Welcome to ED O rientation

1. Welcome to ED Orientation Alina Tsyrulnik MDAssistant Professor Assistant Residency program director Off-service Resident Director Department of Emergency Medicine Yale University School of Medicine

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

3. ED Rotation Orientation Process and Resources • Mandatory • ED orientation (mandatory): you are here • ED online module (mandatory): • yaleem.org • Resources • Doc Launcher App • Full ED Orientation (yaleem.org) • Mobile Heartbeat phones

4. Objectives of this Orientation • Logistics of working in the ED • Your ED team • Observations vs. Admission • EPIC details • Admission/ Discharge • Note completion • Introduction to Doc Launcher • 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

5. LOGISTICS OF WORKING IN THE ED

6. 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 • May still get trauma patients that are not “full” or “modified” traumas • Staffing • At least 3 resident/PA teams in each section during the day • supervised by an attending+/- senior resident • Senior resident present at high volume times TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK

7. ED Layout- Other areas of Interest • Patient entrances/ triage/ registration areas: • Ambulance • Waiting Room • Intoxication Observation Unit (IOU) • Located in hallway next to CIU • Staffed by an ED tech • Crisis Intervention Unit (CIU) = Psychiatric ED • Separate unit staffed by psychiatry residents, attendings, nurses, techs • Prior to going there, patients >50yo must be medically cleared • Chest Pain Center (CPC) • Separate ED observation unit for low/moderate risk chest pain patients • Staffed by B-side attending, PA (during working hours), nurse, tech

8. Your team: • Attendings • Supervise multiple teams simultaneously • 24/7 in-house coverage for every section of ED • Senior ED Resident • Not available on every shift • ED Nurse • ED Technician • Information Associate (IA)

9. Your ED shift: Arrival and Sign-out • Arrival: at least 5 min. prior to scheduled time • A side • Green: outside rooms A5-6 • Purple: outside rooms A14-15 • Bside • C side • Sign-out: Done by attending or senior resident • After sign-out • See all new patients • Introduce self/ re-evaluate old patients

10. Your ED shift: Seeing patients • When ready to see a patient, assign your name to switch patient status from “waiting for provider” to “in process” • See them within the first 5 min. of arrival in section A or 20min. 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

11. 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- admitted patients’ PMDs notified by IA • 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 • Encourage return to the ED

12. Your ED shift: Admission vs. Observation • Not all patients meet insurance criteria for admission • Attending makes the observation vs admission decision • Logistics: • Put in correct admission order • Utilization Managers 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

13. 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 private (non-university) Cardiologist • Klatsin =ESLD • ESRD • Donaldson = HIV/AIDS • Fill out the rest of the booking (specify tele vs. floor, etc)

14. Your ED Shift: Admission to an ICU • Step 1: Make decision with attending • Step 2: Call appropriate team for sign-out. Get name of admitting attending. Your are not calling them to get permission to admit, you are calling to give sign-out • 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.

15. 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: • Order Sets: “ED Chest Pain 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)

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 environment: YNH Emergency Adult • Sign in • Pick your work area

18. Navigating EPIC in the ED Typical day in ED

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 • ROS • PE • If you did procedures (e.g. EKG)

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 • Also, free-text • PMD/ consultants contacted • DO NOT WRITE IN THE “ED COURSE” SECTION

21. ED Notes in EPIC • When finished documenting: Share • When an attending has signed the note, the system will only let you Sign • Pick your attending to Co-sign • Do not start 2 separate notes

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

23. Discharging Patient in EPIC • Double click 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/ precausions

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

25. Doc Launcher: getting started Choose appropriate clinical department from “Apps Menu”

26. Finding specific items

27. Doc Launcher Cogwheel • “Cogwheel” at bottom left • recently viewed content • Apps menu

28. Questions

29. THE ED PATIENT WITH CHEST PAIN

30. Background • 5% of all ED visits = 5 million visits per year in the US • One of the highest-risk chief complaints • For patient morbidity/ mortality • For MD litigation • Wide differential- most is high mortality IN THE ED, WE MUST THINK OF WHAT WILL KILL THE PATIENT • Acute Coronary Syndrome • Pulmonary Embolism • Aortic Dissection • Pneumonia • Pneumothorax • Pericarditis • Esophageal Rupture

31. ACS: STEMI=CATH LAB ACTIVATION • National guidelines for STEMI cath lab activations: • Door-to-EKG: 10 minutes • Door-to-balloon: 90 minutes • All EKGs seen and interpreted by an attending immediately • “Cath Lab activation” is done by ED attending • Cath lab personnel are assembled (if not in-house overnight) • Cath lab attending gives a call to the ED attending to get quick story • NO role for… prior to activation: • Cardiac enzyme results • Cardiology Fellow consult • Chest x-ray results • Patient needs to be rolling to the cath lab within 25 minutes from arrival at ED triage, having gotten: • ASA 325mg • Oxygen • Plavix/ Ticagrelor (Brilanta) 180mg PO • Heparin 5000U • +/- morphine • +/- nitroglycerin • +/- Beta-blocker ACTIVATION IS BASED PURELY ON EKG and PATIENT’S PRESENTATION

32. ACS: STEMI=CATH LAB ACTIVATION • What does the attending look for to activate cath lab? • Activation Criteria • ST elevations of >1mm in 2 consecutive (anatomical) leads • Other signs that may be present • Dysrhythmia • Reciprocal changes • Dynamic changes • New LBBB • Why should you care? • As an MD (doesn’t matter what specialty), you must know what to do with acute chest pain!

33. ACS: “good story” • What if the EKG is not clear-cut, but the patient is giving a “classic MI story” • No immediate cath lab activation: role of cardiology consult • Resident calls fellow • Attending calls attending • Instruct the nurse to do q10min. EKGs • Dynamic EKG changes activate cath lab • Possibilities for ACS: all should get heparin • Good story – EKG changes – troponins = unstable angina/ ACS • Good story – EKG changes + troponins = NSTEMI/ACS • Good story + EKG changes +/- troponins = STEMI/ACS • Especially if came in first few hours (<6hr) • Bad story/ no CP – EKG + troponins= NOT ACS • Look for other causes of troponins • ESRD • Tachycardia/ Sepsis • Myocarditis

34. Chest Pain Patient Disposition Low/ Moderate Risk CP High Risk CP • Need a ROMI • EKG and enzymes q3-6hrs x 3 times +/- stress • In-hospital ROMI vs. CPC • Decision made by ED attending in consultation with cardiologist and PMD • ACS • Heparin gtt • unstable vital signs • Cardiology team • Goodyer / General Cardiology • telemetry • CCU/CSDU

35. Cocaine Use Chest Pain • Rule in approx. 6% of time • Avoid Beta-Blockade • Treat chest pain and/or tachycardia with benzodiazepines

36. Questions

37. THE ED PATIENT WITH ANAPHYLAXIS

39. Anaphylaxis/ Angioedema • Immediate Medications • Epinephrine: • Mild- moderate: 0.3mL of 1:1000 dilution IM in thigh • May repeat q5min. Up to max 3 doses • Severe: 1-5mL of 1:10,000 IV drip over 10min…continuous • Solu-Medrol 125mg IV • Benadryl 50mg IV • Pepcid 20mg IV • Fluids • Albuterol PRN • Why should you care? • Anaphylaxis happens on every in-hospital unit • Will NOT have time to look up treatment

40. Questions

41. THE ED TRAUMA PATIENT

42. The Trauma Patient • There are triage criteria for activating “trauma alerts” for patients: “full trauma” vs. “modified trauma” • You are responsible for those who didn’t meet criteria THIS DOES NOT MEAN THAT THEY ARE NOT SERIOUSLY INJURED • Most are on back-boards and with c-spine collars • Back-boards must be removed within 15 min. of arrival • To prevent pressure ulcers • To prevent agitation • Spinal precautions maintained at all times Never remove a c-collar, never allow a patient to remove a c-collar

43. Backboard Clearance • 4 person job: need 3 other people • One holding C-spine stability (with collar in place) • Two holding torso • One (you) palpating spine and rectal tone • Tenderness at midline • Bruising • Lacerations • Stepoffs • Rectal Tone • Gross blood on rectal exam

44. Clearing a C-collar • Done by senior resident/ attending ONLY • Clinical Rules for clearing C-collars • Canadian • Nexus • Midline tenderness • Focal neurological deficits • Altered level of consciousness • Intoxication • Distracting Injury

45. Trauma ABCDE’s Airway Breathing Circulation Disability (GCS) Exposure Document all injuries and formulate a plan for intervention/ imaging if necessary

46. FAST exam • Focused Assessment by Sonography for Trauma • Ultrasound exam looking for free fluid • Abdomen • RUQ/ LUQ • Pelvis • Pericardial Effusion • E-FAST: extended FAST • Examines for pneumothorax • More sensitive than supine x-ray • Validated in unstable patients • Can not be used to exclude intra-abdominal trauma

47. “Pan-Scan” • “Pan-scan”= CT scan • Head (no contrast) • C-spine (no contrast) • Chest/ Abdomen/ Pelvis (contrast x2) • T-/L- Spine reconstructions • Contrast: IV and PO • PO contrast given by the tech immediately prior to the scan • Evaluates duodenal injury • Protocol MUCH different from usual PO contrast • Must specify this when ordering the study and make nurse aware • Usual protocol: wait 2hrs. after PO contrast complete

48. More Trauma Pearls • Laceration/ Abrasion • Tetanus • Contaminated wound: ?Antibiotics • Beware • ICH • Old people: subdural/ intraparenchymal bleeds • Splenic lacerations • Immediately alert the attending for any vital sign abnormalities or changes in mental status • Vital Signs • Narrow pulse pressures • Mild tachycardia • Cause of trauma: mechanical vs. medical

49. Questions

50. The Intoxicated ED Patient