Harbor:Operations manual

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Closing to EMS (ALS) Ambulances

The decision to close to ALS ambulances should be made as a joint decision by the AED charge nurse and the ED attending. Although looking at the NEDOCS score can be a helpful indicator of the level of congestion, it does not need to be the only factor that goes into determining the need to close to ALS ambulances. With our recent adjustment of the equation to calculate the NEDOCS score (we now have the accurate ED bed count in the equation) - you may find at times that you need to close at lower NEDOCS scores.

As always, the decision to close should be carefully considered, as it results in longer transport times for potentially critically ill patients.

Surge Plan

There are three levels of surge. The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator, in consultation with the ED attending, will enact the surge plan. Alerts go out to all hospital departments. If you think criteria have been met to activate the Surge Plan - contact the Patient Flow Facilitator at x3434 or on Beeper x0939.

What Happens in the ED at Different Surge Levels
  • Level 1
    • Ambulance Diversion (Diversion is for ALS only, never BLS)
    • Four RME Rooms should be converted to Fast Track if not already done
    • Assign residents as available to staff the extra Fast Track rooms
    • UR Nurse works with Hospitalist and Admitting Residents to identify 2.76 Transfers (Hospitalist and Nurse Analysts look for patients to transfer that County will find special funding for)
    • Charge nurse facilitates full staffing of Gold Unit by reallocating staff as available
  • Level 2
    • Above and:
    • When beds are available upstairs, 4 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.
  • Level 3
    • Above and:
    • CMO or designee makes determination to go on Diversion to Trauma
    • When beds are available upstairs, 6 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.

(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)

Resource Utilization Indicators (Need any 3, you no longer need a majority)
  • Level 1
    • NEDOCS >140
    • > 50 Patients in Triage/Waiting Room
    • > 11 OBS/CORE/Boarders in AED
    • Inpatient census > 320
    • Low inpatient bed count (<16 Ward AND <5 ICU/PCU beds)
  • Level 2
    • NEDOCS >180
    • > 50 Patients in Triage/Waiting Room
    • > 14 OBS/CORE/Boarders in AED
    • Inpatient census > 330
    • Lower inpatient bed count (<11 Ward AND <3 ICU/PCU beds AND No "Bump Bed" for Trauma or STEMI)
    • 4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU
  • Level 3
    • NEDOCS 200
    • > 75 Patients in Triage/Waiting Room
    • > 17 OBS/CORE/Boarders in AED
    • No available gurneys, chairs or monitors for new patients in ED
    • Inpatient census > 345
    • Low inpatient bed count (<5 ward AND 0 ICU/PCU beds with no "Bumps")
    • 5 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU

(Hosp Policy 337)

Adult ED Attending Standard Work During Severe ED Overcrowding
  • 1. Ensure that the MICN / Charge RN has updated the NEDOCS score. (Click on the colored bar to see when the NEDOCS score was last updated - should be updated every 2-3 hours)
  • 2. If surge criteria met (see above), call Patient Flow Facilitator to check if surge plan has been initiated.
  • 3. If you have ward beds and ED is impacted by Observation and Boarders - admit stable patients to the ward rather than placing them on Observation. (EXCEPTION: Placement patients - always initially place on Observation.)
  • 4. Consider using the RME Fast Track rooms and/or Pediatric ED rooms to see patients who don't need to stay in a bed.
  • 3. If time allows, go through patient charts on the admissions track and contact admitting inpatient teams of patients that might be downgradable.

(Director OPS, 3/22/18)

Observation Surge Plan

Whenever the number of OBS/CORE patients that overflow in the AED due to lack of GOLD Unit available beds equals or exceeds 5 patients AND there are inpatient beds available at the appropriate level of care:

  • 1. Emergency Physicians will ADMIT any additional patients that are empanelled to the DHS network* to an inpatient bed rather than place the patient on Observation.
  • 2. The Observation hospitalist will ADMIT any patients already on observation that are in DHS network*, giving priority to WARD level patients, followed by TELEMETRY level patients for this activity.
  • 3. These two activities will only continue until we reduce the number of OBS/CORE patients in AED beds down to 5, after filling up all available GOLD beds.

EXCEPTION: Regardless of empanelment - patients perceived to have a high likelihood of needing placement will ALWAYS be placed/kept on Observation.

EMPANELLED TO DHS NETWORK = Provider name in the Empanelled Provider area of the Banner Bar in Cerner OR an insurance type that is listed as "DHS"

Peterson 8/15/ 18


Detailed Instructions are in the Harbor-UCLA DEM Emergency Operations Plan Binder on the shelves next to the clerk's desk in the AAED A-side.

General Instructions
  1. Everbridge System notification for callbacks if at home - Call to clerk's phone to report if available and receive assignment.
  2. Activate the DEM Emergency Operations Plan (EOP) based on info from EMS/Reddinet: Criteria:
    1. 5 or more "Immediate/Red" patients,
    2. 10 or more "Immediate/Red" or "Delayed/Yellow" patients from the same incident.
    3. Multiple patients arriving from incident involving Hazmat exposure.
    4. Directive from hospital administration, via activation of Hospital Code Triage.
  3. Step-by-step instructions for activating the ED EOP are located in the "Checklist: Activating the ED EOP" document posted behind each console in the Base Station Radio Room, and in the ED EOP binder by the AED Clerk's desk.
  4. The ED Nurse Manager, or Overall Charge Nurse on weekends/evenings, assumes the role of ED/Casualty Care Unit Leader, and coordinates all role assignments and/or other activity in the ED during the Disaster period.
  5. The DEM Organizational Chart contains all ED roles during a disaster event.
  6. Roles that may be assigned to physicians include: Immediate Unit Leader (Purple Attending), Delayed Unit Leader (Green Attending), Minor Unit Leader (Fast Track NP or MD), Pediatric Unit Leader (PED Attending), Triage Unit Leader (Screening MD or NP), Decon Unit Leader (Any Decon-Trained MD/NP/RN).
Disaster Triage
  1. ADULT AND YOUNG ADULT Triage Category Definitions
    • Minor - Ambulates without assistance OR minor lower extremity injury
    • Expectant - No spontaneous breathing after airway positioned
    • Immediate
      • Apnea responds to positioning
      • RR >30
      • No palpable Radial Pulse/Cap refill > 2sec
      • AMS
    • Delayed - Needs gurney but not immediate
  1. CHILD Triage Category Definitions
    • Minor - Ambulates without assistance OR minor lower extremity injury
    • Expectant - No spontaneous breathing after airway positioned and 5 rescue breaths
    • Immediate
      • Apnea responds to positioning or rescue breaths
      • RR <15 or >45
      • No palpable Radial Pulse/Cap refill > 2sec
      • Posturing or unresponsive
    • Delayed - Needs gurney but not immediate
  • Airway Cart –
  • Atropine - use ED supplies first- Mark I antidote stock in basement - requires MAC approval (see Code Triage Manual for Phone number)
  • Cones - Triage Color Coded - Wheelchair Storage Closet
  • Decon Team Supplies (PAPRs, Level C PPE) - Storage Closet under Helipad
  • Decon Trailer - Trailer Lot
  • Disaster Cart - Central Supply and Linen Room SE BF09 - keys on big ring in Command Post (1L1) cupboard
  • Disaster Packets/Clipboards - Shelving unit next to clerk's desk, AED A-side
  • Disaster Tags - (Pedestrian spine storage by Router desk)
  • Dosimeters - Radiation Safety Office Building N32
  • Geiger Counters
    • 3 in ED Charge Nurses Office
    • 6 in Radiation Safety Office Building N32
  • Gurneys, disaster – Trailer #3 - Give keys to housekeeping - they will open trailer and assemble gurneys
  • Keys - AAED Pyxis (SE 1J25)
    • For instructions see disaster manual
  • Privacy Kits for Patients - Decon Trailer
  • Signs - Triage Station - Wheelchair Storage Closet
  • Trailers 1-5 - keys in Pyxis AAED
  • Additional Vests - Wheelchair Storage Closet
  • Wheelchairs - (SE1A04) - NA7 Key

Dir OPS 9/14/16

ORCHID Downtime

ED Computer Downtime Emergency Instructions
This document contains information on both unplanned and planned downtimes. Information for planned downtimes is in [].

  • Identify affected systems and request a fix
    • Assigned Staff: Any tech savvy staff member.
    • Check which of the following systems are affected:
      • ORCHID
      • Computer network
      • Landline phones
      • Spectralink Phones
      • Paging system
      • Synapse
    • Assign someone to see if any of the affected systems can be used from nearby locations outside the SE building, such as the psych ED, D-9, or the nursing administration office in the hallway leading to the cafeteria.
    • Call the Help Desk at x5059 or 323-409-8000 to report the problem.

View the ORCHID 724 Backup

    • Assigned Staff: Any tech savvy staff member.
    • There are two levels of 724 backup computer:

Level 2: There are nine computers designated as level 2 724 backups. These computers are always available, and can print the state of the ED at the time of the downtime as well as limited information for visits going back 10 days. At downtime, a login and password will be distributed throughout the hospital.

    • Locations of the level 2 backup computers:
      • Peds Nursing Station 200HUMDSK45054
      • Trauma Nursing Station 200HUMDSK45265
      • RME Nursing Station 200HUMDSK45527
      • ED Registration Office 200HUMDSK45588
      • Acute Adult Front Nursing Station HARSE1J2572401
      • ED Pediatric Nursing Office SE141
        • Charge nurses have a key to this office
      • Gold Unit 200HUMDSK45604
      • Psych ED Station #1 200HUMDSK42257
      • Psych ED Station #2 200HUMDSK42668
      • Urgent Care 200HUMDSK43298

Level 1:

  • If a downtime is planned or prolonged, a level 1 viewer will be activated on ALL computers. This will require at least 30 minutes after the beginning of the downtime. This is a read-only version of FirstNet as it was at downtime and includes full information about previous visits.
    • Go to the Harbor Home Page --> Open ORCHID Here --> 724 Read Only folder. The login will be publicized just before the downtime.

  • Open the “724AccessViewer” from the desktop.
  • Login using the ID and Password that will be distributed at the downtime.
  • Click on the “Firstnet Search” tab
  • Choose the Tracking Group “HAR ED”
  • Click the “Tracking Location” column to sort by that. You could also sort by DOB to bring the pediatric patients to the top.
  • Click “Print List”
  • Choose “Landscape” orientation and only the essential columns. If you choose them all, they will not fit on the page.
  • Print a copy for each pod and distribute them.
  • To read a patient’s chart, double click on it. There is a button at the top left to print the chart.
  • Assign someone to staple them, sort by pod, and distribute to each pod and triage.

Gather your forms

  • There is a cabinet in each of the four nursing stations and the triage hallway labeled “Downtime Forms” stocked with forms for about 200 patients.
  • [Prior to a planned downtime, forms will be set out in each area. Packets will be prepared in advance for newly arriving patients containing a physician documentation form (253), nursing note/MAR (or PEDS version), MSE form, and order sheet].

Waiting room and triage

  • Print the 724 charts of patients in the waiting room.
  • Registration will enter patients who arrive during downtime on a log with name, mode of arrival, DOB, arrival time, and chief complaint at the router desk.
  • Registration will perform quick registration into the downtime registration program (ADR). They will print patient stickers and place a blue armband on the patient. The patient will being given an MRN (use the patient's old MRN if it can be found in the 724 or patient’s documents) and new FIN, assigned by the downtime registration system (ADR).
  • Registration will give each patient’s chart a preassembled packet including: MD note (253), nursing note/MAR, MSE note, and order sheet.
  • The Router will start the nursing triage note on each patient with name, sex, chief complaint, arrival time and triage priority. These forms will be taken to the triage nurse.
  • A senior triage nurse will be assigned the sole job of managing waiting flow of waiting room patients from router to triage to MSE to final room. She will use stacks of sorted patient charts and/or a list.
  • Patients who are “bring back now” or have chest pain of cardiac origin will be taking directly to a treatment area and will be quick registered by the registration staff in those areas.
  • Stable patients will wait in the waiting room and will be called to the registration windows for full registration.
  • The triage nurse will sort the triage forms by acuity and arrival time and call patients in order.
  • If the patient is sent to a room for RME or treatment, their forms will accompany them.
  • If the patient is sent back to the waiting room, the triage form will be sorted by ESI score and arrival time and kept on the triage counter.
  • Sort the 724 printouts on patients that were in the ED prior to downtime in with the forms of newly triaged patients.
  • A nurse will visit each patient in the waiting room to create a list of all patients. This list will be compared to the piles of charts in the "waiting for room" and "waiting for triage" stacks to ensure that nobody has been missed. [This will not be necessary for a planned downtime, as the time of the switch from regular registration to downtime registration should be clear].
  • Consider calling the sheriff for assistance with crowd control if needed to separate patients from family members if needed to determine who has been accounted for.

Medical Screening Exam/RME

  • MSE/RME providers will come to the waiting room flow coordinator to be told who the next patient is for MSE.
  • Providers doing a screening MSE will use the MSE form.

AED, PEDS, RME and Psych ED patient tracking

  • Assigned staff member: Area charge RNs
  • Write patients on the white boards. In the AED, color code green and purple team patients.
  • The charts of new patients waiting to be seen will be placed in a basket in the physician workroom.
  • The ED clerk will make a log of patient departure times and dispositions.

Order Managements

  • Move each pod's chart rack to the front counter.
  • Providers will write all orders on the generic order sheet.
  • After the clerk has transcribed orders from the order sheet to the lab and radiology requisition forms, he will place them standing up in the chart rack, signifying there are orders to be done.
  • When the orders have been completed, the nurse will place the chart down on its side in the folder.

Lab Ordering

  • Call the laboratory supervisor to notify him or her of the problem.
  • Providers will write all orders on generic order sheets.
  • Clerk will transcribe to a one-page lab requisition form. Clerk will notify nurse that there are new orders.
  • Nurse will draw (or call phlebotomy), label with timed patient stickers, and place in tube with requisitions and tube to lab.

Lab Results

  • The lab will print lab results and fax them to the PED at 310-212-0109. The tube system can also be used.
  • Designate a runner to distribute the results to providers around the ED. They will attempt to find the appropriate workroom based on age and the white boards in RME and the AED.

Radiology ordering

  • Provider will write the order on a generic sheet.
  • Clerk will transcribe to a radiology requisition form.
  • Clerk will notify nurse that there is a new order
  • Nurse will be responsible for communicating with technician and getting them the requisition form and getting the patient to the study or the portable tech to the patient.

Radiology Results

  • If Synapse is down, you will need to view images on the machine on which they were shot (eg, CT scanner, X-ray machine, or portable x-ray machine). For CT reads, call the reading room x7295 (daytime). At night page the radiology resident at 5814 to come down and make preliminary reads on the scanner. Ask if radiology can dedicate a staff member to the ED. If Synapse remains operational, residents may continue to place preliminary reads in Synapse. If the downtime occurs during a US Radiology reading time, you may need to call them to get emergent reads and discuss whether they can fax their reads.

Medication ordering

  • Providers will write orders on an order sheet and give it to the area clerk. For urgent orders, the provider will notify the nurse.
  • The clerk will copy the order form and place a copy in the bin at each nursing station for collection by the pharmacist.
  • The pharmacist will review antibiotics, anticoagulants, and drips prior to administration. The collected order sheets will be needed for use by pharmacy at recovery.

Medication Administration

  • Nurses will be notified by the provider (urgent meds), clerk, or pharmacists that there are medication orders and will review the order sheet.
  • For patients who were not in the Pyxis prior to downtime, the nurse will add the patient to the Pyxis. If patients move from Acute ED to boarding, they will need to be moved from the acute Pyxis to the boarding Pyxis.

Nursing documentation

  • Nurses will document on the nursing note/MAR form. There is an addendum page that can be added if necessary.
  • The nurse will keep her documentation in the chart rack that will be placed on the counter.

Physician documentation

  • If you begin seeing the patient during the downtime, document on the 253. If you started seeing the patient before the downtime, you can either finish their documentation on a 253, or wait for ORCHID to come back up and finish in ORCHID.

Divert patients and notify necessary stakeholders

  • Assigned staff: Attending MD
  • The extent of the closure should be determined by the attending, charge nurse, and administrator on duty. For example, a crash of FirstNet only may allow us to remain open to trauma, while failure of all network systems might require diversion of all ambulance traffic.
    • “ED Saturation” is a closure to Advanced Life Support ambulances, remaining open to trauma, STEMI, and BLS ambulances.
    • “Internal Disaster” closes to ALL ambulances, including trauma and STEMI. Consider involving the trauma and cardiology attending in the decision to go on internal disaster.
  • Notify the nursing supervisor, who will call the administrator on duty. Discuss whether to open the hospital emergency operations center to provide additional planning resources.
  • Notify the MICN to place us on the appropriate level of diversion to ambulance traffic.
    • If access to Redinet is down, the MICN should call the MAC, who can update Redinet
    • If needed, the nursing supervisor can call MLK and ask them to stop sending patients.
    • Email (and call during daytime hours hours) Ross Fleischman


  • Providers will write the Request for Admit order on an order sheet, including service, attending, diagnosis, and level of care.
  • Registration will perform hourly rounds to identify patients needing admission.
  • The clerk will call bed control with each admission so they can search for a bed.
  • Bed control will call the clerk when a bed has been found.


  • The nurse will check with registration that they have completed full registration prior to discharging patients.
  • The 253 form has a section for your handwritten discharge instructions. Give the carbon copy to the patient.
  • Write prescriptions on paper with the patient’s MRN and note them on the 253
  • Discharge instructions can be printed from the 724. Go to the FirstNet Search Tab. Choose any patient and click the "Patient ED" button on the left. You can search through any standard discharge instruction and modify as you wish. Print it. There are no custom DHS instructions. There is no record kept of what was written or printed.
  • Nurses will depart discharged patients from the board when they have departed from the ED. Lab and radiology will ensure that the necessary orders are in on the back end as part of their recovery process.

Follow Up

  • Providers will be responsible for arranging follow up after go live, having appropriate appointments made, and communicating this to the patient after recovery.

Orders for admitted patients

  • Write on paper. Fax medications to pharmacy.

After recovery

  • [For a long, planned downtime, a team may be allowed back into the system prior to the system being release for everyone. Their priorities will be: 1. Entering patients into ORCHID that arrived during downtime. 2. Moving patients to their correct rooms in ORCHID. 3. Removing patients who were discharged during the downtime and entering: arrival time, diagnosis [Best ICD10 guess], disposition, providers, last room (or just AOF or POF for adult vs peds), and time left ED entered in ORCHID].
  • For a short or unplanned downtime, registration will enter patients who arrived during downtime into ORCHID. There is a “downtime registration” box on the quick registration page that allows using the MRN that was assigned during downtime. Registration will register the patients who are on boarding status or already admitted. Bed control will change the encounter status to inpatient for the admitted patients.
  • When the system comes back up, clinicians should stop documenting on paper and continue documentation in ORCHID.
  • Providers will enter all ongoing orders except medications for patients still in the ED at recovery. This will include entering the Request for Admit and diagnoses.
  • For patients who were admitted during downtime but are still physically in the ED, the ED provider will enter the Request for Admit and diagnoses into ORCHID. Other orders will be responsibility of the inpatient teams caring for the patients.
  • For patients that were admitted and have departed the ED at recovery, back-entry of information into ORCHID will be the responsibility of the personnel on the units caring for them at that time.

Medication documentation after recovery

  • For all patients who are still in the ED or were admitted at the end of downtime, pharmacy will back-enter all medications orders placed during downtime. For patients who were discharged during the downtime, pharmacy will enter only narcotic medications. Bedside nurses will chart the administration of these medications on their patients based on the written record.

Preparation Checklist for Planned Long Downtime
T-2 Weeks:

  • Check with Elaine and Mario that forms are stocked
  • Assemble 100 packets of MD 253, nursing note/MAR page 1 (20 with peds nursing note for PED), MSE, and order form
  • Registration checks stocks of downtime forms, labels, wristbands

T-2 Days:

  • Registration sets up files to be moved to Router counter for quick registration

T-2 hours:

  • Check that 724 Level 2 computers are running
  • Put out forms

T-1 hour:

  • Go on ED Saturation to EMS. Remain open to STEMI and trauma
  • Registration will take over quick reg, but will continue entering patients in ORCHID up until T-0.
  • Pharmacy will print the MAR on boarding patients

T-30 minutes:

  • Patient arriving at this point will still be registered into ORCHID, but will have clinical documentation started on paper.
  • Write patients on white boards
  • Print charts from level 2 724

Day after recovery:

  • Email Elaine and Mario that there was a downtime so they can check the levels of forms.

Infectious Disease Threats

Hepatitis A

The County Department of Public Health has declared a Hepatitis A Outbreak in Los Angeles County and we are being asked in the emergency department to do our part to stem this outbreak.   In order to help we need to do the following things for all ADULTS (>18 years):  

  1. Suspect: Consider acute viral hepatitis, especially in homeless patients or patients using illicit drugs.
  2. Test: If you suspect the patient may have acute viral hepatitis, order appropriate serologic studies (Hep A IgM, Hep B Core IgM, Hep B Surface Ag, Hep C Antibody Ab.) These are all available in the "AMB Hepatitis Workup" order set. STAT 45 minute turnarounds for the Hep A IgM is available, must be ordered as a standalone STAT test from the ED Quick Orders Page. If it is bundled with other Hepatitis tests, the machine runs all of them, delaying the turnaround time.
  3. Report: All suspected and confirmed cases of Hepatits A should be immediately reported to both the Dept of Health at (888) 397-3993 or after hours (213) 974-1234 AND Harbor Infection Control at x3838 While Patient Is Still in the Emergency Department
  4. Vaccinate: Anyone (regardless of why they are here) who is or has been homeless in the last two months, or uses illicit drugs (NOT JUST IV; except marijuana) should be offered the initial dose of Hep A vaccine while in the ED (the Cerner order is "Hepatitis A adult vaccine" on ED Quick Orders Page). They can be referred to the Department of Health for their second injection in six months. Check the "immunizations" area in Cerner to make sure they are not already immunized.
  5. Protect Yourself: If you haven't gotten the hepatitis A vaccine, it is recommended that you go to employee health to get vaccinated.


  • Influenza-like-illness (ILI) is defined as fever >100.0 F / 37.8 C AND cough or sore throat.
  • Per our DHS policy, please consider treatment for high-risk populations.
    • Antivirals for influenza are most effective when administered when symptoms have been present for <48 hours.
    • May benefit for severely ill patients who have had >48 hours of symptoms.
  • High risk patients for complications include:
  1. Age < 2 years or > 65 years
  2. Pregnancy
  3. Chronic disease. Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes)
  4. Immune suppression, including that caused by medications or HIV
  5. Persons younger than 19 years of age who are receiving long term aspirin therpay
  • Don't send POC influenza test, due to low sensitivity (50-70%).
  • Please send the Biofire / Respiratory Panel PCR for admitted ILI patients.
  • Don't send POC RSV unless it will change your management.

Harbor Ebola Precautions

  • Never enter a room with an Ebola PUI (Person Under Investigation) without full Ebola level PPE.
  • The definition of a PUI is simple - possible exposure to Ebola and subjective complaints consistent with Ebola infection (basically viral syndrome symptoms or abdominal pain or bleeding). No fever or other visible findings are required to classify the patient as a PUI patient.
  • Currently countries identified as travel locations we should be concerned about are coded into the "ID Risk Screen" the routers perform and you can find on Cerner under "Provider Notes"
  • There are other ways to be exposed to Ebola virus: including sexual intercourse with a patient who has recovered from an Ebola infection.
  • As soon as the patient is identified as a PUI - they should go straight into isolation (in AAED or PED, not RME); all further evaluation is done there.
  • Residents should not be in a room with a PUI patient - only attendings and fellows acting as attendings should be involved in wearing PPE and entering a PUI room
  • Notify the infectious disease service that you have a PUI patient in the emergency department - they will guide further screening to determine if the patient can be cleared or not.
  • PUI patients are not allowed to use the sink or toilet. Mechanical should bring a porta-potty for patient use.
  • The policy of the County of Los Angeles is that any provider may decline to care for a PUI patient. Nursing has a list of nurses who have volunteered to care for PUI patients.
  • Extreme care should be taken in any situation where a PUI patient may undergo a procedure that aerosolizes body fluids - the best PPE in this case is a PAPR unit - which is a helmet with a positive pressure fan. We will receive additional training on these in the future.
  • There is a cart in the AAED that contains all of the PPE equipment to care for a PUI patient. It is currently across from the B side desk in the AAED, and looks like all the other yellow PPE carts. We are in the process of having it marked with a large "E" to distinguish it from the other PPE carts.
  • In the top drawer of the Ebola PPE cart is a binder that has step by step instructions for getting into and out of PPE for both the treating provider and that provider's "buddy". We will plan more training to refresh everyone on this.
  • The instruction book also contains a log to record who goes in and out of a PUI room.
  • UCLA Medical Center in Westwood will be our referral center for patients who cannot be cleared in a reasonable timeframe' or become confirmed Ebola patients. The decision for the timing of transfer will be made in conjunction with the infectious disease consultant.
  • EMS has a special unit to transport such patients - make sure they're aware that you have a PUI or confirmed case of Ebola.

M. Peterson 5/8/15

EMS: Screening Ambulance Patients

ALS & BLS Direct to triage (2/5/18)

  • ALS or BLS patients with the following:
    • Stable Vital Signs
      • T 36-38C
      • HR 60-100
      • SBP 100-210, DBP 60-120
      • RR 12-20
    • Ambulatory
    • Cleared by Charge RN
    • If your patient meets all 3 criteria, take them directly to the physician in triage
  • Charge RN must:
    • Quick-register the patient AND
    • Use the Pre-Hospital template to enter:
      • VS
      • EMS unit
      • Brief statement about patient being stable and ambulatory to triage

Patients not meeting "Direct to Triage" criteria

  • AED Charge:
    • Quick-registers patient
    • If clearly needs to stay AED and Room Available
      • Place in room
      • Assign to appropriate team (purple/green) based on room
      • Notify Senior Resident via Spectralink that EMS is waiting to give report
      • Hold EMS personnel until physician arrives (30 min max)
    • If no rooms available, alternate assignment to Purple or Green (for screening) while EMS waits at the wall
      • Notify Senior Resident via Spectralink that EMS is waiting to give report
      • Hold EMS personnel until MD arrives (30 minute max)
    • Once patient screened by senior resident
      • If assigned "AED" by screening MD, place patient in next available room (patient will stay with the screening team regardless of geographical room assignment)
      • If assigned "Triage" by screening MD, take patient to triage for physician in triage to perform MSE
  • Senior Resident:
    • Regardless of whether patient is in room or on wall, respond to request to screen as soon as is reasonably possible (to avoid keeping EMS too long)
      • Take EMS report
      • Release ALS personnel (Paramedics -- BLS may have to stay until patient in room)
    • If the patient is in the hall and after brief evaluation appears stable for triage/WR, discuss with your attending
      • If attending agrees, then use .edambutriage note but do NOT click the "MSE"
        • Revised .edambutriage : This patient was brought in by EMS for ___. I initiated the medical screening exam and feel the patient is stable to go to triage at this time. The patient is ambulatory, vital signs are stable, and they will have their MSE continued by the provider in triage. I discussed the case with Dr. ____ who agrees with this plan.
      • Write "Triage" in the RN Comments column
      • These patients will then go to team triage for MSE & RN triage, financial screening, tasking, then location based on the triage provider's notation in the RN Comments column
  • MICN
    • ALS Arrivals ONLY
      • Download and print 2 copies of ePCR (aka EMS Report Form)
      • Place stickers on them
      • Leave 1st copy with patient’s RN
      • Give 2nd copy to clerk

Chappell 1/31/18


iSTAT Tests

EG7+: Na, K, Ca, Hgb/hematocrit, Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

CG4+: Lactate, Blood gas(pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

CHEM8+: Na, K, Cl, CO2, AG (Ref range "10-20"), Ionized Ca, Glu, BUN, Cr, Hgb, HCT



RSV/Influenza PCR

  • Comes back in ~1hour
  • Mon-Fri 24 hours, holidays and weekends day time hours until 3pm


Respiratory Panel - Mon-Fri 24 hours, holidays and weekends day time hours until 3pm, call lab if will make a difference in workup so they can prioritize

  1. Adenovirus
  2. Coronavirus HKU1
  3. Coronavirus NL63
  4. Coronavirus 229E
  5. Coronavirus OC43
  6. Human Metapneumovirus
  7. Human Rhinovirus/Enterovirus
  8. Influenza A
  9. Influenza A/H1
  10. Influenza A/H3
  11. Influenza A/H1-2009
  12. Influenza B
  13. Parainfluenza Virus 1
  14. Parainfluenza Virus 2
  15. Parainfluenza Virus 3
  16. Parainfluenza Virus 4
  17. Respiratory Syncytial Virus
  18. Bordetella pertussis
  19. Chlamydophila pneumonia
  20. Mycoplasma pneumoniae

Meningitis/Encephalitis Panel (CSF from LPs only)

  1. E.Coli K1
  2. H. Flu
  3. Listeria monocytogenes
  4. N. Meningititis
  5. Strep agalactae
  6. Strep pneumonia
  7. CMV
  8. Enterovirus
  9. HSV-1
  10. HSV-2
  11. Human herpes virus 6
  12. Human parechovirus
  13. Cryptococcus neoformans/gatti
  14. Varicella zoster

Stool Culture

  1. Salmonella
  2. Shigella
  3. Campylobacter
  4. Aeromonas
  • If specifically want E.Coli O1:57 need to order Shiga Toxin Ag test separately.


  • Gonorrhea/Chlamydia
    • Purple/White - cervical and urethral specimens
    • Yellow - urine specimen
    • Orange - vaginal specimen

Critical Lab/Radiology Results Callback

  • Lab or radiology calls ED for critical result, senior resident or attending takes the call
  • If patient is admitted, lab/radiology told to contact admitting team
  • If patient is discharged already, then patient is called back by senior resident/attending
  • Senior resident/attending documents a note of whether patient was able to be reached
  • If patient is returning to ED for re-evaluation, then place pre-arrival note and notify the charge nurse


Formal US in the ED

  • All studies should be performed in the ED unless the techs are simultaneously attempting to perform multiple ED studies.
  • 2 US techs are generally assigned to the ED at night, and ED studies are given priority over inpatient studies.

Katherine Tran, Rads US Supervisor, 11/29/18

Rules for Performing ED Ultrasounds

Always know ahead of time if the exam you are doing is "for the record" or for "training" only. ANY EXAM WHICH FACTORS IN ANY WAY INTO THE CARE OF YOUR PATIENT OR INTO YOUR DECISION MAKING AT ANY POINT IS "FOR THE RECORD"

"For the Record" Exams

  1. Your attending MUST be approved in the exam you are doing EVEN if you also are. If your attending is not, you cannot do the exam. Ask your attending. If not sure, check WikEM Ultrasound Approval List.
    1. https://www.wikem.org/wiki/Harbor:Ultrasound_approval_list
  2. If you are approved in the exam you may perform the exam and report and use the results without any attending over-read if you are confident with the results.
  3. If you are NOT approved, your approved attending MUST confirm your findings BEFORE you report your results verbally (including calling out results in a trauma or discussing with a consultant) or in writing.
  4. All "for the record" exam images must be uploaded to Synapse (except in cases where there isn't time to create an order). If you can't upload - note why in your ultrasound procedure note.
  5. If you are not approved - your images should NOT be uploaded until reviewed by an approved attending.
  6. All for the record exams should be documented in an Ultrasound Procedure note, along with your approved attending's name. Please DO NOT put results in your H&P, other than to mention "see Procedure Note". Procedure notes are designed to prevent you from over reporting on findings you are not trained in.

If your exam does not meet all the criteria for a "for the record" exam, it must be treated as a "training" exam , and any findings can not be reported or used to make decisions.

"Training" Exams

  1. Ask the patient for verbal permission to perform. These are not covered by the ED consent the patient signs.
  2. Never use info from a training exam for patient care decisions.
  3. Do not record anything about the exam in a procedure note or in the medical record.
  4. Do not upload any images from a training exam.
  5. If asked by a consultant or the patient or anyone else what the US shows - say only "I'm training so I'm not allowed to comment on what I think I see in the exam"
  6. During Trauma Activations - please delay training exams until after the initial resuscitation period, to avoid confusion. DO NOT CALL OUT RESULTS as the assumption will be that this was an exam "for the record".

T. Jang, Dir. of ED Ultrasound 11/3/16

CT Scanner Specs

  • CT: Toshiba Aquilion Prime, Weight capacity: 660 lbs, Max Diameter (CT 2): 78 cm (approximately 30 inches).


  • The decision to order a STAT MRI will be made after discussion with an attending physician AND for which MRI results will alter the current treatment plan (including admit vs discharge decisions - Drs. Lewis, Mahajan, & Munn 4/2018); external services may be consulted, but their "permission" is not necessary to order the study
  • Once the MRI is ordered
  1. Call the MRI building 212-5939 from 7a-7p, Monday to Friday; Rosalinda on-site manager
  2. After hours, contact the MRI tech at 218.2379 (rings 6x, VM has back-up numbers)
    • Expected response time is 1 hour from contact to arrival (Trauma Criteria - CD 11-46, ACS COT VRC)
  • The tech will need the following information from the ED attending:
    • Patient's name, MRUN, DOB, the type of MRI (you may want to discuss with the radiology resident to ensure the optimal type of scan +/- if contrast is needed), and suspected diagnosis
    • Does the patient have a pacemaker?
    • Past surgical history
    • Does the patient have any electronic implants?
    • Does the patient have any retained metallic fragments in the eyes (or anywhere else)?
    • Are the patient labs (creatinine) in the computer?
    • Patient's weight for dosing purposes
  • The patient's nurse should complete the MRI safety form: https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/HUCLA%20Safety%20Screening%20Form%20English%20and%20Spanish%2011-2018.pdf
  • Policy 367B: Priority for the portable MRI will be given to the following groups of patients:
  1. Emergency Department patients
  2. Acute Trauma or ICU patients
  3. Any Pediatric or Adult patient (including outpatients) requiring sedation or Anesthesiology support for monitoring or provision of sedation
  4. Inpatients with potentially treatable neurological or neurosurgical emergencies
  • WITH one of the following documented indications:
  1. Acute spinal cord injury
  2. Suspected spinal instability
  3. Suspected spinal compression or ischemia
  4. Concern for epidural abscess or discitis
  5. Suspected acute/subacute myelopathy or focal neurological deficit
  6. Concern for acute/subacute cauda equina/conus medullaris syndrome
  7. Acute stroke symptoms with non-diagnostic head CT
  8. Suspected meningitis, encephalitis, or CNS vasculitis
  9. Concern for CNS tumor or abscess with acute change in neurological status
  10. Evaluation for cerebral hemorrhage
  11. Emergent arterial imaging (aortic dissection, aneurysm leak, etc.) when contraindication to IV CT contrast
  12. Pregnant female with equivocal physical examination and ultrasound for appendicitis
  13. Urgent Magnetic Resonance Cholangiopancreatopgraphy (MRCP)
  14. Assessment of VP shunt malfunction
  • Limitations:
    • 350 lb weight limit
    • 15 inches high, 21 inches wide
    • MRI lift 1000 lbs total for gurney, staff, equipment, etc.
  • Transport to MRI (Policy 367B)
    • Mobile Unit
      • CODE BLUE
        • Hospital gurney will be left on the lift while patient is getting scanned if ambulatory patient and they will be transferred from MRI table to gurney for transport to ED
        • If critical/ICU patient, gurney will not stay on the lift during the scan; in case of code, the MRI table will be used to transport the patient to the ED
        • CODE BLUE Team should receive the patient at the loading dock, move patient to the ED, and ED team assists with resuscitation
        • Move to trauma bay for resuscitation and use paper code sheet, quick reg all patients (outpatient, inpatient)
        • Patients who are admitted as inpatient and in an inpatient bed will be re-registered using the same MRN and an ED FIN will be created. The inpatient FIN will stay active and the ED FIN will be used for the stay in the ED and discharged when the patient is stable enough for transfer and the inpatient FIN will be used when the patient returns upstairs.
        • Ambulatory patients may be taken to MRI via wheelchair or gurney
        • Need for physician accompaniment determined by R2 and above (discuss with ED Attending)
        • R1 or above to assure maintenance of spinal precautions at times of transport only; need not stay during entire study
        • RN will assist with transport of adult patients to MRI but only needs to be present during MRI if sedation is occurring
        • RN will remain with ALL pediatric patients during the entirety of the MRI regardless of need for sedation
        • ED Physician proximity in the AED meets the requirement for physician presence during the administration of IV contrast
      • SEDATION
        • Anxiolysis to be provided by anesthesia (attending, resident, or CRNA)- Anesthesia attending must be present for pediatric sedations
          • Place order in ORCHID “Request for Out of OR Anesthesia”; if issues, call Operating Room Scheduling Center at x6439 during regular hours and OR Front Desk x2797 after-hours
          • Anesthesiologist running the board Spectralink x23337 can also assist
          • Assessment by anesthesia will occur in the ED room as well as post-MRI sedation monitoring/recovery
          • Sedation is defined as IV pushes, and excludes IV drips maintained at a stable rate or oral anxiolytics(Policy 367b, Section IV)
        • If patient is unstable, must be accompanied by physician (R2 and above) AND nurse
  • American College of Radiology Appropriateness Criteria for MRI (numbers below in parenthesis - ranked 0-10, with 10 most appropriate study)
    • Emergent (to Portable MRI Trailer)
      • Neurology
        • Stroke within therapeutic window with negative head CT (9)
          • MRI brain w/o contrast
          • Consider MRA
        • Vertigo with concern for posterior fossa infarct (9)
          • MRI brain w/o contrast
        • New myelopathy or plexopathy (9)
          • MRI spine w/o contrast
        • Venous sinus thrombosis (if CT Venogram is contra-indicated); (9)
          • MRV brain with and w/o contrast
      • Trauma
        • Traumatic cord injury/cord syndrome (9)
          • MRI spine w/o contrast
        • Spinal cord compression/ischemia
          • MRI spine w/o contrast
      • Neurosurgery
        • Cauda Equina Syndrome or suspected spinal tumor with motor loss (9)
          • MRI spine w/o contrast
          • MRI spine with contrast if infection suspected
        • Epidural abscess/hematoma or discitis (8)
          • MRI spine with and w/o contrast
        • Non-traumatic SAH with contra-indication to IV contrast to assess for aneurysm (8)
          • MRI brain w/o contrast + MRA brain w/o contrast (8)
        • Intracranial AVM with intraparenchymal hemorrhage (when CTA contra-indicated)
          • MRI brain with and w/o contrast + MRA brain w/o contrast
        • Concern for subdural empyema/intracranial abscess (8)
          •  MRI brain with and w/o contrast
        • Brain tumor with acute change in mental status (8)
          • MRI with and w/o contrast
        • Spinal tumor with acute change in neurological status
          • MRI with and w/o contrast
      • Surgery
        • Emergent arterial imaging with contra-indication to IV contrast (carotid, vertebral, or aortic dissections/aneurismal leaks); (8)
        • MRA head and neck with and w/o contrast
      • Pediatrics
        • Assessment of VP Shunt malfunction
          • MRI brain w/o contrast (T1/T2)
    • Urgent (to Portable MRI trailer)
      • Neuro
        • Suspected meningitis/encephalitis (unable to perform LP); (8)
        • MRI brain with and w/o contrast
      • Trauma
        • Spinal instability due to ligamentous injury (9)
          • MRI spine w/o contrast
        • Concern for spinal fracture with equivocal CT (9)
          • MRI spine w/o contrast
        • Suspicion of diffuse axonal injury (8)
          • MRI brain w/o contrast
      • Neurosurgery
        • CT equivocal for intracranial hemorrhage
          • MRI brain w/o contrast
        • Post-op intracranial surgery to evaluate for abscess
          • MRI brain with and w/o contrast
        • Concern for posterior fossa mass (8)
          • MRI brain with and w/o contrast
      • Surgery
        • Pregnant female with equivocal exam/US for appendicitis (vs. enroll in CODA/empiric antibiotic treatment); (7)
          • MRI Abdomen/pelvis w/o contrast
      • Pediatrics
        • Concern for Septic Hip/Joint (7)
          • MRI pelvic w/o contrast
      • GI
        • MRCP
      • Pulmonology
        • PE in pregnancy (if CTA or VQ contra-indicated or not feasible); (3)
        • MRA chest with and w/o contrast
      • OB
        • Stable patients with equivocal US/HCG where outpatient evaluation is not feasible (extenuating circumstances) or concern for ectopic/heterotopic pregnancy
          • MRI pelvis w/o contrast
    • Urgent (to MRI building)
      • Neurology
        • Stroke outside therapeutic window (8)
          • MRI brain w/o contrast
        • Opthalmoplegia (9)
          • MRI brain and orbits with and w/o contrast
        • Concern for Multiple Sclerosis (8)
          • MRI brain/spine with and w/o contrast
      • Neurosurgery
        • Concern for pituitary apoplexy (8)
          • MRI brain with and w/o contrast with multiplanar thin sellar imaging
        • Post-op brain tumor to evaluate for residual tumor
          • MRI brain with and w/o contrast
        • Spinal compression fractures (7)
        • MRI spine w/o contrast
      • Ortho
        • Osteomyelitis (9)
          • MRI with and w/o contrast
        • Concern for hip fracture with negative CT (9)
          •  MRI w/o contrast
        • Septic arthritis (unable to perform arthrocentesis)
          • MRI with and w/o contrast (T1/T2)
      • Pediatrics
        • Slowly progressive vision loss (8)
          • MRI brain and orbits with and w/o contrast
      • Medicine
        • Evaluate for brain metastasis with equivocal CT (9)
          • MRI brain with and w/o contrast
        • Concern for Primary CNS lymphoma (9)
          • MRI brain with and w/o contrast
        • Concern for opportunistic CNS infection (9)
          • MRI brain with and w/o contrast
    • Outpatient (to MRI building)
      • Any stable patient not requiring sedation
      • All outpatient imaging orders
      • Ortho
        • Ligamentous injuries of the extremities
          • MRI w/o contrast

Chappell, Wu, 2/2017

Discrepancy Review Process

  • ENTERING ED PRELIM Read on non-contrast head CT's ONLY:
    • “ED Prelim - WNL. Peterson 2320x”
    • “ED Prelim - Small SDH R parietal area. Peterson 2320x”
    • Be sure to click the button that says “Add new note” to enter your read.
  • REVIEWING PRELIM DISCREPANCY LIST (QI function) Starting 10/1/18
    • Synapse: DHS Enterprise Synapse => Conferences => Critical Findings => Ed Discrepancy
      • If "Status" column says "completed", no further action needed
    • Open radiology file
    • Determine if discrepancy requires further action. Discuss with ED attending as needed
    • Place note titled "Radiology Discrepancy Review" in patient's medical record describing action taken:
      • I.e.: "CT Head from ED visit xx/xx/xx originally read as negative shows subacute cerebellar infarct. Patient needs an MRI, but transferred to outside hospital before one was done here. Called patient at xxx-xxx-xxxx, left message to call back at x3900-23202. Telegram sent. Discussed with Dr. Peterson"
      • If no further action needed - note this in discrepancy review note.
        • "Discrepancy on CT Head from xx/xx/xx noted - requires no further action. Discussed with Dr. Chappell"
    • When f/up is finished, please mark as completed: Right click on case => shortcut status => completed
    • File should be checked once per day for new cases.

Peterson/Chappell 10/1/18

Discrepancy E-mail

To: smunn@dhs.lacounty.gov; BKalantari@dhs.lacounty.gov; amlikotic@dhs.lacounty.gov; jrees@dhs.lacounty.gov; rlewis@dhs.lacounty.gov; tlittle@dhs.lacounty.gov; cavaughn@dhs.lacounty.gov

On [Date], USROC contract radiologist [Radiologist Name] submitted an interpretation for a [type of study] for patient [last name, first name], MRUN [Insert MRUN].

After our review of the study and interpretation for clinical purposes, the Department of Emergency Medicine has identified the following potential quality problem(s):  Accuracy of interpretation (may include omission of significant finding)  Delay in interpretation  Other (specify):

Following is relevant information on this case: [Insert clinical context and explanation of concern].

Therefore, we request that this study undergo a quality review as part of the Department of Radiology’s monitoring of the USROC contract.

Should you have questions on this matter, please do not hesitate to contact [Your Name] at [DHS Username]@dhs.lacounty.gov.

Thank you.

Dr. Lewis 5/2018

Other Testing

ECG STEMI screening

  • R4s, in addition to attendings can screen for ECGs to ensure a timely screen for STEMI.

The point of this screen is to pick up STEMIs as soon as possible. If you see any other emergent issues on the EKG, feel free to call the responsible provider, but it's not the screener's job to relate all EKG issues to the responsible physician.

  • Please do not refuse EKGs from the EKG tech if you are an attending or R4 no matter what you are doing (including rounds). It takes only seconds to look at the EKG for a STEMI. Computer entry can be done later if necessary.


  • ECGs being done in AED rooms would be given to the R4 or attending in the AED/Purple physician workroom, similarly ECGs done in the RME area would be given to the R4/attending in the RME/Green physician work room. IT DOESN'T HAVE TO BE YOUR PATIENT.
  • If the ECG tech is unable to locate the R4 or attending, then they should call the ED attending Spectralink phones (Purple/AED 23202, and Green/RME 23206) to find their location and bring them the ECG. (Even if rounding or seeing a patient).
  • If a STEMI is identified, or if there are any questions about a possible STEMI, the R4 should confirm with an ED attending prior to activating a STEMI.
  • ECG techs should not be batch handing the ECGs to the R4/Attending in order to prevent any unnecessary delays.
  • Of note: there is not always an R4 working each shift, so it's important for the ECG tech to ask who is interpreting ECGs on any given shift. We will ensure that the physician appropriately identifies themselves and are receptive to this plan prior to implementation.
  • R4s and attendings will click on the ECG in ORCHID, and perform the ED Screen: Document "NO STEMI” or "STEMI ACTIVATION PERFORMED" on the EKG interpretation and click on the "ED Review" button to clear the eyeglasses icon . The time of the entry is stamped on the EKG read.
  • For patients already admitted or officially on OBS/CORE - perform the screen but do not enter an interpretation or clear the eyeglasses, so the responsible physicians know that they have a EKG waiting. If there's a STEMI or other concerning finding NOTIFY THE RESPONSIBLE TEAM.
  • Should you not have immediate access to enter your interpretation on the computer (sometimes the EKG has not been uploaded, or you are occupied and/or not near a computer), write the interpretation time on the EKG and save it. Then when you have time, go back and do the entry but now add the time "NO STEMI ACTIVATION READ AT [TIME]"

Occupational Exposure

  • Charge RN has the exposure packet (needs to be filled out to avoid employee getting the bill)
  • Use autotext ".edexposureharbor" for documentation template and guidance text on when to consult HIV service
  • Check Rapid HIV and Hep C RNA “HCV RNA RT_PCR Quantitative-PHL” on source patient (consent not needed if lab already has blood sample to add on test) and ensure employee has Hep B vaccine; no blood testing of the employee in the ED
    • If source patient refuses HIV, it can be added on to a pre-existing blood specimen but the results may not be shared with the patient
  • Call HIV service if source patient Rapid HIV is positive or is untestable AND was a clinically meaningful exposure (see occupational exposure template https://www.wikem.org/wiki/Harbor:_Macros_and_Autotext#Occupational_Exposure)
  • Message Erika Sweet at Employee Health after any exposure to ensure follow-up
  • Additional info in "INDUSTRIAL ACCIDENTS" section below

Non-Occupational Exposure

Stats on Risk: https://www.wikem.org/wiki/HIV_post-exposure_prophylaxis

Per email from Dr. Lewis on 1/23/18:

  • Pre-exposure prophylaxis to sexual exposure has been studied as part of a preventive public health strategy and is effective in some well-controlled, very limited circumstances. This is rarely an emergency medicine issue.
  • The possible exception would be the case of exceptionally high risk exposure (partner or assailant in the case of sexual assault is known or highly likely to be HIV positive with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma), occurring within the prior 72 hours. Sexual assault victims should be referred immediately to a RAPE center where PEP may be offered as part of the overall care plan.
  • For the vast majority of cases in which a patient seeks post-sexual-exposure HIV prophylaxis, the patient should simply be referred to the Los Angeles LGBT Center. The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure. Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis). The emergency department is generally not the place to start post-sexual-exposure prophylaxis because it ideally is part of an ongoing risk reduction strategy.
  • If you happen to see a patient who meets the criteria in (2) above, then a baseline rapid HIV should be sent to make sure the patient is not already infected. If the baseline rapid HIV test is negative and if the end of the 72 hour window is near, or it is a Friday night or a weekend, then the HIV service may be consulted, as they may choose to offer a few doses of post-exposure prophylaxis for the patient to take prior to being seen at the LA LGBT Center. Please remember that the HIV fellows and attendings are on call for weeks at a time, so middle of the night calls should be reserved for emergencies.


  • DO NOT WAIT. IA’s have to be called in within 24 hrs of the event (see packet for phone #. An IA packet has to be started immediately and completed as soon as possible
  • Applies to IAs that happen on outside rotations also (residents).
  • Supervisors/Attendings: Besides applying this to yourself should you experience an IA, it is your responsibility to give the packet to the respective resident when an IA happens.
  • Copy of packet was emailed by Christiane to everyone on 6/18/18

Christiane/M. Peterson 6/18/18


Equipment Locations


Equipment Issues

For equipment issues, notify the Area Charge RN to report the issue. Also notify the appropriate director below so they can follow up:

  • Spectralink phones - notify Charge RN to get replacement phone and Dr. A. Wu
  • Ultrasound equipment - notify Dr. T. Jang
  • AED equipment - notify Dr. A. Wu
  • RME equipment - notify Dr. B. Chappell
  • PED equipment - notify Dr. P. Padlipsky
  • IT equipment, including computers and landline phones - place a ticket by using hospital intranet IT support icon or calling in ticket, and also notifying the appropriate area Director above to follow up.

A.Wu Dir AAED 2/14/17

4. Durable Medical Equipment (DME)

  1. Order in ORCHID is "DME subphase." Items can be selected from a list of available supplies or enter item under ‘Misc’. MD also enters an end date, quantity, or refill amount.
  2. Call Durable Medical Equipment (DME) office at x5497 (p0623) Frank and provide patient’s MRN. Hours Mon-Fri 8 am to 5 pm, office is 1-G-13 (near old Ped ED, current Heart Station)
  3. Frank prints the ORCHID script and faxes to patient’s insurance company. DME will be delivered directly to patient’s address in approximately 4-5 days. If necessary, ensure patient has some supplies until delivery starts.
  4. After hours or weekends: can contact Supercare (the DME supply company) at 800-206-4880. Can deliver to ED (may not be right away) or patient home.

J Singh 5/9/17


a. first, MD enters prescription in ORCHID. Then call Frank who is with DME medical supply company - see above - during business hours - ext 5497.

b. if during business hours and no reply from Frank, consult s/w. s/w may help get patient home and then arrange for home walker delivery (see bullet a. - it may take a few days for insurance to approve). insurance may pay for it - but it may take a while

c. if after hours, there is a limited supply of walkers for use after hours when DME office is closed. Ask Charge Nurse to obtain from Nursing Supply Office.

d. if all else fails and pt is unsafe to go home, then we must place the patient in obs

A.Wu, Dir AAED 12/7/16


a. same as above, except we do not have a secret stash

other DME

a. process is same - except for supplies - patients will not get delivery for 4-5 days - so make sure they have 4-5 day supply when they go home.

TLSO Braces

a. Call Dynamics at 213-383-9212, request the needed brace, provide the patient's height and weight

b. Enter order for "DME Brace" in Orchid, noting "TLSO" in special instructions

c. Mon-Fri 8am-5pm: Call DME office at x5497 (p0623) and inform Frank

d. Weekends: Dynamics needs additional documentation for the order:

  1. Right-click the "DME Brace" order and click "reprint requisition"
  2. Print any provider note stating that TLSO brace is required

K.Preston-Suni 10/10/18

New iCare

This is the new version of our current model. Quick tips for getting started:

  1. To turn on, hold the square button on the side about 2 seconds (it will beep when it turns on)
  2. Insert probe (same as old ones, spares are in the supply room I the special equipment cart); it has a red lens cap to help keep it clean – please replace this after use
  3. The light turns green on the tip when it is level; there will be a warning on the screen if you are too far or too close to the eye
  4. Push the arrow to measure … it will average the measurements (discards highest and lowest of 6) and display in green; if there is too much variability, it recommends repeating your measurement.
  5. Hold the square button down for 2 seconds again to turn it off.

If you get an error message, please email Brad Chappell. DIR RME 5-29-18


  • Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - Peterson 5/2016
  • Only patients with internal medicine (or family medicine) covered illness can be placed on obs. All other services require admission (or transfer) - Lewis 5/2016
  • If the hospitalist is capped (cap is 20 if single overnight hospitalist coverage, which includes Obs and CORE leftover from dayshift, new Obs or CORE, and new admissions), and you have a patient you’d like to place in Observation, CORE, or an admission:
    • Do not place the order for obs placement, CORE, or the ‘request for admit’ order. This becomes confusing for nursing who is actually managing the patient. Only place this order when you have discussed the patient and the care officially transfers to the inpatient/obs/CORE physician.
    • Continue to manage the patient until the next hospitalist shift starts (typically 7:30am) or the next medicine slot is available.
    • Do put in an Attending Admit Note at the time of the actual admit decision but document in your notes that patient is being held in the ED due to lack of hospitalist/Medicine capacity.

Observation Placement Guidelines

  • There is no cap on observation patient numbers
  • Placement: All patients requiring placement at an extended care facility should go to OBS even if they require physical therapy assessment for placement
  • Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients (Lewis - 10/2017)
  • TB rapid rule-out (GenExpert PCR) takes about 12 hours: order AFB bundle, saline chloride 10% for RT, and 2 specimen cups with 1ml and 5ml total expectorate
  • Coumadin Bridging requiring heparin drip (not low molecular weight heparin or NOAC candidates) - ADMIT (Lewis - 7/2017)
    • Please do your best to prescribe rivaroxaban (Xarelto) to avoid this as it is available on our DHS formulary.
  • Multi-drug resistant history requiring antibiotics while awaiting culture results - ADMIT (Lewis - 7/2017)
    • MDR infections such as ESBL, VRE, CRE, etc., admit to medicine if you are worried about a repeat MDR infection (ie.,: urine culture in pyelonephritis patient)


  • Admit for non-CHF edema, anasarca, or requiring significant diuresis (>10kg)
  • Psych can consult in CORE, or patient can be discharged from CORE to psych ED on patients requiring cardiac clearance

Chappell, 8/2017



These are meant to be representative of minimum levels of care that can provide said services and should NOT replace clinical judgment.

  • Observation
    • Goal of our observation unit is admission avoidance
    • All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs
  • Ward
    • Unmonitored
    • Stable Patients
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
    • Chronic CPAP or Nasal BiPAP (with pulm fellow approval)
    • Palliative/comfort care admissions, including vented comfort care patients
    • OK on ward: NG tube, chest tube, peritoneal dialysis
    • Meds: Ativan IV q6, Bumex, CaCl, digoxin IV, Dilantin IV, Dilaudid IV, heparin IV, Lasix, potassium IVPB
    • FUTURE POSSIBILITY (currently 1 per day when boarding >5 obs patients): DHS empaneled OBS-level patients
  • Telemetry
    • Continuous cardiac and pulse ox monitoring
    • Stable patients – same level of nursing care as ward
    • Nursing interventions q4 hrs (vitals, labs, POC testing)
    • Non-titrated IV meds: Adenosine IV, amiodarone IV/gtt, fosphenytoin IV, hydralizine IV, insulin gtt (IVP only for hyperkalemia; DKA patients require a higher level of nursing intervention), labetalol IV, Lovenox IV, metoprolol IV, Precedex, Vasotec IV
    • Continuous cardiac and pulse ox monitoring
    • Nursing interventions q2 hrs (vitals, suctioning, labs, POC testing)
    • Non-titrated IV vasoactive drips approved for PCU: Cardizem, Esmolol, NTG gtt
    • Respiratory txs q2 hrs
    • BiPAP
    • Mechanical ventilation with FiO2<40% and infrequent ABG/vent adjustments
    • OK: subdural drains, special peritoneal dialysis, procedural sedation
    • NOT allowed: temp pacer, active chest pain, significant dysrhythmia or acute ischemic EKG changes, significant pulmonary edema
  • ICU
    • Actively managed ventilators
    • Nursing interventions q1 hr (vitals, labs, POC testing)
    • Actively titrated Drips: Cardene, Nipride, pentobarbital IV, phenobarbital IV, propofol, tPA, TXA, Versed, vasoactive dose pressors

Chappell 12/18, Hospital Policies 307 & 325M

Admitting a Patient

We have admitting privileges to all hospital services. Once a patient is admitted by us, the service has two hours to write admitting orders or the ED will do it for them. We should hold services to the two-hour time limit as closely as possible in order to expedite ED flow.

If you are not sure if a patient needs to be admitted, you may always consult the service instead. Please make sure that the residents make it clear to the service that they are either admitting or consult on a patient.

When admitting patients, please follow the "Admission and Consultation Guidelines" as closely as possible to determine which service to admit to. If not listed, emergency department determines the admitting service.

The admission process steps below should be followed in strict order to avoid admission errors.

  1. Place an 'Interqual Request' to begin Utilization Review (UR) process.
  2. Resident or nurse practitioner in RME must discuss the case with the attending, who must agree with the admission.
  3. The attending must write a note in the orchid specifying the following three things:
    • Service to admit to (if to the general surgical service, It should be listed as "Acute-Care Surgery" for the admitting service, even though the trauma service officially does all of our consults in the emergency department. Observation patients are not technically admitted, for these put "OBS", and for CORE patients put "CORE".
    • Reason for admission: if the service itself made the decision to admit, then put "at request of ______ (Service). Otherwise note the brief medical indication for admission. "Placement" may be used as a reason to place the patient observation service; we do not admit placement patients to the hospital. You may put a more detailed justification in your attending note.
    • Level of care (Ward, PCU, ICU, Tele)
  4. Once the admission note is placed by the attending, then the resident may contact the service to inform them of the admission. At this time the service can discuss the admission with emergency physician if they feel the admission is not justified or the patient should be admitted to another service. It is especially helpful if they have other information about the patient which may be important for a disposition decision. The final decision rests with emergency physicians, but if there is significant disagreement the ED attending should be involved in the discussion.
  5. Once the service has been informed, the ED resident should place the order "Request for Inpatient Bed", which defines the time of admission decision. From this time the admitting service has two hours to disposition the patient. They may discharge the patient, write admitting orders for the patient, or transfer the patient to another service. ED department physicians should not be involved in these transfers; once the patient has been transferred to a new service, that service must contact the ED at which time a new two-hour period is established. The admitting service is responsible for the care of the patient once the "Request for Inpatient Bed" order is placed
  6. if the admitting service does not write admitting orders within the two-hour timeframe, the ED resident should contact the admitting service, or if unable, have made a reasonable effort to contact it makes service to inform them that the ED is going to write admitting orders. The ED resident then should proceed to write a brief admitting order set. ED attendings need to encourage the writing of admission order sets by the ED as soon after the two-hour time limit is up in order to expedite flow.

Admission and Consultation Rules

The following guidelines for specific medical disorders are intended to expedite care of ED patients. They have been reviewed and agreed upon by all Departments and Divisions that provide consultation to the Adult ED.

The detailed guidelines can be found in decommissioned hospital policy 312 [Link Coming Here] which remain the agreed upon criteria until such time that new agreements are reached by individual departments with all stakeholders. New agreements are so annotated below.

Surgical or Subspecialty Patients with Medical Co-morbidities

  • If patients have a condition listed in the admission guidelines that direct their admission to a non-medicine service (ie, surgical or subspecialty) but have another significant co-morbidity that separately would require admission to a medicine service, consider admitting that patient to medicine with the surgical or specialty service on consult
    • Examples include: hip fracture with DKA
    • Simply having stable co-morbidities that require continuation of home medications and therapies does not constitute a reason to deviate from the admission guidelines
  • Note: the following service can assist in management of patients with concomitant medical conditions
    • Geriatrics may be consulted 24/7 and is available to assist in the care of patients greater than 65 years old (will go as low as 60 for ortho patients)
    • Diabetes: endocrine may be consulted to assist with blood sugar management
    • Hypertension: nephrology may be consulted to assist with blood pressure control; if the patient needs cardiac clearance as well, cardiology can perform this function and help manage hypertension
    • Pre-operative Clearance: If >65, consult geriatrics; otherwise, third-call can assist in providing this service

Aortic Aneurysms

Brain Death

  • Admit to the service who would have cared for the primary illness or injury
  • Admitting service should notify organ donation agency

Breast abscess/mastitis

From DHS expected practice:

  • Obtain breast ultrasound in ED
  • If no abscess, only phlegmon, treat with PO abx and obtain close follow up with PCP.
  • Superficial abscess <1cm from the skin, need I&D.
    • I&D can be done by either ED or Acute Care Surgery (ACS) / Breast surgery consult.
    • Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.
    • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.), and needs admission, contact Acute Care Surgery (ACS) / Breast Surgery for admission.
    • Discharge with expedited follow up into Breast Surgery Clinic for DHS/MHLA patients – for abscess I&D or aspiration follow up only
      • Tell patient following Tuesday at 9am in N24
      • Clerk to message clinic to schedule appointment via ORCHID communication:
        • Jessica Mendez NP
        • Melissa Burla NP
        • Dr. Christine Dauphine
        • Dr. Junko Ozao-Choy
        • If during the weekdays and daytime hours, Clerk/ED provider could call the clinic directly to have appt scheduled or for any questions x3476.
  • Deep abscess >1cm from the skin, needs needle aspiration
    • ED provider can perform - if simple abscess, no concern for malignancy, and attending feels comfortable
    • Send wound culture, d/c patient with PO abx, f/u as above in Breast Surgery Clinic.
      • If breastfeeding: 1st line dicloxacillin, consider lactation consultant, continue breastfeeding/pumping/manual expression
      • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.) and needs admission, contact ACS/Breast Surgery for admission, needs BDC needle aspiration ASAP. Surgery resident discuss with on-call Radiology resident, then Radiology perform procedure emergently
    • Breast Diagnostic Center (BDC) performs same day/next business day
      • ED provider orders both “US Breast R/L” and “US Drainage Abscess or Cyst, future order,” for next business day or date/time discussed w/ BDC over the phone. Place in clinical info in “relevant history: location what o’clock and r/o abscess.” Do not need to fax form.
      • ED provider initiates PO antibiotics.
      • During business hours: contact BDC to add on case x5666, 5635, 2803
      • Afterhours: Next business day follow up 830a in BDC in B200
      • Applies to DHS or MHLA or OOP
      • Once seen in BDC – gets auto-f/u with Breast Surgery Clinic
  • Consider eConsult to Specialty Breast Services:
    • if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department
    • recurrent mastitis/abscess, or chronic granulomatous mastitis

Breast mass/malignancy

  • Highly suspicious symptoms for breast malignancy
    • Still needs imaging to diagnose, needs urgent BDC referral 2 wks (Currently, have backlog at Harbor BDC, will send onto MLK or other DHS Breast Imaging Center.)
    • ED to message PCP or CCC, send back to MHLA clinic. PCP will work on getting patient to a BDC.
    • Once, seen in BDC, patient’s gets auto-f/u into Breast Surgery Clinic
  • Newly diagnosed without obvious metastatic disease
    • If diagnosed from outside, patient must obtain outside records (CD and packet with path slides)
    • ED provider messages empaneled PCP or CCC. PCP/CCC initiates e-consult to Breast Surgery Clinic
    • ED clerk sends ORCHID communication message to Breast Surgery Clinic team for follow up to help expedite scheduling
      • Jessica Mendez NP
      • Melissa Burla NP
      • Dr. Christine Dauphine
      • Junko Ozao-Choy
  • Obvious metastatic breast cancer
    • BDC w/in 1 wk – Need biopsy to prove is breast source (results usually in 2d)
    • ED will consult Med Onc for urgent f/u w/in 2 weeks
    • ED provider will message empaneled PCP or CCC.
    • No Breast Surgery Clinic needed at this point.


  • Transfer to a hospital with a burn unit, if admission is required
  • Trauma surgery to provide consultation and admission if burn unit bed unavailable


  • Cardiology consults and admissions:
  • For quick questions during business hours, CORE fellow p1035 (follow up, CORE vs Cteam admission, etc.)
  • For Admits, contact Third call p6534
  • For anything else (potential STEMI, not sure what a patient has, not sure what the rhythm is, discharge coordination when CORE isn’t here, etc.) --> Fellow consult pager - p6483
  • Any issues reaching on-call fellow, 1) check MedHub and call the on-call fellow, or 2) call the CCU, or 3) consider contacting attending


  • Admit to medicine with the following exceptions
    • Upper extremity (hand to the antecubital fossa): Hand call (plastic surgery or ortho)
    • Necrotizing fasciitis or requiring surgery in 24 hours: Trauma Surgery

Dialysis fistula/graft problem (e.g. bleeding or thrombosed

  • Do NOT need to go immediately to the operating room: admit to medicine (with inpatient vascular surgery consultation)
  • Need immediate operative intervention: admit to Trauma (are transferred to vascular next day)
  • Recently post-op for their fistula: urgent surgical consultation in the ED

Putnam/Kaji email 8/5/16

Decubitus Ulcers

  • Wound care primary indication for admission: Plastic Surgery
  • Placement, management of medical problems: Medicine

Deep venous thrombosis

  • Women, suspected DVT< 6wk postpartum: OB
  • Women, followed by gyn-onc, OR < 6wk post-op by gyn-onc: Gynecology
  • Post-operative DVT, < 6wk post-op: Surgical service who performed operation
  • All other DVTs: Medicine


  • Acute delirium: Medicine
  • Established dementia: Medicine
  • New onset or previously undiagnosed dementia: Neurology

GI Bleeding

Hand Injuries

  • Open and closed fractures of the forearm and hand: Orthopedics
  • Soft tissue injuries of hand up to AC fossa: Hand call (ortho or plastics)

Intracranial mass lesions

  • Solitary lesion with no other significant medical problem: Neurology (note, HIV positive or suspected HIV infection does not constitute significant medical problem)
  • Non-hemorrhagic intracranial mass lesion with urgent or emergent medical problem: Medicine
  • Solitary intracranial lesion at risk of herniation: Neurosurgery

Lower back pain

  • With neurologic deficit (motor, sensory or reflex): Neurosurgery
  • Without neurologic deficit: Orthopedics

Maxillofacial trauma

  • Soft tissue and bony injury: Face call
  • Orbital floor fx with ocular injury: Ophthalmology

Maxillofacial infections

  • Infections involving orbit: Ophthalmology
  • Dental infection or odontogenic abscess: OMFS
    • "Tooth Call" pager: 800-233-7231 x32831 (per ENT 10-2-16)
  • Infection of sinuses, complicated dental infection with facial and/or neck extension: Head and Neck Surgery
  • Other maxillofacial infections: Face Call


  • Even MRN: Medicine
  • Odd MRN: Neurology
  • Significant medical problem not including positive HIV: Medicine

Osteomyelitis requiring admission

  • Even MRN or with urgent/emergent medical problems: Medicine
  • Odd MRN or requiring surgical management: Orthopedics

Painless Jaundice

  • Medicine


  • Effective 3/31/16, the following change in this practice will be implemented as approved by the Chairs of IM, Surgery, and EM:
  • Patients seen in the Emergency Department with pancreatitis who require admission to the hospital will undergo a right upper quadrant ultrasound by either a certified emergency medicine provider or in Radiology to determine the presence of gallstones. For ultrasound images acquired by emergency medicine physicians, the adequacy of the images to determine the presence or absence of gallstones will be determined by the emergency medicine attending physician;
  • Patients who are found to have gallstones and pancreatitis requiring hospital admission will be admitted to the Trauma/Acute Care Surgery service; and
  • Patients who have pancreatitis requiring hospital admission who do not have gallstones will be admitted to the Internal Medicine service.


  • Pregnant women: Obstetrics
  • Pyelo with nephrolithiasis or other urinary tract obstruction: Urology

ROSC (Approved by the Chairs of IM and EM 5/1/16)

  1. Patients whose cardiac arrest was of a presumed cardiac etiology, who obtain a sustained ROSC, will be admitted to the C-team;
  2. Patients whose cardiac arrest was of a presumed non-cardiac etiology, who obtain a sustained ROSC, will be admitted to Medical Intensive Care Unit team; and
  3. The presumed etiology will be determined by the ED Attending physician supervising the ED care of the patient.

Septic Arthritis

  • Involving the shoulder or hips, unless concurrent medical condition requiring urgent/emergent intervention: Orthopedics
  • All other joints: Medicine

Spinal Injuries

  • Spine call rotates between Neurosurgery and Ortho Spine.
    • When Ortho Spine is on call, they would like the Ortho resident p0345 to be called for the following indications: boney and structural spine problems, such as trauma, infection, degenerative, stenosis, disk, and boney tumors and diskitis /osteomyelitis for patients aged 18 and up with or without neurologic deficit.
    • Neurosurgery will continue to see intradural pathologies and pediatric patients under the age 18. For patients with head trauma for which a neurosurgical consult is being obtained, it may be best for them to also be the consulting service for concomitant spine pathology, to ease the coordination of care.
  • How to know who is on call:
    • Spine call has been added onto the ED Call List made the clerks each morning, please look there to see which service is on call for spine emergencies.
    • You can also look on intranet page ‘Call Schedule’ link which takes you to MedHub (new amion) – if the Orthopedic Surgery Spine Call section is blank, that means Neurosurgery is on call. If there are names listed, then that means Ortho Spine is on call.

A.Wu, Dir AED 10/28/16


  • Nontraumatic intracranial hemorrhage requiring surgical intervention: Neurosurgery
  • Traumatic intracranial hemorrhage: Neurosurgery consultation, generally Trauma Surgery admission
  • Stroke and requiring urgent/emergent medical therapy: Medicine
  • All other strokes admitted to Neurology

See Harbor:Code stroke

Thyroid Masses

  • Refer to endocrinology

Trauma patients

  • Can admit to subspecialty service when only one organ system involved, at discretion of Trauma Surgery

Vaginal Bleeding

  • If symptomatic anemia from vaginal bleeding and requires extended stay and greater than 2U pRBC's, admit to Gyn (not obs)


Orders on Admitted Patients

Recently we had problems in the care of a patient due to both the emergency physician and the admitting team writing non-emergent orders on the patient at the same time.

Please do not write orders an admitted patient unless it is an emergency. If you do write an order on the an admitted patient, please communicate this as soon as reasonably possible to the admitting team. If nursing staff request that you write non-emergent orders on an admitted patient, please direct them to call the admitting team.

Admission officially occurs at the time you place the order "Request for Admit", and only after you've communicated with the admitting team about admission (or made a reasonable attempt to do so)

Dir OPS 5/5/15

Boarding Patients Sent from Clinic

Just a reminder to the seniors in the Emergency Department running the board: the correct procedure for patients admitted from clinic who do not need a monitored bed, especially when the clinic is closing, is for the clinic to contact the patient flow facilitator to assist in locating a bed in the hospital, and only contact the emergency department to board the patient if the flow facilitator cannot make other arrangements.

Monitored bed patients can be sent from the clinic to the emergency department to board when we are out of monitored beds. If it does not sound like the patient needs a monitored bed, please talk to the ED attending.

(Dir. OPS, February 03, 2015)

Direct Admission after Hours

  • If a patient who appears stable presents to the ED stating they are a direct admission, they should be sent to ED registration
    • ED registration will confirm with bed control/patient flow that the appropriate paperwork has been completed
      • If the patient was inadvertently registered prior to discovering they were a direct admit, they can be removed ("registration in error")
    • If the paperwork has not been completed, ED registration will attempt to contact the admitting physician to complete the process
    • If they are unable to contact an admitting physician, the patient should be directed back to the router for entry into the ED process
  • Patients may be directly placed in CORE by cardiology without ED evaluation
  • All patients going to Observation must be evaluated in the ED with an ED Chart completed (no direct placements on Observation by clinics, etc.)
  • Any inpatient direct admissions presenting before 8pm on Weekdays: admitting physician directly contacts Bed Control (x2185) for Ward Beds or Patient Flow (x3434) for Tele/PCU beds
  • If after 8pm on weekdays, or weekends and holidays: Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from ED registration window x2075/2076/2078 or Bed Control)
  1. Admitting physician provides a copy of the request to ER Registration and they create a pre-admit FIN
  2. Admitting physician provides a copy of the request to Bed Control/informs location of patient to release bed (ER)
    1. UR (x3226) financially clears patient or calls to obtain authorization (if OOP) and informs Bed Control of approval or denial
      1. If the patient is denied, UR informs the admitting physician and Bed Control of denial
      2. Admitting physician then must decide whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment
      3. If patient is DHS (approved), admitting physician inputs the admitting order on the pre-admit FIN
  3. ER Physician will document the patient's presence in AWR/ED as a Pre-arrival with name and patient location (AWR or room #) with brief note with admitting service and physician to contact for questions (pager #)
    1. Stable patients should be placed in one of the internal waiting rooms and until the upstairs bed is available; reassessment should occur per nursing protocol (q2 hours for ESI 2-3)
    2. If a patient is in any way unstable or requires immediate intervention or cardiac monitoring, they should be registered and seen as an ED patient and the admitting team should be notified of the change in patient status as soon as possible
  4. The Scheduled Admission Office (x2137) is open from 530am until 8pm, and admitting physicians should take stable patients there while awaiting a bed. If no bed is obtained by 8pm, then the admitting physician will be contacted and their service should take the patient to the ED to wait until a bed is obtained. They should be held in the WR and placed on the tracking board as a pre-arrival, but not registered in the ED as they already have admission orders.
    1. If the hospital capacity is limited, it is important that orders are placed as PLANNED, NOT ACTIVE, so they can be activated in any hospital location (this will allow a pre-admission that is boarded in the ED to have orders such as antibiotics completed while waiting for a bed)

Chappell 7/2016

Insurance Problems

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



There are generally four types of transfers that come into the emergency department:

  • "STEMI 911" and "Trauma 911" Transfers - these are transfers from other emergency departments in our area that are not Trauma Centers or STEMI centers. Since we are both a Trauma Center and a STEMI center we have agreed to take urgent transfers from other emergency departments if they feel their patient needs these services. The sending facility may contact you directly. We rarely say "no" to these cases as long as we are "open" to trauma and STEMI patients (ask the MICN/Radio Nurse or Charge Nurse about our status), and just take information and activate the appropriate resources within our facility. The sending facility is responsible for calling EMS and arranging for the emergent transfer. Note: these transfers are from the emergency department, and should not be from the inpatient units of the sending hospital.
  • Transfers should be ED to ED; if there are extenuating circumstances where an inpatient requires transfer to Harbor ED, do what is in the best interest of the patient; the DEM Chair will happily provide advice or address any questions/concerns 24/7
  • EMTALA or "Higher Level of Care": we consider accepting these as long as we are open to "EMTALA Transfers" - check with the charge nurse. Depends on our Surge status. In order for us to accept these transfers from other emergency departments, they must be approved by all of the following:
    • The subspecialty service that will likely be involved in the care of the patient (they determine if they have the right personnel and equipment to care for the patient.) The trauma service may serve as approval authority for all surgical patients, whether trauma or not.
    • The Patient Flow Facilitator ("PFF" - he or she determines if we have the right bed type available - the bed must be currently open)
    • The Emergency Department (we determine if we are uncrowded enough to safely take another patient). A general approach is to look at how many ESI 2 patients are waiting to be seen, and how far backed up we are with triaging, and to a lesser extent how many total patients are waiting to be seen.
  • The usual process is:
    • The sending facility contacts the Medical Alert Center or MAC, which is the clearinghouse for transfers within the County of Los Angeles. Any facilities that contact you directly for EMTALA transfers should be redirected to the MAC (unless it is one of the other types of transfers)
    • The MAC contacts the Patient Flow Facilitator first, who determines if we have the right bed available, and then the PFF or MAC (preferably the PFF) contacts the subspecialty service to get approval before contacting the emergency department. If these two approvals occur, then
    • The PFF calls the emergency department to talk to the ED attending to get acceptance. If the emergency department is too crowded or for other reasons cannot accommodate the transfer, then inform the PFF that the ED has "No Capacity" and state why.

If the MAC contacts you first about a transfer, you should redirect them to the patient flow facilitator. All transfers are seen first by the emergency department, and then appropriate subspecialty services are contacted. Subspecialty services are not expected to primarily evaluate the patients.

  • "Lateral Transfers" - these are transfers of patients who do not require a higher level of care, but generally have no funding so the sending facilities are referring them to the County. To accept these we should be open to "Lateral Transfers". The process is the same as EMTALA transfers.
  • "Impending Deterioration" transfers from our sister facility, Olive View-UCLA Medical Center. This is another County hospital that lacks some services that we have, including neurosurgery, orthopedics, and trauma services. Although generally transfers from this facility would go through the same procedures as above for EMTALA transfers (even to us), we have a special agreement for patients they think are likely to decompensate acutely if not transferred immediately. These are generally neurosurgical cases. These are pretty rare, and we take these regardless of our open or closed status. Emergency physicians from Olive View will generally contact you directly rather than going through the MAC.

Dir OPS 1/9/17

Responding to a Helicopter Landing

  • Requires 2-3 trained individuals, does NOT require a physician, though one may elect to go.
  • Only individuals with helicopter safety training should respond to a helicopter landing.
  • Must wear following (available in radio room):
    • Eye protection
    • Gloves
    • Ear plugs
    • Secure loose equipment, they may become a projectile.
    • Face shields are not permitted.
    • Stethoscopes are not to be worn around the neck.
    • Items are not to be left on top of the gurney

Clinic Referrals to ED

Occasionally you will get a call from a clinic either directly or through MAC to "transfer" a patient. These are not considered transfers under EMTALA, and should be considered simply "referrals". Clinic physicians can refer their patients wherever they like; we can't really "refuse" these patients. It's recommended that you listen to the clinical situation, advise the clinic doctor on whether or not the emergency department visit is likely to be helpful for the situation, and advise the clinic doctor if you think the patient needs to come by ambulance. In the end all of these decisions belong to the clinic physician. Also, depending on the complaint, I give the clinic doctor a rough estimate of the time the patient will wait to be seen. (Clinic patients do not necessarily get priority over other patients that are waiting in the waiting room, who may be sicker.) I ask the clinic doctor to advise the patient of the possible wait so they can make an informed decision about coming to the emergency department. (They may want to go elsewhere if we are highly impacted.) This hopefully helps prevent the clinic doctor from falsely informing the patient that they will seen "right away". If the clinic is one of our in-house clinics at Harbor (these calls are often taken by the senior resident), in order to maintain good working relationships with other hospital services we request that there be attending involvement if a decision is made to send such a patient to wait in the waiting room. This decision should be documented in the EHR the same way we document ambulance patients sent out the waiting room. We don't have a rule that states clinic patients jump to the head of the line; you are free to use your judgment, as again there may be sicker patients in the waiting room. Do consider however that this patient has in essence already been triaged by a (clinic) physician in most cases. Special note: transfers from the hospital in the city of Avalon on Santa Catalina Island are generally viewed as referrals from a clinic, so we normally accept them without question due to their extremely limited facilities on the island. These transfers almost always come by helicopter.

Dir OPS 1/9/17

Guidelines for Flow of patients between the Psychiatric and Adult Emergency Departments (ED Policy 3.4)

  • Ambulatory Patients: Patients presenting with abnormal behavior WITHOUT prior psych diagnoses or with acute ALOC are initially evaluated in the adult ED
  • Patients with a known psych history and behavior consistent with their previous diagnosis, without apparent acute medical condition requiring intervention, are initially evaluated by the Psych ED
  • Patients arriving by ambulance with psych complaints but not under a 5150 should be triaged by a physician in the adult ED then directed to appropriate location
  • Psychiatric Consultations in the ED: patients requesting voluntary evaluation by a psychiatrist are transferred to the psych ED after medical clearance for evaluation and should be transferred to the psych ED as soon as there is space available; ED physician to psych physician discussion should occur prior to transfer
  • All patients on a 5150 hold
  1. With ETOH>200, delirium, complicated alcohol withdrawal, drug overdose, or acute medical problems should be evaluated in the adult ED
  2. Require psych evaluation prior to discharge or transfer to medical unit; this should be done within 30 minutes of request for consult
  • Patients in the psych ED that require medical evaluation (or re-evaluation) should be transferred to the adult ED as soon as a bed is available; prior to the transfer, the psych physician should discuss the case with the ED physician; exceptions will be made on a case-by-case basis
  • Patients in the Psych ED who require treatment with sedatives and are deemed to be at risk for significant oxygen desaturation should be transferred to a monitored bed in the adult ED; these patients are co-managed by the physicians from both areas
  • Psychiatric patients with chronic disorders who require placement are managed in the Psych ED

Approved June 2015, Chappell 2/22/16


Transferring patients out for HLOC - Time Sensitive Life/Limb/Permanent Disability Threatening Conditions

  1. If Transferring to another DHS Facility that offers needed service:
    1. Call Medical Alert Center (MAC) and state "This is a Higher Level of Care Emergent/Urgent transfer under DHS Policy 373.3"
    2. MAC should get transfer approved within 60 min to appropriate DHS facility
    3. If any resistance from receiving facility immediately have ATTENDING to ATTENDING discussion (through MAC)
    4. Sending physician (YOU) has right to make final decision about sending for an evaluation. The receiving physician can decide what therapy to give the patient, but as long as they have the appropriate PERSONNEL and EQUIPMENT, they must accept the patient for evaluation if you request it. (Per DHS Policy and EMTALA Law)
    5. Receiving facility CANNOT DECLINE DUE TO LACK OF BEDS, under Policy 373.3 and agreement with USC CMO.
    6. Sending facility (YOU) MUST ACCEPT PATIENT BACK ONCE STABILIZED by receiving facility at their request (per agreement with USC CMO).
    7. If transferring to USC and problems are occurring on USC end, ED Attending should try to resolve with USC accepting physician. If this does not work, call USC Medical Officer of the Day (MOD). Number available on amion.com. Password distributed in email Oct 31, 2017 (Can't post on WikEM as this site is public)
  2. HLOC Transfer Sites
    1. Re-implantation Candidates
      1. USC
      2. UCLA Westwood
    2. Burns
      1. USC
      2. Torrance Memorial
    3. STEMI but our cath lab is encumbered: 911 to closest STEMI Receiving Facility. MICN - has what SRCs are open, courtesy call to their ED
  3. Advanced Transport Options
    1. Critical Care Ground Transport can be arranged through MAC - but may require 45 min or longer to activate
    2. Aeromedical transport
      1. ALS-level care
        1. LA County Fire- -Air Captain number is 818-890-5755.
      2. Critical Care Transfer
        1. Private air ambulance - ask for critical care team.
          1. Reach Medical: (800) 338-4045 or
          2. Mercy Air: (800) 222-3456).
          3. Consider sending RN, MD or RT staff with LA County fire when CCT level of air ambulance transport is required and private CCT is unavailable or the ETA is too long.
  4. Ask MAC to speak to the EMS Agency Administrator on Duty or Medical Director if quoted transport time unacceptable.
  5. Consider using our on campus ambulance, which is available until about 1130p (Code Assist EMT is not a paramedic, just EMT) +/- our own RN or MD with transport if indicated as a last resort.
  6. 911 (last resort). Takes the local unit of paramedics out of service for an extensive period of time.

(Dir OPS 11/7/17) (DHS Policy 373.3 v10-1-12)

Transfers out to Out of Plan (OOP) patient's health network

  1. Any OOP patients who are deemed stable for transfer, should have Interqual request placed to see if Utilization Review (UR) staff can transfer the patient back to a hospital in the patient's insurance network.
  2. Applies for patients who would otherwise be admitted, placed in observation or CORE.
  3. If UR is unable to contact the health plan, or unable to find a bed in a timely fashion (up to attending discretion considering status of ED), then the patient can be admitted/obs/CORE'd at HUMC.



REFER TO ED follow up flow chart

DHS Patient with Empanelled Provider

  1. Instruct the patient to follow up with their empaneled provider
  2. Use the 'communicate' tool to send a message to the empaneled provider listed in the banner bar
  3. Write a brief message explaining why and when the patient needs follow up
  4. Their empaneled provider can initiate e-consults if applicable
  5. Starting Feb 2018, empaneled providers will automatically be notified of ED visits but you can still message them with any specific concerns

Urgent <2 Week Specialty Follow-up for DHS or MHLA Patients

Write the following items in the follow up field for clerk to book:

  1. Name of approving doctor
  2. Time frame (I.e., 2 days, 1 week, etc.)
  3. Reason for urgent follow up

Discharging Patients Direct to Specialty Clinic

  • In certain situations, patients can (and should) be discharged to a specialty clinic for same/next business day visit (Ophtho, ENT, Cast room, OMFS, etc.). This is considered a continuation of ED care to stabilize their presenting emergent medical condition. Once care is completed in the clinic, the patient should NOT be sent back to the ED.
  • This allows consultants to evaluate and treat patients in their clinic as opposed to coming to the ED
  • The patient CAN BE "OUT OF PLAN" FOR THIS SERVICE as is considered part of ED visit
  • Process/Troubleshooting:
  1. Get agreement from consultant
  2. Must be seen in 24 hours or next business day (if weekend)
  3. ED Care should be complete
  4. Must be during normal clinic operating hours and clinic must be open (Cast room is open until 11 pm 7 days a week)
  5. ED physician should note time and place for patient to follow-up on the ED discharge paperwork, and make sure patient takes paperwork with them to clinic
  6. ED Clerk schedules the visit as appropriate
  7. If any issues, consider attending involvement and/or contact Dr. Roger Lewis via cell.

Dir AED, Chair EM, Dir OPS 9/20/17

Follow up in CCC

REFER TO ED follow up flow chart

LAB/SYMPTOM FOLLOW-UP: DOES NOT INCLUDE Urine cultures or STI follow up anymore. Otherwise, can be any patient seen in the Adult ED, regardless of insurance or empanelment.

  • Be specific re: f/u time frame when filling out the form
  • CCC reviews requests in a few business days. No abnormal lab result review after hours or on weekends or holidays
  • If you think a patient needs an urgent face to face evaluation, have them go to the Urgent Care if DHS eligible.
  • CCC will only call patient if an abnormal result needs to be addressed. (Example: Urine culture shows antibiotic needs to be switched).
  • For pediatric patients, do not select PVCC/CCC, rather select PED

Bridge to PMD: only DHS patients discharged home, not empaneled on banner bar, not MHLA/OOP.

  • Only for DHS patients without other resources.
  • Only for patient's dispositioned HOME.
    • If unassigned MediCal, patient can go to Health Care Options office to get help choosing a PCP. Health Care Options is located at. Main Hospital PCDC 108, Window #8, Mon and Wed 8a-430p, x8101
    • If the patient was dispositioned to Obs/CORE/Psych ED/Admitted, they cannot go to CCC.
    • Don’t place the ‘ED Post Visit Plan’ form for CCC referral until you’ve decided the patient’s final disposition. If you place it too early, have to cancel or ‘place in error’ the referral form.
  • Need at least one Ambulatory Care Sensitive Condition (ACSC)
    • Chronic conditions which appropriate outpt care prevents inpt admission and/or complications.
    • Asthma, CHF, Cancer, CVA, ESRD, CF, DM, HIV/AIDS, IBD, Heart Dz, HTN, HL, Neuromuscular dz, Psych d/o, CKD, RA, Sz d/o, Substance abuse d/o, Specified debilitating conditions
    • CCC will work to transition to primary care via NERF submission
    • If they want to switch to Harbor UCLA or have problems with their health plan, they can call their own insurance plan. For MHLA patients, they can also contact MHLA directly and request the change if eligible.
    • If they are Out of Country/County, and now reside in LA County, they can go to Registration PCDC Rm 108, 1st floor main hospital, ext 8101 to change their address by bringing any mail or DMV record.

E-consult for non-urgent specialty referral - DHS patient discharged home, not empaneled, not MHLA

  • Only non-urgent/not time-sensitive. If request for specialty visit <2wks, do not use CCC. Instead, call specialty consultant to schedule appt prior to d/c
    • Appointment Service Center contacts patient to schedule the appointment around 2 weeks just to start arranging follow up.
    • If e-consult submitted already, patient can call ASC themselves to schedule their appointment 855-521-1718.
  • Need BMI and smoking status in chart for patients who are being referred for elective cholecystectomy or hernia repair. Elective cholecystectomy requires formal RUQ US prior to clinic evaluating patient. Consider obtaining formal RUQ US if appropriate. (Otherwise, could add several months delay to referral process).
  • If outside records available, ask ED clerk to copy and upload to ORCHID

How to submit CCC referral

  • Fill out ‘ED Post Visit Plan’ in the Depart Process. Select ‘PVCC/CCC – Har’ and fill out the form to put patient on their tracking list. Make sure there is a correct phone number.
  • Forgot to do the form, patient off the tracking board?
    • Highlight your patient on the “HAR Look Up” track
    • Click ‘Modify Event’ on the toolbar.
    • Then, manually request BOTH:
      • ‘Post Visit PVCC’ for adult patients or ‘Post Visit Peds’ for peds patients,
      • ‘Post Visit Follow Up’ event to put the patient on the follow up track.
      • If you placed the form by accident, cancel the PVCC form or place ‘in error’ notification. Example, if patient doesn’t get discharged from ED, need to cancel PVCC form if placed earlier.
  • Finish your ED Provider Note. CCC can’t do anything until you’ve finished your note!

Follow up MAT/Buprenorphine/Opiate Withdrawal Treatment

REFER TO MAT Pathway File:Harbor UCLA ED Bup DH 11-28-18 Final.pdf

Patient Discharge Handout File:Bup Start (Harbor).pdf

Patient MAT/Buprenorphine Follow Up Options

Insurance Clinic Hours
All Patients Tarzana Treatment Center, Long Beach

5190 Atlantic Blvd Long Beach, CA 90805 Phone 818-654-3933



DHS Empaneled and DHS Eligible (but not Harbor Family Medicine) Primary Care & Diagnostic Center (PDCC)

Basement Clinic C 1000 W. Carson Street Torrance, CA 90502 (310) 222-8221


Monday AM Thursday AM

DHS Harbor Family Medicine Empaneled Lomita Clinic

1430 West Lomita Blvd, 2nd Flr Harbor City, CA 90710 (310) 534-7600


Tuesday AM Friday AM

DHS Empaneled, DHS Eligible, MyHealthLA, Uninsured (No OOP) LAC+USC Medical Center Urgent Care

2051 Marengo St. 2nd Floor D/T Building Los Angeles, CA 90033 323-409-1000


Tuesday – Thursdays & Saturdays 8am-7pm

All patients can call the Substance Abuse Service Hotline 24/7 for more help 1-844-804-7500

Follow up In Other Clinics

For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center x1220 to take over. Patients can also call 310-222-1200 to schedule appointments (Rather than calling the clinic directly).

Anticoagulation (Coumadin) Clinic

  • Book without consultant approval
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

Breast Surgery Clinic


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Expedited Work-up Clinic (EWC)

  • Clerk books without consultant approval
  • HAR CCC Rm 4, every Monday afternoons.
  • Must have reliable contact info, confirm phone number and address
  • Ideal candidates are those patients that would be admitted in the absence of EWC, and do not have a primary care provider. Patients must have reliable contact information to attend this clinic.
  • Katrina Pasion, RNI, is the EWC care coordinator. Please address any questions to her via ORCHID communication, Outlook email kpasion@dhs.lacounty.gov, or 310-222-2859.
  • If no slots available, send a message to CCC to book the patient.
  • Clinical criteria:
  1. New onset ascites: New diagnosis and first presentation of ascites. Requires paracentesis performed in ED to rule out infection, SAAG >1.1, transaminases < 3x normal, rapid HIV, CBC, lipase, CMP. No referral for therapeutic paracentesis alone, No evidence of pancreatitis or biliary obstruction.
  2. Anemia (Hgb< 8g/dL on initial presentation): Requires CBC, peripheral smear, CMP, rapid HIV, ECG, CXR, type and screen No evidence of pancytopenia, HIV, leukemia, active GI/GU bleeding, or evidence of hemolysis. Patients with suspected gynecologic etiology should be referred to the GYN service. Post transfusion CBC required.
  3. Weight loss, unexplained >10% within 1 month or >15% in 6 months: Requires CBC, CMP, ECG, CXR, rapid HIV. Patients with prior imaging must have actual images or be instructed to retrieve images prior to clinic appointment.
  4. Undiagnosed mass (excluding primary breast, brain, renal, head and neck masses): Requires results or radiographic imaging to confirm presence of mass. Patients with prior imaging must have actual images or be instructed to retrieve imaging prior to clinic appointment. Send CBC, CMP, PT/INR, HIV on all patients.
  5. New onset pleural effusion: Requires thoracentesis, CMP, CBC, serum amylase, LDH, and pleural fluid analysis (predominant lymphocytic effusion or high suspicion for Tuberculosis must be admitted). Chest CT only if immediately clinically indicated (ie. suspicion for pulmonary embolism).
  • Patient is stable (T< 38.3c, HR<100, RR <24, BP >110/50, BP <180/110, pulse ox >92% on room air, oriented x 4)
  • Able to be seen in 2-10 business days without significant risk
  • No ACTIVE co-morbidities (ie infection, CAD, CHF, stroke, metastatic cancer, renal failure, dyspnea).


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)

Nephrology Clinic

  • For non-dialysis patients only: Don’t need Nephrology fellow approval per Sharon Adler, MD, Chief, Division of Nephrology and Hypertension, 7/28/17)
    • 3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
    • 2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • For new pregnancy: discharge patient with OB clinic intake phone number (310-222-7200) so they can schedule appointment


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up.
  • Newly diagnosed, metastatic cancer - discuss with oncology fellow p7862


  • Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
  • All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Adolescent Clinic

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Cardiology

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


Place order in ORCHID for "CV Treadmill Stress Test"

  • If test is abnormal, cardiology follow up automatically generated by HEART station.
  • If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.
  • Outpatient P-MIBI Nuclear stress has to be arranged by CORE


Per DHS Policy 516.1, Out of County/Country Patients who need an urgent follow-up for an emergency medical condition may be provided such follow-up at Harbor

  1. Emergent Conditions:
    1. Places health in serious jeopardy
    2. Threatens serious impairment to bodily functions
    3. Threatens serious dysfunction to any organ or body part
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. Do not arrange follow-up for NON-EMERGENT/URGENT issues
  • If patient is no longer Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

Dir AED, Dir OPS, DHS Policy 516.1 9/25/17


Important Numbers

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

Printable FORMS

  • Work Notes
  1. Work Excuse http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Work%20Excuse.pdf
  2. Family Work Excuse http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Family%20Work%20Excuse.pdf
  • Clinics
  1. Health Care Options (HCO), where unempaneled MediCal patient can go to choose a PCP: https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/HCO%20FLYER%20ENG_SPAN.pdf
  2. CHC Clinics http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/CHC.pdf
  3. South Bay Public Health Clinics (STI, vaccines) http://publichealth.lacounty.gov/chs/SPA8/index.htm
  4. Dental Clinics http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Dental%20Clinics.pdf
  5. Breast Diagnostic Center (Radiology Imaging) Referral Form http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Breast%20Clinic%20Referral.pdf
  6. Women's (Gyn) Clinics List http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Womens%20Clinics.pdf
  7. Pediatric Same-Day Clinic http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Pediatric%20Same%20Day%20Clinic%20at%20Harbor.pdf
  8. Adult Mental Health Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Psych%20Referrals.pdf
  9. Pediatric Mental Health Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Peds%20Psych%20Referrals.pdf
  10. Shelter Resources for the Homeless http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Shelter%20Resources.pdf
  11. Substance Abuse Resources http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Substance%20Abuse%20Referral.pdf
  • Clinical Forms
  1. Interventional Radiology http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Interventional%20Radiology.pdf
  2. Heparin Infusion http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Heparin%20Infusion%20Adult.pdf
  3. Peripheral Pressor Extravasation (pages 5-6) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Extravasation%20Management.pdf
  4. Cytology Request Form https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Cytology%20Request%20Form.pdf
  5. Pathology Tissue Report http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Path%20Form.pdf
  6. Pediatric Tylenol/Motrin Dosing http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Tylenol%20Motrin%20Peds%20Dosing.pdf
  • Legal Forms
  1. General Consent (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/General%20Consent-English.pdf
  2. General Consent (Spanish)http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/General%20Consent-Spanish.pdf
  3. Telegram http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Telegram.pdf
  4. DMV Form http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/DMV%20LOC%20Form.pdf
  5. OK to Book http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/OK%20to%20Book.pdf
  6. AMA (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/AMA%20English.pdf
  7. AMA (Spanish) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/AMA%20Spanish.pdf
  8. PHI Release http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/PHI%20Release.pdf
  9. Imaging Request http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Imaging%20Request%20Form.pdf
  10. Photo Consent http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Photo%20Consent.pdf
  11. POLST (English) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/POLST-English.pdf
  12. POLST (Spanish) http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/POLST-Spanish.pdf
  13. Dog Bite Reporting (PDF | Online Form)
  • Resident Procedures Direct Observation Forms
  1. Central Line http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20Central%20Line.pdf
  2. Chest Tube http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20Chest%20Tube.pdf
  3. I&D http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20I+D.pdf
  4. Intubation http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20Intubation.pdf
  5. Laceration Repair http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20Lac%20Repair.pdf
  6. Lumbar Puncture http://www.emedharbor.edu/private/Contact%20Info/ED%20Documents/Direct%20Obs%20-%20LP.pdf


  • Paging
  1. For consults:
    1. Place order for consult in quick orders tab; these orders are located in the right hand column of the quick orders page
      1. Auto-page consults: enter your callback number
      2. No auto-page consults: after placing order, enter your page through the Harbor Alpha Page link on the intranet home page
  • Order Sets
  1. Within the quick orders tab, use the "Search for new order" bar at the top of the third column
    1. ED focused order sets generally start with "ED "
      1. i.e., "ED Chest Pain," "ED Trauma," "ED Intubation"
      2. ICU Therapeutic Hypothermia Targeted Temperature Management
      3. ICU Vasopressors Subphase
      4. ICU Anti-Hypertensive Medications
      5. Med TB Sputum AFB Bundle
      6. Med Insulin One Time Dose
      7. Med or Ped Med/Surg IV Fluid Subphase
      8. ED Holding orders: Don’t forget you can write holding orders for admitted patients past the 2 hour window.
      9. ED Sepsis Screening and Management Bundle: Has recommended antibiotics based on source of infection, labs, and IVF orders. Don’t forget to use the .sepsis autotext phrases as well for documentation requirements.
    2. Select "Modify order" and select the components of the order set you need
  • Bedside US
  1. Place order for study from within the quick orders page
    1. Located at the bottom of the second column
      1. Orders titled "ED US __"
  2. Open the US machine, end the current study and select "New patient"
  3. Select "Update" from the list of tabs along the bottom of the screen (this may take a minute to appear)
  4. Select your patient from the list
  5. Perform POCUS study, freeze and save images with necessary measurements
  6. Review images and delete inadequate or poor quality images prior to placing US machine back in charging dock
  7. Select "New patient/End Study" to end the current study and automatically upload images
  • Placing in Obs
  1. Place order for interqual request to initiate utilization review process of evaluation for possible transfer
  2. When green "Met" icon appears on tracking list indicating able to place on observation:
  3. Write the patient's name and MRN in the aluminum Obs binder next to the AED Clerk, in the next available time slot that has not yet passed
  4. Page the ED hospitalist at 310-204-9753
  • Admitting
  1. Place order for interqual request to initiate utilization review process of evaluation for admission vs transfer
  2. When green "Met" icon appears on tracking list indicating able to admit to Harbor:
  3. Write the patient's name and MRN in the aluminum Admissions binder next to the AED Clerk, in the next available time slot that has not yet passed
  4. Page the admitting resident at the number provided
  5. Inpatient hospitalists admit on Tuesdays and Saturdays, this information is also in the aluminum binder
  • Transfers
  1. EMTALA form
  2. Transport patient between facilities

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

When you need to urgently contact the attending on a consulting or admitting service I would suggest your follow this approach, assuming the resident or fellow on the service hasn’t been able or willing to reach their attending and have them call you:

  1. Check AMION to see if the attending’s pager, cell-phone, and home phone numbers are listed. If so, try those numbers, in that order;
  2. If no information listed on AMION allows you to reach the attending, then call the hospital operator and ask the operator to contact the physician via his or her home number. (They may not release the number to you - in that case they should dial it for you.)
  3. If you still have no luck, and it is a true emergency then please text Roger Lewis’ cell at 310-720-1661. You can also call Dr. Lewis but texting gives a better record of the issue and makes it easier to respond and address.

A true emergency is something in which a delay in care is likely to permanently affect outcome (e.g., STEMI, testicular torsion, SDH);

DEM Chair, Dir OPS 5/18/15

On Call Plan - Emergency Department Attending Physicians

When it becomes clear for any reason that an Attending Physician in the Adult or Pediatric ED will be unable to cover a scheduled shift due to illness or personal emergency, that physician should:

  1. Send out a group wide email in an attempt to find coverage, as time permits. The address backup@emedharbor.edu will reach all ED faculty, fellows, and adult and pediatric clinical attendings as well as Becki McKenzie and Veronica Lopez.
  2. Outside business hours, contact the attending on duty in emergency department, who will notify involved physicians that the shift extension backup plan is in effect (see section 5 below). Contact information for all ED physicians is available on our intranet website http://www.emedharbor.edu/private/
  3. During business hours, call the Department Offices at 310 222-3500 and inform Maria Figueroa, or if unavailable, Juno Chen. Maria (or Juno) will contact the Chair, or in his absence, one of the Vice Chairs, who will initiate an e-mail attempt to arrange coverage. If no coverage is found, the Chair or Vice Chairs will notify the attending in the emergency department to activate the shift extension backup plan.
  4. Part time hourly physicians and volunteer physicians are not obligated under this plan, but will be compensated for their time per their usual agreement should they decide to cover additional hours under this plan.
  5. Shift Extension Back-up Plan: When no coverage can be found - the physicians working the shifts before and after the missed shift will extend their shifts to 12 hours to cover the missed shift. AAED A-team physicians are responsible to cover A-team absences and AAED B-Team for B-Team absences, and PED team physicians cover PEDS team absences.
  6. In the event one of the covering physicians is a part-time physician and unable to extend their shift, the physician from the opposite team should extend their shift to 12 hours to help cover the missed shift.
  7. A full-time faculty member or Fellow will generally be responsible for making up the first 2 shifts missed from any single incident. At the discretion of the Chair, the requirement to make up subsequent shifts may be waived.
    • Faculty will not be required to pay back specific individuals who worked their missed shifts. Shift pay back will be accomplished through the regular scheduling process.
    • Faculty working extra to cover missed shifts should notify the scheduler to ensure appropriate credit is given.

(Dir of OPS 6/2/15, Upheld by Fulltime Faculty Vote on 5/10/16)

Trauma Activations

In addition to the standard trauma activation criteria published on a badge card that everyone should carry and refer to, the Trauma Service can be activated in patients not meeting trauma criteria to help in several ways:

  1. Getting CT scans READ quickly (Trauma will read them)
  2. Getting lots of extra hands to do whatever needs to be done for the patient.
  3. Getting surgical decisions made more quickly.

You can even activate the trauma service if you have a non-trauma patient that needs emergent surgical intervention.

All of these decisions are covered under "ED Judgment"

(Dir OPS 7/15)

STEMI Activations

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

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

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

(See also "TRANSFERS")

Dir OPS 1/9/17


  • Code Stroke Neurology Spectralink 23369
  • Code Stroke Pager -0921
  1. Timeline Goals
    1. 10 minutes from arrival: ED MD evaluation
    2. 15 minutes from arrival: Neurology evaluation
    3. 20 minutes from arrival: CT head noncontrast obtained
    4. 45 minutes from arrival: CT head read by radiologist
    5. 60 minutes from arrival: TPA given for appropriate candidates
    6. 20 minutes from Neuro IR discussion: If have IR capacity at Harbor
    7. 120 minutes from arrival: LVO with no IR capacity at Harbor --> transfer to Comprehensive Stroke Center
    8. 45 minutes from Neuro IR activation: LVO with IR capacity at Harbor
  1. CODE STROKE Procedure
    1. INCLUSION: age 18 years or older, new focal neurological deficit for <24 hours
    2. Rooming:
      1. From Triage: BBN and call charge RN to place in AED room immediately
      2. By Ambulance: room immediately
      3. **If no room available: RN to start IVs, obtain POC and labs; Initial ED MD evaluation then proceed directly to CT
      1. Initial ED MD evaluation within 10 minutes
      2. Stabilize ABCs
      3. Last known well time (LKWT), patient’s age, and deficit (consider deferring complete NIHSS until after activated)
    4. ACTIVATE CODE STROKE: notify ED clerk to page with information above: “code stroke, name/MRN if available, location, age, M/F, deficits/NIHSS, LKWT”
      1. p0921: Batch page to Neurology (chief and attending, resident on call), lab, CT tech, radiology/IR, ED pharmacist, patient flow coordinator
      2. Neurology to bedside to evaluate patient w/in 15min
    5. Prior to CT, in AED room
      1. Complete ED MD evaluation/orders: Perform full NIHSS exam, and use order set “ED Suspected Stroke TPA Intervention Candidate Initial Orders”
      2. Automatic Imaging: CT head, CTA head and neck, CT cerebral perfusion study (can cancel later if a bleed on non-contrast CT)
      3. Labs/Studies
        1. Automatic: CBC, BMP, PT/PTT, POC glucose, POC chemistry for Cr
        2. Consider: EKG, troponin, T&S, CXR, Upreg, U/A, Utox (NOT in order set)
        3. RN: obtain POC glucose and chemistry (including Cr), place 2 large bore IVs, send blood work to lab
    6. Go to CT
      1. Always CT head non-contrast
      2. Complete NIHSS if not already done so
      3. IF high risk of Large Vessel Occlusion with NIHSS ≥ 6 obtain CT Perfusion and CTA Head and Neck at the same time [regardless of if Cr on POC testing]
    7. Back to AED room from CT
      1. RN to obtain weight from scale on bed, EKG/CXR and other studies as needed
      2. Further history as needed (including TPA contraindications https://www.wikem.org/wiki/Thrombolysis_in_Acute_Ischemic_Stroke_(tPA), await CT results
    8. CT Head result – Radiology calls Neurology Spectralink 23369 with read (back up ED clerk transferred to resident Spectralink)
      1. Intracranial hemorrhage
        1. Neurosurgery consult, if subarachnoid hemorrhage consider IR intervention; admit neurosurgery ICU
      2. No intracranial hemorrhage
        1. <4.5 hours from LKWT, 18+ years old = possible TPA Candidate
          1. TPA Candidate (no ICH, symptoms <4.5 hours). Use “ED Ischemic Stroke/TIA” order set
            1. Manage BP to goal SBP <180, DBP <105
              1. IV labetalol, Nicardipine drip (in order set); if still uncontrolled, no TPA
            2. If not IR candidate as below and no contraindications to TPA Neurology consents patient, discuss with neurology ED team; Neurology orders TPA (alteplase), ED as backup if Neurology unable
              1. TPA protocol per neurology/ED pharmacist (in order set): 0.9 mg/kg IV (max 90mg) total with 10% as bolus and remainder over 60 min
            3. Admit to neuro ICU
              1. Q15 minutes neuro checks for first 2 hours
              2. No anticoagulation/antiplatelets for 24 hours
              3. No foley catheter or NG tube placement after TPA
              4. Consider ordering MRI brain with DWI (non-contrast), MRA head and neck with and without contrast
        2. <6 24 hours from LKWT, NIHSS ≥ 6, CTA findings of large vessel obstruction = possible IR thrombectomy candidate
          1. IR Thrombectomy candidate (<6 hours with LVO on CTA, up to 24 hours in some cases – DAWN trial); Neurology will activate stroke IR batch page
            1. Yes IR Capacity --> obtain CT cerebral perfusion --> IR thrombectomy; admit to neurology ICU
            2. No IR Capacity --> give TPA if candidate as above; Neurology coordinates transfer to Comprehensive Stroke Center (Long Beach 562-480-3487 or Little Co of Mary, Torrance 310-4-STROKE. Do not use MAC, the accepting comprehensive stroke center arranged their own transport)
        3. 4.5-24 hours from LKWT without suspicion for LVO = Not TPA or IR Candidate
          1. Not TPA Candidate, no evidence of LVO
            1. Give aspirin, permissive HTN (only treat for SBP >220, DBP >120), glucose control (60-180), early swallow evaluation by RN
            2. Admit to neurology on telemetry for further workup/management

Scheduled Dialysis Patients in ED

  1. The router will place them on the pre-arrivals each AM (M/W/F)
  2. HD times should be 5-9a and 930-130p
  3. They will receive a MSE at triage – if they decline the MSE and only want their scheduled HD, please document that “the patient declined a MSE and no emergent medical condition exists at this time” in the MSE note and we are done from the ED perspective
  4. If the patient appears unstable, please discuss with one of the AED attendings to determine if they need to be on an AED team or simply need dialysis with a call to the nephrologist for urgent evaluation.
  5. Once the MSE is performed, they will be taken to one of our HD rooms – preferentially Gold 29, then RME 19, then Acute 15 (likely a max of 2 rooms at a time).
  6. They will be cared for by the nephrologist (typically Dr. Anuja Shah) who will place the discharge orders (so these patients should NOT be placed on AED teams).
  7. If for some reason Dr. Shah is unable to evaluate the patient prior to discharge, the FastTrack NP (not resident) will briefly evaluate the patient when ready for discharge - documenting vitals, heart, lung, and lower extremity exam, and page Dr. Shah to clear for dispo and subsequently print the discharge instructions (“HEMODIALYSIS” patient education).
  8. The NP will forward the chart to Dr. Shah, not ED R4 or Attending.

DIR RME 12-1-17

Attending Documentation

  • For all patients physically present in the department at change of shift (whether dispositioned or not) attendings should write and save one note (ED Attending Note), to be modified by the subsequent attending as needed for that episode of care. This note will include all attending documentation, including language regarding admission or change in status (observation or CORE). Attendings should make sure notes are completed prior to leaving the ED.
  • For patients seen only on your shift and that depart prior to the end of your shift: attendings have the option of modifying the residents note with an attending note OR completing a separate attending note. These notes can be completed within the 72 hour documentation completion timeline.
  • Interqual documentation will always be in a separate note, called "Interqual Override Note".

(T. Horezcko 7/7/15, Clarification 9/28/15, Dir OPS 9/28/15)

Minimum Content for Attending Notes

    • Acute problem list (should justify the need for Admission/OBS/CORE)
    • Brief history supporting admission/OBS/CORE required only if problem list does not support your decision
    • Care Level (ICU/PCU/Tele/Ward, etc.)
    • Admitting Service

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

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

(Faculty Agreement 11/16)

Resident Documentation

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


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



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

(Hosp Policy 375B 9/16)


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

(Hosp Policy 375B 9/16)


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




  • What Does the Airway Management Team Respond To
    • The airway management team is responsible FOR THE AIRWAY ONLY and will respond to:
  1. All Airway Management Team Pages
  2. All Code Blues (If already intubated - please check tube placement)
  3. All Code Whites
    • Anesthesia primary always
    • ED will also respond when on airway management call
Airway Coverage Times

ED - Sunday 7 AM to Wednesday 7 PM

  • Anesthesia - Wednesday 7 PM to Sunday 7 AM
  • Whoever has the pager around time of handoff will respond
  • Who Responds
    • Purple Attending, Purple Senior (PGY 3/4) (if available), and ED Pharmacist (if available).
    • The Purple Attending may ask the Green Attending or the Peds Attending for assistance at the Purple Attending's discretion.
    • The Purple Attending may take another senior resident (PGY 3/4) if the Purple Senior is not available.
  • Pager Handoff
    • Pick Up: Purple Senior gets from OR front desk at 6:50 AM on Sunday.
    • Drop Off: Purple Senior to OR front desk at 6:50 PM on Wednesday.
    • The pager cases for anesthesia (extra - not tied to phones) are in the purple doctor's box clipped to the boxes for the McGrath blades.
  • Equipment
    • The airway management team bags - purple doc box in the drawers under the pager. There are two bags.
    • BVM/PPE/MAPS - plastic bags to the right of the drawers. There are two bags.
    • Please replace the ED airway tray with one from the crash cart on the floor where it was used
  • Keys
    • The Purple Attending, Green Attending, Purple Senior, Green Senior and ED Pharmacist have keys to the drawers.
  • Medications
    • Each bag in top compartment:
      • Rocuronium
      • Succinylcholine
      • Etomidate
    • Pharmacy will check each day.
    • Residents are also responsible for checking the medications and logging this in the log kept in the drawer for pharmacy.
    • Replacement of Meds
      • Return the box to the pharmacist with a patient sticker for new box
      • If no pharmacist take used box with a patient sticker to the trauma nurse for new box
  • Restock and Bag Check
    • Whoever uses the bag is responsible for restocking it.
    • The bags will be checked by the Purple Senior as part of the 5S process.
    • Zip tie after restocking.
    • If zip tie is in place, no need to open
  • When you return to the ED:
  1. Search for patient using magnifying glass in top right corner of Firstnet
  2. Click “Ad-Hoc” button at top and complete “ED Procedures” form as usual (This will give you procedure log credit)
  3. Start a new note
  4. Right-click field at the top that says “Type:”
  5. Choose “Document Type List” à “Personal”
  6. Choose “Rapid Response/Code Blue Records”
  7. If you have not added this Document Type to your personal list, choose “Complete” to see entire list
  8. Use the “.edairwayteam” autotext to add the template


Harbor: Macros and Autotext


RME Phones

  • Triage Resident x23223
  • Triage NP (9a) x23209
  • FT NP (6a/6p) x23203
  • FT NP #2 x23222
  • FT R2 x23210
  • FT R4 x23213
  • RME Charge x23930
  • RME 1 EKG Tech x23922
  • Chest Pain Triage RN x23909
  • USA M-F 7a-11p x29737; pgr 501-2047 (Francisco 7a-3p, Reuben 3p-11p)
  • Lori x23972; Martee x23973
  • Triage Printer in registration cubby (; PH011E16RX)

Chappell 10/2017

RME Patient Flow

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


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

Chappell 1/2018

Triaging Clinic Patients

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

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

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

Direct to Back

  • IF beds in the AED are wide open (> 3-4 open beds including Trauma), still perform team triage, but:
    • RN
      • takes vitals
      • asks the necessary triage questions (RIPT, etc)
      • documents the triage form
      • screens for critical patients,
      • click MSE note,
      • assign ESI,
      • assign to FT Team if low acuity
      • If critical let the receiving team know.
      • 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


  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

Nurse practitioners may independently order any x-rays; all advanced imaging studies (US, CT, MRI) require physician consultation prior to ordering.

  • Tips for imaging selection:
    • X-rays: consider evaluation of joints above and below for concomitant injury
    • Non-contrast CT of the brain for symptoms of “sudden onset” headache or “worst headache of life”
      • Consider CTA Brain for aneurysm if patient is unwilling to have lumbar puncture (discuss CTA with attending)
    • Non-contrast CT of the brain for patients who have minor head trauma following 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
    • CT brain with IV contrast – for 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
    • Non-contrast CT of the abdomen/pelvis for 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 bedside renal ultrasound to evaluate for hydronephrosis
    • Limited Right upper quadrant ultrasound for patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
    • Abdominal ultrasound for patients with high suspicion for first episode of pancreatitis
    • Pelvic ultrasound for 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
    • Chest Pain: NP should obtain a brief history on any patient with signs or symptoms of cardiac ischemia or with ECG read that is not “normal sinus rhythm” then present the ECG to the Attending
  • Trauma
    • 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 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)

Chappell 7/2017

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

  • NPs may independently discharge patients whose complaints are limited to the following and only if they feel physician consultation is not warranted:
    • Allergic reactions (without signs of anaphylaxis)
    • Asthma exacerbation that responds to Albuterol, not immune compromised
    • Bell’s Palsy with complete unilateral facial paralysis and no other focal neurological deficits
    • Breast Complaints
    • Superficial (1st) and Partial Thickness (2nd) Burns 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)
    • Chest pain (low risk – HEART Score <4, age < 30, no syncope/SOB, no drugs, no significant family history of early cardiac disease or sudden death, no tachycardia, normal ECG without arrhythmia)
    • Conjunctivitis
    • Constipation without signs of obstruction
    • Dental Complaints
    • Dizziness consistent with Peripheral Vertigo (normal HiNTS exam, no cerebellar findings)
    • Ear, Nose and Throat (no angioedema, drooling, phonation changes, or stridor)
    • Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin)
    • Genitourinary, minor complaints (male and female, no torsion)
    • Gynecological, minor complaints (not pregnant, no active bleed, hemoglobin >8)
    • Hemorrhoids
    • Hyperglycemia (asymptomatic, no DKA/HHS)
    • Hypertension (asymptomatic)
    • Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury)
    • Low back pain without associated fever or neurologic deficits
    • Medication Refill
    • Minor head or facial trauma
    • Musculoskeletal injuries/musculoskeletal pain
    • Nausea and vomiting without significant abdominal pain
    • Ocular complaints (minor, no significant acute decreased vision, no trauma)
    • 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; sugar tong or 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
      • Metacarpal: non-displaced shaft and neck
        • MCP 2&3: Radial gutter splint, ortho 3 weeks
      • 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/splint, ortho 1 week
      • Hand Distal Phalanx: buddy tape/alumiform splint, ortho in 3 weeks
      • Occult Scaphoid: thumb spica 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 (or e-consult/call ortho if needs closer follow-up)
    • Palpitations
    • Psychiatric Patients without psychosis, homicidal ideation, or suicidality (but these patient may be screened for medical conditions and sent directly to the Psychiatric ED if it is deemed no other medical workup is necessary prior to psychiatric evaluation)
    • Rash (no petechiae/purpura)
    • Seizures (known disorder, no new trauma)
    • Soft tissue infection or simple abscess
    • Simple UTI
    • STI exposure
    • URI
  • Exclusion
    • Any cases not specifically listed on the inclusion list
    • Any patients meeting Trauma Team Activation criteria
  • 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, Pox <92% on room air
    • SBP >210 or <100, DBP >120 or <50

Chappell 4/2017

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


  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


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



  • Psychiatric reason:
    • 5150 (5585 for Peds) only for a mental health disorder.
    • Voluntary patients usually not placed on a 5150/5585, but can be.
    • Non-psychiatric medical personnel can detain anyone who meets criteria until they can be evaluated by a psychiatrist.
    • 5150 can be placed by:
      • Sheriff ANYWHERE OUTSIDE MAIN HOSPITAL BUILDING, including rest of hospital grounds
        • Sheriff has independent authority to place the 5150 or not
  • Medical reason:
    • Patients who lack capacity and are a danger to themselves or others for non-psychiatric reasons. Do not need psych consult to determine capacity when restraining patient for a medical reasons, and psych cannot override decision to restrain a patient for non-psychiatric reasons. DO NOT REFER TO THIS AS A "HOLD" AS THIS MAY LEAD LAW ENFORCEMENT TO BELIEVE THE PATIENT IS ON A 5150.
    • If they try to elope you can detain/restrain, if they become violent or aggressive, call a CODE GOLD (see below).
    • These patients can be held against their will for their own safety no 5150 is required or applies (5150 for psych issues only).
    • No specific legal form for restraining medical patients - document reasons in chart. Use restraint form for restraints.
  • Code GOLD:
    • For all patients who become physically aggressive, either for psychiatric or medical reasons.
    • They will be placed in hard restraints by CODE GOLD team
    • Call x111.
    • No requirement patient be placed or already on 5150
    • LASD (Sheriff) responds but is not part of team, only assists if detect or to prevent criminal activity by patient (assault)
    • Behavioral Response Team leader (BRT) should ID themselves on arrival and ED physician or nurse in charge of patient should brief them.
    • BRT leader has option of turning over situation to LASD as needed.
  • Code GREEN:
    • Already on or eligible for a 5150/5585 and attempting to, or have physically left the department.
    • Call x3311 LASD(Sheriff)
    • On a 5150 hold - LASD will return patient
    • NOT on 5150 hold
      • Inside Hospital Building - LASD can only convince patient to return - can't forcibly return. Only Psych can place 5150 inside hospital building
      • Outside Hospital Building - LASD makes independent determination to place patient on 5150
        • Physician or nurse in charge of patient should brief LASD if patient on 5150 or if not, indication for 5150
    • If LASD decides not to place patient on 5150, document Code Green in chart and officers involved
  • Code GRAY
    • ANYONE (patient, visitor, staff) who is combative or assaultive and it is not felt due to a medical or psychiatric reason
  • Above vetted by Law Enforcement, Psychiatry, Behavioral Response Team, ED Leadership, and Nursing leadership
  • Additional References
    • 436 Procedures in Cases To Be Reported to Are Investigated by Law Enforcement Authorities
    • 301 Discharge Policy, Procedures, and Guidelines Including Elopement and AMA
    • 138 Law Enforcement Use of Force on Harbor-UCLA Campus
    • 347A The Use of Restraints Including Seclusion
    • 346 Involuntary Holds on and on Psychiatric Units and Emergency Medical Department
    • 379 Safety Attendant (Continuous in Person Monitoring)
    • 453 Patients in Police Custody
    • 347B Code Gold-Behavioral Response Team
    • 620 Consent for Medical Treatment for Patient Lacking the Capacity to Provide Consent
    • Sheriff "Cheat Sheet" for Code Green and Code Gold

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

Mandatory Reporting of Adverse Events

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

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

  1. Immediate supervisor
  2. SI (Safety Intelligence System entry)
  3. Risk Management x2168

Events to be Reported

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

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

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


Lost Triplicate Prescriptions

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

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

D. Harrington, 11/3/16

Safe Pain Medication Prescribing Guidelines

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

Template:Triaging Ambulance Patients

Family Viewing of Deceased Patients

If you have a death in the ED, please don't direct family to the morgue and don't promise body viewing. If the death is potentially criminal (violence, hit and run, etc.), the family may not be allowed near the body for concerns of evidentiary integrity. For any death that we will be disclosing to the family, the ED social worker should be present to handle the details of discussing body and funeral preparations with the family.

Dir AAED Mar 29, 2015

Law Enforcement Escorting Patients Out Of the Emergency Department

Because of the potential conflicts with EMTALA law, it is important that a physician be involved in any decision to remove any patient or potential patient from the emergency department. For this reason, any time law enforcement is either requested by nursing staff, or decides on its own, to escort a patient from the emergency department (including the waiting room), an attending physician should be notified and agree with (and document) the decision. The House Supervisor should also be notified (x3434) before involving law enforcement. Documentation should specifically state that the patient has had a medical screening exam and does not have an emergency medical condition, or if there is an emergency medical condition that it has been appropriately stabilized. Obviously, it should also be safe for the patient to be removed from the emergency department.

Dir AED 5/26/16

Weapons in ED

  • As a general rule, no patients should have weapons on them (INCLUDING PEACE OFFICERS), even if they have concealed weapons permit.
  • No visitors should have weapons. The only exception to visitors carrying weapons are active peace officers.
  • We are working with hospital administration to make this hospital policy for campus grounds.
  • If you encounter issues, call the Sheriffs Department for assistance.

A.Wu, Dir AAED, LASD, Dir OPs 12/9/16


  • Marijuana less than an ounce (plant) or 8 gms (concentrate) and patient at least 21 years old - keep with patient belongings
  • Marijuana quantity more than above (or not sure), or possessed by person under 21 - Call Sheriff
  • All other illicit drugs (or suspect as illicit) - Call Sheriff

Dir OPS 2/27/18


  • There can never be an observer of any type in the ED without the prior permission of hospital administration or the chair, or one of the vice-chairs in the department.
  • Observers must be introduced to any patient whose care they observe and the patient must be given the opportunity, in a non-coercive and open manner, to not have the observer present during their care.
  • Observers must never be present during sensitive parts of medical care (e.g., genital exams, during history taking regarding abuse or sexual assault, etc.).
  • Observers must wear a clearly visible name tag that provides their first and last name and identifies them as an “Observer” or using a more descriptive label (e.g., “Medical Student” or “Residency Candidate”).

Chair, EM 9/2017

Social Work

Social Work Consultation Guidelines

Generally, please call Social Work early if you anticipate any issues so they can get things during business hours and get to families before they leave. Consult by placing a social work order in Orchid (documents consult time).

1. SW Order Indications

Choose the indication that best fits your clinical need/question. Special instructions are helpful.

Lack of Resources

Those who need help connecting with resources (financial, placement, housing, food, transportation, etc)

  • Community resources - food banks, gov benefits
  • Disability - how to apply for disability (not for filling out application itself)
  • Discharge planning/placement - when a patient needs placement to a facility of lower acuity than an acute care hospital (not to be used if homeless)
  • Homeless - for housing/resources. If patient has chronic physical and mental health problems, ask for patient to be signed up for Housing for Health.
  • Hospice - still need to place a home-health order (only if going home on hospice, not a care facility)
  • Transportation - transportation home or to appointments, see section 1.2
  • Crisis/Trauma - SW is consulted automatically for all TTAs. Ask for referral to Violence Prevention program if victim of violent crime (shooting/stabbing, etc)
Poor judgement/Substance Abuse
  • Behavioral issues
  • EtOH related trauma - SW provides a screening & brief intervention
  • Non-compliance
  • Poor communication
  • Positive toxicology screen - mainly used in peds
  • Refusal of treatment
  • Substance abuse - SW will provide screening & brief intervention
Psychosocial Support

This category has a lot of overlap with psychiatry.

  • Adjustment to illness - for psychosocial assessment by SW, help provide coping skill
  • Anxiety
  • Crisis/trauma - see above
  • Depression
  • End-of-life issues - for family or patient, help with GOC discussions
  • Family conflict
  • Grief/bereavement
  • HI
  • Mental health - SW can provide more resources than just the DMH list, provide full assessment of patient's financial abilities and other social factors
  • New diagnosis - overlaps with Adjustment to Illness
  • Poor coping
  • SI
  • Teenage pregnancy - provide resources & support
Regulatory/Legal Issues
  • Adoption
  • Advanced directive
  • AMA
  • Domestic Violence
  • Reportable pressure ulcer - Stage 3+ ulcers upon presentation. SW will contact adult protective services (if coming from home) or ombudsman (if coming from a health care facility).
  • Suspect child abuse
  • Suspect elder/dependent elder abuse
  • Unidentified person
  • Other
  • Assessment

J Singh 7/7/17

2. Transportation home:

  • bus:
  1. during day 8-4:30 - send to s/w office / page s/w for bus fare voucher
  2. nights/wkends/holidays - call nursing's supervisor @ x3434 to approve bus token and then pt can pick it up from ER registration
  • taxi:
  1. If pt is UNINSURED - limited number of vouchers - if MEDICALLY necessary (ie can't take bus for medical reason) - s/w can help with this
  2. If pt is INSURED (including medi-cal) - some insurance companies will pay for taxi (pt may have to wait a few hours) - consult s/w and they can help figure it out
  • ambulance: for patient's that have a medical necessity (cannot ambulate, here w/o wheel chair, etc) and medically cannot take a taxi
  1. If pt is INSURED (including medi-cal) - the insurance company will pay for an ambulance home
    1. UR can help with insurance specific contact info for coordination of ambulance
    2. May be limited by patient's home location (i.e. LA vs Torrance, etc)
  2. If pt is UNINSURED (including restricted medi-cal) - use county transport to get an ambulance home
    1. If pt lives outside of LA County, call nursing supervisor or SW as they may need further authorization

J Singh 5/9/17

  • kids without car seats: For kids who arrive (usually by ambulance) w/o a car seat, we do not have car seats available. however, options are:
  1. take the bus home (no need for car seat)
  2. have someone bring a car seat and pick them up or go home in a taxi with the car seat that is brought
  3. if a. or b. will not work, can try arranging for ambulance (see section above)

3. Patient who are homeless:

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

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

J Singh 7/15/17

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

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

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

b. other community resources are available

c. help family brainstorm other ideas

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

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

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

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

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

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

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

7. Clothing rack / clothing for patients

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

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

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

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

J Singh 5/9/17

8. Patients who need PT/OT for placement

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

Whole Person Care

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

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

Core Measures

  • Door to Doc: Door to diagnostic evaluation by a qualified medical personnel
  • Fracture to analgesia: Median time to pain management for long bone fractures
  • Door to Discharge: Median time from ED arrival to ED departure for discharged ED patients
  • Door to Admission: Median time from ED arrival to ED departure for admitted patients
    • Admit decision time to ED departure for admitted patients
  • Stroke Head Imaging: Head CT or MRI within 45mins of ED arrival for stroke patients
  • Sepsis
    • Overall performance
    • Initial lactate 6hrs prior to 3hrs after presentation
    • Blood culture 48hrs prior to 3hrs after presentation
    • Broad spectrum IV antibiotic administration 24hrs prior to 3hrs after presentation
    • Antibiotic selection post presentation
    • Repeat lactate within 6hrs of presentation
    • IV fluid resuscitation 30ml/kg minimum after septic shock presentation
    • IV vasopressor administration within 6hrs of septic shock presentation (informational only)
    • Repeat focused exam after IV fluid initiation and within 6hrs of septic shock

SEPSIS Core Measure Guidelines

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

**Age 18 and older

  • Exclusion:
    • Comfort care
    • Transferred from another acute care facility
    • Expire within 3 hrs of severe sepsis presentation or 6 hrs of septic shock presentation
    • Received IV antibiotics more than 24 hrs prior
    • Documented treatment refusal
  • Systemic Inflammatory Response Syndrome (SIRS) definition
    • Fever (temperature >38.3 C or >100.9 F) or hypothermia (temperature <36 C or 96.8 F)
    • HR >90
    • RR >20
    • WBC >12 or <4 or >10% bands
  • Sepsis definition (not included in Core Measure)
    • At least 2/4 SIRS + Infection Source

*Severe Sepsis (included in Core Measure)

    • Sepsis + acute organ dysfunction
    • Acute organ dysfunction = 1 or more of the following:
      • Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40
      • Acute respiratory failure (Sat <92% without oxygen)
      • Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg/hr
      • DIC: PLT < 100, INR > 1.5
      • Hepatic dysfunction: bilirubin > 2
      • Lactate > 2
    • Actions required for severe sepsis:
      • Use the ED Sepsis Orderset, and .sepsisseveresepsis autotext for documentation
      • Start 30ml/kg IVF bolus and the below required actions
      • 3 hour bundle:
        • Draw initial lactate
        • Obtain blood cultures prior to antibiotics
        • Administer broad spectrum antibiotics targeted at source
      • 6 hour bundle:
        • Repeat lactate if initially 2 or greater
  • Septic Shock (included in Core Measure)
    • Severe sepsis + persistent hypotension despite 30ml/kg IVF bolus OR,
    • Lactic acid > 4
    • Actions required for septic shock:
      • Use the ED Sepsis Orderset, and .sepsissepticshock autotext for documentation
      • 3 hour bundle: (in addition to the above requirements of sending initial lactate, blood cultures, and antibiotic administration within 3 hours)
        • Start 30ml/kg IVF bolus (order needs to include duration over which IVF were given, so use the order in the ED Sepsis Order Set, which has this prefilled for you)
        • Currently no exclusion for fluid overloaded patient, but use your clinical judgement, and document accordingly.
      • 6 hour bundle:
        • Start vasopressors if no improvement
        • Perform repeat focused exam of “volume status & tissue perfusion assessment” within 1 hour after giving 30/ml IVF bolus
          • Option 1 (most used): Must include all elements below
            • Vital signs: Must include actual Temp, HR, RR, BP. In the 'reexamination/reevaluation' section of your provider note, in the 'vital signs' area, click on 'results included from flowsheet' to automatically drop in a selected set of vitals
            • Heart exam: RRR, Irregular, S3, S4
            • Lung exam: Clear, wheezes, crackles, diminished
            • Pulses: 2+, 1+
            • Cap Refill: <2 sec, >2 sec
            • Skin: Must include color. Mottled, not mottled, pale, pink
          • Option 2: Need 2 of the following
            • Central line: CVP, SCVO2
            • Bedside ultrasound cardiovascular/volume assessment (such as IVC, systolic function, pulmonary edema, etc.)
            • Passive leg raise or fluid challenge
    • If you see the SIRS/Sepsis screening icon or think your patient may have severe sepsis or septic shock, use the ED Sepsis Order Set. Has recommended antibiotics based on source of infection, labs, and IVF orders with duration times, etc. Also has some informational text about definitions and management.
    • Use the .sepsis autotext phrases for documentation (.sepsisseveresepsis, and .sepsissepticshock)

Sepsis Abx

  • Cefepime 2g should be restricted to:
    • febrile neutropenia
    • HCAP for patient who weighs > 120kg, for others he'd suggest 1g iv q8h over 2g iv q12h based on time-dependent pharmacokinetic of the beta-lactam class
    • Meningitis that may involve hospital acquired organism, e.g. patient with VP shunt
  • Meropenem
    • Severe sepsis, septic shock, over cefepime as there is trend for ESBL in ~ 20% of klebsiella pneumonia and E. Coli based on cultures

A.Wu AED Director 6/13/16


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

3.0 Admissions and Consultations

21.3 Respiratory Isolation Patient Protocol[1]

All adult patients presenting to the DEM will be screened at the time of triage by a RN for risk factors, symptoms or complaints of respiratory/tuberculosis (TB) using the RIPT criteria in the EHR; five points or greater indicates the need for immediate initiation of the RIPT procedure.

  1. A mask will be placed on the patient and PA/Lateral chest x-ray will be ordered by the triage provider or nurse (with a DEM Attending on duty as ordering physician)
  2. The patient will be escorted to the radiology waiting area, and the triage nurse will hand off communication to the Area Charge Nurse (ACN).
  3. On completion of the chest x-ray, the ACN will follow-up with the R-3 or Attending Physician for interpretation of the chest x-ray. The decision to release the patient back to the waiting area or continue isolation in a designated isolation room will be made by the provider at that time.



21.4 Care of Potential Myocardial Ischemia Patient in Triage

  • All adult patients presenting to the DEM triage area with a chief complaint suggestive of myocardial ischemia will be screened rapidly by the Router RN to determine the need for immediate intervention using the following criteria:
  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
  • If the patient meets the above criteria the Router RN will assign a triage priority of cardiac, order an EKG, and notify the triage RN via phone; the patient will be placed in RME1 for immediate EKG
  1. Once the ECG has been completed, the triage nurse will notify the RME provider who will review the ECG

Approved June 2015, Chappell 2/22/16

21.5 Medications in Triage: Standardized Procedure

  • Administration of medications in triage (MIT) is to provide timely treatment for patients arriving to the ED with pain, fever, dyspepsia, or nausea and vomiting at the time of triage/assessment and reassessment. Available medications include Acetaminophen, Ibuprofen, Maalox, or Ondansetron.
    • PAIN: All patients who arrive to the ED Triage area will have their level of pain assessed and documented in the EMR. The pain scales used are FLACC, Numeric, and Faces, depending upon the age of the patient.
    • FEVER: All patients who present to the ED Triage area will have their temperatures taken and documented in the electronic medical record. All patients who present with a temperature > 100.4º F (38º C) [can be axillary, rectal, or oral temperature] shall be offered acetaminophen or ibuprofen. If a previous antipyretic has been given (either at home or in triage), an alternate antipyretic will be given if temperature >100.4º F (38º C). Rectal temperatures must be obtained for all of the following pediatric patients: Infants less than 2 months old, Children less than 2 years old with the exception of children presenting with minor trauma, & Active seizure patients up to 3 years old
  • Assessment of the patient’s symptoms (pain, fever, gastritis symptoms, nausea and/or vomiting) should be reassessed within 1 hours of the medication given in triage.
    • Patients who after reassessment of pain (within one hour of receiving the 1st dose of acetaminophen or ibuprofen) continue to complain of pain and desire further analgesic treatment will then be offered acetaminophen or ibuprofen alternating from the previous medication administration.
    • Patients who continue to complain of pain and/or fever may have a repeat dose of acetaminophen 4 hours after the initial dose, and/or a repeat dose of ibuprofen 6 hours after the initial dose.
    • Patients who continue to complain of dyspepsia may have a repeat dose of aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) 6 hours after the initial dose.
  • A nurse practitioner or physician provider will be notified of any patient that:
    • The triage nurse assesses to require more analgesia than oral acetaminophen or ibuprofen or aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) can provide


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

Approved November 2015, Chappell 2/22/16

See Also


  1. Approved June 2015, Chappell 2/22/16