Cornell ED

Cornell Adult Emergency Department

The Cornell Adult Emergency Department consists of four separate areas (A, B, C, D) plus the Psychiatric and Pediatric EDs. Residents will be assigned daily to either Area A, Area C, or Area D. (Area B is staffed by mid-level providers and ED attendings) Residents are responsible for taking care of all patients assigned to their patient care area. The Residents’ patient care will be directly overseen by the EM Attending assigned to their patient care area.

EM Attending Schedule: 24 hours a day there will be one attending assigned to each of the three areas, and an attending assigned to Urgent Care for day-time hours. Attending shifts are either 8 or 12 hours. Often, there may be an extra attending in the afternoon assigned to help with patient flow. Often on Wednesday mornings extra Attendings work in the ED during conference.

Resident Schedule: The schedule is posted on the teamsite. In general, the schedule is released 4 weeks before the start of each block.

Resident shifts (EM PGY1s & 2s): 730AM-730PM, 12N-12M, 730PM-730AM

See specific PGY3 and 4 roles for shift details.

Daily Schedule:

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

7:30 am Morning Rounds / Transfer of care to oncoming team

8:00 am Morning Report in Room M-107 (unless otherwise specified) on Monday through Friday; Area D opens

9am Resume clinical responsibilities on Monday through Friday

3:30 pm Attending Rounds in Area A and Area B

7:30 pm ED wide Evening Rounds / Transfer of care to oncoming team

11:30 pm Attending Rounds in Area A and Area B

12 mid 12n-12m resident signs out to resident that remains until morning

Exceptions

EM Conference is conducted every Wednesday from 8am to Noon (see below for location). No morning report is conducted on Wednesdays, weekends, or holidays.

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

To convey a succinct signout, use the eDPASS system for sign out. The eDPASS (emergency Disposition, Patient Summary, Action List, Situational Awareness, Synthesis) is designed to facilitate efficient and accurate transfer of care. The structure of eDPASS is as follows:

• 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 yo 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 consult 4N.

(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 (usually in area A and C at 7:30 pm on weekdays when Attendings change shift at 3:30 pm and 11:30 pm if 8-hour shifts)

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

Morning Report takes place all weekdays except Wednesday. This will take place in the Residents’ conference room M-107 at 8am. This educational effort will be led by an incoming senior resident (and a precepting attending) who will be designated on the monthly morning report schedule. The purpose of these rounds is to offer an educational conference; the format will vary depending on the style of the responsible speaker. The presentation will generally be 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. During inservice training time, topic will specifically be assigned to assist studying efforts. The overall goal is for these to be interactive and to offer a regular and formal educational effort.

Evening Sign-out (7:30PM-8PM) 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.

Cornell Adult ED Logistics:

• 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 bed-requesting or calling patients in for admission.
• To admit a patient to a medical floor bed, you must fill out an “ED Bed request” order in Eclipsys. Check the patient’s isolation status and select the appropriate isolation or non-isolation option. Choose the appropriate setting (general bed, telemetry, step-down, ICU). If admitting to a surgical service, ask the surgical consult resident who the admitting attending is an input into “Admitting Attending” field. If admitting to Medicine, the medical bed coordinator may call you with questions. If there is a private medicine attending to whom the patient belongs, indicate the name.
• You must make a formal hand-off to the admitting team. If they have not called you, page them to your mobile heart beat. Provide the admitting Medicine resident with a complete sign-out of the patient. Document the admitting Medicine resident (or PA)’s name, the team, the pager number and the time patient care was signed-out in the Disposition note.
• To admit a patient to the Medical Intensive Care Unit, Cardiac Care Unit, 4 North (Cardiac telemetry unit), you will call the consult resident covering these services.
• To admit a patient to all non-medical services (eg: neurology, burn, surgery, etc.) call the consult resident for that service. When a decision is made to admit to a non-medical service, enter an “ED Bed request” order in Eclipsys.
• The EM Attending may ask you to see patients outside of your patient care area at their discretion.
• Designate on the Eclipsys tracking board your name by every patient you are responsible for, including all patients that have been signed out to you.

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 residents with the exception PGY1 and PGY2 residents 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 either a Tuesday or Wednesday overnight shift. PGY3 and PGY4 residents working until midnight on Tuesday are expected at conference at 10 am.

IM Noon report is on Mondays and Tuesday (90 minutes), and Wednesday and Friday (60 minutes).

Only the D+a resident will attend noon report. If an IM resident is assigned a Wednesday D+ shift, they will not attend the Wednesday EM conference, and will instead work a regular 9am-8:30pm D+ shift.

As the resident physician taking over for a patient who requires ongoing care, you should introduce yourself and briefly reassess the patient while making sure that the patient is aware of their pending tests, disposition and any results of tests available. When a patient has an abrupt change in hospital course (e.g. new interventions or plan are needed) and four hours have not elapsed, write a follow up note to explain the change. Upon admitting any patient to the hospital, the resident should go to the bedside, inform the patient of admission (and to which resident/attending and inpatient service) and then write a brief note in the chart (in the Disposition Note) documenting this transfer of care to the inpatient service. Finally, for patients who are discharged home, residents must write a discharge (progress) note in the ED Disposition Note. Residents need not perform these tasks or write notes on patients who are in the ED but admitted to the hospital and awaiting an inpatient bed.

We expect that our senior EM residents will help set an example and help the junior residents get in the habit of reassessing their patients and writing progress notes. At the designated times, please encourage the junior residents to spend about 15-20 minutes checking up on all of their patients. We strongly believe that this simple process improves patient care and satisfaction.

Summary of Expectations for the 4 hour Progress Note:

1. Resident should first look up all pending labs, radiology studies, etc. and inquire about any pending studies that have not yet been performed.
2. Resident should reassess patient (e.g. check vitals if relevant, ask patient how they are feeling, perform any part of a follow up physical exam that is indicated)
3. Resident should inform patient of the results of completed studies and tell the patient what they are still waiting for and what their likely disposition will be, if known.
4. Resident should document these interactions in the chart with a brief timed note.

Examples:

Brief Progress Notes:

“12pm: abdomen soft, mild RLQ tenderness, pt finished PO contrast, awaiting CT”

“4am: patient CP free, on nitro drip, SBP 110, lungs clear, awaiting 4N consult”

Transfer of Care Note:

“7:45pm Mr. DJ signed out to me. Plan: check labs and IV / PO CT scan. Abdominal exam: mild RUQ tenderness, no rebound. IV Morphine while patient awaits CT.”

Transfer of Care to Inpatient Service Note:

“9 pm: Red Surgery admitting patient. CT scan shows acute appendicitis, patient aware of CT findings and need for surgery. NPO. IV morphine for pain control.”

Discharge Progress Note:

“2pm Pt feeling better s/p 2 Liters of NS; Tolerating PO, Abdominal Exam benign; Will d/c home; Patient instructed to return for abdominal pain or difficulty taking PO”.

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:

Code to Triage is 3-2-4

Code to the staff room is 3-2-4.

Code to the Bathroom is 4-5-2

Code to Med Room is 3-2-1-5

Take the time and introduce yourself to the nurses that you will be working with on any given shift. Look in Eclipsys if you need help recalling the nurse’s name. There is more downtime on the Cornell overnight and weekend shifts. Push your attendings and senior residents to teach you something during this time – many attendings LOVE this.

Ask Megan for a key to the M107 Resident’s room