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Archive for November, 2010

Intake Zone Intro

The following areas need to be on your tracking board:

.Adult ER South (Hallway)
.Adult ER-North (Hallway)
.Waiting Room-Adult
.Waiting Room-East Zone
.Waiting Room-Peds
.Waiting Room-Peds Screening
.Waiting Room-West
Waiting
Intake Area



The waiting room is your zone. You pluck out patients from the waiting room and either perform a brief or full evaluation.

Brief evaluation
a. Assign yourself to the patient
b. Introduce yourself and perform whatever elements of the history and physical exam are necessary to generate an initial plan.
c. Enter orders
d. Write a brief progress note in the chart. Example: “Patient briefly evaluated by me in intake area. Preliminary studies initiated; patient is pending full emergency evaluation.”
e. Un-assign yourself from the patient

Full evaluation

Identical to seeing any patient primarily; these patients are fully charted and dispositioned by you. If you discharge a patient from intake, dispo is not discharged, it’s “discharged from intake.”

Indirect admissions, i.e. patients referred to the ED not for an emergency evaluation but for admission to the hospital, are particularly good candidates for full evaluation at intake.



Which nurse performs initial orders depends on the relative flow of the nurses at intake vs. inside. If there are 20 patients waiting to be triaged, the priority of the intake RN is to evaluate those patients, not to perform orders for patients evaluated by the intake MD.

Patients who require an ECG get it in intake. For these patients, review the ECG, sign it, enter it into the chart. Pull up comparison ECGs yourself and print them out. Perform a brief evaluation. Give the ECGs to the patient to give to the next provider.

Refer as many patients to IMA as possible. These patients must be triaged and put into IBEX. Assign yourself, very briefly assess the patient, document “Medical screening exam performed. ┬áPatient stable to be seen in clinic.” No attestation is necessary. Final diagnosis is “Sent to clinic.” Disposition is “Sent to clinic.”

Written by reuben

November 26th, 2010 at 6:14 am

Posted in Intake

Measles Exposure

We had confirmed Measles case in the ED last Thursday and Friday. Staff that was exposed was already contacted, or will be contacted soon.
Also some patients and family members of patients were exposed. The Department of Health may send some exposed patient or family members to the ED for testing. If a patient presents to the ED and says “The Department of Health sent me”… for measles exposure, then follow the following procedures:
1. Give the pt and “green” N 95 mask
2. sit the patient in a chair in intake
3. pull the curtain
4. quick reg, then full reg pt (EHS code)
5. Quick triage pt
6. order (as a custom order for now) “measles Igg”
7. draw gold top tube, label it with pt works label
8. send specimen on downtime form to the lab–
9. d/c “non billable visit.
Please make sure that the contact information is correct so that infection control and or the DOH can contact the patient with titer information.
Please remember. Any pt with a fever and a rash should go into an isolation or single room, at least until a provider can see the patient.
any questions?
email me at kevin.baumlin@mssm.edu

Update:

the order was put in so… no need for down time form..

look in:

I added the test in the following grp under miscellaneous:

Common labs

Common labs-peds

Common orders

Lab-miscellaneous

*Measles Antibody

is the name of the test

-kb

Written by reuben

November 25th, 2010 at 5:19 am

Posted in ID

Creatinine And Consent May Be Waived In An Emergency

[see attached radiology department policy. reminder courtesy of dr. chan, as it pertains to CT brain perfusion studies below]

Dear Colleagues and Residents,

Per Dr. Tuhrim, certain acute ischemic stroke patients may require emergent CT perfusion scans in addition to the non-contrast head CTs. For this particular subset of acute stroke patients, creatinine and written consents are not required before obtaining the CT perfusion scans- please see the attached radiology protocol.

Please do not hesitate to contact us with any questions or concerns.

Have a very happy Thanksgiving.

Yu-Feng Yvonne Chan, MD, FACEP

Radiology Policy: Contrast and Consent for IV contrast for emergent CT

Written by reuben

November 22nd, 2010 at 9:12 pm

Posted in Radiology

Skull and Elbow US Study

Hi Everyone,

After many long months going back-and-forth with the IRB, we have FINALLY obtained approval from the IRB!!! From this point forward, please enroll any patient who presents with a suspected skull or elbow fracture who you are planning on ordering X-rays and/or CT scan.

The IRB was tough and we have some extra paperwork which we did not anticipate. There is a formal written consent document. However, this form is voluntary does NOT have to be signed by the patient/guardian. It does need to be given to each patient/guardian to read over though. If possible, try to have them sign it. There is a HIPAA form which DOES need to be signed by every participant.

I have printed copies of all of the required documents and bundled them together to hopefully make it easier for everyone. It seems like a lot of paperwork but it is actually not that much. I have pre-assigned a “patient #” on each form. Here is the run-down; there are 6 documents (only 4 of which will be completed/given to patient) …

The 1st 2 documents are the most important:
1st page – “Ultrasound/Fracture Data Sheet”: includes demographic info, exclusion criteria, US findings, etc; please fill out as completely as possible; attached is a copy for you to review
2nd page – “Verbal Consent/Assent Form”: 3 check boxes, then you sign; also attached

Either 3rd OR 4th document depending on patient’s age:
3rd document – Written consent document for patients aged 18 years and older; signature of patient NOT required
4th document – Written consent document for patients aged younger than 18 years; signature of guardian NOT required

Either 5th OR 6th document depending on patient’s age:
5th document – HIPAA for patients aged 18 years and older; signature of patient required
6th document – HIPAA for patients aged younger than 18 years; signature of guardian required

Right now, all of these documents are in bundles in paperclips in the Peds ED in a single hanging folder next to the PACS computer. Nicos is working on getting another hanging folder so that in the future we will have one folder for blank forms and the other for completed documents.

I am really excited to get this project underway and thank everyone for your support and for your future participation! Please e-mail or call me with any questions about the study or documents.

Lana

Written by reuben

November 5th, 2010 at 11:29 pm

Posted in Research

Withholding Life Sustaining Treatments in the ED at EHC

Hi folks,

As some of you may know, the recently passed Family Health Care Decision Act allows the withholding and withdrawing of life sustaining treatments in patients who lack capacity, even in the absence of a health care proxy.

This is an enormous step forward for palliative care.

However, the procedure to do this is rigorous and exacting. I have gone through HHC’s 30 page policy and I have created a 3 page summary. It is absolutely critical that we follow all of the steps completely. If we half-ass this, I am sure there will be greater administration involvement. Once that happens, it becomes more difficult to give our patients the palliative care they deserve. Please, please comply with HHC’s policy.

Scott

Withholding Life Sustaining Treatments under FHCDA

Question 1- Does the patient have capacity to make the decision on the particular life sustaining therapy?

An attending physician must make the initial determination that the patient lacks decision-making capacity.
The note should include language similar to: I have determined, to a reasonable degree of medical certainty, that the patient lacks the ability to understand and appreciate the nature and consequences of proposed health care, including the benefits and risks of and alternatives to proposed health care, and lacks the capacity to reach an informed decision.

A concurring attending must make the same determination and document it in the chart as well.

If mental illness is the cause of the lack of capacity, one of the two attendings must be BC/BE in Psych or Neurology.
If mental retardation or developmental delay is the cause of the lack of capacity, call risk management to get involved.
If the patient has any ability to comprehend, you must tell them of the decision that he or she lacks capacity. If the patient objects to the determination of lack of capacity, call risk management and do not continue.

Question 2 – Did the Patient State His or Her Wishes Previously?

Statements that are acceptable for this purpose are:
A Living will
Written statement regarding their wishes
Prior medical orders pertaining to the particular life sustaining treatment (DNR or DNI signed at the same.) Document the nature of these prior statements, and if possible include a copy in the chart. If the patient stated their wishes in one of the above forms, the attending can honor them. If the patient did not state their wishes, then a surrogate will make the decisions regarding life sustaining treatment.

Notify the surrogate (if one is available) of the prior statement of wishes, if the surrogate objects, call risk management.

Question 3- Is there a surrogate who is reasonably available, competent, and willing to serve?

Search for one person from the following list who is reasonably available, willing and competent to serve as surrogate: (The list goes from highest to lowest priority class)
1. A guardian authorized to decide about health care pursuant to Mental Hygiene Law (Call risk management before making any decisions using a guardian)
2. Spouse, if not legally separated from the patient, or a domestic partner;
3. A son or daughter eighteen years of age or older;
4. A parent;
5. A brother or sister eighteen years of age or older;
6. A close friend. A close friend is any person, eighteen years of age or older, who is a close friend of the patient, or a relative of the patient (other than a spouse, adult child, parent, brother or sister), who has maintained such regular contact with the patient as to be familiar with the patient’s activities, health, and religious or moral beliefs. Such person must write and present a signed statement to that effect to the attending physician. This statement should be added to the chart.

Patient Objection to Choice of Surrogate
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to the choice of surrogate, the patient’s objection must prevail until Risk Management becomes involved.

Surrogate Designation of Another Surrogate
If the surrogate designates any other person on the surrogate list, such person designated will be the authorized surrogate, provided no one in a class higher in priority than person designated objects. If there is such an objection or disagreement, the attending physician must promptly refer the matter to Risk Management.

Document the surrogate in the chart.

Question 4 – Is there a situation which would allow a surrogate to make decisions to withhold or withdraw life-sustaining treatment?

In order for a surrogate to withhold or withdraw life sustaining treatments, one of the following must be satisfied:
1. If the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
2. If the patient is permanently unconscious, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
3. If the patient has an irreversible or incurable condition, as determined by the attending physician with the independent concurrence of another attending physician, the provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or extraordinarily burdensome under the circumstances.

If the decision revolves around the provision of artificial nutrition or hydration (unlikely in the ED), then you should consult risk management.

Duty to Give the Surrogate Information
Health care providers must provide the surrogate information necessary to make an informed decision, including information about the patient’s diagnosis, prognosis, the nature and consequences of proposed health care, and the benefits and risks and alternatives to proposed health care.

Expression of Decisions
The surrogate must express a decision to withhold or withdraw life-sustaining treatment either orally to the attending physician or in writing.

Documentation
Three conditions above was present as a progress note. The concurring attending must write the same sort of note as a progress note.

Patient Objection to Surrogate’s Treatment Decision
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to a health care decision made by a surrogate the patient’s objection prevails until a determination is made by risk management.

Standard Forms
If the decision revolves around DNR, the surrogate should sign a DNR form. If the decision concerns intubation, vasopressors, dialysis, etc.; then documentation should be done in a progress note by the attending and the concurring attending.

Health care decisions for adults without available, willing, and competent surrogates

***Consult Risk Management for these decisions***

Written by reuben

November 1st, 2010 at 9:55 pm

New PO Contrast Flow for CT

Docs- please order CT’s based on the protocals listed.
if you need contrast– order the contrast by using the CT scan order set in Med Svc.

Nurses– the contrast is in the pyxis, bottles in the med room. when the pt starts drinking– print out the med order to the “ED CT MED” printer. this print out will let the CT scan BA know that the pt is drinking– they will schedule a pick up in 2 hours from the start time!

thanks for all your help with this… hopefully it will indeed reduce turnaround time for CT’s with contrast.

Kevin M. Baumlin

Written by reuben

November 1st, 2010 at 9:41 pm

Posted in Radiology

Discharged from Intake – DINT

We are trying to track the number of pts discharged from intake– all pts that are treated and released from that area should have the dispo “discharge from INTAKE”.

Also– all pts with an “Im” or “pc” xxx complaint– they should be referred (if willing to go) to ima or peds clinic, (m-f 9 to 7p) . Their dispo should be “sent to clinic”.
Thx
Kevin Baumlin

Written by reuben

November 1st, 2010 at 9:20 pm

Posted in ED Flow