Ver el código de «Harbor:Operations manual»

==Pre-hospital/Surge Plans==
===[[Harbor:Incoming transfers|Incoming transfers]]===
===Ambulance Triage===
*[[Harbor:Screening EMS Patients|Screening EMS Patients]]
===Surge Criteria and Plan===
*[[Harbor:Surge Plan/Disasters|Harbor Surge Plan/Disasters]]

=== Disaster Plan & Equipment===
Detailed Instructions are in the '''Harbor-UCLA DEM Emergency Operations Plan''' Binder on the shelves next to the clerk's desk in the AAED A-side.

====General Instructions====
#Everbridge System notification for callbacks if at home - Call to clerk's phone to report if available and receive assignment.
#Activate the DEM Emergency Operations Plan (EOP) based on info from EMS/Reddinet: Criteria: 
##5 or more "Immediate/Red" patients, 
##10 or more "Immediate/Red" or "Delayed/Yellow" patients from the same incident.
##Multiple patients arriving from incident involving Hazmat exposure.
##Directive from hospital administration, via activation of Hospital Code Triage.
#Step-by-step instructions for activating the ED EOP are located in the "Checklist: Activating the ED EOP" document posted behind each console in the Base Station Radio Room, and in the ED EOP binder by the AED Clerk's desk.
#The ED Nurse Manager, or Overall Charge Nurse on weekends/evenings, assumes the role of ED/Casualty Care Unit Leader, and coordinates all role assignments and/or other activity in the ED during the Disaster period.
#The DEM Organizational Chart contains all ED roles during a disaster event. 
#Roles that may be assigned to physicians include: Immediate Unit Leader (Purple Attending), Delayed Unit Leader (Green Attending), Minor Unit Leader (Fast Track NP or MD), Pediatric Unit Leader (PED Attending), Triage Unit Leader (Screening MD or NP), Decon Unit Leader (Any Decon-Trained MD/NP/RN).

====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)
*Cones - Triage Color Coded - Wheelchair Storage Closet
*Decon Team Supplies (PAPRs, Level C PPE) - Storage Closet under Helipad
*Decon Trailer - Trailer Lot
*Disaster Cart - Central Supply and Linen Room SE BF09 - keys on big ring in Command Post (1L1) cupboard
*Disaster Packets/Clipboards - Shelving unit next to clerk's desk, AED A-side
*Disaster Tags - (Pedestrian spine storage by Router desk)
*Dosimeters - Radiation Safety Office Building N32
*Geiger Counters
**3 in ED Charge Nurses Office
**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
*Privacy Kits for Patients - Decon Trailer
*Signs - Triage Station - Wheelchair Storage Closet
*Trailers 1-5 - keys in Pyxis AAED
*Additional Vests - Wheelchair Storage Closet
*Wheelchairs - (SE1A04) - NA7 Key

Dir OPS 9/14/16

===Orchid Downtime===
*[[Harbor:ORCHID Downtime|ORCHID Downtime]]
===ID:  Flu, Hepatitis, Ebola===
*[[Harbor:Infectious Disease Threats|Infectious Disease Threats]]

==[[Harbor:Labs|Labs]]==

===Specimen Collection by Providers===
#Provider places order for specimen
#Request clerk/nurse to print labels
#Provider affix label to specimen
#Leave specimen in room on cart
#NO NEED TO INITIAL OR PUT PROVIDER ID ON LABEL
#If no specimen labels printed
##Affix generic patient label
##RN prints and affixes specimen label
#Provider notifies RN specimen ready to send
##If RN unavailable notify Charge RN
#RN scans specimen and patient wristband
#RN sends to lab
(Wu 1/2019)

==Radiology==
*[[Harbor:ED Radiology Specs|MRI Specs]]
*[[Harbor:ED Radiology Specs|CT Specs]]
*[[Harbor:Rules for Performing ED Ultrasounds|Formal & ED Ultrasounds]]
*[[Harbor:STAT MRI|STAT MRI]]
===Discrepancy E-mail===
To:  smunn@dhs.lacounty.gov; BKalantari@dhs.lacounty.gov; amlikotic@dhs.lacounty.gov; jkuo@dhs.lacounty.gov; akaji@dhs.lacounty.gov; tlittle@dhs.lacounty.gov; cavaughn@dhs.lacounty.gov; iclaudius2@dhs.lacounty.gov

On [Date], USROC contract radiologist [Radiologist Name] submitted an interpretation for a [type of study] for patient [last name, first name], MRUN [Insert MRUN]. 
 
After our review of the study and interpretation for clinical purposes, the Department of Emergency Medicine has identified the following potential quality problem(s):
  Accuracy of interpretation (may include omission of significant finding)
  Delay in interpretation
  Other (specify):

Following is relevant information on this case: [Insert clinical context and explanation of concern].
 
Therefore, we request that this study undergo a quality review as part of the Department of Radiology’s monitoring of the USROC contract.
 
Should you have questions on this matter, please do not hesitate to contact [Your Name] at [DHS Username]@dhs.lacounty.gov.
 
Thank you.


Dr. Lewis 5/2018

==EQUIPMENT==
*[[Harbor:Equipment|Equipment (AED/RME)]]
*[[Harbor:Equipment and supplies (peds)|Equipment (peds)]]
===Ordering DME===
*[[Harbor:DME|Durable Medical Equipment (DME)]]

==IA/Exposures==
===[[Harbor:Occupational exposure|Occupational Exposure]]===
*[[Harbor:Industrial Accident (IA)|Industrial or On-the-Job Accidents (IA)]]
===Sexual Assult/STI Exposure===
*[[Harbor:Non-Occupational Exposure|Sexual Assult/STI Exposure]]

==Patient Disposition==
===F/up Flowchart===
* https://gallery.mailchimp.com/9d46ba488168336ff904bf5e2/files/f3e83cc1-58eb-404b-99c7-5c1a5542ddaf/ED_followup_flowchart_3_7_18.pdf ED follow up flow chart]
===[[Harbor: ED Follow-Up Options|ED Follow-Up Clinics]]===

===[[Harbor:Discharge|Law Enforcement Escort]]===
*[[Harbor:Prescribing|Prescribing]]

===Other===
*[[Harbor:Deceased patients|Deceased patients]]
*[[Harbor:Transferring a patient|Transferring a patient]]
**[[Harbor:Transferring to psych ER|Transferring to psych ER]]

==ADMISSIONS==
===Admission Policy===
*[[Harbor:Admitting a patient|Admitting a patient]]

=== OBS & CORE===
*[[Harbor:Observation placement|Observation placement]]
*[[Harbor:CORE|CORE placement]]

===Admission Guidelines===
*[[Harbor:Admission and consultation guidelines|Admission and consultation guidelines (policy 312)]]
**[[Harbor:Right level of care|Right level of care]]
**[[Harbor:Internal Medicine Admissions|Internal Medicine Admission Template]]
**[[Harbor:C-Team|C-Team Admissions]]
**[[Harbor:Who Goes to Family Medicine|Who Goes to Family Medicine]]
*[[Harbor:Post-admission management|Post-admission management/Orders on Admitted Patients]]

===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.

(Dir. OPS, February 03, 2015)

===[[Harbor:Direct Admission after Hours|Direct Admission after Hours]]===

===Insurance Problems===
# For issues with insurance, refer patients to the CA Dept of Managed Healthcare:  https://www.dmhc.ca.gov/

==Physicians==
===[[Harbor:Forms|Forms]]===

===[[Harbor:PC Cheat Sheet|PC Cheat Sheet]]===

===[[Harbor:Phone numbers|Phone numbers]]===
===[[Harbor:Paging]]===

===[[Harbor:ED attending on call plan|ED attending on call plan]]===

===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)


===[[Harbor:Code STEMI|STEMI Activation]]===
*[[Harbor:EKG STEMI Screening|ECG STEMI screening]]

===[[Harbor:Code stroke|Code Stroke]]===

===Scheduled Dialysis Patients in ED===
#The router will place them on the pre-arrivals each AM (M/W/F)
#HD times should be 5-9a and 930-130p
#They will receive a MSE at triage – if they decline the MSE and only want their scheduled HD, please document that “the patient declined a MSE and no emergent medical condition exists at this time” in the MSE note and we are done from the ED perspective
#If the patient appears unstable, please discuss with one of the AED attendings to determine if they need to be on an AED team or simply need dialysis with a call to the nephrologist for urgent evaluation.
#Once the MSE is performed, they will be taken to one of our HD rooms – preferentially Gold 29, then RME 19, then Acute 15 (likely a max of 2 rooms at a time).
#They will be cared for by the nephrologist (typically Dr. Anuja Shah) who will place the discharge orders (so these patients should NOT be placed on AED teams).
#If for some reason Dr. Shah is unable to evaluate the patient prior to discharge, the FastTrack NP (not resident) will briefly evaluate the patient when ready for discharge - documenting vitals, heart, lung, and lower extremity exam, and page Dr. Shah to clear for dispo and subsequently print the discharge instructions (“HEMODIALYSIS” patient education).  
#The NP will forward the chart to Dr. Shah, not ED R4 or Attending.  
Chappell 12-1-17

===ED Procedure Videos===
* LP
* Para ...

==Documentation==
===[[Harbor:Attending documentation|Attending Documentation]]===

===[[Harbor:Resident documentation|Resident documentation]]===


===[[Harbor:Prescribing|Prescribing]]===

===[[Harbor:Codes|Codes]]===

===[[Harbor:Airway management team|Airway management team]]===

===[[Harbor: Macros and Autotext|Macros and Autotext]]===

==[[Harbor:RME & TRIAGE|RME & TRIAGE]]==

==LEGAL==

===AB 2760: Naloxone for patients at risk for opioid overdose===
Requires providers to offer a prescription for naloxone (or other reversal agent) when 
#Prescribing ≥90 morphine milligram equivalents/day (for example, 9 Norco 10/325 tabs/day) Here is a link to the CDC tool for daily opioid dose calculations: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf, or 
#When co-prescribing an opiate with a benzodiazepine.  
#''''''Even when not prescribing opioids if the patient just has a history of overdose or substance use disorder''',''' or if the patient is at risk for returning to a high dose of opioid medication to which he or she is no longer tolerant.  Cal/ACEP is looking further into this latter provision but for now, it’s the law.
*At Harbor, we have '''naloxone intranasal''' on formulary. Further, if a prescription for naloxone (or other reversal agent) is given, the p'''rovider must educate the patient''' (or someone designated by the patient) on overdose prevention and how to use naloxone (or other reversal agent).  To help you with that requirement, below is a link to a sample patient education handout, which includes naloxone information. [https://gallery.mailchimp.com/e35e5fa1ba46b6de2508eeb46/files/917ffb95-8676-4a7d-be20-bba0f996b22b/Patient_Education_on_Overdoses_and_Naloxone.pdf?utm_source=CA+Providers+%28ED%2C+Hospitalists+%26+ICU%29+ICs%2BAPCs&utm_campaign=01cf5a6775-EMAIL_CAMPAIGN_2018_12_28_08_49&utm_medium=email&utm_term=0_4c468cb1a3-01cf5a6775-157632935 Patient Handout]. We are working making this flyer available at each clerk’s station and in the doc boxes, and there are similar naloxone instructions in ORCHID.

===SB 1152 - New California homeless patient discharge planning law===
Bottom line, 
#Consult social work as early as possible once you have identified a homeless patient ("HL" icon). Social work wants to be consulted for EVERY homeless patient. 
#Infectious disease (ID) screening and vaccinations are now mandated by law, so based on current ID concerns, please document that you offered Hep A vaccine to those that qualify since there is an ongoing Hep A outbreak. 
#If medically appropriate, please order a meal prior to discharge. 

Details: 
*New definition of homeless:
**Lack fixed and regular nighttime residence
**Primary nighttime residence in supervised area or area not designed for living/sleeping
**Examples: Car, shelters, tent, hotel, street, beach, park, abandoned building, bus/train station, etc. 
*Offer meal - please order of medically appropriate: Provider and RN
*Offer weather appropriate clothing - SW and RN
*Discharge meds or prescriptions - Provider
*Referral for follow up care - Provider
*Offer infectious disease screening and vaccinations: Currently, Hep A vaccine to address local outbreak. Provider and RN. 
*Offer transportation: bus tokens from social work, House Supervisor, Registration
*Screening for affordable healthcare coverage: Patient Financial Services (PFS), Registration
*Identify post-discharge destination: SW
*Communicate discharge needs to receiving entity: SW

More info: https://californiaacep.site-ym.com/page/Legislation_Implementation

===[[Harbor:Involuntary holds|Involuntary holds]]===

===[[Harbor:Adverse event mandatory reporting|Adverse event mandatory reporting]]===

===[[Harbor:Prescribing|Prescribing]]===

{{Triaging Ambulance Patients}}

{{Harbor follow up}}





{{Family Viewing of Deceased Patients}}

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



{{Harbor Ebola precautions}}

{{Contacting attending consultant}}

{{Harbor Elective Transfers to MLK Hospital}}

===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

===ILLICIT DRUGS/MARIJUANA IN ED===
* Marijuana less than an ounce (plant) or 8 gms (concentrate) and patient at least 21 years old - keep with patient belongings
* Marijuana quantity more than above (or not sure), or possessed by person under 21 - Call Sheriff
* All other illicit drugs (or suspect as illicit) - Call Sheriff

Dir OPS  2/27/18

===OBSERVERS IN THE ED===
*There can never be an observer of any type in the ED without the prior permission of hospital administration or the chair, or one of the vice-chairs in the department.
*Observers must be introduced to any patient whose care they observe and the patient must be given the opportunity, in a non-coercive and open manner, to not have the observer present during their care.
*Observers must never be present during sensitive parts of medical care (e.g., genital exams, during history taking regarding abuse or sexual assault, etc.).
*Observers must wear a clearly visible name tag that provides their first and last name and identifies them as an “Observer” or using a more descriptive label (e.g., “Medical Student” or “Residency Candidate”).

Chair, EM 9/2017

==[[Harbor:Social work|Social work]]==

===[[Harbor:Whole person care|Whole person care]]===

==[[Harbor:Core Measures|Core Measures]]==

==[[Harbor:ED policy manual|Harbor ED policy manual]]==

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

==References==
<references/>

[[Category:Admin]]