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Archive for October, 2010

ED Patients to IMA

If a pt is followed at IMA and they come to the ED for non emergent care, they can be asked to go to IMA for care. IMA has walk-in slots available from 9am to 7p Mon-Friday. The process as described below began yesterday afternoon:
pt arrives, ED BA notes during quick reg that the pt is cared for in IM—they enter the reason fro visit as “IM-xxxcough”
triage nurse sees IM-XXX in complaint and briefly evaluates pt, if low acuity..
RN asks MD/provider for medical screening –
MD/provider sees pt (north zone doc or designee, or intake doc or PA)
MD/provider documents in ibex “mse performed…”
pt goes to IMA
if pt needs assistance, call for pt transport

This process has been working with peds clinic pts for the last week, with good success.
Thank you for your cooperation
Kevin

Written by reuben

October 22nd, 2010 at 4:47 am

IMA Medical Screening Exams

If a pt is followed at IMA and they come to the ED for non emergent care, they can be asked to go to IMA for care. IMA has walk-in slots available from 9am to 7p Mon-Friday. The process as described below began yesterday afternoon:

1. pt arrives, ED BA notes during quick reg that the pt is cared for in IM—they enter the reason fro visit as “IM-xxxcough”
2. triage nurse sees IM-XXX in complaint and briefly evaluates pt, if low acuity..
3. RN asks MD/provider for medical screening –
4. MD/provider sees pt (north zone doc or designee, or intake doc or PA)
5. MD/provider documents in ibex “mse performed…”
6. pt goes to IMA
7. if pt needs assistance, call for pt transport

Written by phil

October 22nd, 2010 at 12:35 am

Peds ED to Clinic Diversion Flow & Policy

1. Patient presents to the front desk staff at greet desk.
2. BA ascertains name and DOB of patient and checks to see if they have previously been to PEDS Clinic.
3. Once BA identifies patient as PEDS clinic patient they will indicate in Reason for Visit Field: PC (PEDS Clinic)/reason for visit.
4. Triage nurse quick triages patient in IBEX to assess acuity of patient (emergent vs. non-emergent) and then calls Attending/Fellow to validate assessment.
5. Attending/Fellow assesses patient as well, validates decision and suggests to patient/parent that they can go to PEDS Clinic as walk-in patient.  If parent agrees, attending writes note in IBEX and dispositions patient as “sent to clinic”.  If parent disagrees, they are sent to the ED waiting area to wait as triaged.
6. BA will then: 1) identify patient under “sent to clinic” disposition, 2) discharge patient from IBEX, and 3) cancel patient visit from Cerner.






Introduction:

The following describes the process by which The Mount Sinai Hospital’s Emergency Department will handle non-emergent pediatric patients during the hours of 8:30am -3:30pm Monday – Friday and 10am – 2:30pm on Saturdays.

Policy:

All patients that present to the Mount Sinai Emergency Department will receive a medical screening exam to determine level of acuity by a health care provider.   In the event the exam indicates that the visit is non-emergent, then the ED staff will refer the patient to the Pediatric Clinic if they are an established Pediatric Clinic patient in the past 12 months and participate in an insurance plan accepted by the Pediatric Clinic.

Procedure:

When a patient presents to the Mount Sinai Emergency Department, the ED-BA located at the Greet Desk will validate the patient’s name and date of birth.  During the look-up of the patient in the Cerner ADT system (between the hours of 8:30am to 3:30pm  Monday –Friday and 10am-2:30pm Saturday) the ED-BA will determine if the patient is an established patient in the Pediatric Clinic (seen within the past 12 months and participates in an insurance plan accepted by the Pediatric Clinic).  If the ED-BA determines that the pediatric patient has met the criteria as a Pediatric Clinic patient then the ED- BA will process the patient in the ADT system (Cerner) as a “Quick Registration.”  The Quick Registration will include the national patient identifiers (Name & DOB), referring source, PC (PEDS Clinic)/the reason for visit along with the onset date.

Once the patient’s Quick Registration has been completed with required data elements, then the patient’s information will be sent from the ADT system to the Emergency department’s electronic medical record system (IBEX).  The patient’s information will be viewed in the triage nurse’s queue and the patient will be called for triage.

The triage nurse will expedite all pediatric patients with the PC designation in the reason for visit field.    Once the triage nurse has assessed the acuity level of the pediatric patient (emergent vs. non-emergent), he/she will call the Attending/Fellow to validate the assessment.

Once the Attending/Fellow assesses the patient and validates the decision that the patient is non-emergent patient, the Attending/Fellow will suggest to the patient/parent that they can go to the PEDS Clinic as a walk-in patient.  If parent agrees, the Attending/Fellow will write a note in IBEX and disposition the patient as “sent to clinic”. If parent disagrees, they are sent to the ED waiting area to wait as triaged.

The BA will then: 1) identify the patient under “sent to clinic” disposition, 2) discharge the patient from IBEX, and 3) cancel the patient visit from Cerner.

Written by reuben

October 14th, 2010 at 11:02 pm

Posted in Peds,Policy

CDR Training

You had a little taste of Epic this morning with Amish, Romona and
Rocko’s demo of the ASAP ED module.

You can also learn more abotu Epic when you head over to our
intranet’s tutorial on CDR. CDR is Epic’s clinical data repository
that will exist alongside the familiar EDR and be accessible for
clinical care starting in a few weeks (10/26).

Like EDR, CDR will give you read-only access to old visits, labs and
reports. You’ll also see clinic notes, d/c summaries, etc. EDR is not
going away anytime soon but we think it’ll be helpful to start
accessing CDR — because clinic notes are organized better in CDR, and
because it’s a good idea to start getting familiar with Epic’s
navigation.

The tutorial is available at http://intranet1.mountsinai.org/epic/ (if
you access this from campus, you can hear the computer narrator voice
over slides — otherwise, there’s captions)

To the left of the nice picture of Bruce Darrow and Romona Tulloch,
you’ll see a link for “E-learning”. Click that.

Then you’ll be prompted to enter your login and password — this is
the same login you use to tunnel into MS Onsite Health and Citrix from
home.

Then you’ll see a screen with three columns. At the top of the middle
column is the CDR training module. Click that. Learning CDR through
this tutorial is a good idea because it’ll show  you some of the Epic
interface, some of their terms and quirks, etc. This tutorial is
specifically geared toward a medicine intern and focuses on features
to make rounds easier (lists of patients, lab printout for rounds,
etc). But you might find a lot of it useful, as well.

You may notice in the third column on the E-learning page, there are
tutorials for Epic’s ED software, called ASAP. The really curious
among you are of course welcome to start looking at these modules but
please understand we’ve working to customize ASAP so that the
templates, tracking boards and workflows that we’ll have for go-live
will be more familiar and suitable. Those ED training modules don’t
reflect these changes.

That’s all for now. If you’ve got questions or access issues, please
let me or Geoff Lapp (cc’d on this email) know.

Thanks,
Nick

Written by phil

October 13th, 2010 at 6:38 pm

Posted in Epic

Patients with recent I-131 Treatment

A patient who comes in s/p I 131 treatment within a month of their treatment:

Isolate the patient in an Isolation room in the ED.  Stay 6 feet away from the patient as much as possible at all times.

Keep pregnant staff and children away from the patient.

Call Endocrinology Consult 24/7 to make them aware the patient is in the Emergency Department.  The alternative will  be would be to contact the Radiation Safety Officer.

If the patient needs admission admit them to the “Radiation Room” on A3 OR a private room if this is not available.

If it was a patient recently discharged from EHC and needs admission – re-admit the patient back to the room from where they were discharged.

Of note: the patient should be wanded with a Geiger Counter.  < 2mr/ hr all children and pregnant staff need to stay 6 feet from patient.  >2mr/ hr all staff need to stay 6 feet from the patient.  If the patient is in extremis, treat the patient first as radiation emission is a secondary concern.  More on wanding and Geiger Counters to come…

Laura Iavicoli-Allensworth, MD

Written by reuben

October 13th, 2010 at 4:38 pm

Posted in ID

Kyphoplasty for Compression Fractures

[The following was submitted by the anesthesia department. If neurosurgery or orthopedics are involved, make sure to discuss with them before involving another service]
The Department of Anesthesiology, Division of Pain Management is pleased to announce the availability of balloon Kyphoplasty here @ Mount Sinai.
Balloon kyphoplasty is designed to correct the angular deformity caused by vertebral compression fractures (unlike Vertebroplasty, which does not correct the deformity), significantly reduce back pain and improve patients’ ability to return to their daily activities in  patients suffering from vertebral compression fractures (VCFs) due to osteoporosis or cancer. 3,4
With over 700,000 VCFs occurring each year in the U.S., VCFs are the most common fracture caused by osteoporosis. The incidence of VCFs is higher than hip fractures and breast cancer combined. However, an estimated 2 out of 3 VCFs go undiagnosed and untreated. Vertebral compression fractures are also the most common skeletal complication of metastatic cancer with an estimated 75,000 to 100,000 cancer-related VCFs occurring annually in the U.S. Common tumors causing VCF are breast cancer, lung cancer, and prostate cancer. Left untreated, VCFs are associated with an increased risk of future fractures, chronic pain spinal deformity, and kyphosis all of which can dramatically impact your patients’ quality of life.
In the past, traditional treatment for VCFs have included bed rest, medication and back bracing. While these therapies may help to decrease a patient’s pain over time, they do not treat the deformity related to the osteoporotic fractures. 1,2 Multiple studies show balloon kyphoplasty can correct vertebral deformity, reduce back pain, significantly improving mobility and increase overall quality of life. The procedure typically takes less than one hour per treated level and can be performed as an inpatient or outpatient procedure. Most patients recover well and return to normal activities within a few days. 3,4,5
If you have VCF patients presenting with acute back pain who can benefit from balloon kyphoplasty, I would be pleased to provide a patient consult. Early VCF diagnosis can result in optimal treatment. I am committed to providing excellent patient care by utilizing the most effective and safest treatments of spinal conditions. Please feel free to contact Dr. Lawrence Epstein @ for a consult or if you would like further information at 212-241-8916 or contact the Pain service @ pager 0329 and make sure that you say that the patient has a (potential) compression fracture.
1. Ross PD. Clinical consequences of vertebral fractures. Symposium on osteoporosis. AM J Med. 1997; 103:30S-43S.
2. Silverman SL, Minshall ME, Shen W, et al, for Health-Related Quality of Life Subgroup of the Multiple Outcomes of
Raloxifene Evaluation Study. Arthritis Rheum. 2001; 44:2611-2619.
3. Ledlie JT, Renfro MB. Spine. 2006;31:57-64.
4. Garfin SR et al. Spine 2006;31:2213-2220.
5. Brunton S, Carmichael B, Gold D, et al. Vertebral compression fractures in primary care: recommendations from a
consensus panel. J Fam Pract. 2005; 54:781-788
Click here for movie.

Written by reuben

October 9th, 2010 at 11:40 pm

Posted in Ortho

ED Central Line Policy

All central lines placed in the emergency department on patients who are not arrested or nearly arrested must meet these criteria:

1. The key portions of the procedure, which include initial cannulation of the vein and confirmation of venous placement, must be performed with an attending present.

2. The appearance of dark and non-pulsatile blood flowing from a freshly-inserted needle or catheter is insufficiently accurate to reliably distinguish arterial from venous placement. All central lines must be confirmed by ONE of the following methods prior to vessel dilation. This applies to standard triple-lumen and 8.5 Fr (introducer/Cordis) catheters.

a. Formal pressure transduction to confirm a non-arterial waveform.

b. Manometry using extension tubing. 8.5 Fr catheter kits come with sterile extension tubing in the set; triple lumen catheter kits do not. The sheath housing the guidewire can easily be used for this purpose. Patients with low arterial pressure or high venous pressure can generate misleading results.

c. Analysis of blood oxygen content using a blood gas drawn from the line. Results can be compared against a known arterial sample if ambiguous (e.g. in a hypoxic patient).

d. Anatomic ultrasound confirmation of the wire in a vein. Images or clips saved should demonstrate the wire in a collapsible vein juxtaposed to a non-collapsible artery; please save or print and scan images or clips.

e. Functional ultrasound confirmation by seeing normal saline rapidly injected through the catheter pass through the right heart. This is called the bubble test. Please save or print and scan images or clips.

If any single confirmation technique is inconclusive, use another confirmation technique.

These confirmation techniques do not replace the post-insertion chest xray, which evaluates for depth and complications of central line placement. The CXR is poor at distinguishing arterial from venous placement.

All central lines must be documented with the appropriate MD Procedures template, within which the steps for appropriate placement and confirmation are listed.

Contact me with any questions concerns.

reuben

Hospital Central Venous Catheterization Safety Policy

The Bubble Test

Written by reuben

October 8th, 2010 at 3:39 am

Charting Deficiencies

i had a meeting with beth & jill this morning to review our charting deficiencies as a practice. though there are some outliers, it seems that A LOT of our deficiencies can be attributed to holes in the documentation of review of systems & past social/family history sections.

several pearls/caveats …

· in psychiatric ROS, even though etoh abuse is listed there, it does not technically count as a psychiatric review. the coders will put that into the social history bucket.

· documented allergies can count as either part of the past medical history OR the review of systems …. as long as you click the boxes “nursing records reviewed” & “agree with nursing records” you get credit for it.

· for medical student charts, the coders can only use the PMH & ROS sections from their chart. you MUST reproduce the HPI & PE to get credit for it.

· and always remember the 5/10/20 rule … 5 elements in HPI, 10 in ROS, and 20 in PE. in addition, you must chart in any 2 of 3 sections of past medical history: medical/surgical history, social history or family history.

· please remember to chart for critical care time if appropriate. remember, what the insurance company defines as “critical care” is not necessarily what we consider to be “critical”. it must meet 2 requirements: 1) clinical condition – the probability of imminent or life threatening deterioration in that case and 2) treatment – the failure to deliver treatment or withdraw it would cause clinical deterioration. so for example, you could bill critical care on a rapid a fib patient – because 1) they could deteriorate if you didn’t attend to them & 2) if you didn’t give the appropriate agent to slow down their heart rate, they could develop cardiac ischemia or hypotension.

i will be meeting with some of you individually to go over charts & see if we can determine where the deficiencies specifically lie. i will try to do the top 2 (or should i say bottom 2) on a monthly basis.

as always, feel free to find me to discuss any questions or problems.

vaishali

Written by reuben

October 7th, 2010 at 11:22 pm

Posted in Billing

Adolescent Health Center Expansion

The adolescent health center is now seeing patients from age 10-24 and are looking to expand their volume by 150%. They offer free services to their pts through grant support including dental/ophtho care. Please refer as many pts as you are able to them. Rather than med/peds in the 20/21 year old pts please refer everybody to AHC.
Thanks,

Adam Vella, MD

Written by reuben

October 7th, 2010 at 11:20 pm

Posted in Peds

Sickle Cell Pager and HbSS Research

Hello Faculty,

We now have three clinical Sickle Cell studies that are actively recruiting subjects. Rather than post paper advertisements in the ED, we have established a Sickle Cell research pager that can be paged through a single-click order in IBEX. So I am writing to everyone to ask (beg, plead) that, if you see a patient with Sickle Cell disease, please page the SCD pager as soon as possible.

The process is easy: go into the Sickle Cell order set (or the consults order set) and click “Sickle Cell MD” then press enter. I will automatically be paged.

Don’t worry about whether or not the patient is eligible for a study. I will take care of everything. If the patient is not eligible, I will still see the patient to arrange follow up and follow the patient as an inpatient. Don’t worry about the time of day either, page me 24-7.

Once you’ve paged me, continue with standard care as usual.

Thanks so much for your help!

Jeff Glassberg

RESCUED Combined Consent and Initial Data

Written by reuben

October 4th, 2010 at 3:43 pm

Posted in Research

Pneumonia Core Measure

From: Corinne Geller

PATIENTS ARE AUTOMATICALLY GIVEN A PNEUMONIA DX FOR WRITING:
R/O PNEUMONIA
INFILTRATE
LOWER REPIRATORY IFECTION
NEED TO EVALUATE FOR PNEUMONIA
PNEUMONITIS
POSSIBLE/PROBABLE/QUESTIONABLE/ OR SUSPECTED PNEUMONIA

Once a pneumonia diagnosis is inadvertantly given, you are expected to follow all the core measure guidelines for a pneumonia pt. Otherwise, we fail. Our failures are publicized on the internet and we are financially penalized.

If you are a providor select the drop down check-box indicating:
CLINICAL PICTURE WAS UNCLEAR OR NOT SUGGESTIVE OF PNEUMONIA; DELAY IN THE DIAGNOSIS OF PEUMONIA AT TIME OF ADMISSION.
If this situation applies. Corroborate in your notes. Nurses please help remind providers. Cannot make this selection once 6 hours has already passed.
THANK YOU!

Written by reuben

October 2nd, 2010 at 5:18 pm

Posted in ID