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Archive for January, 2012

Metoprolol Shortage

All:
Our supply of metoprolol injection is now at a critical level. Based on our current utilization, we will exhaust our supplies by the weekend. We have been unable to obtain additional metoprolol, and it appears unlikely that we will get any in the foreseeable future. We have increased our supplies of propranolol injection, as well as labetalol and esmolol. We are also experiencing difficulty obtaining diltiazem injection and enalaprilat injection. Please use oral therapy or alternative agents when ever possible.
Gina

PS- please don’t kill the messenger

Gina Caliendo, BS, Pharm.D, BCPS

Written by reuben

January 31st, 2012 at 10:08 pm

Posted in Pharmacy,Shortage

Locations of Security Alarms in the ED

Written by reuben

January 31st, 2012 at 5:04 pm

Posted in Security

ABO Confirmation

What is an ABO confirmatory specimen?
ABO confirmatory specimen / 2nd ABO specimen policy has been in place at Mount Sinai since 2007. It is a patient safety measure designed to help prevent ABO hemolytic transfusion reactions due to phlebotomy / patient identification errors. Many patients have had at least two type and screens before any transfusion is ordered, and hence will never need an ABO confirmatory specimen, as their blood type has already been confirmed.
An ABO confirmatory specimen is needed only once, ever, to confirm a patient’s ABO blood type, in order to ensure the patient is given the correct blood type. An ABO confirmatory specimen is required on patients who have never had a type and screen while at Mount Sinai, and thus have no historical blood type on record to compare with the current specimen.
The only exceptions, for which a 2nd ABO is not needed, is for T&S specimens drawn in Perioperative Services (which has never had a phlebotomy error resulting in a mislabeled specimen). Perioperative Services areas that do not require ABO confirmatory specimens include: DAS, Cardiac Pre-Admission, Cardiac Cath, Ambulatory and Special Procedures.
All inpatient locations, outpatient locations, Emergency Department, Labor and Delivery, FPA and private physician offices require ABO confirmatory specimens. The Blood Bank will notify the patient care area when a 2nd ABO confirmatory specimen is needed. ABO confirmatory specimens do not include an antibody screen, and have a shorter turnaround time.
In the event of an emergency transfusion, type O red blood cells will be provided until the ABO blood type can be confirmed.

Written by reuben

January 30th, 2012 at 10:20 pm

Posted in Blood Bank

How to Arrange for an Autopsy at MSH (not medical examiner case)

1. Consent the family, using this form.

2. Call the mortuary, extension 47376. If no one answers, leave a message.

Written by reuben

January 30th, 2012 at 9:49 pm

Posted in Death

Rapid Strep Documentation

Hi All:
Rapid strep results must all be documented in the chart as POCT.
Nursing has an easier way of doing this on their template, and the
EPIC team is working on giving us the same easy way to document any
point of care testing (POCT) we do in the ED. In the meantime, please
make sure the residents are ordering the rapid strep test ( easily
found in peds common orders ) . To record the result, click on ‘more
activities’ located on the bottom of the left sided menu that has
‘snapshot’, ‘chart’ , etc . This will open a menu where you should
choose ‘enter / edit results’ . The page that will open for you will
have the ordered POCT at the top. You have to highlight the test for
which you are recording the results , and the place your ‘neg’ or
‘pos’ in the result box that will open at the bottom of the page.
Remember to also record the date.
This should all be less painful once we have the somewhat easier
version the nurses have. But, please record these results. We are at
risk for losing all POCT in the ED if we do not comply with some
changes.
Thanks

Sylvia

Written by reuben

January 30th, 2012 at 8:40 pm

Posted in Peds

A plea re: hypothermia

Folks,

I know this is beating a dead horse, but some of us are still cooling patients that are inappropriate and will not benefit from the therapy. The other day I walked in to a patient being hooked up to arctic sun pads that was 83 y/o, with dementia, and possible sepsis. We discontinued hypothermia, signed a FHCDA and got palliative care involved. The patient went up to the floor and was terminally extubated with all of the family present.

This case brings up the need to reiterate the following:

Please don’t cool patients with dementia or sig. cognitive decline.
Please don’t cool patients who can’t manage their ADLs independently
Please don’t cool patients with poor baseline status
Please don’t cool patients with a significant downtime unless they were found in v-fib/vtach
The default is not to cool patients >=80 y/o. I have left this as relative b/c if you have an 80y/o who looks 50 with none of the above, you may want to cool, but the DEFAULT is not to cool these patients
Each use of the arctic sun costs about $2000 in pads; in addition if the ICU continues cooling, the pt will be in the ICU for 5-7 days unnecessarily.

Now let’s say you just can’t handle making this decision. You can’t handle withholding care from ANYONE; it just isn’t in your practice pattern. You have some recourse:

Email Me; if I am around I will call you back immediately and I am happy to take the burden of withholding this therapy
If it is a borderline case, use ICED SALINE and the BLANKETROL machine instead of the arctic sun. If the ICU decides to continue, then they can switch over to arctic sun. If they don’t you have only wasted $100 instead of $2000
Please send me your thoughts and comments.

thanks,
Scott

Written by reuben

January 27th, 2012 at 9:10 pm

Posted in Elmhurst,Hypothermia

Disposition of LVAD Patients

LVAD patients can only be admitted to one of 3 floors—CSICU, CCU or 7 West.

Stable patients are admitted to 7West. They are covered by the CTS physician assistants. The attending of record may be either cardiology or CT surgery. Usually, coming from ER it will be under cardiology.

Unstable patients are admitted to the CCU. They are covered by the CCU fellow and medicine housestaff. The attending of record will be a cardiologist.

If it is a surgical emergency, patients may on rare occasions be admitted from the ER to CSICU. I don’t think I have ever seen this happen.

Best,

Sean Pinney

Written by reuben

January 27th, 2012 at 1:18 am

Posted in LVAD

Diabetic Foot Admissions

Written by phil

January 26th, 2012 at 2:55 am

Death Notification Resources

Written by reuben

January 26th, 2012 at 12:58 am

Posted in Death

NICE Team Update

greetings from the NICE team:

 

for those of you that don’t know what that is … it is the “Novel Interdisciplinary Care for Emergencies” team.  we evaluate pts that are frequent users of the ED to see if there are better resources that the pts can be referred to to facilitate & improve their care.  the criteria for referral to the team is more than 3 ED visits per month for 3 consecutive months.  we get a report generated from EPIC that filter pts based on this criteria that we review plus any referrals that staff send to us.

 

once the pt is part of the NICE program, an FYI is entered into EPIC.  currently, most FYIs just say to call the appropriate social worker while the pt is here so that they can share pertinent clinical or psychosocial information with you.  we are exploring avenues to get this data centralized so that it will be accessible even when they are not available – but  it is a work in progress right now.  You should see a red upward arrow in the column labeled “FYI” on the track board.  if you double click on it, it will take you directly to the FYI information.  while in a chart, there is also an FYI notification in the header – if you click on that section, it again will take you to the information that is there.  please make every effort to call SW for every NICE team pt that comes to the ED so we can track their visits & to re-educate them about the proper resources & where they can go for care.

 

if you have any questions, please feel free to email me, liza ronda or jessica hochstadt.

 

best,

vaishali

Written by reuben

January 26th, 2012 at 12:12 am

VNS Paperwork

i’m sure all of you get those nagging VNS envelopes containing paperwork requesting signature for continuing VNS services for a patient that you saw in the ED months ago … and i’m sure most of us don’t fill it out as we are not the pt’s primary care providers.  VNS coordinators are aware that the forms should be going to the primary mds but frequently we are the only md’s identified on the initial paperwork.  in the future, when you get these papers, please place them in the SW box in the attending office – they will then take the initiative to return them to VNS & tell them to find the appropriate md.

 

best,

vaishali

Written by reuben

January 26th, 2012 at 12:10 am

Posted in VNS

Concussion Patient Information

Written by reuben

January 2nd, 2012 at 9:03 pm

tPA for Stroke Patient Information

Written by reuben

January 2nd, 2012 at 9:01 pm

How to Transfer to Mount Sinai

Patients who are accepted by an inpatient attending for admission ideally do not go through the ED, they go directly to their inpatient bed. Arrange this though the transfer office (x46467 or 212.241.6467). If there are no inpatient beds, either the patient can wait at the referring facility for an inpatient bed or the patient can be transferred to the MSH ED; this determination is made on a case-by-case basis. The less sick and the more able the referring facility is to provide appropriate care for the patient waiting for a Sinai bed, the more the patient should wait at the referring facility for their Sinai bed.

For unstable patients (e.g. diagnosed aortic dissection), a brief attempt should be made to transfer directly to the relevant ICU and if no beds available, transfer to the ED is appropriate.

For stable patients who require services not available at the referring facility (ophthalmology, ENT, orthopedics, neurosurgery, etc), who may or may not require admission, ER-to-ER transfer is appropriate.

Written by reuben

January 1st, 2012 at 10:15 pm

Posted in Transfer