MOST OF THE INFORMATION YOU ARE AB OUT TO READ WILL BE A REVIEW OF

THE IN-PERSON ORIENTATION THAT YOU ALREADY ATTENDED.

IT IS IMPORTANT TO BE FAMILIAR WITH THESE ED PROCESSES AND PROCEDURES

PRIOR TO YOUR FIRST SHIFT.

Welcome to the ED Orientation on-line module

PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT CARE IN THE ED FROM THE

MOMENT THEY START THEIR ROTATION

Goal of this Orientation

Objectives of this Orientation

Logistics of working in the ED Your ED team Observations vs. Admission EPIC details

Admission/ Discharge Note completion

High- Yield Emergency Medicine Topics Cardiac Chest Pain

ACS: STEMI vs. NSTEMI Low/ Moderate risk CP

Anaphylaxis Trauma

Backboard clearance C-spine precautions and clearance E-FAST exam

Intoxicated Patient Psychiatric Patient

Medical Clearance

LOGISTICS OF WORKING IN THE ED

ED Layout

Section A: Highest Acuity- open 24/7 2 resident teams

Green: 9 beds +2 resuscitation bays Purple: 10 beds + 2 resuscitation bays

Staffing: 2 attendings 9am-1am (1 attending 1am-9am) Senior Resident Supervision

Trauma: All trauma patients that go to resuscitation bays are designated as “full” or “modified” trauma Off-service residents are not responsible for taking care of “modified” or “full” trauma Off-service residents are responsible for trauma patients that don’t meet “modified” or

“full” trauma criteria

Section B+C: Lower Acuity- open 24/7 (as of July 2014) May still get trauma patients that are not “full” or “modified” traumas Staffing

At least 3 resident/PA teams Supervised by an attending

TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK

ED Layout- Other areas of Interest

Patient entrances/ triage/ registration areas: Ambulance Waiting Room

Central Communications Desk (a.k.a. “the bubble”) Located at the ambulance entrance All calls/ faxes Location of Medtronic Pacemaker interrogation equipment

Intoxication Observation Unit (IOU) Located in hallway behind Section C Staffed by an ED tech

Crisis Intervention Unit (CIU) = Psychiatric ED Separate unit staffed by psychiatry residents, attendings, nurses,

techs Chest Pain Center (CPC)

Separate ED observation unit for low/moderate chest pain patients Staffed by B-side attending, PA (during working hours), nurse, tech

Your team:

Attendings Supervise multiple teams simultaneously 24/7 in-house coverage for every section of ED (when

open)Senior ED Resident

Only during high volume times (Mondays daytime)ED NurseED TechnicianBusiness Associate (BA)

Your ED shift: Arrival and Sign-out

Arrival: at least 5 min. prior to scheduled time B+ C sides: divide patient beds equally between available

providers (podiatry and dental residents do not get bed assignments)

Sign-out: 2-part process Off-going senior resident or attending presents patients in

bed-order to the on-coming team Part one: at the computer- all the details (including labs, social

issues, Ddx) Part two: at the bedside- off-going attending introduces the in-

coming team Patient is made aware of the work-up progress, pending

studies and reason for why s/he is still in the ED, and approximate timeline

Your ED shift: Seeing patients

All patients assigned to your bed assignment are YOUR patients See them within the first 5 minutes of arrival in section

A or 15min. in section B&C See patients in parallel: essential EM skill

Present your patients as soon as you saw them To senior and/or attending Do not pile up patients to present in bulks

Enter all lab orders ASAP Notify your nurse of the plan as soon as you know it

Charts must be completed by the time patient leaves the department

Your ED shift: Disposition

Important to notify the patient and nurse as soon as the decision is made

NEVER discharge the patient prior to making the ATTENDING AWARE that the patient is being discharged

All PMDs need to be notified that their patient was in the ED Especially for high-risk CC: HA, CP, AP, BP Document all communication in chart

AMA discharge: ALWAYS alert the attending ASAP Document capacity to make decision

Can not be: intoxicated, mentally retarded, cognitively impaired Give appropriate discharge instructions and prescriptions AMA form must be signed by patient Encourage return to the ED

Your ED shift: Admission vs. Observation

Reasoning: patients who have normal vital signs, normal lab results, normal imaging may not meet criteria by insurance companies to pay for a full hospital admission These patients may still require medical care not

reflected by the criteriaLogistics: most of the time, the ED attending

will be able to determine admit vs. obs Care Coordinators are specially trained in making the

decision Will sometimes ask you to change the admitobs or

obsadmit booking Always make the attending aware of the change

The attending makes the final decision

Your ED Shift: Medical Admission

Enter order in EPIC: “ED Admit” Observation vs. Admission Medical vs. Non-medical

For medical, pick team: Hospitalist =patient’s PMD is on hospitalist team All other medical admits =no PMD or PMD doesn’t admit to

hospitalist YED attending= CPC PCC/ generalist= patient goes to PCC Goodyear =cardiology complaint without Cardiologist or

University Cardiology General cardiology =cardiology complaint with Non-University

Cardiologist Klatskin =ESLD ESRD Donaldson = HIV/AIDS

Fill out the rest of the booking (specify tele vs. floor)

Your ED Shift: Admission to an ICU

Step 1: notify Bed ManagerStep 2: Call appropriate team for sign-out. Get

name of admitting attending. CCU: page CCU fellow MICU: page MICU admission team SDU: page SDU resident SICU: the surgical team is responsible for getting SICU

attending aproval NICU: don’t need to page anyone b/c you are admitting to a team

that should already be involved in patient care

Step 3: Attending- to- attending sign-out.YNHH admission policy: the ED attending makes the final decision where a patient is admitted

Please let your senior resident and/or attending aware of any push-back you get from the admitting team.

Your ED shift: Admission to CPC

CPC or in-hospital ROMI Both:

low/ moderate risk chest pain patients who need a ROMI Observation, telemetry admission Not for ACS patients

No nitro drips, no heparin drips CPC: patient will get Stress Test at the end of their admission

Your role Place appropriate EPIC order:

• ED chest pain place in CPC observation EPIC Note:

• Smartphrase: “.edobsadmit” Order all out-patient medications

In-Hospital ROMI: most will NOT get a stress test Patient had a stress in the past year Patient with other diagnoses possible (other than CAD) Patient needs isolation Patient morbidly obese (will not fit stress table) Patient can not self-transfer (onto stress table)

Your ED shift: Admission of hip fractures

For isolated hip fractures No other traumatic injuries Mechanical cause (i.e. not syncope that needs to be worked-up)

Orthopedic team evaluates patient (as all other ortho consultations)

Computer orders: Admit to: Hospitalist Service: Medicine Unit type: free-text ortho/ hospitalist 7-7

Page hospitalist at 766-7416 to give verbal sign-out NO DICTATION NEEDED WHEN VERBAL SIGNOUT

DONE

Other ED Pearls

COMMUNICATION IS CRITICAL Team-work is essential to surviving in the ED (both

patient and resident): greatest off-service resident pitfall is not communicating with the nurses and attending/senior

Let your senior/ attending know: Patient seems to be sicker…

than triaged than last time seen than signed out

You are feeling overwhelmed and are falling behind You need a break (nourishment/ bodily functions)

Navigating EPIC in the ED

Log in and pick correct department: YNH EMERGENCY ADULT

Sign inPick your work area

Navigating EPIC in the ED

Typical day in ED: this is what the board looks like…

ED Notes in EPIC

Double click patient name My note TAB is open

Pick My Note buttonYou are responsible for…

HPI: add chief complain Complete by clicking Add free-text in “comments”

ROS: “All Other Systems Negative” must be clicked off PE: “VS Reviewed” and “Nursing Note reviewed” must be clicked

offIf you did procedures (e.g. EKG)

EKG: change the “provider” from your name to your attending

ED Notes in EPIC

To view your full note click on NotesBellow PE and above Proceduresfree-text Assessment and Plan

MDM What was done/ found in ED Disposition

Also, free-text PMD/ consultants called (name and time)

DO NOT WRITE IN THE ED COURSE SECTION

ED Notes in EPIC

When finished documenting: ShareRefresh Note after “clinical impression” and

“disposition” is complete (after you admitted or discharged the patient in EPIC)

When an attending has signed the note, the system will only let you Sign Pick your attending to Co-sign Feel free to edit as many times as needed to complete

the note until the patient leaves the department

Admitting Patient in EPIC

Double click patient name to open patient chart Open Admit Tab

Navigate through sections Clinical Impression= diagnosis Manage Orders= “ED admit”… Disposition= admit

Discharging Patient in EPIC

Double click name to open patient chart Open Discharge Tab

Navigate through sections Disposition= discharge Follow-up= pick appropriate MD/ interval of follow-up Clinical Impression= diagnosis Orders= Discharge prescriptions Discharge instructions= diagnosis/ symptoms

Discharging Patient in EPIC

When patient ready to leave, open Discharge Tab

Pick Preview/ Print SectionClick PrintHand Instructions to nursewith signed prescriptions

EPIC PEARLS (feel free to print this page)

Every note MUST have the following elements complete HPI: CC filled in

All click boxes that are applicable filled ROS

“All other systems negative” clicked PE

“Nursing note reviewed” clicked “Vital signs reviewed” clicked

Disposition filled Clinical Impression filled

Note must be refreshed before you sign it

I H AV E R E A D T H R O U G H T H E E D O R I E N TAT I O N O N L I N E M O D U L E I N C LU D I N G T H E I N S T R U C T I O N S O N H O W T O N AV I G AT E T H R O U G H E P I C ( N O T E S , A D M I S S I O N S , D I S C H A R G E ) P R I O R T O M Y F I R S T S H I F T I N T H E E D . I A M A B L E T O P E R F O R M T H E F U N C T I O N S T H AT A R E D E TA I L E D I N T H E O N - L I N E O R I E N TAT I O N M O D U L E . S H O U L D I H AV E A N Y Q U E S T I O N S A B O U T A N Y I N F O R M AT I O N D E S C R I B E D I N T H E M O D U L E , I K N O W T O C O N TA C T T H E E D C H I E F R E S I D E N T S O R T H E E D O F F - S E R V I C E R E S I D E N T D I R E C T O R .

P L E A S E S I G N Y O U R N A M E A N D T H E D E PA R T M E N T Y O U A R E F R O M .

Now that you have read and understand the module, please copy and paste the following statement into an e-mail and address it to:

ana.madureira@yale.edu

A LINA TSYRULNIKA SSISTA NT RESIDEN CY DIRECT OROF F-SERV ICE RESIDENT DIRECTOR

CLINICA L IN ST RUCTORDEPA RT M EN T OF EM ERG ENCY M EDICINEYA LE UN IV ERSIT Y SCHOOL OF M EDICINE

A L I N A . T S Y R U L N I K @ Y A L E . E D U

THANK YOU FOR YOUR ATTENTION