Sept 2023 Update

Happy September! We are close to completing new listservs to cut down on excess or irrelevant emails and get the most up to date faculty list. Thanks for your patience as we get them up and running. Please forward this email to any LLU adult ED provider who you find who did not get it. 

Don’t forget, lots of helpful info available here:

https://sites.google.com/view/lluem/llu-ed-operations-manual/ops-manual

LLU EM Residency - Ops Manual

Surge 2/ Crisis Physician Response 24 Hour Pharmacies Addiction Assistance : Suboxone Resources , Substance Use Navigation , Medication Assisted Therapy , Narcan Distribution Project APPs in the ED Blood Patch Information Body Fluid Exposures: General Information, Non-Employee Body Fluid

sites.google.com

Pass: 42828

Here are adult operations updates since last month: 

QI: 

Procedure Time outs: 

When performing any non-emergent bedside procedure on a patient (lac repair, I+D, etc), please click “time out was performed” on your procedure note. These time outs do not always need the bedside nurse present (can be just you and the patient unless nurse directly involved). The important part is documentation of time out being performed in any procedure note, there is a click box in procedure note templates for this already. This time out can be covered with the patient as you provide informed consent immediately prior to procedure. This is important from a hospital compliance standpoint with the department of public health. 

Diabetic foot/gallbladder pathways: Please be aware of these pathways (on operations website) as there are service agreements in place regarding which teams admit different conditions. This can greatly increase patient LOS when wrong teams are consulted early on. 

Asymptomatic Bacteriuria:  This should generally not be treated with antibiotics unless pregnant, recent urological procedure, or in renal transplant patients up to 2 months post transplant. Cloudy or foul smelling urine is not an indication to treat with abx. For patients with chronic foley catheters, patient should have fever, CVAT or suprapubic pain or systemic symptoms such  as AMS, SIRS, hypotension.

Home BP Meds: From MOD: For patients pending admission, please order home BP meds if possible. Med-surg floors will not accept SBP >200 and so if BP meds haven’t been taken for prolonged period, this puts us in a jam between floor and ICU when BPs get too high. Thank you!

Patient Care:

For admitting service disputes leading to delayed patient care, please email Dr. Amye Farag (surgical QI) and Dr. Eric (Weyjuin) Chao (medical QI) with MRNs. Secure chat is ok, but please make sure the patient is attached to the chat subject and not buried in chat text. 

Scheduling: 

For any late scheduling requests, please email Dr. Amye Farag. Please do not text these requests. The holiday schedule is being worked on, please send any last minute changes ASAP. 

Trauma: 

Trauma Transfers: 

1. Please use the new templated Trauma Transfer note when taking calls for trauma patients from outside hospitals. We have worked hard with the trauma team to improve the quality of information available for review. It is simple to F2 through to rapidly complete.

2. Please review trauma criteria for accepted transfers. Most will be level B activations, but occasionally will need to be level A activations upon review of criteria.

Trauma Activations: 

1. If you activate or upgrade a trauma level (particularly for walk in patients, but also true in general), please give handoff and assist the trauma team with your patient. 

ED MRIs:

We now have two new rapid ED MRI studies available to us which have been developed for hip fracture and cauda equina in conjunction with radiology and the MR physicists. Epic order names are as below:

1. “MRI Limited Cauda Equina Syndrome Lumbar Spine WO Contrast”: This is a T2 weighted scan that should take 7-8 minutes to complete and is useful for ruling out cauda equina. As we typically place these patients in EDOU for Cauda Equina rule out (for full sequence MRI), this should help us expedite these workups much more quickly than before. If you are worried about other spinal level cord compression or epidural abscess, for the time being, full MRI should be ordered. 

2. “MRI Limited WO Contrast Bilateral Limited Occult Hip Fracture”: This is an 8 minute long MR study to evaluate for occult fracture for orthopedic surgery colleagues. 

Important details: 

1. These MRI studies should not require admission by ortho or neurosurgery or other service prior to completion (given their short duration of completion vs full studies). If the patient is going to require procedural sedation or general anesthesia, however, it makes the most sense to order a regular/complete study and the patient should be placed in EDOU or admitted depending on the situation. It is reasonable to order a dose of pain meds or medication for anxiolysis for the brief procedure 

2. MRI phone numbers are #17680/17681. There are two available scanners at any time. MRI techs have been trained to squeeze these tests in between longer studies and should be feasibly completed during a normal ED LOS (or so I have been reassured). Please also call them to inform them of the order. 

3. For MRI for hip fracture (proximal femurs generally speaking), these should primarily be ordered when both X-ray and CT imaging are inconclusive but there is high clinical suspicion for fracture, usually in consultation with orthopedic surgery. If fracture is evident on x-ray or CT imaging, patient should not get an MRI. 

4. Patients do still need MRI safety screening performed prior to MRI completion, which should be performed by nursing (this is not a change from current practice)

5. As this is a new process, as QI issues arise, please email Dr. Farag and Dr. Chao with QI issues. 

6. Currently, these are the only 2 MRI orders which can be completed without admit orders prior (no c-spines, etc). 

Transferring Patients to the Children’s and Women’s Hospital:

1. Please remember that for patients being transferred to the Children’s Hospital (Peds ED and Labor and Delivery), that the transfer center should be called and relevant attending spoken with to get acceptance for transfer. These patients should have a disposition of “transferred” selected. These patients should not be discharged and taken to the Peds ED or L+D. 

2. Patients can be transferred from Advanced Urgent Care to the Peds ED or L+D directly, in the same fashion as from the ED. 

ED Security/Safety Huddles:

You have likely heard of recent episodes of violence towards ED staff. This has heightened and accelerated already ongoing security improvements in the ED. 

1. There is now (newly instituted and already active) a security officer with 24/7 posting in the ED (station is the lobby box adjacent to the 111 consult room). This security officer does not have responsibilities outside of the ED at any time. 

2. There is a multidisciplinary task force (nursing, MDs, etc) which is being formed to proactively address security concerns and issues. Stay tuned for further updates. 

3. We are considering multiple different ways of improving screening of patients/family/friends at check in for weapons or other dangerous items. Stay tuned for further updates. 

Safety Huddles: You will soon begin to hear overhead announcements for your name in the event of a “safety huddle” for patients with aggressive or violent behavior. If there is no provider assigned, you will hear “available provider” being called for. Please go to these safety huddles and check in with the other ED team members present to learn about the specific issue and address the issues with appropriate intervention. Please avoid simply looking from a distance to see if things are handled. It is imperative for the safety of our patients and all ED team members to close the loop on each scenario. We would like to promote a no tolerance environment in our ED regarding violent or aggressive behavior (verbal or physical) towards all ED team members. 

APP Education: 

Drs. Escamilla and Tena have worked with our APPs to provide education on frequently encountered problems in the ED/AUC. The list of recent/upcoming topics are below as you converse to give you reference as to what has been covered recently:

1. Documentation changes + MDM structure

2. Vaginal bleeding: pregnant vs non pregnant

3. Optho: painless vs painful vision loss

4. GIB: massive vs minor/stable

5. CV 1: EKG basics, ACS, Afib

6. CV 2: Syncope, PE

7. CV 3: CHF + flash pulm edema

8. Peds 1: pediatric fever neonates/infants vs older children

9. SIM day: Primary + secondary exams, PECARN rules, EFAST exams, Sim case: fall with HS on AC with elevated ICP

10. Neuro 1: AMS

Next upcoming lectures

1. Neuro 2: CVA/TIA, Dizziness

2. Resp 1: Approach to dyspnea

3. Resp 2: Asthma/COPD, PNA

4. Endo: DKA/HHS/hyperglycemia 

5. SIM day: unstable SVT sim case, ocular US, airway basics 

6. GI: Abd pain Upper vs Lower

Restraints: 

General: 

For violent restraints, in addition to “face to face” note and initial restraint order, a new order is required each time a restraint is removed. We have asked our nursing colleagues to directly communicate when a restraint has been removed as it’s sometimes hard to keep track of when those events happen. Please see the ED operations website for the details on restraint order requirements. 

You do not need to complete a face to face note for non-violent restraints (this is different than what has been distributed previously), but orders must still be accurate and updated. 

BMC: 

For transporting psychiatric patients on psychiatric holds to BMC via our CCST team, patients will require an order for restraints. This comes from regulatory compliance. Essentially, patients on holds (5150, 5250, 5260) will need a restraint order for transportation to BMC. I believe this applies to both adult and pediatric patients. Ideally, most of these will be non-violent restraints. Please do not be surprised if nursing or transport staff asks you for a restraint order prior to transport. You can select “immobilization needed to prevent possible patient injury” unless more appropriate reason applies.  If an ambulance company like AMR or other non-LLU transport company takes the patient, the below does not apply as they have internal protocols in place. 

1. All patients will need to be placed in non-violent restraints (upper and lower extremities), when placed on the transport gurney for the safety of the patient and staff.

2. The ER MD will need to write a restraint order (upper and lower extremities), unless one was already in place for us to have per regulations for acute care hospital settings.

3. If the patient is needing violent restraints the same would apply for the need for an order (only if the patient is actively violent at the time of pick up)

4. If a patient is in restraints and already has an order for them, CCST can continue to monitor and take the patient with the current order for restraints

5. The patient will stay admitted to the ER until CCST/BMC discharges them when the patient arrives at the BMC.

6. The ER may place the patient in an off the unit bed if needed.

Chart Completion:

Please be diligent to complete your charts in a timely matter. Charts should be completed within 24 hours for admitted patients and 48 hours for discharged patients. Delayed charting has direct implications to financial wellbeing of our department. 

Advanced Urgent Care (AUC): 

Sickle Cell Pathway: For patients with sickle cell pain crises, providers may give up to three doses of IV narcotics prior to admission request. Please assess patient for admission after the second dose of IV narcotics. Please let the patient know that if plan is for admission after 3rd dose that patient will be started on PCA pump. Please call the team who will be admitting the patient to place orders for PCA pump for the patient.  

Metal Instruments:  There have been issues with OR instruments being thrown in the trash by providers. Please do not throw away ANY metal instruments (even disposable ones) at AUC. After procedure, please only dispose of scalpels and sharps and leave all other instruments for nursing to sort out what needs to be send for sterilization vs discarded.  

Documentation: 

The following EDOU dotphrases are available with me as a user (Can also choose Savino or Rossie if you want) for you to copy/share. These notes don’t have the scribe attestation part on them, so are handy for your work as you write notes on your own. 

Regular EDOU

GREENDOCEDOUHP

GREENDOCEDOUPROG

GREENDOCEDOUDC

Psych EDOU

GREENDOCEDOUPSYCHHP

GREENDOCEDOUPSYCHPROG

GREENDOCEDOUPSYCHDC

Palliative Care Consults: Nurses are screening patients who may benefit from early palliative care consult. If you are approached by nursing for this and agree with their assessment, please order consult early. 

ED shift operation changes: The ED operations team is excited to announce that there is a big change coming to ED scheduling/shift layout, which is already present on the October Adult ED schedule. This will be covered in depth at ED faculty meeting and there will be a separate email. Stay tuned. 

Fun fact of the day: Australia is wider than the moon. 

Don’t forget to take a cold shower (shout out to Dr. Choi),