Category:Emergency Room

From Guide to YKHC Medical Practices
Jump to: navigation, search

Overview

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..

Job Description/Duties

ER Documentation

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:

  1. Chief complaint – can be pulled in from the nursing chief complaint
  2. HPI- this should be free-texted in narrative format
  3. Review of Systems – can be from pre-completed notes, auto-text or macros
  4. Past Medical History – can be pulled in from the record
  5. Past Surgical History – can be pulled in from the record, if completed
  6. Social History – use the SH smart template for this by entering ..ykSocialHistoryMostRecent
  7. Allergies – can pull in from record
  8. Medication list – make sure the list is accurate if you are pulling in from record, may need to compete the meds rec first.
  9. Physical Exam – including pertinent vital signs
  10. Summary of diagnostic studies (lab, imaging, EKGs, etc)
  11. Description of any procedures – can use precompleted templates in RAVEN or free-text
  12. Emergency Department course/Medical Decision Making – make sure this includes differential diagnosis if appropriate.
  13. Impression and Plan – this should be free-texted
  14. Follow up – include from your depart summary

To discharge a patient:

  1. Click on the Depart button in the grey section at the top of the screen
  2. Complete the top 5 sections
    • Diagnosis
    • Patient Education/Follow up
    • Prescriptions (if any)
    • Medication Reconciliation – this MUST be completed on every patient
    • Charges
  3. Under “Charges” click on discharge order
  4. Remember to complete E&M charges at this time.

Types of Encounters

Use YKHC published guidelines for all types of encounters, if a guideline is available. If you deviate from the guidelines, document in the chart why you didn't follow the guidelines.

  1. Alcohol related encounters
    • These are quite common here as in many EDs. We have a “sobering center” where patients can be sent to sober up, but the patients have to be able to ambulate with minimal assistance and have a BRAC of <400 (they have to check breath alcohol levels because of the grant funding of the sobering center.) If the patient is being cleared for jail or is under arrest, they need to have a BRAC <300. You need to complete the paper form for the patient to be released to the jail or sobering center.
    • Acutely Intoxicated ER Patient
  2. Respiratory illnesses
  3. Boils/cellulitis
    • Community acquired MRSA is very common here and boils and cellulitis is a common reason for visits to the ED. Please follow our guideline on boils. Most of the MRSA is sensitive to Septra. We prefer the use of penrose drains if at all possible in our patients, especially in children
    • Boils — Outpatient
    • Severe Abscess/Cellulities
  4. Fever in child/neonate
  5. T-47
    • These are patients who are placed on an involuntary hold who are sent to the ED for evaluation by our emergency behavioral health clinician. They need medical clearance and appropriate disposition. They must be sober (blood alcohol level <80) before the clinician will evaluate them. They are held in the ED until they are sober enough for evaluation and sometimes after evaluation until definitive disposition can be arranged.
    • Title 47 Hold
  6. Abdominal pain
    • This is another very common reason for a visit to the ED. Most of our patients do not have access to fresh fruits and vegetables and reliable safe drinking water and therefore constipation is very common. The nursing staff has standard orders for triage for this problem. We do not have surgeons in Bethel (except for OB related issues) and so all appys need to travel to Anchorage if the surgeon wants to take out the appendix. They can often travel in on a commercial flight if they are stable. If unstable, or if pain can’t be controlled, they will need a medevac.
  7. Bleeding in first trimester of pregnancy
  8. Injuries/Fractures
    • Please send all x-rays with fractures diagnosed to ANMC orthopedic telerad. This is a paper form you must complete. That allows for non-urgent consultation to take place via the ambulatory clinic. If there is an urgent need, please call ANMC and speak to the on-call ortho doc. They can give you some advice over the phone and, during the day, look at your x-rays.
    • If the patient is a trauma victim, call ANMC surgeon on call. They handle all calls related to trauma, even if the primary injury is orthopedic.
  9. Head injuries
    • Head injuries in our region are common and often related to motor vehicle crashes and alcohol. We have developed guidelines to use locally and ANMC has state-wide guidelines as well. Generally speaking, these patients need to come to Bethel for evaluation. Our pediatricians can be consulted on the use of CT scans in children with head injuries.
    • Head Injury/Concussion in Children 5-18 years
  10. Infant Jaundice
    • Occasionally infants with jaundice will come to the Emergency Department from villages for the express purposes of checking a serum total and direct bilirubin. Since this lab test takes considerable time to return, a general recommendation is to sequester this child and mother in either the quiet room or in another area away from the general ED population while awaiting test results. If the child is ill appearing, or has other complaints such as fever, of course have them evaluated in the main ED per guideline.
    • Neonatal Jaundice Evaluation & Treatment
  11. Sepsis
    • Sepsis is very common in our population, both adult and pediatric patients. As a consequence we have St. Johns Sepsis alerts in RAVEN (our EMR) and order sets for you to use when sepsis is suspected. Don’t hesitate to start antibiotics on a village-based patient who appears septic and is awaiting medevac.
    • We also have a very high rate of neonatal sepsis. Follow the guidelines on neonatal sepsis . ANY neonate <30 days requires an LP as part of the workup and MOST neonates <90 days also require an LP. In general, err on the side of a more conservative approach due to the high incidence of sepsis and the distance folks have to travel.
    • Adult Sepsis
  12. Acute MI
    • Acute MI has become increasingly common in our population and, as a result, our use of lytics has increased. If acute MI is suspected, the order set for chest pain will be initiated. Cardiology is usually available at ANMC to review your EKG if you wish before initiating lytics. Most acute MI patients will be medevac’d to ANMC – possible exceptions include the elderly with multiple co-morbid conditions who aren’t eligible for operative intervention.
    • If you give lytics, the patient goes via medevac to ANMC.
  13. Acute Stroke
    • We do give lytics for acute stroke if appropriate and no contraindications. Neurology at ANMC must be consulted if you are considering lytics.
    • All acute strokes and TIAs are medevac’d to ANMC for further workup. This is true even if they have recovered from a neuro standpoint.

Common Procedures

Procedural Sedation

  • You must have privileges for procedural sedation in order to perform this procedure. Your privileges are available through our email system if you are not sure.
  • Any “deep” sedation requires use of the OR and CRNAs.

If you plan to use ketamine, providers have to administer this medication. This works best with 2 providers – one to administer the med and another to perform the procedure.

  • Our CRNA staff is always happy to help with sedation as well.
  • Except for emergency procedures, patients must be NPO for a minimum of 6 hours prior to the sedation.

Chest tubes

  • We have a commercial kit for chest tube insertion along with a wide variety of chest tube sizes depending on the indication for the chest tube. Our inpatient unit will take care of our chest tube patients if admission at YKHC is indicated. Generally multi-system trauma patients are medevac’d to ANMC for management of their multiple injuries.

Intubations

Closed Fracture reductions

  • This is a common procedure in our ED. The ortho docs will expect you to telerad both pre and post-reduction films when you have a displaced fracture.
  • You need to use the ortho telerad form.

Special Situations/Protocols

Dog Bites

  • Dog bites are relatively common in this region. A “[[Rabiesinvestigation.pdf|rabies investigation report]” from our Office of Environmental Health (OEH) department must be completed on every patient with a dog bite.
  • Rabies prophylaxis: if the dog can’t be found, the bite wasn’t provoked or if the dog was behaving strangely, rabies prophylaxis should be administered and the State of Alaska, section of epidemiology notified: 907-269-8000 or 800-478-0084.
  • The order for the rabies immune globulin and vaccination are in RAVEN and have attached references in the reference tab of the order.
  • Link to the web site from the State of Alaska: Rabies
  • Link to the post-exposure prophylaxis recommendations from the State of Alaska

Botulism

  • Food borne botulism is very common in our region as the consumption of fermented traditional foods is very common. Bethel is one of the repositories of botulism anti-toxin from the CDC and we have several kits here that we can use to treat patients. Botulism should be suspected in any patient with a history of consuming traditional fermented foods and symptoms such as weakness, dry mouth, blurred vision, urinary retention, ileus, diarrhea or dyspnea (especially without gasping or rapid respiratory rate.)
  • All suspected cases of botulism MUST be reported immediately to State of Alaska section of epidemiology 907-269-8000 or 800-478-0084. The state of Alaska has a very nice booklet on botulism that outlines symptoms and case recognition and appropriate treatment that can be found on the following web site. There are also *hard copies in the ED and on NW.
  • Link to: State of Alaska website on botulism
  • Patients with suspected exposure to botulism should be treated with the anti-toxin and hospitalized. Measured Forced Vital Capacity needs to be measured and repeated hourly and if less than ____% predicted or a decreased in ____%, intubation should be considered. There is a special kit with the anti-toxin in the ED that you need to look over with information on administration and dosage. This paperwork MUST be completed and returned to the State of Alaska.

Acetaminophen overdose

  • This is a common occurrence in our region. Many times the patient overdoses in a village. This doesn’t always mean they are medevac’d in, so most patients are started on oral Mucomyst in the village clinic. The Health Aides can draw a 4-hour post-ingestion level of acetaminophen to send in with the patient, while continuing the oral protocol. Once they arrive in Bethel, the level can be run and the Mucomyst can be continued or not depending on the level. This can be switched to an IV protocol once they arrive as well.
  • Poison control number is 800-222-1222
  • Acetaminophen Overdose

Sexual assault/sexual abuse of a minor

  1. This is an unfortunately common occurrence in our region as well. If the alleged abuse took place in a village, the state troopers must be called, if the alleged abuse occurred in Bethel, the Bethel Police Department must be called.
  2. The Office of Children’s Services must also be notified in all cases.
  3. The Alaska State Troopers arrange travel in from the villages.
  4. If you have a strong suspicion for abuse that law enforcement has declined to investigate, please re-contact law enforcement, CAC and OCS.
  5. The Tundra Women’s Coalition (TWC) has a Children’s Advocacy Center (CAC) who handles all these cases and must also be notified.
  6. The children, unless medically unstable, are all interviewed first at the CAC which is located in Bethel at TWC. The CAC has trained bilingual forensic children’s interviewers.
  7. Depending on what is disclosed at the interview, the child can either need an acute exam with evidence collection (this is very uncommon and occurs only a few times per year) or can have a well-child exam scheduled in the ambulatory clinic in Bethel. These special appointments are arranged between the CAC and the outpatient scheduling department.
  8. Child/Adolescent Sexual Assault Flow

ER Guidelines

Admissions to Inpatient Unit

  • We have 24 inpatient Family Medicine hospitalists who will admit all patients who require admission to the inpatient unit. They write the orders.
  • When you determine that a patient would benefit from inpatient admission, have the med tech page the on call inpatient doc for the appropriate village.

Consults

Bethel Consult Services

Outside Consult Services

Transfers

  1. 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.
  2. 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.
  3. You must complete a paper consent for transfer, signed by you and the patient.
  4. You must complete a paper PTO – Patient Transfer Order.
  5. 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.
  6. 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.
  7. 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

Referrals

  1. 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.
  2. 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.)
  3. 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

  1. The ED is allotted a certain number of appointments for patients who need follow up in the ambulatory clinic the next day.
  2. 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.

Medevacs

See Medevacs and Transport

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.)
  7. 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.
  8. 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.
  9. 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)

  1. There are 2 types of RMT: emergency/urgent and routine.
  2. 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.
  3. Routine RMT is handled by ambulatory providers and the CHA sends in a document and the provider responds is electronically.
  4. 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.
  5. 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.

Ancillary Services

  1. Lab: YKHC has a lab staffed 24/7 by lab techs. At night there is a single tech on. If you need blood products or have a massive transfusion at night, they will need to call in help. Have the charge nurse let them know to do that as soon as you know you will need lots of blood or blood products.
  2. Radiology: YKHC has 24/7 in house radiology services with the exception of ultrasound which is available only Mon-Friday 9-5.
  3. Pharmacy: YKHC has 24 hour pharmacy available, usually in house but sometimes on call from home. They come to all critically ill patient bedsides and help with meds. We have wonderful, highly competent clinical pharmacists who will answer your questions and help you make good choices about meds. Use them and listen to them.
  4. Respiratory Therapy: YKHC has in house RT from 7a-7p and on call from 7p-7a. They come in for all intubated patients who need to be placed on a ventilator.
  5. Physical Therapy: YKHC has several PTs. If you want a patient to have a PT appointment, make a referral within RAVEN. During the day, feel free to call them. They also provide our wound care services and can be enlisted to help with complicated wound care. They are not on call and not available on the weekends. If you need splints like wrist or ankle splints, or crutches, the ER charge nurse has a key to their supply room.
  6. Diabetes: YKHC has a robust and well-staffed diabetes team. They educated and manage all of our diabetics. They can be reached during the day by calling their number or having them paged. The med techs know the number.
  7. Tobacco Cessation: YKHC has a very strong tobacco cessation department as well. You can provide the patient with the number to call if they are ready to quit.
  8. Dietary: YKHC ED has food available around the clock for patients, the kitchen can bring trays during the day or sandwiches and crackers available at night.
  9. Community Relations/Translation: YKHC has 24 hour Yupik language translators available.
  10. Specialty Clinic: YKHC has multiple visiting specialists from ANMC. The list of when they are coming is published and posted in the ED. If you would like to refer a patient to be seen at one of these clinics, place an order for referral (type in the word refer in the search order window and the list of specialists will pop up.) Choose the one that says “internal” to indicate that the patient can wait until the visiting specialist arrives from Anchorage.

This category currently contains no pages or media.