JHEMS Providers

PROVIDER RESOURCE MANUAL

General Operations

Layout

The ED has 36 beds. 18 designated on the Blue/Acute side and 18 on the Red/Subacute side. There is also a 4 bed Fast Track.

There is a Behavioral Health Unit that has 5 beds. All psychiatric patients must be seen by a physician. See below for a more detailed instruction regarding psychiatric patient management.

Triage – At the front entrance of the Hospital, is a 6 room triage center.

Shifts

Physician:

Acute side – 7a-3p; 9 -5p; 3p-11p; 9p-5a; 11p-7a (weekend slightly different)

Subacute side- 9a-5p; 5p-1a (weekend slightly different)

Screen – 11a-9p on Monday - Friday

Physician Assistants:

Subacute – 7a-4p; 10a-6p (rapid dispo); 11a-8p (flex); 4p-1a; 6p-2a (rapid dispo); 9p-7a

Screen - 11a-9p on Monday - Friday

Please login to TangierWeb (tangierweb.com) to view your schedule, make trade requests, and edit your hours.

Paige Stella does the schedule (pstella1@jhmi.edu) and Dr. Don Berlin oversees the scheduling (dberlin2@jhmi.edu)

All schedule switches with a Locums Tenems physician or parti-time physician must first be approved by Dr. Berlin or Dr. Linton

Triage

The screening provider will be the go to for the triage staff.

The providers on the Subacute will serve as the “back up go to” docs should the triage nurses have questions about patients waiting in triage, need pain medication, or request orders not contained in advance triage protocol order sets.

When able, all providers should attempt to make contact with all patients waiting in triage.

All orders placed under nursing guidelines will be placed under the charge doctor's name, when you assign yourself to a patient please sign all outstanding verbal orders.

Responsibilities

“Charge doc”

The core provider (7-3p;3-11; 11p-7a)

The Charge Doc will assume responsibility for any major decisions regarding allocation of departmental resources, etc. (i.e. If the Acute side is overwhelmed with critical patients and the chart rack is stacked with patient charts, subacute providers may be asked to help with the Acute side, and vice versa.)

Referrals

The Subacute providers (11-7a; 4p-12a) will be responsible for all phone referrals not handled by the charge nurse. Please carry ASCOM phone 2125 for referrals

Please document and give to charge nurse.

Psychiatric Patients

The Acute/Blue side providers will be responsible for all psych patients. For disposition - if involuntarily admitted both certifiers must see and document their evaluation in the record. Whenever a psychiatric patient is discharged a progress note must be placed by the discharging physician. Use .BHU when signing out Psychiatric patients to the next provider.

“Culture Book”

The positive cultures are handled by the Clinical Program Manager, Amanda Means. She may contact you on your shift regarding help with a culture.

Radiology discrepancies

The responsibility of subacute physician assistant. All clinically important discrepancies should warrant a call to the patient. The radiologists only compare the official read to any ER note you place in the PACS system. Please document in the medical record your conversations with the radiologist and the patient.

Scheduling

Please go to www.tangierweb to access schedule and make requests. Please refer to the scheduling guidelines provided at initial hire.

Provider Productivity Data

Go to https://emweb.jhmi.edu/apps/jhems for provider productivity data. You should use your JHED ID and password to log in

Patient Care

Signup

Please use the Assign Me function to assign yourself to the treatment team

Credit

Be sure to sign your charts, shared charts cannot be billed. If you are assuming care of a patient, and provide some substantial amount of patient care, please create a progress note with the SmartPhrase ".eddispo" and a summery of the care you provided.

For PA charts, cosign their notes with a summery of your involvement in the case.

Admissions

Review the Admission Guide to determine the proper hospitalist or hospitalist service.

If the patient has no PCP or a PCP that does have a working relationship with one of the private hospitalists, the general hospitalist service (CIMS) will accept the admission.

Note: All Kaiser Permanante patients will first need Kaiser’s approval for admission. Have the PCA call Kaiser to arrange a phone call with the Kaiser physician responsible for admission decisions. Once approved CIMS will be the admitting service. Be aware that most Kaiser patients will be transferred.

ICU -- If you feel any patient will need admission to the ICU, please call the intensivist on call at X2460.

SCU – The Special Care Unit serves as a step-down unit and will accept patients that are ill, but do not meet criteria for the ICU. These patients will be placed by the ICU doctor

Admission orders for the SCU should be done by the admitting hospitalist, unless the service is CIMS

If CIMS will be the ultimate admitting team, the SCU doctor will admit the patient. If the decision is still gray, have the CIMS doctor evaluate the patient first.

In the evening and overnight, the ICU attending will admit patients for all hospitalist services to the SCU and ICU.

“Direct” admits

There are no direct admissions through the ED. If a patient is sent to the ED to be admitted, please provide a medical screening evaluation.

Discharge

After completing the after visit summery please print out, place in chart, and hand to nurse or place the patient’s chart with discharge instruction.

Please be sure to address the patient work note, prior to discharge as many patients often need to return or call for such notes.

Make sure all printed prescriptions are signed with a handwritten signature.

Signout

When you sign out at the end of your shift print the trackboard view "My Patients" and review this with the oncoming provider. When you sign out assign the new attending to your patients.

Radiology

There is a radiologist in-house from ~8a-2a. They will provide a written dictation to be seen on the PACS system and in EPIC.

After 2a, all CT scans and ultrasounds will be sent to the nighthawk radiology at American Radiology (443-663-2580

). Plain films will not be read unless the provider asks the radiology technician to send the film to nighthawk.

PRELIMINARY RADIOLOGY RESULTS ENTRY - providers will be responsible for entering comments into PACS on any study where the patient is being discharged before a voice clip has been entered including all overnight studies. This is for both normal and abnormal reads. This will close the loophole where a patient is discharged by a provider with a preliminary "normal study" , but later read as abnormal by the radiologist.

CT table weight limits - 400 lbs for chest, abdomen, and pelvis studies, 450 lbs for others.

Psychiatry

There will be psychiatric social worker who will be in contact with a Psychiatrist for determining patient disposition in regards to the patient’s mental condition.

The ED Provider will be responsible for medically clearing the patient.

The provider will be called upon to sign Certificates of Admission as well as voluntary admission documentation.

The ED provider will be responsible for all non-psych medications and emergent medications needed to stabilize the agitated patient. All other psychotropic medications (ie. Seroquel, Geodon, etc.) should be administered after consultation with the psychiatry attending.

Special Order sets

Most chief complaints and admission diagnosis are listed in order sets in EPIC

Triage

Whenever you are able to break free from the actue or subacute areas, please attempt to make contact with patients in the waiting room

There is a policy that you cannot administered IV narcotics in the waiting room, however, you may order oral narcotics.

Consultants

There will be a daily sheet at the doctors’ station detailing the ‘on call’ schedule. Be sure to review the Provider Resource Manual to determine the relationships between a PCP and the proper consulting service (primarily for Cardiology, Surgery, etc.)

Cardiology

Cardiovascular Specialists of Central Maryland are the predominant consulting group.

Padder Health Services

Dr. David S. Jackson

Surgery

Johns Hopkins Surgeons

Maryland Surgeons

Dr. Mohammed Gheba

Dr. Cornelius Musara

Dr. Nanavati

Dr. Sunkara

Gastroenterology

Maryland Digestive Disease Center

Digestive Disease Associates

Neurology

Dr. Eric Aldrich (in house)

Dr. Kao

Dr. Ansher’s group

Dr. Wagle

Ophthalmology

Anshu Sinha

Dean Glaros

Maxillofaical fractures

Dr. Dan Georgescu (Oculoplastics) - will not treat mandibular fractures

Dr. Domenick Colletti

Dr. German

Special Protocols

STEMI (HAT)

If you feel that a patient’s EKG illustrates a STEMI (elevation in contiguous leads, ST depressions in V1), immediately activate HAT. The threshold for activating HAT should be extremely low. Field activations are at the discretion of EMS and cannot be called off until the interventionsliast has been consulted.

The PCA will activate the HAT once instructed. You will also be able to activate by calling 410-955-9444

(Hopkins Access Line). The clinical coodinator may activate the HAT team for all EMS field activations.

During the day (~8-4pm) you may contact the in-house cardiologist at 2182 for a second opinion regarding an EKG in a potential STEMI patient.

Stroke (BAT)

If a patient’s has evidence of a stroke and presents within 3 hours (can extend to 4.5) of time of onset (or ‘last seen normal’), perform a NIH Stroke Scale assessment, and call the BAT pager.

The PCA will activate the BAT once instructed. Please be clear to state you are activating a Brain Attack Protocol for Howard County to ensure you talk to the right person.

Please be sure to review the tPA packet before administering tPA, especially the contraindications to tPA and the consent forms.

The patient’s must be admitted to the ICU or transferred to an ICU for post tPA monitoring for hemorrhage.

tPA can only be administered in the ED. Occasionally inpatients from the hospital who have an acute stroke will come down. When this happens they are still considered inpatients. Your role as the ED attending is to assist the hospitalist as a consultant in their evaluation and decision to administer tPA. The BAT Neurologist should also be involved.

Special Urgent Specialty Referrals

Hand and Upper Extremity Injury

Complex hand and upper extremity injuries (amputation, deep multi tendon lacerations) likely would be best served at Union Memorial's Curtis Hand Center - Since last month the "Hand Center Union Memorial" will set up transfers and make all the arrangements, even connecting with the accepting attendant. Call 410-261-8100

(just like the Hal line and Express care) to make set up possible transfer to Union. Fax face sheets to 410-554-6544.

Ophthalmology

After hours and on weekends the Wilmer Eye Center will accept all patient who require urgent ophthalmology evaluation. The Ophthalmology resident can be reached via the HAL line. These transfers are processed in the same way that all other transfers are.

Residents

a. All patients seen by a resident must also be seen by an attending physician.

b. You are required to cosign their note in epic and also to document an attestation note. You can use the SmartPhrase ".edresattest" to accomplish this. You are required to provide at lease one element of HPI and one element of a physical exam as well as your independent assessment and plan in your note to bill.

c. Please direct the residents towards the proper consultants and admitting physicians.

Important Phone Numbers

Main ED : (410) 740-7777Robert Linton II, Medical Director – X7568/2128; (410) 740-7568

Don Berlin, Assistent Medical Director - X7571

Clinical Coordinator: X2100; (443) 718- 2100

Charge Doctor: X2121

Provider Phones: X2122, X2123, X2124, X2125

Intensivist: X2460

Special Care Unit Physician: X2600, X2460 in the evening

Patuxent Hospitalist: X2179

CSCM Cardiolgoy: X2182

Maryland Surgeons: X2185

ED CT tech: X7573

ED Rads tech: X7914

Radiology Reading Room: X7681