Alternate ER page
- 1 Overview
- 2 Common ER Encounters
- 3 Common ED Procedures
- 4 Special ED Situations/Protocols
- 5 Emergency Guidelines/Protocols
- 6 Admissions to Inpatient Unit
- 7 Consults
- 8 Transfers Out
- 9 Critical Care Transfers between the Inpatient Ward and the ED
- 10 Referrals
- 11 ED follow up appointments
- 12 Medevacs
- 13 RMT (Radio Medical Traffic)
This department is open 24 hours a day/7 days a week and is responsible for the management of all emergent and urgent patients in our region. The primary ER doc serves as medical control for all medevacs in and out of our region. The Emergency Department is designated a Level IV Trauma Center.
Unit Description (facility)
The Emergency Department contains 9 beds and 2 trauma bays. We have approximately 25,000 patient encounters per year, about 50 percent of them are for pediatric patients. The coverage of the ED is physicians 8 a.m.– 8 p.m. and 8 p.m.– 8 a.m., a second physician 10 a.m.– 10 p.m. (sometimes this physician is a pediatrician), a PA/NP from noon to midnight and a Fast Track NP/PA from 1 p.m.–11 p.m..
All patient encounters must be documented in RAVEN, our electronic medical record. There are standard pre-completed notes to choose from and modify for your own use.
All notes should include the following elements:
- Chief complaint – can be pulled in from the nursing chief complaint
- HPI- this should be free-texted in narrative format
- Review of Systems – can be from pre-completed notes, auto-text or macros
- Past Medical History – can be pulled in from the record
- Past Surgical History – can be pulled in from the record, if completed
- Social History – use the SH smart template for this by entering ..ykSocialHistoryMostRecent
- Allergies – can pull in from record
- Medication list – make sure the list is accurate if you are pulling in from record, may need to compete the meds rec first.
- Physical Exam – including pertinent vital signs
- Summary of diagnostic studies (lab, imaging, EKGs, etc)
- Description of any procedures – can use precompleted templates in RAVEN or free-text
- Emergency Department course/Medical Decision Making – make sure this includes differential diagnosis if appropriate.
- Impression and Plan – this should be free-texted
- Follow up – include from your depart summary
To discharge a patient:
- Click on the Depart button in the grey section at the top of the screen
- Complete the top 5 sections
- Patient Education/Follow up
- Prescriptions (if any)
- Medication Reconciliation – this MUST be completed on every patient
- Under “Charges” click on discharge order
- Remember to complete E&M charges at this time.
Admissions to Inpatient Unit
- We have 24-hour inpatient Family Medicine hospitalists who will admit all patients who require admission to the inpatient unit. They write the admission orders.
- When you determine that a patient would benefit from inpatient admission, have the med tech page the on-call inpatient provider for the appropriate village. Once the decision has been made for admission the inpatient provider assumes the responsibility of disposition; if they feel on reviewing the case that the patient is not ill enough to warrant admission they are responsible for discharging the patient from the emergency room.
- Call ANMC when you need to transfer a patient and ask for the appropriate service to consult for the transfer. For example, the surgeons take all trauma patients, the intensivists take all intubated patients, etc.
- All patients who require medevac to ANMC go by LifeMed, the air ambulance service that is 50% owned by YKHC and 50% by Providence Hospital in Anchorage. You have to activate this service as soon as you have an accepting doc at ANMC. ANMC uses Guardian for their air ambulance service, but you must use LifeMed, unless the LifeMed service is busy and you believe that delaying the transport until a LifeMed flight is available would be unsafe for the patient.
- You must complete a paper consent for transfer, signed by you and the patient.
- You must complete a paper PTO – Patient Transfer Order.
- You must complete your transfer note – usually right before the team gets there so that the med tech can print out the chart to send along with the patient.
- If the patient’s condition changes, call and update the accepting doc, for example if you have to intubate the patient, let them know because this affects where the patient can go.
- For patients who are traveling via commercial flight to Anchorage, the ER doc can authorize this travel if the patient does not have Medicaid or a means to pay for travel. See Preauthorized Travel
Critical Care Transfers between the Inpatient Ward and the ED
- Anticipate 5-6 minute transport time IF everything goes smoothly. Appreciate risk of unanticipated obstacles/obstructions (such as long elevator wait, maintenance working in the hall, etc).
- Secure ET tube with a tube holder. If reasonable, place OG tube prior to the tube holder.
- Establish two working IV's.
- Either sedate with long acting meds (versed, fentanyl, etc) or use an infusion pump for propofol. Bolusing propofol in route is discouraged.
- Transfer on a gurney rather than a hospital bed (the large size of a hospital bed is problematic in the elevator and more difficult to navigate past equipment in the hallway).
- Place ventilator, O2 tank, monitor, etc. ON THE GURNEY (at the foot). Minimize the amount of equipment pushed alongside the gurney.
- Secure the patients' wrists (to prevent them pulling out the ET tube in route).
- Transport with an AMBU bag, mask, and oral airway even if the patient is inbutated and on a ventilator. Be prepared to ventilate the patient in the case of ventilator failure and/or unintended extubation in route.
- Occasionally you will need to place a referral on a patient that you see in the ED. For example, a non-emergency hernia repair will need an order placed in the chart for the referral to surg.
- Type in the search order window the word “refer” and hit enter or the binoculars. The list of services that you can refer to come up and you will need to choose the correct service and complete the order (yellow parts are required.)
- Once you sign the order, it goes to a queue for the case managers to review and forward the appropriate documentation.
ED follow up appointments
- The ED is allotted a certain number of appointments for patients who need follow up in the ambulatory clinic the next day.
- To obtain one of these appointments, our current work flow is to ask the med tech to make the actual appointment for the patient in the computer. The patient is then given a letter with the appointment time on it. You also need to indicate this in your discharge paperwork under the follow up tab.
- YKHC owns a medevac service called LifeMed. This is the service that is used for both village to Bethel medevacs and Bethel to Anchorage medevacs. You have to activate the medevac for all patients traveling to Anchorage via LifeMed because ANMC has a different contract for all other sites in Alaska (Guardian.) It is very important that you document very well about why you chose to “roll over” the medevac to Guardian.
- The ED doc is the med control for all medevacs that arrive in Bethel from the surrounding villages. This is often 2-3 per day.
- The exception to this is our OB medevacs when we send a Family Med doc and a pediatrician along. Med control is then with the doc on the plane.
- The ED doc should also know about every single medevac that is going out of Bethel to Anchorage, regardless of the location of the patient. For example, if OB is medevacing an OB patient, the ED doc needs to know about the medevac and at least a cursory clinical knowledge of the patient. This is for purposes of triage. If a sicker patient comes into the ED, the plane may need to be diverted to get the sicker patient.
- Once the inpatient doc tells you about the patient being medevac’s in from the village, you assume medical control. This means that you talk to the Health Aide when he/she calls and you document in the record any interventions and changes in condition. You can either start your own note or add to the RMT note already started by the CHA and the inpatient doc. Just right click and modify the document.
- All weather delays must be clearly documented in the patient’s chart, as well as all other delays. For example if another medevac is already underway in another village, this should be noted in the chart (not the details obviously, just that the medevac team and plane are in another village and unavailable.)
- Our hard-working medics will occasionally time out because of too many hours of continuously flying. They will then go on “red” status meaning they can’t fly for at least 8 hours. If they are on “yellow” status, it generally means that whatever flight you send them on is the last flight before they go on “red.” When this happens, sometimes LifeMed can put another plane and team in Bethel to perform the village flights and sometimes the plane from Anchorage can go directly to the village to pick up the patients. Creative problem solving is key in these situations. Clear documentation in the chart as to what is going on is key in these situations as well.
- In general, do not activate a medevac for CPR in progress in a village. The CHAs can only do BLS and return of spontaneous circulation is rare. The exception to this is cold water drowning in a child with high-quality CPR on-going since they were taken out of the water. It may be appropriate to send the plane out in these situations. Consult with peds in these cases.
- If you transfer a meningitis patient to ANMC, send an extra tube of CSF with the patient to ANMC for faster turnaround on identification of the causative agent.
RMT (Radio Medical Traffic)
- There are 2 types of RMT: emergency/urgent and routine.
- Emergency/Urgent are cases where the CHA sends in an RMT document to the message center proxy called NW emergency/urgent RMT. The CHA then calls the on-call inpatient doc for that village and they talk about the patient and what to do for the patient. These calls can sometimes end up in a medevac, sometimes the patient is sent to the ED via commercial flight and sometimes the patient is treated and sent home.
- Routine RMT is handled by ambulatory providers and the CHA sends in a document and the provider responds is electronically.
- Sometimes the CHA will call the ED and ask to talk to the ED doc, usually because they are doing CPR on a patient and haven’t had time to start any documentation. See above about activating medevac for CPR in progress (generally don’t.) You will be expected to talk the CHA through the case. These are highly stressful situations for the CHA – remember this is certainly someone they know and often a relative. There is often chaos in the background and it can be hard to hear the CHA or determine what is going on. Please be very patient at these times. The CHA will want you to make the determination when to stop resuscitative efforts. Generally speaking, we don’t have them do CPR for more than an hour. So at about the 45 minute mark, ask them to start thinking about stopping CPR. Sometimes they don’t want to and we let them keep doing CPR longer. This is especially true if it is a baby or a child. If it is a child, get the pediatrician on the phone if you think that will help. Link to code resuscitation section of Emergency RMT.
- If you get other calls from CHAs regarding other emergencies (strokes, seizures, village deliveries, etc) re-direct CHAs to the NW doc on call for that village. Peds on call can also be contacted for any pediatric patient.