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Archive for August, 2008

Pictures For Education

From: “Cohen, Ari” <Ari.Cohen@mountsinai.org>
Date: August 22, 2008 1:48:22 PM EDT

Please if you are taking pics for educational purposes use the flash card in the attending cabinet. Please take picture of patient label before and after your pictures. Please have patient consent scanned into chart. Please put the Photo ID page in the loose leaf labeled “photo book” so we can have a catalog of the pictures we have in stock ( I am putting this looseleaf over the PACS)

Written by reuben

August 22nd, 2008 at 6:02 pm

Posted in Peds,Photography

AIDET

AIDET is the acronym for a tool implemented by the Studer Group to improve communication with patients. The tool has been proven to decrease patient anxiety, increase adherence with your recommendations, improve clinical outcomes and increase patient satisfaction. AIDET stands for:

A = Acknowledge

  • Make Eye Contact
  • Greet in a pleasant manner

I = Introduce

  • State your name and role

D = Duration

  • Give the patient expected time for tests, results and length of stay

E = Explanation

  • Explain the reason for tests

T = Thank You

  • Consistently thank the patient
  • Ask about questions before ending the session

Written by phil

August 18th, 2008 at 8:10 pm

Posted in Service Excellence

Prevention of Unrecognized Arterial Cannulation

Written by phil

August 17th, 2008 at 12:01 pm

OB/GYN Follow Up

First Trimester Bleed/Ectopic Precautions
Call ext 47238 and leave the following information:
1. Last and first name, date of birth and the medical record number of the patient.
2. An active telephone contact.
3. The time range that the patient should be scheduled for follow-up care.

Other Indications for Referral to OB/GYN
Pregnancy
Dysfunctional uterine bleeding (H/H>30)
Post-partum patients
Vaginitis
Urinary tract infection
Pelvic inflammatory disease
Sexually transmitted diseases
Contraception (all forms)
Routine Gyn exam
Pelvic pain

Refer to Specialty Clinics
Colposcopy (Abnormal PAP) -> Pt with abnormal PAP smear
Menopause
Cystometrics (Urinary Incontinence) Speciality clinics

Refer to JMF Clinic not GYN
Sexual assault patients

Refer to Gyn Surgery Clinic
Bartholin cyst/abscess (1 week//use Word Catheter)
Ovarian cyst premenopausal pt (>5 cm) (1-2 wk)
Ovarian cyst postmenopausal pt (any size) (1-2 wk)
Pt requiring elective surgery (1-2 wk)
Fibroids(symptomatic or >12 wk) [3-4 wk; If H/H <30, w/in 1 wk] DUB unresponsive to treatment [3-4 wk; If H/H <30, w/in 1 wk] Cysto/rectocele 3-4 wk (needs neg urine C&S) Uterine prolapse 3-4 wk Other Gyn pathology 3-4 wk Refer to Infertility Clinic Infertility Gyn endocrine disorder OB/GYN Consultation:

Written by phil

August 17th, 2008 at 12:00 pm

Posted in OB/GYN

ICU Bed Management Protocol

(a) Intensive Care Unit patients being transferred should have highest priority (over the Emergency Department and Holding Area patients) for the first available bed on the appropriate service. These decisions will not be at the discretion of the House Staff.

(b) A rotational call schedule will designate for each day a critical care fellow and attending physician (“ICU bed management team”) from the MICU, SICU, and NSICU who will have authority for movement of patients into and out of critical beds in those units, respectively. Each of these ICUs will maintain a daily priority list of patients who may be moved out of the ICU if necessary and appropriate.

(c) When a patient treated in the Emergency Department is critically ill and requires treatment in an ICU setting, the attending emergency physician will contact the clinically most appropriate unit for the patient.

(d) Upon receiving a request to transfer a patient to the ICU, the ICU bed management team of the designated ICU will determine if transfer to the ICU is appropriate, and if so, they will identify a physician to whom that patient will be admitted.

(e) If the patient is appropriate for transfer and a bed is available in the designated ICU, that ICU will make arrangements for transfer as rapidly as possible.

(f) If the patient is appropriate for transfer and no bed is available in the designated unit , the ICU bed management team of that unit will have the responsibility for finding an ICU bed for the patient at the earliest possible time. This may involve appropriate discharge of an ICU patient to another unit or “boarding” of the Emergency Department patient in another ICU. During the period that the patient is “boarding”, the critical care staff of the boarding unit will direct and manage the care of the patient. The ICU bed management team will endeavor to minimize the time that the patient is boarded by making appropriate transfers.

(g) If it is anticipated that there will be a delay in the transfer of a patient to either the designated ICU, a boarder ICU or another service, at the request of the ED Attending, the ICU team will write a critical care consultation for assistance in the management of the patient. Such consultations will be provided in accordance with Medical Board policy.

(h) On call lists for critical care attending physicians and fellows will be provided to the ED and contact numbers provided to the Telecommunications on a regular basis, with changes communicated in a timely manner.

(i) ICU and CCU admissions and consultations will have quality assurance review

Written by phil

August 17th, 2008 at 11:59 am

Posted in ICU

ICU

ICU Consult and Admission

ICU Consults: When consulting any ICU, initiate the consult via AMAC (43611). This allows the consult to be time stamped so that ICU consults can be monitored by the QA committee. The MARS team consultation criteria outline what they feel are appropriate parameters to summon a formal consultation by their team and after hours, a critical care consultation by the MICU. Be sure to print a consult with specific questions so that the consultant can provide management recommendations as needed.

MICU Admission Criteria: are available on the Mount Sinai Intranet. A copy is available here as well.

ICU Bed Management: See full policy here. If the patient is deemed appropriate for ICU admission and no bed is available, it is the responsibility of the consulted ICU to attempt to find an ICU bed where the patient may be boarded. It is then the responsibility of the ICU boarding the patient to manage the patient until a bed in the accepting ICU is available. The critical point is that the consultant state that the patient is indeed an ICU candidate, that the patient is accepted to the ICU, but that a bed is not available. The patient can not be denied solely due to bed availability. Patients accepted to an ICU who remain in the Emergency Department pending bed availability in the unit are the primary responsibility of the ED Attending – this is why it is key that management recommendations be provided by the icu consultant.

Written by phil

August 17th, 2008 at 11:57 am

Posted in ICU

IBEX Tips

FROM THE ED:
– In an emergency call 4HELP and ask for the IBEX SUPPORT PERSON ON CALL (Roberson, Badia or Baumlin)
– the HELP DESK doesn’t understand what this means

FROM HOME:
– Screen resolution in IBEX has changed -> FIX THIS IN CITRIX (Start Menu -> CITRIX -> MetaFrame Access Clients -> Program Neighborhood –> Then select the “Settings” button in the toolbar -> Default Options -> change Window Colors to “True Color (24 bit) and Window Size to 1024×768.

DOCUMENTATION:
1. Medical Decision Making: Coders look for MDM first… They use a point system that adds up based on how many tests you order AND documentation of your gathering of information and analysis of information. In other words use the “DOCTORS NOTES” section. The more boxes you check in this section, (greater that 4 is “high”) the more MDM points you get. Below in addendum A is the coding specialist discussion of this topic

2. We document Critical Care on 1.38% of our patients. The national average is 2-4%. In order for our coders to bill out a case as critical care you need: (for those of you who wanted “the written definition”)

a. Clinical Condition Criterion-There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently. (An acute allergic reaction, or severe asthma attack, or bad CHF, or Acute MI, or CNS bleed, etc… all count…..)
b. Treatment Criterion-Critical Care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these intervention on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.

One of the keys to remember is that the provider has to be immediately accessible to the patient. (We are always in the Department!) Critical Care is not time spent exclusively at the bedside of the patient, but time spent in work directly related to the patient’s care

Critical Care time cannot be requested if the patient is not yet in the ER, such as en-route in the ambulance or if the patient is deceased as the Critical Care time ends when the patient is no longer alive. The patient does not have to be admitted to a CCU or ICU in order to request Critical Care, and can in rare instances be sent home with Critical Care performed during the patient’s ER course.

PLEASE NOTE: Our billing company is unable to return charts for provider documentation of Critical Care when none is requested in the cases where the documentation would have supported it. That means: please respond to Tiffany’s imail request to review a case for potential critical care documentation. She reviews that charts of all patients that physically went to the resus room, every day. If it was not a potentially life, limb or organ if danger… just imail her back “no”. If it may have been critical care, review the chart, “buff it if needed, choose the drop down for critical care and imail her back.

CPR: When CPR is performed the time requested for Critical Care must be time not spent in the direction of the CPR as this is a separately billable procedure which needs to be subtracted from the Critical Care time. Finally, if the provider documentation does not support the requested Critical Care time an EM level will be assigned in place of the Critical Care.

3. IV Hydration: In order for a coder to bill out a separate charge for hydrating a patient they need to see:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient

HINTS: If you use the box in the attending note section you can cover b and c. If your primary or secondary diagnosis is dehydration, then a is covered. If your condition is “improved” then d is covered…..

I supervised the administration of IV hydration which required minutes to completely infuse.

(see addendum B for further explanation)

4. Procedures: All procedures performed should be fully documented so that they can be billed separately as appropriate. Intubations, Central Lines, Chest Tubes, etc are separately billable, however they have to be documented in order to bill separately. USE THE TEMPLATES (addendum C)

a. Splints- use the ORTHO SPLINTING template even if the ortho resident applied the cast or splint!

5. . Medical student documentation is considered invisible with the exception of Review of Systems and/or Past, Family, Social Histories. The ROS and PFSH may be used to supplement the attending’s documentation when the attending checks the appropriate boxes in the ATTENDING NOTE section.

6. ROS: Our billing company considers the statement “All relevant systems reviewed and all negative except for the above” unacceptable. One or two ROS need to be documented and then the statement “All other systems reviewed and negative” if reviewed or at least 10 of the 14 systems listed in order to support High MDM or EM level 99285. This means that you need to make yourself a macro that says “All other systems reviewed and negative”, use this with 2 other systems OR you need to document at least one element (or negative) in 10 systems.

7. RVU’s. An RVU is a numeric ranking assigned to a CPT procedure relating it to other CPT procedures in terms of the time, work and costs associated with the procedure. If you document high levels of care and many procedures then you will have higher RVU’s. More RVU’s is good!

I hope that helps…. Feel free to contact me if you have any questions or concerns. If you would like to speak directly to our billing companies coding specialist, email her (Deb Grieve) at the email below.

Kevin.baumlin@mssm.edu and deborah.grieve@per-se.com

ADDENDUM A

Medical Decision Making is determined by the documentation of the Data, Risk and Problem Categories. In order to have consistency with our coders, we utilize a coding tool based on a tool created by the Marshfield Clinic in Wisconsin that has been approved by CMS. In this system, the Data elements, Risk and Problem Categories are assigned points and those points are added together to come up with the EM level
a. Data- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. The data points are as follows: 1-Review and/or order lab tests, 1-Review and/or order radiology tests, 1-Review and/or order tests from the Medicine section of CPT (EKG, EEG, etc.), 1-Discussion of test results with performing physician (ex. review radiology report with radiologist), 1-Decision to obtain old records and/or obtain history from someone other than patient, 2- Review and summarize old records and/or history from someone other than patient and/or discussion of case with another health care provider, 2-Independent visualization of image tracing or specimen. Please note that 4 or more points scored for data equates to High Medical Decision Making for the Data sub-component.

b. Risk-The CMS table of risk is used to help determine the level of MDM by the Nature of Presenting Problem(s), Diagnostic Procedure(s), Possible Management Option(s). 1-Minimal risk is usually one self-limited or minor problem such as cold or insect bite with management options such as rest and gargles or superficial dressings, 2-Low risk is two or more self-limited or minor problems, one stable chronic illness, or acute uncomplicated illness or injury with management options such as over the counter drugs, IV fluids without additives, 3-Moderate risk is one or more chronic illness with mild exacerbation, progression or side effects of treatment, two or more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, or acute complicated injury with management options such as prescription drug management, IV fluids with additives or closed treatment of fractures/dislocations, 4-High risk is usually one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status with management options such as Parenterally controlled substances given IV, IM or SubQ, drug therapy requiring intensive monitoring for toxicity or decision not to resuscitate or to de-escalate care because of poor prognosis. Please note that the highest level of Risk is chosen based on documentation.

c. Problem Categories-Points are assigned based on the outcome of the patient’s status or the work up performed in the ED. 1/2-Self limited or minor (stable, improved, worsening)(max 2), 1-Established problem to examining physician/group;stable, improved, 1/2- Established problem, worsening, 3-New problem (to examining physician/group), no additional work-up planned (max 1), 4-New problem (to examining physician/group), additional work-up planned. Please note that additional work-up planned includes admitting a patient to the hospital, transferring to another facility, making an appointment for the patient with date and time documented, and/or the amount of diagnostic tests being performed in the ED.

In order to establish the Medical Decision Making based on the providers documentation, Data, Risk and Problem Categories are added up and then 2 of the 3 must meet or exceed to support the appropriate level of EM.

ADDENDUM B
IV Hydration service codes 90760 – 90761 are intended to report a IV Hydration infusion which consists of a fluid and/or electrolyte solution (i.e., normal saline, 30mEq KC1/liter) but are not used to report infusion of drugs or other substances. There is no doubt that start and stop times for each IV infusion, piggyback, etc., should be documented in order to bill the most appropriate code(s) as these are time based codes and would require distinct start and stop times should the procedure be performed greater than 1 hour, since the initial code description is “up to one hour”. Poorly documented accounts (where the hydration was greater than one hour) and no stop times are documented – the code may default to the lowest code for the range. It should also be noted that concurrent infusions may occur during an encounter, and this is another indication of the importance of being able to separate out the services as documented. IV Hydration for hydration of prepackaged fluid and electrolytes – not for infusion of drugs or other substances, typically require direct supervision for purposes of consent, safety oversight, or intrasupervision of staff. Documentation should clearly indicate:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient
The CPT codes that are assigned when documentation supports billing of IV Hydration:
a. 90760 – intravenous infusion – initial – up to one hour
b. 90761 – each additional hour up to 8 hours

ADDENDUM C

In order to accurately assign CPT codes for procedures, the documentation must clearly state what type of procedure was performed, if applicable the location and length and the description of the procedure performed. When a procedure has to be repeated, documentation of the additional steps should be documented as a procedure may be billed separately every time it is performed. An example is the chart we reviewed that had documentation of the patient who was intubated once and then when the ET tube came out, the attending had to re-intubate the patient. Both of the intubations are billable. Attendings should clearly document their supervision of procedures when performed by Residents in order to bill separately for the procedures. When a Medical Student is involved, the attending must re-document the entire procedure in order to bill separately for the procedure. If a PA performs a procedure and the attending documents a face to face encounter with the patient, the PA will be credited with the procedure and the attending with the EM level.

Splinting documentation must support that the splint was placed by the ER provider if the patient has a governmental insurance such as Medicare. For all other insurances, the ER provider can document a post splint placement examination when applied by a nurse or tech and the splint can be billed separately. This can be as simple as a statement such as “splint placed by tech in good alignment with neurovascular status intact”.

Written by phil

August 17th, 2008 at 11:56 am

Posted in IBEX

CT-STAT study

From: “Hermann, Luke” <Luke.Hermann@mountsinai.org>
Date: August 15, 2008 10:20:46 AM EDT
Subject: [Emfaculty] Need help with CT-STAT study

Hello all,

A short plea to remember the CT-STAT Study for your potential ACS patients (we are an enrolling site but thus far have put very few patients into the study):

The basics:

What: Compare CT coronary angiography with nuclear stress testing

Who: patients with
–          possible ACS
–          sinus rhythm without clear ischemic changes
–          normal creatinine
–          no history of CAD

How: Page Aileen at 6780- she will evaluate the patient, consent the patient, and facilitate the appropriate test. Aileen will also be rounding in the AM on CPU patients and if she enrolls a patient may ask you to change the ordered imaging study.

I’ve placed more information in the resident room and in the ED. Any questions? Don’t hesitate to ask.

Thanks in advance,

Luke

Written by reuben

August 16th, 2008 at 1:44 am

Posted in Chest Pain,Research

Q Tips August 2008

“Q”uality tips from recent months:

CVP can be measured off femoral lines with relative accuracy if the patient is lying flat.
When ordering medications, “time” is no longer a mandatory field.
When giving fluids to patients, please be sure to remember to actually enter an order.  In addition, if the patient receives more than 1 liter, please remember to re-order it so there is a clear reflection of how much fluids the patient actually got.
A low B-hcg does not eliminate the possibility of ectopic pregnancy – in fact, low B-hcg are more common in these cases.
If you have an elevated lactate on a patient with presumed sepsis (or in any case actually), be sure to get a repeat value to show either normalization or a trend.
Be sure to document your initial EKG interpretations – especially in pts with STEMIs or USA.
When you talk to the ME regarding a death in the ED, if you do not agree with their interpretation of etiology of death – you can refuse to sign the death certificate & the ME will then have to take the case.

Thanks for your attention.
Vaishali

Written by reuben

August 16th, 2008 at 1:41 am

Posted in Pearls

EM Ultrasound

Here are answers to seven frequently asked questions about the ultrasound program. Further details, tutorials on ultrasound use, and lots of pictures can be found at: www.SinaiEM.us

1. Where is the ultrasound machine?

  1. a. There should be an ultrasound machine in the following locations:

    • i. RESUS area (in alcove to the right of Resus Printer, beneath the blue and grey Ultrasound Poster)
    • ii. Gyn rooms 9 or 13
    • iii. Peds room 4
    • <

  2. b. Often machines find themselves in other areas, including patient rooms, hallways, or Urgent Care

2. Do I need to save images?a. YES
b. EVERY TIME YOU USE THE MACHINE

3. How do I save images? (details with pictures at http://sinaiem.us/?page_id=162 )a. Press “Patient” button on machine
b. Enter YOUR IBEX initials (ie. ABN or EBN) under the Patients’ Last Name
c. Enter the patient’s MR# under ID
d. Press “Done” to begin scanning- you should now see your IBEX initials and the Patient MR# on the top of the screen
e. FREEZE (big blue button) the desired image, and press SAVE
f. SAVE as many images as you like- at least two views of any organ of interest
g. When you are finished, press the triangle (END) key to log off

4. How do I clean the machine?
a. Use the TranSeptic spray- spray liberally, wipe clean

5. What do I do if the probes are dirty?

a. NEVER use a dirty probe for patient care.

b. Clean probes with TranSeptic Spray before using them in patient care, and before returning the machine to its normal location

6. How many ultrasounds do I need to become credentialed?

a. Faculty need 25 (twenty-five) documented ultrasounds (images and interpretations) in a particular indication (ie. Cardiac, pelvic) to become credentialed

b. Residents need the same number, though they cannot be ‘credentialed’ from a hospital perspective while in training

7. Where are the extra-long needles, useful for placing deep peripheral lines with ultrasound guidance?

  1. In the Red Suture Cart located near the ambulance entrance in the North Zone. Top Drawer.
  2. 1.88 inch, 18-guage catheters and 3.25 inch, 16-guage catheters are available there in addition to the standard angiocath sizes.

Thank you for your help, and please email Bret Nelson with any questions.

Written by phil

August 15th, 2008 at 11:58 pm

Posted in Ultrasound

Serum Toxicology Testing

Please note that effective immediately the Mount Sinai Labs will not be offering serum toxicology tests.

These include serum barbituatate, benzodiazepines and tricyclic antidepressants. The methodologies are tedious, the requests are a few and most of the labs in New York are not doing these tests. We will of course continue to offer urine toxicology 24/7. If for some reason these tests have to be ordered, we will send the requests to Labcorp.

Written by phil

August 15th, 2008 at 2:26 pm

Posted in Toxicology

Propofol

Propofol has been approved for use in the ED for post-intubation sedation and may be ordered in IBEX by all attendings.

It should not be used as a continuous infusion for patients under age 18.

The starting dose is 5 mcg/kg/min, titrated upwards by 5 mcg/kg/min every 10 minutes until desired sedation level is reached.

An infusion chart is available on the EHCED site:

http://www.ehced.org/Drips/propofol.pdf

I spoke with Robert Asselta today and he reported that all nurses should be able to hang and deliver propofol as a standard infusion, effective immediately.

For now, only use Propofol on intubated patients being monitored with continuous ETCO2 and automated, repeating blood pressure checks. Although propofol offers minimal if any benefit in most intubated patients when compared to midazolam, we must demonstrate a safe record of use before we petition the P&T committee to allow us to use it for RSI and procedural sedation, where it does offer significant advantages in certain situations. Propofol’s rapid offset of action does have particular utility in the patient intubated for CNS lesions, as the patient’s neurological status can be quickly re-evaluated after discontinuing the infusion.

Propofol causes respiratory depression, which is not an issue in an intubated patient, and hypotension, which can be. Be mindful of hypotension in susceptible patients.

I have pasted the summary I sent out months ago below for further information.

Thanks to all the MSSM attendings for suffering through the preliminary steps, thanks to Haru and Ruben for their efforts. Looking forward to seeing the milk-colored infusions.

reuben

* Propofol is a potent sedative-hypnotic that is structurally
different than but behaves similarly to the barbiturate class. It
produces dose-related sedation and amnesia, up to and including deep
sedation, in which case patients are unresponsive to painful stimuli
and may be apneic.

* Propofol has become popular for use in emergency medicine because
of its unique pharmacokinetics. When given as a bolus, onset of
action is generally within 1 minute, and duration of action is
generally not longer than several minutes. Patients are generally
completely alert within 15 minutes.

* Propofol may be used as an infusion to maintain sedation in
intubated patients. The recommended starting dose is 5 micrograms /
kg / minute, to be titrated to effect every 10 minutes. Note that 5
mcg/kg/min is a very small dose. Propofol is particularly well-suited
for this purpose if following the patient’s neurological exam is
important, as the effect wears off completely within 15 minutes of
holding the infusion.

* Propofol may be used to facilitate painful procedures. The
recommended dose is 1 mg/kg bolus, but experienced providers use
anywhere from .5 to 1.5 mg/kg as their starting doses. Repeat dosing,
usually at .5 mg/kg, must be provided quickly if needed, every 3
minutes at the longest, as the effect is so short-lived.

* Propofol is the most popular agent among anesthesiologists for RSI,
and may also be used to treat refractory delerium tremens and status
epilepticus. We can discuss these indications later as need and
interest warrant.

* Propofol is contraindicated in patients with egg or soy allergy, as
both of these ingredients are in the vehicle.

* Propofol causes pain at the injection site. This pain can be
reduced by adding lidocaine, .5 mg/kg, to the syringe. This is
routinely done in the OR and rarely done in the ED.

** Propofol routinely, reliably produces respiratory depression,
including apnea, as well hypotension. However, the clinical relevance
of these effects is greatly reduced by propofol’s ultrashort duration
of action.

-When end-tidal capnography is utilized (and it should be, if
available), there is no benefit to withholding supplemental oxygen.
In a healthy adult, adequate preoxygenation allows for periods of
apnea much greater than is routinely encountered with bolus propofol,
without desaturation. My experience is that the bolus is delivered,
the patient becomes unconscious, stops breathing, and starts
breathing within about a minute, without the saturation moving from
100%.

– Hypotension is to some degree prevented by pretreatment with
fluids; in any case the drop in blood pressure is brief and rarely of
clinical significance. In patients where hypotension is a particular
concern, it can be abolished with phenylephrine 100 microgram boluses.

** Though propofol has been demonstrated to be safer than
alternatives many of us are more comfortable with ( e.g. fentanyl /
midazolam), those who use it must anticipate its side effects and be
prepared to support blood pressure and ventilation as needed.

Written by phil

August 15th, 2008 at 2:21 pm

Photo Policy

The new camera and photo policy has been deployed in the clinical environment. The Policy can be found with the other department policies on line. The necessary sheets (Photo consent, Photo ID sheet) are located in copies. In summary….

Obtain the camera from the Peds ED Pyxis (if SAFE is not involved), print out the consent and the ID sheet. Get consent (not necessary for child abuse cases). Ensure the memory card is in the camera. Take your first picture of Patient label, take your photos of the patient, document after each photo on the photo ID sheet what the photos are of (ie left arm bruise), take your last picture of the patient label. Remove the memory card. Place card in envelope with the signed Photo ID page (envelopes located behind the storage box), place the sealed envelope in the photo storage lock box located in the attending office. Document in the chart that the photos were taken. SW will download the images the next day. Let Dr. Cohen, Dr. Richardson or Sara Mendes know if there are any questions.

TIPS

1) For close ups use the flower Icon on the camera (macro setting)
2) Spare battery located in the charger in the locked attending cabinet in peds
3) Extra memory cards are located in the pyxis

Written by phil

August 15th, 2008 at 2:20 pm

Guidelines for Digital Photography in the ED

Policy for all Digital photography taken in the Emergency Department must be managed according to this procedure for the following protocol cases:

A. Sexual Assault (Code 11) see policy # 26.4
B. Domestic Violence see policy #26.3
C. Child Abuse/Sexual Abuse/Neglect- see policy #26.1
D. Educational Purposes

Photographs to be taken by SAFE Examiner and/or ED physician.

Consent for the taking of photos must be obtained from the patient except in cases of child abuse! Photo consent form is in Copies.

How to take photographs:
1. Obtain digital camera and Memory Card from Pediatric PYXIS/Safe Cabinet.
2. Ensure that memory card is loaded into camera and empty.
3. Ensure battery is charged. (Spare located in attending cabinet in peds ED.)
4. Ensure that appropriate date and quality setting is correct.
5. Obtain three (3) patient labels from IBEX.
6. Obtain Photo Documentation Page from Copies, affix patient label, fill in your name, document subject of each photo i.e. body part or injury.
7. First and last picture in sequence must be of patient’s IBEX label.
8. For all close up pictures, ensure that ‘macro’ setting (flower icon) is enabled.
9. Include in each picture, patient label and reference marker (paper ruler) if possible.
10. Review all pictures taken to ensure clarity and identification. Delete unusable pictures.
11. Remove memory card from camera.
12. Place memory card and Photo ID page into envelope (located behind lock box in attending office), label envelope, and deposit in locked box located in attending office.
13. Document in Ibex that photos have been taken and by whom.

How to upload images to Onbase (social work):
1. Social work will check the locked box in Attending Office when contacted by on-call SW and weekly to ensure that all pictures have been downloaded.
2. Insert Card into Card reader
3. Select Onbase Program, enter user ID and Password.
4. Download pictures to appropriate secure drive (i.e. Sexual Abuse, etc…) inserting comments from the Photo Id Page.
5. Insure Photos are deleted from memory card.
6. Return empty card to Pediatric Pyxis/Safe cabinet.
7. Document in Ibex that pictures have been downloaded.
8. Give Photo ID Sheet to B.A. to scan into chart

Access to Onbase Program is restricted to:
1. ED Attendings
2. ED social workers
3. Child and Family Support Program
4. Medical Records

After all photographs are completed and uploaded ensure that appropriate documentation is completed in IBEX i.e. “photos taken by ____”. Insure that appropriate consents are scanned into the medical record.

Extra charged battery located in the Attending cabinet in Pediatric ED.

Written by phil

August 15th, 2008 at 2:17 pm

Sexual Assault

As you know, we are a Center of Excellence for sexual assault, one of several in the City.

Stable survivors may be brought here preferentially. When such a survivor is identified,

he/she should be brought into a private area (Urgent Care A, either GYN or Peds GYN), immediate needs assessed

and SAVI, the SAFE, AND social work are called via AMAC 24/7. The SAVI is the patient advocate and provides emotional support and info on options post discharge; the social worker assesses for immediate social needs, safety, clothing, etc.

The SAFE on call will perform the evaluation and documentation on the Comprehensive SA Form and photos, evidence collection as per the patient’s wishes. The SAFE will make every effort to limit the nursing time involved with evidence collection.

SAFE will present their findings to the supervising Attending in the area. Unless the SAFE on call also is a MSH ED physician or PA,, the ED Attendings/residents or PAs would write med orders and lab orders using the order sets and complete the PICIS SA eval . If there is no SAFE on call (per AMAC and /or schedule posted in Urgent Care) then the ED MD/PA does the exam per protocol. Explicit instructions on collection of evidence are in the kit.

The check sheet (attached) can be used as a quick guide to timelines, chain of custody, post exposure

prophylaxis, referrals. This has been updated to include with option of Suprax or cefixime 400 mg oral for GC in lieu of

ceftriaxone IM. (now stocked in the ED and Urgent Care, thanks, Scot) and a reminder about the photo policy.(thanks, Ari)

Thanks for your attention to quality improvement for our survivors.

Barbara Richardson, MD

Medical Director, SAFE Program at Mount Sinai

Written by phil

August 15th, 2008 at 2:16 pm

Posted in Sexual Assault

ABCD2 Score for TIA

The ABCD2 Score is being promulgated by the National Stroke Association as a clinical prediction rule to help dispo your TIA patients.

The Score

A = Age => 60 years 1 point
B = BP => 140mmHg or DBP => 90 mmHg 1 point
C = Clinical Features of TIA
– Unilat Weak w/o speech impairment 2 points
– Speech impairment w/o unilat weak 1 point
D = TIA Duration
– 10-59 min 2 points
– => 60 min 1 point
D2 = Diabetes 1 point

Prognostication:
Score 2d CVA Dispo
0-3 1% Admit for other considerations
4-5 4% Admit
6-7 8% Admit

Reference: Johnston SC, et al, “Validation and refinement of scores to predict very early stroke risk after transient ischemic attack” Lancet 369:283-292, 2007.

Written by phil

August 15th, 2008 at 2:15 pm

Posted in Stroke/TIA

ACEP Focuson Ultrasound

From Dr. Nelson:

There are nice walkthroughs of pelvic ultrasound and ultrasound for procedure guidance (with pictures!) at: www.acep.org/focuson. You can even get CME credit.

There are others if you’re interested (on peritonsillar abscess, lumbar puncture, etc.), but I recommend looking at these two:

  • Focus On: Ultrasound Imaging in First Trimester Pregnancy July 2008
  • Focus On: Ultrasound-Guided Central Venous Access of the Internal Jugular Vein November 2007

Written by phil

August 15th, 2008 at 2:12 pm

Posted in Ultrasound

JCAHO Stroke Designation Visit

We are pleased to share the following Quick Tips with
management, faculty and staff in preparation for the
planned Joint Commission visit on March 10th and 11th in
conjunction with Mount Sinai’s application for a
special “Stroke Designation.”

Below are basic reminders of safety regulations that all
staff should know and keep in mind at all times, to ensure
that we promote a safe, secure and ideal environment for
the BEST in patient care.

If you have a JCAHO-related question, please call Ext. 4-
9136.

1. When and where should employees wear their hospital
ID badge?
At all times, above the waist and in plain sight.

2. What’s the best way to prevent the spread of
infection?
Hand hygiene. With soap and water, wash hands vigorously
for at least 15 seconds. Or, apply Purell, rub hands until
hands are dry.

3. How do all of us protect patient confidentiality?
By maintaining HIPAA compliance at all times. No
unnecessary or unauthorized disclosure or access of PHI
(Protected Health Information) is acceptable.

4. What should you do when you see fire or smoke?
R.A.C.E. [Rescue, Alarm (alarm box or call Ext. 4-3473),
Confine, Extinguish]; know specific plans for your area,
including but not limited to: location of nearest fire
alarm box, location of fire exit stairways, location of
extinguishers, evacuation plan.

5. What are the phone numbers to call in case the
following issues occur?
a. Spills
b. Holes in / repairs to ceiling, leaks, floods,
etc.
– Spills: Building Services at Ext. 4-6125.
– Holes in / repairs to ceiling, leaks, floods etc.:
Engineering at
Ext. 4-6201.

6. Whom do you go to in the case of an
emergency “event”?
Department-specific “Chain of Command.”

7. What does “Code Adam” mean?
Infant abduction from unit. Department-specific actions
apply.

8. What is “Plan E,” and what’s the first thing you
should do?
Plan E outlines how personnel are to be deployed in the
event of an internal or external emergency involving more
than 15 medical casualties. Staff are required to report
to their assigned areas, which are department-specific.

9. How do you accurately identify the patient you are
caring for?
Patient Name and Date of Birth.

10. What is “Universal Protocol”?
It is a set of steps that are designed to prevent Wrong
Site, Wrong Procedure and Wrong Patient Surgery. The
protocol applies to OR and NON-OR settings, including
bedside procedures.

11. Is there a listing of Do Not Use symbols and
abbreviations in the institution? Why is this list
important?
Lists are posted on units to remind employees not to use
those symbols and abbreviations, as they can easily be
misread and can lead to medication errors, potentially
causing patient harm.

12. How do you effectively hand-off a patient to another
provider, caregiver or service?
Follow SBAR: Situation, Background, Assessment,
Recommendation.

13. Provide some examples involving “Environment of
Care.”
Stored items must be 6” from floor and 18” from ceiling;
doors cannot be propped or tied open; door lock
combinations shouldn’t be posted next to the door.

14. What are “Look Alike / Sound Alike” Drugs?
They are drug pairs that require special attention because
they look or sound very similar and can be confused one for
the other. When a Look Alike / Sound Alike drug is
dispensed by the pharmacy, it is labeled in TALL MAN
lettering (e.g., DOPamine vs. DOBUTamine OR hydrALAZINE
vs. hydrOXYzine).

Written by phil

August 12th, 2008 at 12:49 pm

Posted in JCAHO

Clinic Follow-Up

1. There is an “IMA Navigator” by the discharge desk from 1-5pm Monday through Friday. This person can assist in making all IMA and clinic appointments.

2. There are NO GYN WALK-IN appointments. Patients must make an appointment.

3. GYN pts for follow-up b-HCG, can be seen at the GYN clinic, we need to leave the follow up info with the clinic, and they will set it up. The number and info is posted on the bulletin board where the schedules are in the Main ED, on the north side.

4. Medicaid patients- can follow up at IMA or any of the clinics.

5. Health first pts (in general) CANNOT follow-up at Mount Sinai. They can go to Settlement health. (they can follow-up at sinai if they are previously established in the outpt clinics

6. Private patients (i.e. blue cross, affinity, united, 1199, etc) can follow up at the FPA (faculty practice associates). The color FPA brochures for medicine and specialty are in the urgent care.

7. Private specialists- there are business cards in urgent care for docs who will accept pts within the week after being seen in the ED. This is not walk-in. The pt must call for an appointment.

I hope this reminder helps. Please email me or contact me with any questions or clarifications. Thank You, Meika

Written by reuben

August 12th, 2008 at 7:01 am