Emergency Service Operations

Operations in Emergency

1. Emergency Department Patients: Assess and Triage

The role of medical residents on emergency consults are to triage and stabilize patients. If, after a brief assessment, a patient is suitable for admission to the GIM service, complete a concise consult sheet and complete the first page of admission orders with preliminary and life‐saving measures. 

• During the daytime hours of 8 AM to 4 PM, complete the consultation and admission orders for the patient to be admitted and review the case with your attending physician and/or team. 

• If after hours, 4 PM to 8 AM, assign and call a Junior Resident, Student Intern (SI), or Clinical Assistant (CA) to complete the H&P and admission orders. Clearly advise the appropriate learner to complete the H&P (seniors will complete the Consult note) and review their orders. The senior resident should then review the case with the learner and emphasize learning points. (For CA’s, you do need to review their orders but you are not required to provide them with the educational component). 

  • All admissions should be assigned to a learner.

• If patients are ill, the medicine resident should decide if they are able to be handled on the GIM Wards or sent to the ICU. If it is decided that the patients are more suitable for admission to a GIM Ward, there are higher acuity beds that patients can be assigned to. Please review the icare/telemetry guidelines for information regarding this. 

• If a patient is not appropriate for admission to GIM, see UAH Admission Guidelines  for more information, complete the consult and clearly communicate this to Emergency Physician. Although some patients may not need to be admitted under GIM, they may benefit from our advice and medical management. All senior residents are strongly encouraged to discuss these cases with the attending staff (or Junior attending).

2. Bed Allocation

• In morning report and with each hand over, bed availability must be discussed. The bed allocation tracking sheets (as below, and found in the ED Consult Senior folder) can be used to easily keep track. 

• The contact for bed coordinators is below, or at this link, or can also be reached through locating :

  • Weekdays (0900 – 1500): Medicine Bed Coordinator 407‐7718, pager: 445‐3852, cell: 224-4902

  • Weekdays (1500 – 1900): Bed Manager pager 445‐5937

• If uncertain about bed issues, feel free to page the attending on-call. 

3. Keep Track of Patients

• Keep consults organized: Use the Handover consult tracking sheets below and add all patients to the "GIM - ED Consults" list on Connect Care. It is very important for morning handover to know who has been sent to which ward.  

• SBAR Presentations: In morning report, we ask the emergency consult residents to present patients in a concise and organize fashion using the SBAR format. See SBAR - How to give Handover for details. 

• If a patient is moved to the ward overnight, either from emergency or ICU, residents are expected to give handover of those patients to the covering junior resident, student, or clinical assistant.

4. Communication with the Attending On-call

There is a mandatory phone call between the senior residents and attending physician/junior attending on call every evening at about 8‐10 PM.  Any patient admitted to an i‐care or telemetry bed, or patients that are critically ill or expected to pass away need to be communicated with the attending physician/junior attending on call.  As well, any other reasons that residents feel they should call the staff should be done. Learning to know when to call for help is part of the residency training process.  For any triaging issues between services, there should be a staff to staff conversation.   

5. High Volumes 

• Bed cap: Given the volumes in emergency being increasingly high, there has been some bed cap numbers placed. This has been decided at the number of 8, meaning that if there are 8 or more admitted patients in the emergency department and/or Rapid Transfer Unit (RTU), admissions, the GIM ED consult service will be closed for further admissions. They will continue needing to assess patients for consultation but no further admissions will be done. If this should happen, the attending on-call must be notified and the emergency staff physicians should be also made aware.

• When there are 4 or more pending consults to be seen that have not been assigned to any learner, the attending on-call needs to be notified at which point in time they should also be present to the emergency department. 

Special Considerations in Emergency

Protocol for patients with no Active Medical Issues:

• While doing GIM consult in ER, we determine whether or not a patient needs acute care admission ONLY.

• If they do not require admission for an acute medical issue then we need to say that in our consult note and relay it back to the ED physician whereby they get their ED care coordinator involved.

• Our job is not to call Family Medicine directly and ask them to take the patient.

Protocol for Non-operable Injuries:

• Trip and Fall with non‐operable injuries but no active medical issues causing fall go to Ortho.

• The head of the ED department confirms this.

• Emergency has a protocol where they will hold the patient overnight and call the ortho staff in the morning, so you shouldn’t be called.

Transfer of Critical Care of patients to GIM Wards

After regular hours, this will be only on an urgent basis because of volume issues, and then consultations will be to the Senior resident on Emergency Consults.

Assess the patient and complete the Consult in Connect Care. Add the patient to the "GIM - Inpatient Consults/ICU transfers" list. If suitable for transfer to GIM wards, inform the Bed Coordinator.

Attached below is an excellent cheat sheet created by previous chief residents Evan Martow and Debraj Das in 2015.