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Archive for December, 2011

These patients should always be admitted to the Surgical Service

Dear Colleagues,

 

With input from the Department of Surgery we are in the process of revising the earlier admission guidelines.  Going forward please admit these patients to the Surgical Service NOT the Medical Service:

 

Diverticulitis with and without abscess

Cholecystitis

Cholangitits (NOT MEDICINE)

choledocholithiasis (NOT MEDICINE)

Liver abscess

Post-operative complication within 30 days of surgery including DVT (go to the service that operated on the patient)

Spontaneoous pneumothorax

Pancreatitis (except alcohol induced)

 

Thanks,

Phil

 

Written by reuben

December 22nd, 2011 at 7:54 pm

Posted in Elmhurst

Patients who have an initial evaluation by NP/PA/Attending

ED Attendings:

 

Remember to use the “Initial Evaluation” status button on the bottom tool bar when you speak to patients after reviewing their EKGs, order medications or have other patient encounters that satisfies you that a patient is stable for the team or for fast track evaluation.  This is especially important for our intoxicated patients who are in the department for 8 to 12 hours.  It’ll establish your early assessment of them and help to continue to drive down our “time to initial evaluation”.  Our median time to initial evaluation has decreased 25% (to about 30 minutes) and we have shaved about 10 minutes off of our total throughput time for discharged patients.  Remember that when you click on the “initial evaluation” button your name appears in the right column and the “Needs Exam” button changes to blue.  You can clear your name by transferring to “blank”.

 

The progress note macros are useful to quickly document this encounter and list your interventions.

 

Please also be aware that patients who have an initial evaluation by a PA, NP or attending (with or without labs/radiographs/medications) and then leave before a team provider is assigned  have left “BEFORE DISPOSITION” not “LEFT WITHOUT BEING SEEN”.  This initial evaluation at triage or on the team constitutes a meaningful assessment of the patient’s stability and qualifies as a screening exam.  Attendings, PA and NP are qualified to provide this screening evaluation but residents are not.  Therefore, if the senior resident does the initial evaluation and the patient is not later seen by a NP, PA or attending we will continue to document the disposition as LWBS.

 

Thanks,

Phil

Written by reuben

December 22nd, 2011 at 6:51 pm

Posted in Elmhurst

Ketorolac Shortage

The country and therefore the hospital is running out of ketorolac.

For patients who can take PO, ibuprofen is equally effective. Also, it is not well known that the analgesic ceiling for ketorolac is probably around 10 mg IV. I personally use 15 mg, and the hospital still has a reasonable stock of 15 mg vials, so consider this in patients whom you think would benefit from a parenteral NSAID.

 

Ketorolac Shortage Announcement

ketorolacceiling

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Written by reuben

December 22nd, 2011 at 6:26 am

Posted in Shortage

Foot Ulcer Policy

Written by phil

December 14th, 2011 at 3:38 pm

HIV Testing at Elmhurst ED

HIV testing the ED

We talked about this yesterday at our attending meeting and I know there’ll be more to discuss. If you’ve worked this week you’ve probably noticed the HIV icons on the tracking board.

In order to adjust to a hospital funding change and start complying with a new New York State regulation requiring 24/7 HIV offer/testing in ED we had to change how we provide this service. The new funding source has the specific expectation of an expanded testing program throughout the hospital. We are not ready to offer testing 24/7 but will now have 16 hours of additional testing on the weekend. Unfortunately we will no longer have HIV counselors weekday evenings (between 4 and 11 PM). Instead a phlebotomist will staff these hours and can order and enter results in QMED but cannot counsel patients. An important aspect of the change for us then is, during these hours (weekdays 4 to 11pm), a doctor/PA/NP has to give the patient the test result and document the conversation in HMED.

Here is how it should work:

1 ONLY AMBULATORY patients get an HIV fact-sheet at mini-registration (“FORM A”)

2 At triage the patient is asked if they want free HIV test:
a. “YES” response gets the new icon with a check mark in the center
b. “NO” response gets the icon with a “minus” sign
c. “Strike through” (not applicable) goes to patients who have been recently tested, are positive or are arriving by ambulance

3 Consent is signed along with general consent form at registration.

4 Hours of testing:

a. Monday to Friday 9 AM to 4 PM and Saturday/Sunday 11 AM to 7 PM: HIV counselor performs test, gives result and counsels patient. They also document post-test counseling in HMED.

b. ***Monday to Friday 4 PM to 11 PM: Phlebotomist performs the test and enters result into QMED but cannot give result to patient, counsel patient or document in HMED.

i. Tech will give result to Resident/PA/NP if one is assigned
ii. Tech gives result to attending if no Resident/PA/NP is assigned

5 Post-test counseling:
a. NEGATIVE result (>99%):
i. Inform the patient
ii. PRN follow up

b. POSITIVE result (<<1%): i. Counsel patient ii. Page ID fellow and give fellow the patient’s contact information iii. Advise patient to return the next morning, with the test result sheet, to speak to the counselor and set up ID clinic follow up iv. If the patient is admitted the in-patient team will contact ID/HIV counselors 6 Document counseling a. HMED progress notes have pre-set statements that are self explanatory b. HIV counselor document in a different section of the HMED chart If you have any questions please call me 917-533-2660. Thanks, Phil Courtesy of Scott Goldberg: There is some reasonable information on the CDC website. However, the material can be vague and refers back to "following your institutions guidelines." The CDC RESPECT-2 site (http://www.cdc.gov/hiv/topics/research/respect-2/counseling/index.htm) has some excellent information and scripts on what to do with a NEGATIVE result, and on how to counsel patients PRIOR to the test. The script for counseling a patient on a HIV Positive Script. It is useful, but limited.

There is also some useful information on positive test result counseling here: http://www.cdc.gov/hiv/topics/testing/resources/factsheets/rt_counseling.htm. It includes information including the sensitivities and specificities of our rapid tests (appendix), allowing an educated discussion about what this test means with our patients.

Also, remember that at Sinai any positive should get a call to social work for counseling 24/7.

Scott

Written by reuben

December 8th, 2011 at 7:29 pm

Posted in Elmhurst,HIV