Welcome to the ED Orientation on-line module

1. Welcome to the ED Orientation on-line module • 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.

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

3. Objectives of this Orientation • Logistics of working in the ED • Your ED team • Observations vs. Admission • EPIC details • Admission • Discharge • Note completion

4. LOGISTICS OF WORKING IN THE ED

5. 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: Lower Acuity- open 24/7 • May still get trauma patients that are not “full” or “modified” traumas • Staffing • At least 3 resident/PA teams • Supervised by an attending • Section C: Lower Acuity- open 11am-2am • TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK

6. ED Layout- Other areas of Interest • Patient entrances/ triage/ registration areas: • Ambulance • Waiting Room • Central Communications Desk (a.k.a. “the bubble”) • Located at the ambulance entrance • All calls/ faxes • Location of Medtronic Pacemaker interrogation equipment • 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

7. Your team: • Attendings • Supervise multiple teams simultaneously • 24/7 in-house coverage for every section of ED (when open) • Senior ED Resident • Not available on every shift • No senior on B & C side • One senior for the entire A side on Wednesdays • ED Nurse • ED Technician • Business Associate (BA)

8. Your ED shift: Arrival and Sign-out • Arrival: at least 5 min. prior to scheduled time • B+ C sides: divide patient beds equally between available providers (podiatry and dental residents do not get bed assignments) • Sign-out: 2-part process • Off-going senior resident or attending presents patients in bed-order to the on-coming team • Part one: at the computer- all the details (including labs, social issues, Ddx) • Part two: at the bedside- off-going attending introduces the in-coming team • Patient is made aware of the work-up progress, pending studies and reason for why s/he is still in the ED, and approximate timeline

9. Your ED shift: Seeing patients • All patients assigned to your bed assignment are YOUR patients • See them within the first 5 minutes of arrival in section A or 15min. 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

10. 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 • Especially for high-risk CC: HA, CP, AP, BP • BA should help facilitate if you have difficulty • 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 • AMA form must be signed by patient • Encourage return to the ED

11. 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 the criteria • Patients placed in observation are expected to be discharged sooner (1-2 nights) • 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

12. 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 Non-University Cardiologist • Klatskin =ESLD • ESRD • Donaldson = HIV/AIDS • Fill out the rest of the booking (specify tele vs. floor)

13. Your ED Shift: Admission to an ICU • 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. • CCU: page CCU fellow • MICU: page MICU admission team • SDU: page SDU resident • SICU: the surgical team is responsible for getting SICU attending aproval • NICU: don’t need to page anyone b/c you are admitting to a team that should already be involved in patient care • NO DICTATION NEEDED WHEN VERBAL SIGNOUT DONE

14. 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: • ED chest pain place in CPC observation • EPIC Note: • Smartphrase: “.edobsadmit” • Order all out-patient medications • Dictate • 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)

15. Your ED shift: Admission of hip fractures • For isolated hip fractures • No other traumatic injuries • Mechanical cause (i.e. not syncope that needs to be worked-up) • Orthopedic team evaluates patient (as all other ortho consultations) • Computer orders: • Admit to: Hospitalist • Service: Medicine • Unit type: free-text ortho/ hospitalist 7-7 • Page hospitalist at 766-7416 to give verbal sign-out • NO DICTATION NEEDED WHEN VERBAL SIGNOUT DONE

16. 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)

17. Navigating EPIC in the ED • Log in and pick correct department: • YNH EMERGENCY ADULT • Sign in • Pick your work area

18. Navigating EPIC in the ED • Typical day in ED: this is what the board looks like…

19. 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 • Complete by clicking • Add free-text in “comments” • ROS • PE • If you did procedures (e.g. EKG) • for EKGs: change the “ordering physician” to your attending’s name (the default is your name)

20. 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 • Disposition • Also, free-text • PMD/ consultants called (name and time) • DO NOT WRITE IN THE ED COURSE SECTION • it is reserved for attendings only

21. 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 • Feel free to edit as many times as needed to complete the note until the patient leaves the department

22. Admitting Patient in EPIC • Double click patient name to open patient chart • Open Admit Tab • Navigate through sections • Clinical Impression= diagnosis • Manage Orders= “ED admit”… • Disposition= admit

23. Discharging Patient in EPIC • Double click name 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

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

25. Now that you have ready and understand the module, please copy and paste the following statement into an e-mail and address it to:jaydale.poyotte@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.

26. 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