Harper ED Orientation/Resource Manual
2/11/2008
CONTENTS
Admission Patterns
AI Pager
Call Backs
Cardiology
Cardio Team One
Chemotherapy and fever
Contrast Nephropathy Prevention Protocol
Critical Results Read Back Policy
Detroit Tigers Transport Protocol
Domestic Violence
Emergency Numbers and Codes
Endocrinology
ENT
Follow up of results
Gastroenterology
Gynecology
Gyn/Oncology
Hematology/Oncology
HIV
Interpreter
Karmanos Admissions
Medicine
MICU
Needle sticks
Nephrology
Neurology
Neurosurgery
Observation Patients (23 hour Obs vs. Full Admit)
Obstetrics
Peer Review
Physician Assistants
PICC Lines
Plastics
Psychiatry
Radiology
Radiology numbers at DRH
STEMI Principles
STEMI Protocol
Sunquest
Surgery
Transplant
Transfers
Trauma
Triage
Ultrasound
Xray
Admission Patterns
2/11/2008
ALWAYS first try to contact the primary physician
and admit to the service that they request. If unable
to contact them, refer to the patterns below.
For unassigned patients, patients without a primary physicians, please admit these
patients to the on-call physician listed on the call board under Internal Medicine as “No
Doc
For patients who have a primary physician who does not admit in the DMC or for
patients whose primary physician requests the on-call hospitalist, please admit these
patients to the hospitalist on-call which is listed on the call board under Internal Medicine
as “Hosp”
After speaking with the appropriate attending, who will admit the patient, write in the
“Comments” of the admission order Med A or Med B, depending on the service to whom
the patient will be admitted. Most patients admitted to University Hospitalists will be
admitted to Med A. If the residents are “capped,” their patients will be admitted to Med
B. Other physicians, private physicians, can have patients admitted to Med A or B except
where noted. Med A will accept three patients from attendings other than University
Hospitalist each day. Then all patients of private physicians will be admitted to Med B.
Admission Patterns/Insurance
All patients whose primary physician is in the University Clinic will be admitted
to University (6789).
HAP to IPC (1500)
Great Lakes to IPC (1500)
Midwest to University (6789)
Molina to IPC (1500)
Omnicare to University (6789) or IPC (1500) Hospitalists
depending on which group is the hospitalist group on call but all
patients whose primary physician is in the University Clinic will be
admitted to University (6789). The on-call hospitalist is listed on
the call board under Medicine as “Hosp”
Wellness Plan to IPC
Admission Patterns/Physicians
Abbott, Valerie to IPC
Adeleye, Anthony to IPC
Alper, Bernard to IPC
Amouzegar, Syed to University Hospitalists (6789)
Consult preferences
GI- Dr. Prabhu
Nephrology- Dr. Huang
Neurology- Staff or Dr. Andaya
Pulmonary- Dr. Kissner
Surgery- Dr. Flake
Andaya, L to IPC
*Anderson, Arletha to Arletha Anderson, Med B
Consult preferences
Cardiology-Dr. Narsimha Gottam (primary choice) or Dr.
Mahir Elder (second choice)
GI- Dr. Edward Clay or Prince Eubanks
Neurology- Dr. Vaqar Siddiqui
Surgery- Dr. Candace Moody
Vascular/Thoracic Sugery-Dr. John Sealey
Baker, Charles to IPC
*Barber, Theodore to Urology (5161)
Barnette, Ruth to IPC
Bartolomei, Eddie to IPC
Beiderman, Jason (Contact pager 249-337-2273)
Black, L to IPC
Bostic, Oswald to IPC
Brown, Daphine to IPC
Brown, James to University Hospitalists (6789)
Brown, Richard to IPC
Cavel, John to IPC
Cher, Michael to Urology (5161)
Clark, Christina to IPC
Clark, Frank to IPC
*Clarke, Anthony to hospitalist on call
Davenport, Linda to IPC
Densley to Ibrahim
*Dudley, Mary Petty to XHuang
*Ellison, Leonard to Leonard Ellison. After speaking with him his
patients will be admitted to Med B
Evans, George to IPC
Fingal, Rhona to IPC
Ferguson, Margo to IPC
Fowler, Carl to IPC
Gandhi to IPC
Gibson, Willie to IPC
Gorrepati, Uns to IPC
Gottam, Narsimhar to himself
Goyal, Vinod to IPC
*Green, Linda to IPC
Hammond, Mary Jackson to IPC
Harris Anthony to IPC
Hussein (in Dearborn) to University Hospitalists (6789)
Johnstone, Keith to IPC
Jones, Jennifer to Lawrence Greenberg
Karnik, Ashok to IPC
Keefe, Michael (Contact pager 248-337-3654)
Khan, Q to IPC
*Khanzode, Santish to IPC
Lee, Sang to Sang Lee
McRae, Charles to IPC
Malcoun, Anthony (Contact Office)
Mark, R to Saker
Marrone, Mark (Contact pager 248—337-2273)
*Martin, Crystal to herself under Med B
Matthews, O. L. to himself under Med B; If he is out of town, please use
IPC
Mehendale, A to IPC
Murrain, Luis to IPC
*Murphy, Melvin to Melvin Murphy. After speaking with him his
patients will be admitted to Med B
*Murphy-Knight, L to XHuang
Orowe, Stanissaus to IPC
Oshiyoye to IPC
*Paharia (in Hamtramck) to Saker
Parish, Michael to IPC
*Pernell to herself but if not available, to IPC
*Petty-Dudley, Mary to XHuang
Policheria, Bhagyalskshm to IPC
*Pontes, J. Edson to Urology (5161)
Porter, Angela to IPC
Powell, Isaac to Urology (5161)
Rahaim (in Dearborn) University Hospitalists (6789)
*Salib, Marcella to Lawrence Greenberg or IPC
Sawabini, G to Saker
Schwartzenfeld, Ted admits to himself, ENT or Plastic Surgery
Sebastian (in Hamtramck) to Saker
Seman, Susan to IPC
*Singal, Sadarshan to Saker
*Singal, Usha to Saker
*Singla, Ajay to Urology (5161)
Smith, Dwight to IPC
Soloymani to IPC
Spohn. E admits to himself, Surgery
*Tata, V to admits to himself
Tidalgo, Ralph to IPC
*Triest, Jeff to Urology (5161)
Tuma, Martin to IPC or MMurphy but always attempt contact with Tuma
First
*University Internists clinics (50 E Canfield, others) to University
Hospitalist (6789) and Med A (0092)
*Underwood, Willie to Urology (5161)
*Wietrzykowski, Matt (Dr. Matt) to Lawrence Greenberg 248-992-1441
Williams, David to IPC
Wissman, Sheryl to IPC
Wolf, Mervin to himself on Med B
Zelch, James to IPC
Admission preferences with * have been personally verified by Jeff King
AI Pager (6789)
In the event that the attending carrying the 6789 pager cannot be reached, the procedure is to
page Dr. Penumetcha (#1647), and then Dr. Donald Levine (#1810), if Dr. Penumetcha is not
available.
Call Backs
If ED is notified of new finding or result, patient will be asked by attending physician to
return to ED for this. Telephone notification will be attempted. Physician will dictate an
addendum and have it dictated stat. Linda Wilson will also be notified to send written
request for return to ED. If she is not present, nursing management should be notified
and they will make written request to return to Emergency Department. If this return is
needed emergently, urgent notification process is followed. Linda Wilson or Nursing
Management will do this.
Physicians receiving notification of cases needing “call back” will enter them in the Call
Back book in the ED Main so that Peer Review of these cases can occur.
Cardiology
There is the Affiliated Internists Cardiology Group and the private attendings. To
contact the Cardiology fellow from the academic group, please page 6666
STEMI
Rapidly identify STEMI and then ask clerks to activate STEMI protocol.
Although the physician should not need to know the specifics of this protocol , in
summary, it either involves calling the cath lab directly during business hours or
paging the STEMI pager during off hours.
Cardio Team One
ACUTE CORONARY SYNDROME
CONSULTATION GUIDELINE
- STEMI
Activate STEMI pager (no change in procedure)
CardioTeamOne Attending will receive page
- NSTEMI or Presentation concerning for ACS with any of following risk factors:



New EKG changes concerning for ACS
Age > 70
TIMI score* > 2


Signs of instability
Particularly: Hypotension, bradycardia, tachycardia, pulm edema, diaphoresis, S3 gallop
Clinical history concerning for high risk ACS
Particularly: Worsening angina (severity, freq., duration), relief with nitro, new onset
If patient has PMD or Cardiologist:
Contact PMD or Cardiologist to develop plan jointly
If patient does not have PMD or Cardiologist or if no timely response:
Consult CardioTeamOne Attending
- Low-risk chest pain
If concern for ACS remains and/or concern for inadequate outpatient follow-up:
Consult Cardiology Service or CardioTeamOne Attending
or
Admit to Medicine Service
CardioTeamOne
Contact Info
Pager – # 90835
Cell – 803-8380
TIMI Score Sheet
1 point for each of the following:
- Age>65
- Known CAD (stenosis 50% or greater)
- ASA use in past 7 days
- Severe angina (2+ episodes in past 24 hours)
- ST changes 0.5 mm or greater
- Positive cardiac markers
- >3 risk factors for CAD
(HTN, Hyperchol, DM, smoking, +Fam Hx)
Chemotherapy and Fever
Subjective or objective fever in a patient with a history of chemotherapy within the
previous 40 days: STAT CBC with differential and blood culture. Work-up appropriately
Contrast Nephropathy Prevention Protocol
EM PROTOCOL FOR PREVENTION/MONITORING OF CONTRAST NEPHROPATHY
GENERAL CONSIDERATIONS
1) All patients receiving contrast for imaging studies should be evaluated for hypovolemia and if
deemed hypovolemic should receive appropriate volume infusions.
2) All of the measures suggested below are likely to be more effective if initiated 1-2 days prior to
the study. Therefore, if a contrast is being contemplated for a patient at increased risk for contrast
nephropathy, consider either:
a)delaying the study until renal optimization/hydration can be accomplished and/or
b)obtaining a non-contrasted study or using a different imaging technique (e.g., ultrasound) if
appropriate.
PATIENTS AT RISK
Major risk factor
Creatinine ≥ 1.5 or calculated creatinine clearance <50 ml/min (as calculated automatically in the
lab results OR as calculated using the EMR “On-line Clinical Calculator”—click on the calculator
icon on the top of FirstNet).
Other risk factors
Hypovolemia
Diabetes
Low cardiac output states
Anticipated contrast infusion >140ml
Age >65 years
CHF NYHA Class III/IV
Concurrent nephrotoxic agents
Contrast last 72 hours
Renal transplant
Sickle cell anemia
Multiple myeloma
SUGGESTED ACTIONS
Volume loading
• If a patient is volume depleted, every effort should be made to replete volume prior to
administrating contrast.
• For euvolemic, hemodynamically stable patients: initiate volume infusion of a solution with
normal saline 10 ml/kg over 1 hour before or if the study needs to be performed immediately,
over 1 hour after the procedure.*
*ALTERNATIVE: There is some evidence to suggest that a solution of isotonic bicarbonate (150
meq bicarbonate in 1 liter of D5W) given as 3 ml/kg initially followed by 1 ml/kg/hr for up to 6
hours after the contrast study may reduce the incidence of contrast nephropathy.
Acetylcysteine
• If the patient is considered at risk and is not npo, administer acetylcysteine 1200 mg (6 cc of a
20% solution) po prior to the procedure. Dilute N-acetylcysteine 20% solution to 5% with a 4:1
ratio of iced cola or other beverage to NAC. Acetylcysteine IV (Acetadotote®) has not been
approved by the DMC P&T committee for this indication.
Metformin
• Metformin should be discontinued while the patient is in the ED and thereafter until it is clear
that contrast nephropathy has not occurred. If contrast nephropathy occurs, the risk of
metformin-induced lactic acidosis is considerably increased.
Aftercare
• Arrangements should be made to recheck a creatinine 48 hours after the procedure, preferably
at a clinic site or with the patient’s PCP, but in the ED if necessary.
• If the patient is going home from the ED, discharge with a prescription for acetylcysteine 600 mg
po BID for 2 days.
• Diuretics should not be administered for 24 hours after the procedure.
• Metformin should not be re-started until followup assures that no contrast nephropathy has
occurred.
Critical Results Read Back Policy
Staff reporting results to authorized clinical individuals must identify that the test result is
“critical” and request that the person receiving the information “read-back” the test result.
Detroit Tigers Transport Protocol
Transport Guidelines – Detroit Tigers & Comerica Park
The Detroit Medical Center has entered into a contract with the Detroit Tigers to provide
services for Tigers and opponent personnel while playing at Comerica Park.
Additionally, we will receive in transport patrons from Comerica Park should they
require ED evaluation. These patients will be transported to one of our facilities
according to the destination guidelines listed below. Universal Macomb Ambulance is
stationed at Comerica Park and will provide transport when necessary. Physicians
associated with Medical Center Emergency Services will be on duty at Comerica Park
during each home game. The on-duty emergency physician at the receiving facility
should receive a telephone call from the on-duty physician at Comerica Park when
transport is to be effected.
Destination Guidelines:
1. Patrons at Comerica Park (15 years of age and older) with trauma, intoxication, or
Code 1 Medical complaints: transport to Detroit Receiving Hospital (DRH).
2. Patrons at Comerica Park (15 years of age and older) with Code 2 or Code 3
Medical complaints: transport to Harper University Hospital (HUH).
3. Patrons at Comerica Park (14 years of age and younger): transport to Children’s
Hospital of Michigan (CHM).
4. Ilich family members, Detroit Tigers employees (this includes players, coaches,
umpires & staff), and opponent personnel with trauma (other than Code 1) or
medical complaints: transport to HUH. Care for an Ilich family member, Tigers
coach/player, or opponent coach/player will be coordinated with Donald Weaver,
MD (Chair/Specialist-in-Chief, Surgery) and Douglas Plagens, MD (DMC
Orthopedic Sports Medicine). In the absence of Donald Weaver, MD please
contact Brooks Bock, MD. The Senior Surgical Resident on call for HUH should
be contacted on all occasions.
5. Any patient, 15 years of age and older, with Code 1 trauma will be transported to
DRH. In the instance of Ilich family members as well as Tigers or opponent
coaches/players suffering Code 1 trauma, the care will be provided by the DRH
on-duty Level 1 Trauma Center Team and coordinated with Drs. Weaver and
Plagens. In the absence of Dr. Weaver please contact Dr. Bock.
These guidelines will be utilized for the Detroit Red Wings and Joe Louis Arena patrons.
DMC personnel have done exceptionally well in providing care for all concerned. Let’s
continue to show the world how to provide first class care.
April 10, 2006
Revised: June 16, 2006
Domestic Violence
Hotline 313-224-7000
Interim House 313-861-5300
My Sister’s Place 313-371-3900
Emergency Numbers and Codes
FIRE
EMERGENCY
ROUTINE
EMERGENCY
Fire Marshall
111
745-8353
117
745-8980, Pager 6499
MEDICAL
EMERGENCY
117
SAFETY OFFICER
Routine
MSDS
POISON CONTROL
24 Hours
24 Hours
24 Hours
Routine
Routine and 24 Hours
966-7838, Pager
92752
800-222-1222
745-5711
745-8401
Pager 4384 or 6940
745-9136, Pager 6424
24 Hours
745-8343, Pager 9195
RISK MANAGEMENT
Routine and 24 Hours
966-6104, Pager
00592
FACILITY ENGINEERING
AND CONSTRUCTION
Routine
SECURITY
RADIATION SAFETY
EPIDEMIOLOGY
ENVIRONMENTAL
SERVICES
745-8074
CLINICAL ENGINEERING Routine
745-8074
ADMINISTRATOR ON24 Hours
Pager 0921
CALL
TO REPORT ANY AND ALL COMPLIANCE, SAFETY OR ENVIRONMENTAL
ISSUES
COMPLIANCE HOTLINE
24 HOURS
888-484-9200
EMERGENCY CODES
CODE RED
FIRE
CODE YELLOW
DISASTER
CODE GRAY
TORNADO
CODE ORANGE
BOMB THREAT
CODE BROWN
HOSTAGE CRISIS
CODE VIOLET
RADIATION DISASTER
CODE 3000
CODE PURPLE
CODE PINK
CODE BLUE
INFANT/CHILD ABDUCTION
PREGNANT WOMEN ABOUT TO
GIVE BIRTH OUTSIDE OF LABOR &
DELIVERY
NEWBORN EXPERIENCING
CARDIAC OR RESPIRATORY
DISTRESS
ADULT CARDIAC OR RESPIRATORY
DISTRESS
Endocrinology
Currently, only Affiliated Inernists group, which isovered by fellow. Check call schedule
for day numbers and page 5531 at night and on weekends.
ENT
Covered by resident 0978.
Follow Up of Results
Please refer below for the complete protocol. In summary, the ED physician needs to fill
out a form in the follow-up book and include the patient’s name, MRN and tests to be
followed up. Nursing management will follow up the results and attempt contact if
positive result and patient has not yet been treated.
HUH Follow-Up Protocol
1. Follow-up book is kept in cabinet by physician sign in book.
2. Physicians put a sticker, in the follow-up book, of the patient who that they want
results checked. Most of the time, this will be gonorrhea or chlamydia cultures, but
occasionally it will be a herpes culture, RPR, blood culture (usually for a patient who
initially was to be admitted but who is discharged), or anything else that needs follow-up.
They complete the follow-up form.
3. Once per weekday, an administrative nurse checks the book and results.
4. If any positives, they attempt patient contact.
A. First, they attempt to call the patient at home and tell them that “new
information has come to our attention regarding your care and we ask the you
return to the Emergency Department immediately. Please tell the caregivers in
the Emergency Department that you were called back. A letter is also being sent
to you requesting that you return.”
B If the patient cannot be reached, they try calling the emergency contact and ask
that that they give the patient message:
“New information has come to our attention regarding the care of _______. We
ask the you ask them to return to the Emergency Department immediately.
Please tell to tell the caregivers in the Emergency Department that they were
called back. A letter is also being sent to them requesting that their return.”
5. For all positives, whether contacted by phone or not, a certified letter is sent on Harper
University Hospital Emergency Department stationary to the patient’s home address
stating “new information has come to our attention regarding your care and we ask the
you return to the Emergency Department immediately. Please tell the caregivers in the
Emergency Department that you were called back.”
5. Administrative nurse (at Harper, this is a clinical manager or designee) documents
attempts at contact in follow up book. Documentation of certified letter receipt is
attached to the follow up form, if received. This is stored for 5 years in confidential
storage. This information and all call back information will be kept accessible for
physician review when treating patients in the ED.
6. Physician is given this information, sealed and labeled confidential in their mailbox,
immediately after attempts are made at contact so that they can document this as an
addendum in the medical record
Gastroenterology
There is the Affiliated Internists service and the private attendings.
Affiliated Internists group is covered by fellow who can be contacted through the
Gastroenterolgy office 5-8601 or pager 5456.
Patients of the Affiliated Internists clinics are admitted to AI Hospitalist or MICU.
Contact private attendings directly for other admissions.
Gynecology
Gynecology beeper 5741
Rapid Follow-up
M-F 8:30a-9:30a or 12:30p-1:30 p except not Tu am clinic.
Patients are not given appointment but arrive with ED Discharge papers
Gyn/Oncology
Covered by resident 5548. Call resident for most issues.
Hematology/Oncology
Bone Marrow Transplant Service
BMT fellow (pager 9080) will assist with care. If febrile, consider isolation room.
Lymphoma/Leukemia Service
Consider contacting primary physician when caring for these patients. If patient is to
admitted, you may then have to contact physician who is rounding on inpatients. Clerks
can notify residents if patients are admitted.
Red Cell/Hemostasis (Sickle Cell)
Physician who is rounding on inpatients will need to be contacted for admissions. Clerks
can notify residents if patients are admitted
Patients with benign hematology disorders are admitted to HUH>
Oncology
Generally, primay physicians will need to be notified before admission and then
physician who is rounding on inpatients will need to be contacted if patient is to be
admitted. Clerks can then notify residents of admissions.
HIV
When patients with HIV present to the ED, referral to the Infectious Disease Clinic will
be considered.
Interpreter
1-866-588-4655
Cost number 4201
Karmanos Admissions
When writing the admission order for a patient who will be admitted to Karmanos, please
write in the order comments “Karmanos.” This is for patients who are going to a regular
bed and to the ICU.
Medicine
Admissions
First, determine who the primary physician is. Attempt to contact them (both when
patient is admitted to ICU or to the floor) and ask who they would like patient admitted
to. If they want the patient admitted to a different attending, contact them.
If the patient does not have a primary physician, admit to physician on call for “No PCP”
If the patient has a primary physician who does not admit at HUH or who has a primary
physician requesting that the patient be admitted to the hospitalist on call, please admit to
the group on call for “Hosp.”
Both the “No PCP” and “Hosp”: numbers are on the call boards in the ED Main and ED
South.
At the same time, check the patient’s insurance status. Determine if the patient has a
specific hospitalist group to which they should be admitted.
After you know which attending will be admitting the patient and have spoken with them,
determine with them if the patient should be admitted to an ICU, telemetry or general
medicine bed. If the patient is to be admitted to a telemetry or general medicine bed, ask
them if the patient should be admitted to the Medicine A or B service. Now, write the
order to admit and in “comments, write if it is “Med A” or “Med B”. Clerks will contact
Medicine A or B physician or PA to notify them of the admission to their service.
Please refer to “Admission Patterns” for help with information about who to admit
certain attendings’ patients./.
Med B pager 5565
Med A pager 0092
MICU
Fellow at pager 6428
Contact fellow for MICU bed. Also, contact primary physician. Admitting physician is
usually the primary physician or their designee. If patient has a Karmanos physician,
admission to that physician to be considered and notification of that Karmanos physician
attempted. Intensivist will follow patients in ICU.
If patient is a Karmanos admission even if going to the ICU, please note this in the
comments of the admission order.
.
Remember to notify primary physicians when patients are admitted to hospital, even
when it is to the ICU
Needle sticks
Employees with possible exposure to infectious body fluids will be referred to DRH
Occupational Health Clinic (M-F business hours) or ED (off hours), if appropriate for
discharge and immediate followup.
Nephrology
There is the Affiliated Internists service and the private attendings. Affiliated Internists
group is covered by fellow who can be contacted through the pager 5513. Private
attendings like Effendi, Forsac, Griggs, Middlebrook, and Tubie are contacted
themselves.
Nephrology patients are often admitted to 10 Webber South South with its dialysis
machines, telemetry capabilities and ability to manage insulin drips..
Neurology
Covered by resident at pager 9429. If patient has a private neurologist (Andaya, etc),
they can be contacted directly.
Stroke pager…pager 52873
Neurosurgery
Covered by a PA during the day and resident at night.
Women who are diagnosed with pregnancy and it is their first diagnosis by a health care
provider are offered HIV, syphilis and hepatitis B testing. If they consent, the order is
written and they are given instructions for “New Pregnancy” in Logicare and are told to
follow up with Gynecology in the walk-in clinic in 2-3 days. They are told the time that
the walk-in clinic is open.
Observation Patients: (23 hour) Obs vs. Full Admit
1.
It is the use of a bed & periodic monitoring by hospital staff to evaluate an
outpatient’s condition to determine the need for possible inpatient admission.
2. Does Observation require a doctor’s order? YES: the order must be written
prior to the initiation of observation services and may not be backdated. Order must
be dated & timed.
3. How should the physician write the order for outpatient observation
versus inpatient admission? State the level of care being ordered, e.g., “Place
in observation status” or “Admit as inpatient”.
4. When is outpatient observation appropriate?
a. The physician needs additional time to evaluate the patient to determine his need
for admission.
b. The physician feels that the patient will respond rapidly.
5. What doesn’t qualify for outpatient observation?

Convenience of patient/family/doctor


Admitting into observation before outpatient surgery
Awaiting placement in a long term care facility.
6. If an observation patient is acute and is not responding to treatment,
can the patient be admitted as an inpatient? YES, the observation stay can
be converted to inpatient within 48 hours; the physician must then write an order to
“admit as inpatient”. The documentation in the chart must support medical necessity
of the inpatient admission.
If you have questions- please ask your Bed Management Coordinator.
7. What are some examples of observation status?
 Abdominal pain not requiring surgery
 Allergic reaction, generalized
 Altered mental status
 Anemia
 Asthma
 Atypical chest pain
 Heart Failure
 Back pain
 Complications outpatient post-surgery -discharged
 Epistaxis, uncontrolled
 Headache, unknown etiology
 Hypertension
 Kidney stones, renal colic
 Nausea/vomiting/dehydration
 TIA
 Weakness/dizziness/syncope
 Urinary retention requiring cath
 Vaginal bleeding
 Unsure/unsafe to discharge
8. EXAMPLES FOR CHEST PAIN EVALUATION:


History not suggestive unstable angina, no high risk factors, cannot exclude ischemia, noncoronary chest pain= observation status
New onset symptoms consistent with ischemic heart disease but not associated with EKG
changes or convincing diagnosis of unstable ischemic heart disease at rest or with minimal
exertion, known CAD but symptoms do not suggest a true worsening= observation is
beneficial because etiology of symptoms is unclear.
9. CHEST PAIN CASE SCENARIOS:


67 year-old male, history of palpitations for 2 months, usually at rest in evening before bed. Exam
unremarkable, EKG sinus rhythm. Enzymes drawn and sent. This patient requires outpatient
evaluation. Admission would not be warranted.
If EKG is nonspecific and patient doesn’t meet criteria for MI/ischemia, but history is suggestive of
unstable angina and there is high risk clinical CAD, old MI or CABG, admitting patient with
unstable angina is appropriate.
Obstetrics
>16 weeks, triaged to LRC unless unstable medical condition, major trauma, or concern
for imminent delivery (crowning). If patient >16 weeks remains in ED, page Ob resident
during the day or Gyne resident at night. Call a Code Purple for any delivery or
imminent delivery in ED.
Ob pager 9102
LRC 5-0645
Rapid Follow-up for new Ob
Mo or Tu from 8:30a-9:30a and Wed or Th from 8:30a-9:30a or 12:30p-1:30p.
Patients are not given appointment but arrive with ED Discharge papers
Pediatrics
Chief Resident DMC 9454
Transport team DMC 5142 Phone 5-5800
NICU 5-0071
Page for all emergency deliveries in ED.
Peer Review
Initial review of peer review cases will be done by Chief or designee. Cases with issues
for further consideration will be sent to the involved practiononer via DMC or Wayne
State Medical School email. A response will be requested. After receipt of the response,
the case will be presented to the HUH staff for review at the bimonthly staff meeting.
Members of the HUH staff in attendance will review the case and response. With the
involved practitioner out of the discussion, a vote will occur on an adjudication. The case
and adjudication is kept in the department database,
Physician Assistants
Introduction when seeing patients:
''Hi..Mr/Mrs____, I am ____, the Physican Assistant and working with Dr ______.today. What
can I do for you?”
At the end of the session with the patient, they should mention if they did or did not feel that it
was necessary to have the doctor come in.
Badges must be worn visible for patients to see.
PICC Lines
Available M-F from 5a-11p and S/S 11a-11p by paging PICC line team at 97549, 97551,
97547 or 97548. Or simply write an order and clerks will take of the process.
They are also available from Interventional Radiology during business hours.
Plastics
Cover hand cases as well.
Psychiatry
Per Dr. Sweeny on 7/20/2006:
For any patient who is to be transferred to DRH for the primary reason of a psychiatry evaluation,
the transferring physician will first contact the Psychiatrist at the DRH Crisis Center. Phone 313
745 3546. If there are any questions, concerns, or problems with the transfer please contact Dr.
Ali Amisadri, M.D. Chief of Psychiatry at DRH, by calling 313 325 7492. Please do not utilize the
Senior Physician at the DRH ED to accept these transfers.
If a patient is suicidal or homicidal, please have a nurse or other witness complete the peittion.
Certification by an ED physician should not occur.
Radiology
Wetread is a potentially helpful function that should be utilized when reading xrays and
when receiving reports. Although potentially helpful, it should not be used as the sole
way of assuring that radiology agrees with your interpretation. After reading xrays, final
reports need to be checked.
During business hours (8a-5p), access the attending radiology schedule by going to the
Wayne State Radiology Portal. Type radiology in the address bar on the DMC intraweb.
It will forward you to the WUS Radiology Portal. Select schedules, then Har-Htz Staff
Schedule.
Or, refer to the numbers below”
Radiology Front Desk 5-8401 and 5-8402
Interventional Radiology
M-F 8a-5p
07777
Every Day 5p-8a
09999
Neuroradiology
M-F 8a-5p
08888
Every Day 5p-8a
09999
Body (CT/US/Generals)
M-F 8a-5p
Every Day 5p-8a
09999
09999
During off hours, the HUH radiology resident can be paged at 09999.
Refer to Attachment C for ultrasound schedule or ask clerks who are educated on this
schedule.
Radiology Numbers at DRH
The resident should be in the reading room most of the time. The
numbers are:
53425 - phone at reading station at entrance to reading room
68606 - phone at second reading station in center of reading room
54683 - phone in "back" room of reading room
In addition, these numbers may be helpful
53423 - Main desk for radiology in ER
53421 - phone to tech work area
37761 - phone to CT room
STEMI PRINCIPLES
STEMI PRINCIPLES
1. The EKG is the first vital sign.
2. The ED physician is in charge of the patient.
3. If the ED physician suspects an ST-segment elevation or new
LBBB, the global STEMI page is issued immediately.
4. The GOAL is STEMI activation within 10 minutes of arrival.
5. The cardiology fellow is not to be called before the STEMI page is
issued, and the page is not to be delayed or canceled pending a
cardiology consultation.
6. It is better to err on the side of caution and to issue a false alert
rather than to delay STEMI activation. Additional clarification can be
obtained while the team is in transport.
7. The cardiology fellow will not over-ride the orders of the ED
physician for an urgent cardiac catheterization.
8. Unless there are valid clinical reasons to delay the cardiac
catheterization, other testing will not delay STEMI activation or patient
transport to the cardiac catheterization lab.
9. The patient will be in the cardiac catheterization lab within 15
minutes of the call to transport.
10. The re-perfusion target is firm at < (less than) 90 minutes.
STEMI Protocol
STEMI PROTOCOL
Effective 03/14/2006
MOBILIZING THE HARPER UNIVERSITY HOSPITAL CARDIAC
CATHETERIZATION TEAM
A./ CANADIAN PATIENTS
E.D. Actions
[1] Receive call from Windsor hospital ED and IMMEDIATELY active the STEMI
protocol. Use “519 STEMI” in the alpha display to indicate a Canadian patient.
[2] Receive the patient as an entry-point only. Unless patient is too unstable to move,
send to the Cath Lab without examination or testing within the ED. This is an
imperative from the Canadian healthcare provider.
[3] Patient will be registered as Harper IP under Dr. Theodore Schreiber.
[4] Patient is to be registered and taken directly to Cath Lab (if patient is from
Windsor)
B./ AMERICAN PATIENTS
E.D. Actions
[1] Patient triaged and ECG acquired
[2] If ECG is positive for acute STEMI, DRH ER /HUH E.D. mobilize the Cardiac
Catheterization Team as follows:
Hours of 7:00 am – 5:00 pm, Monday through Friday (holidays excluded)
Telephone the Cath Lab at 313-745-2693. If no answer refer to after hours/holidays.
After hours or on Holidays
E.D. will activate the Global Pager number 5692 or alternatively, via the DMC
Corporate Directory. Type “STEMI” and either the HUH ARC (“313-7451477”) or DRH ED (“313-745-3356”) telephone number, before clicking to
page(attached paging instructions when using DMC Corporate directory for first
time users.) This will activate the three Harper Cath Lab pagers, the
Interventionalist’s pager, the Cardiology Fellow’s pager (on-site), the
Interventional Cardiology Fellow’s pager, and the Perfusionist on-call pager.
[3] REQUIRED CATH LAB ACTIONS:
[1] The Cardiac Catheterization Team will confirm receipt of page by responding back
to the number indicated on their pager and by paging the 6666 pager with the following:
The RN will enter “111”, the CVT will enter “222”, and the RT will enter “333”.
Approximately 10 minutes prior to arrival, the RN will call the Emergency
Dept/Unit to transport the patient to cath lab.
[2] The Interventionalist on call: assigns pager number 3033 over to their individual
pager number when they are on call. This way they will be paged when the 5692 STEMI
List Page is paged. Do this by dialing 123 and listen to the prompts to change their status
(sign out pager 3033 to their individual pager). If you have any questions, please call Lisa
Strange at 55132.
[3] The Interventional Fellow on call: assigns pager number 9155 over to their
individual number when they are on call. This way they will be paged when the 5692
STEMI List Page is placed. Do this by dialing 123 and listen to the prompts to change
the status (sign out pager 3033 to their individual pager). If you have any questions,
please call Lisa Strange at 55132.
STEMI PROTOCOL (cont.)
[4] The Cardiology Fellow on site: calls the DRH O.R. at 745-3182, to determine if
assistance is being provided. If the on-site Cardiology Fellow does not receive
confirmation from one member of the Cardiac Catheterization Team, another member
should be contacted by the on-site Fellow (please refer to Cardiac Catheterization team
contact list). The Cath Lab RN will page the Cardiology Fellow when he/she is ~ 10
minutes away. The fellow will go immediately to the Cath lab and call the E.D. @ 60705
and speak with the clinical Coordinator instructing them to have the patient transported to
the Cath Lab. Patient will only be sent after receiving order from Cath Lab.
5. Emergency Physician will speak to cardiology fellow and/or interventionalist attending
when they call back for weekend or after hours. M-F daytime Cath Lab will call for
patient, the emergency physician does not need to talk to the fellow unless he/she desires.
6. The STEMI process MUST always be initiated through the patient unit clerk at each
site.
Sunquest
USER NAME: ALAB
DEVICE CODE: ER
ACCESS CODE: INQ
PASSWORD:INQUIRY (doesn’t show that you typed this on screen but it is there)
FUNCTION: INQ
Type in patient’s SS# and press enter. Select patient/visit and press enter.
Surgery
Generally, resident is contacted before attending, but use judgement depending on
urgency.
Transfers
Stable patients will be accepted to the HUH ED.
In particular, DMC Care patients necessitating possible admission to Gynecology and
who are stable for transfer from outside facilities may be accepted to HUH by the ED
physician and evaluated in the ED.
(Kidneys/Pancreas)
Under 6 months since transplant
Call attending (Scott Gruber, Darla Granger, Miguel West)
Transplant surgery resident on call from 6:30a-5p M-F at pager 11412
Weekend and night resident coverage by surgery resident
Over 6 months since transplant
Call nephrology transplant service and fellow at pager 5513
Triage
clinical circumstances may
necessitate changes. Physicians are to be flexible
and work as a team, calling each other when changes
in the triage assignment are necessary.. The administrative
These are guidelines and
physician on call can always be paged if agreement between attndings or clinical
coordinator is not found.
WEEKDAYS
9a-1p
First 4 patients to ED South, then 1:1 ratio between the ED Main and South
1p-8p
2:1 ratio between the ED Main and South
8p-11:30p 1:1 ratio between the ED Main and South
11:30p-9a
Sequential triage between A and B teams
All ESI Level 1 patients or ESI Level 2 patients with a high risk or unstable condition are
to be placed in ED Main. All patients with a primary eye complaint are to be triaged to
the ED South . The respective teams will get a “skip” when triaged these patients.
When a PA is working, all Urgent Care patients are triaged to ED South Urgent Care,
Team D. Those patients are ESI Level 4 and 5 patients and ESI Level 3 patients if a
young woman with primary gynecologic complaint. An hour before the PA is to finish
their shift, Team D will stop getting patients. A PA can change the triage distribution if
they feel that they have too many patients or if they feel that the flow would improve by
changing the distribution.
9a-11:30p
First 4 patients to ED South, then sequential triage between ED Main and South until 1p
and ratio changes to 2:1.
11:30p-9a
Sequential triage between A and B teams
All ESI Level 1 patients or ESI Level 2 patients with a high risk or unstable condition are
to be placed in ED Main. All patients with a primary eye complaint are to be triaged to
the ED South The respective teams will get a “skip” when triaged these patients.
When a PA is working, all Urgent Care patients are triaged to ED South Urgent Care,
Team D. Those patients are ESI Level 4 and 5 patients and ESI Level 3 patients if a
young woman with primary gynecologic complaint. An hour before the PA is to finish
their shift, Team D will stop getting patients. A PA can change the triage distribution if
they feel that they have too many patients or if they feel that the flow would improve by
changing the distribution.
The Lead Nurse, in consultation with attendings working, can change the triage scheme
as conditions necessitate. As well, patients who are waiting for admission can be moved
to different areas. If there is not unanimity on such decisions, the administrative
physician on call and nursing management will be paged to make a decision.
WEEKENDS: Patients are triaged to ED South from 9a-11:30p. Team C gets the first
four patients who present at 9a. After that and until 11:30p, patients are triaged
sequentially between the ED Main and South So, the ED Main gets one patient for every
one that goes to the South.
TEAM D/URGENT CARE/PHYSICIAN ASSISTANTS
Physician Assistants can operate independently. If any concerns, ED South attending is
available for assistance. If they are not available, ED Main physician is available. If any
assistance provided (questions, examination), ED physician will do dictation.
Physician assistants must consult physician when following vital signs:
Temperature 103.5 or greater
SBP>200 or <100
DBP>130
Pulse>120 or <50
Respiration>24
Physician assistants must consult physician when a pregnant patient, with vaginal
bleeding or abdominal pain who does not have a confirmed IUP, is being discharged.
A PA can change the triage distribution if they feel that they have too many patients or if
they feel that the flow would improve by changing the distribution.
Trauma
Trauma codes:
Provide interventions that are emergently indicated while attempting to expeditiously
transfer patient to DRH. Call DRH senior attending at 6-0701 to transfer.
Isolated orthopedic injuries not necessitating trauma code/team:
Manage as appropriate and orthopedics consultation as needed.
Ultrasound
Available 24 hours per day. Note that pregnant women 12 weeks or less are done by the
ultrasound department and Obstetrics does them for later gestation. Clerks are educated
on schedule or refer to protocol below:
DAY
MONDAY
OTHER
EMERGENT
ULTRASOUNDS
(Pelvis/Abdominal)
DVT ULTRASOUNDS
7:00 a.m.-11:30 p.m. Harper US
8:00 a.m.-4:00 p.m. Harper Vasc. Lab
11:30 p.m.- 7:00 a.m.
See numbers below
4:00 p.m.-5:00 a.m. DRH US
DRH US
TUESDAY
SAME AS MONDAY
WEDNESDAY
SAME AS MONDAY
SAME AS MONDAY
8:00 a.m.-4:30 p.m. Harper Vasc. Lab
4:30 p.m.- 6:00 a.m.
On-call Vasc. Lab Tech.
THURSDAY
FRIDAY
SATURDAY
SUNDAY
SAME AS MONDAY
SAME AS WEDNESDAY
7:00 a.m.-5:30 p.m. Harper US
8:00 a.m.-4:30 p.m. Harper Vasc. Lab
5:30 p.m.-11:00 p.m. On-Call (Harper)
PRE-APPROVAL REQUIRED
PAGE RESIDENT #09999
4:30 p.m.-12:00 a.m.
On-call Vasc. Lab Tech.
11:00 p.m.- 7:00 a.m.
See numbers below
12:00 a.m. - 5:00 a.m. DRH US
DRH US
8:00 a.m.-11:30 a.m. Harper US
8:00 a.m.-4:30 p.m. Vasc. Lab
Phone 58828 or Telepage 55151
11:30 a.m.-11:00 p.m.On-Call (Harper) On-call Vasc. Lab Tech.
PRE-APPROVAL REQUIRED
PAGE RESIDENT #09999
11:00 p.m.-7:00 a.m. DRH US
See numbers below
4:30 p.m.-7:00 a.m. DRH US
7:00 a.m.-11:00 p.m. On-Call (Harper)
PRE-APPROVAL REQUIRED
PAGE RESIDENT #09999
8:00 a.m.-5:00 p.m. Vasc. Lab On-call
On-call Vasc. Lab Tech.
11:00 p.m.-7:00 a.m. DRH US
See numbers below
5:00 p.m.-7:00 a.m. DRH US
HARPER ULTRASOUND
(1)Phone: 59513
(2)Pager: #6354
(3) Supv. Pager: #95167
DRH ULTRASOUND
(1) Phone: 53465
(2) Pager: #95003
(3) Supv. Pager: 5210
HUH VASCULAR LAB
(1) Phone: 58828
(2) Telepage: 55151
(3) Supv. Pager: #6999
Contact department in numerical order. If no one answers the phone, do not leave a message. Proceed to pager. If no response
to pager, repeat page. If second page unaswered then notify appropriate department supervisor.
53425:
68606:
54386:
37761:
Reading room (reading station by door)
Reading adjacent to reading station
Back office
CT
53423: Front desk
53421: Tech work area
202-456-1414 Help and general information
XRAY
The DMC has Wetread so that ED physicians can make sure that their preliminary
reading is reviewed by a radiologist. This system has the potential for the error so HUH
physicians take responsibility for checking radiologist xray reports of their patients.