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

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

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

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

LOGISTICS OF WORKING IN THE ED

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

ED Layout- Other areas of Interest Patient entrances/ triage/ registration areas: Ambulance Waiting Room Intoxication Observation Unit (IOU) 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

Your team: Attendings Senior ED Resident ED Nurse ED Technician 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)

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 B side C side Sign-out: Done by attending or senior resident After sign-out See all new patients Introduce self/ re-evaluate old patients

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

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

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

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)

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.

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)

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)

Navigating EPIC in the ED Log in and pick correct environment: YNH Emergency Adult Sign in Pick your work area

Navigating EPIC in the ED Typical day in ED

ED Notes in EPIC Double click patient name Pick My Note button 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)

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

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

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

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

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

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

Finding specific items

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

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.

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