Version  4/2011

Welcome to the ED.  Here is some information before you start you rotation that may help you.  Please contact us with any questions you may have.

Please send an email to the chiefs gmail account with your contact information just before you start your rotation so that we can contact you if we need to during this rotation.

There are three chief residents for the ED and they will be your point of contact during your rotation.  If you have any questions about the schedule or if you make any schedule swaps with other residents please contact the Scheduling Chief to discuss.  In addition to the normal chief email account, the scheduling chief contact info (phone number) is always at the bottom of the schedule and on www.hopem.org.  The email for all chiefs is Jhemchiefs@gmail.com.

General Expectation

 

Starting last year our emergency department has worked to improve the experience that our patients have under our care.  Our patients often come from very difficult circumstances and have limited access to medical and other resources.  Caring for them can be challenging and stressful.  Establishing a rapport can be difficult given the limited time we will have to interact with each person.  An approach that we have adopted consists of the following key structural elements.

Acknowledge the patient by name and introduce yourself and your role in their care.  Apologize for any delay.  Give them idea of a timeline for their future care.  Explain your plan of action (even if it consists of asking your attending). Thank the patient for their time and ask if there is anything that we can do to make them more comfortable.  Pay special attention to pain, warmth, and hunger and please correct anything you can in the moment (an extra blanket or cup of water as needed).

Our emphasis is more about being a kind and compassionate person than any particular checklist but including the above elements in your interaction with every patient will help both you and the department immensely.

Basics

Schedule and Hours

The schedule is a templated schedule and due to the nature of ED shift work we are unable to take schedule requests.  However, our goal is to have the schedule available well in advance which will hopefully allow for shift swaps with greater ease.  All swaps must be approved the scheduling chief and must follow these criteria.

1.  There must always be 2 upperlevel EM residents (2nd year and a 3rd year EM residents) working in the department at any one time.  

2.  If you are an offservice resident, you can swap with any other EM intern or any other offservice rotator as long as the swap does not violate RRC work violations.  

3.  Off-service interns and residents cannot trade shifts with EM3 residents. 

4.  A PGY2 or PGY3 offservice resident can trade shifts with EM junior residents (EM2) only if during that shift (not day, but shift) there are 2 other upper level EM residents (any combination of EM3 or EM2s) and the EM junior to swap with is not scheduled to be a RAP resident (Last column of the Red/Blue schedule).

5.  Shift swaps cannot not violate RRC work hour rules and it must be approved by the chief residents.

6.  You must contact the person directly via email to make the trade, once they agree, then the email must be forwarded to the chief resident at JHEMchiefs@gmail.com

7. An EM chief resident must approve all swaps/trades.  All trades must be in writing (email).

We understand about significant life events and even though we do not take schedule requests we would like to know about them.  Please contact us with any concerns you may have.

The schedule will be posted on www.hopem.org as soon as it is approved by the program directors. We have worked hard to try to prevent any hours violations but sometimes they still happen. If you have an hours violation or a conflict with your schedule and a mandatory obligation for you own residency program, let us know as soon as possible.

Of note, all offservice rotators are now expected to attend resident conference on Friday mornings.  In order to faciliate this the chief residents have reduced the hours that off service residents work on Thurdays and Fridays.  Basically we have cut down offservice hours by 5-6 hours per week to allow for attendance. 

Shifts are 8 hours or 12 hours.  Please arrive at your scheduled time and be prompt, even 1 minute late is not acceptable.  If this is a issue and you are going to be late please call the ED to inform them.  If your replacement is late let the upper level resident know as quickly as possible.

FAQs about Swaps

If I am trading shifts, which chief resident should I email?

    There is one chief in charge of each scheduling block.  Online, at the bottom of the block schedule is the name of the chief in charge and their phone number for emergencies.  All emails must go to the general chiefs account.

What do I do in the case of a personal emergency?

    The block schedule includes the chief’s phone number and it can also be found on the www.hopem.org website.  You should load this into your phone and pager at the beginning of the block in case an emergency develops.  In cases of emergency it is acceptable to call the EM chief residents.  All non-emergency communication is handled via email.

What do I do if I am extremely sick and unable to work?

    Contact your programs chief resident or ACS and obtain coverage via your emergency staff plan.

Can I have someone else from my program cover shifts for me?

    Yes, this is acceptable as long as the person covering your shift has already worked in the ED during their residency and they have current HMED access.  You must email the chiefs with the shift to be covered, the resident who is covering your shift and their phone number.  Ultimately you are responsible for that shift so if they do not report for work you will be held responsible.   

Attire

Hospital approved scrubs or professional clothing (shirt with tie) and white coats at all times.  Single color no logo long sleeve tee-shirt may be worn under scrubs.  This dress code will be enforced

Rounds/Signout

Attending rounds are bedside rounds that occur at all attending shift changes.  These are done at the bedside and may include the entire treatment team.  You should introduce the oncoming residents and attendings to the patients and give a 2-3 line summary of the patient and the disposition. 

Disposition rounds occur at 7am and 7pm in the back conference rooms.  These include the entire department so please be prompt. Disposition rounds do not take the place of individual resident to resident sign out or attending bedside rounds and are not a detailed form of signout. The intent is to give a 15 sec plan for each patient so that the charge nurse and attendings can assign resources as necessary.  In the past these rounds were more of a complete signout but now the more complete signout is accomplished during attending bed side rounds and resident to resident signout.

Resident to resident sign out will occur at all resident shift changes.  This is the most detailed of the 3 singout processes.  It is very important that you arrive on time and ready to work.  You should assume that if you are 5 mins early you are on time and if you are on time you are late.  Do not sign out an almost completed admission, discharge, or a procedure you have started or that needs completing (specifically pelvic exams, rectal exams).       

Layout of the Department

4 Pods: Acute 4 beds; Subacute 4 beds ; IMC 5 beds; Med/Surg 5 beds. 

Each area will have 1 nurse and usually 1 tech.                             

Hall 7 (aka Room 8) Psychiatric Holding

Staging Unit (SU) – level 4/5 patients and quick turn around patients

Room 25 – usually reserved for patients requiring isolation.

Hallway – number of beds depends upon staffing, usually 4-5. see MISC section re:use.

Room 20 – Pelvic Room. All OB/GYN supplies are kept here.

Team Layout

There are two teams in the ED, Blue and Red. You will be assigned to a team for each shift as well as an area to work.  You can find which team you’re on by looking at the team assignments listed on the board near the charge nurse desk or on the schedule posted on HOPEM. The red team uses the Subacute Room and the Acute Room. The blue team patients will go to the IMC and the Med Surg areas. On each shift, a third year or second year EM resident will function as the team leader. The team leader and the attending will direct patient flow during the shift.  Patients are assigned to each team in an alternating fashion or based on patient load of the individual teams.

The teams split the medical critical cares and traumas.  If you are on the red team you are expected to go to all trauma critical cares during your shift.  If you are on the blue team you will go to all medical critical cares during your shift.  It is easy to "get lost" during these events, specifically in codes.  We would like you to be an active member of the team so let the team leader know you are there and discuss your role for the critical care in order to improve you experience. 

Triage

Upon arrival to the ED each patient is seen in primary triage and assigned a level of acuity.  Very sick patients are labeled as level 1 or 2 and come immediately to the back.  Those patients with very mild complaints are assigned level 4 and 5 and are seen in Super Track during the day.  When Super Track is closed these patient wait in the main ED to be seen.  The majority of patients who present to the ED are level 3 patients and there is a special screening process for these patients in order to help facilitate their workup. 

Once a patient is deemed stable they will undergo a more complete secondary nurse triage.  During the day/evening the RAP (rapid assessment by a provider) process is in place and consists of a short screening encounter that allows the providers to ensure the correct level of acuity was given to each patient and to start a patients work up from the waiting room.

During non RAP hours (overnight) this process is completed by the senior residents and attendings as part of their team assignments.  You may be asked to help with this process by your team leader, particularly on very busy nights. 

Level of Acuity

Definitions:

    Level One patients require immediate life saving intervention.

    Level Two patients are triaged to this level if they have significant vital sign abnormality (elevated pulse, hypoxemia) are confused, lethargic, or are disoriented.  If they are in severe distress or are considered a high risk situation (ie) chest pain, they may be brought back as well.

    Level Three patients require many resources, but do not fit into the above categories, however, if the patient is found to have danger zone vitals or other concerning complaints by the secondary triage nurse or the screening physician in triage, they may be upgraded to Level Two.

    Level Four patients are not acutely ill and are expected to require only one resource (ie) chest x-ray.

    Level Five patients are not expected to require any resources.

The ultimate goal of triage is to identify high risk patients that have fallen through the cracks (1^st and 2^nd nursing triage).  The list below describes the action plans for patients after acuity levels have been assigned.

LEVEL ONE : Patients are critical care and will go immediately to the critical care areas.  These patients will be announced overhead and you should report to the critical care areas as specified in the critical care section below. 

LEVEL TWO: Patients will be placed in a bed immediately either in an area or holding at triage. They must be seen within ten minutes. A workup including orders may proceed as if the patient were in an area. As soon as a bed becomes available in the assigned team areas, the patient will be moved to that bed. Vitals and labs will be performed by the primary nurse if the patient gets a bed immediately or by the waiting room nurse if the patient must wait in the triage area pending bed placement.

TRIAGE AREA:

LEVEL THREE:    Patients will proceed to the secondary triage nurse. The secondary triage nurse may activate first nurse guidelines (X-rays, labs, and EKGs) and perform primary interview for chief complaint as well as assess vital signs. 

During RAP hours, the patient will go to the level three triage area where the patients will be evaluated by the level three triage team which consists of an attendings and upperlevel residents.  At night the attending, team leader, and residents are responsible to go to secondary triage to assess patients.

The goal is for a provider to see patients within 30 minutes of arrival and to conduct a medical screening exam.  This assessment includes a brief interview and limited physical exam in the level three triage area during RAP hours and in the SU or waiting room interview booths at night. 

If you believe that a patient who has been designated a Level Three or lower acuity must be upgraded to a Level One or Level Two patient, please notify the charge nurse.

LEVEL FOUR/FIVE:    These patients will be seen in the Super Track area of the ER during normal business hours.  At night and after limited weekend operating hours these patients will be seen in secondary triage.  Like Level Three patients, these patients will be initially seen by the provider in the secondary triage area. Primary assessment should occur within one hour.  Many of these patients can be treated in the waiting room and discharged without bed placement. These patients may be upgraded as deemed necessary. 

HMED

We have recently moved to a paperless ED chart with the HMED software. The program is still undergoing changes as we make improvements to suit our department

Training

One week before coming to your first shift you should finish the online HMED training modules at ww.hopkinsinteractive.org and also fill out a security form for access.  It takes at least 48 hours to have access granted so please do this as early as possible.  If you already have HMED access, please verify that your access is still current prior to your first shift.

There are two courses to complete. Directions are found on the attachment at the end of this web page.

Admission

Pearls

Post patient as EARLY as possible.  

HIV/AIDS patients seen at the JHH Moore Clinic with any medical problem are admitted to the Polk Service (3-POLK), call early! The Polk service MAY take a patient that was once seen at the Moore Clinic or has NEVER been seen at the Moore Clinic. Call and ask. The specialized service may be of great benefit to the patient.

Most admitted patients will need a CXR and ECG. 

Once a bed has been secured, you will receive a red pack for the patient and the bed icon will turn green. For patients admitted to the medical services the admitting team has 1 hour to examine patient in the department.  After one hour the patient will be transported after you call the admitting team to discuss the patient over the phone.  On certain busy days the department will be put on "Level Two" of the capacity management plan.  This means that there is not a 1 hour period for the admitting team to see the patient and once the bed is ready you should call the provider in order to discuss the patient with them.  This should be done ASAP so that the patient can be transported to the open bed.  

Prior to transporting any admitted patient to their inpatient bed, please ensure that the Emergency Medicine Attending has signed off on the chart and that you have appropriately discussed the case with the accepting physician.  Be sure an appropriate monitor setting is in the order set.

HMED admission order: During your admission order (prior to sending the order), click on ‘Special Instructions’ and type in the admitting diagnosis. For any service besides a general medical service, you must type in the attending name as well. DON’T FORGET TO ASK THE ADMITTING CONSULTANT WHO THE ADMITTING ATTENDING IS! Also include the name of the approval doctor. Any questions about what to include? Talk to the admissions facilitator in the center of the ED.

Levels of Care

HIGHER ACUITY

Medical (ie. DKA, ETOH withdrawal seizures, bad COPD with frequent intubations, severe sepsis) call MICU resident (5-5570). Together, you will decide whether the MPC (Medical Progressive Care Unit, aka “step-down” unit) or the MICU is appropriate. As a rule, all intubated patients and a majority of patients on pressors will go the MICU.

Cardiac (ie. ST depression, enzyme changes, not chest pain free) call CCU resident (5-5572) on call to discuss level of care. Again, a CCP (“step down” unit) bed or CCU bed will be determined.

If needed the ICU resident will come to the ED to evaluate the patient in question within 30 mins of the consult.

LOWER ACUITY

For patients needing short term observation or treatment, the ED has an Emergency Acute Care Unit (EACU) on Osler 6. The EACU serves as a holding area for patients that do not require an admission to another service, but will require extended evaluation/observation and/or are awaiting tests or labs that cannot be done immediately. Discuss whether you feel the case is appropriate with your attending. If so, notify the charge nurse to place the patient in the queue.

Examples (IV ABX for cellulitis, holding for imaging, low risk chest pain including cocaine CP)

Once a bed is available in the EACU, you are to report. Call 2-7842 and ask to speak with a provider. Once finished, let your nurse know so that she may call report as well.

MONITORED BED

Be sure to click ‘monitored bed’ on the admission order if the patient will require continuous cardiac monitoring (chest pain rule out, syncope).  You should know that a monitored bed does not include pulse oximitry.  If your patient will need frequent or continuous pulse oximitry you should request a step down ICU bed.

PSYCHIATRY

Patients that are triaged to the psychiatry area will be assigned to your team as they arrive. For level one and level two patients you will hear an overhead page that will let you know what team is responsible for the new patient. In HMED, a glittering rainbow icon will be appear indicating the need for a medical screening exam. 

Your job is to medically evaluate the patient and clear them for admission or discharge by the psychiatry resident. These patients belong to the ED as Psychiatry is a consulting service. Any medical complaints that require intervention must be worked up before disposition.  You may have many patients with predominantly medical complaints that will be initially placed in your area. Once medically cleared or during a period of stability you may consult the psychiatry resident and/or transfer the patient to Psychiatry.

The ED attending must see these patients and sign the note before they can be discharged.

Critical Care

As discussed above, on each shift, you will be assigned either to trauma or medical critical care. The arrival of a trauma or critical care patient will be announced on the overhead pager with an estimated time of arrival. Head to the critical care bays at the back of the ED, gown, mask, and glove and await the patient’s arrival. If you have a tenuous patient that requires you to be at the bedside and are unable to leave your area, let the attending or your team leader know

TRAUMA

Alpha Trauma: Pediatric High Priority (high speed MVC, low GSC head trauma, shooting/stabbing)

Bravo Trauma: Pediatric Lower Priority (normal GCS head injuries, low speed MVC)

Delta Trauma: Adult High Priority (shooting/stabbing, high speed MVC, low GCS)

Echo Trauma: Adult Lower Priority (minor MVC, Fall)

You may not get an opportunity to do very much (chest tubes, etc.) during trauma codes as you are competing with the surgery residents to get experience. However, volunteer to do IVs or central lines if you are comfortable. Otherwise, ask the ED senior resident what role you should play in the care of the trauma patient. Anesthesia is primarily responsible for airways on ODD days and the ED on even days.  The triage process is not perfect and sometimes a sick trauma patient will be classified as a Echo Trauma, please see these patient quickly and if applicable get them off the backboard as soon as possible.

MEDICAL

Incoming patients in Cardiopulmonary Arrest, Acute Respiratory Distress, or are otherwise acutely ill will be sent to the critical care bays. Patients that become unstable in other areas of the ED may also be moved to this area. If you are assigned to medical critical care, be prepared to start IVs, arterial lines, central lines, and to intubate.  Get involved!

Miscellaneous

Lounge

The resident lounge is located in the back halls of the department, straight past the CT scanner. During regular hours, the office will be open. However, during off hours, you may need to obtain access from a fellow ED resident. There is also a general staff lounge across from the restroom near the IMC. This is a good place to eat.

Hallway

The Hallway beds is an important resource that you should look to utilize in an attempt to optimize  patient flow. Good candidates are patients that have been worked up in an area, but no longer need active workup. You may even place a low resource patient from the waiting room into a hallway bed after consultation with the charge nurse. These patients may be waiting for a CT result or result of other study or may need observation for several more hours. Once a patient is placed in the hall, they must still be followed by the primary provider, but the hallway float nurse or charge nurse will be the nurse responsible for the patient once they are moved.  Hallway patients cannot be on a monitor, they cannot receive vasoactive medications, drips, or intravenous narcotics in the hall. Ask the charge nurse, attending, or team leader which patients in your area may be appropriate for the hallway if you are not sure.

Imaging

All imaging will now be entered through HMED. Please refer to your HMED training for more detail. If you have a question regarding the appropriateness of a study or the results of a completed study and your attending is unavailable, call 3-RADS (on call resident listed on 3rads.com)  to speak with the on call radiologist. During the day, there is a radiologist available in the ED behind the CT scanner to answer questions regarding plain films. At night, that same radiologist reads all studies including ultrasound and CT.

Consults

Common queries

-CVDL (Interventional Radiology) 3-CVDL for vascular emergencies

-General Surgery (Halstead Service) 3-2880 (order a CT!!)

-Hand -alternates between ortho (3-1254) and plastics (3-9999)

-Face (even days ENT, odd plastics)

-Neurology 3-7777

-Neurosurgery 3-8888.

-Polk/HIV Service: 3-POLK

-Call operator @ 5-5000 for all others

Social Work

Available 8:30AM-11:30 PM M-F and 10:00AM-11:30PM on weekends. They can help with medication vouchers for patients who cannot pay for prescriptions. Mandatory referrals include suspected domestic abuse, assault, rape, substance abuse, and all critical care/deceased patients. They are also a great resource for helping you deal with difficult patient family/social issues.

Procedures/ Supplies/ Consents

Almost all supplies are found in the closet across the hall from XRAY in the Pyxis. You’ll find it on your way in from the “bowels of the hospital.”  Supplies individual to each room are also found in the Pyxis. You will have to ask the nurse to access these items in each room. 

Forms that you may need including consent forms are found in the closet near the middle of the IMC.  Consents for lumbar punctures and central lines are in HMED under ‘Forms’.  All procedure notes are to be done in HMED.

Pelvic Exams are performed in room 20 (GC and Chlamydia DNA probes, speculums, and wet preps found in room)

Conference

Conference is now a scheduled part of your rotation and happens every Friday morning from 7-11am sharp. Lunch is provided. Dress is business attire (shirt and tie) or scrubs and a white coat. Most conferences are held at the ED offices at Mount Washington Conference center although once every 6-8 weeks conference is "downtown" at various locations around the hospital. The schedule and location are found on hopem.org. Please ask one of the residents for directions if you need them or if you have any questions.

QUESTIONS?

Email one the chiefs.  If the question is about scheduling (which it usually is), contact the Scheduling chief. All other concerns may be directed toward the ‘Admin’ Chief. Thanks and have fun, we’re excited to have you.