Welcome to ED orientation

Welcome to the ED Orientation
on-line module
MOST OF THE INFORMATION YOU ARE
ABOUT TO READ WILL BE A REVIEW OF THE
IN-PERSON ORIENTATION THAT YOU
ALREADY ATTENDED.
IT IS IMPORTANT TO BE FAMILIAR WITH
THESE ED PROCESSES AND PROCEDURES
PRIOR TO YOUR FIRST SHIFT.
Goal of this Orientation
PREPARE OUR OFF-SERVICE ROTATORS FOR
PATIENT CARE IN THE ED FROM THE
MOMENT THEY START THEIR ROTATION
Objectives of this Orientation
 Logistics of working in the ED
 Your ED team
 Observations vs. Admission
 EPIC details


Admission/ Discharge
Note completion
 High- Yield Emergency Medicine Topics
 Cardiac Chest Pain




Anaphylaxis
Trauma





ACS: STEMI vs. NSTEMI
Low/ Moderate risk CP
Backboard clearance
C-spine precautions and clearance
E-FAST exam
Intoxicated Patient
Psychiatric Patient

Medical Clearance
LOGISTICS OF WORKING IN THE
ED
ED Layout
 Section A: Highest Acuity- open 24/7

2 resident teams



Staffing:



Green: 9 beds +2 resuscitation bays
Purple: 10 beds + 2 resuscitation bays
2 attendings 9am-1am (1 attending 1am-9am)
Senior Resident Supervision
Trauma: All trauma patients that go to resuscitation bays are designated as “full” or “modified”
trauma


Off-service residents are not responsible for taking care of “modified” or “full” trauma
Off-service residents are responsible for trauma patients that don’t meet “modified” or “full”
trauma criteria
 Section B+C: Lower Acuity- open 24/7 (as of July 2014)


May still get trauma patients that are not “full” or “modified” traumas
Staffing


At least 3 resident/PA teams
Supervised by an attending
TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF
THEY COULD BE VERY SICK
ED Layout- Other areas of Interest
 Patient entrances/ triage/ registration areas:
 Ambulance
 Waiting Room
 Central Communications Desk (a.k.a. “the bubble”)
 Located at the ambulance entrance
 All calls/ faxes
 Location of Medtronic Pacemaker interrogation equipment
 Intoxication Observation Unit (IOU)
 Located in hallway behind Section C
 Staffed by an ED tech
 Crisis Intervention Unit (CIU) = Psychiatric ED
 Separate unit staffed by psychiatry residents, attendings, nurses, techs
 Chest Pain Center (CPC)
 Separate ED observation unit for low/moderate chest pain patients
 Staffed by B-side attending, PA (during working hours), nurse, tech
Your team:
 Attendings
 Supervise multiple teams simultaneously
 24/7 in-house coverage for every section of ED (when open)
 Senior ED Resident
 Only during high volume times (Mondays daytime)
 ED Nurse
 ED Technician
 Business Associate (BA)
Your ED shift: Arrival and Sign-out
 Arrival: at least 5 min. prior to scheduled time

B+ C sides: divide patient beds equally between available providers
(podiatry and dental residents do not get bed assignments)
 Sign-out: 2-part process

Off-going senior resident or attending presents patients in bed-order
to the on-coming team
Part one: at the computer- all the details (including labs, social issues,
Ddx)
 Part two: at the bedside- off-going attending introduces the in-coming
team
 Patient is made aware of the work-up progress, pending studies and
reason for why s/he is still in the ED, and approximate timeline

Your ED shift: Seeing patients
 All patients assigned to your bed assignment are YOUR
patients


See them within the first 5 minutes of arrival in section A or
15min. in section B&C
See patients in parallel: essential EM skill
 Present your patients as soon as you saw them
 To senior and/or attending
 Do not pile up patients to present in bulks
 Enter all lab orders ASAP
 Notify your nurse of the plan as soon as you know it
 Charts must be completed by the time patient leaves
the department
Your ED shift: Disposition
 Important to notify the patient and nurse as soon as the
decision is made
 NEVER discharge the patient prior to making the
ATTENDING AWARE that the patient is being discharged
 All PMDs need to be notified that their patient was in the
ED


Especially for high-risk CC: HA, CP, AP, BP
Document all communication in chart
 AMA discharge: ALWAYS alert the attending ASAP

Document capacity to make decision




Can not be: intoxicated, mentally retarded, cognitively impaired
Give appropriate discharge instructions and prescriptions
AMA form must be signed by patient
Encourage return to the ED
Your ED shift: Admission vs. Observation
 Reasoning: patients who have normal vital
signs, normal lab results, normal imaging may
not meet criteria by insurance companies to pay
for a full hospital admission

These patients may still require medical care not
reflected by the criteria
 Logistics: most of the time, the ED attending
will be able to determine admit vs. obs

Care Coordinators are specially trained in making the
decision


Will sometimes ask you to change the admitobs or
obsadmit booking
 Always make the attending aware of the change
The attending makes the final decision
Your ED Shift: Medical Admission
 Enter order in EPIC: “ED Admit”


Observation vs. Admission
Medical vs. Non-medical

For medical, pick team:










Hospitalist =patient’s PMD is on hospitalist team
All other medical admits =no PMD or PMD doesn’t admit to hospitalist
YED attending= CPC
PCC/ generalist= patient goes to PCC
Goodyear =cardiology complaint without Cardiologist or University
Cardiology
General cardiology =cardiology complaint with Non-University
Cardiologist
Klatskin =ESLD
ESRD
Donaldson = HIV/AIDS
Fill out the rest of the booking (specify tele vs. floor)
Your ED Shift: Admission to an ICU
 Step 1: notify Bed Manager
 Step 2: Call appropriate team for sign-out. Get name of
admitting attending.
CCU: page CCU fellow
 MICU: page MICU admission team
 SDU: page SDU resident
 SICU: the surgical team is responsible for getting SICU attending
aproval
 NICU: don’t need to page anyone b/c you are admitting to a team that
should already be involved in patient care

 Step 3: Attending- to- attending sign-out.
YNHH admission policy: the ED attending makes the final
decision where a patient is admitted

Please let your senior resident and/or attending aware of any pushback you get from the admitting team.
Your ED shift: Admission to CPC
 CPC or in-hospital ROMI
 Both:




low/ moderate risk chest pain patients who need a ROMI
Observation, telemetry admission
Not for ACS patients
 No nitro drips, no heparin drips
CPC: patient will get Stress Test at the end of their admission

Your role
 Place appropriate EPIC order:
• ED chest pain place in CPC observation

EPIC Note:
• Smartphrase: “.edobsadmit”


Order all out-patient medications
In-Hospital ROMI: most will NOT get a stress test





Patient had a stress in the past year
Patient with other diagnoses possible (other than CAD)
Patient needs isolation
Patient morbidly obese (will not fit stress table)
Patient can not self-transfer (onto stress table)
Your ED shift: Admission of hip fractures
 For isolated hip fractures


No other traumatic injuries
Mechanical cause (i.e. not syncope that needs to be worked-up)
 Orthopedic team evaluates patient (as all other ortho
consultations)
 Computer orders:



Admit to: Hospitalist
Service: Medicine
Unit type: free-text ortho/ hospitalist 7-7
 Page hospitalist at 766-7416 to give verbal sign-out
NO DICTATION NEEDED WHEN VERBAL SIGNOUT
DONE
Other ED Pearls
 COMMUNICATION IS CRITICAL
 Team-work is essential to surviving in the ED (both patient
and resident): greatest off-service resident pitfall is not
communicating with the nurses and attending/senior
 Let your senior/ attending know:
Patient seems to be sicker…
 than triaged
 than last time seen
 than signed out
 You are feeling overwhelmed and are falling behind
 You need a break (nourishment/ bodily functions)

Navigating EPIC in the ED
 Log in and pick correct department:
 YNH EMERGENCY ADULT
 Sign in
 Pick your work area
Navigating EPIC in the ED
 Typical day in ED: this is what the board looks like…
ED Notes in EPIC
 Double click patient name
 My note TAB is open
 Pick My Note button
 You are responsible for…
 HPI: add chief complain
Complete by clicking
 Add free-text in “comments”



ROS: “All Other Systems Negative” must be clicked off
PE: “VS Reviewed” and “Nursing Note reviewed” must be clicked off
 If you did procedures (e.g. EKG)
 EKG: change the “provider” from your name to your attending
ED Notes in EPIC
 To view your full note click on Notes
 Bellow PE and above Procedures
free-text Assessment and Plan



MDM
What was done/ found in ED
Disposition
 Also, free-text
 PMD/ consultants called (name and time)
 DO NOT WRITE IN THE ED COURSE SECTION
ED Notes in EPIC
 When finished documenting: Share
 Refresh Note after “clinical impression” and
“disposition” is complete (after you admitted or
discharged the patient in EPIC)
 When an attending has signed the note, the system
will only let you Sign


Pick your attending to Co-sign
Feel free to edit as many times as needed to complete the note
until the patient leaves the department
Admitting Patient in EPIC
 Double click patient name to open patient chart
 Open Admit Tab

Navigate through sections
 Clinical Impression= diagnosis
 Manage Orders= “ED admit”…
 Disposition= admit
Discharging Patient in EPIC
 Double click name to open patient chart
 Open Discharge Tab

Navigate through sections
 Disposition= discharge
 Follow-up= pick appropriate MD/ interval of follow-up
 Clinical Impression= diagnosis
 Orders= Discharge prescriptions
 Discharge instructions= diagnosis/ symptoms
Discharging Patient in EPIC
 When patient ready to leave, open Discharge Tab
 Pick Preview/ Print Section
 Click Print
 Hand Instructions to nurse
with signed prescriptions
EPIC PEARLS (feel free to print this page)
 Every note MUST have the following elements
complete

HPI: CC filled in


ROS


All click boxes that are applicable filled
“All other systems negative” clicked
PE
“Nursing note reviewed” clicked
 “Vital signs reviewed” clicked



Disposition filled
Clinical Impression filled
 Note must be refreshed before you sign it
Now that you have read and understand the module,
please copy and paste the following statement into an
e-mail and address it to:
[email protected]
I HAVE READ THROUGH THE ED ORIENTATION ONLINE MODULE
INCLUDING THE INSTRUCTIONS ON HOW TO NAVIGATE THROUGH
EPIC (NOTES, ADMISSIONS, DISCHARGE) PRIOR TO MY FIRST SHIFT
IN THE ED. I AM ABLE TO PERFORM THE FUNCTIONS THAT ARE
DETAILED IN THE ON-LINE ORIENTATION MODULE. SHOULD I HAVE
ANY QUESTIONS ABOUT ANY INFORMATION DESCRIBED IN THE
MODULE, I KNOW TO CONTACT THE ED CHIEF RESIDENTS OR THE ED
OFF-SERVICE RESIDENT DIRECTOR.
PLEASE SIGN YOUR NAME AND THE DEPARTMENT YOU ARE FROM.
THANK YOU FOR YOUR
ATTENTION
ALINA TSYRULNIK
ASSISTANT RESIDENCY DIRECTOR
OFF-SERVICE RESIDENT DIRECTOR
CLINICAL INSTRUCTOR
DEPARTMENT OF EMERGENCY MEDICINE
YALE UNIVERSITY SCHOOL OF MEDICINE
[email protected]