ED

BWH Emergency Department Orientation Manual

5.6.2010

Welcome to the ED! We will outline some simple operational rules that are necessary for the functioning of the ED and will hopefully help you on your first few shifts. We’ve also included an introduction to two topics that would otherwise be confusing – emergency observation, and the ED Tracking computer system. We hope you have a great rotation!

In general, your overall goal is to work hard, know your patients well, and to learn as much as you can while you are here. The ED is a great place for getting exposure to procedures and resuscitations. The more patients you see and the sicker they are, the more you will learn. However, do not spread yourself too thin. Pushing yourself to pick up more patients is encouraged but not at the expense of missing important details on your existing ones.

Despite your best efforts, there may be times when you’ll feel overwhelmed. Don’t be afraid to ask for help – that is why the ED attending and EM senior are there-- especially if you have a sick patient that you’re worried about. The attending and senior EM resident want to know about all of the sicker patients in the department; they will appreciate the heads up if things are going south.

LOGISTICS – HOW TO SEE A PATIENT

I apologize if this seems rudimentary but for your first day or so, it may be helpful to have a sample routine in mind while you get into the swing of things. Just like having a system to keep organized is crucial for your floor rotations, the same applies in the ED. Have a standard method of picking up patients and staying organized. A sample one is this: sign up for new patient, peek in room from hallway: if the patient looks sick, go into the room immediately. If they look stable, go briefly look them up on LMR (ie < 2 minutes), grab their note, find the triage sheet with triage vitals (RN notes, usually in the box), then go into the room. If possible, try to write a good chunk of your note while you’re in the room. After leaving the room, present to a senior EM resident or an attending, write orders on the patient, and start thinking about eventual disposition. Communicate the orders to the nurse preferably as well. Then repeat with the next patient. Be on top of lab results, radiology studies and changes in patient symptoms or vital signs; use this information to modify your treatment and dispo plan.

CHARTING

Residents complete paper charts, found in the patient’s box outside their room at the nurses’ station. Attendings then dictate later using the resident paper chart as a guide. Before walking into the room, grab the chart from the box. The ‘doc note’ (your note) is physically connected to the nursing note. You must remember to tear the nursing note away from your doc note and put the nursing note back in the box. If you forget and place it in your back pocket like I (Emily) often do, the nurse will hunt you down in a rabid display of fury, usually followed by a harrowing glare designed to make your soul melt. This is a classic residency trap. Tread lightly, my fellow comrades. Tear off the nursing note.

The first ink on the chart should be your signature, printed last name and attending’s name at the end of the chart. The next ink on the chart should be the vital signs. As always, vital signs are vital. This is especially true in the ED.

Let the attending know when you’re about to start any procedure – NG tube, Ultrasound-guided IV placement (try it! It’s easy and incredibly useful), suturing, central line, L.P. After any procedure, fill out and sign a procedure form, found in the patient’s box.

COMPUTER SYSTEM (ED TRACK)

Our computer system is a mix of Windows and BICS. The following features are important to know on your first day.

'''Who hasn’t been seen yet? '''A yellow border around a patient’s tile means the patient has not been assigned to a physician. Go get ‘em, tiger.

How do I sign up for a patient? Right click on patient’s tile and click ‘Assignments.’ Click ‘currently logged in user’ button the first time you sign in per day. Your name will pop up. Double click on your name. Your name is now on that patient’s tile as the covering physician. If you sign up for the wrong patient, right-click on the card and choose “Assign doctor.” Then right-click on the assigned doctor’s name and choose “Delete doctor assigned.”

'''How do I place orders? '''Right click on the patient’s tile and click ‘Order Entry.’ Click on the appropriate Windows-type buttons (Labs, Radiology, etc).

<p style="line-height: normal; margin: 0in 0in 0pt">'''How do I look up results? '''Right click on the patient’s tile and click ‘Results.’ Hello, BICS!

<p style="line-height: normal; margin: 0in 0in 0pt">'''How do I discharge someone? '''Right click on patient’s tile and choose “Disposition.” Choose “Home” from the drop-down menu. Go to the patients’ box and fill out their discharge paperwork. On the discharge instructions, be sure to include follow-up plans and reasons to return to the ED. Put it back in the box along with any scripts they may need. The RN will then discharge the patient.

<p style="margin: 0in 0in 10pt">'''How do I admit someone? '''Your attending will place bed requests with admitting and speak directly to GMS attendings, MICU attendings, etc. Once a resident is assigned to take passoff, it will pop up on the patient’s tile and you can page them. Once you have passed off, right click on the tile, hit ‘Disposition’ and ‘Admit to floor/ICU/Faulkner.’

<p style="line-height: normal; margin: 0in 0in 0pt">'''How to I admit someone to OBS? '''

<p style="line-height: normal; margin: 0in 0in 0pt">Three things that have to happen for every OBS admission:
 * 1) Paperwork: There is a file cabinet in each area of the ED near the Business Specialist’s Desk that contains the OBS protocols. The first ink on any medical document must be the patient’s name and your name. Fill out the generic front sheet as well as the admission page of the pertinent protocol’s paperwork. Be specific as to the endpoint that will allow for discharge or that might mandate admission (e.g., 2nd set of enzymes & ETT neg à home; or abdominal CT negative à home, but if positive or unable to eat/ambulate/etc. à admit). Document your conversation with the PCP/others. Please make sure the attending signs the OBS paperwork. 


 * 1) Put in a computerized disposition order - ‘Admit to OBS.’
 * 2) Orders: Every patient admitted to OBS or put in OBS status needs admit orders. Right click the patient box, click ‘orders’, and then scroll down in the upper left area under “chief complaint” next to “template” for the pertinent OBS protocol. Click “use template” and it will forward you to the appropriate OBS admit template. Don’t forget daily meds.
 * 3) Pass off to the PA working in OBS if between the hours of 11am – 11pm. If it’s outside of those hours, you keep your name on the patient.

<p style="margin: 0in 0in 10pt">DRESS CODE

<p style="margin: 0in 0in 10pt">Most people wear scrubs +/- white coat. Alternatively, “business casual” is perfectly acceptable.

<p style="margin: 0in 0in 10pt">PHONES

<p style="margin: 0in 0in 10pt">Get a phone from the business specialist (clerk) in the Alpha area of the ED. (You’ll have to leave keys or an ID as collateral for the phone.)

<p style="margin: 0in 0in 10pt">FOOD

<p style="margin: 0in 0in 10pt">JHACO tells us that there is to be no food or uncovered drinks in the ED. Covered drinks are okay. The ubiquitous (but still delicious) Shweppes’, peanut butter, and graham crackers can be found in the OBS kitchen. There’s a break room (combination 4-2-3) with a fridge you can use. If you are hungry, either bring a meal or grab a very quick bite at ABP/cafeteria. Find a good break point and let your senior know before leaving the department.

<p style="margin: 0in 0in 10pt">HAND HYGIENE POLICY

<p style="margin: 0in 0in 10pt">Please remember to clean your hands (Purell or soap and water) before and after contacting a patient or his environment (e.g., the bedrail) and before and after using gloves. Be especially mindful of this with hallway patients. The hospital has strict policies about hand hygiene, but folks sometimes forget that the same rules apply in the ED as everywhere else. The ED takes this seriously. Secret hand hygiene compliance counts are taken daily in the ED and reported weekly to our residents and Department Chair. Be careful—don’t get busted for not cleaning your hands!

<p style="margin: 0in 0in 10pt">SCHEDULING LOGISTICS

<p style="margin: 0in 0in 10pt">Shift trades are permitted, but must be approved by an EM chief resident. In general, all shifts covered by a PGY 1 or 2 medicine resident or the surgical or emergency intern are interchangeable. Many of the EM2 shifts (except for overnight shifts) are also interchangeable. You must have 10 hours off between shifts. All schedules are on www.amion.com (password haemr); changes are not final until posted on this web site. Email [mailto:EMChiefResidents@partners.org EMChiefs@partners.org ] with any schedule questions or shift change requests.

<p style="margin: 0in 0in 10pt">If you unexpectedly cannot make it to a shift, your chiefs and the EM chiefs need to know as soon as possible! The EM chiefs are available on page at any time and the pager is found in the directory under ‘Emergency Medicine.’ We must find coverage for every shift so need to know if you cannot work.

<p style="margin: 0in 0in 10pt">We have simulations & didactics every other Tuesday, 12-5 p.m, at the Neville House. You are welcome to come if you’re not scheduled for a shift.

<p style="margin: 0in 0in 10pt">We sincerely hope that you enjoy your time in the ED and are committed to making this rotation a positive one. If you have any questions or concerns, please let us know at [mailto:EMChiefs@partners.org EMChiefs@partners.org ] or page or email us directly.

<p style="margin: 0in 0in 10pt">Sincerely,

<p style="margin: 0in 0in 10pt">Emily Brown, Aaron Skolnik, and Lisa Thomas (2010-2011 EM Chief Residents)