Harbor:ED policy manual
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ALL POLICIES ARE IN ADDITION TO AND NOT IN PLACE OF HARBOR-UCLA AND DHS POLICIES
1.0 Abuse (Adult and Peds)
- Peds
- If <120 hours, contact Sheriff, DCFS, and SCAN Teams (8-5 M-F on-site at HUMC, otherwise USC or SART Center)
- If >120 hours, contact SCAN team to determine appropriate evaluation and follow-up
- Adult
- Refer to SART center if <120 hours since assault
- Contact Sheriff who will determine appropriate SART center and either transport or escort the patient
- HIV prophylaxis is not routinely given, but can be offered in conjunction with ID recommendations
- SART Center at Little Company of Mary San Pedro 562-497-0147
1 Abuse (Adult and Peds) POLICY: Assault/abuse should be evaluated and reported to Los Angeles Sheriff’s Department (LASD) in all cases of assault/abuse reported by the patient or patient's caregiver. If the suspected perpetrator is a family member/caregiver or lives in the home of the child, a report should also be made to the Department of Children and Family Services (DCFS).
ADULTS
- See Harbor-UCLA Policies 332A
- Perform MSE and provide appropriate medical care as necessary.
- Call Los Angeles County Sheriff’s Department (LASD) to report the incident. LASD will decide on the SART location, contact the appropriate jurisdictional law enforcement agency, and LASD or appropriate jurisdictional law enforcement agency will provide transport for the patient to the appropriate SART facility. The patient may choose to drive herself/himself, or other alternative transport, but law enforcement should follow them and needs to be present at the SART. You do not need to contact the accepting SART facility unless you have a specific question for them (see attachment 1 for contact information).
- Contact Social Work for supportive counseling and community resource referrals (see attachment 2 for a list of Rape Crisis Centers and hotlines).
- If the patient declines transportation to a SART facility for forensic examination and counseling, ED staff still need to report the incident to law enforcement. The patient should be offered prophylaxis against sexually transmitted illnesses as appropriate. HIV prophylaxis is not routinely offered but may done on a case to case basis after evaluation by the Infectious Diseases service.
PEDIATRICS:
- See Harbor-UCLA Policy 332B
SUSPECTED ABUSE OR NEGLECT OF DEPENDENT ADULTS OR ELDERS
- See Harbor-UCLA Policies 332D
3.0 Admissions and Consultations
- 3.1 - Clinic Admissions
- 3.2 - OOP
- HUMC 308A
- 3.3 - Eval by consultant from the WR
3.4 - Flow of patients between Psych & AED
4.0 - Misc
- 4.1
- HUMC 312
- 4.2
- 4.3
- 4.4
- 4.5
- 4.6
- 4.7
5 - Consent
- 5.1
- 5.2
- 5.3
- 5.4
6 - Deaths
- 6.1
- 6.2
- 6.3
8 - Discharges
- 8.1
- 8.2
- 8.3
- Disability will not be given to emergency department patients by ED staff. Patients requesting disability will be referred to a long term care provider (at Harbor-UCLA Medical Center or in the community). Patients who have been followed in the Harbor-UCLA Medical Center Clinics may be referred to the Medical Records Department (daytime, Monday – Friday) to determine if the medical record contains sufficient documentation to complete the disability forms.
- Short term time off (< one week) or limited duty (< one week) may be given by the emergency physician to a patient with an acute problem needing short term restricted activities. To give limited time off or restricted activity, the emergency physician is to write for the specific restricted activity and duration of time in the discharge-related documentation in the electronic medical record (eg. Off work 2 days; strict bed rest 2 days; no lifting >15# for 5 days). The patient is to be given a copy of their discharge paperwork at time of ED discharge.
- In the setting of infectious diseases requiring a period of quarantine, CDC guidelines should be followed for prescription of time off work/school.
10 - Residents & Medical Students
10.1 Supervision of Medical Students
- Medical Students
- Medical students may perform histories, physical examinations, and procedures with appropriate supervision. All medical orders require co-signature by a licensed physician. Medical students are supervised at all times by the residents and faculty assigned to the DEM. All charts by medical students must be cosigned by a licensed physician and reviewed by the senior Emergency Medicine resident or faculty member.
10.2 Approval of DEM Housestaff in Performance of Invasive Procedures
POLICY:
DEM housestaff are initially allowed to perform specified procedures only under the direct supervision of DEM faculty or other housestaff who have already been approved in the performance of those procedures. Once residents have been approved for a certain procedure, they are allowed to perform the procedure independently, with indirect supervision of faculty.
The following is a list of the procedures that are covered by this policy, including the number of times each procedure must be performed under direct supervision before a resident can be approved in that procedure:
- PROCEDURE MINIMUM NUMBER
- Percutaneous central line:
- Internal jugular 3
- Subclavian 3
- Femoral 3
- Intraosseous line 1
- Cutdown 1
- Tracheal intubation 10
- Thoracostomy 2
- Percutaneous central line:
Procedure
- The following procedure will be used to privilege DEM housestaff in the performance of specified procedures:
- When a resident performs a procedure he/she will fill out a procedure note in the electronic health record (and in a separate electronic log when at outside rotations), which identifies the patient, the procedure performed and the supervising physician.
- Intermittently, each resident will be provided with feedback regarding the number of procedures they have performed. This feedback will note the procedures they are currently credentialed to perform independently.
- This will be posted for reference on iPrivileges/Resident Competencies located on the Harbor-UCLA intranet homepage (Clinical --> Applications -> iPrivileges).
10.3 Transition of Care
All transitions of care for patients occur during rounds. Rounds occur 3 times a day between 8-hours shifts with overlap. Rounds are staggered so that there is not a complete change of providers at any given time. Most patients are seen and discharged or admitted during one shift. There are no more than 3 transitions in a 24 hour period. Patients who are signed out to an oncoming team are assigned a new provider on the electronic health record (EHR) and the providers communicate two identifiers (typically name and MRN#), current clinical condition, what has been done for the patient, any tests, tasks or consults that require follow-up, and a working diagnosis when appropriate. Rounds are supervised by an Emergency Medicine attending physician.
11.1 Medical-Legal Specimens
Medical –legal specimens removed from patients in the DEM will be handed to law enforcement if available or taken to the Pathology Department. Each person handling the specimen will be expected to complete the chain of possession information.
PROCEDURE
- Containers or envelopes for legal specimens can be obtained from Pathology.
- Complete all information on front of the small envelope. Physician to place specimen into the envelope and seal.
- Employee who seals the small envelope must sign across the outside flap.
- RN to fill in all information on the top third of the large envelope as well as #1 under Chain of Possession of Specimen. Place small envelope into larger one, DO NOT SEAL.
- RN to hand envelope to law enforcement or take envelope along with Surgical Pathology Tissue Report Form (completed by Physician) to Pathology Department.
14 Medications
14.2 Prescription Refill for Patients from Harbor-UCLA Clinics
- Medications will only be refilled for registered ED patients. Unregistered patients will be referred back to their primary care provider for refills.
- For psychiatric medication refills, referral can be made to the Psychiatric ED or Exodus.
15.1 Visitors in the ED
- Due to the unique setting of the Emergency Department, the decision to permit visitation is at the discretion of the Emergency Department staff. Visitation may be restricted in an emergency situation and/or any active or potential hospital safety situation.
- In accordance with Harbor-UCLA Policy 109A, each patient has the right to designate visitors of his/her choosing with the following exceptions:
- Staff safety needs to be maintained at all times;
- Staff needs to be able to perform their duties with minimal interference from visitors;
- When no visitors are allowed;
- The patient has notified the healthcare provider that he/she no longer wants a particular person to visit;
- No more than one visitor at the bedside unless approved by DEM staff; or
- Visitors must remain inside the patient’s room. Visitors will not be allowed to stand in the hallways.
In some instances, it may be beneficial to allow a family member or support person to be present while a procedure is being performed at the discretion of ED staff. This usually relates to a parent/guardian of a child, caregiver, or support person who can enhance the patient cooperation interaction experience.
- Family presence at the bedside or in the room is encouraged for a variety of medical or surgical procedures, including resuscitation, while avoiding any disruption in care being provided.
- A chair should be provided for all family members who are present during a procedure/resuscitation for their own safety.
- Prior to a family member entering the resuscitation area, a staff member will notify the team that the family has arrived/present.
- Offer the family simple comforts such as a phone, tissues, water, restroom access, and clergy.
- As much as possible, a staff member (MD, NP, RN, LCSW) will accompany and explain to the family members the following:
- What they are about to see.
- They can leave the room at any time.
- They may be asked to leave the room at any time for a variety of reasons
- While we understand that they may become emotional and we support. their feelings, they must not interfere with medical treatment.
- In the event of patient death:
- Department of Social Services or nursing should provide the family with a copy of the Harbor UCLA Medical Center Bereavement Packet with information on funeral homes, community support groups, and information concerning the disposition of the body.
- For pediatric deaths, nursing may offer the family a lock of hair, a hand or foot print when possible.
- Provide the family with the telephone number to the ED for any questions they may have after returning home.
16 Prehospital Care
16.1 Paramedic Clinical Training Policy
- Paramedic/trainees, during the course of their education, will abide by the clinical practice policies for the Department of Emergency Medicine (DEM).
- Paramedics/trainees shall be directly supervised by a physician or a registered nurse working in the clinical area. Paramedic/trainees must adhere to local EMT-P Scope of Practice, per Ref. 803 Los Angeles County Prehospital Care Manual, while performing clinical duties in the emergency department.
- Paramedics/trainees may administer medication only when directly supervised by a physician, registered nurse, or paramedic instructor. Paramedics/trainees may administer only those medications found in the Los Angeles EMT-P Scope of Practice per Los Angeles County Prehospital Care Manual Ref. 803. It is the responsibility of the paramedics/trainees to be knowledgeable of all information concerning each medication prior to administration.
- Any specific medical questions directed at a paramedic/trainee shall be referred to the patient’s physician or registered nurse.
- In the event of an incident involving a paramedic/trainee in the clinical setting, reporting of the incident should be in accordance with Harbor-UCLA policy 612A. The paramedic/trainee shall report the incident to the Charge Nurse, who will notify the prehospital care coordinator (PCC). The PCC will report the incident to the paramedic/trainee’s training institute and to their provider agency.
16.4 Guidelines for Prouncement in the Field
- Pronouncement may only be performed by an attending physician in the Department of Emergency Medicine or a senior resident (3rd or 4th year resident) that has completed the Base Hospital Physician Course and Radio Internship.
- The physician will determine if futility is met and comply with LA County Prehospital Care Manual Ref No. 814 Determination/Pronouncement of Death in the Field when pronouncing a patient in the field.
- The MICN or Base Physician providing the online medical direction will complete the base documentation form with all of the pertinent information, including the name of the pronouncing physician and time of death
16.5 Paramedic Radio Candidate (Internship) Protocol
- In order to be eligible to begin internship, the MICN or Base Physician candidate must demonstrate completion of the LA County MICN certification examination or Harbor-UCLA Base Physician Course respectively.
- Currently certified MICNs, not sponsored by Harbor, requesting to intern on Harbor’s paramedic radios will: 1) Provide proof of current Advanced Cardiac Life Support Provider Course completion and 2) Provide proof of current Los Angeles County MICN certification.
- Preceptors will directly observe the candidate in the process of taking paramedic runs.
- The direction of the run will be the responsibility of the preceptor.
- Direction of a paramedic run by a MICN or Base Physician candidate without the observation of a preceptor may be considered grounds for failure.
- Preceptors will have a minimum of 6 months experience as a MICN at Harbor, or be a senior DEM resident or a DEM attending that has completed the Base Physician Course and Internship.
- MICNs must comply with LA County Prehospital Care Manual Ref 1010 Mobile Intensive Care Nurse (MICN) Certification and complete the internship in accordance with this policy.
- Satisfactory completion of radio internship will require that the Base Hospital Medical Director (BHMD), PCC and Asst. PCC (if applicable) are in agreement that the MICN or Base Physician candidate has performed in a safe and competent manner in the area of assessment, treatment, verbal communication, or record keeping skills.
- Failure of internship will require that the BHMD, PCC, and Asst. PCC (if applicable) are in agreement that the MICN or Base Physician candidate has failed to perform in a safe and competent manner in assessment, treatment, verbal communication, or record keeping skills.
- In the event of failure of an MICN candidate, the MICN candidate may petition the BHMD and PCC to retake the radio internship. The petition should occur within 6 months of taking the LA County MICN certification, or Harbor-UCLA authorization exam.
- In the event of failure of a DEM physician candidate, the physician will be remediated until competency is achieved.
21.4 Care of Potential Myocardial Ischemia Patient in Triage
- All adult patients presenting to the DEM triage area with a chief complaint suggestive of myocardial ischemia will be screened rapidly by the Router RN to determine the need for immediate intervention using the following criteria:
- Age >35 AND chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
- Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
- Age > 65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
- Clinical concern for myocardial ischemia exists despite absence of 1-3
- If the patient meets the above criteria the Router RN will assign a triage priority of cardiac, order an EKG, and notify the triage RN via phone; the patient will be placed in RME1 for immediate EKG
- Once the ECG has been completed, the triage nurse will notify the RME provider who will review the ECG
Approved June 2015, Chappell 2/22/16
21.5 Medications in Triage: Standardized Procedure
- Administration of medications in triage (MIT) is to provide timely treatment for patients arriving to the ED with pain, fever, dyspepsia, or nausea and vomiting at the time of triage/assessment and reassessment. Available medications include Acetaminophen, Ibuprofen, Maalox, or Ondansetron.
- PAIN: All patients who arrive to the ED Triage area will have their level of pain assessed and documented in the EMR. The pain scales used are FLACC, Numeric, and Faces, depending upon the age of the patient.
- FEVER: All patients who present to the ED Triage area will have their temperatures taken and documented in the electronic medical record. All patients who present with a temperature > 100.4º F (38º C) [can be axillary, rectal, or oral temperature] shall be offered acetaminophen or ibuprofen. If a previous antipyretic has been given (either at home or in triage), an alternate antipyretic will be given if temperature >100.4º F (38º C). Rectal temperatures must be obtained for all of the following pediatric patients: Infants less than 2 months old, Children less than 2 years old with the exception of children presenting with minor trauma, & Active seizure patients up to 3 years old
- Assessment of the patient’s symptoms (pain, fever, gastritis symptoms, nausea and/or vomiting) should be reassessed within 1 hours of the medication given in triage.
- Patients who after reassessment of pain (within one hour of receiving the 1st dose of acetaminophen or ibuprofen) continue to complain of pain and desire further analgesic treatment will then be offered acetaminophen or ibuprofen alternating from the previous medication administration.
- Patients who continue to complain of pain and/or fever may have a repeat dose of acetaminophen 4 hours after the initial dose, and/or a repeat dose of ibuprofen 6 hours after the initial dose.
- Patients who continue to complain of dyspepsia may have a repeat dose of aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) 6 hours after the initial dose.
- A nurse practitioner or physician provider will be notified of any patient that:
- The triage nurse assesses to require more analgesia than oral acetaminophen or ibuprofen or aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) can provide
Consent
- PD Blood ETOH draws: patient must be registered, police sign written consent form
- ED staff will draw samples if the patient submits to the test, but will NOT attempt to obtain blood if physical force is required (by staff or law enforcement) to obtain the test
- persons under arrest are only deemed to have given implied consent if they are unconscious or cannot refuse a test for other reasons
Approved November 2015, Chappell 2/22/16