Harbor:RME Manual

RME Provider Manual

Patient Flow

• Quick team huddle at beginning of shift
  • Physician, NP's, RME charge, LVN
  • Determine team roles (who will primarily screen/discharge)
  • Write names with spectralink numbers on the whiteboard (there are 4 phones!)

• Patient presents at router desk for check-in

1. Quick registration occurs
2. Called to Triage 1 by NA for full set of vitals
3. Patient then called to Triage 2-5 for provider MSE concurrent with RN triage
   1. Limit of one family member with patient
   2. After intake interview, family member may be asked to go back to WR as limited space in tasking area
4. Patient then goes to RME 4-6 for tasking (phlebotomy, medications, transport to radiology)
   1. If tasking rooms are at capacity, patient goes back to WR and LVN's will call the patient back in for tasking

• Triage Priority is to provide MSE to all patients presenting to the ED

1. Patients who appear ill or have unstable vitals should be seen immediately
   1. Critical patients straight to the back; immediate verbal notification to green or purple teams senior or attending
2. Chest Pain (door to ECG <10 min)
   1. To “review” the ECG: Double click eyeglasses, write “NO STEMI Activation”, and click “ED review and close”
   2. NP may review if read is “Normal Sinus” otherwise the physician needs to review in ORCHID
3. Focal neuro deficit (door to eval <10 min, door to code stroke activation <15 min)
4. ESI 2 then 3
5. ESI 4 & 5 based on overall length of stay
6. Once all the patients that have been triaged have had a MSE exam initiated, continue performing MSE on patients in WR who have not yet been triaged
   1. RME Provider may concurrently see patient with NA in Triage 1 if triage RN's are backed up
   2. If pulling patients in from WR, assign to appropriate MSE room on the tracking board so Triage RN knows where patient is if they call the patient during your screening exam
   3. Once MSE initiated and orders placed, patient should go back to WR until called in by Triage nurse UNLESS:
   4. DO NOT assign an ESI number to patients who have not yet been triaged so the Triage nurses know who still needs the nursing triage task performed

• If door to MSE is >30 minutes, NP to assist with screening; if >90 min, second NP to assist with MSE until <60 min wait time

1. Many of the ESI 4 & 5 Patients may be seen and discharged concurrently
   1. If additional workup is needed on these patients, place orders and they should be placed in rooms 7 & 8 for the Fast Track NP/resident

• Fast Track Priority:

1. Simple discharges in independent scope
2. Patients with completed workups and likely discharge home
3. Any other completed workups with high probability of Gold/CORE or admission; once this decision is made, patient needs to be kept in internal WR (RME 7, 8, or 12)

• Communicate with RME charge for patient flow - they will find a bed for critical patients

• Registration: x2075, 2076

Process Improvement

• Router Desk: RN directs traffic to 2 clerks, 1 for adult, 1 for peds/visitor/info
  • 3 separate lines - adult, peds, visitors/info (send to spine visitor desk if note ED patient during regular visiting hours)
  • RN designates CC and HIGH, routine, or CARDIAC (add STROKE???)
    • Cardiac goes straight back to 11 for ECG; triage team goes to 11 to see the patient ... need to follow current process
    • Stroke goes to next triage for immediate assessment

• Patient goes to triage queue (designated seating - hard chairs from far side of WR or orange ones from peds WR)

• Team Triage (double coverage 9a-9p ... target D2 Triage 15 min)
  • RN gets VS during Doc interview (3 min)
  • Doc Scripting: I'm Dr. Chappell, one of the physicians in triage. This is Aurora, the triage nurse working with me today. We are going to ask a few questions to get your workup started.
    • CC, focused HPI, med history, allergies, focused physical exam
  • Doc places orders and writes MSE note while RN completes triage
  • limit POCT in triage - do in tasking unless urgent

• • Triage Note
    • Extended reason for visit: CC and <10 work HPI (ie, pleuritic CP x 3 days)
    • weight - patient stated or estimated - 2 fields
    • Temp, HR, RR, O2, BP - 6 fields
    • Pain assessment - 1 click
    • RIPT - 15 questions/clicks
    • Abuse/violence - 1 click
    • LMP - 1 field
    • Risks
      • Suicide: 2 clicks
      • Falls: typically 1-2 clicks
      • Abuse/violence
    • ??? Histories → social → smoking???
    • Triage Treatments: hard c-collar, dressing, ice, heat, POCT, other
      • need close central location for these items - not running to central supply!
    • ESI - 2 clicks unless using calculator; more appropriate level given direct physician input

• NA to assist with reassessment, filling triage queue, moving patients to XR

• Tasking: Scripting - we are going to move you to the next treatment area to get your lab work and medications
  • need phlebotomy 7a to 10p
    • consider using IA from lab or RN
  • LVN or RN x 2 7a to MN
  • ECG tech - for 10 min ECG
• Radiology
  • Take patients to XR WR - tech checks q15-30 min, afterward takes back to AWR
  • CT: we call when ready to take patient
  • US: Jeremy to discuss inconsistencies with Candy - in ED vs radiology

• AWR (ideally designate as results waiting area)

• Provider D/C vs RME charge

• Clerk
• RME Charge RN - for IV pushes, communicate with AED charge and router
• Reassessment RN - repeat VS, pain score, and give meds (do not take back to tasking)
• Martee: look at router process, review compliance with CP policy
  • Triage Process workgroup: Brad, Regina, Martee, triage RN (Aurora?), LVN, ECG tech, +/- radiology
• Jeremy: what is required for meaningful use for tobacco; med rec on ESI 1-3 with secondary triage, review and acknowledge for ESI 4-5? Linda (lab) - can we use IA employees?
  • Susana Su - med rec should be done but can be in secondary triage
• Brad: review CP policy
• Wilson: D2ECG #'s, Susan (USC) to reorganize triage note
• Metric Goals
  • Door to Triage 15 min
  • D2Doc 25 min
  • LWBS <3%
  • LWTC <7%
  • Decrease dispo to discharge times (provider discharge?)
• How to address the boarding issue
  • Fully staff Gold/Upstairs Gold Overflow
  • Admitted patients to floor hallways (round robin)
• Secondary Triage for ESI 1-3
  • Home meds
  • medical, surgical, social history
• Secondary triage for ESI 4-5
  • Tobacco for meaningless use
• slow transfer outs for OOP
• PCU and ICU at 90% capacity, ward can flex staffing ratios

Patient Screening Process

• Optimal flow is to concurrently see the patients with the triage nurses (move between rooms)
• Once the patient is seen:
  • Click MSE Note:
    • "screening provider" unless you are dispositioning the patient from RME (then "definitive provider")
    • "stable to wait" or "needs room now"
    • Place orders that need to be done now (labs, imaging, medications); do NOT order things such as cardiac monitor, IVF, etc unless it needs to be performed immediately
    • If patient needs IV simply for contrast for imaging, they will need to be placed in room 12 until the test is completed and patient either has a room assigned or IV can be removed
  • On tracking board, label patient as:
    • RME/AWR (to be dispositioned by express provider, stable for WR)
    • RME/8 (simple discharge with no additional resources needed (med refill, clinic follow upp)
    • AED/AWR (dispo per AED team but stable for WR)
    • AED/12 (next back or needs intervention requiring monitoring (IV, antibiotics, etc) - verbally notify RME Charge RN of your concern
• Scripting
  • Seeing provider in triage to expedite workup and make you feel better sooner
  • We will start your workup and you will see one of my partners in the main ED

RME Phones

• RME Charge x23930
• Martee x23973
• Chappell x23203
• MSE Resident x23208
• MSE NP x23209
• FT Resident x23210
• FT NP x23220
• FT NP #2 x23220
• Extra x23213

NP Independent Workup Guidelines

• Nurse practitioners may independently order any imaging study listed below. Other studies not listed require physician consultation prior to test being ordered.
  • Standard X-rays, keeping in mind evaluation of joints above and below for concomitant injury
  • Non-contrast CT of the brain for symptoms of “sudden onset” headache or “worst headache of life”
    • consider CTA Brain for aneurysm if patient is unwilling to have lumbar puncture (discuss CTA with attending)
  • Non-contrast CT of the brain for patients who have minor head trauma following ACEP Clinical Policy Statement:
    • Loss of consciousness or post-traumatic amnesia PLUS one of the following
      • Headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication)
    • Consider if no loss of consciousness but presence of:
      • focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
  • CT brain with IV contrast – for patients being evaluated for mass/tumor or those with HIV and new onset headache
  • Non-contrast CT of cervical spine if any of the NEXUS criteria is present:
    • Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
  • Non-contrast CT of the abdomen/pelvis for patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
    • If previous CT confirms stone, consider renal ultrasound to evaluate for hydronephrosis or pyelonephritis
  • Limited Right upper quadrant ultrasound for patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
  • Abdominal ultrasound for patients with high suspicion for first episode of pancreatitis
  • Pelvic ultrasound for patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding.
  • Risk Stratification for DVT
    • Well’s Criteria: Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous DVT(+1), and alternative diagnosis as likely (-2)
      • If low-risk Well’s (score of 0-1), order d-dimer
      • If score greater than 1, order formal (not bedside) Lower Extremity Doppler US
  • Risk Stratification for PE
    • If low pre-test probability and PERC negative, no further testing for PE necessary
      • PERC measures: Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks
    • If patient falls out of PERC, then apply Well’s criteria:
      • Clinical signs and symptoms of DVT(+3), PE #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
        • If score <2, order d-dimer
        • If Score 2 or greater, CTA or VQ scan (if contra-indication to CTA)
        • If pregnant, discuss with attending
  • Chest Pain: NP should obtain a brief history on any patient with signs or symptoms of cardiac ischemia or with ECG read that is not “normal sinus rhythm” then present the ECG to the Attending

Being Seen by Consultants Prior to ED Evaluation

• ED Policy 3.3
  • A consultant may request from RME/AED attending or senior resident to see or take a patient to clinic
  • Once the specialty evaluation is completed, documentation of both exam and assessment/plan should be in ORCHID and communicated to the ED provider
  • ED to disposition the patient after evaluating for any other needs (full chart)
• Alternately, if the patient has already been evaluated in the ED and found to have an isolated problem that is best cared for by the consulting specialist, care of the patient should be transferred from the ED to the specialist who should discharge them from clinic unless there are extenuating circumstances

NP Consultation Guidelines

• Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult

1. If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.
2. If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and α-page the consult service.

• Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending
  • If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation

NP Independent Discharge Guidelines

NPs may independently discharge patients whose complaints are limited to the following and only if they feel physician consultation is not warranted: • Allergic reactions (without signs of anaphylaxis) • Asthma exacerbation that responds to Albuterol, not immune compromised • Bell’s Palsy with complete unilateral facial paralysis and no other focal neurological deficits • Breast Complaints • Superficial (1st) and Partial Thickness (2nd) Burns which do not meet Burn Center Referral Criteria (3rd degree, 2nd degree with greater than 10% total body surface area, burns of eyes, face, hands, feet, perineum, electrical injuries, inhalation injuries) • Chest pain (low risk – HEART Score <4, age < 30, no syncope/shortness of breath, no drugs, no significant family history of early cardiac disease or sudden death, no tachycardia, normal ECG without arrhythmia) • Conjunctivitis • Constipation without signs of obstruction • Dental Complaints • Dizziness consistent with Peripheral Vertigo (normal HiNTS exam, no cerebellar findings) • Ear, Nose and Throat (no angioedema, drooling, phonation changes, or stridor) • Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin) • Genitourinary, minor complaints (male and female, no torsion) • Gynecological, minor complaints (not pregnant, no active bleed, hemoglobin >8) • Hemorrhoids • Hyperglycemia (asymptomatic, no DKA/HHS) • Hypertension (asymptomatic) • Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury) • Low back pain without associated fever or neurologic deficits • Medication Refill • Minor head or facial trauma • Musculoskeletal injuries/musculoskeletal pain • Nausea and vomiting without significant abdominal pain • Ocular complaints (no significant acute decreased vision, no trauma) • Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can overbook into orthopedic fracture clinic): o Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks o Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week o Humerus:  Proximal: non-displaced; sling, ortho in 1 week  Shaft: non-displaced; sugar tong/sling, ortho 1 week o Radius:  Non-displaced distal or shaft; volar splint, ortho 2 weeks  Non-displaced head with good ROM: sling, ortho in 2 weeks o Ulna: non-displaced; volar splint, ortho 2 weeks

o Metacarpal: non-displaced shaft and neck  MCP 4&5: Ulnar gutter splint, ortho 3 weeks  MCP 2&3: Radial gutter splint, ortho 3 weeks o PIP/DIP dislocations: simple, no fracture; buddy tape/splint, ortho 1 week o Hand Distal Phalanx: buddy tape/alumiform splint, ortho in 3 weeks o Occult Scaphoid: thumb spica splint, ortho in 3 weeks o Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks o Foot Non-displaced phalanx fracture: buddy tape, ortho in 2 weeks o Chronic or non-healing fracture: e-consult or CCC (call ortho if needs closer follow-up) • Palpitations • Psychiatric Patients without psychosis, homicidal ideation, or suicidality (but these patient may be screened for medical conditions and sent directly to the Psychiatric ED if it is deemed no other medical workup is necessary prior to psychiatric evaluation) • Rash (no petechiae/purpura) • Seizures (known disorder, no new trauma) • Soft tissue infection or simple abscess • Simple UTI • STI exposure • URI • Exclusion: o Any cases not specifically listed on the inclusion list o Prior to discharge of any patient with a persistent vital sign abnormality needs consultation with a physician.  Temperature >38F  HR > 110 or <50  RR> 20, Pox <92% on room air  SBP >210 or <100, DBP >120 or <50

Ortho Follow-ups

• Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can overbook into orthopedic fracture clinic): o Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks o Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week o Humerus:  Proximal: non-displaced; sling, ortho in 1 week  Shaft: non-displaced; sugar tong/sling, ortho 1 week o Radius:  Non-displaced distal or shaft; volar splint, ortho 2 weeks  Non-displaced head with good ROM: sling, ortho in 2 weeks o Ulna: non-displaced; volar splint, ortho 2 weeks

o Metacarpal: non-displaced shaft and neck  MCP 4&5: Ulnar gutter splint, ortho 3 weeks  MCP 2&3: Radial gutter splint, ortho 3 weeks o PIP/DIP dislocations: simple, no fracture; buddy tape/splint, ortho 1 week o Hand Distal Phalanx: buddy tape/alumiform splint, ortho in 3 weeks o Occult Scaphoid: thumb spica splint, ortho in 3 weeks o Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks o Foot Non-displaced phalanx fracture: buddy tape, ortho in 2 weeks o Chronic or non-healing fracture: e-consult or CCC (call ortho if needs closer follow-up)

Documentation

• Consults
  • When simply asking a doc if it is appropriate to consult X service, just put in your documentation something to the effect of “Dr. Chappell agreed with consulting ortho for displaced fracture”
  • If you are reviewing a case with a physician and asking for advice on management, you should forward the chart to the physician for signature - “Case discussed with Dr. Chappell who agrees with X plan.”
    • Under no circumstance other than approval for consultation should you write “case discussed with Dr. X” without forwarding the chart to the aforementioned physician.

Timesheets

• Daytime (099) - 6am, 9am, 10am
• Evening bonus (517) - 12n, 2pm, 4pm
• Night Bonus (504) - 6pm or 8pm
• Weekend Bonus (539) - Friday 6pm through
• 703-843: accrued OT (any work over 12 hour shift or 40 hour week; maximum of 81 hours); use this for Staff meetings or elective trainings such as ultrasound
• 701-843: Paid OT (only when offered by director or Lead NP) or Part-time accrued
• 037: mandatory training (computer modules, skills lab)
• 024: Military time

RME Rounds

• Please post/edit after presenting to NP's at rounds