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EM Residents on Ortho Rotation

These are the expectations:

EM residents on ortho will have:
1. one full day off per week (as mandated by Mt. Sinai); overnight to
day turn around that results in “24 hours off” does not count.
2. one weekend off (not starting after a Fri overnight)
3. when possible, off on Wed morning to go to EM conference (but this
does not count as the day off because going to conf is not “off”).
4. no duty hour violations
5. no OR time.

Additionally, if you’d like more practice with shoulder reductions (that are typically NOT called as Ortho consults) you can also create a poster with your name, rotation dates, contact informatio and place in the cardiac/trauma room, as well as inform the Cardiac/Trauma attending that you are availalable to help if needed.

 

RI patients and issues

Whenever you have an issue with a Riker’s Island patient and/or the Correction’s officers please email Dr. Kessler, Dr. Fairweather and Dr.Givre with the patient’s MR # and the incident – on the day it happens.
The Commanding Officer needs to know ASAP.
If you have problems you can call the captain at 42160.

Elmhurst Reminders and Issues August 2014

1) The “Riker’s chart”, sent with the prisoner back to the island,
does include all progress note entries – if there were entries.
Please continue to document significant developments on all patients
in the progress note section of EMR.

2) Take a moment to check patient’s name band when handing them
discharge instructions, prescriptions and/or appointment sheets.  We
are frequently giving patients the wrong information at discharge and
inconveniencing both the patient and your colleagues.  Some patients
are showing up at clinic on the wrong day and with the wrong paperwork
or going to the pharmacy and having to return to the ED.  We’ve all
had near misses or know an occasion when it’s happened to us.  If we
practice checking two patient identifiers at discharge also we’ll
solve this problem immediately.

3) The pharmacy should never refuse to supply the first 24 hour dosing
of antibiotics for lack of ID approval.  Attached is a message from
the director of pharmacy to her colleagues reminding them of that
policy.

4) Abnormal radiology findings not addressed in patient’s disposition plan:
– Remember to read the entire report and not just the assessment.
There are occasions when abnormalities and recommendations for
follow-up are mentioned only in the body of the report and get
overlooked

5) Conscious sedation: (Our Joint Commission Corrective Action Issue)
– No unaccompanied patient is to be discharged before 4 hours of
observation unless they sign out AMA (with documentation of their
capacity to do so).
– If there is an adult accompanying the patient document that person’s
name/relationship and include them in the discharge discussion
– Must check that patient has returned to baseline vital signs and Aldrete Score

6) Surgery Admissions: All patients with Chlolecystitis,
Cholelethiasis and Choledocolithiasis MUST be admitted to the surgical
service – EVEN IF THEY HAVE BEEN SEE IN THE ED BY GI AND GI RECOMMENDS
MEDICINE ADMISSION.
– Review the list of appropriate surgery admissions on the ROL.

7) Sepsis website:
– The ehced.org site is back up.  Ram has sent out an update please review it.
– Remember to use “SIRS”, “sepsis” or “septic shock” in your diagnosis list

8) CAGE questions – please complete them on all yellow/red trauma patients

9) QPATH – If you perform an Ultrasound and use it for medical
decision-making, it must be saved and documented fully.


Sepsis-related issues

first the good news, the GNYHA sepsis collaborative data collection period is over. we (elmhurst) outperformed all 50+ other hospitals in the collaborative over a 3-year period in just about every quality metric tracked. kudos.
that said, we can do better in each individual metric. our success rate at reaching our metrics is variable – there are still way too many fallouts. NY State Sepsis data collection is underway and we need to stay on top of this. The process is the SAME until we get EPIC (sometime next year). 
Generally speaking, the areas where we need to improve are below:

1. delay from the Abx order to administration – time and time again we’re seeing a long delay between Abx orders and administration. this unnecessarily adds to morbidity;  Abx can and should be given simultaneously; if there is any issue, give the antibiotic that is most likely to be most effective first

2. delay from the lactate order to result – we’ve found occasional delays in resulting lactates. we’ve also found that sometimes the lab is not calling for lactates >4; please let me know if this continues to happen; obviously, if you are concerned about the patient, call the chemistry lab to get results more rapidly if your management plan is contingent on the results
3. 30cc/kg initial bolus – this should be done within one hour of triage; often times several hours go by before realization that the patient is still hypotensive despite the ‘initial fluid challenge’ leading to long delays in recognition of severe sepsis/septic shock
4. make sure the amount of fluids given is accurate and documented – reinforce that RN’s are documenting this in the flowsheet and that it corresponds to the amount ordered
5. I’s&O’s – this is mostly a nursing issue, and we’ve discussed the importance of measuring these with them; there should documentation of I’s (see above) and O’s (foley, urinal, etc) to the best of your ability; fluid balance is particularly important later in the patient’s hospital course
6. lactates should get trended q3 hours until clearance – this presumes adequate interim resuscitation
Contact Ram with any questions

Patient Transfers (To & From Elmhurst)

1)A reminder to call the transfer number 4-2200 to arrange transfer of patients TO Bellevue Hospital.

2)You may now expect to receive calls from DirectCall Transfer Center alerting you of a request to ACCEPT a transfer. DirectCall will connect you with the sending provider and receiving consult service (at EHC) if it’s a case from Queens Hospital. The conversations on these calls will be recorded and this is the time to get clear the patient’s plan of care and disposition once the evaluation is done.

  • Inpatient to inpatient transfers should not involve the ED.
  • ED to ED transfers, especially from Queens Hospital Center, will occur after this monitored connection is made.
  • If the patient is coming from the ED but is expected to go directly to an inpatient bed it should not involve us except when there are no beds at Elmhurst and it is deemed unsafe for the patient to remain in the ED at the sending hospital (EMTALA).

ONLY ATTENDINGS CAN AUTHORIZE TRANSFERS BETWEEN EMERGENCY DEPARTMENTS AND SHOULD HAVE THE CONVERSATION WITH THE SENDING FACILITY’S PROVIDER.

All questions and issues can be addressed to Phil Fairweather

Facial Trauma Follow-Up

Facial Trauma patients should follow up at the clinic corresponding to the service that is covering Facial Trauma on the day of presentation (even if they are NOT seen by that service on the day of presentation to the ED).
  • For example if a patient has a nasal fracture and OMFS is covering facial trauma that day, the patient should follow up in OMFS.