Harbor:RME & TRIAGE

RME Phones

  • Triage Resident x23223
  • Triage NP (9a) x23209
  • FT NP (6a/6p) x23203
  • FT NP #2 x23222
  • FT R2 x23210
  • FT R4 x23213
  • RME Charge x23930
  • RME 1 EKG Tech x23922
  • Chest Pain Triage RN x23909
  • USA M-F 7a-11p x29737; pgr 501-2047 (Francisco 7a-3p, Reuben 3p-11p)
  • Lori x23972; Martee x23973
  • router x7910

Chappell 10/2017

RME Patient Flow

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

FastTrack

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

Chappell 1/2018

Triaging Clinic Patients

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

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

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

Direct to Back

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

Peterson 7/23/18

Criteria for an immediate transfer to Chest Pain Room

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

Chappell 4/2017


ECG Screening by Providers

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

Chappell 4/2017

Patient Transfers to other areas of the hospital

Psych ED

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

Gyn UCC

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

Urgent Care

Transfer of Low Acuity Patients from ED to UCC
  • UCC Charge RN: x8111, 8110; RME Charge x23930
    • Starting 12/3/18. 7:45am phone huddle to discuss volume, flow, staffing shortages, etc.
    • Once patient has been triaged/received MSE and designated as ESI 4-5, they will be financially screened by registration for DHS eligibility and then placed in RME 5-6
      • If the patient is eligible for UCC (as designated by the green DHS or MHLA logo), the patient should be offered the opportunity to be seen at UCC as it will likely be a shorter wait; if the patient declines, they will remain in FastTrack
        • Eligible patients include DHS, MHLA, and SELF PAY
        • EXCLUDED PATIENTS: chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, any trauma to the cervical spine, pregnant/vag bleeding, or psych care
        • Financial Screening - once financial screening is done, the patient will be assigned the green "DHS" logo or the orange "OOP" icon (meaning they must stay in the ED); NOTE: the golden key will not disappear when only the financial screen has been performed (only when full registration is complete); if golden key still present at time of discharge, please discharge to the registration window
      • UCC hours of transfer are:
        • Monday to Friday 8am - 8pm with the exception of no transfers Tuesdays 8am to 12:30
        • Saturday and Sunday 8am - 1pm
  1. Once the patient is taken to UCC, they need to be moved in Orchid to UCWR
  2. UCC Nuances
    1. There is no maximum number on the subjective pain scale that precludes transfer to UCC
    2. Pain meds should be given prior to sending to UCC; the patient will be re-assessed upon arrival at UCC by their intake provider
    3. It is ok to transfer a patient who has received an MSE and work-up has been initiated (i.e., x-rays ordered/performed); any orders that have not been completed may be canceled by the definitive provider in UCC
    4. UCC is unable to do CCC but can request e-consult
    5. The UCC has full access to ortho via the cast room
    6. The ability to do simple laceration repair is provider dependent, so please call prior to transferring such patients
  3. Despite best efforts to properly screen the patients, if it is later determined that a patient is OOP, they will still be seen in UCC and not returned to the ED simply for financial concerns in the spirit of patient-centered care.
Pausing Patient Flow from ED to UCC
  1. UCC physician should assess the current volume of patients in UCC WR as well as current and expected coverage (not counting discharged patients in UCC10)
    1. If greater than the expected disposition ratios (NP: 2/hr, Attending 3/hr), discuss with the UCC Medical Director
    2. If there is any concern about patient safety, call the UCC Medical Director
    3. If UCC Medical Director agrees, they will discuss with RME Medical Director the options of slowing or stopping flow and RME Medical Director will instruct the RME Charge RN based on the joint medical directors' decision
      1. If either UCC or RME Medical Director is unable to contact the other director, they will use their best judgment and call the RME Charge RN (x23930) with directives
Transfer of Patients from UCC to ED
  1. Patients presenting to the UCC with the following complaints may be immediately transferred to the ED upon presentation without ever being seen by an UCC provider simply based on stated complaint: chest pain, dyspnea, hemoptysis, bleeding, severe pain, MVA, pregnant/vag bleeding, or psych care
  2. If the decision is made to transfer a patient back to the ED, there must be a physician to physician conversation as to why the patient’s workup cannot be completed in the UCC; call Triage physician x23223 prior to sending back to the ED; Green team attending x23206 or Purple team attending x23202 are alternates
  3. The UCC nurse will transition care to the Triage reassessment RN who will then determine the most appropriate next step for the patient (immediate triage by team, WR queue for triage, etc)


Chappell 7/2017

FastTrack Roles

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


NP Independent Workup Guidelines

  • NPs may independently order any x-rays deemed appropriate.
    • Consider XR above and below the injured joint
  • In Chest Pain pts, obtain a brief history and present to an attending or R4 if signs or symptoms of cardiac ischemia or an EKG read that is not “normal sinus rhythm”
  • NPs should NOT provide care to employees with occupational exposures
  • Trauma
    • ED NP's are not involved in the care of Trauma Team Activation patients. Our NP's may perform the initial medical screening exam of walk-in patients with minor injuries in Triage, but the care of all trauma patients will be performed by a physician that is ATLS certified.
    • If, in the course of evaluating a patient with a minor trauma, it is determined that the patient meets trauma team activation criteria, care of the patient should immediately be turned over to an AED team.
    • If it is determined that a patient with an isolated injury needs admission for surgical repair, the care of the patient will be transferred to an AED Team and Trauma Team consulted prior to admission. (Putnam, 2/2017)
  • Select advanced imaging listed below may be ordered independently when the pertinent decision rules are applied. All other advanced imaging studies (ultrasound, CT, or MRI) must be discussed with an attending physician (not senior resident) prior to ordering.
    • Non-contrast CT of the brain:
      • For symptoms of “sudden onset” headache or “worst headache of life”
        • Consider CTA Brain for aneurysm if the patient is unwilling to have lumbar puncture (discuss CTA with attending)
      • For patients who have minor head trauma
        • Follow the ACEP Clinical Policy Statement:
          • Loss of consciousness or post-traumatic amnesia PLUS one of the following: headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication).
          • Consider if no loss of consciousness but presence of focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
        • OR the Canadian Guidelines:
          • Presenting within 24 hours of closed head injury with initial GCS 13-15 and LOC, confusion, or amnesia to event
            • Excludes minimal trauma with no LOC, anticoagulation use, focal neuro deficit, and post-injury seizure
          • CT if GCS <15 two hours post-injury, suspected open or depressed skull fracture, signs of basilar skull fracture (CSF otorrhea/rhinorrhea, battle signs, raccoon eyes), >2 episodes of vomiting post trauma, age>65, retrograde amnesia>30 min to event, mechanism (ejection from vehicle, MVA vs pedestrian, fall >3 feet or 5 stairs)
    • CT brain with IV contrast
      • Patients being evaluated for mass/tumor or those with HIV and new onset headache
    • Non-contrast CT of cervical spine
      • If any of the NEXUS criteria is present: Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
    • Right upper quadrant ultrasound
      • Patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
    • Non-contrast CT of the abdomen/pelvis
      • Patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
      • If previous CT confirms stone, consider renal ultrasound to evaluate for hydronephrosis
    • Pelvic ultrasound
      • Patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding
    • Risk Stratification for DVT
      • Well’s Criteria: Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous DVT(+1), and alternative diagnosis as likely (-2)
        • If low-risk Well’s (score of 0-1), order d-dimer
        • If score greater than 1, order formal (not bedside) Lower Extremity Doppler US and d-dimer
    • Risk Stratification for PE
      • If low pre-test probability and PERC negative, no further testing for PE necessary
        • PERC measures: Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks
      • If patient falls out of PERC, then apply Well’s criteria:
        • Clinical signs and symptoms of DVT(+3), PE #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
          • If score 4 or less, order d-dimer
          • If Score >4, CTA or VQ scan (if contra-indication to CTA)
          • If pregnant, discuss with attending

Chappell 7/2017, rev 12/2018

Being Seen by Consultants Prior to ED Evaluation

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

Chappell 4/2017

NP Consultation Guidelines

  • Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult
  1. If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.
  2. If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and alpha-page the consult service.
  • Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending
  • Please obtain the vital signs of the eyes prior to consultation (visual acuity, PERRLA, EOMI, quadrantopia, IOP, US for detachment if pertinent)
    • If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation

Chappell 4/2017

NP Consultation with the Attending Physician

As defined in the Standardized Procedures:

  1. Patient has unstable vital signs.
  2. There is an acute focal neurological deficit.
  3. The diagnosis/problem is not covered by the standardized procedures list.
  4. There is an emergent condition requiring prompt medical intervention.
  5. Patient and/or family requests to be seen by a physician.
  • Any case requiring admission, observation, or going directly to the OR should be staffed with an attending. All admissions performed by an NP require an Attending Admission Note (see "Admit Process" for contents of note)
  • If an NP wishes to disposition any patient they have consulted an attending physician on (even if the patient's condition is on the independent disposition list), the attending MUST sign the chart.
    • NPs will refer all such charts to the attending for signature.
  • It is expected that on any case that an attending has been consulted, the NP will discuss the disposition of the patient with the attending before actual disposition.
    • It is at the discretion of the attending whether or not to personally evaluate the patient, however the attending physician will be responsible for the care delivered to the patient.
    • Patients who are under the care of an NP but have been discussed with an attending physician may have the attending's name placed in the attending column but should NOT be given a team color unless requested by the attending.

Chappell 4/2017

NP Independent Discharge Guidelines

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

Chappell 4/2017, rev 12/2018

Rapid Discharge Procedure

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

RIPT

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

M. Peterson DIR OPS 6/8/18

Discharge to Chairs

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

LBTC FOLLOW-UPS

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

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


Chappell 4/2017


See Also

References