Weekly Update – October 25 2021 – NewYork-Presbyterian Emergency Medicine

November 1, 2021

From Dr. Marie Romney, VP of Operations at Columbia:

In follow-up to our Town Hall on Tuesday, I’d like to share an update on nursing staffing for the Milstein ED. In addition to the 24 RN FTEs we discussed that were recently added to the area E nursing pool, we were granted an additional 15 RN FTEs and 31 ERT FTEs. These additional 70 FTEs will result in approximately 7.5 additional RNs and 6 additional ERTs on every shift, 7 days a week. Knowing that it will take some time to hire and train these new team members (approximately 9-12 weeks), we are pursuing an equal number of travelers to help support the department until their arrival. Separate from this, we have several new nurses joining our team in the coming weeks and we continue to fill our remaining vacancies. In the month of November we have 25 new nurses joining the department-18 new orientees and 7 agency nurses. In the interim, as staffing remains a challenge, our nursing leaders will continue to communicate the staffing plan for each shift, via email, after huddle.

I know how challenging these past few months have been, particularly on the heels of our COVID battle. Please know that everyday Vepuka and I are doing everything we can to amplify the need and advocate for the resources you require to continue delivering high quality care to our patients. There’s still much more to be done, but this additional staffing support, while long overdue, is a significant step in the right direction.

We will continue to communicate updates as they come, but please reach out with any new concerns or questions.

Thanks,
Marie

From Dr. Mills: Academic Job Opportunity Near New Orleans

Good morning,

I am the new Chair at Ochsner Medical Center in New Orleans, LA, recruited here to build an academic department. Things are really taking off with gusto as there was already a really fantastic group of faculty physicians in place; we are a tertiary referral site for a large network of hospitals and see ~70,000+ patient visits/year through our ED; we are already in our second year of our EM residency and the institution has ~30 residency/fellowship programs in total (robust GME presence); and we are the home of the UQ-Ochsner Clinical School (our medical students spend the first two years at University of Queensland and the final two years here with us). We have set our foundation, and now we are working on adding depth to our niches and adding an Associate/Assistant Residency Program Director. It is a really exciting time of growth here. I have a passion for education (was the Vice Chair for Education / Residency Program Director at Vanderbilt before taking on this new opportunity). So, if you have any faculty who are also passionate about resident/fellow education and looking for a really great new opportunity, please send them my way. Posting is below and attached as well for a more formal description.

Thanks,

Nicole McCoin

From Dr. Osman Sayan: Job Opportunity at Baylor

Former Columbia APD and now Baylor PD Aleksandr “Sasha” Tichter posted that “Baylor College of Medicine in sunny Houston, TX has openings for full-time faculty of all academic ranks to join our growing department.”

Volunteer with Adam Blumenberg at the NYC Marathon

I’d like to invite you to volunteer with me at the New York City Marathon on November 7!

The New York City Marathon is among the largest marathons with runners joining from all over the world. There are usually over 50,000 runners who cross the finish line. Many of the runners require acute medical care during or immediately after the race, and come in droves to the finish line medical tent.

I have done medical volunteering for the NYC marathon before and plan to be there this year on November 7 as a licensed attending. It is an awesome experience. This is a wonderful opportunity to see another side of medicine and I recommend it for anyone with an interest in event medicine, sports medicine, mass-casualty events (yes really), and rapid triage. I hope you will consider joining me at the race!

If you would like to volunteer go to this website, and sign up! I set up a group called “Columbia Emergency Medicine” so please make sure to request that group. Even though the organization cannot 100% guarantee that we will be together at the finish line, I emailed with them directly and they say they expect they can do it!

If you have any questions please email me!

Best,

Adam

Campus Announcements

Milstein ED Updates

NEW***”Send to ED Admit Area” (aka. OK to E) to be discontinued.
1. We no longer need to order this for patients who are admitted / endorsed. Nursing will be responsible to pull/push patients to Area E/F.
2. If there is a patient slated to go to other hospitals, please communicate directly with the primary RN in person or secure chat.
Reducing CAUTI: Consider using External Female Incontinence Device (see attached) & Male External Catheter:

Indications for this device include:

-urinary incontinence without retention

-need for strict I/O without retention

-pressure injuries and or incontinence associated dermatitis

Contraindications for this device include:

-urinary retention

-uncooperative patient

-patient able to get out of bed independently

-patient able to use a bed pan

FEW Reminders:

1. When we see patients prior to triage, please make sure triage is done before we discharge patient.
2. When putting in an order, whenever possible, please order everything in one bundle. Consider doing add-ons instead on those applicable.
3. EKGs of active ED patients can be signed/timed by any available attendings. We do not need to sign the EKGs of admitted/endorsed patients.
4. When there is someone who expresses suicidality, first thing to do is to let the primary RN know (in person) so she/he can call security to put patient on continuous observation. Keep patient in your sight until security comes.
5. COVID testing & indications in the ED:
  1. LIAT – takes 15-20 minutes depending on availability of machine and workload of RN; done in ED;
    1. aerosol – generating procedures
    2. notifications
    3. emergent procedures/ORs
    4. under clinical / security observations
  2. RAPID “Green Sticker” – takes 4-6 hrs; done in lab; RNs to put the “Green Sticker” prior to sending to lab
    1. admissions, all oncology/transplant
  3. ROUTINE – takes 10-12 hrs; done in lab
    1. treat & release (if needed)
6. Outpatient MRI arrangement from ED:
  1. This involves Neurology consult, Patient Navigator Order (if PCP needed), Care Manager/Social Worker (for pre-auth), Call Center, etc.
  2. Only patients with Neurology involvement/consult, can be floated through this process since they will function as primary providers along with patients’ PCP post-ED visits.
  3. How to:
    1. Get Neurology involved –> if appropriate for outpatient MRI, they will initiate a secure chat with all the stakeholders
    2. Put in Patient Navigator Order if PCP needed and put “outpatient MRI” in the comment.
  4. MRIs are usually scheduled within a week, often 2-3 days. Please keep in mind that, scheduling does not happen overnights and weekends. However, the team will work on the case the next business day.

Regarding staffing shortages at Columbia:

Escalation: Please continue to escalate any events that are out of the ordinary. We continue to have cases that lead to need for ethics, legal, patient services, etc. on off hours. While nursing will ensure the nursing administrator is aware, physician leadership also needs to be aware.
Keepsafe: Please Keepsafe any unexpected events, errors, or safety concerns. Please keep language professional
Worksafe: Please Worksafe any staff safety related events. And reach out to security for any situation that you feel needs to be reported to the police. The report can be made using the Hospital address and phone number, but it needs to come from an individual.

If you have any issues you would like to escalate, feel free to reach out to the chiefs (on shift or post shift) so we can help escalate appropriately.

ED EPIC UPDATES

1. Providers Only: The name of our TRIAGE tab will be changed to MSE INTAKE.

Nothing else will be changed other than the name of this tab, continue to use as normal!
To help accommodate unique triage workflows at our Go-Live 4 sites, we are changing the name of the Triage tab for providers.
This change affects ED providers only (attendings, PAs, NPs, fellows and residents).
It does NOT affect ED nurses, whose tab will continue to be called Triage.

2. The Elopement Risk Screen will now trigger appropriate Watch orders.

If a triage nurse indicates that a patient is an elopement risk and requires a Security Watch, the ED providers on the patient’s care team will see a new pop-up alert when they open the patient’s chart.
When you see the alert, please evaluate the patient, and place a Security Watch order as needed.
Similarly, if a triage nurse indicates that a patient is an elopement risk and requires any other type of watch or frequent rounding, the appropriate orders will now appear on screen.

3. PROVIDERS ONLY: You will no longer be able to discharge a patient who has unreviewed results. This will be a hard stop in Epic.

This is an important patient safety initiative to prevent test results from being missed before the patient leaves the ED.
You must review all results and mark them as “Reviewed” to successfully place the “Discharge Patient” order.
If you have not marked all results as “Reviewed” in Epic and attempt to place a “Discharge Patient” order, a hard stop will appear.
This is similar to the existing hard stop for “No Clinical Impression Entered” when you attempt to place a “Discharge Patient” order.

4. Transfer orders are now a little easier to place. The proper options will be defaulted for the “Close Visit” orders for ED transfers.

If you select “Transfer to Other Hospital” Disposition for a transfer outside of NYP, the correct option will automatically appear in the “disposition” field of the “Close Visit in Preparation for Transfer to Other Hospital” order.
If you select the “Transport to Other NYPH ED/CPEP” Disposition for an ED to ED transfer, the correct option will automatically appear in the “disposition” field of the “Close Visit in Preparation for Transport between EDs” order.

5. FOR PEDS SEPSIS Only: The Pediatric Sepsis BPA has been updated to include an option for “Not Sepsis.”

If you evaluate the patient and feel that they are not septic, select the “Not Sepsis (Snooze 48 Hours)” button on the Pediatric Sepsis BPA.

6. Violent Flag Reminder

An Employee Harm Violence Flag does exist – if entered it displays on the patient’s storyboard (see below).
Nurses and Providers can enter a Violence FYI Flag (please see attached tip sheet on details)

REMINDER EPIC DOWNTIME!

A major Epic Upgrade is coming on November 7!

The upgrade is associated with a 2-hour Epic downtime from 1am-2am on November 7 during daylight savings.
You may have received multiple emails from the EpicTogether Training Team regarding Epic Upgrade modules in SABA. These SABA modules are highly encouraged but NOT required. If you do not complete them, your Epic access will not be affected. Here are the best ones to complete, if you’re interested:
- ET Upgrade General Updates 2021 – for general updates
- ET Upgrade Inpatient Clinical 2021 – for ED updates
- ET Upgrade Haiku Canto 2021 – for mobile updates for providers
- ET Upgrade Rover 2021 – for mobile updates for nursing
- ET Upgrade Outpatient Clinical 2021 – for tele-providers

Epic Read Only (SRO) will be unavailable for the first 15 minutes of downtime

EPIC USER TIPS

Remember that you can place Help Desk tickets from directly within Epic.

Click on the Epic Help button on the topmost menu bar.
Fill out the request form and hit Send.

ED to VUC referrals for MAB infusion

Now live! – ED-to-VUC Referrals for Monoclonal Antibody Infusion – (attached job aid and criteria for eligability)

Ordering monoclonal antibodies for Covid positive or exposed patients is complicated. To offload the ED providers, all monoclonal antibody orders will be routed through the Virtual Urgent Care. From those I have shown how to do this, the feedback is… it is really easy!

Patients at risk: Over 65, liver, lung, kidney disease, DM, HIV, BMI>25, hard hit groups +MORE….see attached document, this doc is also up in ED bays LMH and WCM

Who qualifies for MAB? (See criteria document attached)

1) Patients who are at risk and EXPOSED to COVID

2) Patients who are at risk and COVID + within 10 days of symptom onset

What does current evidence suggest?

– 85% reduction in need for hospitalization, reduction in death

How do I connect a patient who I am discharging to MAB Therapy? (See screenshot below and PDF attached)

– Use the box in “Common Follow-Ups” under DISPO tab in Epic.

– Fill out pop-up box content.

– Patient will receive discharge instructions on how to do the VUC appointment.

– Patients who fail to make a VUC appointment will receive a telephone call to help troubleshoot.

Where is there more information?

– Our AA and AOC leaders will be able to help with this process during shifts.

– https://www.covid19treatmentguidelines.nih.gov/therapies/anti-sars-cov-2-antibody-products/anti-sars-cov-2-monoclonal-antibodies/

From Dr. Robby Tanouye: Long IVs are now stocked in IV carts

Per request from several ED Residents, who noticed a stocking gap in the two (2) WC A Bay IV carts. Thank you for your work on placing US-guided IV’s and hope this makes it a touch easier

Big thanks to our WC Nursing leadership and to David & Bill for the good idea. David & Bill, feel free to spot check this for us and let me know directly.

From Cornell leadership: Reminder about Community Para-Telemedicine program

Cornell ops/leadership has implemented CTP (Community Tele-Paramedicine) to improve post-ED care for our community and to minimize avoidable admissions. As senior residents managing the bay and thinking of all your patients’ disposition, please keep an eye out for patients that meet the criteria and refer them appropriately. It’s a few extra steps but it can really help minimize boarding and overcrowding in the ED.

Who: Cornell ED patients with cellulitis, heart failure exacerbation, pneumonia, sub-segmental PE, syncope, COPD/asthma, dehydration/AKI + must meet other enrollment criteria (please see attached pdf for details)

When: Patient can be discharged from ED and be seen in the next 1-2 days (M-F for now)

What: After discharge, patients will be scheduled for a paramedic visit at home + ED provider televisit. During their visit they will have their vitals/weight/POS FS checked, receive med rec, and in some cases receive medications.

How:

Please use the CTP referral tab in Epic’s Dispo tab AND email Jeanette and Rachel, the CTP care managers: Jeanette Melchor <ejm9017@nyp.org>, Rachel Bestritsky <rab4011@med.cornell.edu>
Jeanette (Elizabeth) and Rachel are also available during business hours on Epic Haiku Chat to discuss potential cases. Please feel free to reach out to the AOC or AA if you are unsure if a case is appropriate for CTP referral.