OVMC:ED

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

Contents

Wiki of the Day

  • Opiate Crisis
    • Opiate epidemic now kills more in the U.S. than MVAs. Life expectancy in the U.S. has gone down because of this epidemic. The crisis is only worsening because of the increased availability of fentanyl.
    • You can make a difference for someone suffering from Opiate Use Disorder (OUD)
    • O - Open your eyes and your patient's eyes to the problem.
    • U - Understand that you can help through ED initiation of buprenorphine for opiate withdrawal and prescribing naloxone
    • D - Direct the patient to ongoing care through Tarzana Treatment Center
    • OVMC has received a very large grant to develop a hospital-wide education program to make buprenorphine available to any patient anywhere in the hospital. The grant will also allow us to develop an MAT (Medication Assisted Treatment) Bridge Clinic that will allow patients to continue their buprenorphine treatment here at OVMC until they are placed into a primary care clinic that can continue the therapy.

Phone Numbers

ED

  • MD Room ED 1A Attendings 73648, 73649
  • MD Room ED 1A Residents 73907, 74732, 73645, 74720 (phones running in direction of ED1 to ED2)
  • MD Room ED 4/5 74936, 74937, 74938, 74939
  • Hospitalist Room 74930
  • ED 1A/Clerk: 74324 (PR1,PR2,15,24,25)
  • ED 1B: 74865 (16-23)
  • ED 2A: 74321 (1-7)
  • ED 2B: 74280 (8-14)
  • ED 3: 74976 (43-49)
  • ED 4/RME Unit: 74974 (34-41)
  • ED 5: 74970 (26-33)
  • ED Fax: 74298
  • Charge/Resource Nurse: 74324
  • ICN/Router: 73440
  • Triage 1: 65658
  • Triage 2: 65661
  • Triage 3: 65662
  • Triage 4/RME: 65697
  • Triage 7: 75709
  • ED Lab 74977
  • ED Xray tech 75496
  • ED CT scan tech 74968
  • ED Ultrasound tech 74940, 74945
  • ED Reading Room 74969, 74971
  • ED Pharmacy 75530
  • Psych ED 74340, 74341
  • UR 74890, 74891
  • PFS 65228
  • TFU 74825
  • ED North Annex 73107

Psych ED

  • 74340
  • 74341

Inpatient

  • ICU

Radiology

  • Main Radiology 74059
  • ED Xray tech 74951
  • ED CT scan tech 74968
  • ED Ultrasound tech 74940
  • ED Reading Room 74971
  • MRI tech 73862
  • MRI front desk 73535
  • ED Reading 74971
  • MRI Body Reading 73770
  • Neuro and MRI Neuro Reading 74082
  • MSK/General Reading 65145
  • UTZ Reading 74177
  • CT Reading 74791, 74792, 66078
  • Interventional Radiology 74554
  • Interventional Radiology Scheduling 73686
  • USC Radiology Overnight Attending 323-409-6679 (M-F 11p-7a and Weekends/Holidays 7p-7a)
    • USC Radiology General ER Radiology 323-409-6688
    • USC Radiology resident VOIP 323-409-1673 (in case above two phone numbers don't work)

Lab

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

Pharmacy

Nursing

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

Clinics

Urgent Care Clinic and CCC 74312 Open Mon-Sat
Clinic A 73125 Derm, Endo, Renal, Primary Care
Clinic B 73129, 73131, 73132 Breast, Chest, Gen Surg, Peds Urology, Plastic Hand, Plastic Surg, Proctology, Thoracic Surg, Urology, Vasc Surg
Clinic C 73133 Cardio, Endo, GI, Heme, ID, MDA, Neuro, Oncology, Pulm
Clinic D 73137 Gyn After Care, Gyn, Gyn Onc, Urogyn, Gyn Endo, Memory
Clinic E 73676 Interventional Rads, Ortho, Podiatry, Rheum
Clinic M 74301 Primary Care
Clinic P 74990 Primary Care
ENT/Ophtho 75630
Peds 73144
Ortho Tech 818-529-5135, 818-529-5509

Operator

  • "0" then "5" then "5"

Other

  • ANO 75526
  • Appointment Center 747-210-8000
  • Bed Control 75959, 73179
  • Central Supply 65946
  • IT Info Technology 74522, 72644, 323-409-8000
  • OR 74364
  • PFS (Patient Financial Screening/Registration) 65228
  • Medical Administration 73025
  • Medical Records (problems with Cerner notes) 73934
  • Physical Therapy 74245, room 1D120
  • Psych ED 74340, 74341
  • Resp Therapy RT office 74422, pager 4055...1392...enter callback number
  • Sheriff XXXX
  • Social Work
    • Consult to Social Work now working in Cerner
    • If no answer,
      • Social Work 7am-7:30pm pager 818-313-1759
      • Social Work 7:30p-7am (off campus) 818-313-1637
      • Social Work Office 74236

USC

  • Teleradiology Night Reads 323-409-6679
  • ED Resusc 323-409-6667
  • ED Resusc Attending 323-409-1610
  • ED Peds Attending 323-409-1650

MAC

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

Kaiser EPRP

  • 800-447-3777

ED Administration

ED Admin Gurus

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

ED Miscellaneous

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

ED Throughput

RME Unit

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

Nursing

MIT Meds in Triage

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

Admission Guidelines

Medicine Admissions UPDATE March 2017

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

Medicine Admissions Upgrades, Downgrades, ICU Admits co-managed

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

Observation

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

Chest Pain Admission Guidelines

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

Tele Admission Guidelines

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

Surgical Subspecialty Admission Guidelines

  • DATE: October 22, 2014
  • TO: Faculty and Housestaff, Departments of Surgery, Medicine, Ob/Gyn, Pediatrics, and Emergency Medicine
  • FROM: Robert Bennion, M.D., Chief, Department of Surgery; Soma Wali, M.D., Chief, Department of Medicine; Christine Holschneider, MD, Chief, Department of Obstetrics & Gynecology; Shannon Thyne, MD, Chief, Department of Pediatrics; Greg Moran, M.D., Chief, Department of Emergency Medicine
    • Re: Emergency Department Hospital Admission Guidelines: IIn order to optimize patient care, housestaff supervision, expedite the admission process, and minimize conflicts regarding admission decisions, this document will clarify how the decision is made to admit emergency department (ED) patients to various inpatient services, and provide guidelines as to what types of patient diagnoses are most appropriately admitted to a specific inpatient service and hospital ward or unit.
    • Decision to Admit an ED Patient to the Hospital & Resolving Disputes: The decision as to whether a patient can be managed as an outpatient or requires more intensive observation and therapy in the hospital can be critically important. Therefore, the service chiefs have decided that after input from the admitting housestaff, the decision regarding admission ultimately must be made by attending physicians, which is consistent with community standards of care.
    • The Department of Emergency Medicine attending physician will make the decision on the need for an ED patient to be admitted. This decision will be made after reasonable evaluation and consultation to determine a presumptive diagnosis, admission service, and level of care. To avoid misunderstandings and delays, consulting residents should, upon completing their evaluation, clearly communicate their recommendations with the ED resident caring for the patient prior to leaving the ED. Patients will not be transferred from the ED to the floor until there is notification and confirmed acceptance by the admitting resident or attending, which should be indicated in the ED patient tracking system.
    • If, once notified, the admitting service resident disagrees with the recommendation of the ED staff, the resident should contact his/her senior/chief resident or attending physician to review the case. All disputes should be resolved first by ED resident discussion with the admitting service senior/chief resident, and, if necessary, by discussion between the ED and the admitting service attending physicians.
    • Diagnosis-Specific Guidelines for Appropriate Admission Service
    • The service chiefs expect that patients with certain designated illnesses will be admitted to the appropriate service, in accordance with the preceding section. Patients with disorders appropriate for surgical admission may not require an acute surgical procedure (e.g., abdominal pain with possible ischemic bowel admitted for observation). Patients with potential surgical diagnoses but who have significant concomitant medical problems (e.g., diabetes out-of-control) may be best managed on the Medicine service, with close consultation.
    • For patients seen in the ED who are within 30-days from their operation and for whom admission is being considered, the operative service (general surgery, urology, GYN, etc) should be the primary consulting service and in most cases the admitting service.
General Surgery & Subspecialties Medicine/Pediatrics/Ob/Gyn
Acute abdominal pain - potential underlying surgical etiology (e.g., possible ischemic bowel), complicated diverticulitis (abscess or microperforation)- non-pregnant (General Surgery) Acute abdominal pain – unclear but possible medical/ non-surgical etiology (e.g., colitits, gastroparesis, uncomplicated diverticulitis) (Medicine)
Pregnant women and non-pregnant women with acute abdominal pain likely to have gynecologic etiology (Ob/Gyn with General Surgery consultation)
Gallstone pancreatitis (including presumed cases), acute cholecystitis, cholangitis, choledocholithiasis with gallbladder, symptomatic biliary colic with PO intolerance (General Surgery) Alcoholic and other non-gallstone-related pancreatitis, choledocholithiasis without gallbladder (Medicine)
Pregnant women with gallstone pancreatitis, acute cholecystitis, choledocholithiasis/cholangitis (Ob with General Surgery consultation)
Hepatitis and hepatic abscess(es) (Medicine)
Mechanical small bowel obstruction - partial or complete (General Surgery) Small bowel obstruction – partial or complete secondary to prior Ob/Gyn surgery or gynecologic malignancy (Ob/Gyn)
Ileus or colitis – (Medicine)
Abscesses with complex wounds or requiring OR intervention (regardless where drained), necrotizing skin and soft tissue infections, post-operative wound infections, other significant skin/soft tissue infections involving specific areas (Surgical sub-specialty, e.g., significant head and neck infections to Head & Neck Surgery, excluding Plastic Surgery, see below) Cellulitis/lymphangitis, abscesses that can drained in the ER with predominant cellulitis, and other skin infections with significant concomitant medical problems (e.g., diabetes out-of-control) (Medicine)
Infections or injuries distal to the elbow requiring immediate operation (Plastic Surgery) Infections or injuries distal to the elbow, not requiring immediate operation, or in patients with significant/unstable medical problems. (Medicine with Plastics consultation)
Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
Obstructing ureteral stone or malfunctioning stent and hydronephrosis with documented fever (> 38o C) and pyuria, or uncontrollable pain, or bilateral hydronephrosis from ureteral stones and renal insufficiency or solitary kidney in adults; acute prostatitis (fever, chills, toxic appearing, severe obstructive voiding symptoms), or with severe hydronephrosis; scrotal abscess requiring OR intervention and/or admission for IV antibiotics (Urology, also see specific inter-departmental guideline) Urinary tract infection without significant anatomical obstruction (Medicine/Pediatrics), pregnancy (Ob) or gynecologic malignancy (Gyn)
Significant tract infection with anatomical obstruction, with or without infection, in stable pediatric patients (Pediatrics with Urology consultation)
Urolithiasis with infection, no obstruction, patient toxic appearing or high risk for complications, or indwelling ureteral stent in appropriate position and no hydronephrosis or mild hydronephrosis; epididymitis requiring admission for IV antibiotics; urologic problem in patient with any complicated medical problem (e.g., diabetes out of control, severe sepsis) (Medicine with Urology consultation); pregnancy (Ob), or gynecologic malignancy (Gyn)
Acute gastrointestinal bleeding (Medicine or Pediatrics)
Ankle and foot fractures (Medicine with Podiatry consultation)
All patients with post-operative surgical problems within 15 days of discharge requiring admission - to specific operating service (with Medicine/Pediatrics consultation as necessary)
    • Admission Orders Admission orders must be written by the responsible inpatient service housestaff who are available to floor nursing in order to direct inpatient management. For cases in which the admitting diagnosis is established (e.g., CT-confirmed appendicitis), an inpatient bed is available, and the admitting service residents are unavailable for > 2 hours (e.g., in the OR), the ED resident will contact the admitting service senior/chief resident in order to seek verbal approval for the admission. The ED physician will then write holding admission orders on the standard admit form and transfer the patient to a hospital bed. If the admitting senior/chief resident is also unavailable or the admission cannot be approved, then the ED attending may contact the admitting service attending physician to facilitate the admission. Admission holding orders should include pain medications, intravenous fluids, and antibiotics (if recommended by the admitting service), and contact information (resident name and pager number) for the admitting service if a nurse needs new orders or to notify a physician about any change in patient status
    • Patient Transfers All patients considered for transfer from Olive View-UCLA must be reviewed and evaluated by the ED attending physician. For pediatric patients, the pediatric attending physician on-call should be notified prior to patient transfer.

Admissions from the Clinic, How to

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

Follow Up Guidelines

Future OVMC Clinic Appointments already scheduled

  • Future OVMC appointments can be found on the Patient Summary (Discharge Instructions). Click Depart. Page that appears is the Patient Summary. Scroll down to Future Appointments.

Future Orders - Outpatient studies ordered by the ED

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

OOP (Out of Plan)

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

DHS Empaneled

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

MHLA (My Health LA)

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

NERF (New Empanelment Referral Form)

  • Used to enroll patients with significant PMH who have no primary care or health plan
  • Patient must have at least one of a specific list of diagnoses
  • Only about 1/3 of patients will actually receive a PCP through the NERF process. Because of that, give patient a clinic list upon discharge so he/she can find a PMD on their own.
  • To enroll in NERF program, click NERF while completing Depart process. Check off diagnoses that apply. Click green arrow. Clerk will complete on-line NERF form.

TFU (Telephone Follow Up)

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

CCC (Continuing Care Clinic)

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

Urgent Referrals for Subspecialty Care/Message Pools

  • Used to refer patients to certain subspecialty clinics for URGENT follow-up appts (<2 weeks)
  • Do NOT refer OOP patients or non-urgent complaints through the Message Pool
  • For ENT and Ophtho patients, page the on-call resident for approval for the urgent follow-up appt. Type in the approving resident's name and the follow-up date/time agreed upon. Tell patient to show up at 10am to the clinic.
  • Current Clinics with Message Pools:
    • OVM Coumadin ED/UC Urgent Follow Up
    • OVM Hand Surgery ED/UC Urgent Follow Up
    • OVM Gyn Aftercare ED/UC Urgent Follow Up
    • OVM Ophthalmology ED/UC Urgent Follow Up
    • OVM Orthopedics ED/UC Urgent Follow Up
    • OVM Otolaryngology (ENT) ED/UC Urgent Follow Up
    • OVM Pediatrics ED/UC Urgent Follow Up
    • OVM Peds Ortho ED/UC Urgent Follow Up
    • OVM Plastic Surgery ED/UC Urgent Follow Up
    • OVM Podiatry ED/UC Urgent Follow Up
    • OVM Procedure Service ED/UC Urgent Follow Up
  • Note: USC Peds Ortho ED/UC Urgent Follow Up no longer exists

Econsult

  • Econsult appointment center for new referrals: 855-521-XXXX
  • When starting a new econsult, ONLY enter the Orchid MRUN (use ORCHID MRN field and not MRUN) and birthdate. All registered patients in the ED can be found in the Econsult system.
  • All ED providers must send econsults using their own log-in username and password. Do not borrow usernames and passwords from other providers. Mistakes are sometimes made and it is impossible to then correct the mistake if providers are sharing log-ins.
  • Used to refer patients to subspecialty clinics for NON-URGENT follow-up appts. Not all referrals are approved. In fact, most from the ED are denied. If approved, appts are likely several months away.
  • Do NOT send econsults on OOP patients
  • Do NOT send econsults on DHS empaneled patients. These patients should be referred back to their primary care doctor.
  • For outside records to be attached, use the Fax-to-Scan form on the Econsult. Print it out. Patient name and MRUN will be on the fax form. Attach it to the outside records and give to the clerk to fax. See job aid. XXXXX
  • For General Surgery gallbladders and hernia referrals, fill out the Cholecystectomy/Hernia form. Patient must be non-smoker with BMI <35
  • Do NOT refer the following:
    • Derm - simple skin conditions (must be SEVERE or worrisome for cancer)
    • GI - diverticulitis, undiagnosed abdominal pain, gastritis without minimum of 3 months of PPI or h.pylori treatment
    • Neuro - simple seizures, headaches
    • Urology - stones less than 5mm

Patient Education

Diabetic Teaching

Cardiology

Code STEMI

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

Dental

Dental Clinics

Dermatology

Dermatology Clinic Referral Guidelines

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

ENT/Head and Neck

Hearing Aids

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

Gastroenterology

H. Pylori Testing

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

GI Clinic Referral Guidelines

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

Infectious Disease

Reportable Diseases and How To

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

Dog Bite Reporting Form

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

Public Health Confidential Morbidity Report Form Reportable Diseases

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

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

Public Health STD Confidential Morbidity Report Form

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

PICC Lines

  • Patients may present with a PICC line in place requesting continued IV antibiotics for an infectious process. Arrangement for on-going antibiotics can only be arranged Monday - Friday (I'm checking this)
    • Step 1: XXXX
    • Step 2: XXXX
    • Step 3: XXXX

TB Outpatient Management Guidelines

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

Neurology

Matt's Reminders

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

Stroke Protocol

  • updated Jan 2019
  • For suspected or presumed stroke with last time known to be at baseline ≤ 8 hrs before presentation
  • Stroke Alert Background: Intent of this protocol is to create a rapid, collaborative care model for the acute stroke patient. The ED Attending or primary team attending (for non-ED patients) retains ultimate responsibility for the care of the patient and any decision-making regarding that care.
  • Stroke Alert Pager number is 818-226-4797. Any physician involved in the patient’s care can activate a Stroke Alert by calling the page operator, requesting a page to the “Stroke Alert Pager,” and provide a call back number. The number can be text paged from www.amion.com or www.myairmail.com (American Messaging). The pager is used to alert appropriate group members to a potential acute stroke in-house or in the ED. The Stroke Alert pager notifies the following staff members:
    • Neurology Resident on-call
    • Stroke Fellow
    • ED Pharmacist
      • please enter the full 10 digit call back number and add *911 or “stroke alert” to note high acuity.

ED Actions

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

Neuro Clinic Referral Guidelines

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

Sleep Study

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

DMV Request for Re-Examination Form

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

Neurosurgery

A few pointers

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

Neurosurgery Transfer Guidelines

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

OB-Gyn

Referral Guidelines for Message Pool vs Econsult

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

Establishing care at OVMC for pregnant patients

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

Oral Contraceptive Taper Patient Instructions

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

Oral Provera Taper Patient Instructions

  • Coming soon!!

Orthopedics and Podiatry

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

Ortho and Podiatry Clinic Referral Guidelines

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

OVMC Pediatric Orthopedics

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

Pediatrics

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

Critical Pediatric Patients

  • 1: Call MAC for transfer to LAC+USC 866-940-4401 then “3” for DHS facility (Insurance issues will be worked out later)
  • 2: For significant delays in acceptance or transportation to LAC+USC:
    • a. call OVMC Peds Attending on-call
    • b. call OVMC CMO on-call
    • c. call CHLA for either help with transportation to LAC+USC or acceptance to CHLA
  • CHLA Access and Transfer (Transport Center) 888-631-2452
  • Call Maureen with questions anytime 310-614-5306

Peds patients seen in ED

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

Child Maltreatment/Non-Accidental Trauma/Sexual Abuse

  • Step 1: Call the Pediatric Attending on-call
  • Step 2: Report case to Dept of Children and Family Services; can be done by SW or provider
    • Phone - (800) 540-4000
  • Step 3: Fill out on-line referral form. You MUST have the 19-digit Referral Number in order to complete the on-line form. You will receive the 19-digit Referral Number when you call DCFS. It may take up to 2 HOURS for the Referral Number to be activated by DCFS.
  • Olive View has a Foster Care Clinic called Hub, on 4C.
    • Composed of child abuse specialized pediatricians, social workers, DCFS caseworkers, and nurses.
  • For pediatric sexual assault, do not perform a detailed history or exam. History and exam should be brief, just to determine if a medical emergency exists. Then:
    • 8 am to 4 pm Monday-Friday: Contact the Peds Attending. Contact Hub/Dr. Woods for guidance.
    • After hours: Contact the Peds Attending on call and the police department in the jurisdiction to determine need for forensic exam.
      • If forensic exam not necessary, you can proceed with your normal ED evaluation.
      • If forensic exam is necessary, the police department will pick up and take patient to Northridge Hospital (CATS).
  • For patients brought in with concerns of other types of abuse:
    • 8 am to 4 pm Mon-Fri: Call Peds attending. Contact Hub clinic for help with the forensic exam and guidance.
    • After Hours: Call Peds attending on call. See the patient and do a limited exam and history. We do not do forensic exams at OV afterhours. They can be referred to LAC-USC VIP Clinic, open 24/7. Please call the clinic to notify the on-call provider that you are sending a patient over:
  • LAC-USC VIP Clinic
    • Outpatient Department Building (Building B)
    • 2010 Zonal Avenue, 3rd floor, 3P-61
    • Los Angeles CA 90033
    • Phone: 323-409-3800

Psychiatry

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

Psych Urgent Care

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

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

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

Radiology

On-Call and In-House Radiology Coverage Schedule

  • Operator has Radiology on-call schedule and pager numbers
  • Also posted on OVMC Website...Departments....Radiology....On-Call Schedules....Radiology Faculty Schedule Current Month

In House Coverage

  • M-F 6 pm-11 pm: STAT Radiology Attending in-house
  • Mon-Fri 11pm-7am: USC Teleradiology coverage 323-409-6679
  • Sat, Sun Holidays before 1pm: General Radiology Attending in-house
  • Sat, Sun, Holidays 1p-7 pm Sat: STAT Radiology Attending in-house
  • Sat, Sun and Holidays 7pm-7am: USC Teleradiology coverage 323-409-6679

USC Coverage for OVMC ED

  • USC Radiology Overnight Attending 323-409-6679 (M-F 11p-7a and Weekends/Holidays 7p-7a)
    • USC Radiology General ER Radiology 323-409-6688
    • USC Radiology resident VOIP 323-409-1673 (in case above two phone numbers don't work)

Over-Reads

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

Film Copy Request and Outside Film Imaging Upload

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

Weight Limits for Imaging

  • ED xray table - 500lbs
  • ED CT scanner - 550lbs
  • MRI - 350lbs
  • Downey MRI - 600lbs (see MRI Imaging for Large Patients)
  • Cath Lab - 500lbs
  • Nuclear Medicine - 300lbs

Plain Films and No Need for Pregnancy Tests

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

Fluoroscopy

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

Interventional Radiology

  • AVAILABLE Intervential Radiology After Hours (Operator has Interventional Radiology on-call schedule. Also available on OVMC Intranet. See above under Radiology On-Call Schedule)
    • Percutaneous abscess drainage
    • Image-guided paracentesis
    • Image-guided thoracentesis
    • Percutaneous cholecystostomy
    • Percutaneous nephrostomy/nephroureteral stent placement and other urologic intervention as applicable
    • Transhepatic biliary drainage and other biliary intervention as applicable
    • Central venous access including placement of tunneled/non-tunneled catheter
    • IVC filter placement
    • Transarterial embolization for unremitting hemorrhage refractory to conventional therapy
    • IR Consultation
  • NOT AVAILABLE Interventional Radiology After Hours (Only available Mon-Fri 8am-5pm)
    • No MSK procedures (e.g. no joint aspirations)
    • No LPs
    • No G/GJ tube replacement (if tube fell out, place foley temporarily)
  • FUTURE ORDERS Interventional Radiology from the DEM
    • Contact IR physician on-duty to discuss case
    • Place an IR request in ORCHID (if given option, make sure to choose Future Order)
    • Please include a note on the IR Orchid request about any high risk meds e.g. anticoagulants, DM meds or any other high risk meds
    • Instruct the patient to be NPO after midnight except approved meds with sips of water
    • Instruct the patient to secure a ride home with family/friends after the procedure
    • Instruct the patient to report to Radiology reception at 7:30am on the day of the procedure
    • Patient should be instructed to call 747-210-3686 for interventional scheduling and for instructions about home meds to hold the morning of the procedure

Dialysis AV Fistula Evaluation

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

MRI After Hours

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

MRI for Large Patients

  • Weight limit at OVMC: 350lbs (same at Harbor and USC)
  • For larger patients, Downey MRI Center, 8515 E. Florence Ave, Downey CA, 90240, 562-904-1340 (weight limit 600lbs)
  • If ED patient, will need County trans to transport patient to Downey and then return to ED
  • For outpatient, order as Future Order; Patient should call OVMC MRI to schedule and OVMC MRI will then arrange the MRI at Downey

Barium/Air Enemas for Intussception Cases

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

UGI for Malrotation/Volvulus Cases in Infants

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

Breast Imaging

  • Radiology keeps an extensive database of all patients receiving breast ultrasound to ensure all patients have follow-up with surgeon, PMD or ED.
  • OK to order UNILATERAL breast ultrasound for these cases. Any significant findings such as a concerning mass on ultrasound will be followed up by radiology and follow-up ensured.
  • Check insurance when deciding follow-up.
  • Breast mass, not concerned about infection, low risk for cancer
    • Outpatient breast ultrasound (future order). Have patient call Radiology for an appt. Phone number on Discharge Instructions.
    • eConsult to Surgery, Breast for follow-up
  • Breast mass, not concerned about infection, high risk for cancer
    • High Risk = family history of +BRCA, skin dimpling, nipple retraction, discharge, palpable lymph nodes
    • Call surgery consult to expedite follow-up
  • Breast mass, concerned about infection/abscess, mild case, do not think the patient needs admission or IV antibiotics
    • M-F 7am-4pm: Order Breast ultrasound, send to Radiology 1D
    • Overnight, weekends, holidays: Order breast ultrasound (future study). Instruct patient to go to Radiology 1D at 8am the next weekday. If patient does have an abscess on ultrasound, Radiology staff will call ED and send patient to the ED
  • Breast mass, concerned about infection/abscess, moderate to severe case, considering surgery consult and/or admission
    • M-F 7am-4pm: Order Breast ultrasound, send to Radiology 1D
    • Overnight, weekends, holidays: ED ultrasound tech can perform a limited ultrasound to evaluate for abscess. Order breast ultrasound and in comments type "Evaluate for abscess". Consult surgery for evaluation and treatment. If surgery defers to IR for drainage, follow After Hours IR Guidelines (in WikEM, under Radiology). Drainage can usually be done in the morning.
    • If the symptoms have been occurring for >1 week, please consider inflammatory cancer which can look like an abscess on ultrasound. In these cases, please obtain surgery consult for evaluation and/or expedited follow-up.

Joint and Spine Injections

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

Surgery

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

Surgery Clinic Referral Guidelines

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

Cardiothoracic Surgery

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

Neurosurgery

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

Vascular Surgery

  • No update

Laboratory

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

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

Critical Lab Results on Discharged ED Patients

To be added

Infrequent Lab Orders - Instructions

Rapid Strep

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

Varicella Testing

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

Influenza Testing

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

Chlamydia/Neisseria gonorrhea RNA:

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

Malaria/Thin Smear

  • Order as Blood Parasite Exam

Pathology Tissue Request:

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

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

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

Specimen Collection Instructions - OVMC Micro Quick Reference Guide

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

Blood Bank

Massive Transfusion Protocol

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

Pharmacy

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

Hours

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

Empiric Antibiotic Recommendations OVMC

http://myladhs.lacounty.gov/ov/Departments/DEM/Forms/Empiric%20Antibiotic%20Recommendation%20Card.pdf

DHS Formulary Pocket Guide 2017-2018

http://myladhs.lacounty.gov/ov/Departments/DEM/Documents/DHS%20Core%20Formulary%20Pocket%20Guide-%202017-2018%20final.pdf

Rhogam Administration

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

Medication Refill Patient Handout

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

Safe Prescribing and Narcan Handouts

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

Buprenorphine Administration in the ED

Physical Therapy, Occupational Therapy and Orthotics

ED Orthopedic Equipment and Hernia Trusses

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

DME Supplies to be ordered as outpatient

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

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

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

Wheelchairs

  • Wheelchairs are kept in the ED1A Clean Utility room, ED5 clean utility room and Roque's closet for after-hours and weekend patients to avoid admissions, e.g. wheelchair-bound patients or patients requiring wheelchair for example bilateral ankle fractures
  • Alternative ordering process:
    • Order DME in Cerner- Do NOT order on OOP patients - must go to Health Plan for wheelchair
    • Order Physical Therapy Outpatient Future Order also in Cerner
    • Patient should be sent to Physical Therapy. Patient will be financially screened. If patient has no insurance to pay for wheelchair through DHS, patient/family will be given list of outside vendors to contact.

Physical Therapy and Occupational Therapy Outpatient

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

Guidelines

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

Back Pain Classes

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

For Emergency Calls After Hours

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

Procedure Clinic

Paracentesis, Thoracentesis, Lumbar Puncture

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

Respiratory Therapy

BiPAP, Transporting patients upstairs on portable BiPAP

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

Home O2, How to obtain

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

Social Work

Contacting Social Worker

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

Substance Abuse Counselor and SASH Hotline

Sexual Assault

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

Child Maltreatment/Abuse

  • See Pediatrics

Transporting patients home

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

Translation Services

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

Community Resources

Transfers

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

Higher Level of Care Transfers

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

BLS vs ALS vs Critical Care vs Helicopters

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

Pediatrics

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

Surgical and surgical subspecialties

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

Neurosurgery

  • See Neurosurgery

Utilization Review (Utilization Management)

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

ED Ultrasound

Link to OVMC Ultrasound website

Transvaginal Ultrasound

ED Supplies and Equipment

Tutorial Videos

Clerk ED1A Cabinet

*MUST LEAVE BADGE FOR ANY EQUIPMENT REMOVED FROM CLERK CABINET

ED1A MD Room

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

Airway Cart in PR Room

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

Room 31

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

Suture Cart

Ortho Cart

Gyn Cart

Central Line Cart in ED 1A/B hallway

Orthopedic supplies in Room 43

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

Crutches, Walkers, Wheelchairs

  • Located in ED1A/B Clean Utility Room

Bronchoscope

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

Glidescope

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

Unusual Supplies

  • Gastrostomy Tubes - ED 1A MD Room "S**T HAPPENS" Cabinet
  • Nephrostomy tubing and bags - try OR
  • Whitacre Spinal Needles - LP Cart

Disaster Preparedness

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

Downtime Protocols

Downtime Documentation

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

Downtime General Orders

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

Downtime Radiology Orders

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

Downtime Laboratory Orders/Workflow

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

Downtime Medication Orders

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

Downtime Blood Bank Orders

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

Downtime Specialty Diagnostic Services

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

Downtime Admissions

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

Downtime Discharge

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

Downtime Recovery - ORCHID Back Online

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

Downtime Frequent Phone Numbers

  • ED Lab (8:30 am - 10:30pm) : 74977
  • General Lab: 73476, 74038
  • Microbiology: 76041
  • Blood Bank: 74062
  • Phlebotomy: 74555/74039
  • ED Xray Tech: 75496
  • ED US Tech: 74940
  • ED CT Tech: 74968
  • MRI Tech: 73535
  • ED Radiologist: 74971
  • LAC+USC Radiology Nighthawk (11pm–7am): 323-409-6688
  • ED UR/Interqual: 74890
  • Pharmacy: 73070
  • ED1A: 74320
  • ED1B: 74865
  • ED2A: 74321
  • ED2B: 74280
  • ED3: 74976
  • ED4: 74974
  • ED5: 74970
  • SuperTrack Provider Room : 74936/74937
  • Main Provider Room: 73645
  • DEM Administrative Offices: 73107

ORCHID/FirstNet

Logon

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

CheckIn

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

Patient Sign Up

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

Documentation

Selecting a Note Template

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

Documentation Workflow

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

Documenting a Re-Evaluation

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

Procedure Consent with iMedConsent

  • from the FirstNet Tracking List, click on the iMedConsent link located on the favorite links bar
  • logon to iMedConsent using your ORCHID user credentials. This part may be automated if using the Imprivata One Sign system.
  • perform a manual patient search (MRN based) from within iMedConsent to auto populate the demographic fields in iMedConsent. Note: if you skip this step, then the patient information will be blank on the printed consent form, and it will be rejected by the medical records department
  • select the appropriate procedure/s that you would like to print for the patient
  • have the patient read, consent, and wet sign the printed procedure consent form
  • place a copy of the wet signed consent in the patient's paper chart. The Health Information Management (HIM) team will scan the consent form into ORCHID after the patient is discharged.

Procedure Documentation (ad hoc forms)

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

then finding the ED Forms Folder.

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

Medicine Admissions

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

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

2) Contact the admitting team via Amion to give report

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

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

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

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

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

Changes in Service or Level of Care after Initial Admission

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

Surgery Admissions

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

ED Holding Orders

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

Observation Patients

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

Consultation & Auto Paging

Consults - No Auto Paging OVMC

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

Consults - Auto Paging OVMC

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

ECGs

Triage ECGs

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

Viewing Prior ECGs

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

Entering ED Provider Radiology Wet Reads

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

Medical Students in FirstNet

Documentation

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

Order Entry

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

Order Entry

Quick Orders

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

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

Required Order Fields

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

Copying Orders

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

Discontinuing Orders

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

Lab Orders

Collection Priorities

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

Nurse Collect:

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

Order Sets

Order Sets

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

Adding Orders from an Order Set already Initiated

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

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

Discontinuing Order Sets

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

Order Favorites

Order Favorites

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

Lab Results

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

Imaging Results

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

Discharge & Follow Up

Discharge Process

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

Follow Up

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

Message Pools

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

TFU/CCC Clinics

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

eConsult

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

ED NERF

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

Ordering Outpatient Studies (Future Orders)

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

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