Transcript File
MLP ORIENTATION WORKSHOP 1 Objectives • • • • • • • • Orientation overview Department orientation Work flow RACE team RME Fast Track Physician consults Charting and documentation Orientation Overview • • • • • • • Business Office orientation Hospital Orientation New Employee Orientation (guideline) Epic MHS training + provider oreintation Workshop 1 Workshop 2 Shadow + Mentorship shifts New Employee Orientation Workflow • • • • Sign into Epic ASCOM phone Huddle with charge RN and attendings Objectives shift specific / location specific TG Workflow Tacoma General 10-8p • 1000 – 2000 • ESI 4 and 5 patients in Fast Track – Signs up as attending • Waiting room RME of patients – Signs up as attending then “end assignment” in Treatment Team tab – Turns patient RME status on track board • Physician extension tasks – – – – – Laceration repair Procedures Consultation Dispositions Re-assessments Tacoma General 2p-12a • 1400 – 0000 (Huddle) • RME WTBS patients in main ED (sickest first) if unable to be seen by physician – Signs up as attending, gets taken over by attending • RACE Team – – – – Signs up as attending then “end assignment” in Treatment Team tab Turns patient RME status on track board ESI 2, then 3 by LOS If all 2 and 3 done, treat and street ESI 5 • Assist with Fast Track ESI 4 and 5 patients • Co-management of patients with physician in main ED • MLP signs up as PA or ARNP in MLP column RACE Tacoma General RACE Allenmore RACE Covington Rapid Medical Evaluation • • • • • Assign as attending Label as RME Brief H&P Labs + Imaging Comfort medications • Consult as needed Fast Track • • • • • • Verb… not noun Goal evaluation <80 min ESI 4 + 5 Seen independently, consult prn RN + tech Focus on oral medications and limited workups Co-manage patients • Initially assigns as attending • Perform H&P • Initiate labs + imaging • Consult attending early • Change assignment to PA or ARNP once consulted • Re-consult after workup complete to discuss management Mandatory Consultation • ESI 1 or 2 • Unstable VS – HR >110 or <50 – SBP <100 or >220/120 – RR >24 or <8 – Pulse ox <95% (unless baseline) – Abdominal pain >50 yrs old – Altered mental status Mandatory Consultation • • • • • • • Active / uncontrolled bleeding Anaphylaxis Chest pain >35 yrs old CVA / TIA Joint dislocation (other than digits) Falls associated with near syncope / syncope Open fractures Mandatory Consultation • • • • • • • Pregnancy with abdominal pain or bleeding Post surgical complications Procedural sedation SOB with abnormal vital signs Telemetry indicated Unexpected (non-follow up) return visit Pediatrics <12 mo, or <3 yr with fever Consultation • Start with reason for consult: run it by you, ED consult, asking for admit. • ED presentations: ok to not be sure • Concise presentations • Other consultants: specific questions. • Know what you want Consult case 1 • 22yo M c/o abdominal pain. Constant, began 4 hours ago, radiates to R testicle. • No PMH/PSH/meds/allergies • VS 140/92, HR 115, RR 30, T 37 • Exam: R testicle swollen and painful. • Labs: normal. US no flow to R testicle Consult case 1 Dx: • HPI: • Plan for care? • Reason for consult? • Present to the ED attending • Present to consultant. Consultation case 2 • 51 yo man c/o left lower leg pain and swelling for 4 days. • PMH: DM, HTN • PSH: none • Meds: insulin, lisinopril • VS: 130/80, HR 130, RR 22, T 38.2 • Left leg swollen, red, hot to touch. • WBC 20, lactate 4, glucose 600, AG 30, Co2 10 Consult case 2 DX: • HPI: • Plan for care? • Reason for consult? • Present to the ED attending • Present to Consultant. Recommends discharge after insulin bolus and single dose of IV antibiotics. Consult case 3 • 25yoF presents to c/o back and leg pain that began several hours after an intense crossfit workout. • No PMH/PSH/meds/allergies • HR 90, BP 120/80, RR 18, T 37 • Exam: uncomfortable. Moderate paraspinous tenderness. Neuro exam normal. • Labs: CBC/CMP normal. UA +heme, no RBC, CK 4,000 Consult case 3 DDX: • HPI: • Plan for care? • Reason for consult? • Present to the ED attending Consult case 4 • 45F HA x3 days. Sudden onset 12 hours ago. +vomiting and photophobia. Worst HA of life • PMH: migraines • VS: 192/120, HR 88, RR 20, T 37 • Exam: uncomfortable, otherwise normal • CT head: negative • LP: +xantochromia, + 100,000 RBC Consult case 4 Dx: • HPI: • Plan for care? • Reason for consult? • Present to the ED attending • Present to consultant. Specialist Consult • Consult ED attending first • Medicine – More detailed information – Tell the story of the patient’s problem – Review recent admissions, clinic visits, imaging • Surgery – – – – Ask your question first Brief presentations Review prior surgeries, admissions Cedar group is different than ACSS Charting and Documentation • • • • Chart at appropriate level (3 – critical care) Don’t forget PMH, PSH, FH, Soc, etc… HPI: OPQRST MDM – Initial impression, DDx – Workup and impression of objective data – How this supports / refuts your DDx – reassessment – Final impression and treatment plan Resources • PSR website – EGO charting tips and tricks – Pdf of previous education lectures • Textbook – An Introduction to Clinical Emergency Medicine • Education Website – Tecpedu.net • • • • • Fundamentals of Emergency Medicine Resident Page Procedures CME Blog From Here • Workshop 2 – Procedural • Select evaluation dates – 30 day, 90 day • Reach out to mentors / sponsors – Set date and agenda • Review onboarding materials Questions • Epic questions – Dot phrases – Preferences – Macros • Workflow