ALINA TSYRULNIK MDCLINICAL INSTRUCTOR

ASSISTANT RESIDENCY PROGRAM DIRECTOROFF-SERVICE RESIDENT DIRECTOR

DEPARTMENT OF EMERGENCY MEDICINEYALE UNIVERSITY SCHOOL OF MEDICINE

Welcome to ED Orientation

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 1 2014)

May still get trauma patients that are not “full” or “modified” traumas Staffing

At least 3 resident/PA teams in each section during the day (down to 3 total teams overnight) supervised by an attending+/- senior resident

Senior resident present at high volume times 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

Senior ED Resident Not available on every shift

ED Nurse ED Technician Business Associate (BA)

Your ED shift: Arrival and Sign-out

Arrival: at least 5 min. prior to scheduled time B+ C sides: divide patient beds among providers

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

order to the in-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 timelineAfter sign-out

See all new patients Introduce self to old patients

Your ED shift: Seeing patients

All patients assigned to your bed assignment are YOUR patients See them within the first 5 min. of arrival in section A or

20min. 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 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 these numbersLogistics: 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 private (non-university)

Cardiologist Klatsin =ESLD ESRD Donaldson = HIV/AIDS

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

Your ED Shift: Admission to an ICUStep 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 careStep 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:

• Order Sets: “ED Chest Pain 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

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 environment

Sign inPick your work area

Navigating EPIC in the ED

Typical day in ED

ED Notes in EPIC

Double click patient name My note TAB is open

Pick My Note buttonYou are responsible for…

HPI: add chief complain ROS PE

If you did procedures (e.g. EKG) EKG: change provider

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: ShareWhen an attending has signed the note, the

system will only let you Sign Pick your attending to Co-sign Do not start 2 separate notes

Admitting Patient in EPIC

Double click 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 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 ready to discharge, open Discharge Tab

Pick Preview/ Print SectionClick PrintHand Instructions to nursewith signed prescriptions

QUESTIONS

THE ED PATIENT WITH CHEST PAIN

Background

5% of all ED visits = 5 million visits per year in the US

One of the highest-risk chief complaints For patient morbidity/ mortality For MD litigation

Wide differential- most is high mortalityIN THE ED, WE MUST THINK OF WHAT WILL KILL THE PATIENT Acute Coronary Syndrome Pulmonary Embolism Aortic Dissection Pneumonia Pneumothorax Pericarditis Esophageal Rupture

ACS: STEMI=CATH LAB ACTIVATION

National guidelines for STEMI cath lab activations: Door-to-EKG: 5 minutes Door-to-balloon: 90 minutes

All EKGs seen and interpreted by an attending immediately “Cath Lab activation” is done by ED attending

Cath lab personnel are assembled (if not in-house overnight) Cath lab attending gives a call to the ED attending to get quick story

NO role for: Cardiac enzyme results Cardiology Fellow consult Chest x-ray results

Patient needs to be rolling to the cath lab within 25 minutes from arrival at ED triage, having gotten: ASA 325mg Oxygen Plavix Heparin 5000U +/- morphine +/- nitroglycerin +/- Beta-blocker

ACTIVATION IS BASED PURELY ON EKG and PATIENT’S PRESENTATION

ACS: STEMI=CATH LAB ACTIVATION

What does the attending look for to activate cath lab? Activation Criteria

ST elevations of >1mm in 2 consecutive (anatomical) leads New LBBB

Other signs that may be present Dysrhythmia Reciprocal changes Dynamic changes

Why should you care? As an MD (doesn’t matter what specialty), you must

know what to do with acute chest pain!

ACS: “good story”

What if the EKG is not clear-cut, but the patient is giving a “classic MI story” No immediate cath lab activation: role of cardiology consult

Resident calls fellow Attending calls attending

Instruct the nurse to do q5min. EKGs Dynamic EKG changes activate cath lab

Possibilities for ACS: all should get heparin Good story – EKG changes – troponins = unstable angina/ ACS Good story – EKG changes + troponins = NSTEMI/ACS Good story + EKG changes +/- troponins = STEMI/ACS

Especially if came in first few hours (<6hr) Bad story/ no CP – EKG + troponins= NOT ACS

Look for other causes of troponins ESRD Tachycardia/ Sepsis Myocarditis

Low/ Moderate Risk CP High Risk CP

Need a ROMI EKG and enzymes q3-

6hrs x 3 times +/- stress

In-hospital ROMI vs. CPC Decision made by ED

attending in consultation with cardiologist and PMD

ACSHeparin gttunstable vital signs

Cardiology team Goodyer / General

Cardiology telemetry

CCU/CSDU

Chest Pain Patient Disposition

Cocaine Use Chest Pain

Rule in approx. 6% of timeAvoid Beta-BlockadeTreat chest pain and/or tachycardia with benzodiazepines

QUESTIONS

THE ED PATIENT WITH ANAPHYLAXIS

Anaphylaxis/ Angioedema

Immediate Medications Epinephrine:

Mild- moderate: 0.3mL of 1:1000 dilution IM in thigh May repeat q5min. Up to max 3 doses

Severe: 1-5mL of 1:10,000 IV drip over 10min…continuous Solu-Medrol 125mg IV Benadryl 50mg IV Pepcid 20mg IV Fluids Albuterol PRN

Why should you care? Anaphylaxis happens on every in-hospital unit Will NOT have time to look up treatment

QUESTIONS

THE ED TRAUMA PATIENT

The Trauma Patient

There are triage criteria for activating “trauma alerts” for patients: “full trauma” vs. “modified trauma” You are responsible for those who didn’t meet criteria

THIS DOES NOT MEAN THAT THEY ARE NOT SERIOUSLY INJUREDMost are on back-boards and with c-spine collars

Back-boards must be removed within 15 min. of arrival To prevent pressure ulcers To prevent agitation Spinal precautions maintained at all times

Never remove a c-collar, never allow a patient to remove a c-collar

Backboard Clearance

4 person job: need 3 other people One holding C-spine stability (with collar in place) Two holding torso One (you) palpating spine and rectal tone

Tenderness at midline Bruising Lacerations Stepoffs Rectal Tone Gross blood on rectal exam

Clearing a C-collar

Done by senior resident/ attending ONLYClinical Rules for clearing C-collars

Canadian Nexus

Midline tenderness Focal neurological deficits Altered level of consciousness Intoxication Distracting Injury

Trauma ABCDE’s

AirwayBreathingCirculationDisability (GCS)Exposure

Document all injuries and formulate a plan for intervention/ imaging if necessary

FAST exam

Focused Assessment by Sonography for Trauma Ultrasound exam looking for free fluid

Abdomen RUQ/ LUQ

Pelvis Pericardial Effusion

E-FAST: extended FAST Examines for pneumothorax More sensitive than supine x-ray

Validated in unstable patients Can not be used to exclude intra-abdominal trauma

“Pan-Scan”

“Pan-scan”= CT scan Head (no contrast) C-spine (no contrast) Chest/ Abdomen/ Pelvis (contrast x2) T-/L- Spine reconstructions

Contrast: IV and PO PO contrast given by the tech immediately prior to the

scan Evaluates duodenal injury

Protocol MUCH different from usual PO contrast Must specify this when ordering the study and make

nurse aware Usual protocol: wait 2hrs. after PO contrast complete

More Trauma Pearls

Laceration/ Abrasion Tetanus Contaminated wound: ?Antibiotics

Beware ICH

Old people: subdural/ intraparenchymal splenic lacerations

Immediately alert the attending for any vital sign abnormalities or changes in mental status

Vital Signs Narrow pulse pressures Mild tachycardia

Cause of trauma: mechanical vs. medical

QUESTIONS

The Intoxicated ED Patient

Intoxication

Need to be screened for other causes of their altered mental status Hypoglycemia Head trauma other toxic ingestions

At minimum: vital signs FSG +/- Breathalyzer

Consider whether any further testing would change management or disposition Most cases will not need serum overdose/ urine tox

Document SI/ HIRe-evaluate after clinical sobriety

Intoxicated Patients

Clinical sobriety is the bar- many patients will go into withdrawal if you wait for their breathalyzer to go below .08

Alcohol levels decrease by ~ .025/ hourLook over all documents in patient’s chart

Police “paper” Requires “physician clearance”

Nursing/ triage/ call-in sheets If medical evaluation is negative, and patient is

only intoxicated Enter “ED Sobriety Hold” order Patient will be placed in IOU until sobriety

Overdose: Physical Exam

Vital SignsPupilsPulmonary EdemaSkinBowel SoundsMental Status

OverdoseDocument SI/ HI on all patients

SI/HI must be re-assessed when clinically soberConsider overdose in any patient with SIPoison Control 1-800-222-1222 must be called

for all ingestions/ overdosesOn-call toxicologist is available 24hrGet EKG

Consider overdose labs: Serum tox, LFTs, Utox

QUESTIONS

The ED patient with Psychiatric Complaint or Ingestion

Medical Clearance

Patients going to CIU require medical clearance if Over 50yo Has any medical PMHx

What needs to happen: Full physical exam

Some may need: EKG/ CXR/ Basic Labs Medical clearance means:

All medical problems resolved no IVs in medically stable

Overdose patients are not medically clear Check past charts

Psychiatric patients may not be forthcoming with their PMHx Once cleared:

Epic order “psych clearance” Alert patient’s nurse Call 688-1616 to give CIU signout

QUESTIONS

THE END

THANK YOU FOR YOUR ATTENTION