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!)
  • Pt presents at router desk for check-in
  1. Quick registration occurs
  2. Called to Triage 1 by NA for full set of vitals
  3. Pt 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. Pt then goes to RME 4-6 for tasking (phlebotomy, medications, transport to radiology)
    1. If tasking rooms are at capacity, pt 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 EKG <10 min)
    1. To “review” the EKG: 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, pt 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 EKG; triage team goes to 11 to see the patient ... need to follow current process
      • Stroke goes to next triage for immediate assessment
  • Pt goes to triage queue (designated seating)
  • 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 hx, allergies, focused physical exam
    • Doc places orders and writes MSE note while RN completes triage
    • Triage Note
      • Extended reason for visit: CC and <10 work HPI (ie, pleuritic CP x 3 days)
      • weight - pt 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
      • ??? 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
    • EKG tech - for 10 min EKG
  • 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
  • Clerk
  • RME Charge RN - for IV pushes, communicate with AED charge and router
  • Reassessment RN - repeat VS, pain score, and give meds (don't take back to tasking)
  • Martee: look at router
  • 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?
  • Brad:
  • Wilson: D2EKG #'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 d/c?)
  • 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 f/up)
      • AED/AWR (dispo per AED team but stable for WR)
      • AED/12 (next back or needs intervention requiring monitoring (IV, ABX, 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

NP Independent Workup Guidelines

NP Independent Discharge Guidelines

Ortho Follow-ups

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 40 hours; maximum of 81 hours)
  • 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

Copied to Ops Manual

UCC

  • UCC Charge RN: x8111, 8110; RME Charge x3900 - 23930
    • Once hourly communication between RME Charge RN and UCC Charge to determine UCC capacity for ESI 4-5 patients
      • Weekday cutoff to send patients 9pm
      • Weekend cutoff for sending patients 2:30pm
    • If UCC has capacity, ED will prioritize screening of eligible patients with one FastTrack provider assisting in the MSE process for these patients as to not inhibit screening of higher acuity patients
  1. Patient must have MSE
  2. Eligible patients include DHS, MHLA, and Self Pay
  3. Financial Screening - once financial screening is done, the patient will be assigned the white stick figure with red checkmark indicating "ok for UCC" or the orange OOP icon meaning they must stay in the ED; NOTE: the golden key will not disappear when only the financial screen has been performed (only when full registration is complete)
    1. Patients will be assigned to Dr. Lewis in the ED and Dr. Munekata in the UCC
    2. During early morning hours, ED registration to prioritize screening these ESI 4&5 patients so they can be pulled to UCC when open
    3. During UCC hours, UCC registration will complete MEDS 270/271 in the background for ED ESI 4&5 patients based on directive from UCC charge nurse to pull patients to the UCC
    4. If UCC registration is unable to perform the financial screenings, the patients will be sent to the ED registration window for financial screening after MSE/tasking performed to determine DHS UCC eligibility
  4. Once the patient is taken to UCC, they need to be moved in Orchid to UCWR
  5. UCC Nuances
    1. There is no maximum number on the subjective pain scale that precludes transfer to UCC -- CAP policy will be re-written
    2. No pain meds should be given prior to sending to UCC; Debbie Terrel is currently working on a process to allow MIT and reassess/document pain level prior to transfer to UCC
    3. It is ok to transfer a patient who has received an MSE and work-up has been initiated (i.e., x-rays ordered/performed); any medications that have been ordered should be cancelled prior to transfer to UCC
    4. UCC is unable to do CCC but can request e-consult
    5. The UCC has full access to ortho via the cast room
  6. If the decision is made to transfer a patient back to the ED, there must be a physician to physician conversation as to why the patient’s workup cannot be completed in the UCC
  7. Despite best efforts to properly screen the patients, if it is later determined that a patient is OOP, they will still be seen in UCC and not returned to the ED simply for financial concerns in the spirit of patient-centered care.

Direct Admission after Hours

  • All patients going to Gold must be evaluated in the ED with an ED Chart completed
  • Patients may directly placed in CORE by cardiology without ED evaluation
  • Any inpatient direct admissions presenting before 8pm: admitting physician directly contacts Bed Control for Ward Beds (x2185) or Patient Flow (x3434) for Tele/PCU beds
  • If after 8pm: Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from registration in ED or Bed Control)
    • Admitting physician provides a copy of the request to ER Registration x2075/2076/2078 and they create a pre-admit FIN UR Financially clears patient
      • Admitting physician provides a copy of the request to Bed Control/informs location of patient to release bed (ER)
      • ER Registration informs Physician/UR if patient is non-DHS
        • If patient is DHS, admitting physician inputs the admitting order on the pre-admit FIN UR calls to obtain authorization Informs Bed Control of approval
        • Informs Physician/Bed Control of denial; if denied, decision must be made whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment
    • ER Physician will document the patient's presence in AWR/ED as a Pre-arrival with name and patient location (AWR or room #) with brief note with admitting service and physician to contact for questions (pager #)
      • If patient is stable, should wait in AWR until upstairs bed is available
      • If needs to be watched for any reason, they can be placed in internal WR (RME 7, 8, 12) until upstairs bed is ready
      • If the patient is in any way unstable or requires immediate intervention or cardiac monitoring, they should be registered and seen as an ED patient and the admitting team should be notified of the change in patient status as soon as possible

Rapid Discharge Procedure

  1. If patient needs an appointment (stress test, CCC, etc), this must be done by the clerk first
  2. Ensure IV has been removed
  3. If vital signs have not been recorded in the past 4 hours, these need to be repeated and recorded prior to discharge
  4. Include CHC referral sheet (at RME clerk computer) if patient has no PCP
  5. SIGN and TIME paper discharge instruction sheet
  6. opt#1: Give completed d/c papers to the RN/LVN who can discharge them with the appropriate timestamp to accurately capture LOS
  7. OR opt#2: When completing the admit/discharge screen, click the bottom "discharge" button
    1. Enter discharge disposition: "home"
    2. Enter discharge date
    3. Enter discharge time
    4. Click complete
    5. Give signed discharge papers to the patient's nurse
Retrieved from "https://www.wikem.org/w/index.php?title=Harbor:RME_Manual&oldid=70884"