Harbor:Pediatric ED (main)

See Adult ED for the main adult Harbor page.

Background

This is the main page for Harbor-UCLA Pediatric ED.

General Administrative

• Schedule and sick backup plans
  • Resident shifts: EM, Pediatrics, Med-Peds
    • Most weekdays will be scheduled with residents (EM or Peds R2, R3, or R4) – two residents 7am-4:30pm, two residents 4pm-1:30am, and an EM or Peds R3 or R4 on mn-7:30am
    • Weekends and holidays and times of short staffing are likely to be scheduled with residents on 8a-8p, 7a-5p, 4p-2a, and an EM or Peds R3 or R4 on 8p-8a
    • Note: by our convention, a midnight – 7:30am shift listed on, for example, July 1st is actually technically on July 2nd. Thus, if you came in one minute early for your midnight-7:30am shift, you would come in at 11:59pm on July 1st. The attending schedules are done the same way.
    • Fellows may be scheduled for any of the resident shifts
  • Intern and FM shifts
    • Depending on the number of interns and FM residents scheduled in the PED for a given block, they will be scheduled for 10a-7:30p, 3p-12:30a, and if there are enough rotators 10p-7:30a
  • Attending shifts
    • There will be 24 hour attending coverage in the PED. The shifts will be 7a-4p, 4p-12mn, and 12mn-7am
  • Teaching rounds
    • Teaching will occur 7a-7:30a, and may occur 4p-4:30p
      • Overnight residents are NOT to leave early before 7:30a, and all residents should get breakfast at 6:45a so they can be present for teaching rounds
    • Huddle (with nursing) will occur at 7:15a
  • Trading shifts
    • Day and swing resident shifts always have at least one EM person or PEM fellow; this is because we need someone present who has experience with trauma
    • EM residents (R2, R3, R4)
      • May trade with other EM residents or PEM fellows
      • May trade a PED shift with an AED shift
        • This will be logged as a switch shift
        • Only R3s, R4s, or PEM fellows can do the overnight shifts
        • EM R3s & R4s may trade overnight shifts only (no other type of shift) with Harbor Peds R3s
    • Pediatric, Med-Peds, and FM residents
      • May trade with each other
      • Only a Harbor Peds R3 can do an overnight (non-Harbor residents will not have the familiarity with Harbor that is needed)
      • Harbor Peds R3s may trade overnight shifts only (no other type of shift) with EM R3s or R4s
      • Peds, Med-Peds, and FM residents can also get someone of equal or higher level from their program to cover a shift and pay that person back however they like
        • Would expect this would just be one shift though, so it doesn’t overly impact your PED rotation
    • Interns and FM residents
      • Interns may trade with each other or with FM residents scheduled in a 10a-7:30p or 3p-12:30a shift
      • May also get another intern from their program (or any EM or Peds intern) to cover their shift
    • Get your trade approved
      • Trade cannot incur an RRC duty hours violation
      • Send your proposed trade to kyoung@emedharbor.edu AND christiane@emedharbor.edu for review
      • Have BOTH people involved in the trade email to assure that they agree (one person can forward an email in which the other agrees)
      • Do this well in advance so your trade can be properly reviewed
  • Sick Back-up Plans
    • If you are too sick to work your shift, or think you may be too sick, please call and notify people as early as possible
    • Notify Kelly Young at kyoung@emedharbor.edu, Christiane at christiane@emedharbor.edu, AND call the current PED attending at 310-222-6939
      • EM residents contact Madonna Fernandez or the chief residents
      • Peds residents contact your chief resident
      • FM residents contact Theresa Nevarez or your chief residents
      • UCLA Med-Peds residents contact your chief resident
    • If 7a-4:30pm resident is sick
      • Jeopardy coverage for EM residents
      • Coverage from own program for Peds or Med-Peds residents
        • If no coverage available, and PED is very busy, EM jeopardy may be called
      • Other 7a-4:30pm resident becomes 7a-5p, 4pm-1:30am resident becomes 8a-8p (or as close as possible depending on previous shift and current time), 4p-1:30am resident becomes 4p-2a, and mn-7:30am resident becomes 8p-8a
    • If 4p-1:30am resident is sick
      • Jeopardy coverage for EM residents
      • Coverage from own program for Peds or Med-Peds residents
        • If no coverage available, and PED is very busy, EM jeopardy may be called
      • One 7a-4:30pm resident becomes 7a-5p and one becomes 8a-8p, the other 4p-1:30am resident becomes 4p-2a and the mn-7:30am resident becomes 8p-8a
    • If mn-7:30am resident is sick
      • Jeopardy coverage from own program (EM or Peds)
    • If EM resident is jeopardized, will attempt to arrange payback coverage, including from Peds or UCLA residents
• Follow-up track information
  • Place lab checks for any lab that will not result during the patient's visit
    • Examples: urine/throat/wound cultures, urine GC/Chlamydia, pertussis PCR, thyroid function tests
    • Use the ED Post Visit Plan on the Depart Process
      • Get a phone number where the patient can be reached best
      • Click Lab/Radiology follow-up
      • Specify result to be checked and plan
      • If you don't do this while the patient is still on the track, you need to do an extra step: Events->Request Event->ED Post Visit Peds, or else they will not be on the f/u track (HAR Follow Up)
  • You can order phone f/u calls to check on patient's symptoms
    • Do as for lab check above, except check Symptom Follow-up and specify what symptoms to ask about
  • If a patient can be seen at Harbor (not OOP), you can put in for a referral
    • Do as for lab check above, except check Referral and specify what referral is needed
  • Phone and lab checks will be done by NPs on Mon, Tues, Thurs, Fri and by the 10am-7:30pm intern / resident on Wed, Sat, Sun, holidays
  • Detailed instructions are in a binder labeled "F/U Instructions" in the PED, and on Pemsource.org on the Harbor page

Managing your Patient

Ordering

• Use the Peds ED tab on Cerner Place Orders for PED quick orders
  • For medication orders
    • Remember that pediatric medications are often dosed on a per kg basis
    • Cerner does not automatically stop at a maximum dose, so check that you are not ordering more than an adult dose
• Ordering a Formal Ultrasound
• Ultrasound approval list
• Ordering a CT
• Ordering Blood Products
• Ordering antibiotics
  • Harbor antibiogram

Documenting

• Attending documentation
• Consenting a Patient

Procedures

• Equipment
• Consenting a patient

Finding Things

• Paging consults
• Consultation of subspecialists
  • For pediatric patients (< 21 years old), pediatric medical subspecialists are consulted
    • MedHub Harbor call schedule (link from PEMsource.org Harbor only page), choose Pediatrics
    • Peds Department Pagers also posted in PED docbox and linked on PEMsource.org Harbor only page
  • For surgical subspecialties (eg Ortho, ENT, Ophtho, Neurosurg, Plastics, Derm, Urology, OMFS), use the on-call schedule as for adult patients except:
    • General surgery, consult resident on Pediatric surgery pager 6105 Mon-Fri 8am-5pm
      • Otherwise, consult Trauma surgery
  • For Psychiatry
    • Mon-Fri 8am-4pm call the Child and Adolescent Psychiatry fellow
      • MedHub Harbor call schedule (link from PEMsource.org Harbor only page), choose Psychiatry -> Child and Adolescent Psychiatry
    • After hours and on weekends and holidays, call Psych ED for Psychiatry resident on call x3144

Patient Disposition

Discharging a Patient

• Prescribing
• Options for follow-up

Admitting a patient

• Paging consultants
• Admission guidelines
  • Patient age
    • Pediatric ward and PICU admit patients up to age 21 years and 364 days old
      • If another service is asking to admit an adult patient aged 18-21 years, state that the patient should be admitted to pediatrics with the other service consulting
    • Patients < 1 month old with no respiratory symptoms or diarrhea may potentially be admitted to NICU or nursery
      • Discuss with admitting nursery (x2311) or NICU (x2340) resident
  • ED attendings have admitting privileges
    • Admissions will be accepted by pediatric residents regardless
      • Pediatric residents, in conjunction with their attending, may evaluate the patient and perform an immediate discharge if they so desire
  • ED attendings determine, with admitting resident input, the appropriate location: ward, step-down, PICU
  • ED should have done all of the following prior to contacting the admitting resident
    • Complete necessary work-up and treatment for stabilization that should occur acutely in the ED
    • Make sure with Utilization Review that the patient can be admitted to Harbor
      • If the attending says patient is not stable for transfer, then the patient will be admitted
      • The Interqual icon does NOT have to be green prior to contacting admitting resident IF ED staff are sure the patient will be admitted to Harbor
  • Peds does not have isolation areas, so if patient needs isolation (eg active TB, meningococcemia, measles, varicella), discuss with admitting resident
    • Patient may need to be admitted to an adult area and followed by peds, or transferred
  • Contacting admitting resident
    • Harbor MedHub call schedule (linked from PEMsource.org Harbor only page)
    • Protected time
      • Weekdays 6:45am-7:30am
      • Weekends 7:45am-8:30am
      • All evenings 7pm-7:30pm
    • For ward and step-down
      • Mon-Fri 7a-7p: Pediatrics Ward Senior Admit resident (will be Gold or Blue, depending on which team is admitting)
      • Mon-Fri 7p-7a: Pediatrics PM Ward Senior
      • Sat-Sun 24 hours: Pediatrics Ward Senior Admit resident
      • If unsure, can call Peds ward at x2333 to ask for admitting resident
    • For PICU
      • Mon-Fri 7a-7p: Pediatrics PICU
      • Mon-Fri 7p-7a: Pediatrics PM PICU
      • Sat-Sun 24 hours: Pediatrics PM PICU
      • If unsure, can call PICU at x2480 to ask for admitting resident
    • If you forget to ask, the Attending name for Ward Blue or Gold team, or PICU will be listed on MedHub
  • After admission
    • Once the ED staff puts in a "Request for Admit" order, the pediatrics team is managing the patient
      • ED staff should have all ED orders in and completed prior to putting in Request for Admit
        • Make sure nursing has had a chance to complete ED orders prior to putting in Request for Admit
    • As part of their admission orders, pediatric residents may order additional labs, imaging, etc.
      • These do NOT need to be done in the ED prior to the patient going upstairs
      • Ultrasounds can be difficult to obtain from inpatient, so attempt to get any ultrasounds done prior to leaving ED
    • For any delays in patient going upstairs, have nursing contact Patient Flow

Other

• Deceased patients

Disaster

• General disaster info
• Harbor:Surge plan
• Suspected Ebola protocol

See Also

• Harbor:Main
• Harbor:Operations manual