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Archive for July, 2011

Headache and High INR Guidelines

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Headache Guideline

1. Does a response to therapy predict the etiology of an acute headache?


Level C recommendation: Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

2. Which patients with headache require neuroimaging in the ED?


Level B recommendations: i. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent* noncontrast head CT. ii. Patients presenting with new sudden-onset severe headache should undergo an emergent* head CT. iii. HIV-positive patients with a new type of headache should be considered for an emergent* neuroimaging study.
Level C recommendation: Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination should be considered for an urgent† neuroimaging study.

*Emergent studies are those essential for a timely decision regarding potentially life-threatening or severely disabling entities. †Urgent studies are those that are arranged prior to discharge from the ED (scan appointment is included in the disposition) or performed prior to disposition when follow-up cannot be assured. Routine studies are indicated when the study is not considered necessary to make a disposition in the ED.

3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain CT scans are interpreted as normal?


Level B recommendation: In patients presenting to the ED with sudden-onset, severe headache and a negative noncontrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage.

4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?


Level C recommendations:
i. Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.
ii. In the absence of clinical findings suggestive of increased intracranial pressure, a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar puncture does not assess for all causes of a sudden severe headache.)

5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture?


Level B recommendation: Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

Recommendations for Managing Elevated INRs or Bleeding in Patients Receiving Vitamin K Antagonists

INR more than therapeutic range but < 5.0; no significant bleeding: Lower dose or omit dose; monitor more frequently and resume at lower dose when INR therapeutic; if only minimally above therapeutic range, no dose reduction may be required (Grade 1C).

INR > 5.0, but < 9.0; no significant bleeding: Omit next one or two doses, monitor more frequently, and resume at an appropriately adjusted dose when INR in therapeutic range. Alternatively, omit dose and give vitamin K (1–2.5 mg po), particularly if at increased risk of bleeding (Grade 1C). If more rapid reversal is required because the patient requires urgent surgery, vitamin K (???? 5 mg po) can be given with the expectation that a reduction of the INR will occur in 24 h. If the INR is still high, additional vitamin K (1–2 mg po) can be given (Grade 2C).

INR > 9.0; no significant bleeding: Hold warfarin therapy and give higher dose of vitamin K (2.5–5 mg po) with the expectation that the INR will be reduced substantially in 24–48 h (Grade 1B). Monitor more frequently and use additional vitamin K if necessary. Resume therapy at an appropriately adjusted dose when INR is therapeutic.

Serious bleeding at any elevation of INR: Hold warfarin therapy and give vitamin K (10 mg by slow IV infusion), supplemented with FFP, PCC, or rVIIa, depending on the urgency of the situation; vitamin K can be repeated q12h (Grade 1C).

Life-threatening bleeding: Hold warfarin therapy and give FFP, PCC, or rVIIa supplemented with vitamin K (10 mg by slow IV infusion). Repeat, if necessary, depending on INR (Grade 1C).

Administration of vitamin K: In patients with mild to moderately elevated INRs without major bleeding, give vitamin K orally rather than subcutaneously (Grade 1A).

2008 ACEP Clincal Policy for Headache
ACCP Vit K Antagonist Guidelines 2008

Written by reuben

July 25th, 2011 at 11:23 pm

Posted in Required Reading

Anonymous HIV Testing

Attached find:

ANONYMOUS HIV tests:

1. Anonymous HIV results in EPIC. All anonymous patients have the same name: Stick, Needle. But different codes & time.
2. Procedure steps- as an FYI- to provide for you background
3. Narrative-as an FYI- more background.

All ED providers should add Stick, Needle to their patient list.

Note: HIV results for KNOWN Source patients for Needlestick/BBFE are accessed in EPIC the same way as other lab tests.

Please let us know if there are any difficulties in accessing rapid HIV results.
If a inservice session is appropriate, Dr Wallach & I are available.

Thank you,
Alexandra (Sandy) Derevnuk, MEd, FNP-C
Department of Infection Control
Needlestick/BBFE Coordinator
212-659-9469/ Beeper 4118
FAX 212-849-2582

HIV RESULTS:

To view anonymous HIV rapid test results in EPIC.

Reminder: all Anonymous Source patients are named Stick,Needle.
All sources have the same name, MRN, DOB, location,

but DIFFERENT DATE, TIME & anonymous CODE.

Go to Patient Lists…Go to Add Patient.

ADD: Stick,Needle to your patient list.
All providers should add Stick,Needle to your patient list in order to view rapid HIV anonymous test results.

Leave Pt name: Stick,needle on your list.

HIV ANONYMOUS TESTING: PROCEDURE:

Special Form: Stat Laboratory-ANONYMOUS TESTING NEEDLESTICK SOURCE PATIENT REQUISITION

to use in Occupational exposure situations where the source patient is unable to give HIV consent.
Each pre-printed form is used for one source patient. It has 3 special pre-printed code labels. The labels are used by the needlestick coordinator(NSC)/nursing administrator:

1. For the BBFE worksheet p.1
2. For the BBFE worksheet p.2
3. Affix to the green top blood specimen tube-for the rapid HIV test.

The NSC puts this code label on top of the specimen tube labeled with the source person’s name. The NSC knows which code is linked to the specific source patient.

The green top tube goes to the lab with the pre-printed green form with the date & time written in by NSC.

All the source patients have the same name: Stick, Needle
All the source patients have the same MRN 3592458
All the source patients have the same DOB 11/11/1900
All the source patients have the same location 444

Different anonymous code: NS ____ anony

This enables the provider of the exposed person ability to look up in EPIC one patient name: Stick, Needle. The provider does not need to know the source patient name or memorize the MRN. They only need to know source patient name: Stick, Needle.
Results also in SCC.

The ED/EHS provider will be informed of the date, time & code of the source in order to look up the rapid HIV test result.

HIV Anonymous Testing Procedure

After many months of careful planning, Mount Sinai has created a procedure for anonymous HIV testing to conform to the new HIV consent law effective September 2010. The procedure applies to the provision concerning patients who are the source of an occupational exposure and are incapable of providing consent (deceased, comatose, demented). In such instances, the patient can be tested anonymously without consent.
A Needle stick Source Patient Requisition form is now in place for the Stat Laboratory. This form contains three labels with an anonymous code; two of the labels are affixed to the Blood/Body Fluid Exposure Worksheet and the third label is affixed to the green top blood specimen tube. The anonymous test result can be seen in all systems under the name Stick, Needle. Within the name Stick, Needle, each needle stick case will have its corresponding anonymous code. Only the nursing administrator or needle stick coordinator will be aware of the patient’s real name and this will remain confidential. The code will then be provided to the ED or EHS provider in order to retrieve HIV results.

Written by reuben

July 21st, 2011 at 9:53 pm

Posted in Needlestick

Pediatrics Admissions Disposition

Under 12 without a known MD goes to Peds Associates.

Under 12 followed by peds assoc, med/peds, known voluntary is assigned as such.

12 and over not followed already by peds assoc, med/peds, known voluntary or already followed by adolescent should be admitted to adolescent.

Subspecialty pts should be assigned to the appropriate team after discussion with them, if not then the rules above apply.

Written by reuben

July 15th, 2011 at 8:52 pm

Posted in Admitting,Peds

Clutter Bins

There is a blue clutter bin on north and a red clutter bin on south. If you see any supplies lying around, put them in the clutter bin. Not papers. Supplies. The techs will put these misplaced supplies back where they belong.

Written by reuben

July 13th, 2011 at 5:56 pm

Posted in Cleanliness

Referring Patients to Dental Clinic

Written by reuben

July 12th, 2011 at 10:58 pm

Posted in Dentistry

ED ICU Cooperation/Transfer Policy

Policy regarding MICU/ED cooperation & transfers from ED to MICU, and to clarify aspects of process improvement and practice parameters for the triage and management of critically ill patients.

1. Goal: MICU patients should be transferred from the ED to an available MICU bed in under one hour.

2. Inter-department communication: ED and MICU leadership will designate liaisons who will work to resolve ED/ICU issues both in real time as they arise (by prompt email reporting) and with regular meetings to address patient care issues that affect both departments. The points below stem from such inter-departmental communication:

2. Transfer of moribund patients from the ED to the ICU: The ED will seek to identify the subset of critically ill patients not expected to survive more than 1-2 hours, and the management focus for these patients will be on optimizing all aspects of care in the ED rather than transfer to the ICU. A set of criteria Criteria to identify these patients was discussed and includes are:
– serum ph<7 in an intubated patient - HR <40 or SBP<60 on high dose vasopressors - two or more cardiac arrests in the ED. The ICU will be available to provide consultative intensivist support in the ED for these patients and their families, but will not assume primary management of the patient. If patient is sustained >2hours after initial notification of the ICU, despite moribund physiology, then transfer to MICU will be discussed on a case-by-case basis, as the MICU recognizes the need to admit patients with sustained care needs.

3. Management of patients who are difficult to ventilate or oxygenate after intubation. Routine post-intubation blood gas analysis will be obtained promptly after intubation. The ED will focus on identifying the subset of intubated patients who are difficult to ventilate; this includes but is not be restricted to the following specific criteria: high peak airway pressures [>35 sustained despite sedation attempt], refractory hypoxemia, and severe patient ventilator dyssynchrony. Repeat blood gas analysis will be performed as soon as difficult to ventilate status is detected. The ICU will strive to arrange for early transfer of these patients and, when this is not possible, will focus on providing timely substantive intensivist consultation in the ED.

4. Recognition and early intervention for severe sepsis: The ED and MICU have initiated efforts to join the GNYHA sepsis identification and treatment collaborative STOP Sepsis (Strengthening Treatment and Outcomes for Patients) project. This participation includes adoption of an automated EPIC-based ED triage instrument that helps to identify patients with severe sepsis or sepsis with shock, and to utilize protocol driven resuscitation measures. Time stamped data collection will document the completeness, timeliness, and effectiveness of protocol components including time to antibiotics, time to fluid resuscitation, lactate clearance measurement, ivc collapsibility index measurement, cvp measurement, according to protocol triage instrument/resuscitation protocol/ data collection instrument.

5. No Beds policy. This is to reaffirm existing medical board policy [circa 2003] regarding the situation when no bed is readily available for a patient accepted by the MICU. If the patient is deemed by the MICU fellow as an appropriate candidate for MICU admission, then several situations may occur:
a. If no bed is available, all attempts should be made as rapidly as possible to create an open bed for the patient. Ongoing efforts to increase the available stepdown beds and to establish a safe/acceptable cohorting program are two examples of efforts to enhance throughput and improve bed availability. If no patient can be transferred out of the MICU safely, then the MICU fellow is responsible to call the fellow on call in another ICU [in the following order: SICU, NSICU, and then CCU]; he/she will arrange transfer. The fellow will notify the MICU attending of the transfer process.
b. If the patient is accepted to another ICU, daily attempts will be made by the MICU attending and fellow to transfer the patient to the MICU according to bed availability, with fellow to fellow communication on a daily basis.
c. A top down evaluation will be undertaken by ED/MICU/hospital administration to develop an improved process to address the care needs of the critically ill patient who remains in the ED for an extended interval because of bed unavailability. At present, MICU will not be responsible for managing the patient in the ED, but the MICU attending and fellow are available to provide Critical Care Consultation for patient management questions. Critical Care consultation is not an avenue to “make” a bed for a patient or to adjudicate triage decisions. The MICU not having available beds does not preclude formal consultation when intensivist decision support is requested by the ED.
d. Patients who are intubated in the ED but deemed not to benefit from ICU admission (e.g., severe co-morbidity that precludes meaningful functional recovery) may be admitted to available step down or medical ward floor bed as appropriate. Each medical floor has capacity to accept at least 2 patients with mechanical ventilatory needs, and the palliative care service may be an appropriate destination for some patients in this category.

ED MICU transfer Policy july 2011 kb rjs tk

Per this policy:

MICU Consult Policy

When a patient is accepted to the ICU but no beds are available, if a bed will not soon become available, the MICU fellow will call the other hospital ICUs to attempt to board patient in an alternate ICU pending availability of ICU beds.

Separate from ICU admission requests, the MICU is available to receive critical care consultations, upon which the ICU team will assess the patient in the ED and provide treatment recommendations.

Cooperation Document Rev Nov 11 2010

Written by reuben

July 9th, 2011 at 7:00 pm

Posted in ICU

Peds Ortho Clinic

Hi Adam,

Just a quick e-mail to make things run smoother:

1. Regarding transfers from other facilities: if something is
being transferred that is thought / known to be operative, please call
the ortho resident first to ensure that we can accommodate them when
they get here. Calling will also help in the opposite way: it may not
need to be transferred if it is something that can be scheduled
electively. This will save the patient an ER visit and we can likely
just give them a clinic visit. (I’m writing this now secondary to the
fact that a type III supracondylar was transferred over here tonight,
but now the OR can not accommodate us and we can’t do the case in the
relatively timely fashion it should be done…. I am also trying to fix
this separate OR problem as well… but that is a much harder problem to
fix at the present time.)
2. Regarding peds ortho clinic: just wanted to reiterate that this
is not a walk-in clinic. Every patient seen in peds ortho clinic needs
to be run by the ortho resident in order to get there. The only time
they don’t need an official appointment is if they come during weekend
hours, but it still needs to be approved by the resident. This helps
because the resident may be able to delineate which clinic would be the
best clinic for them to go to (example: it may not just be the next
Monday … but it may be 3 Mondays away that is the better date for them
based on their injury) or they may be better off being seen by their
primary care doctor first and then they can refer them if there is still
a problem.

Thanks for your help, Adam!

Abby

Abigail Allen, MD

Director, Pediatric Orthopaedic Clinic

Written by reuben

July 8th, 2011 at 8:34 am

Updates on intake, east zone, fast track criteria

All,
Median time to doc is up to 51 minutes, from 42.— we need to be 30 minutes!
LWBT is up—from 2.5% to 4.8%
Some of this is due to Epic, some due to flow issues…. Below is what we are going to do to address some of the problems.

1. Intake: nursing has committed to staffing intake mon-Friday 11a-11p with 3 nurses. This is a priority assignment and it will be filled
2. Intake: if you notice several ambulances at intake— let them know that one member of a crew can go to the intake, and one to the ambulance bay to arrive a pt in epic.
3. East: on July 18th we will be changing how the east zone is used: no admitted pts will go to East—it will be used for Observation pts, Gyn and Ortho care. “OGO” It will also be used for “after intake care”.
4. Fast track—below are the new FAST TRACK GUIDLINES– nursing is in the process of educating all RN’s on the new guidelines—go live date will be July 18th.

Thanks for you input and support

Kevin, Suzanne, Dwayne and Francine

FAST TRACK GUIDLINES
NEW TRIAGE

-If brought by ambulance, must be able to get off of the stretcher and in to a wheelchair
-Only 2 asthmatics at one time, others must go to main ED
-Goal is to see and dispo pt in under 20 minutes

YES
(VS: sat ,95%, HR<110, RR <22, BP < 160/100) -uri -minor laceration (less than 6cm) -abscess (not rectal or perirectal) -cough, -uti -uncomplicated ortho <65 y.o, no, IV meds or admission -digit dislocation, not requiring sedation -eye complaint -BBFE -cellulitis in otherwise healthy adult with normal VS -wound check/suture removal -rash -allergic reaction, skin involvement only (no respiratory symptoms) NO -obvious ortho deformity -if needs US or CT -if needs labs (other than POC, rapid HIV, repeat hcg quant) -ortho >65 y.o.
-fall >65
-HA
-code 11
-needs isolation
-OB/GYN complaint
-testicular pain
-active epistaxis
-dislocation that will likely require sedation (hip, shoulder, elbow)

Any patient that requires more care than is appropriate for the fast track area will be immediately relocated to the main ED treatment area and the ED physician and charge nurse will be notified

Kevin M. Baumlin

Written by reuben

July 6th, 2011 at 10:24 pm