EMERGENCY PEDIATRIC GROUP

DEPARTMENT MEETINGAugust 8, 2007

Hughes Spalding

3

Hughes SpaldingStaffing – Hughes Spalding is up to full staffing. There is currently 1 RN position openNursing update• The Rapid Response Team is currently training nurses in

response to the closing of PICU.• Room One is slated to become a Procedure Room• A new med rec form will streamline ED physician signature

process and lower the number of unsigned forms. The new form has not yet been approved.

Issues with transfers – general transfers to other facilities seems to be working well other than with orthopedics cases.Alert• New interns: provide close supervision• Do not leave the ED/ UC without informing the senior resident

and charge nurse (even for a few minutes)• Prehospital medications cannot be given to patients once they

arrive in the EDHS physician documentation – See Attached• Review and send suggestions or comments to Jeff Linzer

Admissions to the NICU at Grady• Age less then 28 days• Infected babies may be accepted if isolation room available

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Egleston

6

Orthopedic IssuesNursing checklist

What to do when there is no orthopedic coverage at Egleston• Place Egleston ED on a modified diversion for orthopedics

only. Type “Ortho Diversion” in the “enter alert” section of the GAEMS website. Update the GAEMS website on a daily basis and write it on the wipe-off board for the physicians.

Accept “Trauma Stats” and “Trauma Alerts” with OBVIOUS orthopedic injuries only if they are UNSTABLE AND WE ARE THE CLOSEST FACILITY. STABLE trauma patients with obvious orthopedic injuries should be diverted to Scottish Rite. NOTE: Here are some examples of Orthopedic injuries that meet Trauma Stat and Trauma Alert criteria:TRAUMA STAT: Proximal amputationsTRAUMA ALERT: Proximal extremity GSW, Pelvic Fracture, Femur Fracture, Amputation or de-gloving distal to knee/elbow

7

Nursing checklist - contd.

EMS call-ins for isolated OBVIOUS orthopedic injuries should be diverted to SRAll orthopedics referrals from outside hospitals including HS and our own Immediate Care centers should be diverted to SR All walk-in patients requiring orthopedic consultation will be transferred to SR. You must follow the current transfer policy and fill out all of the transfer paperwork for these patients. Call Children’s Response for transport ext. 56540You will need to log any and all patients that were diverted due to no orthopedic coverage in the Diversion Log Book. In the event that Scottish Rite is unable to accept a patient, you may call one of the following hospitals for transfer:

• MCG @ Macon: (478) 633-1584

• MCG @ Augusta: (706) 721-3153

• Erlanger Medical Center @ Chattanooga: (423) 778-7000

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Physician information

Effective August 3rd emergency orthopedics coverage is limited to 15 days out of the month leaving large gaps in the schedule

• Coverage is 0700-0700• If there is only a resident listed on the EG call schedule (no attending) -

there is NO orthopedics coverage - please do not call the resident

FOR ESTABLISHED PATIENTS OF AN ORTHOPEDIC PHYSICIAN• ie. post surgical complication, splint problems after orthopedic reduction

etc) please call the answering service of the orthopedic physician who performed the procedure

FOR NEW PATIENTS ON UNCOVERED DAYSStabilize and transfer to SR after talking to the orthopedic attending on call at SR (this process has been confirmed with Dr Mike Schmitt @ SR)

• If there is a question re appropriate management of a specific orthopedic injury, consult your colleague in the ED at EG before calling the SR orthopedic attending for a consult.

• We hope to work out some practice guidelines with the orthopedics attendings to ensure standardized care for the most commonly encountered fractures.

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Physician information

FOR OUTSIDE REFERRALS• No orthopedic patients should be accepted at EG- refer to SR

FOR UNSTABLE TRAUMA PATIENTS FROM THE SCENE• Accept all for stabilization - once stabilized, if necessary may need to be

transferred for orthopedics care• Since SR does not do chest and abdominal penetrating trauma, we

should accept these patients to EG and stabilize and transfer if definitive orthopedic care is needed.

FOR STABLE TRAUMA PATIENTS FROM FIELD OR ANY TRAUMA PATIENT AT OUTSIDE FACILITY • Do not discriminate based on trauma stat, alert or consult, rather base

our decisions on the pre-hospital report of whether there is major orthopedic trauma which may require the immediate intervention of an orthopedic surgeon. It would not be in the best interest of the child to allow them to come to EG knowing that we do not have orthopedic coverage

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Physician information

HAND SURGERY ISSUES• On "even" days if orthopedics is not on, there is no hand

coverage. As per previous policy the hand surgeons at SR will not take these patients without a direct call from an "orthopedic consultant" at EG. Nevertheless SR remains our 1st choice for transfer. For children ≥ 15 years you can try Piedmont or Grady and then Augusta, Macon, Chattanooga

IF SCOTTISH RITE IS ON TRAUMA DIVERSION ON A DAY WITHOUT ORTHOPEDIC COVERAGE• Deal with it on a case by case basis• Involve the trauma surgeon

IF SR ORTHOPEDICS REFUSES A PATIENT FROM EITHER EG OR HS AND YOU AS AN ED PHYSICIAN DEEM EMERGENCY STABILIZATION IS NECESSARY• Call the administrator on call

Fast Track

Goals and Progress

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Overall Goal

Keep our LOS time to 90 minutes or less for all fast track patientsThis will help our overall flow in EDProvide excellent customer service by being thorough and efficientUltimate goal will be a LOS of 60 minutes or less

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Non Fast Track Times

Month Jan Feb Mar Apr May Jun Jul

Count 2930 3072 3272 2983 3081 2670 2801

LOS(mins)

Max 1248 1591 1178 1194 1186 1472 1296

75th 261 273.75 300 281 283 264 248

Median 172 188 207 190 188 164 159

25th 110 121 142 121 120 102 100

Min 12 24 16 28 26 25 22

Mean 202 215 234 219 220 207 191

Std Dev 128 136 131 135 140 161 128

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Fast Track Times

Month Jan Feb Mar Apr May Jun Jul

Count 442 1171 1340 774 686 368 371

LOS(mins)

Max 388 548 726 417 491 290 453

75th 169 190 199 190 175 165 142

Median 133 143 156 149 139 122 101

25th 99 109 116 113 112 89 77

Min 38 30 26 36 22 34 22

Mean 141 156 163 157 148 130 113

Std Dev 57 67 67 61 55 53 55

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Fast Track Total LOSno pinks/redEgleston

80

90

100

110

120

130

140

150

160

170

Med

ian(

Tota

l LO

S)

133

143

156149

139

121.5

101

1 2 3 4 5 6 7

Month

Target = 90

50

60

70

80

90

100

110

120

130

140

Med

ian(

Tota

l LO

S) 113 116

108

8885

66.5 67

1 2 3 4 5 6 7

Month

Target = 90

Scottish Rite

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ED Overall LOSEgleston

160

170

180

190

200

210

220

230M

ean

of T

otal

LO

S1 2

1 2 3 4 5 6 7

Month

mean = 204.2

mean = 190.1

140

150

160

170

180

190

200

Mea

n of

Tot

al L

OS

*1 2

1 2 3 4 5 6 7

Month

mean = 180.2

mean = 158.6

Scottish Rite

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Problems

Triage End to Bed time• Space restraints• Can’t really fix this until new ER opens• But this is not improved in summer

Bed to MD time• What can we do to affect this?

AwarenessStaffingOther

• We will be monitoring this and total LOS

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Staffing

Night coverage in September• 2a-7a shifts• 1st dibs to the 5p-2a HS ED doc• Rest open for moonlighting

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Faculty Issues

Grady privileges need to be maintained to keep malpracticeTDJ update - use by August 31, 2007Ultrasound course• Can use this segments TDJ or next segments TDJ

(or partial from each)• Remember that the APA is in Hawaii next year -

big expense• 10 people/ 3 sessions in september and october• Cost approx $730/attending• There may be 1-2 open slots for urgent care docs

as well

Revised: 8/1/2007 Original: Chart Copy 1: Chief of Service Copy 2: Billing

---

Children's Healthcare of Atlanta

at Hughes Spalding

EMERGENCYCENTERPROCEDURERECORD STICKER

o Seeadditionaldocumentation

Date & Time

Pre-Procedure Diagnosis

Post.Procedure Diagnosis

Procedure Type Risk, benefits and alternatives discussed with: Dlmplied emergent consentLaceration: Location Length: DSimple DLayered/lntermediate DOther:

1&0:DSuperficial Simple/Paronychia DSuperficial Complex/Multiple DDeep Soft Tissue DPerianal DOther:

Ortho: DClosed Fracture Care DSplint DStrap DDislocation DArthocentesis Location:

Foreign Body DEar DNose DCornea DConjunctiva DSQ Simple DRing DOther:

DLumbar Puncture DCerumen Removal DCPR Dlntubation DBladder Cath DBurn Care DVascular Access, Type:Other:

Attending

Assistant(S)Anesthesia DAnxiolysis DProcedural Sedation

Procedure(s) In Detail DUsual Clean And Prep

Estimated Blood Loss (EBL)Drains/Tubes

Case Classification: DClean DClean Contaminated DContaminated DDirty & Infected

Complications DNone

Disposition/Condition

Practitioner/Resident Signature & ID Number

Attending Signature & ID Number

01 was present for the key/critical portion of the procedure and immediately available the remainder of the time

01 was at the bedside for the entire procedurePROCEDURALSEDATION ON/A

If not for procedure listed above then name of service and procedure:NPO Solids NPO Clears Pre-Medication ASA Class (circle): 1E 2E 3E 4EPrevious Sedation/Anesthesia? DYes DNo Previous Anesthesia/Sedation Reactions? DYes DNo ON/A

Note any changes from ED H&P:

Informed consent obtained from: Dlmplied emergent consent

Sedation Summary: Start Completed Sedation Duration DAttendingbedsidetime>30 min

List medication(s), total dose and route:

DAdequate sedation achieved Dlnadequate sedation, procedure completed Dlnadequate sedation, unable to complete procedurePost Sedation Evaluation: DVS Stable DReturned to satisfactory level of consciousness DTolerating PO

Complications: DNo Post-Sedation Complications

Practitioner/ResidentSignature& IDNumber AttendingSignature& ID Number

Revised: 8/3/2007 Original: Chart Copy 1: Billing

Children's Healthcare of Atlanta

at Hughes Spalding

EMERGENCYDEPARTMENTPHYSICIANRECORD STICKER

o Seeadditionaldocumentation

ExamDate:

[ExamTime: I Translationrequired I 0 Triagesheetreviewed I Relevantfindingsfromreviewofoldrecords:Language: andexceptionnotedbelowType:

CHIEFCOMPLAINT: UnabletoobtainHxduetoDAbsenceofguardian/historian0 Patienrsunstableclinicalcondition

HPI: HxobtainedfromDParentDRelativeDGuardianDEMS/PD/DFACSDOther:

REVIEWOFSYSTEMS(Circlepo$es Slashnegitives) Const DNeg Fever/Chills/Bodyaches/!Appetite NeuroDNeg Headache/WeaknesslDizziness

Eyes DNeg Pain/Discharge/Photophobia/RednessGI DNeg PainNomitinglDiarrhea/Constipation PsychDNeg Depression/SuicidaVHomicidal

ENT DNeg Rhinorhea/Sorethroat/Earpain GU DNeg Dysuria/FrequencylDischargelUrinet or! AI DNeg SeasonalaliergiesIHlVrisk

CV DNegChestpain/Palpitations MusS DNeg Pain/Jointswelling/LimplBackpain Endo DNeg Polyuria/Polydypsia

Resp DNeg CoughiSOB/Wheezing/Choking/StridorSkin DNeg Rash HemILDNeg Easybruising/Swollennodes/Pallor

PMH:DNothingpertinent Allergies DNKMA ImmunizationsDUTDDDelinquent/DeferredLMP:

Medications: Hospitalizations/Surgeries:

SH:DHomecareDDaycareDSchool011IcontactsDTobaccoexposureDRecenttravel DSexuallyactive,Protection:DUsedDNone

FH:DNon-contributory

PHYSICALEXAM:(NL:normal;SIfike9IIIifnotexamined)TEMP HR RR BP 02Sat PAIN WT

General GU DNL

Eyes DNL Mus DNL

HeadlENMTDNL Skin DNL

Resp DNL Neuro DNL

CV DNL Psych DNL

GI DNL HemlLymphDNL

IMPRESSION& PLAN LAB,X-RAYANDEKG INTERPRETATION REASSESSMENTS(note time) OSeeRespiratoryform

Consult Calledat Arrivedat: X-rayinterpretedbyDPECCattendingDRadiology Hoursof IVhydration:

ATTENDINGPHYSICIANNOTE 01 personallyperformedtheH&P,anyresidentdocumentationisincidental

o Totalnumberofminutesbyattendingphysicianindirectandindirectcareofthiscriticallyillpatientexcludingprocedureorotherservicetime: minutes

CaretransferredtoDr. at Receivingphysiciansignature&10number.

DIAGNOSIS(listsign/symptom/complaintfrommostserioustoleast)

CONDmONONDISCHARGE DISPosmON:Time: OHome Din custodyOFACSlLawOTransfer/Mode:

DGood DFair DSerious DCriticalDExpired DAdmissionDSlep-downService;DGen PedsDOlher OCR DMorgue

Practitioner/ResidentSignature& number

I Attendingsignature&number