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.

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

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: Lower Acuity- open 24/7

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

At least 3 resident/PA teams Supervised by an attending

Section C: Lower Acuity- open 11am-2amTRIAGE 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

Not available on every shift 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 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 BA should help facilitate if you have difficulty 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 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

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

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. 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 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 painplace in CPC observation EPIC Note:

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

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 in Pick 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 button You are responsible for…

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

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 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 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 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 Section Click Print Hand Instructions to nursewith signed prescriptions

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 OFF-SERVICE RESIDENT DIRECTOR.

PLEASE SIGN YOUR NAME AND THE DEPARTMENT YOU ARE FROM.

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

jaydale.poyotte@yale.edu

ALINA TSYRULNIKASSISTANT RESIDENCY DIRECTOROFF-SERVICE RESIDENT DIRECTOR

CLINICAL INSTRUCTORDEPARTMENT OF EMERGENCY MEDICINEYALE UNIVERSITY SCHOOL OF MEDICINE

ALINA.TSYRULNIK@YALE.EDU

THANK YOU FOR YOUR ATTENTION