View source for Harbor:Operations manual

==ADULT ACUTE ED==
{{Harbor Surge plan}}

===DISASTER INSTRUCTIONS===
Detailed Instructions are in the CODE TRIAGE Notebook in the Radio Room

====General Instructions====
#Everbridge System notification for callbacks if at home - REPORT to Treatment Area Manager for assignment
#Activate “Code Triage” based on info from EMS/Reddinet: Criteria: Affects at least 10 patients and may exhaust the medical center’s resources  (For less than 10 patients, can activate "Code Triage Alert")
#Notify Incident Commander (IC)
##Business day (M-F 8-5): Hosp Admin: x2101
##After hours: House Supervisor: x3434
##Request lockdown type from Administrator or House Supervisor
###No security threat anticipated: "Modified Lockdown"
###Possible security threat (including large number of family, etc) - "Full ED Lockdown"
##Activate Trauma Team as appropriate
##If  HAZMAT - 
###Charge RN assembles DECON team
###Small Scale - Decon Shower in ED - NA7 key
###If large scale - call mechanical to setup decon trailer x3301 (Takes up to 1 hour)
###(?) Consider activate 911 to get HAZMAT involved
#Accept patients from EMS, generally we suggest the following initial maximums, but the situation will dictate need to exceed these numbers:
##10 Immediate
##20 Delayed
##20 Minor
##Burns - we may need to accept up to 12 if system overwhelmed
#A "sub-command" post will be set up and overseen by the Casualty Care Unit Leader (Nurse) in the Pedestrian Spine.
#Assign roles:
##Immediate Unit Leader (IUL): Purple (A) ED attending 
###Location: Trauma Area, use AAED as needed
##Delayed Unit Leader (DUL) - Green (B) Attending
###Location: AAED, RME, use Pedestrian Spine as needed
##Pediatric Unit Leader (PUL) - Pediatric Attending
###Location: PED
#Other Unit Leaders
#*Casualty Care Unit Leader (ED=Casualty Care Unit) - Nurse Manager/RN
#*Treatment Area Manager - Nurse Manager/RN
#*Communications officer - MICN
#*Triage Unit Leader - Overall Charge/Senior RN
#*Expectant Unit Leader - RN
#*DECON Unit Leader - Most experienced RN, NP, LVN, or NA on shift
#IUL, DUL, PUL Responsibilities
##Activate as per above
##Put on vest
##Inform CT, Xray of situation
##Determine Spectra Phone numbers of other leaders (Additional Phones may be obtained from nursing office)
##*IUL________
##*DUL________
##*PUL_______
##*MTUL_________
##*Casualty Care Unit Leader (CCUL) (ED=Casualty Care Unit) _______
##*Treatment Area Manager (TAM)______
##*Communications officer (CO)_________
##*Triage Unit Leader (TUL) ________
##*Expectant Unit Leader (EUL)_________
##*DECON Unit Leader  (DecoUL)_________	
##Facilitate transfers and DCs out of your area
##Communicate situation with Trauma Attending
##If additional staff needed - Notify TAM - can use Everbridge
##For additional supplies/resources - notify TAM
##Supervise care of patients in your area
##At end - debrief with TAM
#Minor Treatment Unit Leader (MTUL): Nurse Practitioner
##Put on vest
##Determine Spectra Phone numbers of other leaders (Additional Phones may be obtained from nursing office)
##*DUL________
##*PUL_______
##*MTUL_________
##*Casualty Care Unit Leader (CCUL) (ED=Casualty Care Unit) _______
##*Treatment Area Manager (TAM)______
##*Communications officer (CO)_________
##*Triage Unit Leader (TUL) ________
##*Expectant Unit Leader (EUL)_________
##*DECON Unit Leader  (DecoUL)_________	
##Facilitate transfers and DCs out of your area
##For additional supplies/resources - notify TAM
##Supervise care of patients in your area
##At end - debrief with TAM
#Tracking Patients
##Patients are initially tracked on paper form (HICS 254)
##They are quick registered by Triage Unit as time permits
##If can't quick register all - use disaster packets (Pedestrian spine storage by Router desk)
##If disaster packets exhausted -- use Disaster Triage Tags (Pedestrian spine storage by Router desk)
#Labor Pools
##Physician – Resident’s Lounge
##Other labor/Runners – Employee/Public Cafeteria
#Communication Options
##Spectra Phones - Primary communication tool in ED for Code Triage - Additional phones in nursing office.
##Runners 
##Pay phones
##*Work on different system than hospital phones
##Cell Phones
##Reddi-net
##*Email to County Emergency Medical Services Agency and private EDs
##Red Walkie-talkies - Channel 5 - Pedestrian Spine storage by Router Desk, for use  by Casualty Care Unit Leader only, or all Unit leaders if Spectra phones do not work.
##County-wide Integrated Radio System (CWIRS) 
##*Long range
##*Links all County Depts/Facilites/Emerg Op Center

====Area Setup====
#< 30 victims
#*Triage - Triage Room and main entrance
#*Post Triage - Pedestrian Spine
#*Immediate - Trauma
#*Delayed - AAED/PED
#*Minor - RME
#31-100 victims
#*Triage - Triage Room and main entrance
#*Post Triage 
#**Immed and Delayed -Pedestrian Spine
#**Minor - Front of SE, possibly UCC WR or Old WR?
#*Immediate - Trauma and AAED/PED
#*Delayed - AAED/PED and RME
#*Minor - UCC, Peds Clinic
#>100 victims
#*Triage - Triage Room and main entrance
#*Post Triage
#**Immed -Pedestrian Spine
#**Delayed - Waiting Room
#**Minor - Public Walkway in Front of SE, possibly UCC WR or Old WR?
#*Immediate - Trauma and AAED/PED and RME
#*Delayed - RME. Pedestrian Spine
#*Minor - UCC, OB-GYN Clinic, Peds Clinic
#Pedestrian Spine
#*Place color coded triage signs 
#*Place color coded cones for "post triage" areas
#*Move 2 tray tables and 2 large trashcans to spine
#*Move PPE cart w/ extra gloves to spine
#Vehicle Entrance to Ambulance Ramp
#*Line up wheelchairs, gurneys and spare backboards
#*Housekeeping should get and assemble disaster gurneys from Trailer #2

====Disaster Triage==== 
#ADULT AND YOUNG ADULT  Triage Category Definitions 
#*Minor - Ambulates without assistance OR minor lower extremity injury
#*Expectant - No spontaneous breathing after airway positioned 
#*Immediate
#**Apnea responds to positioning
#**RR >30
#**No palpable Radial Pulse/Cap refill > 2sec
#**AMS
#*Delayed - Needs gurney but not immediate

#CHILD Triage Category Definitions 
#*Minor - Ambulates without assistance OR minor lower extremity injury
#*Expectant - No spontaneous breathing after airway positioned and 5 rescue breaths
#*Immediate
#**Apnea responds to positioning or rescue breaths
#**RR <15 or >45
#**No palpable Radial Pulse/Cap refill > 2sec
#**Posturing or unresponsive
#*Delayed - Needs gurney but not immediate

====Supplies====
*Airway Cart – 
*Atropine - use ED supplies first- Mark I antidote stock in basement - requires MAC approval (see Code Triage Manual for Phone number)
*Code Triage Packs - Wheelchair Storage Closet
*Cones - Triage Color Coded - Wheelchair Storage Closet
*Decon Team Supplies - Decon Closet - Second backboard closet outside of ambulance entrance - Keys in Pyxis in AAED (SE 1J25)
*Decon Trailer - Trailer Lot
*Disaster Cart - Central Supply and Linen Room SE BF09 - keys on big ring in Command Post (1L1) cupboard
*Disaster Packets - (Pedestrian spine storage by Router desk)
*Disaster Tags - (Pedestrian spine storage by Router desk)
*Dosimeters - Radiation Safety Office Building N32
*Geiger Counter
**1 in ED Pyxis
**6 in Radiation Safety Office Building N32
*Gurneys, disaster – Trailer #3 - Give keys to housekeeping - they will open trailer and assemble gurneys
*Keys - AAED Pyxis (SE 1J25)
**For instructions see disaster manual
*Manuals for Area leaders- Wheelchair Storage Closet
*PAPR - Decon Closet
*PPE –  Decon Team Supplies Closet - Second backboard closet outside of ambulance entrance - Keys in Pyxis in AAED (SE 1J25)
*PPE - Level C - Decon Closet
*Privacy Kits for Patients - Decon Trailer
*Signs - Triage Station - Wheelchair Storage Closet
*Trailers 1-5  [Whats in these?] - keys in Pyxis AAED
*Vests - Wheelchair Storage Closet
*Walkie-Talkies (Red) - (Pedestrian spine storage by Router desk)
*Wheelchairs - (SE1A04) - NA7 Key

Dir OPS 9/14/16

===ECG STEMI screening===
* R4s, in addition to attendings can screen for ECGs to ensure a timely screen for STEMI. 
The point of this screen is to pick up STEMIs as soon as possible. If you see any other emergent issues on the EKG, feel free to call the responsible provider, but it's not the screener's job to relate all EKG issues to the responsible physician.

* Please do not refuse EKGs from the EKG tech if you are an attending or R4 no matter what you are doing (including rounds). It takes only seconds to look at the EKG for a STEMI. Computer entry can be done later if necessary.

Process:

* ECGs being done in AED rooms would be given to the R4 or attending in the AED/Purple physician workroom, similarly ECGs done in the RME area would be given to the R4/attending in the RME/Green physician work room. IT DOESN'T HAVE TO BE YOUR PATIENT.

* If the ECG tech is unable to locate the R4 or attending, then they should call the ED attending Spectralink phones (Purple/AED 23202, and Green/RME 23206) to find their location and bring them the ECG. (Even if rounding or seeing a patient).

* If a STEMI is identified, or if there are any questions about a possible STEMI, the R4 should confirm with an ED attending prior to activating a STEMI. 

* ECG techs should not be batch handing the ECGs to the R4/Attending in order to prevent any unnecessary delays. 

* Of note: there is not always an R4 working each shift, so it's important for the ECG tech to ask who is interpreting ECGs on any given shift. We will ensure that the physician appropriately identifies themselves and are receptive to this plan prior to implementation. 

* R4s and attendings will click on the ECG in ORCHID, and perform the ED Screen: Document "NO STEMI” or "STEMI ACTIVATION PERFORMED" on the EKG interpretation and click on the "ED Review" button to clear the eyeglasses icon . The time of the entry is stamped on the EKG read.

* For patients already admitted or officially on OBS/CORE - perform the screen but do not enter an interpretation or clear the eyeglasses, so the responsible physicians know that they have a EKG waiting. If there's a STEMI or other concerning finding NOTIFY THE RESPONSIBLE TEAM.

*Should you not have immediate access to enter your interpretation on the computer (sometimes the EKG has not been uploaded, or you are occupied and/or not near a computer), write the interpretation time on the EKG and save it. Then when you have time, go back and do the entry but now add the time "NO STEMI ACTIVATION READ AT [TIME]"

===iSTAT Tests===
EG7+: Na, K, Ca, Hgb/hematocrit, Blood Gas (pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

CG4+: Lactate, Blood gas(pH, pCO2, pO2, TCO2, HCO3, base excess, sO2)

CHEM8+: Na, K, Cl, CO2, AG (Ref range "10-20"), Ionized Ca, Glu, BUN, Cr, Hgb, HCT

===BIOFIRE TESTS===
#Meningitis/Encephalitis Panel (CSF from LPs only)
##E.Coli K1
##H. Flu
##Listeria monocytogenes
##N. Meningititis
##Strep agalactae
##Strep pneumonia
##CMV
##Enterovirus
##HSV-1
##HSV-2
##Human herpes virus 6
##Human parechovirus
##Cryptococcus neoformans/gatti
##Varicella zoster
#Respiratory Panel
##Adenovirus
##Coronavirus HKU1
##Coronavirus NL63
##Coronavirus 229E
##Coronavirus OC43
##Human Metapneumovirus
##Human Rhinovirus/Enterovirus
##Influenza A
##Influenza A/H1
##Influenza A/H3
##Influenza A/H1-2009
##Influenza B
##Parainfluenza Virus 1
##Parainfluenza Virus 2
##Parainfluenza Virus 3
##Parainfluenza Virus 4
##Respiratory Syncytial Virus
##Bordetella pertussis
##Chlamydophila pneumonia
##Mycoplasma pneumoniae




{{Admitting a patient}}

===Observation (Gold/CORE)===
*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - Peterson 5/2016
*Only patients with internal medicine (or family medicine) covered illness can be placed on obs.  All other services require admission (or transfer) - Lewis 5/2016
*If the hospitalist is capped (cap is 20 if single overnight hospitalist coverage, which includes Obs and CORE leftover from dayshift, new Obs or CORE, and new admissions), and you have a patient you’d like to place in Observation, CORE, or an admission: 
**Do not place the order for obs placement, CORE, or the ‘request for admit’ order. This becomes confusing for nursing who is actually managing the patient. Only place this order when you have discussed the patient and the care officially transfers to the inpatient/obs/CORE physician.
**Continue to manage the patient until the next hospitalist shift starts (typically 7:30am) or the next medicine slot is available.
**Do put in an Attending Admit Note at the time of the actual admit decision but document in your notes that patient is being held in the ED due to lack of hospitalist/Medicine capacity.

Dir AED, 7/2016

{{Admission Guidelines}}

====Direct Admission after Hours====
*If a patient who appears stable presents to the ED stating they are a direct admission, they should be sent to ED registration
**ED registration will confirm with bed control/patient flow that the appropriate paperwork has been completed
***If the patient was inadvertently registered prior to discovering they were a direct admit, they can be removed ("registration in error")
**If the paperwork has not been completed, ED registration will attempt to contact the admitting physician to complete the process
**If they are unable to contact an admitting physician, the patient should be directed back to the router for entry into the ED process
*Patients may directly placed in CORE by cardiology without ED evaluation
*All patients going to Observation must be evaluated in the ED with an ED Chart completed (no direct placements on Observation by clinics, etc.)
*Any inpatient direct admissions presenting before 8pm on Weekdays:  admitting physician directly contacts Bed Control (x2185) for Ward Beds or Patient Flow (x3434) for Tele/PCU beds 
*If after 8pm on weekdays, or weekends and holidays:  Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from ED registration window x2075/2076/2078 or Bed Control) 
#Admitting physician provides a copy of the request to ER Registration and they create a pre-admit FIN  
#Admitting physician provides a copy of the request to Bed Control/informs location of patient to release bed (ER)
##UR (x3226) financially clears patient or calls to obtain authorization (if OOP) and informs Bed Control of approval or denial 
###If the patient is denied, UR informs the admitting physician and Bed Control of denial
###Admitting physician then must decide whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment 
###If patient is DHS (approved), admitting physician inputs the admitting order on the pre-admit FIN  
#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 #)  
## Stable patients should be placed in one of the internal waiting rooms and until the upstairs bed is available;  reassessment should occur per nursing protocol (q2 hours for ESI 2-3) 
##If a 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
#The Scheduled Admission Office (x2137) is open from 530am until 8pm, and admitting physicians should take stable patients there while awaiting a bed.  If no bed is obtained by 8pm, then the admitting physician will be contacted and their service should take the patient to the ED to wait until a bed is obtained.  They should be held in the WR and placed on the tracking board as a pre-arrival, but not registered in the ED as they already have admission orders.  
## If the hospital capacity is limited, it is important that orders are placed as PLANNED, NOT ACTIVE, so they can be activated in any hospital location (this will allow a pre-admission that is boarded in the ED to have orders such as antibiotics completed while waiting for a bed)

Chappell 7/2016

===Social Work Consultation Guidelines===

Generally, please call Social Work early if you anticipate any issues so they can get things during business hours and get to families before they leave.  Consult by placing a social work order in Orchid (documents consult time). 

====1. Transportation home:====

======bus:======

a. during day 8-4:30 - send to s/w office / page s/w for bus fare voucher

b. nights/wkends/holidays - call nursing's supervisor @ x3434 to approve bus token and then pt can pick it up from ER registration

======taxi:====== 

a. If pt is UNINSURED - limited number of vouchers - if MEDICALLY necessary (ie can't take bus for medical reason) - s/w can help with this - 

b. If pt is INSURED (including medi-cal) - insurance company will pay for taxi (pt may have to wait a few hours) - consult s/w and they can help figure it out

======ambulance:======

For patient's that have a medical necessity (cannot ambulate, here w/o wheel chair, etc) and medically cannot take a taxi

a. If pt is INSURED (including medi-cal) - the insurance company will pay for an ambulance home
* UR can help with insurance specific contact info for coordination of ambulance
* May be limited by patient's home location (i.e. LA vs Torrance, etc)
b. If pt is UNINSURED (including restricted medi-cal) - use county transport (866-941-4401) to get an ambulance home
* If pt lives outside of LA County, call nursing supervisor or SW as they may need further authorization

J Singh 5/9/17

======kids without car seats:======

For kids who arrive (usually by ambulance) w/o a car seat, we do not have car seats available.  however, options are:

a. take the bus home (no need for car seat)

b. have someone bring a car seat and pick them up or go home in a taxi w/ the car seat that is brought

c. if a. or b. will not work, can try arranging for ambulance (see section above)

====2. Patient who are homeless:====

a. Homeless Task Force - looking for patients with chronic illness (HTN, diabetes, psych, etc) who have had 2+ visits.  Put in s/w consult and choose "Homeless" under reason for consult, NOT "Discharge planning/placement".  If eligible - they will help sign up the patient - however, they may be on a waitlist for days to months.

b. Patients discharged overnight who are not safe to go out into the night CANNOT wait in the ED lobby.  However, they can wait in the main hospital lobby in front of the social work offices to speak w/ s/w for resources on housing in the AM.

J Singh 5/9/17

====3. Durable Medical Equipment (DME)====
# Order in ORCHID is "DME subphase." Items can be selected from a list of available supplies or enter item under ‘Misc’. MD also enters an end date, quantity, or refill amount.
# Call Durable Medical Equipment (DME) office at x5497 (p0623) Frank and provide patient’s MRN. Hours Mon-Fri 8 am to 5 pm, office is 1-G-13 (near old Ped ED, current Heart Station)
# Frank prints the ORCHID script and faxes to patient’s insurance company. DME will be delivered directly to patient’s address in approximately 4-5 days.  If necessary, ensure patient has some supplies until delivery starts.
# After hours or weekends: can contact Supercare (the DME supply company) at 800-206-4880. Can deliver to ED (may not be right away) or patient home.

J Singh 5/9/17

======walkers======

a. first,  MD enters prescription in ORCHID.  Then call Frank who is w/ DME medical supply company - see above  - during business hours - ext 5497. 

b. if during business hours and no reply from Frank, consult s/w.  s/w may help get patient home and then arrange for home walker delivery (see bullet a. - it may take a few days for insurance to approve). insurance may pay for it - but it may take a while

c. if after hours, there is a limited supply of walkers for use after hours when DME office is closed. Ask Charge Nurse to obtain from Nursing Supply Office. 

d. if all else fails and pt is unsafe to go home, then we must place the patient in obs

A.Wu, Dir AAED 12/7/16

======wheelchairs======

a. same as above, except we do not have a secret stash

======other DME======
 
a. process is same - except for supplies - patients will not get delivery for 4-5 days - so make sure they have 4-5 day supply when they go home.

====4. Patients whom family is no longer able to take care of====

Please page social work asap - before family leaves - s/w will work with them to see if:

a. IN HOME SUPPORT SERVICES (IHSS) - Medi-Cal program - can either be started or have hours increased (to help w/ supervision, cooking, bathing, grocery shopping, other ADLs)

b. other community resources are available 

c. help family brainstorm other ideas

d. if family dumps patient and doesn't respond, s/w may file an adult protective services report

e. if the patient truly needs to be placed and resources and strategies of a/b/c do not work, per Dr. Wu, please place in obs and the inpatient team will work on placement from there

====5. Pt/family not happy with current skilled nursing facility (SNF)====

a. generally, this is not an appropriate use of the ED - the family needs to work with the SNF s/w to facilitate transfer to another SNF, exception point c. below

b. if actual abuse, s/w at Harbor can help w/ ombudsman report

c. APPROPRIATE if pt needs a HIGHER level of care b/c of medical needs - then s/w at Harbor can help  

d. Different levels of care are outlined in slides (attached) - shelter vs respite vs board and care vs SNF vs ?

====6. Clothing rack / clothing for patients====

a. s/w has a small stash in ED - consult/page to get access
* Located behind double doors in ambulance bay. NA-7 key for access.

b. volunteers office has another stash but only open 8-5 M-F

ED stash is in need of donations for men's pants, flip flops, sweat pants, sweat shirts

J Singh 5/9/17

====7. Patients who need PT/OT for placement====

a. place the patient in obs for placement and PT/OT evaluation - this way the hospitalist can then admit the patient from obs if they cannot get PT/OT (which they more likely than not cannot) - this is needed to document the need for PT/OT so we can get resources (it shows how many avoidable admissions there can be as the ED hospitalists are collecting this data manually).

===Mandatory Reporting of Adverse Events===

There are events which we must report to the state in a timely fashion or face being penalized by State Licensing. Below are some general guidelines for what to report. Please make sure that the ED attending is aware of these events and documents their involvement in the record.

Events must be reported within 4 hours to both of the following:
#PSN (Patient Safety Net)
#Risk Management x2168

Events to be Reported
#Procedure performed on a wrong body part, patient, or the wrong procedure all together.
#Retention of a foreign object (e.g. central line guidewire) 
#Patient death or serious disability through any actions or errors which are not an expected part of the patients medical condition or treatment, including elopement of an incompetent individual or minor, or an assault.
#Visitor or staff death or severe disability while on hospital grounds for any reason.
#An infant discharged to the wrong person.
#A maternal death or serious disability within 42 days post delivery 
#Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
#Any abduction or sexual assault of anyone on hospital grounds.

(Ref: Reporting Form – Adverse Events -Julie Rees)

(Hospital policies 612A, 612B  5/14)

===Prescriptions===

====Lost Triplicate Prescriptions====

If you find that your providers are missing prescriptions or are contacted from a pharmacy regarding suspected fraudulent prescriptions please do the following as required by the Department of Justice,.If you are unsure if you are missing any individual prescriptions, please assume that they have been stolen and report.  

#The loss or theft must be reported by the physician to local law enforcement. The physician should take note of the law enforcement agency report number. 
#The loss or theft must be reported by the physician to the Department of Justice Controlled Substance Utilization Review and Evaluation System (CURES) program. A law enforcement agency report number is required when submitting a report of lost or stolen prescription forms to CURES.
#The physician should notify the California State Board of Pharmacy.
#The physician should notify the Medical Board of California.
#In addition, to the above 4 steps please email Dr. Harrington at dharrington@dhs.lacounty.gov.

D. Harrington, 11/3/16

====Safe Pain Medication Prescribing Guidelines====
We will be shortly launching the implementation of the Safe Pain Medication Prescribing Guidelines, a Los Angeles county-wide project to decrease inappropriate opioid prescriptions from the ED and other settings. Patients will receive upon discharge a color pamphlet (English or Spanish) explaining the project, including messages about how stolen prescriptions need to be reported to the police, that the ED does not refill pain pills and that pain pills for chronic pain should really come from a single, continuity provider. Residents, NPs, and nursing staff got some in-depth lectures about this. 
(Dir Adult ED 10/14/14)

===Boarding===
====Boarding Patients Sent from Clinic====
Just a reminder to the seniors in the Emergency Department running the board: the correct procedure for patients admitted from clinic who do not need a monitored bed, especially when the clinic is closing, is for the clinic to contact the patient flow facilitator to assist in locating a bed in the hospital, and only contact the emergency department to board the patient if the flow facilitator cannot make other arrangements.

Monitored bed patients can be sent from the clinic to the emergency department to board when we are out of monitored beds. If it does not sound like the patient needs a monitored bed, please talk to the ED attending.

====Triaging Clinic Patients====
Because we have a large volume of patients waiting at any given time, many of whom are quite ill, we support independent medical decision-making about whether a patient coming from a clinic needs immediate attention or can safely wait to be triaged.

We do ask however that when triaging clinic patients, you follow the same protocol we use for ambulance patients (see below 1.9.2). Specifically, should a resident decide that a clinic patient is stable to go wait in the waiting room, they discuss it with the attending and document that decision in the medical record. You can use the same autotext you'd use for an ambulance patient.

Regarding sending the patient to RME: we have no workflow that allows a patient to be placed directly into RME - please do not ask the nursing staff to do this. If you decide that the patient is not stable to go to the waiting room and be triaged, then please keep them in the AAED.

(Dir. OPS, February 03, 2015)

{{Triaging Ambulance Patients}}

{{Harbor follow up}}

===[[Harbor:ED follow-up options|Follow up]] In Other Clinics===

#How to Book
##No Booking: Call the clinic directly and their unit clerk will book the appt
###Anticoagulation (Coumadin clinic), M-F  8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995
###Mira Niko Cardiology/Anticoagulation Clinic Coordinator
###Cardiology (specialty services),Mira Niko/ kim Ext 5146 7am -11pm, Ok to book during after hours only 11pm -7am
###Breast Clinic, Pamela Ext 3475
###CCC, Marina ext: 8117
###Diabetes Clinic, Jose Ext 1864
##OK to book: with consultant approval - get name of approving doctor
###ENT
###ORTHO 
###GYN
###PEDS
###SURGERY
###UROLOGY
###OPHTHO
###72 HRS STRESS TEST
###CARDIOLOGY (after hours only 11pm-7am)
###Expedited Work-up Clinic (EWC)- HAR PC Room 8 - see below section

===[[Harbor:ED follow-up options|Follow up]] in Expedited Work-up Clinic (EWC)===
*This clinic primary serves to avoid admitting stable patient for diagnostic evaluation. Ideal candidates are those patients that would be admitted in the absence of EWC, and '''do not have a primary care provider.''' Patients must have '''reliable contact information to attend this clinic.'''
*The form that previously was required to be fax is no longer required/accepted. The clinic will be available every Tuesday PM in the PCDC Basement Clinics (B and C).
*Katrina Pasion, RNI, is the EWC care coordinator. Please address any questions to her via ORCHID communication, Outlook email kpasion@dhs.lacounty.gov, or 310-222-2859.
 
*Clinical Problems to be referred to EWC:
#'''New onset ascites:''' This must be a new diagnosis and first presentation of ascites. Requires paracentesis performed in ED to rule out infection, SAAG >1.1, transaminases < 3x normal, rapid HIV, CBC, lipase, CMP. No referral for therapeutic paracentesis alone, No evidence of pancreatitis or biliary obstruction.
#'''Anemia (Hgb< 8g/dL on initial presentation):''' Requires CBC, peripheral smear, CMP, rapid HIV, ECG, CXR, type and screen No evidence of pancytopenia, HIV, leukemia, active GI/GU bleeding, or evidence of hemolysis. Patients with suspected gynecologic etiology should be referred to the GYN service. Post transfusion CBC required.
#'''Weight loss, unexplained >10% w/in 1 month or >15% in 6 months:'''  Requires CBC, CMP, ECG, CXR, rapid HIV. Patients with prior imaging must have actual images or be instructed to retrieve images  prior to clinic appointment.
#'''Undiagnosed mass (excluding primary breast /brain masses):''' Requires results or radiographic imaging to confirm presence of mass. Patients with prior imaging must have actual images or be instructed to retrieve imaging prior to clinic appointment.
#'''New onset pleural effusion:''' Requires thoracentesis, CMP, CBC, serum amylase, LDH, and pleural fluid analysis (predominant lymphocytic effusion or high suspicion for Tuberculosis must be admitted). Chest CT only if immediately clinically indicated (ie. suspicion for pulmonary embolism).
 
*'''Clinical Criteria:'''
**Patient is stable (T< 38.3c, HR<100, RR <24, BP >110/50, BP <180/110, pulse ox >92% on room air, oriented x 4)
**Able to be seen in 2-10 business days without significant risk
**No ACTIVE co-morbidities (ie infection, CAD, CHF, stroke, metastatic cancer, renal failure, dyspnea).
**Patient has RELIABLE contact information.

Joy Lagrone, 10/12/16; A. Wu. Dir AED 10/27/16


{{Family Viewing of Deceased Patients}}

{{Harbor Law Enforcement Escorting Patients Out Of the Emergency Department}}

===Orders on Admitted Patients===
Recently we had problems in the care of a patient due to both the emergency physician and the admitting team writing non-emergent orders on the patient at the same time. 

Please do not write orders an admitted patient unless it is an emergency. If you do write an order on the an admitted patient, please communicate this as soon as reasonably possible to the admitting team. If nursing staff request that you write non-emergent orders on an admitted patient, please direct them to call the admitting team.

Admission officially occurs at the time you place the order "Request for Admit", and only after you've communicated with the admitting team about admission (or made a reasonable attempt to do so)

Dir OPS 5/5/15

{{Harbor Ebola precautions}}

{{Contacting attending consultant}}

{{Harbor Elective Transfers to MLK Hospital}}

===On Call Plan - Emergency Department Attending Physicians===
When it becomes clear for any reason that an Attending Physician in the Adult or Pediatric ED will be unable to cover a scheduled shift due to illness or personal emergency, that physician should:

#Send out a group wide email in an attempt to find coverage, as time permits.  The address backup@emedharbor.edu will reach all ED faculty, fellows, and adult and pediatric clinical attendings as well as Becki McKenzie and Veronica Lopez.
#Outside business hours, contact the attending on duty in emergency department, who will notify involved physicians that the shift extension backup plan is in effect (see section 5 below). Contact information for all ED physicians is available on our intranet website  http://www.emedharbor.edu/private/
#During business hours, call the Department Offices at 310 222-3500 and inform Maria Figueroa, or if unavailable, Juno Chen. Maria (or Juno) will contact the Chair, or in his absence, one of the Vice Chairs, who will initiate an e-mail attempt to arrange coverage. If no coverage is found, the Chair or Vice Chairs will notify the attending in the emergency department to activate the shift extension backup plan.
#Part time hourly physicians and volunteer physicians are not obligated under this plan, but will be compensated for their time per their usual agreement should they decide to cover additional hours under this plan.
#Shift Extension Back-up Plan: When no coverage can be found - the physicians working the shifts before and after the missed shift will extend their shifts to 12 hours to cover the missed shift. AAED A-team physicians are responsible to cover A-team absences and AAED B-Team for B-Team absences, and PED team physicians cover PEDS team absences.
#In the event one of the covering physicians is a part-time physician and unable to extend their shift, the physician from the opposite team should extend their shift to 12 hours to help cover the missed shift.
#A full-time faculty member or Fellow will generally be responsible for making up the first 2 shifts missed from any single incident. At the discretion of the Chair,  the requirement to make up subsequent shifts may be waived.
#*Faculty will not be required to pay back specific individuals who worked their missed shifts. Shift pay back will be accomplished through the regular scheduling process.
#*Faculty working extra to cover missed shifts should notify the scheduler to ensure appropriate credit is given.

(Dir of OPS 6/2/15, Upheld by Fulltime Faculty Vote on 5/10/16)

===Trauma Activations===
In addition to the standard trauma activation criteria published on a badge card that everyone should carry and refer to, the Trauma Service can be activated in patients not meeting trauma criteria to help in several ways:
#Getting CT scans READ quickly (Trauma will read them)
#Getting lots of extra hands to do whatever needs to be done for the patient.
#Getting surgical decisions made more quickly.

You can even activate the trauma service if you have a non-trauma patient that needs emergent surgical intervention. 

All of these decisions are covered under "ED Judgment"

(Dir OPS 7/15)

===Lab===
*Gonorrhea/Chlamydia
**Purple/White - cervical and urethral specimens
**Yellow - urine specimen
**Orange - vaginal specimen

===Critical Lab/Radiology Results Callback===
*Lab or radiology calls ED for critical result, senior resident or attending takes the call
*If patient is admitted, lab/radiology told to contact admitting team
*If patient is discharged already, then patient is called back by senior resident/attending
*Senior resident/attending documents a note of whether patient was able to be reached
*If patient is returning to ED for re-evaluation, then place pre-arrival note and notify the charge nurse

===Radiology===
====CT Scanner Specs====
*CT:  Toshiba Aquilion Prime, Weight capacity: 660 lbs, Max Diameter (CT 2): 78 cm (approximately 30 inches).

====Rules for Performing ED Ultrasounds====
Always know ahead of time if the exam you are doing is "for the record" or for "training" only. ANY EXAM WHICH FACTORS IN ANY WAY INTO THE CARE OF YOUR PATIENT OR INTO YOUR DECISION MAKING AT ANY POINT IS "FOR THE RECORD"

"For the Record" Exams

#Your attending MUST be approved in the exam you are doing EVEN if you also are. If your attending is not, you cannot do the exam. Ask your attending. If not sure, check WikEM Ultrasound Approval List.
## https://www.wikem.org/wiki/Harbor:Ultrasound_approval_list
#If you are approved in the exam you may perform the exam and report and use the results without any attending over-read if you are confident with the results.
#If you are NOT approved, your approved attending MUST confirm your findings BEFORE you report your results verbally (including calling out results in a trauma or discussing with a consultant) or in writing.
#All "for the record" exam images must be uploaded to Synapse (except in cases where there isn't time to create an order). If you can't upload - note why in your ultrasound procedure note.
#If you are not approved - your images should NOT be uploaded until reviewed by an approved attending.
#All for the record exams should be documented in an Ultrasound Procedure note, along with your approved attending's name. Please DO NOT put results in your H&P, other than to mention "see Procedure Note". Procedure notes are designed to prevent you from over reporting on findings you are not trained in.

If your exam does not meet all the criteria for a "for the record" exam, it must be treated as a "training" exam , and any findings can not be reported or used to make decisions.

"Training" Exams

#Ask the patient for verbal permission to perform. These are not covered by the ED consent the patient signs.
#Never use info from a training exam for patient care decisions.
#Do not record anything about the exam in a procedure note or in the medical record.
#Do not upload any images from a training exam.
#If asked by a consultant or the patient or anyone else what the US shows - say only "I'm training so I'm not allowed to comment on what I think I see in the exam"
#During Trauma Activations - please delay training exams until after the initial resuscitation period, to avoid confusion. DO NOT CALL OUT RESULTS as the assumption will be that this was an exam "for the record". 

T. Jang, Dir. of ED Ultrasound 11/3/16

==== STAT MRI's====
* The decision to order a STAT MRI will be made after discussion with an attending physician AND for which MRI results will alter the current treatment plan;  external services may be consulted, but their "permission" is not necessary to order the study
* Once the MRI is ordered, please page the radiology resident (p501-5814) to help them prioritize the queue of MRI (in case multiple emergent MRIs have been ordered simultaneously; i.e., brain bleed may trump spinal instability)
** MRI Building x5939;  Mobile MRI x2580; MRI Tech 310.218.2379

* Policy 367B: Priority for the portable MRI will be given to the following groups of patients:
# Emergency Department patients
# Acute Trauma or ICU patients
# Any Pediatric or Adult patient (including outpatients) requiring sedation or Anesthesiology support for monitoring or provision of sedation
# Inpatients with potentially treatable neurological or neurosurgical emergencies

*WITH one of the following documented indications:
# Acute spinal cord injury
# Suspected spinal instability
# Suspected spinal compression or ischemia
# Concern for epidural [[abscess]] or discitis
# Suspected acute/subacute myelopathy or focal neurological deficit
# Concern for acute/subacute cauda equina/conus medullaris syndrome
# Acute stroke symptoms with non-diagnostic head CT
# Suspected meningitis, encephalitis, or CNS vasculitis
# Concern for CNS tumor or [[abscess]] with acute change in neurological status
# Evaluation for cerebral hemorrhage 
# Emergent arterial imaging (aortic dissection, aneurysm leak, etc.) when contraindication to IV CT contrast
# Pregnant female with equivocal physical examination and ultrasound for appendicitis
# Urgent Magnetic Resonance Cholangiopancreatopgraphy (MRCP)
# Assessment of VP shunt malfunction

*Limitations:
**350 lb weight limit
**15 inches high, 21 inches wide
**MRI lift 1000 lbs total for gurney, staff, equipment, etc.

* Transport to MRI (Policy 367B)
** Mobile Unit
*** CODE BLUE
**** Hospital gurney will be left on the lift while patient is getting scanned if ambulatory patient and they will be transferred from MRI table to gurney for transport to ED
**** If critical/ICU patient, gurney will not stay on the lift during the scan;  in case of code, the MRI table will be used to transport the patient to the ED
**** CODE BLUE Team should receive the patient at the loading dock, move patient to the ED, and ED team assists with resuscitation
**** Move to trauma bay for resuscitation and use paper code sheet, quick reg all patients (outpatient, inpatient)
**** Patients who are admitted as inpatient and in an inpatient bed will be re-registered using the same MRN and an ED FIN will be created.  The inpatient FIN will stay active and the ED FIN will be used for the stay in the ED and discharged when the patient is stable enough for transfer and the inpatient FIN will be used when the patient returns upstairs.
*** TRANSPORT
**** Ambulatory patients may be taken to MRI via wheelchair or gurney
**** Need for physician accompaniment determined by R2 and above (discuss with ED Attending)
**** R1 or above to assure maintenance of spinal precautions at times of transport only;  need not stay during entire study
**** RN will assist with transport of adult patients to MRI but only needs to be present during MRI if sedation is occurring
**** RN will remain with ALL pediatric patients during the entirety of the MRI regardless of need for sedation
**** ED Physician proximity in the AED meets the requirement for physician presence during the administration of IV contrast 
*** SEDATION
**** Anxiolysis to be provided by anesthesia (attending, resident, or CRNA)- Anesthesia attending must be present for pediatric sedations
***** Place order in ORCHID “Request for Out of OR Anesthesia”;  if issues, call Operating Room Scheduling Center at x6439 during regular hours and OR Front Desk x2797 after-hours
***** Anesthesiologist running the board Spectralink x23337 can also assist
***** Assessment by anesthesia will occur in the ED room as well as post-MRI sedation monitoring/recovery
***** Sedation is defined as IV pushes, and excludes IV drips maintained at a stable rate or oral anxiolytics(Policy 367b, Section IV) 
**** If patient is unstable, must be accompanied by physician (R2 and above) AND nurse

*American College of Radiology Appropriateness Criteria for MRI (numbers below in parenthesis - ranked 0-10, with 10 most appropriate study)
** Emergent (to Portable MRI Trailer)
*** Neurology
**** Stroke within therapeutic window with negative head CT (9)
***** MRI brain w/o contrast
***** Consider MRA
**** Vertigo with concern for posterior fossa infarct (9)
***** MRI brain w/o contrast
**** New myelopathy or plexopathy (9)
***** MRI spine w/o contrast
**** Venous sinus thrombosis (if CT Venogram is contra-indicated); (9)
***** MRV brain w/ and w/o contrast 
*** Trauma
**** Traumatic cord injury/cord syndrome (9)
***** MRI spine w/o contrast
**** Spinal cord compression/ischemia
***** MRI spine w/o contrast
*** Neurosurgery
**** Cauda Equina Syndrome or suspected spinal tumor with motor loss (9)
*****MRI spine w/o contrast
***** MRI spine w/ contrast if infection suspected
**** Epidural abscess/hematoma or discitis (8)
***** MRI spine w/ and w/o contrast
**** Non-traumatic SAH with contra-indication to IV contrast to assess for aneurysm (8)
***** MRI brain w/o contrast + MRA brain w/o contrast (8)
**** Intracranial AVM with intraparenchymal hemorrhage (when CTA contra-indicated)
***** MRI brain w/ and w/o contrast + MRA brain w/o contrast
**** Concern for subdural empyema/intracranial [[abscess]] (8)
*****	MRI brain w/ and w/o contrast
**** Brain tumor with acute change in mental status (8)
*****MRI w/ and w/o contrast
**** Spinal tumor with acute change in neurological status
*****MRI w/ and w/o contrast
*** Surgery
**** Emergent arterial imaging with contra-indication to IV contrast (carotid, vertebral, or aortic dissections/aneurismal leaks); (8)
**** MRA head and neck w/ and w/o contrast
*** Pediatrics
**** Assessment of VP Shunt malfunction
*****MRI brain w/o contrast (T1/T2)
**Urgent (to Portable MRI trailer)
*** Neuro
**** Suspected meningitis/encephalitis (unable to perform LP); (8)
****MRI brain w/ and w/o contrast
*** Trauma
**** Spinal instability due to ligamentous injury (9)
***** MRI spine w/o contrast
**** Concern for spinal fracture with equivocal CT (9)
***** MRI spine w/o contrast
**** Suspicion of diffuse axonal injury (8)
***** MRI brain w/o contrast
*** Neurosurgery
**** CT equivocal for intracranial hemorrhage
*****MRI brain w/o contrast
**** Post-op intracranial surgery to evaluate for abscess
***** MRI brain w/ and w/o contrast
**** Concern for posterior fossa mass (8)
***** MRI brain w/ and w/o contrast 
*** Surgery
**** Pregnant female with equivocal exam/US for appendicitis (vs. enroll in CODA/empiric antibiotic treatment); (7)
***** MRI Abdomen/pelvis w/o contrast
*** Pediatrics
**** Concern for Septic Hip/Joint (7)
*****MRI pelvic w/o contrast
*** GI
**** MRCP
*** Pulmonology
**** [[PE]] in pregnancy (if CTA or VQ contra-indicated or not feasible); (3)
**** MRA chest w/ and w/o contrast
*** OB
**** Stable patients with equivocal US/HCG where outpatient evaluation is not feasible (extenuating circumstances) or concern for ectopic/heterotopic pregnancy
***** MRI pelvis w/o contrast
** Urgent (to MRI building)
*** Neurology
**** Stroke outside therapeutic window (8)
***** MRI brain w/o contrast
**** Opthalmoplegia (9)
***** MRI brain and orbits w/ and w/o contrast
**** Concern for Multiple Sclerosis (8)
***** MRI brain/spine w/ and w/o contrast
*** Neurosurgery
**** Concern for pituitary apoplexy (8)
***** MRI brain w/ and w/o contrast with multiplanar thin sellar imaging
**** Post-op brain tumor to evaluate for residual tumor
*****MRI brain w/ and w/o contrast
**** Spinal compression fractures (7)
**** MRI spine w/o contrast
*** Ortho
**** Osteomyelitis (9)
***** MRI w/ and w/o contrast
**** Concern for hip fracture with negative CT (9)
*****	MRI w/o contrast
**** Septic arthritis (unable to perform arthrocentesis)
***** MRI w/ and w/o contrast (T1/T2)
*** Pediatrics
**** Slowly progressive vision loss (8)
***** MRI brain and orbits w/ and w/o contrast
*** Medicine
**** Evaluate for brain metastasis with equivocal CT (9)
***** MRI brain w/ and w/o contrast
**** Concern for Primary CNS lymphoma (9)
***** MRI brain w/ and w/o contrast
**** Concern for opportunistic CNS infection (9)
***** MRI brain w/ and w/o contrast
** Outpatient (to MRI building)
*** Any stable patient not requiring sedation
*** All outpatient imaging orders
*** Ortho
**** Ligamentous injuries of the extremities
***** MRI w/o contrast

Chappell, Wu, 2/2017

===Occupational Exposure===
*Charge RN has the exposure packet that needs to be filled out to avoid employee getting the bill
*Check hep C on patient (consent not needed) and ensure employee has Hep B vaccine;  no blood testing of the employee in the ED
**if patient refuses HIV, it can be added on to a pre-existing blood specimen but the results may not be shared with the patient
*Call HIV service (501-4260) if rapid HIV is positive and clinically meaningful exposure (penetration of skin or mucosal exposure with blood or CSF) or if unknown/untestable source patient
*Message Erika Sweet at employee health after any exposure to ensure follow-up

===Weapons in ED===
*As a general rule, no patients should have weapons on them (INCLUDING PEACE OFFICERS), even if they have concealed weapons permit. 
*No visitors should have weapons. The only exception to visitors carrying weapons are active peace officers. 
*We are working with hospital administration to make this hospital policy for campus grounds. 
*If you encounter issues, call the Sheriffs Department for assistance. 

A.Wu, Dir AAED, LASD, Dir OPs 12/9/16


===STEMI Activations===

	Harbor - UCLA is a STEMI Center, with 24/7 cardiac catheterization availability. STEMI activations are often called in from the field. During normal business hours, we generally will activate the STEMI Pager when receiving the prehospital call. After hours when Cath Lab staff are out of the hospital, we generally wait until the patient arrives to evaluate the situation before paging the STEMI Pager. Not all hospitals in our area are STEMI receiving centers; a hospital that is not STEMI Center may call you in the emergency department to inform you that they are activating the STEMI 911 protocol. This allows the hospital to call 911 to emergently transfer a patient suspected of having STEMI to a STEMI Center without a formal transfer process. We generally accept these without question.

(See also "TRANSFERS")

Dir OPS 1/9/17

===TRANSFERS - INCOMING===
There are generally four types of transfers that come into the emergency department:
*"STEMI 911" and "Trauma 911" Transfers - these are transfers from other emergency departments in our area that are not Trauma Centers or STEMI centers. Since we are both a Trauma Center and a STEMI center we have agreed to take urgent transfers from other emergency departments if they feel their patient needs these services. The sending facility may contact you directly. We rarely say "no" to these cases as long as we are "open" to trauma and STEMI patients (ask the MICN/Radio Nurse or Charge Nurse about our status), and just take information and activate the appropriate resources within our facility. The sending facility is responsible for calling EMS and arranging for the emergent transfer. Note: these transfers are from the emergency department, and should not be from the inpatient units of the sending hospital. 
*EMTALA or "Higher Level of Care": we consider accepting these as long as we are open to "EMTALA Transfers" - check with the charge nurse. Depends on our Surge status. In order for us to accept these transfers from other emergency departments, they must be approved by all of the following:
**The subspecialty service that will likely be involved in the care of the patient (they determine if they have the right personnel and equipment to care for the patient.) The trauma service may serve as approval authority for all surgical patients, whether trauma or not.
**The Patient Flow Facilitator ("PFF" - he or she determines if we have the right bed type available - the bed must be currently open)
**The Emergency Department (we determine if we are uncrowded enough to safely take another patient). A general approach is to look at how many ESI 2 patients are waiting to be seen, and how far backed up we are with triaging, and to a lesser extent how many total patients are waiting to be seen. 

*The usual process is: 
**The sending facility contacts the Medical Alert Center or MAC, which is the clearinghouse for transfers within the County of Los Angeles. Any facilities that contact you directly for EMTALA transfers should be redirected to the MAC (unless it is one of the other types of transfers)
**The MAC contacts the Patient Flow Facilitator first, who determines if we have the right bed available, and then the PFF or MAC (preferably the PFF) contacts the subspecialty service to get approval before contacting the emergency department. If these two approvals occur, then
**The PFF calls the emergency department to talk to the ED attending to get acceptance. If the emergency department is too crowded or for other reasons cannot accommodate the transfer, then inform the PFF that the ED has "No Capacity" and state why.
If the MAC contacts you first about a transfer, you should redirect them to the patient flow facilitator.
All transfers are seen first by the emergency department, and then appropriate subspecialty services are contacted. Subspecialty services are not expected to primarily evaluate the patients.
*"Lateral Transfers" - these are transfers of patients who do not require a higher level of care, but generally have no funding so the sending facilities are referring them to the County. To accept these we should be open to "Lateral Transfers". The process is the same as EMTALA transfers.
*"Impending Deterioration" transfers from our sister facility, Olive View-UCLA Medical Center. This is another County hospital that lacks some services that we have, including neurosurgery, orthopedics, and trauma services. Although generally transfers from this facility would go through the same procedures as above for EMTALA transfers (even to us), we have a special agreement for patients they think are likely to decompensate acutely if not transferred immediately. These are generally neurosurgical cases. These are pretty rare, and we take these regardless of our open or closed status. Emergency physicians from Olive View will generally contact you directly rather than going through the MAC.

Dir OPS 1/9/17

===Clinic Referrals to ED===
Occasionally you will get a call from a clinic either directly or through MAC to "transfer" a patient. These are not considered transfers under EMTALA, and should be considered simply "referrals". Clinic physicians can refer their patients wherever they like; we can't really "refuse" these patients. It's recommended that you listen to the clinical situation, advise the clinic doctor on whether or not the emergency department visit is likely to be helpful for the situation, and advise the clinic doctor if you think the patient needs to come by ambulance. In the end all of these decisions belong to the clinic physician.
Also, depending on the complaint, I give the clinic doctor a rough estimate of the time the patient will wait to be seen. (Clinic patients do not necessarily get priority over other patients that are waiting in the waiting room, who may be sicker.) I ask the clinic doctor to advise the patient of the possible wait so they can make an informed decision about coming to the emergency department. (They may want to go elsewhere if we are highly impacted.) This hopefully helps prevent the clinic doctor from falsely informing the patient that they will seen "right away".
If the clinic is one of our in-house clinics at Harbor (these calls are often taken by the senior resident), in order to maintain good working relationships with other hospital services we request that there be attending involvement if a decision is made to send such a patient to wait in the waiting room. This decision should be documented in the EHR the same way we document ambulance patients sent out the waiting room. We don't have a rule that states clinic patients jump to the head of the line; you are free to use your judgment, as again there may be sicker patients in the waiting room. Do consider however that this patient has in essence already been triaged by a (clinic) physician in most cases.
Special note: transfers from the hospital in the city of Avalon on Santa Catalina Island are generally viewed as referrals from a clinic, so we normally accept them without question due to their extremely limited facilities on the island. These transfers almost always come by helicopter.

Dir OPS 1/9/17

=== Equipment Locations===
https://www.wikem.org/wiki/Harbor:Equipment


===Equipment Issues===
Each pod in ED has an equipment notebook at nursing station to write down any issues (broken, need more of, etc.)

For more urgent Issues: notify Charge RN and:
*Spectralink phones - notify Charge RN to get replacement phone and Dr. A. Wu
*Ultrasound equipment - notify Dr. T. Jang
*AED equipment - notify Dr. A. Wu
*RME equipment - notify Dr. B. Chappell
*PED equipment - notify Dr. P. Padlipsky
*IT equipment, including computers and landline phones - place a ticket by using hospital intranet IT support icon or calling in ticket, and also notifying the appropriate area Director above to follow up.

A.Wu Dir AAED 2/14/17

==RME/TRIAGE==

===RME Phones===
* Triage Resident x23223
* Triage NP (9a) x23209
* FT Resident x23210
* FT NP (6a/6p) x23203
* FT NP #2 x23222 

* RME Charge x23930
* Room 11 EKG Tech x23922
* Chest Pain Triage RN x23909
* USA  M-F 7a-11p x29737; pgr 501-2047 (Francisco 7a-3p, Reuben  3p-11p)
* Martee x23973

* Triage Printer in registration cubby (10.107.132.219; PH011E16RX)


Chappell 4/2017

===RME Patient Flow===
# Patient arrival → router who assign triage priority (cardiac, high, normal) and quick reg so orders can be placed
# Team Triage → VS by RN with required questions, MSE by Physician/NP
## Designate patient end location
### AED/12  (task then RME 12 - notify RME charge if next back), 
### AED/AWR (task then waiting room - can be converted to RME2 once workup is negative, but likely AED patient based on ESI 2-3 workup), 
### RME  (will be a RME discharge but something is ordered that will not be immediately resulted - UA, etc), 
### RME11  (ready for d/c, just needs to be typed up ... Rx, work note, CCC)
## If arrival to triage is >60 minutes, an additional RN should assist with triage (and provider should be pulled from FastTrack if needed to keep up with the screening)
# Registration (behind triage 3)
## Patients sit in chairs in hall until seen by registration staff;  if no staff, then registration will be done in the back 
## At a minimum, the "financial screening" to determine DHS eligibility will occur, but if slow arrival flow of patients, can perform complete registration at this point
## There should be a second registration clerk in RME who can catch any missed patients (ie, bypassed registration for ECG)
# FastTrack
## If patient is eligible for UCC (ESI 4-5 with green DHS logo), pull the patient in your room, let them know they are eligible to be seen at the Urgent Care which will likely be a shorter wait, and if they say yes, then the USA or NA can take them over
## ED R4 Fast Track Note
# Tasking
## USA/NA to assist with patient movement to AED, FT, UCC, AWR
# Reassessment
## 2 hours for ESI 2
## 4 hours for ESI 3-5
## 30 min for IM/IV pain meds, 60 min for PO pain meds (CAP)
# Room Assignments
## RME 1 = EKG
## Triage 1, RME 2, RME 3, RME 4 = provider rooms
## RME 11 = ESI 4/5 internal WR
## RME 5, RME 6 = Tasking internal WR
## RME 7 Phlebotomy; RME 8, RME 9 tasking
## RME 10 - pain reassessment
## RME12 = next back, IV for CT, etc.

Chappell 4/2017

===Criteria for an immediate transfer to Chest Pain Room===
*Router RN identifies patient with Triage Priority "Cardiac" based on:
*# Age >35 AND  chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
*# Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
*# Age >65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation.
*# Clinical concern for myocardial ischemia exists despite absence of 1-3.
*Router RN calls CP Triage RN x23909 and handoff patient to CP Triage RN at RME 1; 2 chairs available if another patient is currently getting EKG
** CP Triage RN orders EKG, call EKG Tech x23922 if not in RME 1, and notifies the triage provider if they are not already present (x23223 7a-11p [physician], x23203 11p-7a [NP])
*** EKG Tech will hand the EKG to a R4 or Attending (NP ok if interpretation is "sinus rhythm")
**** If STEMI:
***** Notify Charge RN x23910 to determine which team will be assigned and what room is available
***** Triage provider should immediately notify the appropriate attending (Purple x23202, Green x23206)
***** The AED team is responsible for activating the cath lab and speaking with interventional cardiology
*** If no other patients are waiting for EKG, MSE can be performed in RME 1; otherwise, patient with completed EKG should be taken back to a triage room for MSE while additional patients are getting EKG
*** Patient then gets financial screening and should be moved to RME 5/6 for Tasking
*** Once tasking is completed, they should be moved to the appropriate location based on the "RN Comments" column notation

Chappell 4/2017


{{Harbor EKG screening}}

===Transfer of Low Acuity Patients to UCC===
*UCC Charge RN:  x8111, 8110;    RME Charge x3900 - 23930
**Once patient has been triaged/received MSE and designated as ESI 4-5, they will be financially screened by registration for DHS eligibility and then placed in RME 2-3
***If the patient is eligible for UCC (as designated by the green DHS logo), the patient should be offered the opportunity to be seen at UCC as it will likely be a shorter wait;  if the patient declines, they will remain in FastTrack (RME 11)
****Eligible patients include DHS, MHLA, and SELF PAY
****Financial Screening - once financial screening is done, the patient will be assigned the green "DHS" logo 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);  if golden key still present at time of discharge, please discharge to the registration window
***UCC hours of transfer are:
****Monday to Friday 8am - 8pm with the exception of no transfers Tuesdays 8am to 12:30
****Saturday and Sunday 8am - 1pm
# Once the patient is taken to UCC, they need to be moved in Orchid to UCWR
# UCC Nuances
## There is no maximum number on the subjective pain scale that precludes transfer to UCC
## Pain meds should be given prior to sending to UCC;  the patient will be re-assessed upon arrival at UCC by their intake provider
## 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 orders that have not been completed may be canceled by the definitive provider in UCC
## UCC is unable to do CCC but can request e-consult 
## The UCC has full access to ortho via the cast room
## The ability to do simple laceration repair is provider dependent, so please call prior to transferring such patients
# 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;  call Triage physician x23223 prior to sending back to the ED; Green team attending x23206 is an alternate
# 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.

Chappell 4/2017

===NP Independent Workup Guidelines===

* Nurse practitioners may independently order any imaging study listed below.  Other studies not listed require physician consultation prior to test being ordered.
** Standard X-rays, keeping in mind evaluation of joints above and below for concomitant injury 
** Non-contrast CT of the brain for symptoms of “sudden onset” headache or “worst headache of life”
*** Consider CTA Brain for aneurysm if patient is unwilling to have lumbar puncture (discuss CTA with attending)
** Non-contrast CT of the brain for patients who have minor head trauma following ACEP Clinical Policy Statement:
*** Loss of consciousness or post-traumatic amnesia PLUS one of the following
**** Headache, vomiting, age>60, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicles, post-traumatic seizure, GCS <15, focal neurological deficits, or coagulopathy (including blood thinning medication)
*** Consider if no loss of consciousness but presence of:
**** Focal neurological deficit, vomiting, severe headache, age >65, signs of basilar skull fracture, GCS<15, coagulopathy (including blood thinning medications), ejection from MVA, vehicle vs pedestrian, or fall >3 feet or 5 stairs
** CT brain with IV contrast – for patients being evaluated for mass/tumor or those with HIV and new onset headache
** Non-contrast CT of cervical spine if any of the NEXUS criteria is present:  
*** Midline cervical tenderness, focal neurologic deficit, ALOC, intoxication, or significant distracting injuries; the patient should be placed in a cervical collar and placed in AED
** Non-contrast CT of the abdomen/pelvis for patients with signs or symptoms suggestive of ureterolithiasis (“kidney stone”) who do not already have an imaging study in the Harbor database confirming this diagnosis
*** If previous CT confirms stone, consider bedside renal ultrasound to evaluate for hydronephrosis
** Limited Right upper quadrant ultrasound for patients with concern for cholecystitis (fever, RUQ tenderness, N/V)
** Abdominal ultrasound for patients with high suspicion for first episode of pancreatitis
** Pelvic ultrasound for patients with a positive pregnancy test AND abdominal pain/cramping OR vaginal bleeding
** Risk Stratification for DVT
*** Well’s Criteria:  Calf swelling >3cm compared to unaffected leg (+1), entire leg swollen (+1), localized tenderness along deep venous system (+1), pitting edema to symptomatic leg (+1), varicose veins present (+1), paralysis/immobilization (casting)/bedridden >3 days/surgery within 12 weeks (+1), active cancer (+1), previous [[DVT]](+1), and alternative diagnosis as likely (-2)
**** If low-risk Well’s (score of 0-1), order d-dimer
**** If score greater than 1, order formal (not bedside) Lower Extremity Doppler US
** Risk Stratification for PE
*** If low pre-test probability and PERC negative, no further testing for [[PE]] necessary
**** PERC measures:  Age <50, HR<100, O2 sat >94% on RA, no exogenous estrogen use, no history of DVT, no unilateral leg swelling, no hemoptysis, no trauma or surgery is last 4 weeks 
*** If patient falls out of PERC, then apply Well’s criteria:  
**** Clinical signs and symptoms of [[DVT]](+3), [[PE]] #1 diagnosis (+3), HR >100 (+1.5), immobilized >3 days or surgery in past 4 weeks (+1.5), Previous PE/DVT (+1.5), Hemoptysis (+1), malignancy in past 6 months (+1)
***** If score 6 or less, order d-dimer
***** If Score >6, CTA or VQ scan (if contra-indication to CTA)
***** If pregnant, discuss with attending
** Chest Pain:  NP should obtain a brief history on any patient with signs or symptoms of cardiac ischemia or with ECG read that is not “normal sinus rhythm” then present the ECG to the Attending

* Trauma
** NP's are not involved in the care of Trauma Team Activation patients.  Our NP's may perform the initial medical screening exam of walk-in patients with minor injuries in Triage, but the care of all trauma patients will be performed by a physician that is ATLS certified.  If it is determined that a patient with an isolated injury needs admission for surgical repair, the care of the patient will be transferred to an AED Team and Trauma Team consulted prior to admission. (Putnam, 2/2017)    

Chappell 4/2017

===Being Seen by Consultants Prior to ED Evaluation===
*ED Policy 3.3
**A consultant may request from RME/AED attending or senior resident to see or take a patient to clinic
**Once the specialty evaluation is completed, documentation of both exam and assessment/plan should be in ORCHID and communicated to the ED provider
**ED to disposition the patient after evaluating for any other needs (full chart)
*Alternately, if the patient has already been evaluated in the ED and found to have an isolated problem that is best cared for by the consulting specialist, care of the patient should be transferred from the ED to the specialist who should discharge them from clinic unless there are extenuating circumstances

Chappell 4/2017

===NP Consultation Guidelines===
*Any case potentially needing a consultant evaluation in the ED should be staffed with an Attending prior to initiating the consult
# If communication is made with a consultant to simply assure appropriate close follow-up, these do not need to be staffed with an attending.  
# If a consultation is needed, place order in ORCHID (creates a timestamp on the chart) and alpha-page the consult service.
* Patients with isolated ophthalmology complaints may be referred to clinic without attending pre-approval, but if the patient returns to the ED [not discharged directly from clinic], the case must be staffed with an attending 
* Please obtain the vital signs of the eyes prior to consultation (visual acuity, PERRLA, EOMI, quadrantopia, IOP, US for detachment if pertinent)
**If ophthalmology is initiating the consult (without being requested), they must discuss the case with the ED attending or senior resident prior to taking the patient out of the department for evaluation

Chappell 4/2017

===NP Consultation with the Attending Physician===
As defined in the Standardized Procedures:
# Patient has unstable vital signs.
# There is an acute focal neurological deficit.
# The diagnosis/problem is not covered by the standardized procedures list.
# There is an emergent condition requiring prompt medical intervention.
# Patient and/or family requests to be seen by a physician.	

*Any case requiring admission, observation, or going directly to the OR should be staffed with an attending.  All admissions performed by an NP require an Attending Admission Note (see "Admit Process" for contents of note)
*If an NP wishes to disposition any patient they have consulted an attending physician on (even if the patient's condition is on the independent disposition list), the attending MUST sign the chart. 
**NPs will refer all such charts to the attending for signature. 
*It is expected that on any case that an attending has been consulted, the NP will discuss the disposition of the patient with the attending before actual disposition.
**It is at the discretion of the attending whether or not to personally evaluate the patient, however the attending physician will be responsible for the care delivered to the patient.
**Patients who are under the care of an NP but have been discussed with an attending physician may have the attending's name placed in the attending column but should NOT be given a team color unless requested by the attending. 

Chappell 4/2017

===NP Independent Discharge Guidelines===
*NPs may independently discharge patients whose complaints are limited to the following and only if they feel physician consultation is not warranted:
**Allergic reactions (without signs of anaphylaxis)
**Asthma exacerbation that responds to Albuterol, not immune compromised
**Bell’s Palsy with complete unilateral facial paralysis and no other focal neurological deficits
**Breast Complaints 
**Superficial (1st) and Partial Thickness (2nd) Burns which do not meet Burn Center Referral Criteria (3rd  degree, 2nd degree with greater than 10% total body surface area, burns of eyes, face, hands, feet, perineum, electrical injuries, inhalation injuries) 
**Chest pain (low risk – HEART Score <4, age < 30, no syncope/SOB, no drugs, no significant family history of early cardiac disease or sudden death, no tachycardia, normal ECG without arrhythmia)
**Conjunctivitis
**Constipation without signs of obstruction
**Dental Complaints 
**Dizziness consistent with Peripheral Vertigo (normal HiNTS exam, no cerebellar findings) 
**Ear, Nose and Throat (no angioedema, drooling, phonation changes, or stridor)
**Epistaxis (no active bleeding, no coagulopathy, normal hemoglobin)
**Genitourinary, minor complaints (male and female, no torsion)
**Gynecological, minor complaints (not pregnant, no active bleed, hemoglobin >8)
**Hemorrhoids
**Hyperglycemia (asymptomatic, no DKA/HHS)
**Hypertension (asymptomatic) 
**Lacerations (not crossing vermillion border, joints, associated with a fracture, or tendon injury)
**Low back pain without associated fever or neurologic deficits
**Medication Refill
**Minor head or facial trauma
**Musculoskeletal injuries/musculoskeletal pain 
**Nausea and vomiting without significant abdominal pain 
**Ocular complaints (minor, no significant acute decreased vision, no trauma) 
**Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
***Clavicle:  <5mm mid-shaft;  sling, ortho in 2 weeks
***Shoulder dislocation:  after reduction, place in shoulder immobilizer, ortho 1 week
***Humerus:  
****Proximal: non-displaced;  sugar tong or sling, ortho in 1 week
****Shaft: non-displaced; sugar tong/sling, ortho 1 week
***Radius:
****Non-displaced distal or shaft; volar splint, ortho 2 weeks
****Non-displaced head with good ROM:  sling, ortho in 2 weeks
***Ulna:  non-displaced; volar splint, ortho 2 weeks
***Metacarpal:  non-displaced shaft and neck
****MCP 2&3:  Radial gutter splint, ortho 3 weeks
***MCP 4&5:  Ulnar gutter splint, ortho 3 weeks
***	MCP 2&3:  Radial gutter splint, ortho 3 weeks
***PIP/DIP dislocations:  simple, no fracture;  buddy tape/splint, ortho 1 week
***Hand Distal Phalanx:  buddy tape/alumiform splint, ortho in 3 weeks
***Occult Scaphoid:  thumb spica splint, ortho in 3 weeks
***Metatarsal 2/3/4 with <2mm displacement and no rotational deformity:  post op shoe, ortho in 2 weeks  
***Foot Non-displaced phalanx fracture:  buddy tape, ortho in 2 weeks
***Chronic or non-healing fracture:  CCC (or e-consult/call ortho if needs closer follow-up)
**Palpitations 
**Psychiatric Patients without psychosis, homicidal ideation, or suicidality (but these patient may be screened for medical conditions and sent directly to the Psychiatric ED if it is deemed no other medical workup is necessary prior to psychiatric evaluation)
**Rash (no petechiae/purpura)
**Seizures (known disorder, no new trauma) 
**Soft tissue infection or simple abscess
**Simple UTI
**STI exposure
**URI

*Exclusion
** Any cases not specifically listed on the inclusion list
** Any patients meeting Trauma Team Activation criteria

*Prior to discharge of any patient with a persistent vital sign abnormality needs consultation with a physician:
**Temp >38F
**HR > 110 or <50
**RR> 20, Pox <92% on room air
**SBP >210 or <100,  DBP >120 or <50

Chappell 4/2017

===Rapid Discharge Procedure===
#If patient needs an appointment (stress test, CCC, etc), this must be done by the clerk first
#Ensure IV has been removed
#If vital signs have not been recorded in the past 4 hours, these need to be repeated and recorded prior to discharge
#Include CHC referral sheet (at RME clerk computer) if patient has no PCP
#SIGN and TIME paper discharge instruction sheet
#option#1: Give ED copy of the signed discharge papers to the RN/LVN who can discharge them with the appropriate timestamp to accurately capture LOS 
#option#2: When completing the admit/discharge screen, click the bottom box (yellow highlight) "patient demonstrates understanding of instructions given"
##click the "discharge" button 
##Enter discharge disposition:  "home"
##Enter discharge date
##Enter discharge time
##Click complete
##Give signed discharge papers to the patient's nurse or place in bottom slot of black divider at RME Clerk desk

Chappell 4/2017

===E-Prescribing===
* Ask patient if they would like to pick it up at Harbor - convenient, low cost to patient, saves county $$$
** Pharmacy hours M-F  7a - 10p, Weekend and Holidays 8a - 6p
** x5434, 5433 - Call if discharging pt <1 hour from closing time so they know to fill the Rx
*** When selecting location ("send to"), choose "find pharmacy" instead of the default printer
*** In Pharmacy name, type "HUMC" and select "LA CO HUMC OPD" then sign and it is on its way to being filled before you even discharge the patient

Chappell 4/2017

==EMS==
===Responding to a Helicopter Landing===
*Requires 2-3 trained individuals, does NOT require a physician, though one may elect to go.
*Only individuals with helicopter safety training should respond to a helicopter landing.
*Must wear following (available in radio room):
**Eye protection
**Gloves
**Ear plugs

*FOR SAFETY:
**Secure loose equipment, they may become a projectile.
**Face shields are not permitted.
**Stethoscopes are not to be worn around the neck.
**Items are not to be left on top of the gurney
===Closing to EMS (ALS) Ambulances===
The decision to close to ALS ambulances should be made as a joint decision by the AED charge nurse and the ED attending. Although looking at the NEDOCS score can be a helpful indicator of the level of congestion, it does not need to be the only factor that goes into determining the need to close to ALS ambulances. With our recent adjustment of the equation to calculate the NEDOCS score (we now have the accurate ED bed count in the equation) - you may find at times that you need to close at lower NEDOCS scores.

As always, the decision to close should be carefully considered, as it results in longer transport times for potentially critically ill patients.

===Screening Ambulance Patients===

*Stable for AWR
**If the nurse believes the patient is stable to be triaged normally, the purple team senior resident should perform a brief assessment and determine if patient may go to the waiting room, or needs to stay in the AED. 
**If the resident feels the patient is stable to go to triage - they go to triage ONLY after discussion with the attending and a note documents this decision.
***Use the dotphrase documentation ".edambulancetriage"
***In general, we aren't really supposed to send out any transfers (MLK, Harbor on-campus clinic, Harbor Urgent Care) or ED trauma patients to triage, but in severely overcrowded cases, it can be done, just run it by the attending 

*If the patient needs to stay in the AED (cannot go to waiting room), the charge nurse will assign the patient to a team in alternating fashion and placed in room "ATri"
**The senior resident or attending should screen the patient within 20 minutes of being assigned to the team. 
***Write your initials and the word "screen" in MD comments so everyone knows the patient was screened.
***A brief assessment and MSE note should be completed and screening orders can be placed (appropriate labs, minimal medications, imaging if needed).  Inform the Charge RN of any pending critical orders. Items such as cardiac monitors, IVF, and Td should be ordered once the patient is in a room.  
***Reassess the patient as needed until an open room is available. 
**If the patient is found to need a room immediately, all efforts should be made with the Charge RN to find an open room as soon as possible.
--Chappell, 4/18/16

==TRANSFERS - OUTGOING==

===Transferring patients out for HLOC - Time Sensitive Life/Limb Threatening Conditions===
Some tips below regarding transferring patients to higher level of care (HLOC) out of Harbor for time sensitive issues. Occasionally, we need to transfer patients out of Harbor UCLA to another hospital for HLOC, (examples, hand/finger reimplantation and burns).  Some of those patients have time sensitive life/limb threatening issues that need timely transfers. If you find that the ETA given by MAC is too long, you have a few options to consider:
 
1.  Notify the Medical Alert Center Coordinator that this is an 'Emergent Urgent' transfer (When the patient is located in the ED) and “Emergency Life Threatening Condition Transfer” (When Patient is considered inpatient).  This triggers a set of procedures with prioritization of the transfer, and applies only for transfer to another County facility.  It is most commonly used by Olive View and we receive these transfers, but Harbor can also use it for transfers out that truly are life/limb threatening.
 
2.  Consider requesting aeromedical transport.   LA County Fire may be contacted to request ALS-level care; the Air Captain number is 818-890-5755.  Private air ambulance provider should be considered for those air ambulance transfers that require critical care team (CCT) level of transfer. Reach Medical: (800) 338-4045 or Mercy Air: (800) 222-3456).  The hospital may consider sending RN, MD or RT staff with LA County fire when CCT level of air ambulance transport is required and private CCT is unavailable or the ETA is too long.
 
3.  Ask to speak to the EMS Agency Administrator on Duty or Medical Director regarding the case if these options still do not result in an acceptable transport time. (Thanks in advance to Nichole and Marianne, since they often are on call).
 
4.  Consider using our on campus ambulance, which is available until about 1130p (Code Assist EMT is not a paramedic, just EMT) +/- our own RN or MD with transport if indicated as a last resort.  
 
5.  Or 911 can certainly be used, as a last resort. Keep in mind that you would take the local unit of paramedics out of service for an extensive period of time. (So if transferring a patient to USC, at least 1 hour). Additionally, if the patient requires any critical care outside the scope of paramedics (management of a drip, pump, ventilator, etc.) it would require that one of our staff nurses or physicians also accompany the patient during transfer.
 
These options have been vetted by Drs. Bosson, D. Patel, Peterson, myself, Joy LaGrone and MAC.

(A. Wu, Dir. AED 4/18/16)

==FINANCE==
==ORCHID (CERNER)==
{{Harbor attending documentation}}

{{Resident Documentation}}

{{Downtime}}

==HARBOR ED POLICY MANUAL==

=== Home Page → Policies and Procedures → HUMC → HUMC Policies and Procedures ===
===3.0 Admissions and Consultations===
====3.4: Guidelines for Flow of patients between the Psychiatric and Adult Emergency Departments====
*Ambulatory Patients:  Patients presenting with abnormal behavior WITHOUT prior psych diagnoses or with acute ALOC are initially evaluated in the adult ED
*Patients with a known psych history and behavior consistent with their previous diagnosis, without apparent acute medical condition requiring intervention, are initially evaluated by the Psych ED
*Patients arriving by ambulance with psych complaints but not under a 5150 should be triaged by a physician in the adult ED then directed to appropriate location
*Psychiatric Consultations in the ED:  patients requesting voluntary evaluation by a psychiatrist are transferred to the psych ED after medical clearance for evaluation and should be transferred to the psych ED as soon as there is space available;  ED physician to psych physician discussion should occur prior to transfer
*All patients on a 5150 hold
#With ETOH>200, delirium, complicated alcohol withdrawal, drug overdose, or acute medical problems should be evaluated in the adult ED
#Require psych evaluation prior to discharge or transfer to medical unit;  this should be done within 30 minutes of request for consult
*Patients in the psych ED that require medical evaluation (or re-evaluation) should be transferred to the adult ED as soon as a bed is available;  prior to the transfer, the psych physician should discuss the case with the ED physician;  exceptions will be made on a case-by-case basis
*Patients in the Psych ED who require treatment with sedatives and are deemed to be at risk for significant oxygen desaturation should be transferred to a monitored bed in the adult ED;  these patients are co-managed by the physicians from both areas
*Psychiatric patients with chronic disorders who require placement are managed in the Psych ED
Approved June 2015, Chappell 2/22/16

{{Harbor Respiratory Isolation Patient Protocol}}

===21.4 Care of Potential Myocardial Ischemia Patient in Triage===
*All adult patients presenting to the DEM triage area with a chief complaint suggestive of myocardial ischemia will be screened rapidly by the Router RN to determine the need for immediate intervention using the following criteria:  
#Age >35 AND  chest, arm, neck, jaw pain that is described as pressure, heaviness, or discomfort.
#Age >45 AND Shortness of Breath, weakness, or arm numbness, CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
#Age > 65 AND Nausea, lightheadedness, “indigestion”, or “dizziness" CONCERNING FOR A CARDIAC ETIOLOGY and without other explanation
#Clinical concern for myocardial ischemia exists despite absence of 1-3
*If the patient meets the above criteria the Router RN will assign a triage priority of cardiac and notify the triage RN via phone;  the patient will be placed in room 11 in the RME area
#The triage nurse performs the complete focused assessment and appropriately orders the ECG under the DEM Attending on duty
#Once the ECG has been completed, the triage nurse will notify the RME provider who will review the ECG
Approved June 2015, Chappell 2/22/16

===21.5 Medications in Triage:  Standardized Procedure===
*Administration of medications in triage (MIT) is to provide timely treatment for patients arriving to the ED with pain, fever, dyspepsia, or nausea and vomiting at the time of triage/assessment and reassessment.  Available medications include Acetaminophen, Ibuprofen, Maalox, or Ondansetron.     
**PAIN:  All patients who arrive to the ED Triage area will have their level of pain assessed and documented in the EMR.  The pain scales used are FLACC, Numeric, and Faces, depending upon the age of the patient.
**FEVER:  All patients who present to the ED Triage area will have their temperatures taken and documented in the electronic medical record. All patients who present with a temperature > 100.4º F (38º C) [can be axillary, rectal, or oral temperature] shall be offered acetaminophen or ibuprofen.  If a previous antipyretic has been given (either at home or in triage), an alternate antipyretic will be given if temperature >100.4º F (38º C).  Rectal temperatures must be obtained for all of the following pediatric patients:  Infants less than 2 months old, Children less than 2 years old with the exception of children presenting with minor trauma, & Active seizure patients up to 3 years old
*Assessment of the patient’s symptoms (pain, fever, gastritis symptoms, nausea and/or vomiting) should be reassessed within 1 hours of the medication given in triage.
**Patients who after reassessment of pain (within one hour of receiving the 1st dose of acetaminophen or ibuprofen) continue to complain of pain and desire further analgesic treatment will then be offered acetaminophen or ibuprofen alternating from the previous medication administration.
**Patients who continue to complain of pain and/or fever may have a repeat dose of acetaminophen 4 hours after the initial dose, and/or a repeat dose of ibuprofen 6 hours after the initial dose.
**Patients who continue to complain of dyspepsia may have a repeat dose of aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) 6 hours after the initial dose.
*A nurse practitioner or physician provider will be notified of any patient that:
**The triage nurse assesses to require more analgesia than oral acetaminophen or ibuprofen or aluminum hydroxide and magnesium hydroxide antacid (Mag-Al Plus) can provide
Approved November 2015, Chappell 2/22/16

==SEPSIS CORE MEASURE==
*Joint Commission/Center for Medicare & Medicaid Services (CMS) determined national standard of quality: early management bundle for severe sepsis and septic shock patients
*Time sensitive management and documentation requirements must be met
*Compliance has financial implications, publicly reported
*Clock starts when patient meets criteria for severe sepsis or septic shock
*Inclusion: 
'''**Age 18 and older'''
*Exclusion: 
**Comfort care
**Transferred from another acute care facility
**Expire within 3 hrs of severe sepsis presentation or 6 hrs of septic shock presentation
**Received IV antibiotics more than 24 hrs prior
**Documented treatment refusal

*Systemic Inflammatory Response Syndrome (SIRS) definition
**Fever (temperature >38.3 C or >100.9 F) or hypothermia (temperature <36 C or 96.8 F)
**HR >90
**RR >20
**WBC >12 or <4 or >10% bands

*Sepsis definition (not included in Core Measure)
**At least 2/4 SIRS + Infection Source

'''*Severe Sepsis''' (included in Core Measure)
**'''Sepsis + acute organ dysfunction'''
**Acute organ dysfunction = 1 or more of the following:
***Hypotension: SBP < 90 or MAP < 65 or SBP decrease >40 
***Acute respiratory failure (Sat <92% without oxygen)
***Kidney Injury: creatinine > 2 or UOP < 0.5 ml/kg/hr
***DIC: PLT < 100, INR > 1.5
***Hepatic dysfunction: bilirubin > 2
***Lactate > 2
**Actions required for severe sepsis: 
***Use the ED Sepsis Orderset, and .sepsisseveresepsis autotext for documentation
***Start 30ml/kg IVF bolus and the below required actions
***'''3 hour bundle:'''
****Draw initial lactate
****Obtain blood cultures prior to antibiotics
****Administer broad spectrum antibiotics targeted at source
***'''6 hour bundle''': 
****'''Repeat lactate if initially 2 or greater'''

*'''Septic Shock''' (included in Core Measure)
**'''Severe sepsis + persistent hypotension despite 30ml/kg IVF bolus''' OR,
**'''Lactic acid > 4'''
**Actions required for septic shock:
***Use the ED Sepsis Orderset, and .sepsissepticshock autotext for documentation
***'''3 hour bundle:''' (in addition to the above requirements of sending initial lactate, blood cultures, and antibiotic administration within 3 hours)
****Start 30ml/kg IVF bolus (order needs to include duration over which IVF were given, so use the order in the ED Sepsis Order Set, which has this prefilled for you)
****Currently no exclusion for fluid overloaded patient, but use your clinical judgement, and document accordingly.
***'''6 hour bundle:''' 
****Start vasopressors if no improvement
****Perform '''repeat focused exam of “volume status & tissue perfusion assessment” within 1 hour after giving 30/ml IVF bolus'''
*****Option 1 (most used): Must include all elements below
******Vital signs: Must include actual Temp, HR, RR, BP. In the 'reexamination/reevaluation' section of your provider note, in the 'vital signs' area, click on 'results included from flowsheet' to automatically drop in a selected set of vitals
******Heart exam: RRR, Irregular, S3, S4
******Lung exam: Clear, wheezes, crackles, diminished
******Pulses: 2+, 1+
******Cap Refill: <2 sec, >2 sec
******Skin: Must include color. Mottled, not mottled, pale, pink
*****Option 2: Need 2 of the following
******Central line: CVP, SCVO2
******Bedside ultrasound cardiovascular/volume assessment (such as IVC, systolic function, pulmonary edema, etc.)
******Passive leg raise or fluid challenge

**'''If you see the SIRS/Sepsis screening icon or think your patient may have severe sepsis or septic shock, ''use the ED Sepsis Order Set'''''. Has recommended antibiotics based on source of infection, labs, and IVF orders with duration times, etc. Also has some informational text about definitions and management.
**Use the .sepsis autotext phrases for documentation (.sepsisseveresepsis, and .sepsissepticshock)

=== Sepsis Abx ===
* Cefepime 2g should be restricted to:
** febrile neutropenia
** HCAP for patient who weighs > 120kg, for others he'd suggest 1g iv q8h over 2g iv q12h based on time-dependent pharmacokinetic of the beta-lactam class
** Meningitis that may involve hospital acquired organism, e.g. patient with VP shunt
* Meropenem
** Severe sepsis, septic shock, over cefepime as there is trend for ESBL in ~ 20% of klebsiella pneumonia and E. Coli based on cultures


A.Wu AED Director 6/13/16

==INVOLUNTARY HOLDS, CODE GOLD, COLD GREEN==

*'''Psychiatric reason:''' 
**5150 (Adult) / 5585 (Peds) legal holds may be placed only on patients who are suspected of being a danger to themselves or others, or gravely disabled, for a '''mental health disorder.''' Patients who are danger to themselves or others or gravely disabled for medical reasons cannot be placed on a 5150/5585. Patients who voluntarily remain for treatment or evaluation are usually not placed on a 5150/5585, but can be if necessary. Non-psychiatric medical personnel can detain anyone who meets 5150/5585 criteria until they can be evaluated by a psychiatrist.

*'''Medical reason:''' 
**Patients who suffer from acute or global cognitive impairments (coma, advanced dementia, altered mental status, delirium) '''lack capacity''' to make decisions and sign out AMA. The basis of the capacity decision rests on the patient’s ability to communicate to the assessing physician the risks, benefits, and alternative to treatment/decision. If the patient cannot do that, then they don’t have capacity. If they try to elope, call a Code Gold (see below). These patients can be held against their will for their own safety, which can include physical and chemical restraints. A sitter may be requested in lieu of restraints, if appropriate. There is no specific hold form for this action, other than the typical documentation for placement of restraints for patients who lack capacity. Therefore, it is important that justification is clearly documented in the provider notes. If the note assessing capacity is not yet written, it should be done by the treating physician while the Code Gold team is present and de-escalating/redirecting the patient. 

*'''Code GOLD:''' 
**This activation is appropriate for patients who become physically aggressive, either from psychiatric or medical reasons, while in the department who need hard restraints. Call x111. The Code Gold team will help you physically restrain the patient. There is no requirement that the patient be on a 5150/5585 for the Code Gold team to respond and assist.
**On arrival, the leader of the Behavioral Response Team (BRT) will identify themselves to the ED nurse(s) and physician(s) caring for the patient. The most knowledgeable medical team member will inform the BRT leader of the reason for the initiation of the Code Gold. The Code GOLD team typically only uses hard restraints.
**LASD is not part of the Code Gold Team, though they will respond to standby as they are available. The BRT leader may elect to turn the situation over to LASD as they see fit. LASD can generally only get involved if a crime has been committed or is about to be committed.

*'''Code GREEN:''' 
**This activation is appropriate for patients are already on or eligible for a 5150/5585 hold who are a danger to themselves or others or who are identified as a "safety risk", and who are attempting to, or have physically left the department. Direct call to sheriff, x3311. 
**LASD will respond to a Code Green, but unless the patient is on a 5150 hold, or the officers deem that the patient is appropriate for initiation of a 5150 hold (which they can do), they do not have authority to forcibly return the patient to the department. In these cases they can only attempt to convince the patient to return.
**It is helpful in such cases to get as much information to the officers about why the patient is a danger to themselves and should be returned to the emergency department. It is also important to inform the officers of whether or not the patient is on a 5150 hold. It is also prudent to document in the medical record the initiation of a Code Green, and officers involved should a decision being made not return the patient to medical custody.

*The above is summarized based on the below references from Hospital Policies, and was vetted by Law Enforcement, Psychiatry, Behavioral Response Team, ED Leadership, and Nursing leadership.
**436 Procedures in Cases To Be Reported to Are Investigated by Law Enforcement Authorities
**301 Discharge Policy, Procedures, and Guidelines Including Elopement and AMA
**138 Law Enforcement Use of Force on Harbor-UCLA Campus
**347A The Use of Restraints Including Seclusion
**346 Involuntary Holds on and on Psychiatric Units and Emergency Medical Department
**379 Safety Attendant (Continuous in Person Monitoring)
**453 Patients in Police Custody
**347B Code Gold-Behavioral Response Team
**620 Consent for Medical Treatment for Patient Lacking the Capacity to Provide Consent
**Sheriff "Cheat Sheet" for Code Green and Code Gold

Dir AED, 10/28/16

==CODE ASSIST==
*Physicians are NOT part of the ED Code Assist Team. The ED Code Assist team is comprised of nurses.
* The ED Code Assist Team covers the first floor and basement, but NOT 1 South.
* The rest of the hospital and 1 South are covered by the Inpatient Code Assist Team.
(Hosp Policy 375B 9/16)

==CODE BLUE==
*All Code Blues are run by the Inpatient Code Blue Team (Not the ED).  
*ED will respond to manage airway only when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.  
(Hosp Policy 375B 9/16)

==CODE WHITE==
*All Code Whites are run by the Inpatient Code White Team (Not the ED).  
*Anesthesia will be primary airway management for all Code Whites.  
*ED will also respond when ED is the Airway Management Team: Sunday 7 AM - Wednesday 7 PM.

==AIRWAY MANAGEMENT TEAM==
===What Does the Airway Management Team Respond To===
*The airway management team is responsible FOR THE AIRWAY ONLY and will respond to:
#All Airway Management Team Pages
#All Code Blues
##If already intubated - please check tube placement
#All Code Whites
##Anesthesia primary always
##ED will also respond when on airway management call

===Timing===
*ED - Sunday 7 AM to Wednesday 7 PM.  
*Anesthesia - Wednesday 7 PM to Sunday 7 AM  
*Whoever has the pager around time of handoff will respond

===Who Responds===
*Purple Attending, Purple Senior (PGY 3/4) (if available), and ED Pharmacist (if available).  
*The Purple Attending may ask the Green Attending or the Peds Attending for assistance at the Purple Attending's discretion.
*The Purple Attending may take another senior resident (PGY 3/4) if the Purple Senior is not available.

===Pager Handoff===
*Pick Up: Purple Senior gets from OR front desk at 6:50 AM on Sunday.  
*Drop Off: Purple Senior to OR front desk at 6:50 PM on Wednesday.  
*The pager cases for anesthesia (extra - not tied to phones) are in the purple doctor's box clipped to the boxes for the McGrath blades.

===Equipment===
*The airway management team bags - purple doc box in the drawers under the pager.  There are two bags.  
*BVM/PPE/MAPS - plastic bags to the right of the drawers.  There are two bags.

===Keys===
*The Purple Attending, Green Attending, Purple Senior, Green Senior and ED Pharmacist have keys to the drawers.

===Medications===
*Each bag in top compartment: 
**Rocuronium 
**Succinylcholine 
**Etomidate  
*Pharmacy will check each day.  
*Residents are also responsible for checking the medications and logging this in the log kept in the drawer for pharmacy.
*Replacement of Meds  
**Return the box to the pharmacist with a patient sticker for new box
**If no pharmacist take used box with a patient sticker to the trauma nurse for new box

===Restock and Bag Check===
*Whoever uses the bag is responsible for restocking it.  
*The bags will be checked by the Purple Senior as part of the 5S process. 
*Zip tie after restocking.  
*If zip tie is in place, no need to open

===Documentation===
*When you return to the ED: 
#Search for patient using magnifying glass in top right corner of Firstnet
#Click  “Ad-Hoc” button at  top and complete  “ED Procedures” form as usual  (This will give you procedure log credit)
#Start a new note 
#Right-click field at the top that says “Type:”  
#Choose “Document Type List” à “Personal” 
#Choose “Rapid Response/Code Blue Records”  
#If you have not added this Document Type to your personal list, choose “Complete” to see entire list 
#Use the “.edairwayteam” autotext to add the template

==See Also==
*[[Harbor: Main]]
*[[Harbor:RME Manual]]
*[[Harbor:Code STEMI]]

==References==
<references/>

[[Category:Admin]]