Welcome to the ED Orientation on-line module

1. Welcome to the ED Orientation on-line module Most of the information you are about to read will be a review of the in-person orientation that you already attended. It is important to be familiar with these ED processes and procedures prior to your first shift.

2. Goal of this Orientation Prepare our off-service rotators for patient care in the ED from the moment they start their rotation

3. Objectives of this Orientation • Logistics of working in the ED • Your ED team • Observations vs. Admission • EPIC details • Admission/ Discharge • Note completion • High- Yield Emergency Medicine Topics • Cardiac Chest Pain • ACS: STEMI vs. NSTEMI • Low/ Moderate risk CP • Anaphylaxis • Trauma • Backboard clearance • C-spine precautions and clearance • E-FAST exam • Intoxicated Patient • Psychiatric Patient • Medical Clearance

4. LOGISTICS OF WORKING IN THE ED

5. ED Layout • Section A: Highest Acuity- open 24/7 • 2 resident teams • Green: 9 beds +2 resuscitation bays • Purple: 10 beds + 2 resuscitation bays • Staffing: • 2 attendings 9am-1am (1 attending 1am-9am) • Senior Resident Supervision • Trauma: All trauma patients that go to resuscitation bays are designated as “full” or “modified” trauma • Off-service residents are not responsible for taking care of “modified” or “full” trauma • Off-service residents are responsible for trauma patients that don’t meet “modified” or “full” trauma criteria • Section B+C: Lower Acuity- open 24/7 (as of July 2014) • May still get trauma patients that are not “full” or “modified” traumas • Staffing • At least 3 resident/PA teams • Supervised by an attending TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK

6. ED Layout- Other areas of Interest • Patient entrances/ triage/ registration areas: • Ambulance • Waiting Room • Central Communications Desk (a.k.a. “the bubble”) • Located at the ambulance entrance • All calls/ faxes • Location of Medtronic Pacemaker interrogation equipment • Intoxication Observation Unit (IOU) • Located in hallway behind Section C • Staffed by an ED tech • Crisis Intervention Unit (CIU) = Psychiatric ED • Separate unit staffed by psychiatry residents, attendings, nurses, techs • Chest Pain Center (CPC) • Separate ED observation unit for low/moderate chest pain patients • Staffed by B-side attending, PA (during working hours), nurse, tech

7. Your team: • Attendings • Supervise multiple teams simultaneously • 24/7 in-house coverage for every section of ED (when open) • Senior ED Resident • Only during high volume times (Mondays daytime) • ED Nurse • ED Technician • Business Associate (BA)

8. Your ED shift: Arrival and Sign-out • Arrival: at least 5 min. prior to scheduled time • B+ C sides: divide patient beds equally between available providers (podiatry and dental residents do not get bed assignments) • Sign-out: 2-part process • Off-going senior resident or attending presents patients in bed-order to the on-coming team • Part one: at the computer- all the details (including labs, social issues, Ddx) • Part two: at the bedside- off-going attending introduces the in-coming team • Patient is made aware of the work-up progress, pending studies and reason for why s/he is still in the ED, and approximate timeline

9. Your ED shift: Seeing patients • All patients assigned to your bed assignment are YOUR patients • See them within the first 5 minutes of arrival in section A or 15min. in section B&C • See patients in parallel: essential EM skill • Present your patients as soon as you saw them • To senior and/or attending • Do not pile up patients to present in bulks • Enter all lab orders ASAP • Notify your nurse of the plan as soon as you know it • Charts must be completed by the time patient leaves the department

10. Your ED shift: Disposition • Important to notify the patient and nurse as soon as the decision is made • NEVER discharge the patient prior to making the ATTENDING AWARE that the patient is being discharged • All PMDs need to be notified that their patient was in the ED • Especially for high-risk CC: HA, CP, AP, BP • Document all communication in chart • AMA discharge: ALWAYS alert the attending ASAP • Document capacity to make decision • Can not be: intoxicated, mentally retarded, cognitively impaired • Give appropriate discharge instructions and prescriptions • AMA form must be signed by patient • Encourage return to the ED

11. Your ED shift: Admission vs. Observation • Reasoning: patients who have normal vital signs, normal lab results, normal imaging may not meet criteria by insurance companies to pay for a full hospital admission • These patients may still require medical care not reflected by the criteria • Logistics: most of the time, the ED attending will be able to determine admit vs. obs • Care Coordinators are specially trained in making the decision • Will sometimes ask you to change the admitobs or obsadmit booking • Always make the attending aware of the change • The attending makes the final decision

12. Your ED Shift: Medical Admission • Enter order in EPIC: “ED Admit” • Observation vs. Admission • Medical vs. Non-medical • For medical, pick team: • Hospitalist =patient’s PMD is on hospitalist team • All other medical admits =no PMD or PMD doesn’t admit to hospitalist • YED attending= CPC • PCC/ generalist= patient goes to PCC • Goodyear =cardiology complaint without Cardiologist or University Cardiology • General cardiology =cardiology complaint with Non-University Cardiologist • Klatskin =ESLD • ESRD • Donaldson = HIV/AIDS • Fill out the rest of the booking (specify tele vs. floor)

13. Your ED Shift: Admission to an ICU • Step 1: notify Bed Manager • Step 2: Call appropriate team for sign-out. Get name of admitting attending. • CCU: page CCU fellow • MICU: page MICU admission team • SDU: page SDU resident • SICU: the surgical team is responsible for getting SICU attending aproval • NICU: don’t need to page anyone b/c you are admitting to a team that should already be involved in patient care • Step 3: Attending- to- attending sign-out. YNHH admission policy: the ED attending makes the final decision where a patient is admitted • Please let your senior resident and/or attending aware of any push-back you get from the admitting team.

14. Your ED shift: Admission to CPC • CPC or in-hospital ROMI • Both: • low/ moderate risk chest pain patients who need a ROMI • Observation, telemetry admission • Not for ACS patients • No nitro drips, no heparin drips • CPC: patient will get Stress Test at the end of their admission • Your role • Place appropriate EPIC order: • ED chest pain place in CPC observation • EPIC Note: • Smartphrase: “.edobsadmit” • Order all out-patient medications • In-Hospital ROMI: most will NOT get a stress test • Patient had a stress in the past year • Patient with other diagnoses possible (other than CAD) • Patient needs isolation • Patient morbidly obese (will not fit stress table) • Patient can not self-transfer (onto stress table)

15. Your ED shift: Admission of hip fractures • For isolated hip fractures • No other traumatic injuries • Mechanical cause (i.e. not syncope that needs to be worked-up) • Orthopedic team evaluates patient (as all other ortho consultations) • Computer orders: • Admit to: Hospitalist • Service: Medicine • Unit type: free-text ortho/ hospitalist 7-7 • Page hospitalist at 766-7416 to give verbal sign-out NO DICTATION NEEDED WHEN VERBAL SIGNOUT DONE

16. Other ED Pearls • COMMUNICATION IS CRITICAL • Team-work is essential to surviving in the ED (both patient and resident): greatest off-service resident pitfall is not communicating with the nurses and attending/senior • Let your senior/ attending know: • Patient seems to be sicker… • than triaged • than last time seen • than signed out • You are feeling overwhelmed and are falling behind • You need a break (nourishment/ bodily functions)

17. Navigating EPIC in the ED • Log in and pick correct department: • YNH EMERGENCY ADULT • Sign in • Pick your work area

18. Navigating EPIC in the ED Typical day in ED: this is what the board looks like…

19. ED Notes in EPIC • Double click patient name • My note TAB is open • Pick My Note button • You are responsible for… • HPI: add chief complain • Complete by clicking • Add free-text in “comments” • ROS: “All Other Systems Negative” must be clicked off • PE: “VS Reviewed” and “Nursing Note reviewed” must be clicked off • If you did procedures (e.g. EKG) • EKG: change the “provider” from your name to your attending

20. ED Notes in EPIC • To view your full note click on Notes • Bellow PE and above Procedures free-text Assessment and Plan • MDM • What was done/ found in ED • Disposition • Also, free-text • PMD/ consultants called (name and time) • DO NOT WRITE IN THE ED COURSE SECTION

21. ED Notes in EPIC • When finished documenting: Share • Refresh Note after “clinical impression” and “disposition” is complete (after you admitted or discharged the patient in EPIC) • When an attending has signed the note, the system will only let you Sign • Pick your attending to Co-sign • Feel free to edit as many times as needed to complete the note until the patient leaves the department

22. Admitting Patient in EPIC • Double click patient name to open patient chart • Open Admit Tab • Navigate through sections • Clinical Impression= diagnosis • Manage Orders= “ED admit”… • Disposition= admit

23. Discharging Patient in EPIC • Double click name to open patient chart • Open Discharge Tab • Navigate through sections • Disposition= discharge • Follow-up= pick appropriate MD/ interval of follow-up • Clinical Impression= diagnosis • Orders= Discharge prescriptions • Discharge instructions= diagnosis/ symptoms

24. Discharging Patient in EPIC When patient ready to leave, open Discharge Tab Pick Preview/ Print Section Click Print Hand Instructions to nurse with signed prescriptions

25. EPIC PEARLS (feel free to print this page) • Every note MUST have the following elements complete • HPI: CC filled in • All click boxes that are applicable filled • ROS • “All other systems negative” clicked • PE • “Nursing note reviewed” clicked • “Vital signs reviewed” clicked • Disposition filled • Clinical Impression filled • Note must be refreshed before you sign it

26. Now that you have read and understand the module, please copy and paste the following statement into an e-mail and address it to:ana.madureira@yale.edu I have read through the ED orientation online module including the instructions on how to navigate through EPIC (notes, admissions, discharge) prior to my first shift in the ED. I am able to perform the functions that are detailed in the on-line orientation module. Should I have any questions about any information described in the module, I know to contact the eD Chief residents or the ED off-service resident director. Please sign your name and the department you are from.

27. THANK YOU FOR YOUR ATTENTION AlinaTsyrulnik Assistant Residency Director Off-service Resident Director Clinical Instructor Department of Emergency Medicine Yale University School of Medicine Alina.tsyrulnik@yale.edu