Below are the updated AWS guidelines for the EHC emergency department. Note that chlordiazepoxide/librium is favored in all patients who are able to take oral medications and who are not severely agitated (RASS ≥3). The goal of therapy is a calm to drowsy patient (RASS 0 to -1) regardless of HR/BP. If a patient remains tachycardic despite adequate sedation, strongly consider concurrent or alternative pathology, eg. sepsis.
EHC AWS algorithm 11-28
In addition, use of the non-benzodiazepine (BZD) adjuncts such as dexmedetomidine/precedex is not advised unless the patient is refractory to BZD and barbiturate therapy. The refractory AWS pathway (pg2) outlines a suggested strategy for those patients in whom adequate control cannot be obtained despite diazepam 200mg and phenobarbital 390mg. In these patients the overall goal is to avoid intubation unless absolutely necessary. The suggested non-BZD adjunct in this scenario is ketamine, which is more strongly supported by evidence.
The goal of management in AWS is to determine the dosage of benzodiazepine that is required to control a patient (calm/alert to slightly drowsy or RASS 0 to -1) for at least 1hr from last administration of medication.
In addition to admission to a unit capable of appropriate level of care, evaluate patients for co-morbid conditions such as trauma, sepsis, pancreatitis, DKA/AKA, etc. Strongly consider the supplementation of multivitamin/thiamine/folate to patients at risk for malnutrition.
These guidelines were adopted from Bellevue’s AWS protocol and updated with the assistance of our EHC/MSSM toxicologists Alex Manini, Rachel Shively and Beth Ginsburg. Any questions or concerns please feel free to contact me at firstname.lastname@example.org
Changes, Updates, Important Information
- When you are on a cardiac room shift or trauma shift, please arrive a few minute early to check that your supplies are well stocked and airway boxes are ready to go. When you use supplies and airway boxes, don’t forget to reset.
- If a patient leaves during evaluation (this means “provider in” is clicked, orders of any kind are placed, any note is written by a midlevel or attending provider) please indicate “Left During Evaluation” and NOT “Eloped” or “LWBS…”in the Dispo section of the chart.
- Current drug shortages: kayexelate, epipen
- Psychiatry consults: (Do not use the paging operator, amion is not yet updated)
- Mon-Fri 8a-5p call 6-6934 (cordless); OR as backup page 40524 for the consult attending
- Mon-Fri 5p-8a, weekends, holidays page 15094 – consult resident; OR as backup call the Bell attending 6-4750 (cordless)
- Patients from Rikers Island who are discharged back to Rikers should have printed copies of their:
- (1) H&P and consultant notes (i.e. psych notes);
- (2) “ED to PCP summary” (i.e. results of diagnostic studies); and
- (3) AVS (i.e. clear discharge instructions with medication recommendations)
- (4) placed in a sealed envelope and handed to the Corrections Officer, NOT the patient
- Please provide “Procedural Sedation” and “Stroke and TIA Prevention” discharge instructions to patients as appropriate.
- Please take the time to schedule appropriate follow up appointments for patients. This is especially important for our Elmhurst population with generally poor health literacy.
- All patients diagnosed and treated or suspected and treated for a sexually transmitted illness (STI) MUST be followed up in the Sexual Health Clinic (SHC). Discharge clerks can schedule appoints as early as the next business day. This includes women treated for possible PID, men with confirmed or suspected GC/Chlamydia and anyone with suspected/confirmed syphilis.
- Newly diagnosed HIV positive patients are to be referred to the ID clinic NOT to the SHC. There are resources in the SHC for face-to-face patient counseling, HIV pre-exposure prophylaxis (PreP) medication and partner surveillance. They’ll also refer female patients to the gynecologic clinic, if necessary, after they’ve met with these patients.
- Do NOT overbook Proctology Clinic. If there is no availability, in the timeframe you need, then send the patient to the General Surgery clinic.
- Patients with suspected ectopic pregnancy should follow up in GYN Surgery clinic.
- Transfer formsMUST be completed on all transfer patients regardless of the service requesting the transfer.You’ll find the Transfer Form after you’ve selected “Transfer to Another Facility” on the Disposition Tab >> TRANSFER/EMTALA Forms >> complete the form – especially the ACCEPTING HOSPITALand ACCEPTING ATTENDING PHYSICIAN (not resident)! Then save, print, and give the form to the sending RN.
- For radiology studies select an indication AND include a brief comment on the reason for exam.
- When ordering PLAIN X-ray imaging place a patient transport request in EPIC. On the main tracking board select the patient, click on “patient transport”, select “EL Radiology” as the location and priority “high”.
- If you change the admitting service or level of care, you need to (1) change the admission service order in EPIC AND (2) also call Admitting
- The ED attending makes the final admission decision, please check with them before admitting.
- Any patient with a traumatic injury MUST be admitted to a surgical service. If they need telemetry or have complex medical diagnoses, the SICU fellow or attending should be consulted for SICU or surgical step down bed assignment.
- Please use the “quick lists” to order medications. These are set up to have appropriate dosing, administration and titration instructions for the ED. In addition the IV push doses of relevant medications have now been added to this list.
- Click the provider in button and indicate the time you first saw the patient for every patient you see (if it has not already been done).
- Uses the physical exam checkboxes in EPIC to document guaiac results.
- Vaginal ultrasound probe cleaning (Trophon)/use monitoring: Name-sticker placed in the black folderwhen we use the pelvic ultrasound probe. This must be done every time by either the ED provider, chaperoning PCA, or the Gyn consultant.
- Ultrasounds: Please clean the ultrasounds and plug them in after use. Please order, save images, and read all ultrasounds performed in the ED.
- We have Naloxone kits available for free distribution to at risk patients. Most of the attending physicians have completed the training to dispense the kits. Please consider this for your patients and ask the attendings when appropriate.
- Apply a patient label or baxter label to the EMS notification sheet when applicable. Continue to place these sheets in the bin by the phones.
- Continue to save all ultrasounds, especially all FAST exams done during trauma to Q-path. These should be linked to the patient in Q-path, interpreted by the resident and signed by the attending.
- Please help us meet sepsis treatment criteria. We are missing sepsis marker primarily because of these four things:
- Blood cultures not marked as collected prior to antibiotic being marked as given – REMIND YOUR RN;
- Time to fluid and antibiotic administration – We have 3 hours from arrival;
- Failure to repeat elevated lactate by 6 hours;
- Failure to write a sepsis reassessment note after fluids are given.
Colleen and Moira
FULL BLOCK 4 UPDATE Elmhurst Updates SEPTEMBER 2018
The most recent EHC Traumatic spine and brain injury protocols. Both can be found permanently linked under the cardiac/trauma tab