Intern Survival Guide: ED EDITION

Outline Orders Introduction Consults Schedules Admissions FirstNet Discharges Procedures Introduction Schedules FirstNet Where things are When things happen Charts

So you’re starting the ED… The pediatric emergency room department is located on the 4th floor of the new wing. Even though tons of people will show you where it is, you will still get lost for the first week. It’s okay. We understand. Dress code is scrubs ± white coat. As it stands right now, pediatric residents work in the ED during 1 of 3 shifts: Daily: 10am – 10pm or 2pm to 2am Wednesdays: 12pm – 10pm (plus above mentioned night shift) Be prepared to see at least 10 – 12 patients in a 10-hour shift, more during the winter months. You will hopefully learn the finer details of time-management, triage and emergency management of pediatric patients.

Scheduling For every 14 days of ED, you will work 7 12-hour shifts. Continuity clinic will be once per week and full days. You will be post-call on days after you’ve worked 2pm to 2am, but you can work multiple night shifts in a row. If you are post-call on a Wednesday, you do not need to attend lectures. If possible, chiefs will schedule shifts so that you will have two entire weekends off for every month you work.

FirstNet FirstNet is our electronic ED board. For access, please email Peter Vecere, ideally 2-3 weeks before the start of your ED rotation. Take an hour or two just to surf around FirstNet and see how things work. The first thing you should do is set yourself up as a provider: Hit the “provider” tab Pick a nice nickname for yourself and a representative color Select “mid-level provider” as provider role. For more information regarding FirstNet, please refer to your previous CPOE orientation/training.

Where Things Are Charts Carts Board When you walk into the ED, chart racks will be in front of the nurse’s station and will house, in order from the first chart you see to the last: Patients waiting to be discharged Charts in process Charts that need orders picked up New charts Carts Green (in each room) Blood/IV/Urine supplies Diapers, pedialyte Yellow – ED wear (gloves, masks, gowns, etc) Blue – Casting supplies Board Our new electronic board is projected in HD to your left as you walk in.

When things happen The ED is pretty straightforward in that you come in when your shift starts, see patients, and sign-out when your shift ends. If your shift ends at 10pm, you should sign out to another resident seeing pediatric patients. If your shift ends at 2am and patients are still under your care, two things must happen before you can go home: The ER* resident must take sign-out from you Attending-to-attending sign-out must take place… though this is obviously not under your control. As a failsafe measure, please log your ED duty hours on new innovations @ https://rms1.newinnov.com.

Triage Form On the green triage form, you will find: Level of acuity (assigned by nurse in triage) Level of acuity will determine how quickly the patient is seen. If ten patients who are a level three are waiting to be seen, but a level two walks in the door, the level two jumps to the front of the line. Always see the higher acuity patients first. Age of patient Chief complaint and 1-sentence HPI Whatever vitals were done in triage Take all vitals with a grain of salt and, if concerned, make sure to repeat them.

Health care practitioner note Brief HPI, PMH and physical exam. Tip: Note the PMD somewhere on your H&P form. Sign, date and time at the bottom.

MD/RN Progress Notes ED, like all of medicine, is all about documentation. You will document any change in patient status, reaction to medication, conversation with a PMD or consulting physician, etc. Document anything that you would want to know if you were a consulting physician looking at the chart for the first time.

Disposition When a patient leaves the ED – whether it is to home, to the OR, to 11N, or to somewhere else – a disposition form must be filled out. Fill out everything except for diagnosis and billing – the attending will take care of those – and sign at the bottom. This will be reiterated multiple times, but if you are discharging a patient from the ED, tell their nurse.

Orders All order writing is now done electronically through our CPOE system. CPOE is accessed via FirstNet by double- clicking a patient’s chart. As with all orders, you should notify the patient’s nurse of any new orders, especially if the order is written as STAT. Lexi-Comp online (http://online.lexi.com/crlonline) is our hospital approved reference for medication. In the ED, all orders are usually STAT and x1 in frequency. The STAT designation is extremely important, especially when you are ordering labs and scans. Don’t forget the STAT! Chem-8s must be ordered using the “ED Whole Panel” option or the STAT lab won’t run them.

Consults When arranging for a consult, put a physician consult order in the computer. The clerk will then page the appropriate person. Just so you are aware: If there are no ophthalmology residents seeing pediatrics patients, consults are attending-to-attending. ENT consults are always attending-to-attending. Cardiology and child pysch consults are arranged via their main offices. To consult either one of these services, have the operator connect you to their main office.  Tip: Before calling a cardiology consult, you should obtain an EKG and 4-limb blood pressure. They are always helpful! Fill out the top part of the consult form and clip it to the chart. Never call a consult without attending approval. Never initiate a plan proposed by a consultant without attending approval.

Admissions If a patient needs to be admitted, you first must determine who the admitting physician will be. A patient with a private attending who admits to the hospital will be admitted under that attending A patient with no PMD or a PMD without admitting privileges will be admitted under the hospitalist service. A patient going to a subspecialty/surgical service will get admitted under their on-call attending. You must then talk to the admitting physician and outline a plan for the patient once they are admitted. Call their destination and talk to: The charge nurse The on-call resident who will be accepting the admission Note on the disposition form who you spoke to and when.

Discharges Patient Information and Follow Up Disposition Form To start the depart process, single-click your patient on the tracking list and then select the notepad (the second-to- last icon) on the toolbar. Complete the “patient education” and “follow-up” forms. Follow-up is generally with their PMD in 1-2 days. Also instruct them to return to the ED within 1 week if necessary for whichever symptoms you would deem appropriate. Check the box that states that the patient verbalizes an understanding of these instructions. Print. Disposition Form As with admissions, fill out the entire form except diagnosis and billing. Make sure to fill out the bottom thoroughly, including if you want your patient to be taking Tylenol and Motrin. Double check doses! Because you’ve already printed out information and follow-up instructions, you can write “please see attached” in the area of the disposition form that asks for that information.

Procedures You will get to try your hand at numerous procedures in the ED from the fairly simple rapid strep swab to the slightly more involved lumbar puncture. All procedures must be logged in New Innovations. Sign in  my procedure log  enter a procedure When you choose a procedure (for instance, lumbar puncture), the program will tell you Your credential target Logs counted toward that target Take one day to look through all of the procedures that require credentialing and how many you need to do. Keep those numbers in mind! You should do all of the procedures possible during your rotation. Practice makes perfect.