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ALINA TSYRULNIK MD CLINICAL INSTRUCTOR ASSISTANT RESIDENCY PROGRAM DIRECTOR OFF-SERVICE RESIDENT DIRECTOR DEPARTMENT OF EMERGENCY MEDICINE YALE UNIVERSITY SCHOOL OF MEDICINE Welcome to ED Orientation

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

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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

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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 High- Yield Emergency Medicine Topics Cardiac Chest Pain ACS: STEMI vs. NSTEMI Low/ Moderate risk CP Anaphylaxis Trauma Backboard clearance C-spine precautions and clearance E-FAST exam Intoxicated Patient Psychiatric Patient Medical Clearance

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LOGISTICS OF WORKING IN THE ED

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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 dont 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

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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

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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)

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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

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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

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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

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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

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Your ED Shift: Medical Admission Enter order in EPIC: ED Admit Observation vs. Admission Medical vs. Non-medical For medical, pick team: Hospitalist =patients PMD is on hospitalist team All other medical admits =no PMD or PMD doesnt 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)

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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.

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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)

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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)

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

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Navigating EPIC in the ED Typical day in ED

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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

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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

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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

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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

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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

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

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

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Finding specific items

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

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QUESTIONS

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THE ED PATIENT WITH CHEST PAIN

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Background 5% of all ED visits = 5 million visits per year in the US One of the highest-risk chief complaints For patient morbidity/ mortality For MD litigation Wide differential- most is high mortality IN THE ED, WE MUST THINK OF WHAT WILL KILL THE PATIENT Acute Coronary Syndrome Pulmonary Embolism Aortic Dissection Pneumonia Pneumothorax Pericarditis Esophageal Rupture

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ACS: STEMI=CATH LAB ACTIVATION National guidelines for STEMI cath lab activations: Door-to-EKG: 5 minutes Door-to-balloon: 90 minutes All EKGs seen and interpreted by an attending immediately Cath Lab activation is done by ED attending Cath lab personnel are assembled (if not in-house overnight) Cath lab attending gives a call to the ED attending to get quick story NO role for: Cardiac enzyme results Cardiology Fellow consult Chest x-ray results Patient needs to be rolling to the cath lab within 25 minutes from arrival at ED triage, having gotten: ASA 325mg Oxygen Plavix/ Ticagrelor Heparin 5000U +/- morphine +/- nitroglycerin +/- Beta-blocker ACTIVATION IS BASED PURELY ON EKG and PATIENTS PRESENTATION

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ACS: STEMI=CATH LAB ACTIVATION What does the attending look for to activate cath lab? Activation Criteria ST elevations of >1mm in 2 consecutive (anatomical) leads Other signs that may be present Dysrhythmia Reciprocal changes Dynamic changes New LBBB Why should you care? As an MD (doesnt matter what specialty), you must know what to do with acute chest pain!

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ACS: good story What if the EKG is not clear-cut, but the patient is giving a classic MI story No immediate cath lab activation: role of cardiology consult Resident calls fellow Attending calls attending Instruct the nurse to do q5min. EKGs Dynamic EKG changes activate cath lab Possibilities for ACS: all should get heparin Good story EKG changes troponins = unstable angina/ ACS Good story EKG changes + troponins = NSTEMI/ACS Good story + EKG changes +/- troponins = STEMI/ACS Especially if came in first few hours (