July 2024

Hello Everyone (and a particularly warm welcome to our new interns!),

Here are your July 2024 Operations Updates. (There were no April or May 2024 operations 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 Updates: 

• Per Radiology, please don't use the combined CT Chest/Abd/Pelvis order at AUC for non-activated traumas. Please order indicated scans separately.

• Please reserve the pediatric transfer process to the adult ED (when peds ED is at capacity) for emergently ill patients. If the patient is stable, please do your best to manage the patient at AUC until Peds ED has capacity. 

• We are currently in the process of hiring several APPs to help with coverage at AUC and MC, stay tuned for more .

Scheduling: 

• We are actively working on a new staffing model to optimize our environment based on current staffing constraints, stay tuned for more. We will also be switching away from Shift Admin to a new program Qgenda, soon. 

Resident Supervision: 

• Please see separate email from Dr. Kiemeney on 6/30 regarding new resident supervision model. In short, senior residents will present to either attending on their side of the workroom for their entire shift. 

Sepsis: 

• There will be a new Sepsis note in the next week, requiring new time stamping for severe sepsis or septic shock or if you do not suspect severe sepsis or septic shock. If epic recognizes triggers for severe sepsis or septic shock it will be automatic, otherwise you can manually enter time. 

Lab QI:

• Please add Dr. Eric Chao (Weyjuin Chao in Epic) to any secure chats you are added to from the lab about critical results (especially those who are already admitted or already discharged). 

GI consults: 

• For any patient you are consulting GI and anticipate admission, please consult MOD at the same time.

Peritoneal Dialysis Patients:

• For patients that require a workup for PD related peritonitis, please contact nephrology immediately upon your evaluation of the patient - 24/7. You do not need to wait for any other workup to be done. If you think a sample will be needed at any point, we need to start the process immediately. Nephrology will write orders for the DART nurse to come collect the fluid.

Restraint orders: 

• Please remember to sign your face-to-face note for violent restraints at the time of restraint order.

• Please make sure to place orders for accurate time of initiation of restraints AND that the order matches what is on the patient. 

• A new order is required each time a restraint is removed (e.g. moving from 4 restraints to 3), but not once all restraints are removed

ECPR in the ED:

• You may have seen or heard of recent ED ECPR cannulations/patients. Please see attached current institutional guidelines for ECPR for indications, contraindications, etc.

• If you have an ED patient that needs to go onto ECPR/be cannulated, please move them to one of the resuscitation rooms (RS1-RS4). Please do not run these cases in the smaller rooms as much as possible. 

• There is a ECPR bundle of supplies in the ED nurse educators' office for use by the CT surgery team (nursing staff and techs to receive education on this)

• The three CT surgeons performing ECPR are Drs. Salabat, Lam, and Chung 

• See attached pdf for a deep dive into ECPR

CT Risk vs Benefit notes:

• See attached file for some new questions at the time of any CT with contrast order.

• Goal is to decrease CT Turnaround time and has been part of a larger project aiming at such. 

Moving ED Patients for re-assessment: 

• Please communicate with Green Pod TL (GPTL) when you need to move a patient. It is ok to bring patients to chairs on your own, but please do not move patients yourself to chairs without asking. Often, nursing/tech colleagues have already marked chairs for other patients and it can be particularly hectic at our most chaotic times in the department. 

Orthopedic Oncology Cases:

• Please do not transfer any orthopedic oncology cases to other hospitals unless the case is first cleared by Dr. Donaldson (chair of orthopedic surgery). If you are working with an orthopedic surgery resident, please remind them of this in your discussion. 

Atraumatic Spinal Compression Fractures: 

• Please place rheum referral re: osteoporosis for all non-traumatic vertebral compression fractures (acute or traumatic). 

• This is a population health issue which may help reduce recurrent visits for the same to the ED

Stroke Updates:

AED reminders:

• new recs recommended AED once seizure occurs and does not require prophylaxis for all neuro cases, for example, see when prophylaxis is indicated.

Seizure prophylaxis- INDICATED 

• Aneurysmal subarachnoid hemorrhage

• Subdural hemorrhage 

• Traumatic brain injury (moderate to severe TBI)

Seizure prophylaxis- NOT INDICATED

• Spontaneous intracerebral hemorrhage 

• Intraventricular hemorrhage

• Ischemic stroke 

Hemorrhagic stroke:

Recommends BP goal: BP <140/90 for bleeds

·                     Instead of BP <160/90, ED SAH/ICH order set requested to modify according to these new parameters 

Focused History & Exam (for HAS):

• There have been several delays from residents and attendings due to performing detailed exam and history. Please keep history pertinent to presentation with brief neuro exam to proceed with stroke activation (don't need to perform NIH scale at that time) since time sensitive to get to CT to avoid fallouts. You may return to the patient at RPCU to finish your exam and history if needed after CT obtained. Be mindful of our metrics.

• Working on configuring an ED iPad with generic login at ambulance bay to place orders quicker instead of walking back to your workstation --- TBD

Pre-activation Order Set:

Hold off on SAH/ICH order set for transfers since NGSY consult time starts with order set. No time urgency to place order set for preactivation, can be done upon arrival. ONLY pre-activate HAS since time sensitive measures. 

RIC to assess stroke 

• reminder for RIC to go to Quick Look alert, there has been several delays with interns trying to do stroke assessment in quick look. I have encouraged nursing to overhead QL alert to specify if stroke related

Uncheck MRI from ED HAS 

• requested that MRI be unchecked from order set with limited time for ED providers to assess for MRI contraindications or devices, etc. Neurology to order MRI if needed from their assessment.

Transfer request for AVM/Non ruptured aneurysms:

·                     Does not meet criteria for surge capacity acceptable since no bleed but can have the call redirect to NSGY as courtesy

Trauma (Updated Geriatric Activation Algorithm, see attached): 

MC ED to CH admissions:

• Children’s hospital is able to admit 18-21 year old patients (non-surgical) and may be able to get a faster disposition for this select group. If you have a patient that falls in this age range and needs admission, please call the transfer center to begin the process. These patients will need to be managed by the adult ED until they physically depart the ED. These are not transfers to the peds ED, but rather transfers for direct admission to the children’s hospital. If transfer center tells you it is not a process, please be insistent as this is a project that has built by administration. 

ED Jackets:

• ED jackets are here for MDs/APPs. Please reach out to Joanna or Ruby if you have not received yours. 

Older but still relevant:

Cardiology Updates:

• Please see attached CHF Lasix order which comes from Dr. Chao.

• Please send secure chats or emails to Dr. Chao about overnight cardiology consults who cardiology refuses to see or staff with attending to provide recs (especially if for patients with anticipated discharge)

Off-service resident note writing:

• The best template is “EDHPADULT” and can be found under Brian Wolk’s user account on epic. Anyone can easily add themselves to it as a dotphrase.

• Please direct residents to use the above template.

Clinical Pathways:

• Please take a moment to explore the Operations Website for the several clinical pathways we have built with our consultants.

• Includes:

  • Ophthalmology flashers/floaters pathway (see Ophthalmology information)

  • Several Urology pathways (see Urology Workflows and Follow ups)

  • Cardiology troponin pathways and outpatient follow up (see Cardiology)

  • Gallbladder pathology management (see Gallbladder Pathways)

  • DVT algorithm

  • Others! Check them out!

ED “Superutilizers” committee:

• Nick Andrew and Rob Barry are spearheading a new committee aimed at better addressing needs of our high ED utilizers (AKA frequent fliers) to decrease their hospital visits. This for both AUC/ED. Please message them if you think there is a patient you believe would benefit from being reviewed in this committee. This can include sickle cell patients at AUC.

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: Identical twins do not have the same fingerprints.