BID-Needham

General workflow and meditech primer: https://sites.google.com/bihcommunityone.com/meditechwiki/home

Staffing: 7p-11a 3RNs, 1 tech, 11a-3a 5 RNs, 2 tech, 3a-7a 2 RNs, 1 tech

Midlevel: 10a-8p everyday

Resident: 3p-11p, most days

Imaging Capability:

CT/ Plain film 24/7

Ultrasound 8A-11P (must order study before 11P!)

MRI – variable, most days 7A-10P, weekends usually 7A-8P, holidays off

Imaging Interpretation – Variable. Chart posted near attending computer.

Special Note: Be careful with resident interpretation of MRI reads after hours. If significant clinical concern, consider observing patient for attending read in AM

Admission Process:

  • Floor - E-Sign-out

    1. STOP: Do a face-to-face discussion with ED RN about admission

    2. Write brief summary in MD comments (as at BIDMC – template on attending computer)

    3. Place order for Admission and inform UCO. COVID category II should be clicked in the order set.

    4. Hospitalist has 45 min to accept patient (usually much faster).

  • ICU

    1. STOP: Do a face-to-face discussion with ED RN about admission

    2. Place order for admission and inform UCO. Verbal sign-out to the intensivist/ICU PA is required.

    3. Patient will be either accepted or if too complex, may require transfer to BIDMC.

Transfers:

BID-Needham has medical, surgical, and ICU beds. There are various medical subspecialties including neurology and oncology, but certainly not as many as BIDMC Boston. There are limited surgical subspecialties, and only general surgery admits to BID-Needham, generally for straightforward cases such as appendicitis or cholecystitis.

PLEASE MAKE EVERY ATTEMPT TO KEEP PATIENTS AT NEEDHAM. IF YOU ARE NOT SURE IF A PATIENT CAN STAY, SPEAK WITH APPROPRIATE SERVICE. For example, borderline troponin – call cardiology, ICU patient not sure if OK for Needham – call hospitalist, Stroke patient – call neurology.

To transfer a patient:

    1. Call the BIDMC Boston transfer attending to get acceptance

    2. Instruct the UCO to call transport

    3. Fill out transfer sheet

    4. Complete your note

    5. Fill out ED dashboard electronic call-in (if appropriate)

E-Order System:

There are 3 ways to order a medication:

1) From the quick picks or existing categories (this option will be improved on future revisions)

2) Search "Medications/Treatments" at the bottom of the screen (solution for most med orders)

3) Free text the medication. This option is more tricky but will solve the problem of not being able to find the drug.

Type: "MISC" in the "Search Labs" tab (we know it's counter intuitive but its a viable work around)

Then free text the med and dosing and you are all set.

CODE BLUE:

ED MD must respond to all Codes (NOT Rapid Response). Primary responsibility is airway management, access (if none or surgery not present). Hospitalist should run code. Goal is to assist with emergency interventions and return to the ED ASAP.

REQUEST FOR ASSISTANCE WITH ICU PATIENT

“Can you put in a Central Line for me?” – ED MD is NOT to leave ED to place central access. If hospitalist is unable to arrange for surgery or anesthesia to place line, patient may be BROUGHT TO THE ED for ED MD to place line.

“I think this patient might need to be intubated” – If patient can wait 30 minutes, inform hospitalist to call anesthesia and ask them to come in to intubate patient. If an airway emergency (CODE BLUE), respond to ICU.

Pediatrics – Special Considerations

  • NO INPATIENT CARE OF CHILDREN UNDER 15 (that means no emergency surgery, no admission to hospital)

  • OK to observe children in ED if needed

  • Boston Children's Hospital ED is always available as a resource if you need help. Just call and ask for an attending.

  • Boston Children’s Critical Care Transport is an excellent resource for critically ill child.

MRSA Testing, Cultures

We now have a very sensitive PCR test for MRSA (similar to flu swab) which results in approximately 1 hour. This may be used to determine the need for Vanco therapy in a subset of patients. Specifically, this would be patients who are not critically ill, that have an infectious source and are being admitted for parenteral abx. This does not include patients who have purulence, fluctuance or other high risk MRSA source. E.g. admit for HCAP - one could send MRSA swab and wait for results instead of adding Vanco to initial abx treatment.

In addition, as we are trying to be more efficient with abx use for patients being admitted - if it is possible to culture the source of infection (abscess, hematoma, wound drainage) prior to initiating parenteral abx, that would be very helpful (this does NOT apply to outpatient therapy - specifically no need to routinely culture abscess I+D's).

Frequently Asked Questions:

“What do I do if things get really busy?”

First question – MD or RN staff issue?

RN – tell charge nurse to page nursing supervisor to get assistance

MD – few options. 1. Ask next attending to come in early 2. Call mid-level in early or see if available to come in to help (contact info with UCO) 3. Activate BIDMC call

“What do I do if I have a violent psych patient? “

Hospital security should be called. If unable to handle, call police.

“The nurse says I should transfer this patient, we never keep these folks.”

If you are not sure, discuss with hospitalist, appropriate consulting service, or call Barb Masser

“ The consultant is not calling me back, what do I do?”

Inform the nursing supervisor. If it’s a fellow, page the attending. If no call back and patient waiting for disposition or ill, it may be necessary to transfer to BIDMC, however this is last-ditch option.

QUESTIONS IN REAL TIME: Ed Ullman 617-913-8152