Emergency Department

1. Emergency Department Orientation Part I Developed by: Lori Baker, RN, BSN

2. Mission and Goals See Orientation Notebook

3. Your Orientation Notebook • Most of your orientation material will be found on Quia (pronounced key’-ah) in an effort to do our part in saving the environment • Some copies have been made of the material you will use more often so it will be close at hand during your orientation • We will review both electronic material and hard-copy material during orientation so always bring your notebook with you

4. Employee Health Infection Control Restraints Wound and Pressure Ulcer Management VTE and SCD Hyper/Hypothermia Systems Telemetry/Cardiology Body Safety and Patient Transfers Codes LifeNet IV Therapy Pain Management Informed Consent Blood Administration Swallow Screening Beyond Orientation – Any Questions?

5. Become Familiar with Your Department • Acute, MEC, and Triage • POCT • Breakroom, Locker room • Utility rooms • Patient rooms • Core • Storage rooms • Ancillary departments

6. Kronos • Remember… • If you clock in after your assigned start time you are still late • Clock in and out NO MORE THAN 7 MINUTES before or after your scheduled time • No meal must be signed by charge nurse • PTO and sick time should be put in by the employee (when possible) • Overtime must be approved • Exception log is located at the charge nurse desk – use if badge does not work, you were at a meeting somewhere other than the hospital, etc – must be signed by charge nurse

7. Scheduling • “Wish list” in breakroom • NOT guaranteed • Sign up for your weekend or holiday • May use an “R” one time per 2 weeks • May not be actual schedule when it comes out – check it!!! • Masters, daily's, and sign-ups are in the schedule book at the charge nurse desk See tip sheet on Quia During your orientation, you are to work your preceptor’s schedule unless other arrangements are made. For consistency, please make every effort to adhere to this arrangement unless absolutely necessary.

11. Holiday Rotations • Full-time and part-time – one major and two minor, alternate with two major and one minor • OPT – one major and one minor per year • Work your usual shift • You will be assigned to group “A” or group “B” • NSER-215 scheduling of Weekends-Holidays is the policy listing what is considered major and minor holidays See tip sheet on Quia

12. Call in procedure • For sick calls, call Nursing Administration at 304-264-1000 ext 1782 • Call-ins are considered unexcused • Put in your own sick time in Kronos • Please refer to… for details See tip sheet on Quia NSER-216 Sick Call-Ins

13. Education • General Hospital Education • NetLearning • ED Specific Education • Quia • Instructions in orientation notebook • You will be given a specific username and password for this

14. Mandatory Education • Intranet>Departments>Education • Accu-Chek • Blood administration • Braun IV pumps • Blood culture collection • Fill out and send to hospital education department via email • Mandatory every 2 years: BLS, CPI, ACLS, PALS • Mandatory every 4 years: TNCC • TNCC is done through the ED, not the hospital education department • This is counted as hours worked – don’t forget to clock in for these

15. One day per month 0715 and 1400 in dept. See tip sheet on Quia • Must sign off on 100% or staff meeting minutes • Minutes are in a book at the charge nurse desk

16. Huddles • To be done every 12 hours by clinical coordinators at the beginning of the shift • It is your responsibility to to be at the charge nurse desk on time • The object is to disperse up-to-date ED pertinent information • Changes weekly • Huddle book at charge nurse desk See tip sheet on Quia

17. Dress Code • Colors • Primary-navy, white and gold for nurses • Any combination • Prints acceptable, only in these colors • Techs – burgundy with gray accent color • NO thermal or denim fabric • NO T-shirts • A thin T-shirt of department colors may be worn under the scrub top • NO logos or pictures visible • May NOT hang below the scrub top • If a cover-up is needed it MUST be a uniform scrub jacket • NO sweatshirts, hoodies, sweaters, etc.

18. Dress Code • Holiday Scrubs • Appropriately themed holiday scrubs may be worn for the following holidays ON the holiday • Christmas – may wear the week before through New Years Day • Thanksgiving • Valentines • Easter • 4th of July • St. Patrick’s • Memorial

19. Dress Code • “Free Friday” • Alternate colors/patterns of scrubs may be worn on Fridays • Still NO denim, flannel, or thermal material • Must be professional and of uniform style (i.e. no fatigue patterns, etc.) • With all uniforms • Tight fitting clothing is inappropriate • Underwear should never be visible (even when bending or stooping) • Tattoos must be fully covered • Hair should be up off collar and out of face • Beards and mustaches should be neatly trimmed

20. Dress Code • Shoes • No open toed shoes allowed • Shoes should be able to be washed or autoclaved • Athletic-style shoes may be worn • Keep in mind all the fluids you may be exposed to • NO body piercings other than 2 earrings per ear should be visible • No artificial nails, tips, wraps or other type of extension • No perfume or cologne • Make-up should be minimal and in good taste

21. Vocera • Vocera • Hands free communication device • MUST WEAR EVERY SHIFT • Part of uniform-NOT an option • Issued own personal device to keep • Batteries in breakroom See tip sheet on Quia

22. HIPAA

23. Confidentiality • Electronic information • Minimize screens • Only use EMR for appropriate use • Do not look up any patient you are not directly taking care of (including relatives and friends) • Verbal • Clinical information for patient care • Be careful who, what and where • Be very cautious using the Vocera (DO NOT use it in or near a patient care area)

24. Other Access • EPIC • Meditech • Omnicel

25. REVIEW TIME!!!

26. ED Documentation • Most documentation is done through EPIC on the computer • Exceptions are the following, which will be done on paper forms: • Traumas • Codes • Suicide risk assessments • Disposition of Body Form • Waiver of medical screening • AMA/Refusal to Treat See tip sheet on Quia

27. Computer Downtime • Appendix F in downtime procedure manual (link is on Quia ED Orientation page) See tip sheet on Quia

28. Consents • Types • Informed – fully explained – sign • Implied – ex. Cardiac arrest • Phone consent – document reason and 2 witnesses • No mind altering drugs before getting consent See policies on Quia

29. Telephone Consent • If parent, MPOA unable to give written consent, can consent over phone • Documentation: • MPOA ( write name of representative) is unavailable to sign an informed consent because (write the reason), but has consented over the telephone for (write the procedure) • Two witnesses to sign, date, time • Please refer to the following policy for all consents: • CH ADM-301-Consent Policy See policy

30. Consent of Minors • Minor – under age 18 • Emancipated minor - <16; court declared or married • Mature minor - >16; deemed mature by physician • Minor consent must be given by parent otherwise • Exceptions: pregnancy, birth control, STD, substance abuse • Minor can give consent for own child See policy

34. EMTALA • Emergency Medical Treatment and Active Labor Act • Require medical screening • Stabilize and transfer if appropriate • Need receiving MD name and a bed • Consents to treat signed • Medical chart sent with patient • Nurse-to-nurse report • DOCUMENT Policy on Quia

35. Triage • QUALIFICATIONS: • Licensed in West Virginia • ACLS, PALS, [TNCC and CEN preferred] • Demonstrated competence evidenced by completion of a triage checklist and preceptor evaluation. A formal class will be provided. • Effective 1/1/03, nurses that have worked 6 month in ED with prior experience can Triage OR 1 year without prior ED experience. However, all nurses must attend the class prior to being assigned to triage. • Effective interpersonal and communication skills and the ability to work collaboratively and effectively interact with public • Flexibility/adaptability to rapidly changing situations • Ability to use decision-making skills • Excerpt from ED Operational Guidelines/Triage Nurse

36. Triage • ESI V Level Triage • Emergency Severity Index • Separate class will be scheduled once you meet the qualifications

37. Immediate Bedding • Trial began June 3, 2013 (still ongoing) • Patient presents to front desk • Pivot nurse directs patient to a bed by chief complaint and general rapid assessment • Bedside nurse performs “triage” assessment

38. Advanced Triage Protocols (ATPs) • Pre-set procedures to follow for patients presenting with the following: • Abdominal pain • Flank pain • Sore throat • Pyrexia/Pain • Orthopedic • Chest pain • Psych complaint • Suture removal • Chest pain Please refer to the specific protocols on Quia See separate Quia page for ATPs

39. Code STEMI • EMS or walk-in • 12 lead EKG to be transmitted from EMS, otherwise, EKG within 5 minutes • Physician calls Code STEMI • Unit secretary calls 1-911 to page the Code STEMI • Cath lab nurse and Hospitalist transport patient to cath lab • Door to cath goal 90 minutes (or less) • Document time accurately!!! • Please refer to the handouts in your orientation notebook See orientation notebook

40. Ten-minute EKG • For all chest pains of patients >16 y/o • If they present to triage, place them on a stretcher and do the EKG BEFORE bringing them back to a room • As soon as the EKG is done, show it to a provider immediately (and document that this was done. • Place ALL chest pain patients in a wheelchair as opposed to walking them to a room

41. Code Stroke • Notification from EMS (or walk-in) • Page for Code Stroke initiated by physician • Draw labs if not done by EMS • Send to CT • Vitals and repeat fingerstick glucose • NIH stroke scale • Contraindications to thrombolytics • Please refer to the handouts in your orientation notebook See orientation notebook

42. REVIEW TIME!!!

43. Admissions Process • Admitting physician enters orders in EPIC • Nurse views admission orders • Nurse enters a bed request • Page or call for bed • Call report • Transport patient to assigned bed • Discharge from ED • See policy on Quia

44. Gateway Admissions (Psych) • Crisis worker evaluates patient in ED • ED medically clears • Same admission process • When admitted, patient is escorted to Gateway with crisis worker and security guard See tip sheet on Quia Policy also on Quia

45. Suicidal/Homicidal Risk Assessment • Suicidal/homicidal pts should change into paper scrubs. Belongings out of room. • Ensure room clear of IV tubing, wires, etc. • Notify security only if needed Policy found on Quia ED Orientation Page

47. Commitment • Involuntary • Clear and present danger to self or others • Deprives patient of rights and freedoms • Petition filed at county clerks office • Patient to ED for evaluation by psychologist • Hearing takes place • Decision by mental hygiene commissioner • Patients pending a commitment hearing will have PD at bedside at all times for duration of hold order

48. Restraints • RN may initiate but physician order must follow • Identify alternatives to physical restraints first • Monitor circulation, measure dignity, behavior, loosen every 2 hours, provide hydration, elimination, passive ROM every 4 hours • Document on restraint documentation