Updates & Reminders
New Tools, Updates & Reminders
New Tools: I bought a head-light as well as a set of tools and have stocked them in the Pyxis at both FEDs. So if you need a headlight for sutures, ear exams, nose exams, vaginal exams, etc - just have the nurse (or you!) pull it from the Pyxis under “Head Lights”. Additionally, the “Tools” are under “Tools” in the Pyxis - different size/type of pliers and other tools.
TeleProvider Surge Process: We need to utilize this! I am very excited and thankful to announce that Nichole Campbell, NP, has agreed to be the TeleProvider Point Person for this process.
UMC Burn Center Transfer Protocol: PLEASE REVIEW!! UMC has reached out and requested that we review their transfer protocol. Note they want LR fluids, not NS. They are NOT using the Parkland formula - basically use the ½ parkland formula. They do NOT want us to give antibiotics. Electrical burns are special and do use the higher fluid Parkland formula. Note that Fluid time starts at time of burn, NOT time of arrival
Click here to review the UMC Burn Center Transfer Protocol (also now pinned on the main page!)
Signing Up For Patients: don’t forget to sign-up for patients on the board AFTER you see the patient. Only AFTER you have seen the patient, “Assign” yourself to the patient on the Tracking List.
This is the trigger to let Registration clerk know that you have seen the patient and they can then go discuss billing collection with the patient. Note: per EMTALA, registration cannot discuss billing until the physician/apc has seen the patient.
When starting your note in Cerner, the “Date & Time Seen” is timed from when you lay eyes on the patient – even if they are walking by the desk. The goal is to ‘see’ all patients within 15 minutes of arrival.
Click here to review the ‘Seeing Patients’ process in the Provider Manual.
Open Fractures: don’t forget that even open finger fractures fall under this category and we need to ensure we are giving appropriate antibiotics within 60 minutes for any open fracture.
Decision to Admit: don’t forget to enter this order AS SOON AS YOU THINK A PATIENT MAY REQUIRE ADMISSION. This is a metric we are measured by and need to make sure we are making this decision within 150 minutes of arrival.
Calls for admission and consults: document ALL calls - even if you page or leave a message - in the “Calls-Consults” section under the “Impression and Plan” in the note. For more than one call, right-click on ‘(repeat)’ and select ‘repeat’ to document multiple calls/consults.
Residents and Students: don’t forget we have residents as well as students. Residents can and are expected to do notes, but students are not. Watch Video Below on putting the “Attestation” for staffing residents notes
Macros: see the video below on how to create macros in Cerner - useful for creating standard physical exams, and the “Attending Attestation” for supervising residents. This video is also available in the Cerner Training Videos (click here to go to the page).
2022/04/25 Updates
NW FED Spring Social: Please make an effort to join us! Click HERE to RSVP!
Patient Surges at Town Square
Town Square Teledoc Surge Support: Any time you have a volume-surge at Town Square, don’t forget that we have the Teledoc Surge Support process in place! If you are the on-shift physician, make sure you take over the note done during the televisit and do not start a new note. This is triage-independent and the sole goal is to decrease door-doc time and prevent LWOTs. If you would like to be included in the process, let me know. Click HERE to view the process in the “FED Provider Manual”.
Ortho
OTS: Ortho Trauma Surgery: NW is fortunate to now have two ortho traumatologists - Dr. Reddix and Dr. Potter.
for ALL ortho cases (except hand), we just need to the regular ortho on-call and then they will guide us if they can manage or if we should call the Ortho Traumatologist.
Pediatric Ortho Trauma: can call Dr. Potter (NW Ortho Traumatologist) Monday-Friday at 06:00 - 18:00. Otherwise, call the Pediatric Intensivist on the Call Roster and they will guide us if they can accept the patient.
Sepsis
Sepsis: We need to do better with out sepsis compliance. NW has fallen from #1 in all UHS to the bottom ⅓ in rankings on sepsis outcomes. I am working on a dedicated Sepsis section on tips and flow charts.
Lab
Culture Reports & Send-Out Labs: we are all responsible for following up on the culture reports and send-out labs. This is now available within Cerner. The labs will not be printing out reports. The day-shift physician and midlevels should review these at the beginning of each shift and make calls as indicated throughout the day as time permits. Click HERE to view the process.
Add-On Lab Orders: Effective immediately, when ordering additional labs, change the order status to “Add On STAT” instead of STAT.
NOTE: if a patient requests a test that is a send-out such as flu/rsv/covid pcr/respiratory panel, do NOT tell them to go to the main ED so they can get it faster. Simply inform them that we can do the test, but will have to either wait the several hours for the result or we can call them over the next 48 hours. I almost never order any of these tests as it will not change my management.
Medications
Lidocaine/Bupivicaine: We are no longer using the multi dose vials, but are moving to 10-cc single-dose vials. Please do not ‘save’ any vials after using them.
SGLT2 Inhibitors: NW has added two Sodium-Glucose Cotransporter Type 2 Inhibitors - Empagliflozin (Jardiance) & Dapagliflozin (Farxiga) - to the formulary. Click HERE to view the P&T Committees Executive Summary regarding these medications.
IMPORTANT WARNING: EUGLYCEMIC DKA: one of the subtle adverse events that can occur with SGLT2-i drugs is EUGLYCEMIC DKA. This requires a high degree of suspicion to catch, so pay attention to the CMP, anion gap, and bicarbonate levels - DESPITE a normal glucose level.
Policy Updates
NWTHS Provider Orientation Manual: the orientation manual that Delynn gives to every physician during on-boarding and training is now uploaded to the “Policies | Procedures | Processes” section of the newsletter. Click HERE to view
NWTHS Bylaws and General Rules & Regulations: these have been updated and are now available to review in the “Policies | Procedures | Processes” section of the newsletter.
2022/03/11 General Neurology Telehealth Consults
General Neurology Telehealth Consults are now available. The process is detailed in the “Provider Operation Manual”.
2022/03/08 Updates: FED Ambulance; Transfers to the Main ED; Covid19 Testing
FED Ambulance
I am excited that we now have our own FED-dedicated ambulance! We went live on March 1, and they will be working every day from 11a-11p. Their primary objective is transporting patients from the FED to the main campus, but can also be helping hands while not transporting. They will be based at GST, but can float to TSQ if they are needed.
FED-to-MainED Transfers
After discussing with Dr. Belaval and the main ED physicians, we have come to an understanding on transferring patients to the main ED.
Going forward, these will now be treated as a “Patient Hand-off” - similar to shift-change hand-offs - and the main ED physician will assume complete care for that patient. When we need to transfer FED-mainED, check the “ED Call Roster” and make sure you call and speak directly with the accepting physician at the main ED who has been on-shift the least amount of time, and give a complete verbal check-out. Also make sure to log that phone call in the “Consults” section under “Impression and Plan” in your note and that your note is completely done. The main ED physician will assume care and add an “Addendum” to the chart.
Dr. Belaval has ensured the main ED physicians are on-board, so there should be no push-back on this. Once the patient has left the FED and arrived at the Main ED, they are no longer our patient, but are then under the care of the main ED physician.
CoVID19 Testing
Starting today, we no longer need to test every admission patient for CoVID19. We only need to test patients with exposure or for respiratory type illnesses, as well as anyone going for a procedure. For patients with pyelonephritis, cellulitis, etc, we do not need to test them.
2022/02/04 Resume Outpatient CoVID19 Testing
NW resumed outpatient CoVID19 rapid antigen testing today.
2022/01/31 Ear Cleaning Kit
Ear Cleaning Kit
I bought ear cleaning kits for both FEDs and stocked them in the Pyxis under the title “Ear Cleaning Kit”. You can pull it yourself, or ask the nurse to pull it.
Preparation: use LUKEWARM water to mix:
1 part hydrogen peroxide or white vinegar
4 parts water
After use: Make sure you CLEAN IT with a purple-top wipe or Clorox wipe. Empty the bottle and place back in the kit-box. Return the kit to the Pyxis.
2022/01/27 Managing Patient Complaints and Grievances: Physician and Hospital Perspectives
As patient volumes have bounded back and hospitals are facing staffing shortages and long patient throughput times, overall patient complaints—and correlating risk—are on the rise. To minimize your risk exposure and enhance our overall commitment to excellence in patient experience, we are excited to bring you a live webinar prepared exclusively for APP.
"Managing Patient Complaints and Grievances: Physician and Hospital Perspectives" will be presented by attorneys John Floyd, Jr., Partner, and Lynn Audie, Partner, both from Wicker Smith, a firm that has focused on keeping healthcare providers apprised of legal and regulatory changes as well as how to mitigate potential risks for more than six decades. The webinar will focus on understanding the physician and hospital process for managing patient complaints, grievances, and family meetings. John and Lynn will provide real scenarios and risk mitigation tips.
Please save the date on your calendar and join us for this informative presentation
Wednesday March 9, 2022 10am - 11am CST.
Join on your computer or mobile app
Or call in (audio only): +1 629-216-4519,,699572795#
Phone Conference ID: 699 572 795#
2022/01/23 Down Codes
Overall, we are doing a very good job documenting; however, we still have some areas to improve - mostly with EKG and PFSH documentation. By not documenting appropriately, we are not getting compensated appropriately for the excellent care we provide our patients.
We had a total of 40 down-codes for November (most recent data) with 19 for no EKG documentation and 17 for inadequate PFSH (past family and social history). These charts have already went through billing, so nothing to correct.
If you don’t see an EKG section, you can add it by right-clicking on Medical Decision Making and then Insert Sentence, where you can select EKG.
2022/01/22 New Lab Tubes
We are switching labs collection tubes - the benefits are decreased hemolyses and decreased rejection rates, as well as smaller sample sizes.
COVID Tests Back In Stock
NW received over 900 CoVID-19 antigen tests yesterday evening, so we can restart testing for FED patients with antigen tests. We are NOT doing any ‘outpatient walk-in’ testing. Just for actual FED patients.
NW does not have any single PCR (Covid) or quad-PCR (Covid, Flu, RSV).
NW does have plenty of the 20-panel Respiratory PCR, and all machines are currently working, so results are typically within 24-hrs. However, the Respiratory panel literally costs $2,000, so I strongly advise caution when considering the respiratory panel. If it will affect your management for the patient, then go ahead. However, if it is for an otherwise healthy patient in no distress and not requiring an antibody infusion, then I would strongly consider diagnosing presumptively based on symptoms and exposure and providing the COVID19 Work/School Note with the "presumptive positive” check-box checked.
Admissions: continue current process:
if admitting for non-respiratory problem and have a negative antigen at the FED, then that’s fine.
if admitting for respiratory issue, or have a high-suspicion high-risk patient and have a negative antigen, then can order the respiratory panel. Lab will the main lab to rush the panel testing. You can still admit the patient as a PUI (patient under investigation).
Blood Product Shortage
Due to severe national blood product shortage, UHS is changing how to order blood products in Cerner. Click Here to View Handout
SHORTAGE: Antibody Infusions
The Amarillo Regional Infusion Center is currently out-of-stock of all antibody infusions for COVID19, with their next expected shipment not until Wednesday, Jan 12. NW does not have any infusions either.
EKG Date & Time Stamp
EKG
We must date and time and sign the EKG when we read it. Andrea has a Date & Time Stamp now for each FED that the nurses will be stamping when they pull the EKG.