Hospitalist Workflow and Priorities

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Overview

The inpatient/ward rotation can be extremely busy and organizational skills and multi-tasking are essential. It is best to begin rounds on the inpatients as early as possible as the health aide calls can begin to get heavy starting at 10am. You may have between 15 and 40 RMT consults-some routine, some urgent and some requiring long distance management/stabilization with initiation of transport (that may involve multiple call-backs) as well as a lot of other unexpected emergences, deliveries (FM), newborn resuscitation (peds), consults (peds) and other urgent demands (such as the rare “code blue”).

Rounds should begin with any potential discharges unless there is an unstable or concerning patient. All discharges will need to have discharge orders and discharge meds written (ideally) before noon and early enough for pharmacy to have time to fill the meds and for travel home to be arranged for the patient. Begin discharges as EARLY as possible so travel can be arranged or the room may potentially be available for a pending admission.

Often we are short nurses and patient beds are in short supply. We will sometimes treat patients on an outpatient bases that in the lower forty-eight would be treated as an inpatient. As an example, a patient with pneumonia is usually not admitted unless they require oxygen or require IV fluids, or occasionally, for social reasons i.e. care taker exhaustion or inability to care for the patient. Pneumonia patients that require IV antibiotics may receive IV ceftriaxone daily through one of our clinics or the ER.

If you are unsure if a particular patient can be treated as an outpatient or needs to be admitted, use resources in guidelines (example: Pneumonia Severity Index) and/or consult a more experienced YK physician. If there are no beds and a patient requires admission, the patient will need to be transferred to ANMC.

Getting the Day Set and Organized

  • Get Sign Out from NF Doc
  • Meet with Nurses and RT to check on patients
  • Let Charge Nurses know of any discharges
  • Prioritize Patient Work Load
    • Take care of sickest patients or stage 2 labor patients that need attention/delivery
    • Get Discharges Completed before noon (as able)
    • Round on stable patients
    • New admissions
    • Finish rounding as early in the am as possible to leave time for RMT, consults (peds), emergencies, OB (FM), follow-ups, etc.

Admissions

Admissions come from the outpatient clinics or the Emergency Room (and rarely from ANMC or an SRC). The provider seeing the patient in the ER or clinic contacts the inpatient physician to obtain accepting pediatric or FM physician and to discuss the workup, diagnoses, and plan for the patient’s admission. After the hospitalist physician accepts a patient, a pre-admit fin is created for the patient’s admission by registration. At that point, North Wing admit orders can be written.An admitting diagnosis is required before the patient can be transferred to NW. It is important that all documentation be created using that North Wing FIN, otherwise the billing and coding department can’t bill for our services.

The pediatrician admits all Chronic Pediatric Patients (CPP), patients they have been consulted on and agree to accept and sicker pediatric patients per family medicine request. Both services will help each other out as needed and able. The pediatricians do not admit BH/Title 47 pediatric/teen patients.

Admission Process

Admitting orders: Orders must be written (and accompanied by at least one admission diagnosis) before a patient can come to the floor. Orders can be written before or after going to see the patient in the ER or clinic.

Medication reconciliation: this process (w/ Order Reconciliation) must be completed following Nursing Initiation of orders to activate appropriate regular medications. The reconciliation process helps sort out any conflicting medication orders.

H&Ps : All admission H&P’s should be completed as early as possible after a patient arrives on the floor and must be signed and in the electronic chart within 24 hours of admission. You can use a Raven general admission note, create one of your own or use a shared pre-completed admission note. Ex: There is a shared admission note by McClure that has a prompt for the free text HPI and A/P and imports the last 24 hours of labs and limited summary vital data. If you choose to use a shared note, please save it as a new note with your new title. This keeps the shared notes from being changed.

E&M Charges: An appropriate level EM Order/Charge must be placed for every admission. These charges can be ordered in the power order section at the bottom of the Admission Orders or can be added to phase as a separate order.

Update Diagnoses and Problem List: All admissions must have at least one diagnosis. This is also a good time to review and update the Diagnoses and Problems after reviewing the patient’s history and EMR.

Immunizations and PPD Status: Please have NW clerk or nurse check Vac Trak (state immunization site) for all new admissions and propose any needed vaccines prior to discharge. For infants and children it is a good idea to give the immunizations at least a day prior to discharge so there will be no concerns about a fever after discharge.

PPDs that have not been done in the past 6 months can be repeated on admission. TB is a problem in the region and good surveillance is encouraged, especially for any patients admitted with respiratory illnesses.

Adult Admissions

There are a wide range of Adult Patients which often also include adolescents. As mentioned above (see Inpatient Unit), adult admissions must be stable and not require a large amount of resources to manage them.

At least one family member or escort can usually be accommodated with the patient. If the patient is breastfeeding, her infant can also usually be accommodated if there is a 3rd person present specifically to care for the infant.

If patients do not improve or if they worsen despite appropriate evaluation and treatment available at YLLHC, consult ANMC and transfer to a higher level of care as appropriate.

Common Adult Admissions

Abdominal

See acute abdomen, acute cholecystitis, gastrointestinal bleed, inflammatory bowel disease and pancreatitis all below

Abcess and Cellulitis

See YKHC Clinical Guideline for Abscess/Cellulits *link here and the IDSA MRSA Guidelines http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full#sthash.AnySZuMj.dpuf

A Raven PowerPlan is available on Adult Admit Orders and Wound Care is automatically consulted as is Pharmacy for vancomycin management. Lower extremity abscess and/or cellulitis patients should have a VERY LOW threshold for admission.

Acetaminophen OD

see Tylenol OD

Acute Abdomen

Often, the ANMC on-call surgeon will ask us to admit and monitor an acute abdomen patient (often partial small bowel obstruction) when appendicitis has been ruled out by CT. If the patient does not improve, they can be transferred to ANMC in consultation with Surgery.

Acute Cholecystitis

If the common bile duct appears patent, the ANMC on-call surgeon will sometimes ask us to admit and monitor these patients while on antibiotics. If the patient improves clinically, they can then be scheduled for non-emergent surgery.

Altered Mental Status (AMS)

AMS patients with normal vital signs and no overt etiology for symptoms may be monitored inpatient in consultation with ANMC Internal Medicine.

Alcohol related/Withdrawal

See YKHC Clinical Guidelines-p.20 as well as the Raven PowerPlan (also includes our Ativan Protocol) for this type of admission. Anyone hallucinating following cessation of alcohol ingestion should be admitted for Withdrawal and placed on the Ativan Protocol.

Anemia

If an anemic patient is symptomatic, they can be admitted for a blood transfusion.

Behavioral Health / Title 47

See YKHC Clinical Guidelines as well as the Raven PowerPlan for this type of admission. BH manages these four closed-circuit monitored beds in two rooms which are cohorted by gender and behavior. The Title 47 part is a special Alaska law which allows a police officer, physician or psychologist to temporarily take a person rights away (for good cause) if there is perceived threat to self or others. There is an outpatient form that is generally signed to transport the patient to the ER prior to admission and a required pre-checked order sentence in the Power Plan for T-47 (that allows up to get paid for the admission) before the patient will be allowed on NWing. WE as the physician admit and discharge the patient while the BH Clinican generally deals with the BH aspects works with the patient to move them where they need to go to for the best care. Physician-BH Clinician communication is essential for the best care of these patients.

Also, if a higher level of care is considered best for the patient, the BH Clinician will make the initial arrangements with the referral facility and if involuntary, obtain the necessary “exparte” from the local Judge.

Cellulitis

See abscess/cellulitis above

Cerebrovascular Accident (CVA)

Direct transfer of an acute CVA patient from the ER to ANMC should always be considered as these patients have better chance at rehab as the rehab-queue for Alaska Regional starts at ANMC inpatient.

That being said, non-hemorrhagic, non-brain stem and stable stroke patients can be monitored inpatient for 1-2 days to assure there is no clinical worsening. On a cardiac-respiratory monitor emboli-producing arrhythmias can be screened while Physical Therapy can help assess for rehabilitation potential and ability to swallow can be grossly assessed.

Neurology and/or IM at ANMC should be consulted and the patient transferred there if rehabilitation is a possibility. YKHC inpatients can only go to rehab via ANMC inpatient. Otherwise, YKHC patients are discharged home with an ANMC IM follow-up appointment for an MRI, echocardiogram and carotid duplex (if latter not done in Bethel).

Chest Pain

No MI patients are admitted to Northwing unless they are DNR/DNI and decline transport to Anchorage. A patient can be admitted for non-ischemic chest pain with cardio-respiratory monitoring to clarify the chest pain etiology.

COPD

See YKHC Clinical Guidelines for this as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. RT has been encouraging us to use Spiriva (tiotoprium) in favor of ipratropium as well as adding Advair on all such patients inpatient (and out outpatient as well). Albuteral nebulized orders for less than Q4hrs should be a rarity and CPAP use is very much an exception and if used at all, should only be for short periods. Patients requiring BiPAP cannot be admitted to NW.

CHF

See YKHC Clinical Guidelines for this as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. Also be cognizant that, like pneumonia above, this is one of CMS’s “high profile” illnesses and the CMS discharge recommendations for this diagnosis-includes EF and weight monitoring-is posted in the NWing Doc’s Office (important for billing). The known LV function (Ejection Fraction [EF]) for these patients is very important to document and if not available in Raven is often hiding in the old soft chart, RPMS-HIS Patient Chart, or online through ANMC. If this is a new CHF patient or no recent echocardiogram is in the record, a referral to Cardiology either through YKHC Specialty Clinic or at ANMC should be sent. Feel free to directly call the cardiologist at ANMC most familiar with the patient as needed or sometimes, especially during the weekend, IM will have to do.

CVA

See Cerebrovascular Accident above

Diabetes

It is reasonable to admit a diabetes patient with out of control blood sugars for glucose monitoring, medication adjustment, and education.

Frostbite

Any frozen body part should first be thawed in the ER. Wound Care Nursing and ANMC Orthopedics should also be consulted prior to admission and throughout admission. There are also YKHC Clinical Guidelines to cover this and a Raven PowerOrder set. Severe frostbite involving digit loss tend to be long admissions as ANMC advises “auto-amputation,” which in the long run has shown to reduce tissue loss, prior to a definitive surgical procedure.

GI Bleed

These patients can generally be admitted for blood transfusions, IV PPI and monitoring if the are “stable” and the ANMC surgeon is consulted. Emergency endoscopy is sometimes available at YKHC for further evaluation. Please also see the YKHC Clinical Guidelines and Raven PowerPlan for this.

Hospice

In consultation with the “Palliation Team” and because no Hospice service is available locally in Bethel of the surrounding villages, sometimes NWing is the best place for a person with a terminal ailment to comfortable and respectfully die.

Inflammatory Bowel Disease

Both ulcerative colitis and Crohn’s Disease are not common but we do admit these patients occasionally. We now have a GI specialist at ANMC to help us. Also, endoscopy can assist in making a new diagnosis and is often available M-F at in the YKHC Surgery Department. Contact the Surgery Case Manager or the endoscopy physician if your patient might be a good endoscopy candidate.

Pain Patients

Pain alone is a reason to admit a patient when outpatient treatment is inadequate. This could include acute low back pain, chronic abdomen pain or cancer with bone metastases.

Pancreatitis

The lipase level and the clinical situation usually make the diagnosis. The main reason for admission is usually the need for “gut rest” = IV hydration along with IV analgesia. Inpatient treatment usually consists of advancing the diet while switching to oral analgesia.

Feel free to consult with ANMC IM for both clinical help and any f/u needs. Follow-up with their PCP is also key to preventing re-admissions.

Pneumonia

See YKHC Clinical Guidelines for this (includes PSI-Pneumonia Severity Index to guide on who needs admission) as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. Also be cognizant of CMS discharge recommendations for this diagnosis posted in the NWing Doc’s Office (important for billing).

Pyelonephritis

All pregnant patients with a kidney infection should be admitted for initial treatment. Additionally, any patient who fails outpatient therapy or is unable to tolerate oral intake is a good candidate for admission.

Stroke

See concerebrovascular accident above

Title 47

See Behavioral Health above

Tuberculosis (TB)

If you suspect Active PULMONARY TB, then the patient should already be on Airborne Precautions* prior to arrival on Inpatient. This is also true if you order an AFB smear. Please see the YKHC Clinical Guidelines for TB, the Tuberculosis Book in the Doc’s Office and the Raven PowerOrders for this.

As a general rule, do not order a tuberculin skin test (TST) as most elders have either been treated for active TB or currently have a Latent TB Infection-treated or not. In addition to our medical record system, Bethel Public health Nursing (543-2110) has the best records for past TST results and treatment history.

It is unnecessary to admit a reliable Bethel resident for suspicion of TB if they are clinically stable. This is not true for village patients in Bethel who may become a community infection risk if they travel home by airplane.

Until the rapid TB assay (Xpert® MTB/RIF) is implemented sometime this year in 2015, it will take between 3-7 days to receive 3 AFB reports from the State Epi Lab (907-334-2100) to effectively rule-out infectious pulmonary TB depending on a number of factors. Generally, seek advice from one of our fine YKHC TB Control Officers (currently Elizabeth Roll, Ron Bowerman, Cindy Mondesir or Mien Chyi) or the State TB Officer, Dr. Michael Cooper (or his associated mid-level provider), before initiating therapy. T rapid TB sputum assay mentioned above will give more certainty and speed in clinical decision-making.

Tylenol OD

Please contact Alaska Poison Control (1-800-222-1222) which is based at OHSU in Oregon. They are very helpful and have access to a toxicologist if needed.

Our initial contact with these patients is usually through RMT. Oral mucomyst is in the village clinics and can be given every 4 hours until the patient arrives in the ER where blood levels are available and IV mucomyst, as needed, can be administered. Once admitted (see the Raven Tylenol PowerPlan), these patients complete their IV treatment with lab monitoring. Once medically cleared, BH should evaluate for suicide risk and appropriate discharge planning.

Pediatric Admissions

On the inpatient unit we are able to admit moderately sick pediatric patients, but if a patient is expected to need nebs q 2 hrs for more than 8 hours or require too much nursing care, the patient will need to be transferred to Anchorage directly from the ER. Any pediatric patient being admitted from the ER or the clinics must have a YKHC modified PEWS score calculated and reviewed per protocol. ER nurses can calculate a score in the ER and the NW nurses can calculate a score on clinic patients with information from the clinic nurses. Patients with a YKHC PEWS scores of greater than 5 require ER and Inpatient nurses, providers and RT (if indicated) to huddle a access whether the patient is stable enough for YKHC admission or whether they should be medevaced to a higher level of care.

In general, vital signs on the unit are done every four hours. Diapers can be weighed for strict I’s & O’s if necessary. The nurses are able to place IV’s and draw blood. Parents typically room in with their children; however, siblings under the age of fifteen are not allowed on the ward overnight. Children who require high flow O2, continuous IV drips, central lines, close monitoring, imaging or evaluation not available at YKHC or who require NICU or PICU level care are transported to ANMC or Providence Hospital in Anchorage. Occasionally we will admit a patient that is pretty sick, but is felt to have a good chance of improving. If this is not happening in the expected length of time, the nursing or RT staff is uncomfortable with the patient or if you feel the patient is getting worse—do not hesitate to transfer the patient to Anchorage. YKHC PEWS scores should be completed and reviewed on patients who worsen during their admission. This is done to identify, as early as possible, the patients who may need a higher level of care.

Common Pediatric Admissions

Chronic Peds Patients (CPP) link to CPP definition in peds section

The pediatricians admit CPP patients. These patients have complex, chronic illnesses and are managed by the pediatric group and the pediatric case manager. The pediatricians may ask the family medicine providers to take a CPP patient if they are overloaded. Any CPP patient admitted as a BH/Title 47 patient will be admitted to family medicine and peds can consult on the patient as needed.

Neonatal Fever

Infants under 90 days of age with fever who meet admission criteria per the ‘0-90 Day Infant Fever Guideline’ *link here are admitted after an initial work up, on or off antibiotics, as indicated. Use the PEDS Admission power plan plus the admit subphase PED Infant 0-90 Day Old orders that have preselected and other order choices to help with these admissions.

Infants who were pre-treated in the village and/or those patients where a tap was not obtainable in the ER present a challenge for management and treatment. Your options are to try to:

  • 1. repeating the LP on NW the following day and look at CSF cell count and gram stain OR
  • 2. watch off antibiotics and re-tap if patient worsens and needs to start antibiotics OR
  • 3. treat for 10-14 days of IV therapy for possible meningitis

Hyperbilirubinemia

Infants are admitted per our Hyperbilirubinemia Guideline’ *link here for phototherapy. At the top of the general peds admission orders there is an additional powerplan labeled PED Phototherapy that has preselected and selectable choices to help with these admissions.

Abcess and Cellulitis

Use the Skin and Soft Tissue Infection Guideline *link here to direct care. Admit using pediatric admission order plus the sub powerplan labeled PED Abcess/Cellulitis that has preselected and other choices to help with these admissions. Consider using dilute bleach baths with these patients as well.

Pneumonia/Bronchiolitis:

Use the ‘Community Acquired Pneumonia and Wheezing Guidelines’ *link here to direct care plus the additional powerplan labeled PED Respiratory Infection that has preselected and other choices to help with these admissions. Note: if a patient is requiring q 2 nebs, more than 2L O2 or our RTs and nurses are uncomfortable with a patient’s clinical status, it is time to consider transferring the patient.

TB Screening Admission

Kids under 5 years and those that are too young to give a reliable sputum sample are admitted for morning gastric aspirate collections for three mornings. Please refer to the ‘Pediatric TB Guideline’ *link here. Use the additional admission sub powerplan labeled PED TB Gastric Aspirate that has preselected and other choices to help with these admissions. Although patients under 5 do not produce large enough to be contagious, regional and lower 48 standard of care is to put anyone on the inpatient unit in a negative flow room.

The aspirates are sent to the state lab for initial screening and you will have to call the afternoon or the morning after the last aspirate is sent to get the results. The final results will take weeks to get back so you will need to speak to a pediatric (Chyi) or adult TB (Bowerman and Roll) officer to determine therapy and follow up. These admissions will be 3-4 days minimum.

Stomatitis

Occasionally a patient will fail outpatient treatment/support of bad stomatitis and they will be admitted for pain control and fluid support until they improve enough that they can stay orally hydrated on their own. Use the regular Pediatric Admission powerplan plus the additional sub powerplan labeled Derm Oral that has preselected and other choices to help with these admissions. It is a good idea to put the kids on the magic mouthwash that contains lidocaine, monitor Is & Os and weights and push cold fluids. IV bolus and/or maintenance fluids can used for additional hydration as needed. Motrin and Tylenol are usually all that are needed for additional pain control. We recommend against anything stronger as it is usually not necessary. By the time a patient is admitted it is usually too late to start acyclovir which is considered of limited benefit anyway.

Superinfected eczema

These patients usually have pretty bad skin disease and have failed outpatient therapy. They are admitted for aggressive therapy, support and family teaching. These kids will need bleach baths and possibly IV Clinda or Vanco. Use the regular Pediatric Admission powerplan plus the additional sub powerplan labeled PED Derm Oral that has preselected and other choices to help with these admissions. There are also good discharge handouts that have been customized by peds that can help with home care.

Failure To Thrive (FTT)

These infants and children are generally admitted by peds. Most of these patients are admitted with presumed inadequate calorie support and social issues. Use the regular Pediatric Admission powerplan plus the additional sub powerplan labeled FTT which has preselected and other choices to help with these admissions. If a patient is not gaining after 3-7 days of adequate caloric intake, then a organic FTT work up can be started. If a more comprehensive workup is required, it is better done at ANMC or Providence as most of the labs for this are send outs from here and it takes weeks to get the reults.

Brief Resolved Unexplained Events (BRUE)

Generally low risk BRUE events do not need work up and admission, but occasionally these patients are admitted for observation for 12-24 hours, with close monitoring, to reassure parents and caretakers that the event does not repeat and to further evaluate other possible etiologies such as reflux, aspiration, seizure, RSV in a less than 2 month old, meningitis, etc

Seizures

Occasionally seizure patients are admitted for monitoring. see link to seizure evaluation guideline . This may be for reassurance and education, for starting or re-starting medications or to rule out meningitis or another concerning cause. If the patient experienced status, had a focal seizure or has had more than one seizure in 24 hours, then the patient should be transferred to ANMC for further evaluation and treatment. For any post seizure admission, make sure the patient has an IV and both IV and rectal diazepam are ordered. Referrals made for an EEG and MRI if indicated usually take weeks to months to get completed as an outpatient. This is because these referrals are considered non urgent and the patient must have or obtain their tribal card and have Denali Kid care or pay for their travel. The appts then often get missed because of weather or family responsibilities etc. It is therefore best to transfer seizure patients, that need more urgent work up, to Anchorage. When you discharge a patient > 6 months of age at risk for seizures—please make sure they go home with rectal diastat with refills and a peds discharge handout for seizures.

Rounding

Progress Note: Every patient must be rounded on daily and have a progress note completed. Daily progress notes must be written in a SOAP note format. There are templates and shared SOAP Note/Progress Notes to choose from and modify if desired.

All pertinent/interval labs should be included in addition to documenting interval history and patient/ parent teaching. It is helpful to have a free text assessment and plan with a clear explanation of the problems and plans for the patient daily. This will help the next provider/cross cover provider if they need a quick snap-shot of the patient and plans.

E&M Charges: An E&M charge order must be placed for each day a patient is seen. If you come on service and charges have not been entered by the proceeding physician, please back enter them for them :)

Procedures

There are a variety of procedures done on the inpatient unit under a provider’s scope of practice which include core, specific and proctored categories. Procedures need to be documented and some require consents to be completed. You can use pre-completed Raven procedure notes, document procedures as a free text within a note, or documented a procedure in a separate note. The following is a list of procedures that are regarded as appropriate to perform inpatient.

LP: This is more commonly done in the ER on the way to NW but is done either in the Peds Treatment room or if adult, in the patient room.

I&D: same as above but conscious sedation is not an option on NW. Usually local anesthesia only is used or IV anxiolytics can be added for patient comfort.

Nexplanon: This family planning option is only done by a Nexplanon-certified provider

Joint Aspiration/Injection: same as “LP” above

Wound Care/Debridement: This is done by all members of the healthcare team including but not limited to the physician, nurse, wound care RN, and PT.

Paracentesis: appropriate with proper credentialing & clinical situation; also consider US suite or ER

Thoracentesis: same as above

Central Line: same as above

Intubation: same as above

Special Situations

BH to North Star: sually at the recommendation of the behavioral health clinician and requires a doc-to-doc conversation

Code: The *Doc (star-doc) wears the code beeper and in addition to responding to all hospital “code blues,” is the code leader on NW until the ER attending arrives. There are 2 crash carts with Zole defibrillators on NW and the closest AED is immediately outside of NW in the Surgery waiting area. Early “shock” and transport to the ER should be considered. Preventive code blue measures such as not accepting unstable patients to NW and designating code or “natural death” status are encourage.

Death on NW: This requires a physician to “pronounce” the patient, write a “death note” as part of the discharge summary and contact the state medical examiner. The charge nurse has the complete list of things that need to be completed before sending the body to our morgue. link to death

Remote resuscitation or videoconference: As mentioned earlier, there are 3 VTC phones in the hospital (2 on NW) to assist with a remote resuscitation. No medevac should be activated without a pulse present.

Patient to OR or Endoscopy: Usually this occurs when a GI bleed patient is actively bleeding or an elderly patient requires an inpatient prep and of course a procedureist is available

Breastfeeding patients: If the patient is breastfeeding, her infant can also usually be accommodated if there is a 3rd person present specifically to care for the infant. This is current 2015 policy per both our chief-of-staff and corporate nurse CEO.

When a patient asks to leave early: This may involve the art of mutual respect as well as the art of medicine and sometimes an interpreter. The key issues involve whether discharge now can be a viable plan and if not, the patient is asked to sign a “left Against Medical Advice (AMA)” form.

This of course does not apply to a “titled” BH, incarcerated or TB-isolated patient. The latter patient may require the rare order from our state TB control officer (see TB section above) to keep him inpatient.

Please feel free to consult a fellow clinician for advice.

Disruptive patients/family: see above 1st paragraph

No boarding: per Peds Group

Isolation: In addition to Universal Precautions on Northwing, patients requiring isolation fall into 3 categories

  1. . Contact
  2. . Droplet
  3. . Airborne

All patients with the above isolation status have signs posted outside their room with instructions on how to responsibly enter. Also outside each isolated patient’s room should be a shelf or cart with the necessary protective equipment. Every nurse and physician should be fitted for the appropriate N-95 respirator.

In addition, washing (or antiseptic gel/lotion) before and after contact with any patient is our infection disease standard and is enforced. Northwing nurses/physicians have had a good history of compliance

Discharges

Remember that discharge planning should begin early to anticipate equipment, follow up, travel and other challenges. Interdisciplinary rounds can help with this process. Discharges should be done when the patient is well or stable enough to be supported at home in a village with health aide support. If the weather is bad in the village that a patient is returning to or if you need to monitor the patient closer to the hospital for another day or two, the patient can be discharged to Bethel to stay at the hostel or with family or friends. If needed the patient can be followed daily in the clinic or ER.

That being said, keeping a patient for an additional day or two may ensure the patient return soon to inpatient.

Follow the “discharge summary” process on Raven

(all buttercup-colored items need addressing or open circles filled in the depart process depending on the system you use for your discharges)

  • Provide at least one discharge diagnosis
  • Complete Discharge Instructions /Education. Raven has a lot or pre-completed education handouts that will be suggested OR you can chose ‘ALL’ patient education and type in what you want to search for. There are about 50 pediatric handouts that have been customized by the pediatricians and can be located by typing in “peds” or choosing education materials that are marked ‘PEDS custom’. There is also a Peds Discharge education handout that is a nice generic summary that is good to add to the pediatric discharges.
  • Add follow up instructions with click and pick menu or with free text option.
  • Order discharge meds— For chronic medications please give 11 refills
  • Complete the medication reconciliation process
  • Complete a discharge charge for greater or less than 30 minutes.
  • Only order patient discharge when process is complete and you are ready to have the nurse print out discharge paperwork. Otherwise incorrect material may be printed out for the patient, thus confusing the discharge process.

Complete a Discharge Summary: Every patient discharged from the inpatient unit needs a discharge summary. You can use a general Raven discharge summary, create one of your own or use shared pre-completed template. Ex: Paster’s pre-completed note has incorporated all the required elements requested by our Chief of Staff.

In your discharge summary follow up and plan…Be sure to let the follow up providers know what the plan is and what to be concerned about. Make sure the follow up plan and any concerns are clearly documented in your discharge summary. Always let the family know that the patient (usually) is not completely well, but that we feel they have improved enough that we feel that they will continue to slowly get better at home. They should also be warned that there is a small chance that the patient will not improve and might have to return. Be sure to document that the patient/caretaker is comfortable with discharge and knows when to return to see the health aide if the patient should get sicker.

Note: For pediatric discharges there is a peds custom patient education sheet documenting this information that should be given to the parents/caretakers.

Update the Problem List: It is important to update the diagnoses and problem list for each patient on discharge. Think about what you would like to know, at a glance, about this patient for a future ER visit, RMT, admission etc. You can add additional to any diagnosis or for further detailed information. A well kept problem list, with notes on plan of care/therapeutic goals/important follow up needs etc provides ongoing continuity and good patient care.

Signing out a service

If a patient is admitted for longer than five days or has a complicated course, an off service note should be completed when ending your wards rotation. In place of the above, a detailed daily SOAP note should suffice.