OVMC:ED

Revision as of 17:11, 26 January 2017 by Llovato (talk | contribs) (Added section on Instructions for Specific Lab Orders)

WikEM OVMC:ED is meant as a guide to providers working in the ED at Oliveview UCLA Medical Center. It is only a guide. Management of the patient is always at the discretion of the ED provider.

Wiki of the Day

  • Did you know that 10mg of Toradol IV seems to be as effective as 30mg IV? (Motov et al Comparison of Intravenous Ketoralac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial, presented at Society for Academic Emerg Med May 2016 and NY ACEP Annual Meeting July 2016)

Phone Numbers

ED

  • MD Room ED 1A Attendings 3648, 3649
  • MD Room ED 1A Residents 3907, 4732, 3645, 4720
  • MD Room ED 4/5 4936, 4937, 4938, 4939
  • Hospitalist Room 4930
  • ED 1A/Clerk: 4320, 4323, 4324
  • ED 1B: 4865
  • ED 2A: 4321
  • ED 3: 4976
  • ED 4/RME Unit: 4974
  • ED 5: 4970
  • ED Fax: 4298
  • Charge/Resource Nurse: 4320
  • ICN/Router: 5235, 5236
  • Triage 1: 5658
  • Triage 2: 5661
  • Triage 3: 5662
  • Triage 4/RME: 5697
  • ED Lab 4977
  • ED Xray tech 5496
  • ED CT scan tech 4968
  • ED Ultrasound tech 5623, 4940
  • ED Reading Room XXX
  • Psych ED 4340, 4341
  • UR 4890, 4891
  • PFS 5228, 5165, 5876
  • TFU 4825

OVMC

Radiology

  • Main Radiology 4059
  • ED Xray tech 5496
  • ED CT scan tech 4968
  • ED Ultrasound tech 5623, 4940
  • ED Reading Room 4971
  • MRI tech 2064
  • MRI front desk 3535
  • MRI Body Reading 4791, 4082
  • Neuro and MRI Neuro Reading 4082
  • MSK/General Reading 5145, 5141
  • UTZ Reading 4543
  • CT Reading 4791, 6078

Lab

  • Lab - ED 4977
  • Lab - Processing 6033
  • Lab - Blood Gas 3314
  • Lab - Micro 6041, 6045
  • Lab - Pathology 3532
  • Lab - Blood Bank 4062

Pharmacy

  • Pharmacy Outpt 3068,3066
  • Pharmacy Inpt 5956,6152

Clinics

Urgent Care Clinic 4311, 4312 Open Mon-Sat
Clinic A 3125 CCC, Derm, Endo, Renal, Primary Care)
Clinic B 3129, 3131, 3132 Breast, Chest, Gen Surg, Peds Urology, Plastic Hand, Plastic Surg, Proctology, Thoracic Surg, Urology, Vasc Surg
Clinic C 3133 Cardio, Endo, GI, Heme, ID, MDA, Neuro, Oncology, Pulm
Clinic D 3260, 3137 Gyn After Care, Gyn, Gyn Onc, Urogyn, Gyn Endo, Memory
Clinic E 3676 Interventional Rads, Ortho, Podiatry, Rheum
Clinic M 4301 Primary Care
Clinic P 4990 Primary Care
ENT/Ophtho 3118, 3538, 5630, 6621, 5260
Peds 3143
Ortho Tech 818-529-5135, 818-529-5509

Other

  • Bed Control 5959, 3179
  • IT Info Technology 4522, 2644
  • OR 4364
  • Psych ED 4340, 4341
  • Resp Therapy RT 4055
  • Sheriff 3409
  • Medical Records (problems with Cerner notes) 3934

USC

  • Teleradiology Night Reads 323-409-6679
  • ED Resusc 323-409-6667
  • ED Resusc Attending 323-409-1610
  • ED Peds Attending 323-409-1650

MAC

  • 866-940-4401

Kaiser EPRP

  • 800-447-3777

ED Throughput

RME Unit

  • Monday - Sunday, 8am to 8pm
  • ED 4: 34,35,36,37,38,39,40,41
  • ED 31/Procedure/Discharge Room will be left open and used for slit lamp exams and ENT procedures as needed, consults and discharge patients home as needed.
  • Staffing: two NPs, two RNs, one NA
  • Responsible for ESI level 4 and 5 patients
  • Responsible for overall turnover of rooms by discharging patients and bringing in new patients to be seen
  • NP and RN will pair up and take 4 rooms each, 34-37 and 38-41
  • RME Unit rooms will be set up with gurney against the wall and a chair in center of room in which patients will be placed.
  • Patients who remain in the ED 4 from the nightshift will either be discharged or moved to another area as soon as is possible for nursing staff. Night shift staff will attempt to move these patients at 6am. Dayshift stay will continue moving patients held over from the night shift.
  • In the morning when ED 4/RME Unit rooms are empty, Triage RN will place ESI level 4 or 5 patients directly into empty ED 4/RME Unit rooms; when these rooms are finally full, the responsibility for room turnover will shift to the staff in the RME Unit.
  • In the morning, when ED 4/RME Unit beds have been filled by the Triage RN, additional ESI 4 and 5 patients can continue to be placed into other ED beds in ED 1,2,3 or 5 if ESI 1-3 patients do not take precedent.
  • NP provider will sign up for the patient in the Res/ML column
  • RN will not sign up for the patient on the Tracking Board. The RN, however, will be responsible for patients who are under the care of the NP with which they are paired.
  • RN is not required to complete an assessment on every RME Unit patient. If medications given, etc, then a reassessment should be completed. If RME Unit patients are on the track more than 4 hours, a reassessment must be done by the RME Unit RN in the waiting room.
  • RME Unit Nursing (RN/NA) responsibilities: visual acuities, drawing blood, obtaining urine samples, sending patients needing plain films to PWR, calling Radiology about patients need utz or CT scan, anticipating procedures such as lac repairs or gyn exams and moving carts to the room, moving patients to and retrieving patients from the waiting room, etc.
  • Any patient placed in RME Unit who is subsequently deemed too complicated for RME Unit will have an RME documented, their ESI level changed to 3, orders placed as needed, and patient moved either back to the waiting room or when possible to ED 1, 2, 3, or 5. Responsibility for these patients should also move to the ED provider and nursing staff in those areas. If moved back to the waiting room, responsibility falls back to the Triage and Reassessment RNs.
  • Patients requiring plain films will be sent down to PWR/Radiology WR to wait for their imaging. RN or Provider will change the bed assignment to PWR. Radiology tech will then look on the tracking board, find the patient in PWR, complete the plain film imaging and then tell the patient to return to the RME Unit/ED 4 Nursing Station. The RME Unit RNs will then change the bed assignment to TR4 and send patient to waiting room to wait for imaging results.
    • ONLY RME Unit patients requiring plain films will be sent to PWR/Radiology WR.
  • Patients who are waiting for laboratory testing results, imaging such as utz or CT, plain film imaging results, or consultations by subspecialits can be moved to the waiting room. Bed assignment will be changed to TR4 in order to keep them visually separate from the other waiting room patients. These patients will remain the responsibility of their providers while they are in the WR awaiting results.
  • Patients moved to the waiting room (TR4) or ED 31/Procedure/Discharge Room will not be counted toward the nurse/patient ratios because they will need limited nursing interventions.
  • Patients who need to receive discharge instructions will be discharged in their ED room assigned or in ED 31/Procedure/Discharge Room.
  • RN will notify housekeeping when a room needs to be cleaned; RN will choose a new ESI level 4 or 5 patient from the WR to fill the room.
  • At 7pm the night shift RNs assigned to RME Unit will assume care for the day shift RN’s patients and continue working with the NP per the above guidelines.
  • At 8pm, the RME Unit will close, and patients who are still in progress of being cared for by the RME Unit team will be signed out by the day shift NPs to one of the night shift residents. The night shift RNs assigned to EDs 4 continue to care for the patient until discharge.
  • At 8pm, ED 4 will be used along with ED 1,2,3 and 5 beds for a variety of patients. Triage RN will be responsible for assigning patients to those beds.
  • If the RME Unit is successful, we may extend hours to 8pm-8am when a night shift Nurse Practitioner has been hired. We may also extend the RME Unit, as needed, to include additional ED beds and other ED nursing and provider staff.

Nursing

MIT Meds in Triage

  • Triage RNs are able to administer acetaminophen, ibuprofen, ondansetron or mylanta under a Medication in Triage Protocol
  • Applies to adults and children
  • One time dose only
  • If patient has already been RME'd and requests pain medication, then MIT protocol does not apply and provider will be asked to order medication

Admission Guidelines

Medicine Admissions Upgrades, Downgrades, ICU Admits co-managed

  • Inpatient teams are required to write inpatient admission orders (hosp icon) within 2 hours of Order to Admit (red circle)
  • Once inpatient admission orders are written (hosp icon),both Attending and Resident column on Tracking board can be changed to Inpatient Attending and Inpatient Resident
  • ED Admissions to Ward, Tele, Stepdown are managed by inpatient Medicine team once hospital icon appears
  • ED Admissions to ICU are managed by ED with ICU consultation
  • Ward, Tele, Stepdown then upgraded to ICU are co-managed by original medicine inpatient service and ICU team
  • ICU then downgraded to Ward, Tele, Stepdown are managed by the inpatient medicine team; ED should give report to Medicine

Observation

  • Observation unit upstairs has 8 beds all with tele capabilities
  • Request for Interqual not needed
  • Order "Place in Observation"
  • Once patient is admitted (Request for Admit placed/red circle on tracking board), provider cannot cancel the admission and place in Observation. Decision for observation has to be made prior.
  • If the status of an Observation patient changes/worsens, can be changed to a full admission (Request for Admit) by the Observation team.
  • Apparently, on occasion, Gyn has been allowed by Medicine to obs gyn patients in the Obs unit. Primary service would be Gyn.

Chest Pain Admission Guidelines

  • High Risk = Any of the following:
    • Objective signs of myocardial infarction/ischemia or new LV dysfunction:
      • Diagnostic ST/T changes or new LBBB on EKG
      • Abnormal Troponin result
      • Symptoms associated with dynamic EKG changes
      • Signs of CHF or cardiogenic shock
      • Malignant dysrhythmias
    • Typical symptoms known to be ischemic and:
      • Recent (<12 month) PCI
      • Recurrent/refractory despite anti‐anginal therapy
    • Management:
      • Anti‐platelet, anti‐thrombotic, and anti‐anginal therapy
      • Cardiology consult for possible urgent invasive therapy
      • Repeat troponin q3h x3 unless urgent invasive therapy already planned
      • Admit to SDU or ICU bed
  • Intermediate Risk = No High Risk Features, but one or more of the following:
    • Abnormal but non‐diagnostic EKG, cannot exclude ischemia:
      • LVH with strain
      • Digoxin effect
      • Ventricular‐paced rhythm
    • New, typical angina symptoms in a patient with:
      • Known CAD
      • Age>70
      • Inability to complete outpatient ETT
      • Intermediate Score on Risk Estimation Tool (e.g., TIMI 3 or higher)
    • Management:
      • ASA; anti‐anginal therapy as needed
      • Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
      • Observation or Telemetry admit (in consultation with Hospitalist and/or Cardiologist) for risk stratification prior to discharge, unless already performed in past 12 months.
  • Low Risk = No High or Intermediate Risk feature, plus
    • TIMI 0-2
    • Highly atypical symptoms
    • Recent negative objective study (e.g. angiogram, nuclear imaging, CCTA, ETT with Duke score 9 or greater)
    • Management:
      • ASA
      • Repeat EKG and troponin q3h until negative assay >6h from onset of most recent chest pain
      • Refer for expedited (<72h) outpt. risk stratification if not already done in past 12 months
      • Refer for primary care to assess and manage vascular risk factors

Tele Admission Guidelines

  • Based on AHA/ACC guidelines, see reference at: http://circ.ahajournals.org/content/110/17/2721.full
  • Class I (Valid for 72 hours)
    • CONSIDER SDU OR ICU LEVEL OF CARE, IF INDICATED
    • Mild – moderate heart failure
    • Hemodynamically stable arrhythmia (HR > 45 and < 150 bpm): atrial fibrillation/flutter, non-sustained ventricular tachycardia, or other non-sustained SVT
    • Following percutaneous coronary intervention
    • QTc prolongation (> 460 msec in women, > 450 msec in men)
    • Hemodynamically stable (HR > 45 bpm) atrioventricular block (consider higher level of care for 3rd deg)
    • Drug overdose with arrhythmic potential (e.g. digitalis, TCA’s, phenothiazines, antiarrythmics)
  • Class II (Valid for 48 hours):
    • Transfer from ICU or SDU after Acute Coronary Syndrome (STEMI/NSTEMI) or cardiac/respiratory arrest
    • Chest pain requiring inpatient evaluation (troponin < 0.8, no significant ECG changes)
    • Stroke
    • Syncope (true loss of consciousness)
    • Post-operative patients with presumptive or confirmed obstructive sleep apnea
    • Cardiac contusion, myocarditis or pericarditis
    • Initiation/adjustment of antiarrhythmic medications
  • Class III (Valid for 24 hours):
    • Electrolyte abnormality requiring cardiac monitoring but not requiring higher level of care due to underlying process such as diabetic ketoacidosis
    • Following pacemaker placement or cardioversion
  • Other Diagnosis (Valid for 24 hours):
    • Cardiology requesting Telemetry

Surgical Subspecialty Admission Guidelines

  • DATE: October 22, 2014
  • TO: Faculty and Housestaff, Departments of Surgery, Medicine, Ob/Gyn, Pediatrics, and Emergency Medicine
  • FROM: Robert Bennion, M.D., Chief, Department of Surgery; Soma Wali, M.D., Chief, Department of Medicine; Christine Holschneider, MD, Chief, Department of Obstetrics & Gynecology; Shannon Thyne, MD, Chief, Department of Pediatrics; Greg Moran, M.D., Chief, Department of Emergency Medicine
    • Re: Emergency Department Hospital Admission Guidelines: IIn order to optimize patient care, housestaff supervision, expedite the admission process, and minimize conflicts regarding admission decisions, this document will clarify how the decision is made to admit emergency department (ED) patients to various inpatient services, and provide guidelines as to what types of patient diagnoses are most appropriately admitted to a specific inpatient service and hospital ward or unit.
    • Decision to Admit an ED Patient to the Hospital & Resolving Disputes: The decision as to whether a patient can be managed as an outpatient or requires more intensive observation and therapy in the hospital can be critically important. Therefore, the service chiefs have decided that after input from the admitting housestaff, the decision regarding admission ultimately must be made by attending physicians, which is consistent with community standards of care.
    • The Department of Emergency Medicine attending physician will make the decision on the need for an ED patient to be admitted. This decision will be made after reasonable evaluation and consultation to determine a presumptive diagnosis, admission service, and level of care. To avoid misunderstandings and delays, consulting residents should, upon completing their evaluation, clearly communicate their recommendations with the ED resident caring for the patient prior to leaving the ED. Patients will not be transferred from the ED to the floor until there is notification and confirmed acceptance by the admitting resident or attending, which should be indicated in the ED patient tracking system.
    • If, once notified, the admitting service resident disagrees with the recommendation of the ED staff, the resident should contact his/her senior/chief resident or attending physician to review the case. All disputes should be resolved first by ED resident discussion with the admitting service senior/chief resident, and, if necessary, by discussion between the ED and the admitting service attending physicians.
    • Diagnosis-Specific Guidelines for Appropriate Admission Service
    • The service chiefs expect that patients with certain designated illnesses will be admitted to the appropriate service, in accordance with the preceding section. Patients with disorders appropriate for surgical admission may not require an acute surgical procedure (e.g., abdominal pain with possible ischemic bowel admitted for observation). Patients with potential surgical diagnoses but who have significant concomitant medical problems (e.g., diabetes out-of-control) may be best managed on the Medicine service, with close consultation.
    • For patients seen in the ED who are within 30-days from their operation and for whom admission is being considered, the operative service (general surgery, urology, GYN, etc) should be the primary consulting service and in most cases the admitting service.
General Surgery & Subspecialties Medicine/Pediatrics/Ob/Gyn
Acute abdominal pain - potential underlying surgical etiology (e.g., possible ischemic bowel), complicated diverticulitis (abscess or microperforation)- non-pregnant (General Surgery) Acute abdominal pain – unclear but possible medical/ non-surgical etiology (e.g., colitits, gastroparesis, uncomplicated diverticulitis) (Medicine)
Pregnant women and non-pregnant women with acute abdominal pain likely to have gynecologic etiology (Ob/Gyn with General Surgery consultation)
Gallstone pancreatitis (including presumed cases), acute cholecystitis, cholangitis, choledocholithiasis with gallbladder, symptomatic biliary colic with PO intolerance (General Surgery) Alcoholic and other non-gallstone-related pancreatitis, choledocholithiasis without gallbladder (Medicine)
Pregnant women with gallstone pancreatitis, acute cholecystitis, choledocholithiasis/cholangitis (Ob with General Surgery consultation)
Hepatitis and hepatic abscess(es) (Medicine)
Mechanical small bowel obstruction - partial or complete (General Surgery) Small bowel obstruction – partial or complete secondary to prior Ob/Gyn surgery or gynecologic malignancy (Ob/Gyn)
Ileus or colitis – (Medicine)
Abscesses with complex wounds or requiring OR intervention (regardless where drained), necrotizing skin and soft tissue infections, post-operative wound infections, other significant skin/soft tissue infections involving specific areas (Surgical sub-specialty, e.g., significant head and neck infections to Head & Neck Surgery, excluding Plastic Surgery, see below) Cellulitis/lymphangitis, abscesses that can drained in the ER with predominant cellulitis, and other skin infections with significant concomitant medical problems (e.g., diabetes out-of-control) (Medicine)
Infections or injuries distal to the elbow requiring immediate operation (Plastic Surgery) Infections or injuries distal to the elbow, not requiring immediate operation, or in patients with significant/unstable medical problems. (Medicine with Plastics consultation)
Infection of lower leg below ankle or foot with or without abscess, including diabetic foot ulcer and/or osteomyelitis (Medicine with Podiatry consultation)
Obstructing ureteral stone or malfunctioning stent and hydronephrosis with documented fever (> 38o C) and pyuria, or uncontrollable pain, or bilateral hydronephrosis from ureteral stones and renal insufficiency or solitary kidney in adults; acute prostatitis (fever, chills, toxic appearing, severe obstructive voiding symptoms), or with severe hydronephrosis; scrotal abscess requiring OR intervention and/or admission for IV antibiotics (Urology, also see specific inter-departmental guideline) Urinary tract infection without significant anatomical obstruction (Medicine/Pediatrics), pregnancy (Ob) or gynecologic malignancy (Gyn)
Significant tract infection with anatomical obstruction, with or without infection, in stable pediatric patients (Pediatrics with Urology consultation)
Urolithiasis with infection, no obstruction, patient toxic appearing or high risk for complications, or indwelling ureteral stent in appropriate position and no hydronephrosis or mild hydronephrosis; epididymitis requiring admission for IV antibiotics; urologic problem in patient with any complicated medical problem (e.g., diabetes out of control, severe sepsis) (Medicine with Urology consultation); pregnancy (Ob), or gynecologic malignancy (Gyn)
Acute gastrointestinal bleeding (Medicine or Pediatrics)
Ankle and foot fractures (Medicine with Podiatry consultation)
All patients with post-operative surgical problems within 15 days of discharge requiring admission - to specific operating service (with Medicine/Pediatrics consultation as necessary)
    • Admission Orders Admission orders must be written by the responsible inpatient service housestaff who are available to floor nursing in order to direct inpatient management. For cases in which the admitting diagnosis is established (e.g., CT-confirmed appendicitis), an inpatient bed is available, and the admitting service residents are unavailable for > 2 hours (e.g., in the OR), the ED resident will contact the admitting service senior/chief resident in order to seek verbal approval for the admission. The ED physician will then write holding admission orders on the standard admit form and transfer the patient to a hospital bed. If the admitting senior/chief resident is also unavailable or the admission cannot be approved, then the ED attending may contact the admitting service attending physician to facilitate the admission. Admission holding orders should include pain medications, intravenous fluids, and antibiotics (if recommended by the admitting service), and contact information (resident name and pager number) for the admitting service if a nurse needs new orders or to notify a physician about any change in patient status
    • Patient Transfers All patients considered for transfer from Olive View-UCLA must be reviewed and evaluated by the ED attending physician. For pediatric patients, the pediatric attending physician on-call should be notified prior to patient transfer.

Admissions from the Clinic, How to

  • Clinic staff places order for "UR Consult"
  • Once UR approves admission through Interqual, UR will contact PFS for a new FIN number to be created
  • UR will then fax admission info and new FIN number to Bed Control
  • Bed Control then contacts clinic staff to give them the new FIN number so admission orders can be placed
  • Clinic staff or inpatient team must write Admission Orders in order for Bed Control to secure a bed
  • For admissions to Obs Unit, clinic staff should contact Hospitalist on-call

Follow Up Guidelines

Future OVMC Clinic Appointments already scheduled

  • Future OVMC appointments can be found on the Patient Summary (Discharge Instructions). Click Depart. Page that appears is the Patient Summary. Scroll down to Future Appointments.

Future outpatient studies ordered by the ED

  • When you order a future outpatient study, it will automatically print on the Patient Summary (discharge instructions)
  • Phone numbers for Radiology, Cardiology Lab, Neurology Lab and TFU automatically print out on the Patient Summary (discharge instructions)
  • Patients MUST call to schedule their own outpatient study. Patient should then call TFU afterwards to get the results of the study
  • Outpatient CTs, ultrasounds and MRIs are generally booked 4-6 weeks out. PLEASE do NOT tell the patient to schedule the appointment within a few days
  • If you think the patient needs the outpatient radiology appointment sooner, you will need to get overbook approval from Radiology during business hours and type the name of the approving Radiologist in the future order radiology request in Cerner. Obviously this is going to be harder to do overnight or on weekend shifts.

OOP (Out of Plan)

  • Orange OOP on Tracking Board indicates out of plan insurance. Patient should be referred back to their health plan and PCP.
  • Info on health plan and PCP found on Patient Summary (Discharge Instructions), Demographics and Utilization Review tabs.
  • Do not refer OOP patients to subspecialty care at OVMC
  • OOP Health Plan and/or clinic name will print automatically on the Patient Summary (Discharge Instructions).

DHS Empaneled

  • To find out if a patient is empaneled to DHS, look at the banner bar on the patient's chart. Look right hand side "Emp Prov". Name of PCP will be written there.
  • If empaneled, DHS or community clinic name can be found listed under Additional Patient Information on ED Summary page.

MHLA (My Health LA)

  • Indicated by green MHLA icon on tracking board
  • Not an insurance plan but gives patient access to primary care clinic and provider (PCP)
  • MHLA patients receive all SPECIALTY care at OVMC or other DHS facilities
  • OK to refer MHLA patients to subspecialty care at OVMC either through Message Pool or econsult.

NERF (New Empanelment Referral Form)

  • Used to enroll patients with significant PMH who have no primary care or health plan
  • Patient must have at least one of a specific list of diagnoses
  • Only about 1/3 of patients will actually receive a PCP through the NERF process. Because of that, give patient a clinic list upon discharge so he/she can find a PMD on their own.
  • To enroll in NERF program, click NERF while completing Depart process. Check off diagnoses that apply. Click green arrow. Clerk will complete on-line NERF form.

TFU (Telephone Follow Up)

  • 818-364-4825 (staffed only 2 days per week)
  • Used for follow-up of culture or GC/chlamydia results and for patients to call for outpatient Radiology imaging results
  • To refer to TFU, click ED Post Visit Plan while completing Depart process, choose ED-TFU-OVM and indicate what needs to be followed up
  • Ensure we have a correct phone number on the patient
  • If patient has already been discharged from the ED and you want to refer to TFU
    • Step 1: Find patient on the Look Up track (only good for 7 days after discharge)
    • Step 2: Choose patient on the Look Up track, click Modify Events.....Request Event......Post Visit ED TFU
    • Step 3: Open patient's chart......Depart.....now fill out ED Post Visit Plan form
    • If you do not follow these steps, TFU will not be flagged to follow-up the patient

CCC (Continuing Care Clinic)

  • ED Followup Clinic used for complicated patients without primary care or an outside health plan
  • Guidelines for CCC: Urgent follow-up of potentially serious internal medicine conditions that might otherwise require hospital admission, ED return visits, or extensive ED workup. The clinic is for patients without any other primary care resource; patients who have insurance and/or an established primary care clinic should be referred back there for follow-up of such conditions. *Consults sent to CCC will be reviewed within a few days by the NP who staffs the clinic; patients who have insurance or who do not meet the referral criteria listed below will not be seen in CCC; they will be referred on for routine primary care.
  • Our DEM TFU program can also refer patients to CCC, so if a test is pending to determine whether a patient meets criteria, please do not generate a CCC referral; the TFU program can review the test and refer to CCC if appropriate.
  • The CCC clinic can coordinate work-ups for possible malignancies including ordering additional outpatient imaging and biopsies.
    • Step 1: Please do not skip this step! Ensure that patient does not have established HMO insurance, other primary care. Do NOT send DHS Empaneled or OOP patients (see DHS Empaneled and OOP).
    • Step 2: Click ED Post Visit Plan while completing Depart process, choose ED-CCC-OVM
    • Step 3: Indicate condition requiring urgent CCC visit:
      • Suspected new or recurrent neoplastic disease
      • Acute medical condition potentially requiring inpatient admission if not followed up promptly
      • Diabetes out of control (Glucose >500, requiring initiation of insulin therapy, or new end-organ dz.)
      • Severe hypertension (>160/100 at time of ED discharge, new end-organ dz., or refractory to tx.)
      • Suspected new significant auto-immune disease (SLE, RA, scleroderma, IBD, vasculitis)
      • Complex or undefined infections requiring further evaluation (FUO, osteo, colitis, fungal/parasite, HIV)
      • Acute pulmonary disease or exacerbation requiring systemic steroids or antibiotics
      • Potentially serious lab or imaging findings (anemia, hepatitis, renal insuff., hyperCa++, incidentalomas)
      • Endocrine disease requiring advanced workup (hyperthyroidism, thyroid masses, pituitary/adrenal dz)
      • New congestive heart failure, arrhythmia, or structural cardiac disease not requiring admission
      • Decompensated liver disease requiring diuretics, paracentesis, or workup for occult etiology
      • New or recurrent deep venous thrombosis or other condition requiring anticoagulation
  • If you have questions about a consult, or wish to discuss a case during regular business hours, contact Dennis Chamling, NP, via the Department of Medicine or by pager on the amion.com internal medicine website. (password ov_im)

Urgent Referrals for Subspecialty Care/Message Pools

  • Used to refer patients to certain subspecialty clinics for URGENT follow-up appts (<2 weeks)
  • Do NOT refer OOP patients or non-urgent complaints through the Message Pool
  • For ENT and Ophtho patients, page the on-call resident for approval for the urgent follow-up appt. Type in the approving resident's name and the follow-up date/time agreed upon. Tell patient to show up at 10am to the clinic.
  • Current Clinics with Message Pools:
    • OVM Coumadin ED/UC Urgent Follow Up
    • OVM Hand Surgery ED/UC Urgent Follow Up
    • OVM Gyn Aftercare ED/UC Urgent Follow Up
    • OVM Ophthalmology ED/UC Urgent Follow Up
    • OVM Orthopedics ED/UC Urgent Follow Up
    • OVM Otolaryngology (ENT) ED/UC Urgent Follow Up
    • OVM Pediatrics ED/UC Urgent Follow Up
    • OVM Peds Ortho ED/UC Urgent Follow Up
    • OVM Plastic Surgery ED/UC Urgent Follow Up
    • OVM Podiatry ED/UC Urgent Follow Up
  • Note: USC Peds Ortho ED/UC Urgent Follow Up no longer exists

Econsult

  • All ED providers must send econsults using their own log-in username and password. Do not borrow usernames and passwords from other providers. Mistakes are sometimes made and it is impossible to then correct the mistake if providers are sharing log-ins.
  • Used to refer patients to subspecialty clinics for NON-URGENT follow-up appts. Not all referrals are approved. In fact, most from the ED are denied. If approved, appts are likely several months away.
  • Do NOT send econsults on OOP patients
  • Do NOT send econsults on DHS empaneled patients. These patients should be referred back to their primary care doctor.
  • For General Surgery gallbladders and hernia referrals, fill out the Cholecystectomy/Hernia form. Patient must be non-smoker with BMI <35
  • Do NOT refer the following:
    • Derm - simple skin conditions (must be SEVERE or worrisome for cancer)
    • GI - diverticulitis, undiagnosed abdominal pain, gastritis without minimum of 3 months of PPI or h.pylori treatment
    • Neuro - simple seizures, headaches

Cardiology

Code STEMI

  • Definite STEMI on EKG and appropriate patient - ACTIVATE Cath Lab per protocol below
  • Probable STEMI or complex patient - CONSULT Cardiology (digital FAX 310-496-0160)
Oliveview UCLA Medical Center Providence Holy Cross
Mon-Fri 7am-5pm Nights, weekends, holidays
Page Code STEMI via Cerner Consults- Auto Paging (pager 818-226-4502) Verbally concept patient for transfer
Verbally consent patient and family for PCI Fax the EKG to Holy Cross: 818-496-4495
Goal: <30 mins in ED Call 818-496-7700 (or 7704) for Patient Placement Center to start the Code STEMI transfer
***Speak with ED physician at Holy Cross to review the faxed EKG
***Chart accepting MD name
For updates, call ED direct 818-496-1270
Call LAFD 213-847-5340 (or 5360) for Code STEMI transfer
***Emergency STEMI transfers ONLY
ED Clerk to fax patient registration info to 818-496-7707
Goal: <45 mins in ED before transfer
  • DEFIBRILLATOR DEVICE AT PATIENT BEDSIDE FOR ALL STEMI's
    • ED: Zoll pads package at bedside (apply only if unstable)
    • OVMC Cath Lab: Cardiology will bring & apply radiolucent Zoll Pads
    • Transfers: LAFD uses Physio monitor. Pads applied PRN arrhythmia.
Primary Medications Optional Medications Nursing Duties
Aspirin 325mg P.O. Nitroglycerin (SL or patch) Undress patient
Heparin 5,000 U bolus IV Morphine IV Two saline locks
Defer 2nd anti-platelet drug to cardiology's choice Ativan IV Hang one bag saline, slow drip
AVOID intravenous drips At OVMC, ED nurse goes with patient to Cath Lab and brings Code Blue kit
For transfers to Holy Cross: call report to 818-496-1270
  • Plan B Transfer to Northridge
    • Rare event of Holy Cross closure or 2 simultaneous STEMI, fax EKG to 818-885-3590 and then call Northridge ED charge nurse at 818-885-5396

Dental

  • No services available at OVMC
  • Refer patients without insurance to XXX

Dermatology

Dermatology Clinic Referral Guidelines

  • ONLY refer patients through econsult with SEVERE skin disorder or concern for skin cancer

Gastroenterology

GI Clinic Referral Guidelines

  • Abdominal pain – do not refer chronic abdominal pain of unclear etiology to GI
  • Abnormal imaging
    • If radiology reading is clearly suspicious for malignancy, refer to GI
    • Do not refer patients with studies that “cannot rule out”, “includes possibility of”, etc.
    • Do not refer patients simply because radiology wrote “endoscopy is recommended” on final read. Send patient to PMD or CCC for further interpretation of study results or further imaging
  • Anemia - Refer ONLY iron deficiency anemia; send Fe, TIBC, Ferritin; refer to TFU who will place e-consult if labs show iron deficiency
  • Barrett’s Esophagus – refer only if documented pathology report can be attached to e-consult
  • BRBPR
    • If patient is anemic, refer to GI
    • If patient is > 40yo, refer to GI
    • If patient is < 40yo, Anusol-HC supp qhs x 14 days. Symptoms persist? Follow-up PMD or have pt call TFU for GI referral
    • Do not refer if bloody diarrhea
  • Cirrhosis – Refer ONLY for banding of esophageal varices
  • Constipation – treat with osmotic laxative (e.g. sorbitol/miralax/prune juice) and send TSH if applicable
    • If severe (<1 BM per week) or rapid onset, refer to GI
  • Diarrhea
    • Will only see chronic non-infectious diarrhea >8 weeks; send C&S, O&P, C.diff, WBC; refer to TFU who will place e-consult if stool studies negative
  • Diverticulitis – do NOT refer to GI; Pt must be asymptomatic for 2 months before GI will consider colonoscopy
  • Dysphagia
    • If problem is high in throat region, refer to ENT instead If patient does not have weight loss, send barium swallow
    • If patient has weight loss or severe dysphagia, refer to GI
  • Dyspepsia (i.e. upper GI pain/epig pain >3 months)
    • If patient is > 55yo OR has worrisome symptoms, e.g., weight loss, refer to GI
    • If patient is < 55yo, order H. pylori test; refer to TFU who will treat with antibiotics if positive
    • If H.pylori test is negative or antibiotic trial fails, try PPI BID for at least 2 months. If that fails, refer to GI for evaluation
  • Family history of colon cancer (must be first-degree relative – mom,dad, sister, brother, child)
    • If only one relative, must be < 60 at age of diagnosis or if two or more relatives, age of diagnosis is not important
    • If patient fulfills above criteria and is either older than 40 or 10 years younger than the age of the relative at diagnosis (whichever is earlier), refer to GI
    • Otherwise, refer to primary care for fecal occult blood testing.
  • GERD (e.g. burning epig/chest pain with acid taste)
    • Do NOT refer to GI – pt must be on maximal therapy x 2months AND have lifestyle changes
    • If patient is not on maximum PPI therapy, change to or increase PPI to BID. Ex: Omeprazole 20 mg BID.
  • Hepatitis C - Do NOT refer to GI – treatment reserved for compensated cirrhotics; send to primary care
  • Inflammatory Bowel Disease
    • If urgent referral needed (moderate flare symptoms), call GI Fellow/Attending on-call; otherwise refer to PMD
  • Irritable Bowel Syndrome
    • Only if associated with worrisome symptoms (sudden onset at late age, weight loss), refer to GI
  • Occult positive stool only – do not refer from the ED
    • Pt must be >50yo, <50 BMI, AND have CLIA-approved lab occult-positive test NOT from ED to be referred
  • Polyps – Do NOT refer to GI unless you can attach endoscopy and pathology reports Ulcer – refer only GASTRIC ulcers that are >5mm; do NOT refer duodenal ulcers
    • If concern for malignancy based on outside endocscopy results, call GI for Urgent Consult
  • Urgent Consults
    • Communicate with on-call GI Fellow/Attending AND place e-consult; Note fellow on call CANNOT overbook a clinic visit

Infectious Disease

Reportable Diseases and How To

  • HIV - if HIV diagnosed at OVMC in our lab, then OVMC ID will take care of reporting positive HIV to LA County Health Department. Not emergency to report. ED does not have to report.

PICC Lines

  • Patients may present with a PICC line in place requesting continued IV antibiotics for an infectious process. Arrangement for on-going antibiotics can only be arranged Monday - Friday (I'm checking this)
    • Step 1: XXXX
    • Step 2: XXXX
    • Step 3: XXXX

Neurology

Matt's Reminders

  • Please call neurology for ANY questions regarding the management of stroke patients
  • All CVAs with symptoms within 8 hours should be discussed with neurology
  • For acute CVAs within a 5 hour window the imaging of choice is CT angiography head with and without contrast
  • Admit TIAs to medicine: we don’t send them home
  • E-mail Matt with any difficult neurosurgery transfers or neurology issues. Matt's cell is posted in ED. Matt has direct contact with USC Neurosurg and is happy to help in the heat of battle

Code Stroke

  • Criteria: Potential new Code Stroke case with ≤8 hours since last know well time.
  • Code Stroke pager available through through AMION (818-226-4797)
    • NOTE: 1/5/2017 - Code Stroke through Consults-Auto Paging OVMC currently not working
  • Code Stroke Team:
    • Neurology Team
    • Stroke Fellow
    • ED pharmacist (M-F 8am-4pm)
  • Step 1: Page Code Stroke
    • If paging through AMION, include patient's name, MRUN, location/room number and last known well time
  • Step 2: Briefly discuss the case with the on-call Neurology Resident. Have the last known well time ready.
  • Step 3: Labs: CBC, BMP (including BUN and creatinine), LFTs, troponin, PT/PTT
  • Step 4: Chest x-ray
  • Step 5: EKG
  • Step 6: Brain imaging to be discussed with Neurology Resident and Stroke Fellow. Generally:
    • STAT Non-contrast CT head AND CT angiogram if there is no contraindication to contrast
  • Step 7: Prepare for STAT imaging. Neurology team will coordinate with Radiology to ascertain the most suitable mode and location of imaging, including determining if MRI would be more appropriate.
  • Step 8: Neurology Resident will come evaluate the patient. The Stroke Fellow will assist by phone/telemedicine unit until the Resident (who may be off campus) arrives.
  • Step 9: Stroke Fellow will handle transfer of any patient (e.g. to UCLA) requiring intra-arterial thrombolysis
    • If MRI is requested by Neurology after-hours and tech needs to be called in, see Radiology...MRI After Hours

Neuro Clinic Referral Guidelines

  • Stroke/TIA
    • TIA. In general, all patients who present with a history suggestive of TIA should be admitted for risk factor assessment. Due to the high immediate risk of ischemic stroke following a TIA and the inefficiencies of outpatient diagnostic testing, inpatient monitoring and assessment ensures comprehensive evaluation and the potential for timely intervention if indicated.
    • Hemorrhagic stroke. In the event of a parenchymal, subdural or subarachnoid hemorrhage, a transfer to LAC+USC should be arranged. The only exception is a parenchymal hemorrhage with symptoms already for more than 5 days, in which case admission to Olive View is permissible.
    • Ischemic Stroke. All ischemic stroke patients should be evaluated by the Neurology Service. The timing of consultation shall be determined by the duration of symptoms.
      • 0-3 hours: Consultation should occur in the Emergency Department to determine eligibility for intravenous tPA.
      • 3-6 hours: Consultation should occur in the Emergency Department to determine eligibility for possible transfer to UCLA for intra-arterial tPA.
      • 6-48 hours: Consultation should occur in the Emergency Department to help determine the appropriate level of care for admission.
      • 48-72 hours: Consultation may be sought after admission (unless symptoms have progressed in a stepwise pattern or if the patient has multiple increasing, stereotypic TIA symptoms, in which case consultation should occur in the Emergency Department). Patients should be admitted to the intermediate care unit or standard care telemetry ward for 24 hours of observation/monitoring.
      • >3 days: Consultation may be sought after admission. The level of care for admission is left to the discretion of the DEM attending.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • If old, check for MRA of neck or Doppler, echocardiogram, MRI brain
      • Labs: RPR, ESR, HbA1c, PT/PTT or INR, homocysteine level
  • Seizures
    • Patients with established epilepsy do not need consultation following a solitary seizure, if an obvious reason for the breakthrough exists (e.g., non-compliance with meds, concomitant illness). If the patient has had a 20% increase in seizure frequency in the recent past, then a request for an earlier appointment may be submitted if the patient’s scheduled visit to Neurology Clinic is >1 month into the future. Patients who have run out of anticonvulsant medication(s) may be given a supply to cover them until the next scheduled Neurology Clinic visit. If an appointment does not exist, then a 5-month supply should be given and a Request for Outpatient Consultation form submitted. If a patient has a stable seizure disorder (no seizures on anticonvulsant medication with the past half-year or more) there is no clinical necessity that the Neurology Service follow them. Medication may be refilled by Primary Care. Stable seizure patients who cannot obtain Primary Care can be most efficiently followed in one of Neurology’s Nurse Practitioner clinics.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • Anticonvulsant levels
      • EEG
      • Brain MRI
  • Headache
    • Patients with established migraine headache who have failed primary-care attempts at management may be referred to the Neurology Clinic. Patients given a new diagnosis of migraine by Primary Care, Medical Walk- In or the DEM, who have not yet had reasonable attempts at management (use of triptans and/or appropriate preventive medications) should be referred to Primary Care prior to seeking specialist care.
    • Studies to be obtained prior to Neurology Clinic consultation:
      • If DEM referral, the patient should be referred to Primary Care first. If referral from Primary Care, and headache of long duration (>1 year), documentation of prior management attempts.
      • Medication history
      • If patient > 50 years old, ESR
      • Documented neurology examination (to help determine the urgency of the referral).
      • If focal findings on neuro exam, neuroimaging results or at least a request submitted for MRI of brain.
  • Dizziness - In all cases of “dizziness”, Neurology is best equipped to help patients who exhibit vertigo and/or disequilibrium accompanied by focal neurological signs. Episodic light-headedness and chronic dizziness are generally better served by Primary Care, Cardiology, or Head and Neck Surgery.
  • Peripheral neuropathy
    • Studies to be obtained prior to Neuromuscular Clinic consultation:
      • If painful, medication history
      • Labs: B12, RPR, TSH, HbA1c, ESR, and consider SPEP, ANA
      • EMG/nerve conduction velocities if available
  • Muscle Disease
    • Studies to be obtained prior to Neuromuscular Clinic consultation:
      • Labs: CPK, ESR, TSH, ANA
      • EMG
  • Dementia
    • Studies to be obtained prior to Memory Disorders Clinic consultation:
      • Do not refer to General Neurology; refer to Memory Disorders Clinic
      • Labs: CBC, B12, TSH, RPR, MHA-TP, Ca, Na, ALT, AST, BUN, creatinine, homocysteine, RBS Vitamin D level, lipid panel
      • MRI of Brain with Dementia Protocol
  • Multiple Sclerosis
    • Studies to be obtained prior to Neurology Clinic consultation:
      • MRI brain and/or spinal cord with contrast if available
      • Labs: ANA, B12, RPR, Vit D level, ESR, SSA, SSB, consider HIV
      • LP if available, for oligoclonal bands, IgG, IgG synthesis, and routine protein glucose, cell counts, differential

OB-Gyn

Establishing care at OVMC for pregnant patients

  • Do not refer OOP patients; refer these back to their health plan
  • For uninsured patients, tell patient to go to Clinc D to request follow-up for pre-natal care, "PK" clinic
  • REMEMBER, use Message Pool for an urgent request for pregnant vag bleeds, rule out ectopics getting BHCG checks, etc

Orthopedics and Podiatry

  • Orthopedic Surgery and Podiatry share clinic space and communicate regarding complex lower extremity cases.

Ortho and Podiatry Clinic Referral Guidelines

OVMC Orthopedics OVMC Podiatry
Patients 16 years of age and older Majority of foot and ankle fractures are managed by podiatry (5th metatarsal fractures, ankle fractures).
High Energy ankle fractures such as a pilon fracture. Diabetic foot including osteomyelitis
Maisonneuve fractures involving the fibular head. Ankle sprains
Lisfranc fractures (tarso-matatasal injury). Plantar fasciitis
No acute soft tissue knee injury (non-fracture) greater than age 55.
No hip fractures)(Transfer out).
No compartment syndromes. (General Surgery)
No Open fractures(Transfer out)
Tibial plateau and knee fractures.
Upper extremity injuries proximal to mid-forearm. (Distal to forearm goes to Hand).
No septic arthritis involving history of arthroplasty (prosthetic joint).
Will operate on septic arthritis with fracture hardware (wires, plates).

OVMC Pediatric Orthopedics

  • Emergent Peds Ortho cases less than 16 years old, e.g. open fractures that require OR debridement, should be transferred out via the MAC for uninsured or to the patient's health plan whenever possible
  • All other pediatric orthopedic cases should be referred to OVM Peds Ortho via the Message Pool. All of these cases will be reviewed by Dr. Farrell and he will determine if the case should stay here at OVMC or be referred to Peds Ortho at USC
  • If the case needs referral to USC Peds Ortho, the Ortho clinic here at OVMC will handle the referral to USC

Pediatrics

  • Pediatric attending should be notified for any pediatric patient transferred out
  • Pediatric patients (non-OOP) can be told to return to the Pediatric Urgent Care clinic for follow-up issues
  • For any pediatric patient requiring follow up with a subspecialist (non-OOP), contact the Pediatric Attending on-call as needed for any questions regarding follow-up

Peds patients seen in ED

  • Peds Resident pager 818-313-1739 Also available through Cerner...Consults Auto Paging OVMC
  • Weekdays: 0830am-3:00pm Triage RN should contact Super Track or MSE Attending or NP to screen patient (ESI 3-5) as OK to go to Peds Clinic. MSE note should be completed. Parents are given map and walk over to Peds Clinic.
    • If patient is roomed in the ED, page Peds Resident
  • Weekdays: 7am-9pm, page the Peds Resident
  • Weekdays: 9pm-7am, call the Emerg Med Resident assigned to Peds
  • Overnights, Weekends, Holidays: Pediatric Resident and Emerg Med Resident will share patients
  • At 9pm every day and 0830am on Weekends and Holidays, Peds Resident and Emerg Med Resident should discuss how they want to share patients during the shift
  • DEM PROVIDERS SHOULD CALL PEDS EARLY for any pediatric patient that is likely to be admitted
  • For patients seen overnight, Pediatrics would like DEM providers to contact Peds in the morning and let them know about the patients that were seen

Psychiatry

  • x4340
  • For patients without medical complaints, medically screen patients at Triage or Ambulance Triage. If medically cleared, provider should call x4340 and speak to Psychiatry MD who should approve patient being sent over to the Psych ED
  • If patient is placed into an ED bed and needs emergent psychiatry, order Consult to Psychiatry and call x4340 to speak to Psychiatry MD.

Psych Urgent Care

  • Oliveview Community Mental Health Urgent Care Center
  • located down the street, 14659 Oliveview Drive
  • hours M-F 8am-7pm, Sat 9am-5:30pm, closed Sundays and holidays
  • Crisis stabilization 24/7

Radiology

On-Call and In-House Radiology Coverage Schedule

  • Operator has Radiology on-call schedule and pager numbers
  • Also posted on OVMC Website...Departments....Radiology....On-Call Schedules....Radiology Faculty Schedule Current Month

In House Coverage

  • M-F 6 pm-11 pm: STAT Radiology Attending in-house
  • Mon-Fri 11pm-7am: USC Teleradiology coverage 323-409-6679
  • Sat, Sun Holidays before 1pm: General Radiology Attending in-house
  • Sat, Sun, Holidays 1p-7 pm Sat: STAT Radiology Attending in-house
  • Sat, Sun and Holidays 7pm-7am: USC Teleradiology coverage 323-409-6679

USC Coverage for OVMC ED

  • Mon-Fri 11pm-7am
  • Sat/Sun and Holidays 7pm-7am
  • 323-409-6679

Over-Reads

  • Urgent or Emergent?
    • Radiology to call x3649 or x4938 and report to ED Attending
    • ED Attending shall document in the........TBD
  • Non-Urgent?
    • Radiology to email patient name, MRUN, date of study, and findings to Ari Orue NP at aorue@dhs.lacounty.gov

Plain Films and No Need for Pregnancy Tests

  • July 2016 - In a discussion with Dr. Patel from Radiology and Mike Ruiz, Sup Rad Tech, it was re-affirmed that women do NOT require a pregnancy test prior to plain film X-rays
  • Under protocol, Radiology techs will ask the patient if she is possibly pregnant and the date of her LMP period (should be within the last 4 weeks).
  • As per the American College off Radiology and the OVMC Dept of Radiology: If a patient can reliably answer that 1) she cannot be pregnant (for example, she is not sexually active, or she is using an effective form of birth control, or she is biologically incapable of conceiving) and that 2) she had a recent complete menstrual period, then it is reasonable to proceed with a medically indicated diagnostic X-ray test of the abdomen or pelvis. The last complete menstrual period should have occurred within the previous 4 weeks.
  • Prior to CT scans, a pregnancy test should be obtained as the amount of radiation is higher. If, however, the patient's medical condition could deteriorate and the CT scan is needed emergently (e.g. head CT for AMS), then a pregnancy test may not always be obtained prior to the scan.

Fluoroscopy

  • On rare occasion, fluoroscopy might be needed to reduce a fracture or fracture/dislocation
  • Fluoroscopy is available Mon-Fri 8am-4pm, call Main Radiology x4059
  • After hours, availability for fluoroscopy will depend upon hospital tech availability; talk to ED Radiology tech
  • Order in Cerner: RF Fluoroscopy Under 1 hour

Interventional Radiology After Hours

  • Intervential Radiology Available After Hours (Operator has Interventional Radiology on-call schedule. Also available on OVMC Intranet. See above under Radiology On-Call Schedule)
    • Percutaneous abscess drainage
    • Image-guided paracentesis
    • Image-guided thoracentesis
    • Percutaneous cholecystostomy
    • Percutaneous nephrostomy/nephroureteral stent placement and other urologic intervention as applicable
    • Transhepatic biliary drainage and other biliary intervention as applicable
    • Central venous access including placement of tunneled/non-tunneled catheter
    • IVC filter placement
    • Transarterial embolization for unremitting hemorrhage refractory to conventional therapy
    • IR Consultation
  • Interventional Radiology NOT Available After Hours (Only available Mon-Fri 8am-5pm)
    • No MSK procedures (e.g. no joint aspirations)
    • No LPs
    • No G/GJ tube replacement (if tube fell out, place foley temporarily)

MRI After Hours

  • MRI tech is in-house Mon-Fri 7am to midnight. All other hours are considered off-hours.
  • MRI tech is on-call for emergent cases limited to acute cord compression and rarely acute CVAs if requested by the Neuro Service for patient management (e.g. large CVA that may be considered for transfer to UCLA for intracerebral angio therapy)
  • Findings that suggest acute cord compression include:
    • 1. Bladder dysfunction (urinary retention or incontinence)
    • 2. Bilateral limb weakness
    • 3. Sensory abnormalities with a sensory level
    • 4. Flaccid areflexia with upgoing toes, loss of anal sphincter tone
  • Some cases may be able to wait until the morning hours such as IVDA, fever and back pain without neuro findings.
  • To request an emergent MRI when the tech is not here, first contact the STAT Radiologist in-house Mon-Fri until 11pm and weekends/holidays until 7pm. If there is no STAT Radiologist in-house (e.g. after 11pm), contact the Neuro Radiologist on standby (on-call).
    • On-call schedule can be found on OVMC Intranet...Departments...Radiology...Radiology Faculty Schedule Current Month.....Neuro/MRI Standby. Operator has on-call schedule also and pager #s.
    • If no STAT radiologist, ED MD pages the Neuro Radiologist on standby (on-call) and requests MRI.
  • STAT Radiologist or Neuro Radiology Attending then pages the MRI tech.
  • For cord compression cases, as much as possible, try to narrow down the level where the possible pathology lies e.g. lumbar vs thoracic. If this is not possible, a "cord compression" MRI protocol can be performed that will give a large field of view (sagittal images) that will cover the whole spine in two slabs (cervical through mid-thoracic and mid-thoracic through lumbar), along with axial T2 images through the whole spine. Will not give great detail, but will see gross cord compression or high grade lumbar spinal canal stenosis. Decision about what imaging is performed will be up to the Neuro radiologist on-call.

MRI for Large Patients

  • Weight limit at OVMC: 350lbs (same at Harbor and USC)
  • Radiology will help arrange an MRI at Downey for patients requiring emergent MRI who are too large for our MRI scanner

Barium/Air Enemas for Intussception Cases

  • Surgical resident on-call should be made aware of any pediatric patient who is considered to have a possibility of intussusception
  • Patient should have no contraindication to a barium or air enema such as evidence of peritonitis or perforation.
  • M-F Business Hours: Peds Radiologist Dr. Chawla usually performs the BEs/AEs
  • M-F 6 pm-11 pm: STAT Attendings will perform any BEs/AEs during their STAT shift
  • Sat, Sun Holidays before 1pm: General Radiology Attending is responsible
  • Sat, Sun, Holidays 1p-7 pm Sat: STAT attendings will perform any BEs/AEs during their STAT shift
  • M-F 11 pm- 7am and Sat, Sun, Holidays 7pm-7 am: General standby call is responsible for performing the BEs/AEs

Joint and Spine Injections

  • Dr. Raffi Salibian x5145
  • Dr. Catherine Yim x4082
  • Joints:
    • Order: X-ray plain view
    • Future Order: US aspirate/injection/biopsy (use Relevant History to indicate which joint)
    • CBC and Coags if patient is coagulopathic
  • Lumbar Spine (facets and epidurals):
    • Send Message Center message to Dr. Catherine Yim requesting lumbar spine injection with the name of the ED Attending requesting the procedure.
    • Future Order: MRI lumbar spine (Patient must call to schedule the MRI. Radiology phone # is pre-printed on ED Patient Summary/Discharge Instructions)
    • Future Order: IR facet inject lumbar (need kg weight)
    • CBC, Coags please
  • Radiology will contact the ED TFU Coordinator or Urgent Care TFU Coordinator through the Message Pool with any problems

Surgery

  • For surgical vs medicine admissions, see Surgical Subspecialty Admissions Guidelines under Admission Guidelines.
  • For ALL surgical transfers out, ED Attending needs to speak to Surgical Subspecialty Attending

Cardiothoracic Surgery

  • We have non-cardiac Cardiothoracic Surgery at OVMC. If you have a case, consult General Surgery who will consult with Cardiothoracic Fellow/Attending

Neurosurgery

  • See Transfers...Higher Level of Care....Neurosurgery

Vascular Surgery

  • Jan 2016 Vascular surgery being covered by several part-time vascular surgeons while full-time OVMC vascular surgeon is on maternity leave. Part-time folks have their own practices to cover during the week. At times, may need to transfer vascular patients out as we have more limited coverage during business hours.

Laboratory

Critical Lab Results on ED and Admitted Patients

  • Lab tech's tracking board in Cerner will indicate if patient is an ED patient or a boarder
  • If ED patient, ask lab tech what bed patient is in (easier to find)
  • If patient is admitted (boarder), lab tech should instead call the ED RN taking care of the patient and report the result. ED RN will then contact the admitting team.
  • ICU patients are jointly cared for by the ED and ICU providers and therefore ED can receive the lab results on ICU patients

Critical Lab Results on Discharged ED Patients

To be added

Instructions for Specific Lab Orders

Chlamydia/Neisseria gonorrhea RNA:

  • females - urine or cervical (not vaginal)
  • males - urine or urethral
  • urine - yellow tube, fluid level in between black lines
  • cervical/urethral - white swab to clean mucus, blue swab for specimen collection
  • don't use Rectal-SO or Throat-SO orderable unless you are specifically checking these sites

Pathology Tissue Request:

  • label prints as soon as the order is signed and cannot easily be printed again.
  • printed in MD room on label printer if ordered from computer in MD room
  • printed in patient room on label printer if ordered from computer in patient room

Peripheral Smear Exam by Lab: usually ordered by non Heme/Onc provider for review by lab tech

Peripheral Smear for Provider Pickup (Slide Wirght Giemsa): usually ordered in consultation with Heme/Onc for MD to personally review

Pharmacy

  • ED Pharmacist Mon-Fri 8am-4pm x5490

Physical Therapy and Orthotics

Orthopedic Equipment and Hernia Trusses

  • Crutches, walkers, canes – stored in ED1A clean utility room
  • Hard shoes, wrist braces, ankle splints - stored in Room #43
  • Hernia trusses – stored in Room #43
  • Other routine orthotics not stocked in EDM: lumbar corsets, etc
    • Order Orthotic Equipment in Cerner. Patient can call Valley Institute of Prosthetics and Orthotics 661-253-1191 to make arrangements to get the equipment.

Urgent Spinal Bracing - TLSO Brace, Miami J Collar, St. Jude Collar etc

  • Order Orthotic Equipment in Cerner under DME (Durable Medical Equipment)
  • Call VALLEY INSTITUTE OF PROSTHETICS AND ORTHOTICS (VIPO)
    • Cell phone: (661) 319-2777 Mike Nelson, CPO
      • Call 24/7 for URGENT spinal bracing otherwise wait until daytime hours
      • IPO headquarters (after hours): (800) 439-1005
  • If Mike Nelson cannot be reached, the following vendors can be tried (all have DHS contracts):
    • PERFORMANCE PROSTHETIC AND ORTHOTIC CENTER, INC (310) 829-2322 LERMAN AND SON (310) 659-2290
    • ALPHA ORTHOPEDIC APPLIANCE COMPANY, INC (323) 721-6706
    • HANGER PROSTHETICS & ORTHOTICS (562) 233-4481
    • DYNAMIC ORTHOTICS & PROSTHETICS, INC (213) 383-9212 ORTHO ENGINEERING, INC. (310) 559-5996
    • PRECISION ORTHOTICS & PROSTHETIC, INC. (213) 388-5847

Wheelchairs

  • two wheelchairs are kept in the ED1A Clean Utility room for weekend patients to avoid admissions, e.g. wheelchair-bound patients or patients requiring wheelchair for example bilateral ankle fractures
  • Alternative ordering process:
    • Order DME in Cerner- Do NOT order on OOP - must go to Health Plan for wheelchair
    • Order Physical Therapy Outpatient Future Order also in Cerner
    • Patient should be sent to Physical Therapy. Patient will be financially screened. If patient has no insurance to pay for wheelchair through DHS, patient/family will be given list of outside vendors to contact.

Physical Therapy Outpatient

  • Do NOT send OOP; refer patient to their health plan
  • Order as Physical Therapy Outpatient Future Order in Cerner
  • Patient should be told to go to Physical Therapy. Patient will be financially screened. If patient has no insurance, patient/family will be given list of outside physical therapy centers to contact.

For Emergency Calls After Hours

  • You may call Physical Therapy by having OVMC Operator use the Disaster Fan-Out list to reach Physical Therapy. Joann York will be the first one tried, then other staff within the Physical Therapy Dept.

Respiratory Therapy

BiPAP, Transporting patients upstairs on portable BiPAP

  • Often we have patients on BiPAP who need to be admitted upstairs.
  • RT currently has 3 BiPAP (V60) machines that have a battery backup so patients can be transported upstairs without turning off the BiPAP
  • Ideally, before placing a patient on BiPAP, we should tell RT that the patient is likely to be admitted so RT can place the patient on a BiPAP machine that has battery backup.
  • If the patient is already on BiPAP that does not have battery backup AND taking the patient off BiPAP would be detrimental to the patient, ask RT about switching the patient to a unit that has battery backup
  • If absolutely necessary, RT has the option to rent a BiPAP machine which can generally be here within 30-60mins.
  • RT Supervisor Jim Pratt is always available (RT is able to page him) if a question cannot be answered by RT

Home O2, How to obtain

  • Call Resp Therapy x4422
  • If already on oxygen and has moved to L.A., lost insurance, etc, will need to prove need for home O2. Get pulse ox on room air. Qualifies if O2 Sat less than 88% on room air.
  • Resp Therapy will bring a Durable Medical Equipment form that will need to be filled out by the ED provider
  • Resp Therapy will contact the company, fax over the form, and arrange for delivery
  • If patient has an outside health plan (OOP), UR may need to be involved for coordination of care

Social Work

Contacting Social Worker

  • Step 1: Place order for SW under Consult - No Auto Paging OVMC (SW does not yet have a 24/7 pager)
  • Step 2: Monday – Friday 8am – 4:30pm
    • 1. Pager 818-320-8499 or x5479 (Erica)
    • 2. If no answer, try x 4294 or x4295 Supervisors’ lines
    • 3. If no answer, try x4236 SW Office
  • OR After hours, 4:30pm – 8am or weekends or holidays, “crisis only” pager, 818-313-1637

Transporting patients home

  • For patients without ability to get home (e.g. brought in by EMS), and no family or friends to take them home, first option is to have patients wait in waiting room until bus resumes in morning.
  • SOCIAL WORKER DOES NOT HAVE BUS TOKENS
  • If more urgent transportation is necessary, County Trans can be used on a case-by-case basis to transport patient home. Patient must have a key to house/apartment. County Trans will not transport to shelters.

Transfers

Higher Level of Care Transfers

  • Patients who require services that OVMC does not offer may need to be transferred out (e.g. neurosurgery, some emergent orthopedic cases).
  • For OOP patients who are clinically stable, every attempt should be made to transfer the patient to their health plan.
  • For uninsured or DHS-empaneled patients, transfer will occur through the MAC.
  • Transfers from the ED via the MAC fall into two categories. This is based on existing DHS policy:
    • (1) Emergent/Urgent e.g. intubated intracranial bleed. MAC will ask minimal questions in order to get transportation to OVMC as quickly as possible. CMO on-call (ask Operator)should be notified regarding emergent transfer. Emergent/Urgent patients cannot be refused by Harbor or USC and may end up being transferred to their ED if no inpatient beds are available. Emergent/Urgent transfers should be used on a rare basis for those patients who need to move RIGHT NOW aka emergently.
    • (2) Non-Urgent e.g. open tib/fib fracture or hip fracture. MAC will ask more detailed questions. Patients will be presented to appropriate service at USC or Harbor. Transportation will be arranged after patient has been accepted.
    • Remember both USC and Harbor have DHS Cerner and have access to our ED records and imaging
    • MAC will NOT transfer to private hospitals such as transfer of neuro patient to UCLA for intracerebral thrombolysis (exception burn cases) or pediatric patient who is followed by UCLA sub specialist at the OVMC clinics. Transportation of those patients must be arranged by the private hospital or OVMC UR.

BLS vs ALS vs Critical Care vs Helicopters

  • BLS is staffed by EMTs, limited abilities, can administer oxygen; cannot push meds and cannot have any hanging IV drips
  • ALS is staffed by paramedics, can take intubated patients, CANNOT take patients with ANY type of IV drip (no heparin, mannitol, norepi, etc) even if those drips are not titratable. Drips must be shut off. ETA variable.
  • Critical care is staffed by paramedics plus Critical Care RN and/or MD, can take intubated patients with IV drips. Often ETA of critical care team arrival 4-5 hours away.
  • Helicopter is staffed by paramedics +/- critical care RN, can take intubated patients with IV drips. Dependent upon weather. ETA variable.
  • For critically ill or injured patients on a drip that cannot be turned off, if critical care team's ETA is too long, consider sending OVMC ED RN, MD and/or RT as needed in ambulance. Arrange head of time for same ambulance to bring staff back to OVMC.

Pediatrics

  • The Pediatric attending on-call should be made aware of any higher level of care transfer out
  • For OOP pediatric patients, UR should attempt to transfer the patient to the hospital requested by the health plan
  • For uninsured patients, not currently followed by a pediatric sub-specialist, attempts should be made to transfer to USC or Harbor via the MAC
  • Patients followed by UCLA Pediatric subspecialties at OVMC may be transferred to UCLA if accepted by UCLA Pediatrics or subspecialist.
    • OVMC Pediatric resident will contact UCLA inpatient staff or subspecialty service about transfer with approval by the Pediatric attending on-call
    • Once accepted, transportation will depend upon the type of transfer: PICU transfers may transported by the UCLA Transport team; Ward transfers to UCLA will need to have transportation arranged by OVMC ED UR staff.
    • MAC WILL NOT ARRANGE TRANSPORTATION TO UCLA

Surgical and surgical subspecialties

  • For all surgical and surgical subspecialties being transferred out for "higher level of care", please contact the Attending of that service prior to transfer out. ED Attending should speak to Surgical Attending to ensure we do not have the ability to care for the patient here at OVMC

Neurosurgery

  • TO BE ADDED

Utilization Review

  • x4890
  • UR can be used to connect OOP patients with their primary care or subspecialty care if urgent follow-up after ED visit is required.

ED Ultrasound

Transvaginal Ultrasound

ED Supplies and Equipment

Clerk ED1A Cabinet

  • Alligator Forceps
  • Bolt Cutter
  • Doppler
  • Dremel
  • EZ-IO
  • Hair Remover
  • Panoptic
  • Ring Cutter
  • Rongeur
  • Stryker
  • Tonopen

*MUST LEAVE BADGE FOR ANY EQUIPMENT REMOVED FROM CLERK CABINET

ED1A MD Room

  • Ultrasound Supplies
    • Gel
    • Probe covers
  • Angiocaths 3inch
  • Headlamp

Airway Cart in PR Room

  • CO2 detectors, ETT
  • CO2 detectors, nasal
  • Nasal Atomizers
  • Trach Atomizers
  • Endotracheal Tubes
  • LMAs

ENT Cart in Room 31

  • OPHTHO
    • pH paper taped to pH folder on top of cart
  • OROPHARYNGEAL
  • NASAL
    • Nasal compression device for nose bleeds
    • Nasal speculum
    • Merocel
    • Surgicel 2" x 3"
    • Silver nitrate sticks
    • Rhino Rocket Slimline - small, medium, large
    • Rapid Rhino 5.5cm Rapid Pac
    • Rapid Rhino 7.5cm Ant/Posterior with Airway
    • Vaseline Petroleum Gauze Strip 1" x 36"
    • Denver Nasal Splint
  • Wood's Lamp bottom drawer

Suture Cart

Ortho Cart

Gyn Cart

Central Line Cart in ED 1A/B hallway

Orthopedic supplies in Room 43

  • Soft collars, slings, wrist guards, CAM walkers, hard shoes

Crutches, Walkers, Wheelchairs

  • Located in ED1A/B Clean Utility Room

Bronchoscope

  • Located in storage room near Triage 4. Disposable scopes in cabinet in same room.

Glidescope

  • Located in PR Room - pediatric and adult batons available
  • Disposable blades located in Glidescope basket
  • Extra blades located in cabinets in PR Room
  • Wipe down batons after each use

Downtime Protocols

  • ED1A Clerk has all downtime forms, lab slips and Radiology Request forms.
  • New patients registered during downtime will have H&P's completed using the XXXX form
  • Nursing documentation will occur on the XXXX form
  • Orders for medications, labs or imaging during downtime will be ordered using XXXXX form. Clerks will fill out the individual laboratory slips and Radiology Request form based on the provider requests. Laboratory forms will then be taken to the nurse where the patient is located. Radiology Requests will go with the patient to Radiology.
  • When Cerner is back up, Pharmacy will manually enter all medications ordered during downtime.
  • Radiology requests ordered during downtime using the Radiology Request forms do NOT need to be re-entered into Cerner.
  • Certain orders such as Admission Orders may need to be re-entered into Cerner once Cerner is back up.

Links

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