Badge Access

-        On your first day of FMG orientation you will receive your new I.D. badge. Your badge will:

·    Provide access to the Residency Library, the restrooms and other offices. A copy of the front and back side of your badge is needed to activate access, and you can present your badge to staff in Rm. A108. - typically Lyne Jones (LJones@llu.edu)

·   The badge is activated at HR for entry to the hospital and parking areas. Human Resources is located at 101 E. Redlands Blvd, San Bernardino, CA 92408. (Just west of Waterman Ave.)

·   Should you lose your badge there is a $10 replacement fee payable to HRM at the time of the issuance of a new badge.  Office hours for getting a new badge are: Monday – Thursday 8 a.m. – 3 p.m. and Friday 8 a.m. – Noon.

Business Cards

-        Business cards are available for you. Please see the Chair’s administrative assistant for specific guidelines and ordering.

Computer Access 

-        You will attend one or more sessions of EPIC training part of your initial orientation.  Your computer sign-ons will be issued once Medical Staff has issued Temporary Privileges. Should you have any problems with your sign-on or other computer related questions, please contact the IS Help Desk at ext. 48889.

-        During FMG orientation, you will have the opportunity to meet with IS to assist with computer access, remote access, Haiku and MModal access. Recommend bringing any devices that you would like set up to orientation (ie phone, tablet, computer)

-        Remote access to LLEAP/Epic requires Secure Authorization, an app. This access is part of your IS access request during credentialing. You should receive an email through your LLU email requesting for you to contact IS to set-up the Secure Auth remote access. If you do not hear from them, then we can submit a processing form. The contact for Emergency Medicine is Patty Hembry at ext. 58239.

Email

-        The Chair’s office needs your main email address that you use for communication and this will be placed on the address list. However, you are also given an LLU email, where all patient related information must be sent. We ask that our physicians check their preferred and LLU emails at least once a day. Your LLU email can be accessed from outside the hospital: https://mcmail.llumc.edu.  To access your Loma Linda email outside the institution, you will remote access login then go to MC Mail on One Portal

-        Please email Ruby Navarro (RNavarro@llu.edu) and Joanna Lopez (JOALopez@llu.edu) to ensure you are added to the appropriate mailing lists/listservs.

Processes and Flow 

-        In each pod, there is a red binder updated with the most recent protocols and department flow changes. You can also access on www.lluemresidents.com under ops manual (pw: 42828) 

-        Please use as a reference when questions arise. Currently, the binders are located in the following locations: shelves by apod attending chair, behind attending computer in surge pod.  Once we move to the new ED, there will be one binder in the main doctor’s workroom (for RED and BLUE PODS) and also the secondary GREEN POD workroom.

-        Communication of our algorithms and most recent systems changes will be uploaded and updated to our TEAMS page. If you do not receive an invite to join the TEAMS page, please reach out to the medical director(s) for assistance

-        Please login in here: https://www.office.com/

-        Short “how to” video showing how to log in to 365 and get to EM Operations/ED Workflow documents. https://drive.google.com/file/d/1gPAk4qE4GApukcXCLKLFXgBqBf7Q_mAe/view?usp=sharing

Mail Box

-        Each physician/APP is assigned a mailbox, which is located in A-890 for full-time or part time providers and in A-113 for per diem providers. Support staff mailboxes are located in the same area as the fulltime mailboxes. 

-        Resident mailboxes are located immediately to the left as you enter the Residency Library (A-109.) 

-        Please check your mailbox at least once a shift.

Parking

-        You must register your car with the security office after you receive your sign-ons via Online Parking System:lluhparking.aimsparking.com 

-        Contact information: 909-651-3025 ext 53025, parking@llu.edu

-        Once your car is registered, the Online Parking System provides a list and/or map of lots you may park in. Most providers park in the bottom floor of the parking structure (north of P2) and the lot west of the Coleman Pavilion which are reserved for physician parking. There is also limited parking in the P2 parking structure. 

Payroll

-        You are paid 24 times per year based on the pay periods of the 1st-15th and 16th-end of month. FMG will give you a payroll calendar during orientation. Additionally, you can access your pay check information through the PayChex Flex system (PayChex Flex Login)  and access is provided at orientation. Should you find a discrepancy in your payroll please contact  the Payroll/Schedule Coordinator at EMPayroll@llu.edu (either Dave Calder or Ruby Navarro), x82252, or externally at (909) 651-5677.         

            Orientation shifts

-        Prior to your first shift, you will work with the chair and/or medical director(s) to set up an abbreviated shadow shift if you would like at both the main ED and Advanced Urgent Care. The purpose of this shift is to allow you to see unique Loma Linda operational components. You will get the opportunity to login to Epic to ensure your access works. During the shift, please make sure to ask questions of your colleague.

-        After completion of your orientation shifts, please email Ruby Navarro (EMPayroll@llu.edu) the hours that you completed on the shift and cc the medical director

CME Expenses

General 

-        CME expenses are a part of a full time faculty member’s benefits.

-        These dollars are to be used within a fiscal/academic year of July 1 – June 30. CME dollars are “use or lose” within the fiscal year – they cannot roll into the next fiscal year.

-        There are specific IRS guidelines for payment and reimbursement of educational items that must be followed. The fiscal year dollars must be spent within the current fiscal year. Any remaining dollars by June 30 are forfeited.

-        For newly hired physicians, your receipts must be dated after your hire date of the current fiscal year in order to be reimbursed.

-        All receipts must be submitted within 60 days of a conference or expense date.

-        For established physicians, receipts can cross fiscal years, but still have a 60 day window of reimbursement.

-        Both the EM Department Chair’s Assistant, Joanna Lopez,  and the Faculty Medical Group have more details regarding the use of CME dollars.

-        The Faculty Medical Group also covers the use of CME dollars in their orientation.

-        Please ask Joanna (JOALopez@llu.edu)  before making a purchase if you have questions about specific items for reimbursement.

-        Reimbursement is completed by filling out and signing an excel file (Expense-Report-2020-FMG.XLSX) along with the receipts and sent to Joanna Lopez (JOALopez@llu.edu)

-        All reimbursement must show the amount and how it was paid or a zero balance due.

-        All expenses must be original receipts

 Dues, Memberships, Subscriptions:

-        Paid for on an annual basis. Multiple years cannot be paid for at one time. 

License renewals:

-        DON’T WAIT! THERE ARE NO GRACE PERIODS! Both the California Medical License and DEA have an on-line process, which is much faster. Submit the on-line renewal receipt for reimbursement. If you want either of these paid in advance, please bring the renewal as soon as possible.

Conferences:

-         For all conference reimbursement, provide the following with your reimbursement form:

-        Registration: A physician can either register for the conference themselves and submit for reimbursement, or bring their completed registration form and the payment can be made via company check. (Issued checks can take 10-14 days, so please plan ahead.)

-        A conference flyer or a copy of your registration noting the conference name and dates.

-        Airfare: either the ticket stub or itineraries showing the travel dates, amount paid and form of payment.

-        Hotel - An ORIGINAL itemized receipt is a MUST. Even if you use the in-room checkout, please visit the desk to obtain a formal paid receipt. FMG will not reimburse your hotel bill from only a credit card statement.  Please make sure the hotel bill reflects a zero balance and reference to a charge on a credit card (or cash payment).  CME dollars only cover the room, taxes and parking. Suites are not reimbursable. However, if a suite is obtained, then the standard room rate will be reimbursed.

-        Mileage reimbursement if you drive to and from with your personal vehicle and, if desired, per diem (food). Attach an internet map to calculate the amount of mileage.

-        Rental cars: Rental cars are reimbursable, but must be booked by the physician

-        Per Diem (Food): Reimbursed at a standard per diem rate for conference days only, when meals are not included in the conference fees.

-        Parking, taxis, shuttles: Original receipts are needed. If a receipt is lost or you are not given one, please write a note and include trip information and the amount. A lost receipt form is available to document your expense, and can be obtained through the Chair’s Office. Please contact Joanna Lopez

-        Cash Tips:  A reasonable “no receipt” amount is reimbursable.

Equipment: 

-        These items are reimbursed on a percentage basis – how much the item is used for work versus home. All equipment remains the property of FMG or LLUSM during the depreciation period. You have the option of purchasing the item by paying balance if the depreciation period has not yet ended.

-        PDAs/iPhones/Droids: A two-year depreciation in accordance with your cell phone carrier contract.

-        Laptop Computers:  A three-year depreciation for items with a value of $1,000 or more. Can purchase one laptop annually.

-        IPads/Readers: A two-year depreciation.

-        Medical instruments: Stethoscope, Otoscope.

-        For other equipment questions, ask before purchase.

Software:

-       Software utilized for work related reasons can be submitted for reimbursement. Examples include the following:  

-        Microsoft Office

-        Medical related software

-        End Note, Key note

-        For additional software, ask before purchase

-        Please note that some software is available free or discounted from the University. https://llu.onthehub.com/WebStore/ProductsByMajorVersionList.aspx?cmi_cs=1&cmi_mnuMain=f189368a-f0a6-e811-8109-000d3af41938

The Schedule 

●      We use a web-based, on-line scheduling system. You may access the system at www.ShiftAdmin.com  Your sign-on and password will be given to you by the Schedule Coordinator at x82252 or the ED physician schedulers:  Drs. Farag (adult: afarag@llu.edu) and Brian Chen (PEM: bgchen@llu.edu). You may also get the ShiftAdmin app (free) to keep track of your schedule easier on your phone

●      Schedule requests due dates for each month are as listed on ShiftAdmin under the “Schedule Requests” tab. When placing requests, ShiftAdmin is geared to an off-request mode – what you cannot work. There is a shift option button if you just need specific shifts off, but are available to work other shifts. 

●      November and December schedules are published together due to the holidays. 

●      Holidays: There are 9 paid holidays a year. Currently, there are three holidays that we request to be ranked in accordance with the most important to have off (#1) to the least important to have off (#3). All other holidays are shared at random. The three ranked holidays are:

○      November

■      Thanksgiving Eve: Shifts starting after 5pm

■      Thanksgiving Day: All day for both Adult and PEM

○      December

■      Christmas Eve: Shifts starting after 5pm

■      Christmas Day: All day for both Adult and PEM

○      January

■      New Year’s Eve: Shifts starting after 5pm

■      New Year’s Day: All day for both Adult and PEM

●      Flexibility in your requests will result in a better personal schedule. Our schedulers do ask for 1.5x days of availability – within reason – to be able to create an overall successful schedule for everyone. Example: need 6 shifts, then 9 open days; need 10 shifts then 15 open days. A day is counted as available if you provide a completely open day - you cannot request off for a night shift and count it as an open day. With this in mind, if needed, a provider can request up to 4-5 non-consecutive days off for personal needs without using vacation or CME days. Please remember vacation is vacation and must be reported as such.

●      Notes about requests for adult schedule: 

○      "Vacation" - benefited day off through FMG, decreases your overall shift count. These are given the highest priority in scheduling along with CME days. As long as you're not requesting every major holiday these will be guaranteed off. 

■      If you request 1 full week of vacation off, 7 days that includes a weekend, you will be "charged" for the 5 weekdays, not the full 7 days. 

○      "CME" - benefited day off through FMG, also decreases your overall shift count. Given highest priority along with vacation days.

○      "Day off" - random days off you need to teach a course, attend a meeting, personal day. Do not decrease your overall shift count. These are granted as much as possible. You should get most of them as long as you have provided 1.5x days of availability compared to your required shifts.

■      E.g. if you have 14 required shifts, you must provide 21 full days of availability including nights/at least 2 weekends per month.  You don't always need to take a vacation day for a random day off request unless you have too many other requests/need to decrease your number of shifts.

○      "Time off" - you just need the morning off for a meeting, US journal club, resident conference, etc. Again I try my best here as long as there aren't too many other requests. 

○      "Shift/day on" - for some reason you really want to work that specific day. Please limit these requests and they are scheduled as available, not guaranteed

●      If you miss the schedule off-request due date, it is assumed that you have no off-requests for that period. If you get a late request for something work-related (e.g important meeting, resident teaching), before the schedule is published, please email the scheduler. Anything after the schedule is published is your responsibility.

●      Weekends: ShiftAdmin is set to honor two weekends off per month as a base requirement. This may be averaged across months if scheduling is tight.

●      Schedule changes are the responsibility of the physician and need to be changed through ShiftAdmin.

●      Using vacation or CME days must be reported on the Vacation/CME/Sick day reporting form with your schedule off request, this helps to adjust your base clinical hours accordingly. There is no back-dating of vacation or CME days. Please submit the attached excel file to Ruby Navarro VacCME Day off request excel

●      Vacation or CME days cannot be saved to take a month off at a time, or the last month of a fellowship year. If there is a need for more than 2 consecutive weeks off, a discussion with the scheduler and medical director/chair, at least 3 months in advance, is necessary. There is a minimum shift requirement of 4 shifts per month for our faculty (based on FTE). 

●      You will be scheduled for ~2 call shifts per month. The on-call physician is scheduled for a 24-hour period. If a physician calls off sick or a physician doesn’t come in for a shift, then the on-call physician can either work the shift or find someone to work the shift. Working an on-call shift is compensated at the on-call rate if you are called in.

●      Sick call coverage is coordinated through the on-call physician scheduled for that day and a sick day must be reported.

●      Spreadsheet: A spreadsheet is created for each full-time physician. The spreadsheet calculates base clinical hours for each month, as well as tracking your vacation, sick and CME days. We also track the night differential for each month. If you have questions about your spreadsheet, please email EMPayroll@llu.edu

●      If a shift change is submitted close to payroll (~15th and end of each month) please ensure you have emailed EMPayroll@llu.edu to ensure the change was captured. Changes made after payroll will be reflected in the next pay period.  

●      Shift Duties. Attending shifts are 9 hours, including 1 hour of overlap in the general adult areas, and 10 hours in the Pediatric EM section. Physicians should continue to see patients until 30 minutes before the next provider arrives. The overlap hour should be used to prepare discharge paperwork, complete charting with scribes, and sign out to the oncoming attending.

Who you need to Know: 

The key groups of individuals you will interface with include emergency medicine administrative staff, ED nursing administration, department physician leadership and the Faculty Medical Group staff.  Included below is the contact information for key individuals from the above groups.  The main line to get into the Medical Center and University system is 909-558-4000.

Emergency Medicine Leadership

Individual 

Position

Extension

Dr. Lea Walters, MD 

Chair and Chief of Service

x87171

Dr. Lance Brown, MD, MPH 

Vice Chair for Operations

909-684-7929

Dr. Dustin Smith, MD 

Vice Chair of Education

Director of Medical Simulation

909-558-7208

Dr. James Moynihan, DO 

Medical Director, Pediatric Emergency Department

Medical Director, Quality Improvement

x85000

Dr. Brian Chen, MD

Associate Medical Director, Pediatric Emergency Department

Dr. Mindi Guptill, MD

Medical Director, Adult Emergency Department

x88065

Dr. Emily Barrett, MD

Associate Medical Director, Adult Emergency Department

Dr. Mike Kiemeney, MD, 

Director, EM Residency Program 

x44085

Dr. Tim Young, MD

Fellowship Director, PEM

x87698

Dr. Molly Estes, MD, r

Director, EM Clerkship 

Fellowship Director, Medical Education 

x85000

Dr. Besh Barcega, MD, MBA

Fellowship Director, Global Health

Dr. Brian Savino, MD, MPH

Fellowship Director, EMS

Dr. Zan Jafry, MD

Fellowship Director, Ultrasound

Dr. Ellen Reibling, PhD, MA 

Director of Research

x87407

Dave Calder, MBA

Administrative Director

x87127

Joanna Lopez

Administrative Assistant to Chair

x87171

Tiana Gonzales

EM Residency Coordinator

x44085

Lyne Jones

Administrative Assistant 

Medical Student Clerkship Director

x85000

Shelly Nelson 

Fellowship Coordinator 

x87698

Ruby Navarro 

Department Secretary 

EM Assistant and Scheduling

x82256

Tammy Phan & Maria Alonso

Research Coordinators

Faculty Research Support

x81510

Connie Cunningham, RN, BSN

Nursing Leadership Executive Director, Emergency Services 

x49444

Shannon Canright, RN, BSN

Director of Patient Care

x44387

Important Phone Numbers to Know

General ED extensions

ED Front Desk ………………………………..x42828

Pediatrics ED…………………………….……x86331

AUC……………………………………………….x65554

Emergency Medicine Office

Administrative Office ……………………..x85000

Direct Line ……………………..(909) 558-4344, 0

Fax …………………………………….(909) 558-0121

 Mailing address:                          

LLUMC – Emergency Med.          

11234 Anderson Street, MC- A890A

Loma Linda, CA 92354

Shipping address:                         

125 W. Club Center Drive                         

San Bernardino, CA 92408

Faculty Medical Group of LLUSM

(Physician/APP Employer Corporation)

11175 Campus Street, Suite 11120

Loma Linda, CA  92354

●      Barbara Sharp

○      Vice-President, Professional Employment

○      Benefits and compensation

○      Phone............................. x88297

●      Debbie Selle

○      Director, Professional Employment/Payroll

○      Employment Orientation

○      Phone............................. x88291

●      Michael Mahoney

○      Vice-President, Clinical Operations

○      Phone............................. x25503

Employment 

Employment Agreement: 

-        During the course of applying for a position with Emergency Medicine you would have signed an employment agreement with Faculty Medical Group of LLUSM. The agreement defines your compensation and benefits and until such time as changes are made to the Compensation Plan as determined by the EM Compensation Committee or in the status of your work, those are the general terms of your employment.  Specific clinical or academic shift requirements are determined and set by the Chair of the Department of Emergency Medicine.

-        If at any time you would like a copy of your employment agreement, please contact Dave Calder, Administrative Director (dcalder@llu.edu, or x87127).

FTE status

Your Full-time Equivalent (FTE) status determines the number of clinical shifts worked per month, and the FTE level sets the amount of compensation you will receive, according to academic rank.  If you would like to change your FTE level, please follow the steps listed below:

-        Meet with the Vice Chair of Operations, Dr. Lance Brown,  and discuss your interest in changing status and come to agreement on the level that will meet your schedule requirements. The Vice Chair will submit your request to the department chair before a contract change request is initiated.

-        Please plan at least two months prior to any FTE change as schedules are made and published during that interval.

-        Contract changes are set to begin only at the beginning of a pay cycle, on the 1st or 16th or the month.

-        We ask that there be no more than 2 contract changes in a calendar year.

Leave of Absence

A request for a Leave of Absence is handled according to FMG policy guidelines, and according to California and Federal regulations. All leave requests should be filed with the Vice Chair of Operations, and/or Department Chair.  For specific details on scheduling, compensation, and benefits related to a leave, contact Debbie Selle in the FMG offices, CP11120, or call Debbie at (909) 558-8291.

Charting and Documentation

Chart Completion

●      All clinicians document clinical activity and treatment in the organization’s electronic medical record called LLEAP (aka, Epic).  Training will occur prior to your first shift, and will be scheduled for you with an ASAP training. Training can take up to 12 hours to complete.

●      EM physicians and APPs will chart on the following document types:

○      ED Note:  used only for documenting inter-facility transfer calls.

○      ED Provider Note:  used to document an H&P, EDOU admit note, EDOU Progress note, and EDOU discharge note.

●      The internal standard for completion of patient charts for encounters in the ED is 48 hours for discharged patients, and prior to you leaving the medical center on the date of service for patients admitted to the hospital.

●      The Medical Staff by-laws state that all patient documentation must be completed in less than 14 days to avoid suspension of practice privileges. This includes visit notes, procedure notes, co-signing of resident or APP documentation and verbal orders.  Just one incomplete document at 14 days will begin a three day notification process to the clinician.  At the end of three days privileges are suspended, and the clinician must complete all outstanding documents and pay a $100 fee before privileges are reinstated. With each successive loss of privileges the fee doubles.  

Charting Guidelines

●      The Emergency Medicine departments utilizes a third-party vendor (Logixhealth) to code all EM clinician documentation, who then returns the coded files to the organization’s Faculty Patient Billing Office (FPBO) for billing of professional services you have provided.  In order to facilitate transfer of your completed charts to Medusind, Inc.,  the LLEAP system allows you a maximum of 72 hours to complete a chart and then it is automatically transferred for coding.  This is in keeping with the department’s internal standard for chart completion of 48 hours for discharged patients, and same day for admitted patients.

●      Verbal orders must be signed within 48 hours. Some nurse-initiated protocols (NIPs) ordered during the initial nursing evaluation of the patient may be assigned to you, even if you have not seen the patient. 

Tips to Avoid Delinquency

●      AT THE BEGINNING OF YOUR SHIFT:

■      Print track board (this way you will have a “check off list” and MRNs.) Check off each patient as you have completed a note

■      Assign yourself on all patients transferred to your care.

■      Have the scribe put the “.addadmtpt”, (AKA yada yada) or your preferred addendum, on all patients being transitioned to you who are being admitted. You can edit this if you end up providing any care to the patient.

■      Have the scribe put the “regular addendum” on all patients transitioned to you that you will follow up on.

■      Have the scribe start an EDOU note on all patients in the EDOU that are transitioned to you.

■      Keep a list (stickers, cards, etc.) on all patients seen during your shift.

●      DURING YOUR SHIFT

■      Sign the charts sent to you by the scribe

■       Dictate MDMs as you go.

■      Ask the scribe to note any rechecks, critical care, procedures, keep an eye out for completed tests, etc.

●      AT THE END OF YOUR SHIFT:

○      Go to your LLEAP inbox. 

■      Open the Hospital Chart Completion folder and sign all verbal orders. (This will include orders you told the nurse to send you, pharmacist orders, triage orders placed in your name, etc.) Also, complete any requests for final disposition, if the patient has been dispositioned. (These will disappear from your folder if the patient is being transitioned and still has workup pending, but if you place an admit consult, click the ‘admit’ disposition.)

■      Open the Co-sign tab. Here you will find notes sent to you from the APPs and residents. DO NOT JUST CLICK CO-SIGN! Please see suggestions below for further details

■      Open Message Routing tab:

●      Review and sign all notes from the scribe.

●      Make sure all the patients you saw have been checked off of your list (just in case the scribe forgets to route you a chart)

Teaching Physician Attestations

●      All attending physician documentation authored by the attending will stand on its own for the purpose of coding and billing.

●      Instances where the note was either created or shared with a resident require a teaching physician attestation.  In the attestation, reference must be made to the resident in the attestation, and that all findings and decisions were reviewed by the attending. 

○      Ex: 

■      Attending Attestation: I performed a history and physical examination of the patient and discussed their management with the resident physician. I reviewed and edited the resident physician’s note and agree with the documented findings and plan of care  ***Signature/Name***

■      Dot phrase .ATTOUTPATIENT then F2 to get “I agree” or “I agree except…”

●      For all procedures, the teaching/attending physician must also state that they were present for the key/critical portions of the procedure.  Please see reference guides for standard teaching physician language and use of the .att smart text.

○      On Epic, found when typing .attproc

○      Ex: I was present during all critical and key portions of the procedure and immediately available to furnish services during the entire procedure” 

●      For signature of APPs (PAs and NPs), an attestation is required for patients that were directly discussed with you. A patient seen by the attending with the APP should include a brief H&P performed by the supervising physician with an attestation discussing agreement with the assessment and plan documented by the APP. The note should then be signed by the attending. Please do not use the “co-sign” function when taking over an APP document; assume the note as your own by opening the encounter and then the note. Supplement the chart with your own history and physical findings, and sign accordingly

○      Ex: 

■      Attending Attestation: I, the treating physician or non-physician practitioner, state that I have reviewed the medical record and that all of the following is true: The Chief Complaint (CC) and History of Present Illness (HPI) were personally obtained by me. I personally performed the Physical Examination (PE) and directed the documentation and generation of the Medical Decision Making (MDM), Diagnosis (DX), disposition and discharge instructions. When not documented by me personally, the CC, HPI, PE, MDM, Dx, disposition and discharge instructions were dictated by me to ancillary staff (scribed). Portions of the Review of Systems (ROS), Past, Family and Social History, (PFSH) may have been independently obtained by ancillary staff but have been reviewed by me for accuracy. I have specifically noted positive responses that are documented in the ROS. When necessary, amendments to the medical record have been made by me.

 In brief, ***(insert brief history and focused physical exam here) 

***Signature/Name***

Scribes in the ED

●      Prior to starting or within 1 month of starting at LLUMC, you will have a brief meeting with one of our scribes - even if on shift -  to set up your preferences, assist with making macros, etc. Please reach out to Earl Tablan (ETablan@llu.edu), our chief scribe, to set up

●      Scribes are used for documentation in the Adult ED and Advanced Urgent Care (AUC). Scribes are assigned to work with one attending physician per shift. Scribes document the physician-dictated patient history, physical findings, past medical history, family and social histories, medications and allergies. They will include workup results including laboratory tests, radiographic studies, ECGs. They can document patient care related activities, including conversations with consultants, family communication, and re-examination of the patient.

●       Scribes will work closely with the upper level emergency medicine resident on shift. The scribe will complete the HPI, ROS, PE and MDM directly with the upper level emergency medicine resident 

●      Emergency medicine interns complete their own medical documentation/charts

●      Scribes will document the HPI, ROS, PE while an off service/rotating resident presents the patient to you. The scribe will work with you directly to complete MDMs for patients seen with rotating residents. 

●      Scribes are instructed to prompt physicians for documentation of procedures, critical care time, MDM dictations.

●      Scribes may not provide any patient care-related activities, place orders, or discharge patients.

●      All scribe documentation must have an attestation by the physician acknowledging that he/she has reviewed the scribed note. This attestation must be placed in the chart by the physician. (The attestation can be accessed with the dot phrase .EDMDSCRIBEATT) (You need only type in .edm to get to the attestation.)

●      Scribes are not used in the Pediatric ED. Residents are expected to scribe the initial note and the attending will assume the note and complete it, placing the teaching physician’s attestation into the end of the note and signing it.

Critical Care Billing

-        Please refer to attached for references on critical care billing

-        MedData Critical Care Tool.pdf

APP Oversight

●      As an attending in the emergency department, you will have the opportunity to oversee APP (physician assistants and nurse practitioners). Below are details about which types of patients APPs will chief with you, information they receive regarding procedures and the signout process for the APPs so you can know what is expected of you in this process

○      Chiefing Guidelines

■      Most Acuity 3s and higher are to be chiefed with an Attending. Newer APPs are encouraged to chief all 3s (and up) until they build up their comfort level with some of the “bread and butter” patients. Soft 3s (and up) may not require chiefing (i.e. chest pain associated with anxiety in a 20 year old with no medical history or risk factors or stable vaginal bleeding, etc.). Other examples of even 2s that do not require chiefing are isolated eye complaints (which always are categorized as category 2 due to threat to sight) that are uncomplicated (stye, easily removed foreign body, etc.) or exposure patients. 

■      Any patient who the APP would like to chief, regardless of acuity, may also be chiefed (as there are times when triage categories fail to accurately represent the entire picture). 

■      When working with the APPs, you may request they chief all patients with you if desired.

■      Level 4 and 5 patients are to be chiefed at the discretion of the APP. If an APP feels as though the patient has been mis-triaged, they should chief the patient. 

■      All patients who are slotted for admission should be chiefed. 

■      If at any point a patient is unstable or an APP uncomfortable moving forward with a treatment plan, the patient should be chiefed as quickly as possible. 

■      Chiefing should take place in a timely manner, ideally before consults or admission, and ideally before an advanced treatment plan has been initiated. Nonetheless, there may be times that this is not feasible, and the APP should ensure proper patient care takes place regardless of if the patient has been chiefed. 

■      Attending physicians all have various styles and prefer different types of chiefing; therefore, the APP must be flexible in how they present a patient. 

■      Patients are to be chiefed to the Attending physician in the POD in which they are stationed. 

■      When in MSE, a patient may be chiefed to any available Attending physician. 

■      APPs will list the supervising physician at the top of a chart. 

■      The APP may request that the attending to whom they are chiefing see any patient. If the patient is seen by the supervising physician, you should receive a chart from the APP.  Place your addendum as noted above. 

○      Procedures

■      PAs are able to complete any procedure in the ED that they have been sufficiently trained on and feel comfortable performing provided the attending physician is comfortable with them doing so.  NPs work under Standardized Procedures determined by the hospital Interdisciplinary Practice Committee. There are specific requirements regarding the training and supervision of these procedures. After completing the required proctoring, NPs can complete these procedures independently. These procedures include I&D, laceration repair, stapling, toenail removal, among others.

■      If a procedure is new, the APP should be supervised and trained by an attending physician in performing said procedure.

■      NPs work under SPs (standard procedures), which dictate required numbers and supervision with regard to procedures. Please reference for clarification. 

■      It is the responsibility of the APP to request supervision for procedures where it is either required or desired.

○      APPs Signing out Patients

■      Patients who are pending results, workup, further treatment, or admission are to be signed out prior to the end of a shift. 

■      If the patient is slotted for admission, APPs will sign out to the attending to whom the patient was chiefed.

■      If the patient is pending further workup, APPs should sign out to another APP if possible (this may or may not be possible based on staffing patterns). If no APP is available, sign out to your supervising attending. 

■      If an APP is signing out to another APP, the APP will try to chief the patient to an attending prior to sign out. 

■      If the patient has been chiefed to an Attending physician, the patient should be signed out to that physician - if slotted for admission, to that attending alone, if not, to both the oncoming APP with that attending‘s knowledge of the APP taking over care of said patient. 

■      If an APP chiefed a patient to the C-Doc or Flex Doc, the APP will communicate with you updates to ensure you are on the same page prior to signing out. 

Required Training

-        Each year, except where otherwise noted, the following training modules are required for all Emergency Medicine providers. These trainings are available on-line and emails with a link to the training is sent to each provider:

-        EMTALA:  Provided annually by the EM department

-        Compliance & HIPPA training:  must be completed within the first 90 days of employment, and annually between April 1 and October 31.  Failure to complete will result in immediate loss of practice privileges (suspension).

-        “Blue Book”

-         Sexual Harassment Prevention Training (SHPT):  required of all providers that supervise staff, medical students, interns, and residents.  Completed within 6 months of hire, and every two years thereafter. The State of California mandates a minimum of 120 absolute minutes of training time (“go slow to finish faster”).

-         Other training as required by the department or medical center.

-        Note:  Full time or part time physicians will complete these training as part of their expected nonclinical duties. Per diem physicians will be paid for their training once it is completed.

While on Shift 

Please refer to TEAMS or red binders for in depth information and knowledge about algorithms, system updates

Transfer Center

-        As a tertiary care center, you will be expected to take transfer center calls. There is a specific transfer center line in the pit. The transfer center will also call the phone at the attending workstations. Please refer to the transfer center algorithm for accepting transfers. 

-        Adult Transfer Algorithm_07-20 update.pdf I recommend printing a copy of the transfer center algorithm for yourself. There is an algorithm in the binders for reference as well

-        If you are uncertain of the best way to proceed, the transfer center personnel stay on the recorded line for the duration of your phone call. Please ask them what the best next steps are 

-        On shift, you will work closely with the charge RNs in regards to department and hospital wide capacity. Please communicate with the nursing team about surge status to ensure we are accepting transfers in line with the current surge capacity protocols. Surge capacity is the tiered designation to communicate with the entire hospital (for adult patients) regarding the bed availability of our hospital. Surge 1 means we have a higher level of capacity to take/receive patients. Surge 5 capacity is when our hospital is almost/essentially at max capacity. Please refer to the document attached for further information. adult-inpatient-surge-capacity-plan.pdf

            Activations

-        At Loma Linda, there are specific activations which are created to mobilize resources and expedite care for potentially life threatening medical conditions. Below is a list of the different activations. Please refer to the requirements for activation located in the radio room or the pit 

1. Trauma level A

2. Trauma level B

3. Trauma level C

4. Geriatric CT alert 

5. STEMI

6. Stroke tier 1 or tier 2 

7. SAH/ICH

            EDOU 

-        The EDOU is our Emergency Department Observation Unit.  The purpose of this unit is to provide a place where patients who are expected to have prolonged emergency care but are expected to be discharged in less than 24 hrs can receive their care. 

-        Ordersets can be found if you type in “observation”

-        When you place a patient in EDOU, you need to complete your HPI note as well as an EDOU H&P. Scribes will help with this.  If you take handover for a patient in EDOU, you will need to write an EDOU Progress Note.  If you discharge a patient that was in EDOU, you need to write an EDOU Discharge Note (with complete physical exam).  

Ultrasound

-        Our Emergency Department uses multiple types of ultrasound machines to obtain billable ultrasounds. For completing the report, we use AGFA. You should automatically get access to AGFA using the same credentials as your EPIC login. If you have issues logging into AGFA, please contact our ultrasound faculty (Dr. Vi Dinh VADInh@llu.edu or Dr. Zan Jafry ZJafry@llu.edu) 

-        Credentialing: If you attended an ACEP recommended training program during residency, you have met the criteria to maintain credentialed for POCUS for our group

-        Using the machines

-        Lluultrasound.org

-        How to use the US machines: 

-        https://www.youtube.com/watch?v=xjBqdZL5O6A

-        BILLED studies:

-       When performing studies used in decision making by the attending, enter an EPIC order. Be sure you comfortable with interpreting and billing for the study. You will then be able to populate the patient’s data onto the ultrasound machine by selecting the patient and appropriate study from the worklist. Beware when multiple studies/orders are requested and perform the appropriate scan under the appropriate EPIC order. When the study is complete END STUDY to ensure upload into cloud server.

-        RAPID studies to be merged with EPIC order:

-       If no patient information is yet available at the time of scanning-in the name fields please enter some case information eg: bounce house rollover. Scan. Save a still image with patient’s identifying information THEN end study. Because at times there are network issues resulting in delay of cloud server upload, this ensures that those studies will not be lost and will be merged appropriately. All studies without any identifiers are ultimately deleted.

-        FILLING REPORTS:

-        After you have ended the study on the machine, login to AGFA and locate the patient under the folder Reading Tasks. Double click on the patient. Under the reports tab- please fill out the brown highlighted areas (these are hard stops) and the appropriate drop down fields. The report defaults to negative so please pay special attention to abnormalities or views not obtained. When finished in the upper left corner select “Sign off” and this will sign the study. 

-        AGFA assistance: https://www.youtube.com/playlist?list=PLerurd-0fhdG_BZ0dmsumSoRShdwGlY-a

Academic Involvement 

Promotion

-        As a faculty member of the emergency department, you are automatically involved in academics. There are many opportunities for in depth involvement. Below are some specifics on how you can be involved

-        Requirements: 

-        Each year, you are expected to attend 50% of the department CQI conferences.

-        We recommend that you keep a personal log (via excel, google, etc) of all the academic events you are involved in for a calendar year. At the end of each year, you will complete an excel sent to you of your accomplishments. It is recommended to update your CV frequently to reflect your involvement.  

-        Research

-        There are many ongoing projects throughout the department. To understand which projects are ongoing and if there are projects looking for further investigators, please contact Dr. Ellen Reibling PhD (EReibling@llu.edu) 

-        Promotion: 

-        Early on, you will have a meeting with Dr. Dustin Smith to discuss the process of promotion, etc. His email is DDSmith@llu.edu.  To learn more about the specifics of promotion, please contact Dr. Smith to receive the faculty handbook

-        Academic promotion follows a predetermined pathway: 

-        Instructor → assistant professor → associate professor → full professor

-       Intro:https://drive.google.com/file/d/12tGjyJbd4-PZeg1wffgu9M-dQuEUnT4T/view?usp=sharing