Category Archives: Protocols

RaCC/Cardiac Room Orientation

 

The Cardiac Room, also known as the “RACC Room” (Resuscitation and Critical Care) is the critical care area of the Elmhurst ED. The sickest patients in the department are seen here. There are only 4 bays although you may use the adjoining trauma room for 3 additional critical care bays if needed.  When the cardiac room overflows into the trauma room try and leave one available bed for the trauma team unless it is absolutely impossible. Unlike the sides or fast track you do not get to pick up patients at your leisure. You must see each patient immediately when they arrive. Patients either come from Triage or the sides.  Patients who are presented to the cardiac room from the side may have had a partial work-up done by another provider or they may have decompensated prior to be seen by the side team.  You may also be asked to care for patients who are still in the emergency department that have been admitted and are awaiting an inpatient bed but decompensate before leaving the ED.

The Cardiac Room is staffed by one resident and one dedicated attending.  The sole exception to this is from the hours of 5AM to 7 AM at the end of overnight shifts during which time the cardiac room resident works with the A side attending.  This shift provides you with a lot of one on one time with your attending and makes for great teaching and learning.  This is your best chance to engage your attending and really pick their brain for the intricacies and details of resuscitative care.  In addition the cardiac room provides you with an excellent chance to practice critical procedures.  Try and explore your patients’ pathology in-depth and “wrap them up” as much as possible before releasing them to the floor services partly for the patient’s good and partly for your own learning and practice.

On occasion there may be an intern shadowing in the cardiac room with you.  This is their introduction to the Cardiac Room and please help make it beneficial for them.  Take them with you as you set up the room (discussed below).  Teach them the basics of ED critical care medicine and show them how to use ventilators and perform essential procedures.  It is also an excellent opportunity to show them the location of all required equipment present in the back.

 

Pre-Shift Preparation

 

At the beginning of your shift. first priority is to prepare the room for the arrival of a potentially critically ill patient.  It is not uncommon that critical patients arrive without EMS pre-notification, therefore all necessary resuscitation equipment should always be immediately available and ready to use.  Review the RACC pre-shift checklist (available in the clipboard above the sink) and begin by preparing both an airway box and the video laryngoscope cart.  The failed airway kit should be stocked with a scalpel, 6.0mm portex trach, and both sizes of LMA with a syringe. Each resuscitation bay headwall should be standardized with O2 delivery supplies, BVM and face shields.  The ventilator should always have clean tubing connected as well as inline filters attached.  The Zoll defibrillator should be in a visible position beside the bay monitor, connected to defibrillator pads and the Zoll mainstream EtCO2 detector should have a clean adapter.  The ultrasound machine should be in its place, plugged in and charging with adequate supply of gel and chucks.  Is the tox/antidote kit available, stocked and are you familiar with its contents?  Next, review the RACC critical equipment inventory verifying adequate stock of equipment in the airway cart, the shelving above the trauma computers and in the green cabinets above the sink.  Keep in mind where each item is located for when you need it.  Finally, check the respiratory equipment stock in the green drawers below the sink. If any items are low stock (eg. only 1 transvenous pacemaker kit left? 2 pigtails? 1 small NIV mask?), contact the appropriate department listed on the inventory contact sheet.  If it is after hours or you were unable to resupply the item, mark the inventory “low stock” column and sign it out to the oncoming resident during the following shift.  For the oncoming resident, once the item is restocked check the appropriate column. If for some reason there are low stock items marked on the inventory sheet that weren’t signed out to you, verify low stock and contact the appropriate department during your shift.
 
Ask yourself during prep, “Do I know how to use every item that we have stocked?” Reuben’s general start of shift checklist is a great review of emergency procedures and strategies you should be prepared for during every shift.  Take some time before your shift reviewing procedures you are either unfamiliar with or haven’t done for awhile. If you have any questions regarding equipment, supplies or anything else Elmhurst critical care related emailcmeyersmd@gmail.com or call 917-749-1004.

 

Workflow

 

Patients will arrive from the triage, brought in by EMS, or sent from the sides in extremis.  Unlike your typical side patients, therapeutic intervention often needs to occur in parallel with diagnostic interventions.  When a patient first enters the Cardiac Room perform a rapid focused assessment of the patient’s airway, breathing and ventilatory status, circulatory status, and neurologic/mental status.  All patient should be exposed to look for concerning skin findings.  You may need to intubate some patients on arrival.  Use ultrasound and the RUSH exam liberally to further clarify a patient’s clinical status.

 

Resuscitative and critical care can be thought of as consisting of two parts.  The first part is action and the second part is detail.  Once you patient is stabilized (or you have assured yourself that they are not in immediate cardiopulmonary or neurologic threat) then turn your attention to detail and begin gathering information pertaining to their present illness and medical history.  Consider forming your assessment of the patient by organ system as you would in an ICU for your most critically ill and complex patients.  Do not forget trauma and toxicology as categories of this assessment unique to emergency medicine.

 

Unique cases include STEMIs and strokes.  For both of these presentations you will work closely with an outside service and page them via the emergency paging system.  This system is reached by dialing 41911 and you should give your name and request a “stroke code” or, for STEMIs, a “C-PORT code” accordingly.  After this you should continue your critical care assessment as usual.  You will be called by the appropriate team (the stroke resident or CPORT fellow) and briefly present the case for them to come to the ED.  A potential pitfall is permitting patients to leave the ER without vascular access due to a desire to expedite their imaging.  Do not allow this to happen even if your consultants request it.  Vascular access (often peripheral or — if that is not possible –central access) is a necessity in order for any critically ill patient to be stable to leave the Cardiac Room and go to imaging.  We are the most skilled specialty in obtaining vascular access and the appropriate tools for doing so are located in the Cardiac Room–not radiology!

 

 

Triage and the Sides

You and your attending will be asked to evaluate patients in triage who are indeterminate in their need for critical care.  Your attending will likely handle this task during your initial shifts but you will be asked to see patients in triage and make a determination on behalf of your attending as the year progresses and your skills develop.   You may begin refusing people to the Cardiac Room as your experience increases, however all patients that are refused need to be run by the Cardiac Room Attending.  Emergency Medical Services may bring patients directly to the cardiac room, bypassing triage, if they are in sufficient extremis.  These patients demand your immediate attention and resuscitative efforts as they are often in cardio-pulmonary distress, experiencing a STEMI, or a stroke.  You will also be asked to receive those patients who decompensate on the side or need closer care.  Your attending will ultimately determine which of these patients are accepted or declined.

Once patients are stabilized and no longer require resuscitation, active critical care, or close monitoring it is important to send them out to the sides as they await their disposition.  Critical care space is limited and it is important to preserve it for new critically ill patients.  However, even though a patient has been sent to the side they remain your responsibility.  Those patients who will ultimately be discharged or require ongoing care before they are admitted should be visited by you for re-evaluation at regular intervals and to update them regarding the progress in their care.

 

Admitted Patients in the Cardiac Room

All patients in the cardiac room are actively managed by you regardless of their admission status.  However, the cardiac room functions as an “open” unit in the sense that when patients are admitted but too unstable to leave the cardiac room you provide critical care in coordination with a primary team that will be also entering orders.  Patients who fall into this category are often admitted to stepdown (called A4) as those patients admitted to an ICU tend to leave for beds very quickly.  Coordinate your care with the inpatient team but always remember that you are the final arbiter of care if patients begin to decompensate.  In this case you do not need the primary team’s permission to intervene and have an obligation to do so.  All patients who require transport to an ICU must be accompanied by a physician per Elmhurst policy.  During the day a resident from the receiving unit will often come down for the patient, but at night most units are staffed by only one resident and as such you will need to accompany many of your patients in order to ensure their effective final disposition.

Outpatient MRI orders

Do not put in MR orders for outpatient follow ups.  The neurology/NS consultant should place the outpatient MR order themselves.  This ensures that it’s their responsibility to review the result and contact the patient appropriately.

 

Thanks,

Phil

 

Phillip G. Fairweather, MD, FACEP

Inter-Hospital Transfers to Mt.Sinai

In general, transfers are initiated by the consulting service with the accepting physician being provided by that service.

Patients should in general be admitted to an open bed, but can on occasion be transferred to the ED.

1-800-To-Sinai

1-800-867-4624

If there are any significant issues, can be discussed with Dr.Abe Warshaw

Sepsis Care Update

There are a handful of issues we need to improve on with regards to our sepsis care and documentation.

1. Make sure all patients with severe sepsis and/or septic shock that you enroll receive a 30cc/kg IV fluid challenge. This is not always 2 liters. Go by estimated actual body weight. If for whatever reason, you don’t want to give that amount – ESRD, CHF (although withholding this fluid challenge is probably not smart if they are truly severe sepsis) – specify on the chart/data sheet why you are withholding fluids

2. Blood cultures need to be ordered and drawn before antibiotics are given.
 
3. DNR/DNI patients still need their MRN’s submitted the usual way. NYS is collecting demographic data on them too. You don’t have to fill anything out. Just write DNR on the data sheet and scan it into HMED
We’re all providing good sepsis care already, we might as well get credit for it.
RP