ER: Detailed Information
Pediatric Hospitalist's encounters with critically ill patients in the ER will be more frequent at YKDRH than your usual small hospitals in the lower forty-eight. Maintain a higher index of suspicion for sepsis, meningitis, and other serious bacterial illnesses.
Respiratory illnesses ranging from pneumonia, empyema, and RSV WILL occur and you will learn to be very comfortable with stabilizing and transporting these infants. If a patient is identified as needing to be intubated, it is best do this earlier rather than later to allow for a smooth procedure. If you feel uncomfortable please ask for back up. All new providers should contact their assigned back up physician as soon as the decision to intubate is made. All patients on the floor should be transferred to the ER if possible) for intubation once that it is determined that this is necessary. The ER nurses are very used to dealing with pediatric intubations and will be very helpful during this process. We have a pediatric intubation guideline and weight based medication worksheets and orders in RAVEN for all intubations, resuscitations and stabilizations…please use them.
Pediatricians see patients in the ER as consultants, when they assume care of a sick patient in the ER, when they are on call, and when on scheduled ER shifts.
If a patient is critically ill and requires PICU admission or if they require services that our hospital cannot provide, the patient must be transferred to Anchorage. If the patient is an IHS beneficiary (all Alaska Native patients), contact the ANMC peds on call to get an accepting physician. You are responsible for activating the transport team and the sooner this happens the better! You then obtain a transport packet and do the necessary paper work. This should include a PTO form, consent for transport, consent for transfer of records, relevant labs/documents, a CD of any relevant films, and a detailed transfer note. If the patient is particularly unstable this transfer note may need to be done after the transport team has left with the patient, as you may not have time prior to this. You can then fax the note to the receiving physician BUT THEY MUST RECEIVE A TRANSFER NOTE as soon as you can feasibly do one. If the patient is not an IHS beneficiary, s/he will be transferred to Providence. All non-PICU transfers to Providence must have a hospitalist-accepting physician and may be directly admitted to the inpatient unit or go through the ER depending on how the patient is doing and what they need. You can contact the pediatric hospitalist directly through Providence operators or through the PICU.
Working and consulting in the ER
If you see an ER patient from start to finish, you must complete the ER H&P and RAVEN discharge process. If you do a curbside consult in the ER, it is best to write a brief note as an addendum to the consulting physician’s ER H&P or on a separate RAVEN communication/consult note. If it is a telephone consult, the ER physician should be documenting their consult and the plan but it is always a good idea to make sure this has been done or add your own note in RAVEN. If a patient needs admission, the nurse must complete a Pediatric Early Warning Signs (PEWS) evaluation first to determine if the patient is an appropriate admission for our site and to facilitate communication between departments. An accepting FM or pediatric physician must be obtained (and documented in your note), sign out given, an admit order placed and an admission FIN # requested. Once the admitting physician has a FIN # then they can write the admitting orders, add a diagnosis and complete medicine reconciliation.
Often the pediatricians on call are called stat to the ER for a pediatric emergency. It is best to determine what the ER physician needs from you—To assist them or assume as lead physician in the patient’s care. ER physicians all have differing levels of comfort in caring for pediatric emergencies. It is best for patient care to determine early on what roles the providers are going to assume and who is in charge. Often the ER docs are better with trauma and the pediatrician acts as an assistant/advisor. Some of the ER docs are comfortable with intubations and other procedures and just want help. Sometimes the ER is so busy that it makes sense for the pediatrician to assume full care of a critical patient. Pediatricians, Family Physicians and Emergency Physicians at YK are all good at pediatric medicine and we all collaborate and help each other to provide the best care possible for our patients.
NOTE: No pediatric patients that require high flow can be admitted to YKHC.
NOTE: If a pediatric patient you are caring for in the ER is stable while awaiting transport (does not need one to one physician care) and the RT, nurses, and ER physician feel comfortable with you leaving the floor, then you can consider this as an option.
Good communication is critical in our care system. We encourage the ER physicians to call us with any pediatric questions. They also need to call us about any concerning or critical peds patients they are seeing. We need to know about any very sick, or potentially very sick patients, earlier rather than later, as we can provide advice and help. Even if a medevac and transport are already arranged, the pediatricians should be notified if there are any concerns about the patient. We may need to come in immediately or be ready to provide consultation and back up as needed. Any pediatric patient that is being admitted will have a Pediatric Early Warning Signs (PEWS) completed prior to admission. Any PEWS score of 6 or above will trigger a protocol for collaborative multidisciplinary evaluation and communication. It is important to determine if a patient is stable enough to be admitted at our facility or if they need to be transported to a higher level of care.
Not all ER physicians call the pediatricians on call for sicker patients. If a patient is concerning and the ER physician has not contacted the pediatrician on call, nursing has been encouraged to page peds on call. The on call pediatrician can then communicate with the ER doc to discuss the patient further.
Communication between ER, wards and on call pediatricians is also very critical. ER peds providers should talk with the inpatient or on call physicians about any potential admissions or very sick patients as early as possible. The on call and ward docs should also be letting the ER pediatrician know about any pediatric medevacs or sick kids coming in by commercial flight.
During a pediatric ER shift, the ER physicians should consult the scheduled ER pediatrician about any peds issues. If the ER pediatrician is tied up, the ER doc can call the ward pediatrician/peds on call. If a patient is going to be admitted, the provider admitting the patient must call the ward pediatrician/peds on call and document that they accepted the patient. The accepting pediatrician will write admission orders as soon as an admit FIN # is made. When the ER pediatrician goes off shift, they must sign out the care of any patients left in the ER to the ER physician with a plan of care established. If the patient is sick or could potentially be an issue, it is best to make the ward pediatrician/peds on call aware of the patient as well.
Please update problem lists and notes in patient charts as much as you are able. If a patient has a new onset of status epilepticus or is intubated for multi lobar pneumonia and respiratory failure etc—put this in the problem list for future reference. This is one of our best ways of clinical information sharing and improves continuity of care.