Harbor:Administrative resident

GENERAL

Always make yourself available to the nursing staff, attending, as they will come to you with questions about patients, if you are going to go grab food, let someone know.

RUNNING THE ROOM

1. Make sure everyone in the ED is seen in expediently
   1. Screen patients---eyeball and maybe write orders as not everyone comes via MSE or may speed pass MSE without orders because they are too sick. Also N.B. patients sent from clinic will have nothing ordered, and on top of that, you will not have screened as those that come via BLS
      1. BBN or beds 1-3-- ASAP
      2. Beds 4-13 or RUSH within about 15 minutes, if possible
      3. Otherwise within 30-45 minutes
      4. Possible critical complaints you should also eyeball: low BP, CP, LN (=?stroke), K+, VB +preg, GIB, SB in a monitored bed.
   2. Assigning patients
      1. if it's been >30min, try to see the pt yourself OR assign the pt to a co-worker
      2. DO NOT try to see everyone yourself. You will need to be available to run the board, move pts around, triage the BLS runs
      3. Don't get stuck in the hallways doing pelvics, or in the suture room doing I&D's and lacs
      4. BE AWARE of all the Tiers that come and assign someone. Often, the nurses do not tell you directly. Keep your eye on the board and listen for the pager to go off.
   3. Any trauma patient in Peds needs a senior (you guys for now!) resident for intubations, so again, assign someone.
   4. Be wary of the intern/med student who has not presented in 1 hour+ -- Actually, as you are busy running the board, it may be easier to take presentations from them, rather than see pt's primarily -- Good trick: assign a student/intern to I&D/lac/easy dispo you have eyeballed
2. Opening up beds (esp monitored)
   1. One bed in bed 1-3 must be opened at all times
   2. After you get your long list of "follows" try to eyeball all your admitted patients as this will help you decide if they can be downgraded (you need to confirm with admitting team)
      1. Tele for r/o ACS patients who have stable vitals, one neg enzyme, and only need to monitor for arrythmias
      2. neg AFBs x 3 can get off ISO
   3. At night Ward Call is in charge of all boarded ED patients
   4. You can write holding orders for Fam Med or Med patients (not hospitalists), for WARD immediately, for PCU within 30 minutes
3. Triaging patients that are BLS runs
   1. Do a quick H&P/exam, can also get BS, hemeaccu
   2. Normal vitals, normal MS, non-worrisome complaint, can walk/sit in chair, not heavily intoxicated, not suicidal, no active vomiting can go to triage -- if in doubt, ask an attending
   3. Tier-0s
      1. Feel their belly, check MS and extremities, ask if they were knocked out-- if anything is "off" you can make it a delayed Tier-1
      2. Try to clear c-spine, or at least get them off the backboard
      3. Can send triage, but if you are feeling nice, and we have spaces open, you may want to keep them
   4. Try not to get bullied by the charge nurse to send patients out. You know better!
   5. "Clear to Psych with no medical complaint" needs a quick note on a 254 (the same the medicine residents use) explaining that you have cleared them
      1. ETOH < 0.2 (use the breathlyzer)
      2. no history of overdose, and same guidelines as above
   6. In general, we aren't really supposed to send out any (MLK) transfers to triage, but in severely overcrowded cases, it's been done, just run it by the attending

PHONE CALLS/CALLBACKS

1. Abnormal lab callbacks
   1. Try to locate patient, check if patient is still in the ED (or even in MSE), admitted
   2. If admitted, tell the tech/rads that they need to call the admitting doctor by calling up to the floor
   3. Check out what was done for the patients -- EDM -- if not yet in EDM, to find out WHO SAW THE PATIENT and the pt's DISCHARGE DIAGNOSIS--- on regular Affinity, go to the Results scroll down for "chemistry" vs "comprehensive" select "ED Log", a new window pops up that should give you the resident who saw them and their diagnosis
   4. If pt was sent home and you feel they need to be recontacted look up pt contact info - I do so by using the "affinity clinic work station" as this has a separate "Administrative data" scroll down button with phone number and address. There is supposed to be a Demographics button on the regular affinity too - Call patient or send them a telegram if they are hard to reach
2. ED Discrepancy Folder....... (over reads)
   1. You are responsible for taking a look at this folder every shift, and clearing 2-3 over-reads
   2. Open synapse and go to -->Conferences--->ED discrepancy
   3. If the patient is admitted, then just write that the pt is admitted in the note section
   4. if not, then it's the same process for pt with abnl labs, depending on the situation you may have to track down the patient and call them/send a telegram
   5. Again, ask an attdg if you have questions
3. Outside clinics, MLK, Hubert-Humphrey transfers
   1. We generally don't refuse any transfers
   2. However, if the pt is unstable, they should call 911 and go to the nearest hospital
   3. Inform the charge nurse that there is someone coming and if they need to be monitored d) You generally cannot triage MLK/HH transfers back out to triage...but if we are severely overcrowded (as above) it's acceptable if the attdg is ok with it
4. Harbor Clinic patients
   1. Again, generally cannot refuse patients
   2. if they do not need to be monitored bed, they can go to Urgent Care instead
   3. if they are being admitted, and are otherwise stable (do not need monitor) then they should bypass the ED and go through pt flow coordinator
   4. When Urgent care closes, pt get sent to the ED
   5. Again FYI the charge nurse about all incoming patients
5. MAC transfer requests
   1. Often for "higher level of care"
   2. Make sure you run the patient by the specialist and admitting team, e.g. multi-trauma pt who needs NSG intervention needs to be accepted by neurosurgery AND trauma
   3. Good trick: tell MAC to call consultant directly, can then bypass the ED if they have a bed.

Source

Hsiao 10/09