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Archive for October, 2012

Healthix

Written by phil

October 31st, 2012 at 11:56 am

Medicine Admitting

If you have a patient you are admitting to medicine:

1. Sort patients into stable / low demand (non-teaching with fewer providers to patients) and less stable / high demand (teaching service where there are more providers per patient) using the following criteria as guidance for who should be teaching:

a. HR > 125

b. RR > or = 30

c. O2 sat < 90% (despite 4L NC) d. BP < 90 or > 200

e. New AMS in setting of abnormal VS

f. Severe laboratory abnormalities requiring frequent (THREE OR MORE TIMES A DAY) bloodwork (e.g.

DKA, GIB, Hyponatremia, Hypernatremia) – excludes PTT for patients on heparin drip

(There is no absolute requirement for any data but do realize that if you underestimate the complexity of the patient and they are assigned a team (i.e. non-teaching) and subsequent lab work or study shows significant abnormality (i.e. trop of 20, Na of 115, CT with appendicitis, etc), the patient may have to be re-assigned which ultimately slows down the process.)

2. List patient in EPIC as you normally would to medicine service

a. (hospitalist of the day for general medicine and ADS attending of the day for cardiology unless the patient has a primary who will act as the admitting physician).

b. In the text box put the zone phone of the ED provider who will provide verbal hand-off to the admitting team.

3. Either speak directly to or call the MAPA / MAR- provide a brief overview of the case, and ask that a team be assigned.

a. In general this should happen on the spot (the MAPA / MAR should not repeat a history / physical exam of said patient unless they have specific questions you can’t answer).

4. Expect a call from the admitting team to allow verbal hand-off the patient.

If there are any issues / speed bumps. Don’t expend a lot of energy trying solve in real time. Forward the case to me and I will send to Dr. Radbill and the medicine chiefs.

Written by phil

October 31st, 2012 at 11:45 am

Posted in Admitting

Imaging the Obese Patient

With the obesity epidemic sweeping our nation (and some other countries), we are faced with caring for a patient population never before seen, in these numbers: The morbidly obese.
Sometimes we need to use CT imaging to evaluate these patients for significant/dangerous pathology. But the rumors abound about the BMI/wt limits. Thanks to our Rads Chief Resident, Serge Sicular, we’ll set the record straight, here and now.

1. The max wt we can image is 450lbs at main CT (the ED CT can only scan up to 350lbs), but with the caveat that if the machine doesn’t move or the pt doesn’t fit into the donut portion, they need to be transferred to an OSH for a scan.

2. If the tech tells us the pt is too big, we should page the rads resident to confirm the need to use the main CT scan or transfer the patient out (this is a big deal bc it costs the dept time/money and delays diagnosis and treatment time; the pt still has to be transferred back to sinai, potentially too)

3. Dr. Sicular will make sure that the rads residents are all aware of the weight limits of the machines.

4. If we do transfer a patient to Jacobi (which has a scan with a larger limit), the rads team there should interpret the images; please get a digital copy of the images for surgery, neurosurg, etc.

Written by phil

October 30th, 2012 at 4:31 pm

Posted in Radiology

Geri Admissions

FAQs about Geriatrics for ER residents/attendings:

Bottom line from Makini: Please, when you call AMAC to page “geri,” do not say “Please page geri.” Be specific. IE, Ask for the pt’s actual PCP, ask for the MACE or phone call fellow when appropriate, or if you are calling a proper consult, you can ask for the geri consult fellow. Seriously, this is more complicated than most of our consults/provider calls, so please refer to this email.

Thanks, Makini

From Dr. Blachman:

What is the MACE team? This is the inpatient geriatrics service, comprised exclusively of Coffey geriatrics patients and residents of the Jewish Home nursing home.

How do I know if my elderly patient is a Coffey geriatrics practice patient? If you look at notes on EPIC, they would have notes from a geriatrics office visit. The person who wrote the note is the PCP.

Who do I call about a geriatrics MACE admission if it’s Monday at 9 am-Friday 5pm, at ALL hours? The PCP (found in EPIC).

What if the PCP does not call back? Please scroll down on amion (password mssm) and see if the PCP is on vacation. The covering attending will be listed, and you can contact them directly. If no one responds to your pages, please call our geriatrics call center operator at 212-659-8552.

Who do i call about a MACE admission on the weekend (Friday at 5pm til Monday at 9am)? The fellow listed under “phone call coverage” (see amion, mssm, search under geriatrics). Please do not call the general “geriatics consult” number since this is held by the other fellow.

On a weekday, why would you call Concurrent/consult fellow? If you want a consult in the ED between 9am and 4pm on weekdays.

On a weekday or weekend, why would you call MACE fellow? If you have already spoken to PCP but want to alert MACE fellow about an admission during the day (note that this is not necessary as PCP or weekend phone call fellow usually contacts MACE fellow directly).

Are the geriatrics and palliative care fellows the same? No, we are in two separate fellowship programs, taking care of different patients.

What is the Coffey practice? This is the outpatient geriatrics practice at the Martha Stewart Center (1440 Madison)

Nina Blachman via Makini

Written by phil

October 29th, 2012 at 2:29 pm

Posted in Admitting,Geriatrics

OB GYN Follow Up

1. Based on ACEP’s recent clinical policy (ask Sigrid) the use of a “discriminatory threshold” to guide decision making in pregnant patients without a visible IUP on bedside sonography is no longer advised.

a. A serum beta < the threshold does not decrease the likelihood of an ectopic b. A serum beta > the threshold does not increase the likelihood of an ectopic

c. So… if no bedside IUP visible get an official sono (regardless of any serum beta level)

d. If no IUP visible on official sono have a low threshold for involving gyn

2. We need to clarify our terminology regarding early pregnant patients (only two common diagnoses):

a. Presents with relevant complaint and has IUP-

i. discharge as threatened miscarriage-

ii. follow-up is 1-2 weeks in new OB clinic and be sure to set patient expectations appropriately (i.e. you are not sending them to the specialist who is going to do a procedure to save the pregnancy- the OB folks can’t do anything for this population except provide reassurance)

b. Presents with relevant complaint and no IUP found-

i. Diagnosis is possible ectopic

ii. Low threshold for involving Gyn (regardless of serum beta level)

iii. If discharged should follow-up in Gyn Urgent clinic (or return to ED)- be sure you indicate in the referral that ectopic is a concern

c. Gyn Urgent Clinic is for patients who need to be seen in less than a month:

i. Patient will be triaged by a provider based on information you put in the request

ii. They want you to document your concern and specify a desired follow-up period (i.e. bleeding fibroids with low HCT- given OCP taper- needs to be seen within 1 week)

d. Gyn Non-urgent is for patients who can be seen in 4-6 weeks (or perhaps not all)…

Thanks,

Luke

Written by phil

October 26th, 2012 at 4:29 pm

Posted in OB/GYN

Communicable Disease Requirements

Written by phil

October 11th, 2012 at 7:12 am

Posted in ID

Lab Update

Dear Colleagues,

I would like to provide you with general information about ordering laboratory tests and getting results of those tests from our clinical laboratories at Mount Sinai. Here is a list of questions that are most frequently asked of our lab staff, together with our answers. I hope you will find them useful. You can also find this list at our new laboratory website: www.mssm.edu/labmed under ‘FAQs for Practitioners’ – http://www.mssm.edu/research/labs/laboratory-medicine/faqs-for-practitioners

If there are other questions that you think might be appropriate to add to this list, or if you would like us to answer your questions pertaining to labs in general, please do not hesitate to contact us.

Best regards,
Ila Singh

Ila Singh, MD, PhD
Vice Chair, Clinical Pathology
Director of Clinical Laboratories
Professor of Pathology
Mount Sinai Medical Center
(212) 659-8181
www.mssm.edu/labmed

Where is my specimen right now?
Click on Chart Review in EPIC and look at the ‘Status’ column. You will see the following status updates.
Standing = Ordered, but not yet released
Ordered or Needs To Be Collected = ordered and released, but not collected
Collected (Date/Time) = collected, but not in lab yet;
In Process = specimen in the lab system
Final result = test completed and verified
Edited = result updated after going to ‘final’ status
Open an order for more details.
How do I see ALL results in EPIC?
In Chart Review mode, check both LAB and MICRO tabs. Also, deselect ‘hide cancellations’ box.
How do I add-on a test to an existing sample?
Most routine chemistry tests can be added on up to 5 days after receipt of the original sample. BNP, lactate and ammonia are very unstable and cannot be ordered as add-ons. Add-ons for coagulation testing should be requested within 4 hours of original draw. Specimen type of add-on must match specimen type in the lab. Add-ons can be requested in EPIC [new order-priority “add-on”], or faxed to 212-987-0038 (ATTN: ADD-ONS), or phoned in to 4LABS.

Is there a way to figure out the correct tube to collect blood for each test?
For most common tests, go to: http://www.mssm.edu/research/labs/laboratory-medicine/blood-collection/common-test-and-tube-types
For other tests, please check the test directory. For now this is available only on the intranet. But starting early next year, we will roll out a different version that you will be able to access in many different ways.
Why is my test canceled? How do I avoid sample rejection?
Quantity not sufficient (QNS): Always allow tubes to fill completely. Collect a tube for each label generated. If the volume of blood drawn is small, clearly indicate the order of priority for tests, if ordering on paper – otherwise call 4LABS.
Clotted: Draw blood into tube with proper anticoagulant and mix immediately by gently inverting ten times.
Hemolyzed: Increase needle gauge if possible. If transferring from syringe to tube, inject blood slowly into tube.
Contaminated: Draw specimen from arm not used as IV site. Follow correct order of draw (blood culture bottles, gold, blue, green, lavender, pink, pearl, grey). Use correct tube type. Tests results are not valid if sample is drawn in an incorrect tube and switched to the correct tube.
Auto-cancellation: If 72 hours after order-placement, a specimen is not received in the lab, the order is canceled by the lab system.

When and how do I collect blood for culture?
Obtain sample before starting antibiotic therapy, or just before the next scheduled dose. Send two blood culture sets from two separate venipunctures, 15-60 min apart. Standard blood culture bottles will grow bacteria and yeast. If suspecting mycobacteria or dimorphic fungi, use an Isolator™ tube or an SPS containing collection tube. Prior to collecting blood for culture, follow correct skin cleaning procedures using chlorhexidine-swabs; do not repalpate vein after cleaning skin.
Should I send an aspirate/fluid or a swab?
For optimal organism recovery, aspirates and fluids are best. Send swabs for throat, surveillance, nasal, ear & genital specimens ONLY.
When should I order Antibiotic Susceptibility Testing (AST)?
When a culture is positive, AST is performed when feasible. An MIC and interpretation is provided if criteria exist for that organism/antibiotic/body site. Susceptibility tests on yeasts and anaerobes are by request only.
When do I need to order a stool culture?
Stool culture for enteric pathogens is performed only during the first 3 days of admission. Stool specimens for Ova & Parasites are accepted only during the first 3 days of admission, unless the patient is immunocompromised.
How do I order testing for C. difficile?
This test is performed only on loose stools (stools that take shape of container). Testing is not repeated within 7 days of a negative specimen and within 14 days of a positive specimen. Send directly to Microbiology Tube Station 74.
How do I find out more about our labs?
Go to the lab website www.mssm.edu/labmed
Information on this site is updated often.

How do I contact the labs?
Laboratory staff is available 24/7 by phone. Call 4-LABS (212 241-5227). You can also find Email addresses of lab directors on our website: www.mssm.edu/labmed

Written by phil

October 8th, 2012 at 9:16 pm

Posted in Labs