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Archive for March, 2014

Massive Transfusion

As promised, see the attached Massive Transfusion Protocol Final.

Some important points are highlighted. The guideline for when a patient might need the MTP is:
· one blood volume transfusion over 24 hours,

· 50% blood volume in 3 hours

· ongoing blood loss >150 ml/min

· expected >10 pRBC units in 24 hours

Most of all, please remember, there are TWO ways to get emergent blood and they are both done by a PHONE CALL to the blood bank:
· Emergent release of blood

o This could be o-neg or type specific uncrossed blood.

o Be aware you might get O-pos blood for men and women over child-bearing years.

o Use this for unstable bleeding patients who need blood ASAP, but don’t meet the above MTP criteria

· Massive Transfusion

o Use this for patients meeting the above criteria.

o The blood bank will put an order into Epic saying which products were sent.

Pleased send a reply to me indicating that you have read and understand the policy.

Peter Shearer, MD FACEP

Written by phil

March 17th, 2014 at 3:11 pm

Palliative Care Unit Admits

Hi Everyone,

There are a few horror stories floating around (I personally have a couple) concerning attempts to get hospice patients admitted from the ED to the PCU.

In an attempt to improve the ED to PCU transition for hospice patients, the palliative care dept. has formalized what the work-flow should look like for these patients. The 1st part of the document addresses what you should do when a patient already enrolled in hospice presents to the ED (and will need admission).

Important point: you should be making 2 phone calls – to the hospice nurse (for VNS pts, 212-609-1900) and to the palliative care pager, 917-632-6906.

Furthermore, for dying patients in the ED not previously enrolled in hospice but who you think should be admitted to the PCU under the care of hospice (meaning their prognosis is limited to days-weeks and the goals are to prioritize comfort), the steps are essentially the same, for you. 2 calls: VNS hospice and the palliative care pager. Of note, as of 1 week ago there is now a VNS hospice nurse on the weekends available for these admissions.

The process of getting patients to the PCU can be complicated, particularly during off hours, but you should NOT be the ones to manage it. You’re busy enough! Outsource this to the palliative care team and defer all questions and concerns from bed board, nursing, etc. to them.

Direct ED to PCU Admits

Thanks and let me know if there are any issues moving forward.


Written by phil

March 10th, 2014 at 5:24 pm

Posted in Palliative Care

Heart Failure

Heart Failure Clinical Pathway_ED_OBS through Discharge _ 1 15 14

A multidisciplinary heart failure pathway is being rolled out this week (linked above). Most of it is common practice- my take on the key points for the ED are as follows.
· BNP testing is requested as the heart failure team is using serial BNP results to gauge response to therapy and readiness for discharge.
· Strict I & O order while patient is in ED is also requested.
· Lasix should be dosed every 8 hours.
· Hold ACE / ARB while in ED.
· Consult the heart failure team for any of the following:

o Recurrent hospitalization for CHF within one year
o Elevated Troponin or Acute Coronary Syndrome
o Concurrent infection
o Worsening renal failure
o Ventricular Tachy Arrhythmia

Thank you for your attention to this important initiative.


Written by phil

March 4th, 2014 at 10:41 pm

Posted in Cardiology