Hello Everyone,
Here are your February 2025 Adult Operations Updates. (There were no December or January updates)
Don’t forget, lots of helpful info available here (now including past operations update emails):
https://sites.google.com/view/lluem/llu-ed-operations-manual/ops-manual
Pass: 42828
AUC:
AUC pediatric transfer dispo when PEDS ED on Surge capacity:
Working on possible modifications to surge 2 criteria or other creative work around since unable to have an internal exception for AUC stable peds admissions. If unstable or emergency, transfer to adult ED. See attached surge exceptions as well (peds surge exceptions.jpeg). Awaiting data on patient progression. (Tip: you can always change context on Epic into CH to check surge status on peds side)
Peds UM Coordinator to help with peds AUC transfers:
For AUC admissions in cases of surge capacity to peds ED, CH UM coordinator can now help with external transfers to other facilities. As well as adult UM coordinators (ext 17601) can help with Redlands admissions or others if applicable.
Ketamine administration at AUC:
Institutional approval for RN to push pain dose ketamine however if used for sedation, you must get verbal consent and do the sedation (PRS) form prior to sedation and must be pushed by MD. Ketamine for peds sedation is pending final approval and nursing education, primetime by April.
Body fluid exposure:
BBPEASSESS - smart phrase recommended to use by Occupational Med, placed a ticket with to have as an universal smart phrase available to all providers.
For now, you may copy from smart list under
Nasrin Kazemi (Name of phrase: BBPEASSESS).
Quality Improvement (QI):
Dispo delays: Please send any dispo delays to us (Eric and Amye) so we can continue to improve our throughput. We know flu season has been bad but we want to continue to provide the best timely care we can.
New EPIC build impacting when ED places Ortho & NeuroSx consult orders: Providers will notice when placing consult order for these specialties that a reason for consult has been added. Please indicate specific reason (see clickbox photos below) for consult or click other (free text option)
ECPR:
Situation: Dr Lam will be away most of March.
Background: Dr Lam’s direct ph number was in ED as we worked on streamlining the process for appropriate consults and trained up the team.
Assessment: We have improved our communication for appropriate ECMO consults. A little more than half of ED staff has been trained now on ECMO.
Recommendation: Moving forward, the team should follow these steps for ECMO consults and contact the correct provider on call for ECMO:
CODING PATIENTS: (ECPR) Direct phone call using Voalt to Voalt. Search for the provider on voalt and call with the required patient information
1. 7 AM – 4 PM: Contact the NP on call.
2. 4 PM – 7 AM: Contact the Fellow on call.
3. Call ECMO Coordinator Available 24/7
4. (If neither of the above is available, then contact the attending)
NON CODING PATIENTS: place an ECMO consult order on LLEAP. We are working with Operator Services, Voalt, Spok, and Qgenda to streamline the process, and we’ll continue improving as things evolve.
Scheduling:
We will likely be moving to QGenda in July, for now keep doing what you're doing with availability. April attending schedule should be out very soon. Please continue to provide 1.5x availability and at least 2 open weekends for shifts in order to be fair to everyone.
Trauma:
Outside ED to SICU direct admission for outside trauma centers:
See attached algorithm (OSH ED to SICU flow). In short transfers from outside trauma centers with need for higher level of care may qualify for direct admission to the SICU. Please use this process to avoid ED to ED transfer if the patient qualifies and if we have ICU capacity.
Infectious Disease (ID) Consults:
ID consults are available 7 days a week.
If you want same day completion of consult, please try to get consults in before noon.
For antimicrobial questions, please contact who is on call. 7 days a week 8a-5pm.
There will soon be an e-consult order (March at latest). If you place that and then page, ID will place a template to document recommendations if in person consult is not needed.
For ID emergencies (e.g. cerebral malaria treatment questions, difficulty with diagnosis of nec fasc), please consult the on call ID attending.
Rapid Screening MRIs:
The same rapid screening MRI for cauda equina (L-spine) is now available for rapid ED screening for cord compression for C and T spine (Search for MRI limited Cord Compression WO contrast)
CHF Lasix order set:
Cardiology has requested that we use the “CHF LASIX PANEL” order when ordering furosemide for diuresis of heart failure patients. This includes a urine sodium post Lasix administration to guide inpatient diuresis. Please use this order set!
MICU Overflow Algorithm:
Please see attached for the current agreed upon process for MICU admissions when MICU is capped (MICU overflow algorithm).
Medicine consults:
Please wait on placing medicine admission consults if a CT/imaging result is pending that may direct a patient to a surgical service for admission.
Contrast Protocol for CT contrast allergy:
An ED resident or Attending are not needed for 4 or 13 hour contrast allergy pre-medication but ARE required to be present in CT for <4 hour preps. Please see attached (Contrast allergy prep).
PERT Algorithm:
Please see the attached PERT algorithm as considerations in management of acute PE. Developed by our PERT team.
PPO Medicine Clinic follow up:
Please secure chat Pamela Swanson as the go to person for PPO primary care follow up at FMC internal medicine clinic.
Older but still important…
Hyperbaric Oxygen Therapy
-LLU can provide HBO services 24/7 for emergency conditions like-CO poisoning, CRAO(central retinal artery occlusion) and Decompression sickness and sometimes if need be for Air Embolism. We have multiple other conditions for which we treat both inpatient and outpatient. To get HBO started, ED physician will need to call the Pulmonary attending on call, General pulmonary attendings and Kerstyn O'Brien (PA) provide the services for consult during 8am-5pm hours and after hours it is the responsibility of MICU attending on call.
Stacey Saunders is the HBO coordinator and is very willing to talk and discuss with any provider regarding HBO services.
Dr. Maken (MICU/Pulm Crit) isalways available via Email/Secure chat and Telephone(714-504-8502) if needed.
FMC Allergy Clinic
-Our FMC Allergy Clinic is able to provide close follow up for patients in ED (24-48 hours.) They do accept IEHP patients as there is not a SAC option. To refer patients to the clinic, please place an Ambulatory Referral to Allergy at discharge. The patient should then contact the clinic to set up an appointment.
Enclosed find potential referrals to clinic that you may see in the ED
Anaphylaxis
Drug allergy
Recurrent visits to the ER for acute urticaria (“allergic reactions”)
Food allergy
Angioedema
Stinging insect (honey bee) allergy
Chest tubes:
For all chest tubes placed for trauma patients, please give a prophylactic dose of cefazolin (ancef) prior to chest tube placement as much as can be safely and feasibly done. This is an ask from the trauma QI committee.
Radio Calls (ICEMA Base Hospital Protocols):
Base Hospital protocols have been added to our online operations manual https://sites.google.com/view/lluem/llu-ed-operations-manual?authuser=0 (PW:42828). The topics cover ICEMAs policies on Continuation of Care, Destination, Cardiac Arrest, Trauma, and Determination of Death on Scene. Please refer to these policies or ask the MICN in the radio room to pull it up if there are any questions on a radio call.
That's it for now.
Fun fact of the day: The cost of a 30 second commercial for the Superbowl this year was 8 million dollars.