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Archive for April, 2009

Nasal Specimen Collection Guide

with one comment

Nasopharyngeal Specimen Guide

Note that as of today we do not have flexible rayon swabs, but may be getting them-

Note also that an order for Flu DFA is now in Ibex under a “flu lab” order set…no more paper forms please

Thanks

Scot

Addendum from Kevin:

Culture media is in the fridge in Pediatric ED utility room with swabs.  Cut swab and place tip in the tube

Ordering the test in ibex

Go to “Flu labs”

Click both “Influenza DFA” and “Rapid flu” test for now

Written by reuben

April 27th, 2009 at 9:23 pm

Posted in ID

Swine Flu

with 5 comments

May 24 Flowsheet

May 22 Guidelines.

modified-strict-precautions-sign_english

swine_influenza_home-isolation_4_30_09af

updated-screening-tool_swine-influenza_2may09

Update 5/6/09

Here is the latest on H1N1

Recommendations are same as those for seasonal flu

patients with fever and cough or fever and sorethroat require mask and single room or 3-6 feet separation

Negative pressure Airborne Isolation and N95 are no longer routinely required

STANDARD and DROPLET precautions for routine medical care

Aersol generating procedures require N95 and eye protection preferably in a negative pressure room

Obtaining nasopharyngeal swabs for Flu testing requires surgical mask

Influenza testing should continue on patients admitted with fever and acute respiratory illness.

current reporting, diagnostic testing, antiviral treatment and prophylaxis remain unchanged

please review attached and information below

There are new discharge instructions for home isolation

Read the rest of this entry »

Written by reuben

April 25th, 2009 at 7:28 am

Posted in ID

Dispositioning Patients

with 4 comments

Discharge Process Summary as of 4/14/09

To discharge a patient safely from the ED, a complete check of the administrative information is done by the BA at the discharge desk. To accomplish this, the BA reviews the information in the patient’s physical red chart, adds any new information (such as phone numbers, address) that the patient provides and scans the signed discharge sheet. To do this the BA needs: the patient or responsible person, the red chart and the patient’s signed discharge instructions. For adult patients, from midnight to 8AM, the discharge desk function is performed by the BA at the specimen desk. No more trips to the hallway.

Patients with no insurance

The IMA is now taking patients without insurance! and patients with healthfirst! but NOT patients with Metroplus.  Patients without insurance will pay $16 at the first visit, and at that visit, IMA will assist them in getting insurance.  If there are any problems with this please send Meika Neblett the patients name and MRN.  Can be given REAP information (available at discharge desk) to initiate process of obtaining insurance.  Patients with Metroplus can follow up at Settlement Health.  Should be referred to REAP as well.

Patients with Medicaid

Can follow up at IMA or any of the clinics.

Patients with Private Insurance (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. In addition, there are business cards in the East Zone for bothe primary care and specialists who will accept patients within the week after being seen in the ED. This is not walk-in. The patient must call for an appointment.

GYN Follow up

GYN patients can follow up at the Klingenstein Pavilion E-Level GYN clinic for repeat B-hCG or for patients with ectopic pregnancy treated with methotrexate regardless of insurance.

Call ext 47238 and leave the following information:

  • Last and first name, date of birth and the medical record number of the patient.
  • An active telephone contact.
  • The time range that the patient should be scheduled for follow-up care.

The assigned clinic business associate will retrieve the messages, schedule the appointment and call the patient to advise them of the date and time of the appointment.

Dental

We have been trying to improve flow of dental patients up to dental and avoid keeping their charts open while they go for a consult. For bureaucratic reasons, they cannot simply be directed upstairs without first receiving a screening evaluation which currently can only be done by a PA or MD (this will hopefully change). Patients with a dental complaint being seen in the ED should receive an expedited screening exam and then:

Between 8 am and 3 pm – be quick registered, quick triaged, and seen by an md or pa who confirms that the problem is dental and stable.  Minimal documentation is needed in IBEX.  The patient is then discharged with an instruction sheet directing them to the dental clinic (Second floor of the Annenberg Pavilion).

Discharge of patients with HIV

Patients with HIV who do not have primary care should be referred to the Jack Martin Fund Clinic.

By Insurance

Metroplus:

Written by phil

April 13th, 2009 at 10:05 pm

HipStat Hip Fracture Study: Improving Pain and Function in Hip Fracture – page 917.205.8474

with 2 comments

Step by step instruction sheet for performing the block here.

The Mount Sinai School of Medicine’s Departments of Geriatrics, Emergency Medicine and Anesthesiology are collaborating on a study examining the efficacy and effects of 2 regional anesthesia techniques, femoral nerve blocks (FNB) and fascia iliaca blocks (FIB), on the treatment of peri-operative acute hip (femoral neck, intertrochanteric) fracture pain.

Patients age 60 years and over presenting to two New York City emergency departments (MSMC or Beth Israel)  with hip fracture will be randomized to receive the intervention or usual care.  The intervention includes single injection FNB in the ED followed by insertion of a continuous FIB catheter within 24 hours of the single injection FNB plus “as needed” non-opioid/opioid analgesia.  Usual care patients will receive conventional therapy with regularly scheduled intravenous or oral opioids plus “as needed” non/opioids/opioids. We will examine the impact of the intervention on patients’ self reported pain intensity; systemic opioid requirements; post-operative function; incidence of delirium, treatment related side effects; and hospital length of stay and participation in physical therapy.

Inclusion criteria:

  • Ages 60 and over
  • Male or female
  • Presenting to the emergency departments at MSMC ED from 8:00 to 20:00 with   radiographically confirmed hip fracture (femoral neck, intertrochanteric, or peri-capsular).

Exclusion criteria:

  • History of advanced dementia
  • Presence of multiple trauma, pathological fractures, bilateral hip fractures, or previous fracture or surgery at the currently fractured site
  • Patients transferred from another hospital
  • Patients with cirrhosis or liver failure

Dr. Sean Morrison is the PI on this study. For more information or questions, please contact the project manager, Taja Ferguson Taja.Ferguson@mssm.edu, or one of the study coordinators, Carla Foster Carla.Foster@mssm.edu, or Lauren Greenberg Lauren.Greenberg@mssm.edu.

If you have a hip fracture, page the study coordinator (917-205-8474).

Management of Severe Local Anesthetic Toxicity

Written by reuben

April 13th, 2009 at 4:31 pm

Protected: Attending Contact List

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Written by phil

April 12th, 2009 at 2:49 pm

Posted in Contacts

Diversion Checklist

Please use this diversion checklist to foster consistency of our diversion protocol.

tags: crowding, crowded

Written by phil

April 8th, 2009 at 7:22 pm

Wireless Phone Details

Goals:
• Decrease overhead paging/ overhead noise
• Make communication more efficient
• Get out of the phone-answering business
• Trialing all clinical staff will have their own phone

MD Responsibilities:
• Don’t lose the phone
• Use the phone during all clinical shifts
• Make sure the phone is bouncing to the right “ED Zone” (1)
• Click over the patients you take over at sign-out so BAs know who is responsible (2)
• Put your call-back number on radiology requests (3)
• Residents: make sure the BAs know which phone you are carrying
• Residents: phones go in resident office if not in use by EM residents
• Residents: these phones are NOT to go to off service rotators(4)

BA Responsibilities:
• Forward calls to the attending/ resident responsible for the patient (5)
• Ask who is calling before forwarding
• Do not overhead unless the phone is not picking up

1)  Opening screen, go to “ED Zones”, select the appropriate zone-  this selects the phone your no-answer calls bounce to.  Especially important when changing from adult to peds/ east or vise-versa.

2) This is the only way BAs will know which MD is caring for a patient. You can use the sign out function in ibex to change them all over.  You do not need to click on patients with ready beds if transport is imminent.

3) Please enter your callback number on radiology requests- there is a dropdown menu available on request, or you can text.

4) Lost phones are the responsibility of the residency.

5) There is a list of all the wireless phones posted.  The residents will let you know which phone they have at the beginning of the shift.

Written by phil

April 8th, 2009 at 7:18 pm

Corrective Action Plans

We have had several ED cases with poor outcomes over the past year that triggered root cause analysis and resulted in corrective action plans.  The following corrective actions directly or indirectly involve our ED practice. The department may be monitored by the state for compliance with these plans.

• New onset adult seizures, syncope, and chest pain will all be treated as if potential cardiac ischemia:  ECG within 15 minutes.

• Initial dosing of hydromorphone is 0.5 -1.4 mg, initial dosing of Morphine is 4 mg.

• Higher doses of pain medications may be given if there is a note in the chart documenting the medical reasoning for choosing a higher dose.

• More than 3 doses of IV pain medication in 3 hours should prompt a pain consult for consideration of PCA pump, or medical reasoning why there is no consult.

• All transfers of patients with thoracic aneurysm or dissection should be discussed with the MSH ED attending before transfer from another institution.

• CT surgery will use AMION for on call and chain of command contacts.  Non-compliance should be reported to Scot Hill.

• Consultants should respond by phone within 10 minutes, and be present within 30 minutes.  Non-response should trigger a call to the next higher level in the chain of command.

Written by phil

April 8th, 2009 at 7:16 pm

Isolyte (Elmhurst)

Hi folks,

In the IV fluid cart in the trauma room, we are stocking a fluid called isolyte.
It is very similar to lactated ringers with three exceptions:
1. It does not contain lactate so it will not affect lactate levels in shock patients
2. It is a true isotonic solution, so it can be used in head injury patients
3. It has no calcium, so it is compatible with blood products

This begs the question: why don’t we just replace LR with isolyte.
Problem is that it costs twice as much, which when you talk about fluid bags still is not very much money, but it adds up.
At this point, the appropriate patient pop. to use this fluid is preexisting acidosis (bad DKA, sepsis, etc.) where NS will make things worse and you still want to send lactates.

Scott Weingart

Written by reuben

April 8th, 2009 at 5:12 pm

Blood Borne Fluid Exposure Reminder

Just a reminder

1. there is BBFE (blood borne fluid exposure) information sheet in copies, and order set

2. if you have any questions after hours call the ID fellow on call

3. the nursing supervisor should take care of all of the testing of the pt on the floor, and will let you know the status of the source pt

4. if the source is hep B+, and the healthcare worker did not complete her dose or is known nonimmune  give hep b vaccine,
BUT, if the worker did not get hepatitis vaccine give immunoglobulin

5. if you give PEP the pt should followup at Jack Martin

6. make sure to fill out BBFE case summary checklist and leave it in the discharge desk. The needlestick coordinator will pick up these forms in the morning.

Employees that are stuck with a needle, or who have fluid exposure follow up at employee health.

Nonoccupational exposure pts who are given pep, ie needlestick, sexual assault or encounter follow up at jack martin.

thanks
meika

Written by reuben

April 7th, 2009 at 6:56 pm

Posted in Needlestick