1. MOST OF THE INFORMATION YOU ARE ABOUT TO READ WILL BE A REVIEW OF THE IN-PERSON ORIENTATION THAT YOU ALREADY ATTENDED. IT IS IMPORTANT TO BE FAMILIAR WITH THESE ED PROCESSES AND PROCEDURES PRIOR TO YOUR FIRST SHIFT. Welcome to the ED Orientation on-line module

2. PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT CARE IN THE ED FROM THE MOMENT THEY START THEIR ROTATION Goal of this Orientation

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

4. 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

5. ED Layout- Other areas of Interest Patient entrances/ triage/ registration areas:  Ambulance  Waiting Room Intoxication Observation Unit (IOU)  Located in hallway behind Section C  Staffed by an ED tech Crisis Intervention Unit (CIU) = Psychiatric ED  Separate unit staffed by psychiatry residents, attendings, nurses, techs Chest Pain Center (CPC)  Separate ED observation unit for low/moderate chest pain patients  Staffed by B-side attending, PA (during working hours), nurse, tech

6. 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 Business Associate (BA)

7. Your ED shift: Arrival and Sign-out Arrival: at least 5 min. prior to scheduled time  A side  Green: beds 4-12, r1-2  Purple: beds 1-3, 13-19, r3-4  B side  EM intern takes beds 15,16,1,2,3  EM PA takes beds (8)9-14  Off-service resident takes beds 4-(8)9  C side  Divide beds among available providers (3-4 teams) Sign-out: Done by attending or senior resident After sign-out  See all new patients  Introduce self/ re-evaluate old patients

8. Your ED shift: Seeing patients All patients assigned to your bed assignment are YOUR patients  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

9. 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 BA  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

10. Your ED shift: Admission vs. Observation Reasoning: patients who have normal vital signs, normal lab results, normal imaging may not meet criteria by insurance companies to pay for a full hospital admission  These patients may still require medical care not reflected by these numbers Logistics: most of the time, the ED attending will be able to determine admit vs. obs  Care Coordinators 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

11. 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)

12. Your ED Shift: Admission to an ICU Step 1: notify Bed Manager Step 2: Call appropriate team for sign-out. Get name of admitting attending. 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.

13. 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)

14. 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)

15. Navigating EPIC in the ED Log in and pick correct environment Sign in Pick your work area

16. Navigating EPIC in the ED Typical day in ED

17. 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)  EKG: change provider

18. 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

19. 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

20. 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

21. 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

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

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

24. Finding specific items

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

26. 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. 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

27. ALINA TSYRULNIK ASSISTANT RESIDENCY DIRECTOR OFF-SERVICE RESIDENT DIRECTOR CLINICAL INSTRUCTOR DEPARTMENT OF EMERGENCY MEDICINE YALE UNIVERSITY SCHOOL OF MEDICINE ALINA.TSYRULNIK@YALE.EDU THANK YOU FOR YOUR ATTENTION