Hello Everyone,
Here are your June 2025 Adult Operations Updates. (There was no May update)
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
ED discharge length of stay (LOS) goals:
-ED LOS for discharged patients is perhaps our single biggest opportunity for metrics improvement as an emergency department. This counts any ED patient who is seen and ultimately discharged from the ED who is not admitted, not placed in observation, or not admitted to EDOU.
The new AAAEM goals for academic centers for patients discharged from the adult ED is 286 minutes (that's 4 hours and 46 minutes). This counts the time from check-in until the time the patient is removed from the system (i.e. Not from the time that discharge button is clicked). Make every effort to discharge patients as soon as possible. Please consider the following ways to decrease ED LOS for discharged patients:
Avoiding unnecessary ED imaging and labs and consults (e.g. is that CT maxface for dental pain or nasal fracture really going to change your dispo/plan?)
Using PO or IM meds instead of IV meds when possible.
Communicating with green pod TL if you think a patient is FT eligible.
Use of the ED discharge clinics for definitive care instead of large ED work ups when clinically appropriate.
ED Observation Unit (EDOU):
-As part of the above efforts to decrease ED LOS for discharged patients, we would like to encourage more liberal use of EDOU for patients who won't be admitted to the hospital. Admitting to EDOU stops the clock for the ED LOS as the patient is technically admitted to an OBS status. Please place these types of patients in EDOU in addition to those already being placed (placement, cauda equina MRI, etc). This list is not comprehensive:
Patients who will receive a blood transfusion and be discharged (since these tend to take hours from start to finish).
Patients who will have delayed transport home, to SNF, etc (even if discharge order has been clicked, while awaiting transport patients still add to LOS until they physically depart)
Patients who are getting a 6 hour repeat head CT in the setting of trauma.
Patients who are getting IV infusions of potassium.
-We are continually working with the inpatient teams to create admission agreements (we feel the challenges of repeat CT scans, etc).
-We understand the increased burden of EDOU H+P and discharge notes. We will update you if there are any changes about documentation requirements.
-Please do not use EDOU simply because a consulting service asks you if they can be observed in the ED (if you would otherwise admit to the hospital, encourage formal admission)
-This is by its nature a dynamic request and ask from ED leadership. Please send your concerns and questions as they arise to Cory, Dan, and Brian. We will send more education and clarification as time goes forward.
Admissions:
-Please wait for CT or imaging results prior to admission consults to medicine if the result might prompt admission to a surgical service.
-Please consider avoiding admission consults for very mild AKI or mild electrolyte abnormalities if the patient is otherwise well and tolerating oral intake without other issues.
Stroke order set preactivation:
-You are ONLY required to preactivate hyperacute ischemic stroke.
-For SAH/ICH you are not required to do so prior to patient arrival however if you choose to place order in advance, just uncheck neurosurgery and NMCCS consult and place them upon patient arrival due to consult time metrics. We are working on modifying stroke template.
AUC:
PEDS AUC Code White:
If physically outside of the AUC building and not checked in, call 911 since EC is adult only campus.
If an AUC patient:
PEDs > 14 years old can be activated code blue and responded by ICU same as adult.
PEDs <14 years old. Working to get them to CH ED faster, see if Surge criteria is met for immediate transfer. Peri-code working to get tele health services to get PEM doc and CHM ED pharmacy present to help with resuscitation and immediate transfer. Also working on carving out subgroup surge exception group for sicker peds transfers to CHM.
Scheduling/Qgenda:
QGenda is here (yay?). July will be the last month that the schedule is released on Shift Admin. June 10 is the deadline for August and September shift requests. Please place them on Qgenda.
If you did NOT receive the Qgenda email, please try to create an account at Qgenda.com/login using the SAME email address you use for Shiftadmin. If that does not work, please contact Ayme Farag so she can try to get it sorted out.
We are aware of issues with logins and requests. Please reach out to Amye individually for issues.
Expect a scheduling guidelines refresher soon.
Hand Trauma/Re-implants Transfers:
The on-call hand surgery attending should now be fielding the initial transfer calls from transfer center for this group of patients. Transfer center may connect with you after a case has been accepted. If you encounter a call from transfer center for a hand call where the on-call hand surgery has not already adjudicated the case, please let transfer center know and do not accept the case on your own until you get a yes from hand surgery.
General ED Discharge Clinic Update (one-click discharge appts in the Dispo tab):
Please use this clinic as much as reasonable to decrease patient workups and LOS in the ED!
Important: Patients do not schedule themselves or call this clinic to follow up. You must schedule these appointments for the patient.
Important: Please be mindful of who you send to this clinic. If you think it is unlikely that the patient will follow up, please save the clinic spot for another patient.
Who this is not for: Currently not for paracentesis patients or patients requiring procedures (we have other options for paracentesis at SAC. Message Dr. Hana Kazbour for that PRN), cardiology/chest pain follow up patients (please message Alicia Rivera, MA to help arrange for this group of patients PRN), Workman’s comp patients, surgical patients. Not for pediatric patients.
ED Communication Nurse Team Requests:
-RUH and ARMC pharmacies will only fill prescriptions from those facilities. Do not send rx to those hospital pharmacies.
-Please place all referrals placed as "urgent" otherwise patients will not get into respective clinics for months and months.
-Lidocaine patch boxes come in boxes of 30. Pharmacies will not break boxes. Please order 30 lidocaine patches if you order them outpatient.
QI:
-Don't forget Pulmonary HTN and CHF lasix order sets. Please use these order sets for patients with pulm htn you are admitting. Please use the CHF lasix order set for patients you are ordering diuretics for in the setting of heart failure for the urine sodium (ideally set for 2 hours after diuretics are given).
-Send interesting cases to Eric and Amye for QI. Educational cases are also great.
Older but still important…
Orthopedic Surgery:
-Consults: Orthopedic surgery department has requested that ortho be consulted for any operative fracture (anything that needs surgery within 2 weeks). This is to help facilitate inpatient/outpatient management as we have had a few patients fall through the cracks.
-Joint Aspirations: If you aspirate a joint for fluid, please take a photo to place in the patient’s media tab/chart as this aids the ortho team.
IV Antipsychotics:
There have been many questions about IV Haloperidol (Haldol) and Olanzapine (Zyprexa). Please see the IV medication guidelines above. ED pharmacy will support the use of IV Haldol and Zyprexa in the appropriate context (though please do not order it as an IV PRN order, this will not be approved). The inpatient floor units have been providing IV Zyprexa by provider preference. Zyprexa is not listed in the institutional medication guideline (though there are some studies supporting safety in IV administration), so you may find some nurses not comfortable giving IV zyprexa themselves, but you may administer it yourself (though if nurse is comfortable that is also ok). Consider ECG for QTc evaluation.
HIV Testing:
Please order CD4 and viral load on patients with HIV requesting medication refill (per Dr Veltman), try to connect with PREP clinic as well for continuity.
Cardiology Scheduling:
For Risk Management and Straight Medicare patients, please consider scheduling patients via the “LL ED discharge Adult Cardio Est Video Visit” option on the ED dispo tab.
For all other patients, please secure chat Alicia Rivera with the patient chart attached. She will often get patients follow up in the next few days to week. If reasonable for discharge without ED Cardiology consult, please use this resource!
That’s it for now.
Fun fact of the day: A team of climbers recently summitted Mount Everest in 5 days (very fast) by using Xenon gas to facilitate acclimatization to altitude at an unrivaled pace, causing a huge debate about the use of the gas in mountaineering/ "peak bagging" (https://www.nytimes.com/2025/05/27/world/europe/mount-everest-xenon-gas-nepal-uk-climbers.html)