logistics of working in the ed

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Welcome to the ED Orientation
on-line module
MOST OF THE INFORMATION YOU ARE ABOUT 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.
Goal of this Orientation
PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT
CARE IN THE ED FROM THE MOMENT THEY START THEIR
ROTATION
Objectives of this Orientation
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Logistics of working in the ED
Your ED team
Observations vs. Admission
EPIC details
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Admission
Discharge
Note completion
LOGISTICS OF WORKING IN THE
ED
ED Layout
 Section A: Highest Acuity- open 24/7
 2 resident teams
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Staffing:
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Green: 9 beds +2 resuscitation bays
Purple: 10 beds + 2 resuscitation bays
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
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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: Lower Acuity- open 24/7
 May still get trauma patients that are not “full” or “modified” traumas
 Staffing
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At least 3 resident/PA teams
Supervised by an attending
 Section C: Lower Acuity- open 11am-2am
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:
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Ambulance
Waiting Room
Central Communications Desk (a.k.a. “the bubble”)
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Located at the ambulance entrance
All calls/ faxes
Location of Medtronic Pacemaker interrogation equipment
Intoxication Observation Unit (IOU)
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Located in hallway behind Section C
Staffed by an ED tech
Crisis Intervention Unit (CIU) = Psychiatric ED
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Separate unit staffed by psychiatry residents, attendings, nurses, techs
Chest Pain Center (CPC)
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Separate ED observation unit for low/moderate chest pain patients
Staffed by B-side attending, PA (during working hours), nurse, tech
Your team:
Attendings
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Supervise multiple teams simultaneously
24/7 in-house coverage for every section of ED (when open)
Senior ED Resident
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Not available on every shift
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No senior on B & C side
One senior for the entire A side on Wednesdays
ED Nurse
ED Technician
Business Associate (BA)
Your ED shift: Arrival and Sign-out
Arrival: at least 5 min. prior to scheduled time
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B+ C sides: divide patient beds equally between available providers
(podiatry and dental residents do not get bed assignments)
Sign-out: 2-part process
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Off-going senior resident or attending presents patients in bed-order
to the on-coming team
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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
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Present your patients as soon as you saw them
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To senior and/or attending
Do not pile up patients to present in bulks
Enter all lab orders ASAP
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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
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
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Especially for high-risk CC: HA, CP, AP, BP
BA should help facilitate if you have difficulty
Document all communication in chart
AMA discharge: ALWAYS alert the attending ASAP
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Document capacity to make decision
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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
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These patients may still require medical care not reflected by the
criteria
Patients placed in observation are expected to be discharged
sooner (1-2 nights)
Logistics: most of the time, the ED attending will
be able to determine admit vs. obs
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Care Coordinators are specially trained in making the decision
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Will sometimes ask you to change the admitobs or obsadmit
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”
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Observation vs. Admission
Medical vs. Non-medical
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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
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Fill out the rest of the booking (specify tele vs. floor)
Your ED Shift: Admission to an ICU
YNHH admission policy: the ED attending makes
the final decision where a patient is admitted
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Please let your senior resident and/or attending aware of
any push-back you get from the admitting team.
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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
NO DICTATION NEEDED WHEN VERBAL
SIGNOUT DONE
Your ED shift: Admission to CPC
CPC or in-hospital ROMI
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Both:
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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
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Your role
 Place appropriate EPIC order:
• ED chest pain place in CPC observation
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EPIC Note:
• Smartphrase: “.edobsadmit”
Order all out-patient medications
 Dictate
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In-Hospital ROMI: most will NOT get a stress test
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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:
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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
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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:
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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 in
 Pick your work area
Navigating EPIC in the ED
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Typical day in ED: this is what the board looks
like…
ED Notes in EPIC
Double click patient name
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My note TAB is open
Pick My Note button
 You are responsible for…
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HPI: add chief complain
Complete by clicking
 Add free-text in “comments”
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ROS
PE
If you did procedures (e.g. EKG)
 for EKGs: change the “ordering physician” to your
attending’s name (the default is your name)
ED Notes in EPIC
 To view your full note click on Notes
 Bellow PE and above Procedures
free-text Assessment and Plan
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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
 it is reserved for attendings only
ED Notes in EPIC
When finished documenting: Share
When an attending has signed the note, the system
will only let you Sign
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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
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Open Admit Tab
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Navigate through sections
 Clinical Impression= diagnosis
 Manage Orders= “ED admit”…
 Disposition= admit
Discharging Patient in EPIC
Double click name to open patient chart
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Open Discharge Tab
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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 Section
 Click Print
 Hand Instructions to nurse
with signed prescriptions
Now that you have ready and understand the module,
please copy and paste the following statement into an email and address it to:
jaydale.poyotte@yale.edu
I HAVE READ THROUGH THE ED ORIENTATION ONLINE MODULE INCLUDING THE INSTRUCTIONS
ON HOW TO NAVIGATE THROUGH EPIC (NOTES, ADMISSIONS, DISCHARGE) PRIOR TO MY FIRST
SHIFT IN THE ED. I AM ABLE TO PERFORM THE FUNCTIONS THAT ARE DETAILED IN THE ON-LINE
ORIENTATION MODULE. SHOULD I HAVE ANY QUESTIONS ABOUT ANY INFORMATION
DESCRIBED IN THE MODULE, I KNOW TO CONTACT THE ED CHIEF RESIDENTS OR THE ED OFFSERVICE RESIDENT DIRECTOR.
PLEASE SIGN YOUR NAME AND THE DEPARTMENT YOU ARE FROM.
THANK YOU FOR YOUR
ATTENTION
ALINA TSYRULNIK
ASSISTANT RESIDENCY DIRECTOR
OFF-SERVICE RESIDENT DIRECTOR
CLINICAL INSTRUCTOR
DEPARTMENT OF EMERGENCY MEDICINE
YALE UNIVERSITY SCHOOL OF MEDICINE
ALINA.TSYRULNIK@YALE.EDU
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