otherwise wait until daytime hours
      • IPO headquarters: 661-253-1191 or after hours: (800) 439-1005
    • VIPO will come to ED with brace or collar if needed before discharge
    • Otherwise patient can be sent to our Physical Therapy on T/Th to pickup brace or patient can go to the company headquarters in Santa Clarita
  • If Mike Nelson cannot be reached, the following vendors can be tried (all have DHS contracts):
    • PERFORMANCE PROSTHETIC AND ORTHOTIC CENTER, INC (310) 829-2322 LERMAN AND SON (310) 659-2290
    • ALPHA ORTHOPEDIC APPLIANCE COMPANY, INC (323) 721-6706
    • HANGER PROSTHETICS & ORTHOTICS (562) 233-4481
    • DYNAMIC ORTHOTICS & PROSTHETICS, INC (213) 383-9212 ORTHO ENGINEERING, INC. (310) 559-5996
    • PRECISION ORTHOTICS & PROSTHETIC, INC. (213) 388-5847

Wheelchairs

  • Wheelchairs are kept in the ED for after-hours and weekend patients to avoid admissions, e.g. wheelchair-bound patients or patients requiring wheelchair for example bilateral ankle fractures
  • Ask RNs where they are kept; or Use Backup Supply list (top of WikEM) and search where wheelchairs are kept
  • Alternative ordering process:
    • Order DME in Cerner- Do NOT order on OOP patients - must go to Health Plan for wheelchair
    • Order Physical Therapy Outpatient Future Order also in Cerner
    • Patient should be sent to Physical Therapy. Patient will be financially screened. If patient has no insurance to pay for wheelchair through DHS, patient/family will be given list of outside vendors to contact.

Physical Therapy and Occupational Therapy Outpatient

  • Do NOT send OOP; refer patient to their health plan
  • Order as Physical Therapy Outpatient or Occupational Therapy Outpatient Future Order in Cerner
  • Patient should be told to go to PT/OT Office, 1st floor, XXXXX. Patient will be financially screened. If patient has no insurance, patient/family will be given list of outside physical therapy centers to contact.

Guidelines

  • Physical Therapy
    • Post-op or acute shoulder injuries
    • Neck, trunk, lower extremities
    • Face
    • Gait, balance, mobility and transfer training
    • Conditioning
    • Cardiopulmonary
    • Lymphedema
    • Chronic Wounds
    • Neuro conditions (except upper extremity)
  • Occupational Therapy (in general)
    • Finger, hand, elbow, wrist injury, fracture, or post-op
    • Chronic shoulder issues/pain
    • Frozen shoulder
    • If patient has difficulty with ADLs, such as bathing, dressing, grooming, feeding
    • Neuro conditions that affect the upper extremity
    • Fine motor control

Back Pain Classes

  • Order as Physical Therapy Outpatient Future Order in Cerner; PT Program: PT Eval and PT Reasons: Back Class as choices in the order

For Emergency Calls After Hours

  • You may call Physical Therapy by having OVMC Operator use the Disaster Fan-Out list to reach Physical Therapy. Joann York will be the first one tried, then other staff within the Physical Therapy Dept.

Procedure Clinic

Paracentesis, Thoracentesis, Lumbar Puncture

  • Medicine Procedure Service (sponsored by the Department of Medicine, Division of Pulmonary and Critical Care)
  • Send requests to OVM Procedure Service ED/UC Urgent Followup Message Pool and patients will be contacted with instructions and scheduled for the requested procedure.
  • Patients will check into Outpatient Special Procedures Area on the 2nd floor on day of procedure. (Procedures done in Medicine Procedure Room on 5th floor).
  • Ensure patient has good contact phone number in ORCHID. Appointment will be mailed.
  • If patient does NOT have reliable phone number, please page Procedure Service Pager 818-313-1733 or x73820 (M-F 8 AM to 4 PM) and we will attempt to give a date/time/instructions.
  • If lab tests are needed on the specimen, please request this in Orchid message to Lisa Morgan RN
  • Patients will be financially cleared prior to scheduled appt.
  • Followup appts for those who need procedures such as paracentesis regularly will be arranged by the Medicine Procedure Service.

Respiratory Therapy

Respiratory Therapy contact phone numbers

  • RT supervisor x75038
  • RT DEM resp therapist x75581
  • RT Lead resp therapist x75331

BiPAP, Transporting patients upstairs on portable BiPAP

  • Often we have patients on BiPAP who need to be admitted upstairs.
  • RT currently has 3 BiPAP (V60) machines that have a battery backup so patients can be transported upstairs without turning off the BiPAP
  • Ideally, before placing a patient on BiPAP, we should tell RT that the patient is likely to be admitted so RT can place the patient on a BiPAP machine that has battery backup.
  • If the patient is already on BiPAP that does not have battery backup AND taking the patient off BiPAP would be detrimental to the patient, ask RT about switching the patient to a unit that has battery backup
  • If absolutely necessary, RT has the option to rent a BiPAP machine which can generally be here within 30-60mins.
  • RT Supervisor Jim Pratt is always available (RT is able to page him) if a question cannot be answered by RT

Home O2, How to obtain

  • Call Resp Therapy x74422
  • If already on oxygen and has moved to L.A., lost insurance, etc, will need to prove need for home O2. Get pulse ox on room air. Qualifies if O2 Sat less than 88% on room air.
  • Resp Therapy will bring a Durable Medical Equipment form that will need to be filled out by the ED provider
  • Resp Therapy will contact the company, fax over the form, and arrange for delivery
  • O2 TANK CAN BE DELIVERED TO THE ED so patient can leave with O2. More tanks will be arranged to be sent to patient's home
  • On occasion, the company may not have O2 tanks readily available in which case patient needs to be admitted to the hospital
  • If patient has an outside health plan (OOP), UR may need to be involved for coordination of care

Social Work

Contacting Social Worker

  • "Consult to Social Work" in Cerner - will send automatic page to SW and fax to the SW office
    • Social Work 7am - 7:30pm pager 818-313-1759
    • Social Work 7:30p-7am (off campus) 818-313-1637 for emergencies such as deaths, significant child abuse
    • Social Work ED Office 74930
    • Social Work 1st floor Office 74236

Sexual Assault

  • OVMC does not have an adult Sexual Assault Nurse Examiner (SANE)
  • Call police dept in jurisdiction/city where assault occurred
  • Police must take patient to our closest center for sexual assaults which is Northridge Hospital
  • Northridge Hospital Center for Assault Treatment Services 818-908-8630

Child Maltreatment/Abuse

  • See Pediatrics

Transporting patients home

  • For patients without ability to get home (e.g. brought in by EMS), and no family or friends to take them home, first option is to have patients wait in waiting room until bus resumes in morning.
  • SOCIAL WORKER DOES NOT HAVE BUS TOKENS
  • If more urgent transportation is necessary, County Trans can be used on a case-by-case basis to transport patient home. Patient must have a key to house/apartment. County Trans will not transport to shelters.

Translation Services

  • In Person Translation Services for Hard of Hearing, Deaf, Deaf Blind, and Non ASL Speakers
    • For American Sign Language, Tactile, and Certified Deaf, In-Person Interpreter Services: Please contact Accommodating Ideas at (800)257-1783 M-F 8:00am to 10:00pm; for Weekends, Holidays and after above hours, call Heather C. at (818)481-9028.
      • They work with contractors and will aim to provide you with an interpreter as soon as one is available.
    • Please have Accommodating Ideas form completed and available when you call:
      • Always include your P.O. Number: DO-HO-19034844-1 effective 09/25/18 thru 06/31/19
      • Your interpreter must be requested for a minimum of 2 hours
      • Our ED clerks will email Accommodating Ideas at aiterps@ai-ada.com & always CC: Laura Onofre, CHI at Lonofre@dhs.lacounty.gov for invoicing purposes and verification
    • You may reach Laura Onofre, CHI at (747) 210-3411 M-F 8:00 am to 4:30 pm, for any support or clarification of the process

Olive View Trauma Recovery Center

  • We provide mental health and wrap-around case management for victims of crime in the San Fernando and Antelope Valleys.
  • Who is eligible for services?
    • Anyone who has been a victim of crime in the past 3 years and/or the victim’s family members.
      • Has a need for mental health and/or case management.
      • Not currently under the care of a mental health professional.
  • We aim to serve:
    • 1. Crime victims who typically are unable to access traditional services, including, but not limited to, victims who are homeless, chronically mentally ill, of diverse ethnicity, members of immigrant and refugee groups, disabled, who have severe trauma-related symptoms or complex psychological issues, or juvenile victims, including minors who have had contact with the juvenile dependency or justice system.
    • 2. Victims of a wide range of crimes, including, but not limited to, victims of sexual assault, domestic violence, physical assault, shooting, stabbing, human trafficking, and vehicular assault, and family members of victims.
  • How do I refer a patient?
    • 1. From Olive View- In ORCHID, place a social work consult with the reason “Other” and write “Trauma Recovery Center Referral” in the comments.
    • 2. From outside Olive View- go to our website https://oliveviewtrc.org/ and use the referral form tab.
  • FAQs
    • 1. Do you provide services for children? Yes
    • 2. What if the crime happened outside the U.S.? We can still provide services to the victim.
    • 3. Does the potential client have to be DHS eligible? No, we can provide services regardless of insurance plan or lack thereof.
  • Email: olvtrc@dhs.lacounty.gov
  • Phone: (747)210-4800
  • Web: oliveviewtrc.org
  • Social: Instagram – @oliveview_trc

Medico-Legal Resources

Olive View now has a Medical Legal Community Partnership (MLCP) in conjunction with Neighborhood Legal Services. If you have a patient who has legal issues that impact their health (unsafe housing, MediCal issues, immigration, employment, etc) they can now consult with a lawyer on the OV campus through the MLCP. There is a lawyer available by appointment in the social work office on Tuesdays and Thursdays. The way to refer is to put in a social work consult order for the patient with the reason as "other" and in the comments write "request MLCP visit for..." with the reason for the referral. See below flyers for more information about areas where they can help.

  • MLCP English: [1]
  • MLCP Spanish: [2]

Violence Intervention Programs

Immigration Resources

The changes to the public charge rule went into effect in February 2020. This has created high levels of fear among our patients because it has the potential to impact future adjustments in immigration status. There is lots of misinformation out there about these changes. For the most part, our patients can continue to obtain healthcare within the DHS without any problem. If a patient has a concern about whether receiving care or signing up for benefits will impact their ability to adjust their immigration status, please give them the attached flyer from the Office of Immigrant Affairs of Los Angeles County. They are available to help answer questions about what these changes mean for specific patients and families. Public Charge Information Card: Link to Info Card

Community Resources

Substance Use Disorders

Substance Abuse Counselors in the ED and SASH Hotline

Opioid Use Disorder Recognition and Treatment/Bridge Program

Goal is to recognize opioid use disorder and initiate treatment with buprenorphine or methadone while the patient is in the ED or hospitalized.

  • Consult Social Work for ALL Opioid Use Disorder patients even if they do not want treatment
    • Consult to Social Work......Substance Abuse.....free text OUD
    • V. Figueroa is our Substance Use Coordinator, Mon-Fri, 8am-5pm, 818-792-0407
  • Medications for Opioid Use Disorder (MOUD) On-call provider 8am-8pm 7 days per week: 818-313-1451
    • Bridge provider on-call can help with recognition of OUD, help with buprenorphine or methadone initiation in the ED and MOUD provider will make sure the patient gets follow-up
  • OVM MAT Bridge ED/UC Urgent Follow Up Message Pool to refer DHS patients to Bridge for follow up.
      • PLEASE DOUBLE CHECK PATIENT'S CONTACT PHONE NUMBER IN CERNER
  • Additional Resources:
    • California Poison Control 24/7 access to addiction fellow/attending for help with difficult cases: 844-326-2626
    • UCSF Substance Use Warmline, access to help with difficult cases, Monday-Friday 6am-5pm: 855-300-3595
    • ovmcbridge.org has a lot of education, videos on a variety of SUD topics

Buprenorphine and Methadone Administration in the ED

  • For any patient with opioid use disorder, OD, withdrawal or seeking care, please page the Meds for Opioid Use Disorder provider on-call 8am-8pm 7 days per week, 818-313-1451
  • Call Dr. McCollough if unable to reach MOUD provider OR anytime 8pm-8am. 310-614-5306 WE WANT TO KNOW ABOUT ALL OF THESE PATIENTS!
  • Please also Consult to Social Work....Substance Use Disorder....OUD in free text
  • Viviana Figueroa is the Substance Use Navigator for the Bridge OUD program - 747-210-5625, pager 818-226-4824, Mon-Fri 8am-5pm
  • ED initiation of buprenorphine (Bup) for patients with opiate use disorder has been shown to increase likelihood patients will continue with addiction treatment. Bup has been shown to decrease mortality.
  • ED Bridge guidelines encourage a higher loading dose of Bup (up to 32mg) which allows patients time to get into an outside addiction treatment program.
  • Buprenorphine may be ordered during the ED visit by ED providers without an X-waiver. ED providers without an X-Waiver have may treat a patient up to 72 hours (3 contiguous days) in order to bridge the patient to outpatient treatment. This means the patient must return to the ED if symptoms reoccur. ED providers WITHOUT an X-waiver cannot prescribe.
  • If patient really wants methadone instead, that also can be started in the ED. Follow-up will be arranged by our Bridge team as patient must go to a licensed methadone clinic. PLEASE MAKE SURE WE HAVE A CORRECT PHONE NUMBER
  • MOUD Providers all have their X-Waiver and can eprescribe buprenorphine to our pharmacy or to an outside pharmacy
  • Bridge program (Viviana and staff) will ensure patient gets follow-up PLEASE MAKE SURE WE HAVE A CORRECT PHONE NUMBER.
  • OVMC Substance Use Disorder Education and Management Website http://myladhs.lacounty.gov/ov/Substance_Use_Disorder_Management/SitePages/Home.aspx
  • ED Bridge Guide https://static1.squarespace.com/static/5adf7f1fa2772cb4f86018b2/t/5aff30cf758d46c1c95b5a40/1526673619420/ED-BRIDGE+BUP+GUIDE+-+MAY+2018+%282%29.pdf
  • ED Buprenorphine Initiation Algorithm

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc255df2d46c2731a7b366c/1573017059129/CA+Bridge+-+Protocol+-+Bup+Hospital+Quick+Start+-+NOV+2019.pdf

  • ED Buprenorphine Initiation for Pregnant Patients Algorithm

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc24f6e67488341e241a1c4/1573015410380/CA+Bridge+-+Protocol+-+Bup+Quick+Start+in+Pregnancy+-+NOV+2019.pdf

  • ED Buprenorphine Initiation after Overdose

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc31217b305036def2229e9/1573065241235/CA+Bridge+-+Protocol+-+Bup+After+Overdose+-+NOV+2019.pdf

  • Buprenorphine and Acute Pain in the ED

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dce41a3b351797406dacc19/1573798309226/CA+Bridge+-+Protocol+-+Acute+Pain+and+Bup+-+ED+and+Critical+Care+-+NOV+2019.pdf

  • Buprenorphine and Acute Pain on the Med/Surg Unit

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dce418a59f2dd43d758b7c6/1573798284017/CA+Bridge+-+Protocol+-+Acute+Pain+and+Bup+-+Med-Surg+-+NOV+2019.pdf

  • Methadone Quick Start

https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5dc2561cd90490301babf7f5/1573017118257/CA+Bridge+-+Protocol+-+Methadone+Hospital+Quick+Start+-+NOV+2019.pdf

Transfers

MAC phone number 866-940-4401, press 3 for DHS facility

Higher Level of Care Transfers

  • Patients who require services that OVMC does not offer may need to be transferred out (e.g. neurosurgery, some emergent orthopedic cases).
  • For OOP patients who are clinically stable, every attempt should be made to transfer the patient to their health plan.
  • For uninsured or DHS-empaneled patients, transfer will occur through the MAC.
  • Transfers from the ED via the MAC fall into two categories. This is based on existing DHS policy:
    • (1) Emergent/Urgent e.g. intubated intracranial bleed. MAC will ask minimal questions in order to get transportation to OVMC as quickly as possible. CMO on-call (ask Operator)should be notified regarding emergent transfer. Emergent/Urgent patients cannot be refused by Harbor or USC and may end up being transferred to their ED if no inpatient beds are available. Emergent/Urgent transfers should be used on a rare basis for those patients who need to move RIGHT NOW aka emergently.
    • (2) Non-Urgent e.g. open tib/fib fracture or hip fracture. MAC will ask more detailed questions. Patients will be presented to appropriate service at USC or Harbor. Transportation will be arranged after patient has been accepted.
    • Remember both USC and Harbor have DHS Cerner and have access to our ED records and imaging
    • MAC will NOT transfer to private hospitals such as transfer of neuro patient to UCLA for intracerebral thrombolysis (exception burn cases) or pediatric patient who is followed by UCLA sub specialist at the OVMC clinics. Transportation of those patients must be arranged by the private hospital or OVMC UR.

BLS vs ALS vs Critical Care vs Helicopters

  • BLS is staffed by EMTs, limited abilities, can administer oxygen; cannot push meds and cannot have any hanging IV drips
  • ALS is staffed by paramedics, can take intubated patients, CANNOT take patients with ANY type of IV drip (no heparin, mannitol, norepi, etc) even if those drips are not titratable. Drips must be shut off. ALS IS ABLE take maintenance IV with max of KCl 20meq/L. ETA variable.
  • Critical care is staffed by paramedics plus Critical Care RN and/or MD, can take intubated patients with IV drips. Often ETA of critical care team arrival 4-5 hours away.
  • Helicopter is staffed by paramedics +/- critical care RN, can take intubated patients with IV drips. Dependent upon weather. ETA variable.
  • For critically ill or injured patients on a drip that cannot be turned off, if critical care team's ETA is too long, consider sending OVMC ED RN, MD and/or RT as needed in ambulance. Arrange head of time for same ambulance to bring staff back to OVMC.

Pediatrics

  • The Pediatric attending on-call should be made aware of any higher level of care transfer out
  • For OOP pediatric patients, UR should attempt to transfer the patient to the hospital requested by the health plan
  • For uninsured patients, not currently followed by a pediatric sub-specialist, attempts should be made to transfer to USC or Harbor via the MAC
  • Patients followed by UCLA Pediatric subspecialties at OVMC may be transferred to UCLA if accepted by UCLA Pediatrics or subspecialist.
    • OVMC Pediatric resident will contact UCLA inpatient staff or subspecialty service about transfer with approval by the Pediatric attending on-call
    • Once accepted, transportation will depend upon the type of transfer: PICU transfers may transported by the UCLA Transport team; Ward transfers to UCLA will need to have transportation arranged by OVMC ED UR staff.
    • MAC WILL NOT ARRANGE TRANSPORTATION TO UCLA

Surgical and surgical subspecialties

  • For all surgical and surgical subspecialties being transferred out for "higher level of care", please contact the Attending of that service prior to transfer out. ED Attending should speak to Surgical Attending to ensure we do not have the ability to care for the patient here at OVMC

Neurosurgery

  • See Neurosurgery

Utilization Review (Utilization Management)

  • x74890
  • Outpatient Service Coordinator OPSC can help with urgent follow-up to primary care for OOP patients (see above Follow-Up...Out of Plan OOP)

ED Ultrasound

Link to OVMC Ultrasound website

Transvaginal Ultrasound

ED Supplies and Equipment

Tutorial Videos

Clerk ED1A Cabinet

*MUST LEAVE BADGE FOR ANY EQUIPMENT REMOVED FROM CLERK CABINET

ED1A MD Room

  • Ultrasound Supplies
    • Gel
    • Probe covers
  • Angiocaths 3inch
  • Headlamp

Airway Cart in PR Room

  • CO2 detectors, ETT
  • CO2 detectors, nasal
  • Nasal Atomizers
  • Trach Atomizers
  • Endotracheal Tubes
  • LMAs

Room 31

  • Upper Cabinet
    • Nosebleed Trays
    • Lollicaine Lollipops (lidocaine lollipops)
    • Ophtho Micoscope
    • Cable for Xenon lamp
    • Magnifying Headlamp
  • ENT Cart
    • OPHTHO
      • pH paper taped to pH folder on top of cart
    • OROPHARYNGEAL
    • NASAL
      • Nasal compression device for nose bleeds
      • Nasal speculum
      • Merocel
      • Surgicel 2" x 3"
      • Silver nitrate sticks
      • Rhino Rocket Slimline - small, medium, large
      • Rapid Rhino 5.5cm Rapid Pac
      • Rapid Rhino 7.5cm Ant/Posterior with Airway
      • Vaseline Petroleum Gauze Strip 1" x 36"
      • Denver Nasal Splint
    • Wood's Lamp bottom drawer

Suture Cart

Ortho Cart

Gyn Cart

Central Line Cart in ED 1A/B hallway

Orthopedic supplies in Room 43

  • Soft collars, slings, wrist guards, CAM walkers, hard shoes
  • Abdominal binders
  • Hernia truss

Crutches, Walkers, Wheelchairs

  • Located in ED1A/B Clean Utility Room

Bronchoscope

  • Located in storage room near Triage 4. Disposable scopes in cabinet in same room.

Glidescope

  • Located in PR Room - pediatric and adult batons available
  • Disposable blades located in Glidescope basket
  • Extra blades located in cabinets in PR Room
  • Wipe down batons after each use

Unusual Supplies

  • Gastrostomy Tubes - ED 1A MD Room "S**T HAPPENS" Cabinet
  • Nephrostomy tubing and bags - try OR
  • Whitacre Spinal Needles - LP Cart
  • Merlin Pacemaker Interrogator - ED 1A Cabinet
  • This device interrogates pacers and ICDs made by St. Jude or Abbott.  The detailed instructions are printed and posted inside of the cabinet door and included below.  It requires cellular data transmission. First interrogate the patient's device at the bedside, then move the unit to the ambulance bay and plug it in there so it can transmit.  The report is subsequently faxed to the ED1 nursing station and is also transmitted to the device reps and our cardiology service.  The device reps are on call for assistance as needed, or you can call Scott Lundberg to try and help.

Disaster Preparedness

  • Olive View-UCLA has a robust plan for a number of possible disasters such as earthquakes. All OVMC faculty and residents should review the materials on the hospital homepage under “Disaster Management.” The link is in the center of the screen. For staff in the ED at the time of a disaster, the important information is as follows.
    • 1. The ANO (Acting Nursing Officer) is designated as the incident commander and is in the hospital 24/7.
    • 2. The ANO will set up a command post in Hospital Administration and will contact the charge nurses in each department.
    • 3. The initial priority is a head count of all staff, and a report on the physical condition of the department.
    • 4. A physician in the hospital will be designated as a medical officer in the incident command center. At night, this may be OB or Anesthesia as they are also in house and we will be responsible for managing the ED.
    • 5. All requests for materials, staff, and questions go though the incident command in medical administration.
    • 6. The ED charge nurse is aware of the location of extra supplies and the hospital wide disaster management plan.
  • Olive View-UCLA has over one week of food, water and medical supplies for an anticipated disaster. There are specific incident commanders and disaster professionals who will be responding, and the emergency physicians on site are not expected to lead the disaster response.

Downtime Protocols

Downtime Documentation

  • H&P will be documented on paper using DEM Physician Record (OV1901). Resident and Attending signatures are required.
  • MSE - when performed by a separate MSE provider, note should be very brief and be written on the upper portion of the History section of the paper DEM Physician Record (OV1901). It should include a separate header of MSE NOTE and must be signed.

Downtime General Orders

  • orders should be written on paper using DEM Physician’s Orders (OV1337) and include a date, time, initials, and signature
  • orders should be placed in the order bin located at each Nursing Station (ED 1-5, RME) for the Nurse/Clerk to initiate
  • clerk has all downtime forms, lab slips and Radiology Request forms.

Downtime Radiology Orders

  • order imaging on paper and include a complete paper Radiology Order Form (OV2059). Runner will hand deliver request to the appropriate ED radiology area.
  • if ORCHID downtime is isolated, iimages and preliminary results will still be available in Synapse even if not viewable in ORCHID
  • radiology orders ordered during downtime using the Radiology Request forms do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur).

Downtime Laboratory Orders/Workflow

  • clerk/nurse will complete paper lab request slips to accompany specimens sent to the lab. The lab slip should include collector's employee number ("e" or "c" number).
  • lab labels will not print during downtime. All specimens must be labeled with the following information:
    • patient info: patient name, DOB, MRN, FIN
    • collector's info: date/time specimen collected, employee number ("e' or "c" number), collectors signature
  • lab results will be faxed to the ED at X74298 and hand delivered to the assigned resident or attending for that patient
  • POCT orders placed by the providers will be resulted verbally to the ordering provider and also resulted in nursing documentation
  • lab will call critical results to the ED
  • lab orders ordered during downtime do NOT routinely need to be re-entered into ORCHID after ORCHID comes back up (exceptions may occur). Results that came back on paper will eventually also be resulted in ORCHID.

Downtime Medication Orders

  • all medication orders should be written on paper using form OV1337
  • patient prescriptions should be written on paper and handed to the patient. A copy of each Rx should be kept in the patient’s paper record. Rxs will be scanned into ORCHID once ORCHID comes back up. Rx’s will not be back entered by the provider into ORCHID after a prolonged downtime.
  • when ORCHID is back up, Pharmacy will manually enter all medications that were ordered during downtime

Downtime Blood Bank Orders

  • enter required orders on paper (T&S, T&C, transfusion, etc)
  • paper blood transfusion indication sheet must be filled out for Adults OV1998 or Peds (OV2015)

Downtime Specialty Diagnostic Services

  • complete paper requisition for Echo, Stress Treadmill/Myocardial Perfusion Imaging, Holter and EEG. Call appropriate department for STAT orders

Downtime Admissions

  • initiate Interqual request by calling UR directly at X74890.
  • discuss with admitting team
  • once an admission is accepted by the admitting team, enter Request to Admit order on paper and include service, level of care, and the name of the admitting attending and resident.
  • admissions during downtime will be tracked by Nursing on a paper log
  • certain orders such as Bed Requests and Admit Orders will need to be manually re-entered into ORCHID once ORCHID is back up

Downtime Discharge

  • complete discharge and aftercare instructions using form OV2014 including discharge impression, recommended follow up, and return precuations. Do not use this form for Rx.
  • Rx should be written on paper Rx pads. Copies should be left in paper chart to be scanned in later.
  • discharge order must be signed on paper
  • all discharges from the ED during downtime will be tracked by Nursing on a paper log. A separate provider log will be kept for downtime discharges that require future labs, studies, message pools, e-consults, TFU referrals so that they may be entered into ORCHID during recovery.

Downtime Recovery - ORCHID Back Online

  • LAB/RAD - results will begin to populate via the interface in ORCHID. Lab and imaging orders previously placed on paper should not neeed to be ordered again.
  • documentation – Provider documentation on paper will be scanned into patient chart.
  • pharmacy will back-enter enter all medication orders placed on paper during downtime back into ORCHID.
  • physicians must re-enter all other paper orders placed during downtime into ORCHID (admission requests, place in obs, isolation, communication, restraints, holds, consults, etc).

Downtime Frequent Phone Numbers

  • ED Lab (8:30 am - 10:30pm) : 74977
  • General Lab: 73476, 74038
  • Microbiology: 76041
  • Blood Bank: 74062
  • Phlebotomy: 74555/74039
  • ED Xray Tech: 75496
  • ED US Tech: 74940
  • ED CT Tech: 74968
  • MRI Tech: 73535
  • ED Radiologist: 74971
  • StatRad Coverage for CT and MRI Overnight and Weekend Reads Only - 858-546-3800, press 1.
  • USROC Coverage for Ultrasound Overnight and Weekend Reads OnlyMonday-Friday 11p-7a and Weekends/Holidays 7p-7a 866-448-7762
  • ED UR/Interqual: 74890
  • Pharmacy: 73070
  • ED1A: 74320
  • ED1B: 74865
  • ED2A: 74321
  • ED2B: 74280
  • ED3: 74976
  • ED4: 74974
  • ED5: 74970
  • SuperTrack Provider Room : 74936/74937
  • Main Provider Room: 73645
  • DEM Administrative Offices: 73107

ORCHID/FirstNet

Logon

  • logon credentials are the same as your Internet Password
  • if you need to reset your password go to the Olive View- UCLA Home Page, under the Links Section (toward the bottom), and choose one of the Password and Account Management links
  • if you still can’t logon, call the Enterprise Help Desk at x74522

CheckIn

  • at the start of a new shift, ORCHID should immediately prompt you to check-in as an available provider.
  • in the Provider CheckIn window, select your Display Name, Provider Role and a Default Relation. Also select the checkboxes for Available Provider and Available Reviewer.
  • if you were already checked-in to see patients on that shift, you will not be prompted to check in again.
  • if you need to Check In manually, click on the little icon of the provider with the Check Box.

Patient Sign Up

  • click once on the patient row then click on the Assign Provider icon. Your Display Name will appear in the appropriate column.

Documentation

Selecting a Note Template

  • click Provider Notes from the tracking list then +Add in the Provider Notes band
  • the Note Type should default to ED Note-Provider so that notes are filed in the correct folder and can be viewed by UR and the ED Attending once they are saved. If the ED Note-Provider option is not available, right-click on the arrow to select from All Note Types.
  • using the Reason For Visit tab select a Note Template to use either by free text search or by using the structured menu (PNED RFV) then hit select OK. Use the checkboxes to select which elements (if any) you would like to import into your note
  • colored notepads on the Tracking Board track the progress of your Provider Note (not started, in progress, or signed) during the patient encounter

Documentation Workflow

  • once saved, notes written using the default ED Note-Provider template, can be viewed by both Utilization Management and the ED Attending. Consultants cannot view provider ED documentation until the note is signed.
  • once you have completed your provider note, click on Sign/Submit and a new window will pop up. Select Request Endorsement, then click inside the yellow area under Endorser. Select the binoculars icon to search for the attending you would like to co-sign your chart. Click OK. Under “Type” make sure that sign is selected (not reviewed). Then click sign to close the window.
  • Attendings: In the Message Center you can view notes forwarded to you for signature. Choose the Correct icon to change a note and write an addendum. If you want to write a separate note before the intern/resident has completed their note, use the Note function (rather than Provider Notes).
  • for patients signed out at rounds, the oncoming resident should write a brief note using the Notes function (not Provider Notes).

Documenting a Re-Evaluation

  • below the Medical Decision Making section of the PowerNote note there is a section to document follow up exams. Choose Re-exam/Re-eval and enter a time before entering details of the follow up exam
  • right-clicking over the Re-exam/Re-eval header and selecting repeat allows you to document repeated re-evaluations

Getting Rid of Spellcheck

  • Open a patient's chart and start a note
  • Click View at the top.....then Customize.....then More......unclick Run Spelling check....click OK

Unable to place Diagnosis?

  • Usually because HLI: Physician Friendly Term box has not been checked
  • Step 1: Type in desired diagnosis and click Binoculars
  • Step 2: Click the 3 dots just to the right of "Terminology"
  • Step 3: Check the box HLI: Physician Friendly Term
  • Step 4: You may have to close the Diagnosis box and re-enter the diagnosis

Procedure Consent with iMedConsent

  • iMedConsent is now accessed directly through Cerner from within a patient's chart. There is an iMedConsent tab available under the Table of Contents Menu (Table of Contents are the grey tabs on the left hand side of the mPage underneath the "ED Summary"). Users no longer have to manually enter patient identifiers to search for a patient. There is no longer a need to maintain a separate username and password for iMedConsent.
  • select the appropriate procedure/s that you would like to print for the patient
  • have the patient read, consent, and wet sign the printed procedure consent form
  • place a copy of the wet signed consent in the patient's paper chart. The Health Information Management (HIM) team will scan the consent form into ORCHID after the patient is discharged.

Procedure Documentation (ad hoc forms)

  • AdHoc Forms are used for specific template driven documentation in the ED. This includes documentation of all ED Procedures. AdHoc forms can be found using the AdHoc link on the ORCHID Menubar,

then finding the ED Forms Folder.

  • template AdHoc forms include documentation for ED Procedures, ED Bedside Ultrasounds, Central Line (CLIP) documentation, and the NIH Stroke Scale.
  • once completed, these AdHoc forms are signed using the Check Mark on the Upper Left corner of the screen.

Medicine Admissions

1) Interqual Request Order - found on the Quick Orders page under the Top Other section. A diagnosis is required.

  • DHS uses Interqual Criteria for Utilization Review (UR). All admissions must be reviewed by UR. The Interqual decision is facilitated by having a note in the chart for UR to review. UR can view ED resident notes as long as they have been saved.
  • the Interqual Request is found under the Events tab and the Request Events sub-tab.
  • the Interqual review process is tracked with ICONs under the ADT column
    • REQ - Requested
    • IP - In Progress
    • MET - Criteria Met the

2) Contact the admitting team via Amion to give report

  • contact the admitting Hospitalist or Resident. Use auto-paging (see below) to help track the time the admitting service is first paged. Confirm with the Hospitalist the name of the receiving Attending, Resident, Service, and Level of Care

3) Enter the Request for Admit. Enter the admitting resident name in the Special Instructions field. Medicine teams will drop Admission orders in the chart within 2 hours from the time the Request for Admit order is placed.

  • Note: Admission orders should NOT be placed on any patient until Bed Control updates their location status to ED Boarders. ED Boarders are easily identifiedin the location field on the Banner Bar and by a slash in the Bed

column on the FirstNet track. If inpatient orders are dropped on a patient before they are changed to an ED Boarder they will have to be re-entered by the Admitting team.

  • the Hospital Icon indicates that the inpatient team has placed Admitting Orders in ORCHID. The Medicine team assumes all responsibility for patient care once Admission orders are placed. Routing questions from Nursing regarding further medical care should be directed to the inpatient provider.

Changes in Service or Level of Care after Initial Admission

  • if you need to upgrade/downgrade an ED Boarder after the initial Request for Admit has been submitted, you need to order Request for Admit again (not Transfer). This is the only way bed control will get the message that a change has been requested. DEM providers will do this if they are still following the patient, however once Admission Orders are written (Hospital Icon), the Admitting Service will re-order the Request for Admit if any upgrade/downgrade must occur.
  • if the post-admission upgrade/downgrade results in the patient going to a different team, the Inpatient team must notify and give report to the new team since these patients are no longer being followed by the ED.

Surgery Admissions

  • the process is similar to the Medicine admission process with the following exceptions:
    • the Request for Admit order is held until the admitting team evaluates the patient in the ED
    • the ED resident places the the Request for Admit order once the admitting information is confirmed with the surgery team
    • Note: the surgery team should NOT place Admission orders in ORCHID until the Request for Admit is placed and the patient’s location has been updated to an ED Boarder otherwise orders may have to be re-written when the patient goes upstairs

ED Holding Orders

  • if the inpatient team has already accepted a patient, but there is an unavoidable delay (> 2 hrs.) in placing admission orders, the ED Team can initiate the ED Holding Orders Order Set for the inpatient setting to either facilitate boarding care in the ED or to facilitate transportation to an available bed upstairs. Make certain the inpatient team is contacted so they are aware ED Holding Orders have been initiated and that the patient may go upstairs.
  • as with all admissions, do not place ED Holding Orders unless the patient has already entered ED Boarding status (see Med Admissions above).

Observation Patients

  • the observation unit is used for patients who require additional care after the ED but less than 24 hours of hospital care. The decision to place a patient in the OBS unit should be made in conjunction with the ED Attending and Hospitalist
  • observation patients do not require Interqual
  • once the patient has been accepted by the Hospitalist for OBS status, order Place in Observation from the ED Quick Order page (top other section)
  • patients should NEVER be placed in OBS status after a Request for Admit has been ordered

Consultation & Auto Paging

Consults - No Auto Paging OVMC

  • consult initiation time can easily be documented by placing the consult order from the Other Pane on the lower right side of the Adult ED Quick Orders page.
  • once the Consult order is signed, a marker is placed on the Events tab. Hovering over this marker will show the duration since the consult was first placed. When the consult is complete, this can be documented by right- clicking over the active order and completing the consult. Once complete it will be removed from the Tracking List.

Consults - Auto Paging OVMC

  • a selected number of consults also page the provider automatically when the consult is placed. In these Orders, the Call Back Phone Number is the only required field. The provider receiving the page will NOT see any instructions included in the Special Instructions on their pager but these instructions can still be reviewed on the Review Orders pane.
  • clear pages from the list using the red X Icon under Task
  • Note: DO NOT click on the close window button to close the ED Paging error will result. Instead use the Minimize window Icon.

ECGs

Triage ECGs

  • nurse will bring paper Triage ECG to the Attending for review
  • ED attending will verbally tell the nurse what to do (STEMI, BRING BACK, or TRIAGE)
  • paper EKG stays with Attending as a reminder to document their read in FirstNet ECG Viewing/Documentation
  • on the FirstNet track, under the ECG column, double click on the completed EKG ICON
  • in the ECG Review Pane, free text either the Triage ECG read (i.e. STEMI, BRING BACK, or TRIAGE), or a more comprehensive read (follow up ECGs)
  • save the ED read by selecting “ED Review & Close” into the window then hit ED Review and Close.
  • the EKG Icon will now have a checkbox on it
  • once EKGs are visible in Cerner and have a ED preliminary read documented, they can be shredded

Viewing Prior ECGs

  • all ECGs from the current FirstNet encounter are accessible directly from the ECG column
  • ECGs from previous ORCHID encounters are available in the Flowsheet tab under the the Cardiology View and Cardiovascular CV Filters
  • ECG archives prior to ORCHID are accessible in Tracemaster using the patient’s legacy Affinity MRN. It can be accessed either through Wellsoft or Clinical Workstation.

Entering ED Provider Radiology Wet Reads

  • from the Tracking List, right-click on the Rad column of any completed imaging order and the Order Info window will open. Click the blue +Add button to display the Wet Read window.
  • select Positive or Negative and free text your wet read then enter OK
  • a red exclamation icon indicates a wet read has already been entered. Click the exclamation mark to view or add another wet read
  • wet reads may also be entered from the Radiology Results section of a Power Note by using the Launch Wet Read button.

Medical Students in FirstNet

Documentation

  • refer to the Documentation section for detailed documentation instructions.
  • initiate and save a note (without signing) early during a patient encounter after taking a history and performing your exam. Next, present to the Attending physician.
  • update your note with any follow up including medical decision making, lab/imaging results, and/or patient updates.
  • once your note is finalized, hit Sign. A window will pop to “Request Endorsement” of your supervising attending to endorse your note. This request will show up in their Message Center.
  • Attendings: medical student notes forwarded to you will show up in your Message Center in a preliminary status. Once reviewed, a brief note documenting supervision should be added, then the note should be signed.
  • students who leave the ED must sign out all their patients to either an NP or resident after reviewing the overall plan with their supervising attending.

Order Entry

  • after discussing with the Attending, enter proposed orders into ORCHID. Medical students cannot use Quick Orders.
  • access the Modular Order Entry Window by going to the Menu pane and select +Add from the Review Orders band.
  • enter the name of the Attending you will be proposing orders to for co- signature.
  • search for orders individually and enter all required details
  • these orders will be forwarded to the attending once you sign them but they won’t become active until co-signed by the Attending. To speed up turn around time, remind the attending verbally that orders are in their Message Center and ready for co-signature.

Order Entry

Quick Orders

  • from the Tracking Board choose a patient then select Place Orders to go to the Quick Orders page
  • orders can be added to the green ‘Shopping Cart’ by selecting them off your menu of choice or via the search line in the New Order Entry widget

• once order selection is completed, click on the green shopping cart to sign, save, modify, or cancel all of the selected orders. If additional required details are required you will be prompted to enter them • orders can also be entered using the Modular Order Entry Window which is accessed by hitting +Add from the Review Orders menu pane

Required Order Fields

  • many orders in ORCHID cannot be signed without filling out required fields. During order selection on the order pane, required fields are indicated by a blue circle icon with an “X”. Within order details, required fields are indicated with a yellow background, bold-face lettering, or an asterisk
  • use the Missed Required Details button to rapidly cycle through a long list of orders with required details
  • alternately, multiple orders can be selected together (SHIFT-select) or (CTRL-select) and common fields shared among them can be addressed more easily

Copying Orders

  • if you would like to repeat an order, right-click on an active order and select Copy. It will be available for you to sign again.

Discontinuing Orders

  • to discontinue any order, right-click on the active order and select Cancel/Discontinue. Note: Don’t forget to sign after you discontinue an order!

Lab Orders

Collection Priorities

  • Add – to add another test to a sample that is already in the lab. Prior to ordering a test with the Add priority, you must first verbally confirm with the lab that they can run this test with an existing sample.
  • Stat – all ED labs
  • Timed Stat – used when the same STAT test is ordered and a Frequency id included (i.e. Troponin q6h). Enter a duration (i.e. 3 times) so that the order will not continue indefinitely. If a Frequency is added to a Stat priority ORCHID will automatically change the Collection Priority to Timed Stat

Nurse Collect:

  • “No”: most ED labs should be ordered as Nurse Collect “No.” The lab order is tasked directly to the phlebotomist. Nurses can intercept the order and draw it themselves if desired.
  • “Yes”: the lab order is specifically tasked to the bedside nurse. If the phlebotomist is available, the nurse can call phlebotomy to perform the draw.
  • Note: lab orders should never need to be re-ordered simply due to the incorrect selection of the Nurse Collect field.

Order Sets

Order Sets

  • Order Sets are individual orders grouped together to simplify order entry for common indications or procedures. Commonly used Order Sets for the ED can be found on the Quick Orders page, under the Order Sets widget. One may also search for Order Sets using the prefix “ED” on any Order search field.
  • all Order Sets are designated by a yellow Icon with multiple geometric shapes. They are designed with some individual orders being pre-selected, however each included order can be selected, modified (right-click) or un-selected prior to order signature

Adding Orders from an Order Set already Initiated

  • Searching/launching an Order Set repeatedly is usually not necessary. If you need to go back into an active Order Set and add or modify something, you can do so without having to reorder the entire Order Set. Go to the Review

Orders menu, highlight the Order Set under the Plans section of the Order View pane, then click the light bulb icon called “View Excluded Components.” Orders already active will show up indented and checked, and all unordered components will have empty boxes. Select the orders you would like to add or discontinue then sign.

Discontinuing Order Sets

  • to discontinue an Order Set, find the active Order Set in the Order View pane and then right-click to select Discontinue.
  • you will be given the option of choosing which orders to Keep active even though the rest of the Order Set is being discontinued.
  • Note: Don’t forget to sign after you discontinue an Order Set!

Order Favorites

Order Favorites

  • right-click on any order before signature and select Add to Favorites

Lab Results

  • hover over the lab column to rapidly view what lab tests have been ordered. The Lab Indicator column on the track shows how many labs have been ordered and how many labs are resulted. Double-click on the Lab Indicator to see a detailed view (Quick View) of lab results. To see full lab results in details click on the Vitals/Nursing/Results pane

Imaging Results

  • hover over the lab column to rapidly view what lab tests have been ordered. The Rad Indicator column on the track shows how many imaging tests have been ordered, how many have images available, and how many images have a preliminary read in ORCHID.
  • double-click on the Rad Indicator to open the Quick Flowsheet Radiology tab.
  • click on the Result box to open up the Document Viewer to view the read if available.
  • viewing Images: within the Document Viewer, click on the image icon to open a link to Synapse and view the image from within ORCHID. You may have to enter your login credentials to open Synapse.

Discharge & Follow Up

Discharge Process

  • select patient from the Tracking List then hit the Admit/Discharge button
  • open each pane by clicking on the pencil
  • fill out the required and optional fields as needed. The Check Marks will help keep track of your progress.
  • Diagnosis, Prescriptions, Med Reconciliation
  • Patient Education - education handouts and Work Excuse notes
  • Follow Up Date - to communicate follow up with your patient. Note: This does NOT result in actually scheduling appointments!
  • ED Post Visit Plan - TFU/CCC referrals (see below)
  • ED NERF - new NERF referrals (see below)
  • Note: DO NOT SELECT THE DISCHARGE PANE! This is how the nurse removes the patient from the Tracking List.

Follow Up

  • once fully registered, patients who cannot follow up at Olive View should have an Outside Of Plan Icon in their Events column. These patients should be referred elsewhere.

Message Pools

  • only for Urgent Appointment requests to selected clinics, that need to be seen within 2 wks. Many of these clinics previously used the “wallbox" referral system.
  • select a patient on the Tracking List then select Communicate - > Message. Patient Name should Autofill.
  • TO: Binoculars Icon, Pool filter, search for the correct Message Pool (see list), Add to Send to list, hit OK.
  • Subject: choose OVM ED/Urgent Care Appt Request from the menu
  • fill out template, check Patient Needs Appointment box, and Send

TFU/CCC Clinics

  • part of the Depart Process. Open the ED Post Visit Plan band and Route to either the Telephone Follow Up Clinic (ED-TFU-OVM) or the Continuity Clinic (ED-CCC- OVM). Specify need for referral and Contact Phone number
  • Click on the Check Mark at the Upper left to close this window.

eConsult

  • the eConsult referral system should be used for non-urgent outpatient referrals that can wait more than 2 weeks to be processed. eConsults should be entered by the Attending Physician using the eConsult link on the ORCHID menu bar.

ED NERF

  • patients new to the county that qualify for outpatient primary care (no OOP Icon) can be referred to primary care using the ED NERF tab. Choose as many diagnoses that apply then click on the Check
  • Mark at the Upper Left of the referral window.

Ordering Outpatient Studies (Future Orders)

  • once a patient is sent home from the ED, all pending orders are automatically cancelled unless they are entered as Future Orders. Any labs, tests, or referrals to be completed after ED discharge should be entered as Orders for Future Visit. This includes all outpatient imaging and cardiology tests.
  • Physical Therapy: outpatient PT should be ordered using Physical Therapy Evaluation and Treatment Outpatient as a future order.
  • Outpatient FNA: outpatient FNAs should be processed as an eConsult by the Attending Physician. The eConsult destination specialty is Pathology - Fine Needle Aspiration. Patients can then show up directly to the lab during regular business hours.

Patient Portal (LA Health Portal) / Giving Medical Records to Patients

  • LA Health Portal.png

  • LA Health Portal QR

The LADHS Health Portal is an extremely important resource to give our ED patients so they may access their own medical records. This includes labs, imaging, provider notes, and ED discharge instructions. This is the best way to give our "OOP" patients access to records they need to share with outside providers. Patients can access the LA Health Portal via the web or by using the LA Health Portal smartphone app (iOs and Android App Stores).

Enroll Patient in Portal

See widely distributed recruitment fliers in ED with QR code for patient smartphones. Best workflow is for patient's to use their own smartphones. All the patient needs to enroll is their name, birthdate, and medical record number (preferred) to confirm who they are. An email or text phone number can also be used to confirm who they are, but only if the email or text number is already in their registration information in ORCHID.

Alternately patient can use any WOW to enroll, but will likely need assistance in finding the LADHS Health Portal website.

Nursing staff are also encouraging LA Health Portal Enrollment for all of our patients.

ED Registration staff can assist if phone numbers or email addresses need to be updated, but neither is required for a new enrollment.

During regular business hours, the OVMC Health Tech Navigator, Jennifer Vargas, can also assist with complicated Patient Portal enrollments (reset existing passwords, proxy access, etc). Jennifer Vargas x74546 - jvargas4@dhs.lacounty.gov

LA Health Portal Sharepoint

Procedure References

These links should serve as a reference for safe and proper techniques on how to perform many common (and some uncommon) procedures in the ED. For some procedures there may be both a longer video explaining in-depth details if this is your first time (eg med students and interns) and a shorter video if it's been a while and you just want to brush up.

Basics

Lumbar Puncture:

Paracentesis:

Resuscitation

IO line Placement

US-guided IV Placement

Central Venous Catheterization

ENT

Facial Nerve Blocks

Nasal Foreign Body Removal

GI

Balloon Tamponade

Digits

Digital Block

Paronychia

Subungual Hematoma Drainage

Rongeurs

Links

OVMC Pages

Retrieved from "https://www.wikem.org/w/index.php?title=OVMC:ED&oldid=372977"