All posts by emcrit

About emcrit

I'm obsessed by ED Critical Care.

New CPU Guidelines

In discussion with cardiology, we have agreed to change the criteria for observation in the CPU to maximize the efficiency of the unit and patient safety.  We have agreed on the following:
The CPU can now take patients with chest pain suspicious for ACS who are:


under 70
have the ability to exercise (consider walking them around the ED)


multiple comorbid illnisses that complicate diagnosis (eg. lung cancer, severe copd)
syncopal or near syncopal symptoms
significant component of palpitations (if they seem very incidental it might be ok)
rest pain (do not put patients with unstable angina there)
ischemic ecg, dynamic changes
alternate diagnoses still likely (eg. pending PE, dissection, pna workup)
In essence, this means that we can put patient who would have been characterized as “intermediate” or even “high” risk previously as long as they are relatively healthy – the 60 year old with a stent and a weak story, the 55 year old with multiple risk factors and stable inferior flipped t waves are now ok.


Esophageal Foreign Bodies

ENT is to be consulted for non-meat foreign bodies believed to be in the cervical esophagus (above the cricopharyngeus).  As a reminder, they are on in-hospital call every third night

GI is to be consulted for all meat-related foreign bodies, as well as those believed to be in the lower esophagus

Chest Pain Unit (CPU)


Step 1: patient is identified as appropriate obs candidate (eg. 55 year old with hx of smoking and 15 minutes of left chest pain, normal ecg).  The basic ED workup is done by the a or b team as it would usually proceed.  The resident/pa/attending primarily caring for the patient will answer the questions on the “observation pathway” on the dispo tab, signout the patient to the NP and have them moved to the obs unit.
Step 2: The attending primarily caring for the patient will then go to the OBS tab, click on the “observation order begin” to write the order which starts obs and write a note (now this note is called risk stratification and obs plan) which needs to include:  1-2 lines about risk stratification of the patient and 1-2 lines about the observation plan.  For billing, it is very important that the word RISK be in the risk stratification statement.
examples could include:
55M with TOB hx and normal ecg is low risk for acs. plan for observation with serial enzymes, monitoring, ecg’s and cardiology evaluation.
43F with symptoms concerning for acs, pt meets low risk criteria. plan for observation including monitoring, repeat ecg’s, cardiac enzymes and provocative testing.
The primary attending will keep that patient until the end of their shift.
Step 3: the NP’s will continue to manage their workflow as they have been, with their notes indicating the intensity of services appropriate to obs status (though we would also like to move all obs patients into the obs unit).
Step 4: The primary attending will sign out the patient to their relief, just as they would any other patient under their care.  The receiving attending will be responsible to cover the NP’s who will be primarily coordinating the patent’s care. Every attending that the patient “goes through” needs to write a brief progress note on the chart.  The progress note can be brief – 1 line. (eg. patient comfortable, no further episodes of CP, repeat ecg normal, pending cardiology evaluation in am).  The NP’s should handle the rest of the work.
Step 5: at 10am, the a/b attendings will sign out the obs patients to the oncoming FT attending (the FT attending should go and seek out this signout).  At this point, the FT attending should go and see the patients and should write a brief progress note (eg. patient had no episodes of chest pain overnight, serial enzymes negative, pending stress echo.).
Step 6:  When the patient is ready to be discharged, it is the FT attending who is responsible to review the case and really needs to be the one to make sure that the patient doesn’t have other occult pathology and is safe for discharge.  That attending will also have to write a 1-2 line discharge summary and plan on the link called “discharge summary and plan.” Then the FT attending will have to click on the obs end line and put the order to end observation in teletracking.  The NP’s should handle the rest of the work.  If the patient is admitted, this attending will have to write 1 line in the chart discussing the reason for admission (eg. patient with complex issues including syncope and chest pain, requiring inpatient evaluation and testing AS RECOMMENDED BY CARDIOLOGY).  The last part is to hopefully prevent medicine from simply discharging these patients directly.
examples of documentation could include:
55M presented with chest pain, low risk for acs. cardiology recommended stress echo which was negative and plan for follow up in mpc clinic in 2 weeks for further eval.
40M presented with epigastric pain. low risk for acs. cardiology evaluated the patient and felt that symptoms were related to a GI source and the patient was safe for discharge. I re-evaluated the patient who has remained pain free with normal labs, cxr, cardiac enzymes and ecg’s.  Plan to start ppi and have patient follow up with diagnostic clinic in 1 week.
The 2 steps which the are bolded above – click on obs begin and end are very important for billing.  ideally they need to be done in real time.  if there is a significant delay that cannot be avoided, please still click on the tabs and also write in a progress note that obs started at xx:xx and/or ended at xx:xx.
I know this is a lot of words… if you have any questions, please email/call me.

Direct Admits from Clinic

The ED staff should not accept direct admissions from the clinics – even when there are no “available beds” on the floors.  She assures us that the bed coordinator (4-6505) is always able to make arrangements for these patients.  These patients shouldn’t have to board in the ED or come to the ED “just for blood draws”.  Please advise those providers to refer the patients to the TR and to the bed coordinator.

Facial Trauma

The service covering facial trauma (ENT, Plastic Surgery or OMFS) covers ED calls from 7 am to 7 am and is responsible for the patient based on the patient’s registration time not the time the consultant is called.  Thanks,

How to Take Care of Video Laryngoscope Blades

I was hoping Joe would be the bad guy on this one, but I guess it falls to me.

There has been a relatively consistent lack of care for the video intubation equipment. I have walked into 5 shifts in the past 2 months with a dirty blade sitting on top of the intubation cart (if you think I am talking about you, I am, but not just you so don’t feel that bad).

Each of these blades cost a few thousand dollars. Joe & Stu worked to get us this new equipment. Convincing the hospital to replace broken items is going to be pretty tough.

So the image above should never exist: Either the blade should be sitting in a drawer or it should be in your hand. NOWHERE ELSE. Getting ready for an intubation–keep it in the drawer. Things fall off flat tops, they do not fall out of drawers.

Clean and ready blades go in the top drawer

Dirty blades go in the sterilization tray and get brought to the front desk to go to central sterile. Blades should not be sent down to central if they are not in the tray.

If you have used a blade, but the sterilization tray is downstairs, put the blade in a specimen bag and put it in the lower drawer.

This should happen immediately after intubation as in IMMEDIATELY after intubation.

The residents should be taking care of this, but it is the responsibility of the ED attending to make sure it happens and happens properly. We will be blaming the attending not the resident if blades are not handled properly because we are consistent while residents come and go as outside rotators or while switching between institutions.

Please write Joe or me with any questions.