Welcome to the Emergency Department at Elmhurst Hospital! We’re glad to have you and hope that you find your rotation interesting, educational and fun. Unfortunately, it’s impossible to carry out a proper orientation because there are so many rotators who arrive at varied times, so we wrote this guide to help you make sense of the way our ED works.
- Remember we provide care to everyone who walks through our doors. “Emergency” is defined by the patient. However we do not see everyone in the order they come in – we prioritize patients who are unstable, then patients who are more likely to become unstable, then everyone else. Patients in the zones you will be working in should all be stable, but incorrect triaging definitely happens and conditions can change quickly. Additionally, within the group of ‘stable’ patients there are patients with chest pain as well as ankle pain. Keep this in mind when you’re deciding who to see next. Alert your attending or a senior resident if you see a patient in distress or with abnormal vital signs. DO NOT complete an evaluation on an unstable patient without getting your attending/senior resident’s help immediately.
- If you are going to be late, please call to let the team know. The ED number is 718-334-3054; call as soon as you think you’ll be late and ask to speak with the attending on the side you are assigned to: A or B. If you are going to need to miss a shift for any reason, please call your chief as soon as possible so sick call coverage can be arranged, and if your decision is last minute, please contact the ED attending immediately. Give your chief as much advance notice as possible.
- Dress code: Either clean, matching scrubs with or without a white coat or business casual clothing with a white coat. Remember the ED is not the cleanest place and you may get soiled.
- The ED is divided geographically into 4 zones (you will work in the A or B room and there is also Fast Track and the Cardiac/Trauma rooms). See the bottom of the schedule for a legend that describes when and where each shift is. Please be sure you have working Epic access before the start of your shift. If you are having problems logging in, call x42405 to speak with the IT help desk.
- You may leave your personal belongings in the resident conference room; however leave valuables at your own risk. On your first day, arrive early so that a member of the leaving team can show you where the room is. If your card does not allow access into the room, you will have to discuss with Hospital Police. Please close the door, even when you are in the room. Please keep the room and refrigerator clean and throw away all your trash.
- Sign Out Instructions: Handover of patients (“sign out”), like all transitions of care, is intrinsically dangerous. Pay close attention to what the previous team tells you about the patients whose care you are assuming and do not hesitate to ask questions about the plan. Remember, patients evolve and plans may need to change. If you have any concerns about a plan, discuss with your senior resident/attending. Sign out is done as a group at the end of the shift, not person to person. The attending will run through the patient list but it is your responsibility to be sure all of your patients are signed out and no one is missed prior to you leaving a shift. All of your patients should have already been presented to a senior resident or the attending prior to sign-out.
- Before you see any patients, log in to Epic and “sign in” to your area (A or B). You should assign yourself to all the patients signed out to you. After you log in, it’s good practice to quickly review all of your signouts, take care of any immediate issues, and briefly go meet the signed out patients to introduce yourself and confirm the plan and then document a “Progress Note” on each patient (for example, “pt signed out to me, currently with normal vitals and no complaints, awaiting lab results” or “patient reports chest pain has recurred, repeat EKG ordered”). This is a great way to spend the first 15-20 minutes of a shift.
- If your first say corresponds to the first day of a block you will have a Epic Orientation specific to the Emergency Department. This is mandatory and will be taken by one of the senior PA’s to review high important nuances of Epic specific to the Emergency Department.
- Throughout the day, you should pick up new patients. Perform history and physical, chart and think about the patient, and present to your senior resident/attending. If you prefer or if the attending/senior is busy, see a second new patient and then present both cases at one time. Try to avoid seeing more than two before presenting especially if you are on the Trauma Team though sometimes it’s unavoidable if the senior/attending is swamped. However, if you feel that a patient is truly sick and needs more immediate attention, do not hesitate to interrupt the senior resident or attending and let them know (abnormal vital signs, altered mental status, etc).
To pick up a new patient:
- Right click on the patient and select “assign me”
- Click the treatment team tab on the top bar and assign your attending to the patient
- Once you are ready to see the patient click “Provider In”
Charting consists of:
- Open the patient’s chart and click on “Note” on the left panel. You will than see “Initial Assessment” under “My Note” just to the right of previous “Note” panel. You will utilize “ED NOTEWRITER TEMPLATE”.
Under Cosigner: Assign your attending
- Complete the HPI tab: You will need to enter a chief complaint into the “Add HPI form” and scroll down to the bottom checking boxes as appropriate to the patient. Once this is completed you will need to than switch to the “comments” section under the same tab to actually write the HPI.
- Complete the ROS tab: Select all appropriate symptoms as pertinent to the patient. Do not complete sections or questions you did not ask the patient about. (your Senior resident can show you how to expedite this process)
- Complete the Physical Exam tab: Again complete all appropriate boxes and add
- free text where pertinent to relate a complete physical exam
- Complete the Note tab: Write your assessment and plan under this section. This is your summary of what you think is going on and what you want to do.
- Complete Progress Notes: As the care of your patient is ongoing you should update the chart findings, reassessments of the patient’s clinical status and changes in the plan based of new information (for example “patient is feeling better, labs are within normal limits, patient pending imaging).
Charting should occur concurrently with care – DO NOT SAVE UP CHARTING FOR THE END OF THE SHIFT. On some occasions, you may want to wait to chart until after discussing with your attending if you are unsure about the assessment and plan or how to proceed. If you are unsure of the plan, it is better to discuss first than to cross out an elaborate but inappropriate plan you devise alone prior to discussing with your attending.
Do not discharge patients until the attending has given the final approval to do so.
- Eat a heart pre-shift meal. It can sometimes be difficult to escape to eat or even use the restroom, but of course you should do this – when you need to take a break, just ask your attending/senior resident, mostly so that they know where you are if they need you and can coordinate not more than 1 team member out of the department at a time. Meal breaks should not be more than 20 minutes long. No food or drinks are allowed anywhere in the emergency Department but may be left in the conference room (please label all food with your name and date). Stay hydrated (and/or caffeinated, PRN)
- 30 minutes prior to the end of your shift is time to stop seeing patients and re-assess all the patients on your roster, tidy up your loose ends, make sure your plan is tight, charts are completed (double-check again that you did HPI/ROS/PE and A&P). and that everything that can be done at this point is done.
- C/T: “The back”: Cardiac Room/Trauma Bay is where unstable patients live while they’re in the ED. If you think one of your A/B patients is too sick for that area, talk to your senior/attending and the patient may need to be moved to the C/T Room. There is a dedicated EM Cardiac Room resident at all times. You will see a “T” on shifts in which you are assigned to the “Trauma Team”. Please listen overhead and respond to all overhead announcements “Trauma team to the trauma room”. You will receive a separate briefing on your roles on the trauma team. If you are not on the trauma team on a given shift, you are then on the “Cardiac Team” and should report to the Cardiac Room whenever you hear “A team to the Cardiac Room” paged overhead. Get involved – do CPR or tasks directed by the cardiac room resident and attending. You may respond to traumas when on the cardiac team and vice versa to see if you can be assistance but do not stay and watch cases if your help is not needed.
- On the A side, you will present to the senior resident (if present) or the attending. On the B-side you will present to the attending, but you may certainly ask questions of the other residents/PAs who are there with you.
- Morning report takes place around 7:45/8 am on weekdays except Wednesday. An EM resident presents a case, leads a group discussion, and provides related teaching points and pearls. Your morning report assignment will be noted on the schedule by a yellow shaded box, please note your day to present and be prepared.
- Arrive to your first shift at least 30 minutes beforehand so that you find the resident room, drop off your stuff and get to the ED to go over some basic information about Epic and ask questions before your shift starts.
- You must report to your side (A or B) at least 5 minutes before your shift starts i.e. if you are scheduled from 7a-7p on the B-side, you need to be on the B-side at 6:55, ready to take sign-out. DON’T BE LATE!
- The ED staff appreciates and enjoys working with you. Take care of yourself during the block. We hope that you find your rotation rewarding and fun. If you have any questions/concerns that aren’t answered here, or by your ED team, you may contact your chief or the Sinai EM Chief, Peter England: email@example.com.
Further resources and ED information may also be found at eched.org.