CRITICAL EPIC UPDATES
1. FOR PROVIDERS: ED Course is coming to Epic by June 20th!
Many of you have been asking for this ever since we switched to Epic, and now it’s finally here! For the past 2 years, we’ve been waiting for an Epic upgrade that would enable us to use ED Course at NYP. The moment has finally arrived!
ED Course allows any provider to quickly document ED updates from the ED trackboard, Workup tab, or Storyboard without needing to open a full note.
ED Course updates will automatically flow into the ED Provider Note, even after the note is signed. This ensures that no information is ever lost.
By June 20th, we will switch to a “one-note” system by using ED Course for updates. The initial MDM, subsequent updates, and handoffs will all appear in the ED Provider Note. In general, you should stop using ED Progress Notes to document updates and handoff and use ED Course instead.
For more details, see the attached ED Course presentation and tipsheet (sent to your email).
Fundraiser to Uvalde Memorial Hospital
I hope you’re all having a good week. The newbie attending crew has been fundraising to send food to Uvalde Memorial Hospital that received 13 GSW patients in the wake of the recent shooting at the local elementary school. We have a pretty good start and are hoping to raise $3200-$3400 to be able to provide a nice meal for the roughly 200 staff from a local favorite down there. If you’re interested in participating, you can Venmo @liza-hartofilis or we can figure out another way if Venmo doesn’t work for you, and we’ll keep you all posted when we reach our goal.
Thanks so much,
Splinting Teaching Opportunity!
On Tuesday 6/21 there will be a procedure workshop for the new interns. Dr Ahmed will be doing a splinting workshop from 9am-12pm. If interested let us know!
Please remember to email your morning report topic to faculty before your presentation!
Medical Student Mentorship Opportunity
See message below from Spencer Dunleavy (Equity/Justice Fellow at Columbia)
I wanted to reach out to you to see if you could help recruit EM residents to potentially mentor students.
The goal is to create a database of resident mentors of all backgrounds across all residency programs at NYP-Columbia to help guide medical students from traditionally less supported backgrounds (with respect to race/ethnicity, socioeconomic upbringing, gender, and sexuality) toward the specialties they wish to pursue. As someone who came from a background where no one in my family had gone to university, I know it has been very challenging to find people with similar experiences to help me on my path through medical school. Our hope is that we can create a sustainable system for students of varying backgrounds to help find role models and mentors.
Would you be able to help us recruit residents in your program? A sign up form for residents can be accessed here. I would be happy to discuss further with you if you have any questions, concerns, or suggestions.
Stroke Reminders at Columbia
- There has been some confusion regarding activation stroke for TIA (stroke like symptoms that resolved) within 6 hours of onset. These patients need an activation since we still need to report our time metrics for TIAs< 6 hours to New York State. Furthermore, sometimes there are subtle findings on their neuro exam or have stuttering symptoms which would make them a stroke patient rather than TIA. Activate Stroke Code for these patients and neurology is aware of this as it is part of our hospital stroke policy
- Activate Stroke Code for patients who presents with symptoms concerning for SAH or ICH within 6 hours. This is also per our stroke policy and we are required to report out those metrics. It will expedite getting the head ct on time and utilize the appropriate resources to take care of these patients.
- Use ED Adult Stroke Order set for patients that a code stroke is activated for. This order set have key elements that trigger multiple departments to expedite results for stroke patients as all these results are time sensitive. In addition, the [Head CT Acute Stroke Team Activation] order triggers the radiologist to be on standby to read this CT scan and expects someone in the CT scanner to communicate the results to. In addition, the CT scanner is usually placed on standby till the patient arrives. As one can imagine, if it is used for a 6/24 that does not meet criteria for LVO, it can lead to delays in other patients’ care when it is not warranted and may hold up valuable resources such as CT scan room as well as radiologist.
4 North Transportation
Transport to 4-North (Cardiac Stepdown) at Cornell is supposed to be supplied by Cardiology. Our providers should not be transporting admissions to 4N. Their department has agreed to this and it is documented in Nexus (in the event that you get push-back).
Cornell Ops Updates
Adult ED Scheduling Update: There are several changes to the shift map and times starting in July:
- WC will again have 2 swing attendings Mon-Fri starting July 5th
- The WC Wednesdayswing #1 shift time is now 10a-8pm
- The WC Mon-Fri swing #2 shift time is now 2pm-12am
- Swing 1 will sign out to Swing 2; and Swing 2 will night out to the overnight team. This will help decompress the evening shifts.
Paxlovid ED Rx Order now LIVE!: nirmatrelvir-ritonovir (PAXLOVID) pack EUA – ED Discharge Dispense
- Available for take-home on discharge starting June 15th.
- No change to criteria, and job aid is available (see Nexus!).
- Job aid: https://epictogetherny.org/Training/TipSheets/EpicTipSheets/COVID-19%20-%20Ordering%20Paxlovid.pdf
- Verified by our pharmacy with dosing and interaction check, and patient fact sheet with meds delivered to patient/nurse.
Interdisciplinary Rounds (IDR’s) @ 10am, 4pm, 10pm:
- Will start to include D Bay patients under evaluation for 4 hours or longer.
- Adult Main Bays will continue to maintain the threshold of 8-hour or longer.
- This is an opportunity to evaluate barriers to disposition, which are being tracked by Patient Services.
Area A Refresh is planned for Mon, June 27:
- Similar to Area B Refresh, it will last for one week and require a complete closure of the area, in this case diverting Trauma and Obstetrics Activations to alternate bays.
- Staffing & workflow details to come.
Major ED Events: Please escalate all of the following major events to the AA in real time:
- Shootings, stabbings presenting to ED
- All physical violence to staff in ED
- ED patients who attempt or achieve deliberate self harm while in the ED(e.g.: cut wrists; try to hang themselves while in ED)
- ED patients with accidental harm event in the ED(fall with head injury, anaphylaxis to med with known allergy)
- Delayed diagnoses in the ED that may have translated to patient harm (e.g.: a aortic dissection that crashes while waiting for CT)
- Patients who expire in the ED(except patients who arrive in the ED peri-arrest)
Transfer of patients from ED to 4N / CCU:
- Transfer of patients from the ED to 4 North / CCU is the primary responsibility of the accepting service. A provider from the admitting service will accompany the patient upstairs within 1 hour of bed assignment.
- The decision for transport without a provider is at the discretion of admitting team.
- 4N team members may cover for the CCU team.
- This process has been reviewed and approved by ED and Cardiology leadership as of June 2022.
Avoid Unnecessary Exposures: Empirically use isolation precautions:
- Contact precautions are for your C.diff, MRSA, VRE, spread by direct or indirect contact, remember to wash your hands with soap.
- Droplet isolation is for relatively larger particles and how respiratory viruses are typically spread via talking, coughing and sneezing.
- Airborneisolation is for your TB rule outs, and Varicella Zoster virus. Needs an N95.
- Monkeypox needs all 3!
- Any suspected disseminated zoster infection or immunocompromised patient with localized zoster should empirically be cared for in NEGATIVE PRESSURE
- Remember to Inform nursing once identified
Neuro QPS & Risk Documentation: Remember to document appropriate near exam for all patients with the following complaints.
- Dizziness – including cerebella
- Lower back pain
- Chest pain with dissection concerns
Food Insecurity Resources Available:
- Screening Questions for Food insecurity (either positive)
- Within the past 12 months, you worried that your food would run out before you got money to buy more.
- Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more
- How to Refer: Epic: Refer using the referral order “AMB REFERRAL TO FOOD INSECURITY”Dx Association – food insecurity
All patients who undergo procedural sedation require a brief pre-sedation evaluation, including an airway assessment, before sedation begins.
To support this workflow, we created a new Pre-SedationAssessment Note to complement the existing ED Procedure Note for procedural sedation.
I. Complete the Pre-SedationAssessment Note Before SedationBegins
- Open the patient’s chart and click on the My Note tab.
- Select the Pre-Sedation Assessment Note.
- Complete the Pre-Sedation Assessment Note template that appears on the right side. This includes information that should be obtained prior to the sedation procedure, including informed consent, an airway assessment, and a focused history and exam including ASA Score and Mallanpati Score.
- Sign the note before sedation begins.
II. Complete the Procedure Note After the Sedation Procedure
- Open the patient’s chart and click on the My Note tab.
- Select the Procedure Note.
- Select the Procedural Sedation template.
- Complete the Procedural Sedation template that appears on the left side. This includes information about what happened during sedation, including findings and complications.
- Sign the note once you are done. Remember to complete a separate Procedure Note for the procedure itself (central line, joint reduction, etc).
Medical Education Research Opportunity
Quality and Patient Safety Lecture
Small Group Sessions
ALiEM Air Pro Series: Cutaneous 2019
Tintinalli’s Emergency Medicine 9th Ed – Chapters 248-253 Derm and Wound Evaluation Link for NYP residents @WCM Library
Shout out to Tyler wise who performed: "2 intubations, 1 crash central line and 1 trialysis catheter in a separate patient so they could get emergent HD. All while taking excellent care of his primary patients!" Rock on Tyler!!!
Chief On Call
William Haussner, M.D.
EM Chiefs’ Cell: 917-410-1056
Please call and do not text/ email so we can address issues promptly.
If you do not hear back within 10 minutes, then call any of the other chiefs