Columbia ED

Columbia Adult Emergency Department

The following is a template for resident and attending activity in the ED. It emphasizes transfer of care at shift change and the conduct of daily academic rounds. Our clinical model consists of 2 separate areas (C and D) of the adult ED in which residents work with ED faculty. **As the new ED is built, this will change.

Attending Schedule: Variable depending on day - ask your attending at the start of the shift when rounds will take place

Resident Schedule: Schedules are posted on Team Site approximately 4 weeks before the start of each block (nypem.org)

Resident shifts (all non-medicine rotators and EM PGY1-2): 8AM-8PM, 12N-12M, 8PM-8AM. Medicine residents do 9p-9a shifts overnight. See specific PGY3 and 4 roles for shift details

Daily Schedule:

24 / 7 Patient Care, with the following interceding events:

Weekdays

Green Team:

• 8am: Morning rounds
• 4pm: Afternoon rounds
• 12am: Night rounds

Blue Team:

• 8am: Morning rounds
• 8pm: Night rounds

Yellow Team:

• 8am: Morning rounds
• 4pm: Afternoon rounds
• 8pm: Night rounds

All Teams:

• 12pm (M, T, Th, F): Noon report (return to clinical duties at 1pm)
• 8am (W): Wednesday conference (return to clinical duties at 12pm)

Weekends

All Teams:

8am: Morning rounds

8pm: Night rounds

Attending-led (or 4^th year EM-led) rounds will be conducted as a walk-around rounds from bed to bed, with incoming and outgoing MDs; nurses will be welcome to participate. Incoming junior residents should print lists from Eclipsys.

To convey signout in a succinct manner, the eDPASS (emergency Disposition, Patient Summary, Action List, Situational Awareness, Synthesis) sign out format will be used.

• Disposition
  • Is the pt an ED patient under evaluation, bed requested, MICU/ICU consult pending, admit aware or to be seen?
  • What is the final disposition plan (home, admit, icu, etc.)?
• Patient summary
  • A brief PMH and history
  • Reason for visit to the ED
  • Care thus far
• Action list
  • What needs to be followed up? Labs, radiology readings, repeat labs to be done, repeat ecg's, consults, etc.
• Situational awareness/contingency plan
  • What will screw up your plan
    • If X happens, then Y should be done? Social issues?
    • What will keep the pt from meeting planned disposition
• Synthesis by receiver
  • Oncoming resident, attending, PA/NP repeats back a short synthesis of the above to person (allows for a closed loop communication to occur so that less chance of missing info).

Here is an example:

(D) Mr. Patient in A2 is a 42 year old man still under evaluation with plans for admission.

(P) He has HTN, HL, DM and came in with 30 minutes of mid-sternal chest pressure associated with radiation to L arm and shortness of breath, resolved with nitroglycerin. First ECG is non-ischemic, unchanged from previous. Labs including troponin and chest X-ray are pending. Aspirin 325 mg was given.

(A) Once labs are back, he should be bed requested for serial troponins. Please contact his PMD to inform him/her of plan.

(S) If his troponin is elevated or ECG change, please repeat EKG and consider starting heparin.

(S) Mr. Patient presented to the ED with HTN, HL, DM, presented with chest pain concerning for cardiac origin. Labs and repeat ECG needs to be followed up and pt needs admission for serial troponins.

Resident-to-Resident Sign-out (Transfer Rounds) are conducted one-to-one between the incoming and outgoing resident when full team rounds are not held

The oncoming resident must clearly understand issues of the timing of tests and what outstanding tests results need to be verified and documented.

The departing resident must sign the Emergency Department record, document all key portions of their exam (example: pelvic and rectal exams) and note the time all consults were contacted. Additionally, all case presentations must be made to the attending by the resident who has seen the patient primarily.

Noon Report will take place in the Residents’ Room. This lecture/discussion will be led by a senior resident under the mentorship of an EM attending. The resident/attending team will be designated on the monthly noon report schedule. The presentation should be, whenever possible, case-based and interactive. It can take the form of multiple short cases or a long case or it may be a presentation of visual images. This would be the appropriate time to review specific exams or to review timely issues such as heat emergencies in the summer or pharyngitis in the winter. We ask that the residents disengage from patient care around 11:45AM and get their lunch. Residents will have their lunch during Noon Report and return to the ED by 1:00 PM

Evening Sign-out (8PM-8:30PM) will occur in the same fashion as morning attending-led sign-out and resident-to-resident transfer rounds.

Information on Wednesday Conference (8AM-Noon) can be found in the Education section of this handbook. The location of weekly Wednesday conference will be posted at the on the residency Team Site and in the Weekly UpDate email.

Columbia Adult ED Logistics:

• Designate on the Eclipsys tracking board all patients for whom you are responsible, including those that have been signed out to you.
• Make sure you present all cases to the attending physician in a timely manner, preferably immediately after you see the patient and before you start ordering diagnostic studies.
• If a patient appears ill (hypotension, respiratory distress, etc), involve the EM attending or senior resident immediately.
• No patient may leave the ED without seeing an EM Attending first.
• You must present every patient you see to an EM Attending prior to your leaving a clinical shift. You must hold your colleagues leaving their shifts to the same standard.
• Make sure you discuss all admission decisions with the EM Attending prior to calling patients in for admission.

• You determine the team to which you will admit based on the patient’s diagnosis and team availability. You may admit to the medicine service for care by housestaff, to the Medicine Hospitalist Attending if the patient has no private attending or has an Associates in Internal Medicine (AIM) Clinic attending, or to the PA Service (PACS) if the patient has a private attending who agrees to an off-service admission.
• To admit a patient to a Milstein Hospital Building medical floor bed, you should do so via Eclipsys by placing the order, “ED Bed Request (Milstein).” Within the body of the request, you need to specify the patient’s diagnosis, enter in or pick a diagnosis for ICD coding system, the requested team, if telemetry is needed, if the patient has any isolation requirements (respiratory, droplet, contact, etc.), and if the patient needs 1-to-1 security or a cluster bed (if the patient poses an elopement risk).
• The Medicine Bed Coordinator (PPOC) confirms the assignment of your team on Eclipsys.
• You then page the medical resident to which the admission will go and give the information about the case. Make sure you have the patient’s name, medical record number and an understanding of why the patient needs to be admitted. The name of the resident to whom you presented, the team, and his/her pager number must be included in the “ED Disposition Note” in Eclipsys.
• The Nurses have a standardized hand-off document using The Joint Commission’s SBAR format. The information required is: diagnosis, admitting team, admitting team pager, admitting team resident name, and EM doctor who endorsed the patient.
• At night, if there are no teams, fill out the Eclipsys “ED Bed Request” order. These requests will be honored by the bed coordinator in the AM in the order you submit your request.

• If you have a critically ill medical patient, you will call the Medicine Consult Resident (Page: 8MED2); if you have a patient whose ICU disposition is immediately known to you (e.g. intubated in the field and regains vitals post arrest), you may page 8ICU8 before any of the relevant data is back to expedite the patient’s transfer (this pager will inform the ICU attending and the fellow as well as the medical consult). The Medical Consult will be responsible for allocation of MICU beds. If admitting to the CCU, call the Cardiology Fellow on-call (Page: 8CRDS).
• To admit a patient to all non-medical services (ex: neurology, surgery, urology, ENT, ophthalmology, etc.), call the respective consult resident.

Attending-Resident Work Relationship

As a resident, you are required to involve an attending physician in the care of every patient. We will expect that the resident will first assess the patient and formulate a differential diagnosis and plan. This will then lead to a formal presentation and discussion of the case with the attending. We expect this to occur within the first 15-20 minutes of the patient’s assessment. A mutually agreed upon plan of action will then occur and the patient’s case will be revisited at some predetermined future time. The attending/resident interactions will be more frequent and intense in the case of the unstable or potentially unstable patient. Should a patient initially triaged as stable be determined to be unstable or become unstable, it is the resident’s responsibility to promptly bring this to the attention of the attending and nurse involved in the patient’s care. Please remember that, although a resident needs to develop a sense of professional autonomy, this can never be done at the expense of proper patient care. There is no situation where it would be deemed too early to discuss a case with an attending physician. When in doubt, ask for help. Over time, you will develop a sense for the proper timing.

EM Wednesday Conference: Attendance is mandatory for all PGY1 and PGY2 residents with the exception of those on Tuesday / Wednesday overnight shifts, on Wednesday noon-midnight shifts, or on off-service rotations where Wednesday conference attendance is not mandatory. The off-service rotation information page indicates whether conference attendance is expected. Wednesday conference is mandatory for all PGY3 and PGY4 residents who are not scheduled for a clinical shift on Wednesday unless they are on vacation or scheduled for a Tuesday overnight shift. PGY3 and PGY4 residents working until midnight on Tuesday are expected at conference at 10 am. When Wednesday conference is on the Columbia campus, all residents scheduled to work a clinical shift in the Columbia ED are expected to report to their assigned area at 12 noon. Residents scheduled to work a clinical shift in the Cornell ED are expected to take the 12:15 shuttle to Cornell and immediately report to their assigned area.

Readings:

Emergency Medicine Concepts and Clinical Practice, Rosen 5th Edition, Mosby.

Emergency Medicine: A Comprehensive Study Guide, Tintinalli 5^th Edition, McGraw Hill.

Tips and helpful hints:

• Door Code to Residents Room: 0-3-4-2
• Door Code to restroom just outside the clinical area: 1-3-5-0
• The Columbia Master Key you were given opens the restroom in RME
• Regarding charting in Eclipsys.
  • Several sections of the chart need to be filled out so there is appropriate documentation and transfer of information; other sections need to be filled out for billing purposes. Speak to your senior resident about how to chart appropriately so all bases are covered
  • If you have urgent or STAT orders for the nurses, be sure to inform the nurse in person immediately after placing orders. This also applies to ER radiology vis-à-vis CT scans and x-rays.
• Stay abreast of the nursing staff’s policies regarding where EMS run sheets, EKGs, Nursing Home documentation, and other paper documents are kept, as these tend to get lost and are often irreplaceable (i.e. the EMS run sheet from an AMS case).
• Many of our patients uptown speak only Spanish. There are in-person Spanish interpreters available 24-7. Many of the interpreters have a medical background and are invaluable in obtaining a precise medical history from our patients.
• Be nice to your fellow staff members. The Columbia ER is a stressful environment, but people work here because they want to. Learn the names of the people on your team and treat them with respect. Offer to start IVs, send labs, push patients to CT, and do EKGs if you feel it will expedite the care of your patient.