Northwest Free Standing Emergency Departments
Provider Operation Manual
Site Medical Director: Frederick D. Poage
Update: August 12, 2022
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4121 S. Georgia St, Amarillo, TX 79110
Opened: Sept 2019
Volume: avg 73 patients per 24 hrs in 2022
7 rooms with 10 beds
All with cardiac monitoring possibility
2 Trauma/Procedure Rooms (Room 1 & 2)
1 OB/GYN Room (Room 7)
1 Seclusion Room (Room 5)
3 Double-Bed Rooms (Room 1, 4, 6)
6 RME (Rapid Medical Exam) Fast-Track Rooms & 2 Hall Beds
Northwest Texas Hospital: 6 miles away
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8960 Hillside Rd, Amarillo, TX 79119
Opened: June 2016
Volume: avg 51 patients per 24 hrs in 2022
12 rooms
All with cardiac monitoring possibility
2 Trauma/Procedure Rooms (Rooms 7 & 9)
1 OB/GYN Room (Room 11)
1 Seclusion Room (Room 8)
4 RME (Rapid Medical Exam) Fast-Track Rooms
Northwest Texas Hospital: 4 miles away
Table of Contents
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American Physician Partners is a limited liability company formed on April 16, 2015, pursuant to the provisions of the Delaware Act. Our company is a medical service organization, headquartered in Nashville Tennessee, that was formed to meet the needs of hospitals throughout the United States. Led by experienced hospital operators and seasoned ER/Hospitalist Physicians, American Physician Partners has a unique perspective of the industry which sets us apart from traditional staffing companies.
Founded in 2015 by bringing together two high quality physician led companies (Align MD and Elite Emergency Services), American Physician Partners was built on the premise of creating a dyad leadership model whereby physician leaders would partner with hospital executives to deliver a comprehensive emergency medicine and hospitalist solution to hospitals and health systems. In bringing these 2 groups together, American Physician Partners is instantly able to capitalize on decades of private practice physician and hospital leadership while achieving greater efficiency and effectiveness via economies of scale for support services.
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American Physician Partners vision is simple: “To inspire, challenge and equip our Leadership Teams to deliver the highest quality care experience for our Patients, Providers and Partners”.
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At American Physician Partners, we have chosen five tenants for operations. These rules govern how we as a company function. The tenants are:
• Teachable - Continuously learning
• Integrity – In everything
• Value – We all have different roles but identical value
• Culture – “We Before Me”
• Transparency – Bad news is not a fine wine; it does not age well
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Creating a Patient Centered Culture for Exceptional Care
The Patient
▪ I will value the “Patient Care Experience” and strive to provide exceptional emergency care to our patients at all times.
▪ I will consistently smile and introduce myself to every patient and accompanying individuals in the room with the patient upon my arrival.
▪ I will take time to thank every patient for allowing us the privilege to care for him or her.
▪ I will sit down in the room whenever possible while interviewing my patients.
▪ I will ensure the patient knows we are a team making appropriate decisions together about their care and will ensure each person’s role in the care visit is explained.
▪ I will communicate clearly the results of their evaluation and our follow up plan of care to ensure a safe transition for the patient.
▪ I understand that many factors interfere with the patient’s ability to understand their condition and I will do my best to explain things in a compassionate, considerate manner to alleviate their fear and enhance their understanding.
The Emergency Department Team
▪ I will emulate professional behavior for the betterment of our team at all times.
▪ I will always support teamwork and encourage all staff members to achieve their best.
▪ I will refrain from speaking negatively about an emergency department team member.
▪ If I have a concern I will address it with my team member directly or with their supervisor if necessary.
▪ I will do my best to be a helpful, supportive teammate to my colleagues and fulfill my responsibilities to the shift requirement needs of our department.
▪ I will always be on time for my shift and if I am going to be late I will extend the courtesy to call ahead and notify the team before my shift is to start.
▪ I will be honest with everyone.
▪ I will remember that I am a representative of the Emergency Department team as a whole and will always be prepared to answer any and all questions asked of me in support of the organization.
▪ I will always give 100% of myself at all times to my team and my patients.
▪ I will comply with ALL the requirements of my partner hospital.
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Being a member of the APP team, we are here to assist you in any way feasible. With our goal to facilitate a high level of interactional satisfaction for you, your colleagues and most importantly, your patients. To accomplish this, we feel that there are basic behaviors that must be a thread running throughout the entire APP team. These include, but not limited to:
• You should make each decision in the ED for the good of the patient.
• You should view each patient in the ED as a “first-timer”. That is, previous visits are to be considered as valuable information, but it should not be used to assume the reason the patient is there each time.
• For patient safety and continuity of care, we ask that you move patients through the ED in a manner dictated by their presenting symptoms.
• You should be a good facilitator with your colleagues.
• As often as possible, you should be the individual discussing a patient’s discharge orders.
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| Year | GST Annual Visits | TSQ Annual Visits |
|---|---|---|
| 2016 | - | 2,633 |
| 2017 | - | 10,348 |
| 2018 | - | 13,081 |
| 2019 | 2,983 | 14,623 |
| 2020 | 13,055 | 11,387 |
| 2021 | 21,946 | 16,277 |
| 2022 | 26,676 | 18,702 |
| 2023 | - | - |
| FED Metrics | Desired Time Frame |
|---|---|
| Door to Triage | Less than 5 min |
| Door to MCE (Meaningfull Clinical Experience | Less than 15 min |
| Door to Decision-to-Admit | Less than 150 min |
| Overall Length of Stay | Less than 120 min |
| Chest Pain Door to EKG | Less than 8 min |
| Chest Pain Door to Troponin-Resulted | Less than 60 min |
| STEMI Arrival-to-Depart | Less than 45 min |
| LWOT/LWBS (Left Without Treatment / Left Without Being Seen) | Less than 0.3% |
| Left AMA | Less than 0.5% |
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At the beginning of each shift, make sure you do the “Provider Check In” on the Tracking List.
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.
Note: Pay attention when seeing patients across midnight! Make sure you are using the correct Date for “Date & Time Seen”.
Dispo that patient accordingly
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Managing AMAs
by
Dr. Fred Poage, FSED Medical Director, Amarillo, TX
Dr. Brad Blaker, Regional Medical Director, Michigan
AMA: Against Medical Advice
The term 'Against Medical Advice' or 'AMA' is commonly understood to indicate when a patient chooses to leave before the treating physician believes it is medically safe to discharge. Please note it is important to distinguish AMA from ELOPED, whereby the patient leaves the treating facility prior to discussing this with the physician.
Background
AMA discharges account for approximately 2% of all discharges. AMA discharges are at significantly higher risk of readmission, with an overall readmission rate of 20% compared to general rate of 3%. AMA readmissions cost up to 56% higher than expected from initial hospitalization.
Analysis
Decreasing AMA discharges should be a top priority for all physicians, including Emergency Medicine, Hospital Medicine, and Critical Care. When busy, it is challenging to commit the time to discussing with a patient his/her desire to leave AMA. Inpatient AMA discharges have been correlated with a misunderstanding of the expected length of stay. Physicians can help mitigate this by not underestimating the length of stay when asked.
Considerations
Know that the treating physician is still responsible to provide as safe and as appropriate care as possible, including prescriptions, referrals, and follow-up. Most Important: ensure the patient understands that we want him or her to return so we can continue providing care; we do not believe leaving at this time is in their best interest. Ensure the nurse informs the physician any time a patient wants to leave AMA. Avoid the myth that insurance/Medicaid/Medicare will not pay if the patient leaves AMA. Know that frequent physician reassessments and clear communication with the patient can decrease AMA rates. Establish a dedicated AMA-liaison.
Documentation
Documentation of AMAs is critical. Example:
The patient has decided to leave AMA because___. He / she has normal mental status and adequate capacity to make decisions. The patient refuses hospital admission and wants to be discharged. The risks have been explained to the patient, including ___, worsening illness, chronic pain, permanent disability and death. The benefits of admission have also been explained. The patient had an opportunity to ask questions about his / her medical condition. The patient was treated to the extent he / she would allow and knows that they may return for care. Follow-up has been discussed and arranged with Dr. ___.
What order do I need to enter in the EMR?
Enter the “Discharge (AGAINST MEDICAL ADVICE)” order
Summary
Patients who leave AMA should be taken seriously. Your goal is to encourage the patient to stay and complete the recommended treatment. If he / she still chooses to leave, proper chart documentation outlined above along with a signed AMA form can help to mitigate risk.
References
Syzek, Tom, MD, The Sullivan Group, Do's & Don'ts of AMA: Patients Who Leave Against Medical Advice (thesullivangroup.com).
MagMutual, When Good Patients Make Bad Decisions an AMA Form Protects Me, Right?,www.magmutual.com, Nov, 9, 2016
Mayz, Kurtis, A. JD,MD, MBA, FACEP, Top 5 Legal Risks in Five Minutes or Less, ACEP21, Boston Convention Center, Boston, MA Oct, 26, 2021.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664598
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378751
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— NOT ACTIVE YET —
Observation patients will be boarded at Town Square only (NOT at GST).
This is for adult patients ≥ 18yo that we think warrant more time than the standard 2-4 hours in the ED, but may not really need a full admission. Think moderate asthma exacerbation, pyelonephritis, cellulitis, etc where the patient needs a couple rounds of IV antibiotics and/or IV fluids, nebs, steroids, etc, and then can go home.
Patient must be in observation status for a minimum of 8 hours - meaning from the time you enter the AOT order.
Once decision is made, enter the “Decision to Admit” and the “Admission/Observation/Transfer” order - with your name as the attending and right click the order and put your name with protocol selected.
If at GST, then call the physician at TSQ to discuss observation, and enter the name of that physician on the AOT order.
Then the patient needs to be transported to TSQ via ambulance.
Whomever is the admitting physician will complete a short-form “History & Physical” note.
This can help tremendously with patient satisfaction and expectations since you can make that decision quickly, and then the patient knows they will be there for at least 8 hours.
If patient is not stable for discharge within 16 hours of observation status, then pursue full admission to the hospital per usual process.
If patient requires more extensive workup/treatment (CPROMI, ECHO, MRI, etc), then admit the patient directly. Even though the patient may be observation status at the main hospital, this is not appropriate for observation at TSQ as we do not have those additional resources.
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Objective: to support the on-site physician during surge times to improve efficiency of care, decrease door-doc times and prevent LWBS’s.
Should be driven by nursing, but if you are drowning and need help, then ask the charge nurse to implement the “TeleProvider Surge Process”. Click here to view the Nursing and Tech side of the process.
Rate: $30 per patient encounter
Procedure
The Charge Nurse will contact Nichole Campbell, NP, first. If she is unable to do the televisions, she will text the message “Teleprovider surge support requested at TSQ” to the “TeleProvider Surge Support Group”
Whoever responds first that they can will be the one responsible, and will call the Charge Nurse iPhone to let them know.
TeleProvider will log on to doxy.me and ‘start call’ to initiate the tele-visit with the patient ‘tsq teledoc’.
Inform the patient this is to help get things started so they are not waiting as long.
TeleProvider will start a note in Cerner and place initial orders for the patient - labs, imaging, fluids, meds, etc. - if needed.
In the ‘Reexamination’ section, we are REQUIRED to “Date & Time” stamp and enter the following statement:
Telehealth visit explained to the patient and/or the patient’s family/caretaker, and they agree to the visit. Total face-to-face time *** minutes. Patient seen by me (<your name>) to initiate the workup. The on-site provider will assume care and disposition the patient accordingly.
Telehealth visit explained to the patient and/or the patient’s family/caretaker, and they agree to the visit and to be dispositioned by me (<your name>). . Total face-to-face time *** minutes. I counseled them on the presumed diagnosis, and I answered all questions. Strong warning signs given on when to return to the emergency department. The patient and/or the patients family/caretaker verbalizes understanding and agreement with the plan, and also expresses appreciation and very pleased with the care received here today.
I highly recommend saving each statement as an ‘auto-text’. I have them saved as ‘ . teledoc ‘ and ‘ .teledoc_dc ‘
When all tele-visits are complete, copy/paste the following into an email to both Dr. Poage [ Frederick.poage@nwths.com ] and Shirley [ sreynolds@praximanagement.com ]:
I completed < X number X > tele-visits to help Town Square today. Below are the patients:
patient name
patient name
etc
Please update the schedule accordingly.
Thank you,
Your Name
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ANY and ALL trauma that is to be admitted, call the Trauma Team FIRST and document.
Sometime the trauma team will advise FED-MainED transfer for evaluation by the Trauma service
Sometime they will advise to admit to medicine and that they are available if needed.
Document ALL calls in the “Consults” section under “Impression and Plan” in your note.
What orders do I need to enter in Cerner?
If going to NW MainED, enter “Intra Hospital System Transfer to NWT” order
If direct admission, enter “Admission/Observation/Transfer” order
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All pregnant patients require a medical screening exam.
For pregnant patient > 21 wga:
If patient has a private OB physician, then call them
If patient does not have an OB physician, then call transfer center at 1233 and tell them to page the Texas Tech OB attending on-call.
Follow the direction of the OB physician - be it discharge home or transfer to the NW L&D unit for monitoring.
Document ALL calls in the “Consults” section under “Impression and Plan” in your note.
What orders do I need to enter in Cerner?
If going to NW L&D unit, enter “Intra Hospital System Transfer to NWT” order
If discharging home, then enter “Discharge” order
Standard protocol is to transfer the patient via Ambulance.
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After completing a medical screening exam, which may or may not include labs/imaging/etc, the patient needs to be screened by Access Staff at the Pavilion - call 1810 option 1. Notify the nurse to initiate the Behavioral Health Telescreen Process. The staff in Access at the Pavilion will then complete a video interview with the patient and advise either discharge or admission.
If the screener advises the patient is safe for discharge, then the FED provider can place the “Discharge” order in Cerner.
If the screener advises that the patient warrants admission to the Pavilion, then the FED provider places the “Intra Hospital System Transfer to NWT” order in Cerner.
Priority: “Stat”
Suggested Placement: Inpatient Psychiatric Unit
Admitting Physician: whomever the Access staff tells you
Reason for Transfer: psychiatric evaluation
Document ALL calls in the “Consults” section under “Impression and Plan” in your note.
The patient is to be transferred by ambulance EVERY TIME. NO EXCEPTIONS. If the patient or the patient’s caretaker refuses ambulance transfer, then they are to sign out AMA.
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1. Patient requiring a General Neurology TeleHealth Consult is Identified
2. Provider initiates General Neurology TeleHealth Consult by calling 877-640-0740. Please provide a GOOD contact number for the TeleHealth Neurologist to reach you
DOCUMENT the consult in the “Consults” section under “Impression and Plan” in your note.
3. TeleHealth Session time will be agreed upon by Provider and TeleHealth Neurologist
4. TeleHealth Neurologist will contact RN/HUC of Session Time and Confirm which CART will be used
5. At Session Time, the RN will bring the cart to the patient room and prep cart and patient for Consult
6. The TeleHealth Neurologist will approve session and conduct Consult
7. At conclusion of Consult, the TeleHealth session will be ended
8. TeleHealth Neurologist will document TeleHealth Consult in Cerner
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coming soon!
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Typically can let female patients self-swab for wet-prep and GC/Chlamydia PCR swabs.
If testing GC/Chlamydia on urine sample, then it must be a ‘dirty catch’ urine - do NOT use a ‘clean catch’
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Patients are triaged utilizing ESI (Level 1- 5). We utilize Pull-to-Full process and patients are direct bedded. If no rooms are available, patients are triaged and placed back into the waiting room until a room becomes available. Midlevels run the front RME rooms and evaluate/dispo Level 4/5 patients in the waiting room. Basically, if a patient requires more than a simple swab/xray/UA, then the patient is transferred to the back and the physician assumes care of the patient, and takes over the note in Cerner as well. The goal is to keep the midlevel running the front and the physician running the back.
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To see patients up front at RME Fast Track. Any patient requiring more than a simple swab, x-ray, UA – basically if a patient needs “line-and-labs” – then the patient should be transferred to the ‘back’ and the physician will assume total care. If a patient needs to come to the back, then the mid-level will type “back” under the “BA (Bed Assignment)” column on the Tracking List. This alerts the physician, as well as the nursing staff, that the patient needs to come back and will be seen by the physician. The goal is to keep the mid-level from running to the back to manage a more complex patient, so they can stay up front and keep the front-end process flowing efficiently.
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When care of the patient is transferred from a mid-level to a physician, the mid-level will document “I performed a rapid medical assessment, and transferred care to the attending physician on-shift.” The physician will take-over the note in Cerner – do not start a new note.
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The Northwest Free Standing Emergency Departments encompass two locations providing emergency medical care to the community. Patient care is provided using an interdisciplinary team in collaboration with Emergency Medical Services, Emergency Department Staff, other departments within the hospitas. Emergency Nursing is an all-RN nursing staff and maintain certifications in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), Trauma Nursing (TNCC), and ENPC (Emergency Nursing Pediatric Course).
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Trauma Designation: Level 3, pursuing Level 2 with survey in 2023.
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o 1 physician: 12-hr shifts: 06:00 – 18:00 – 06:00
o 1 mid-level: 12-hr shifts: 10:00 – 22:00
o 3 nurses 24/7
o 1-2 Medical Techs
o Lab Tech
o CT/XR Tech (US tech on call 24/7)
o Business clerk & EVS
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Cerner FirstNet with Dragon Dictation
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We can send prescriptions electronically through the EMR. To e-scribe scheduled narcotics, we use the Symantec VIP Access mobile app in conjunction with the EMR.
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The Walgreens pharmacy and United pharmacy on Bell Street are the only two pharmacies in Amarillo that are open 24/7. Both are located on Bell Street.
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Scribes are currently available, at your own cost, to Physicians and mid-levels through the scribe service. Additionally, you can have your own private scribe as well.
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NW is the base hospital for Texas Tech Univ HSC Medical School. We routinely have residents from FM, IM, and Pediatrics rotating through the FEDs, as well as 3rd/4th Year Medical Students.
NOTE: Residents are expected to see patients, place orders, and complete notes in FirstNet and submit to the attending for attestation.
CLICK HERE to view a 2-minute video on attesting and co-signing residents notes.
This is also available in the Physican Video Training Library
Students can see patients and present the patient to the attending, but do not complete notes in FirstNet.
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During peak volumes, if needed, we have two surge support processes:
A second mid-level on-call from 10:00 – 22:00. This is listed on the ED Call Roster.
Tele-visits: a physician/apc on-call 10:00 – 22:00 for additional support.
NOTE: This is completely nurse-driven and independent of acuity.
Process: Nurse notifies tele-doc of patients needing to be seen. Tele-doc completes virtual visit using doxy.me and documents accordingly in FirstNet. If patient requires workup, then on-site provider assumes care. If patient to be discharged, then tele-doc can dispo patient completely and the on-site physician does not need to see the patient.
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If I have a personal emergency (family, illness, etc.), who do I call?
- Shirley Reynolds, APP Scheduler: 214-422-4596
- Frederick D. Poage, DO, Medical Director: 936-465-6800
If I need an additional ED Physician based on unusual circumstances (tragedy, epidemic, crowding, etc.), who do I call?
- Frederick D. Poage, DO, Medical Director, at 936-465-6800
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We want to make you aware of our Employee Assistance Program, EmployeeConnectSM, for which all APP providers are eligible to receive confidential help 24 hours a day, 7 days a week for challenges related to family, parenting, addiction, legal issues, financial hardship, relationships, and stress.
For more information about the program, visit GuidanceResources.com, download the GuidanceNowSM mobile app, or call 888-628-4824.
GuidanceResources.com login credentials:
Username: LFGSupport
Password: LFGSupport1
Additional free and confidential resources for providers:
Physician Support Line: 888-409-0141
Crisis Text Line: Text ‘HOME’ to 741741
The National Suicide Prevention Lifeline: 800-273-8255
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Scrubs preferred, business casual accepted. Only NW approved T-shirts allowed.
Closed-toe shoes required. No flip-flops or sandals.
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Make sure to park in an actual parking spot - either behind or beside the FED.
Do not block the dumpsters.
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This should be setup by credentialing.
Your badge should allow you access to the building, the pharmacy lock room, as well as computer log-in.
If you have any problems, call the operator - dial ‘0’ - and ask for “Security”.
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All providers should have access to the Pyxis machine in the Pharmacy room. This allows you to witness for the nurses and also occasionally pull your meds instead of having to wait on a nurse.
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View NW ED Call Roster example to familiarize yourself with the layout
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24/7 Coverage
General & Trauma Surgery
Orthopedic
Hand Surgery
Orthopedic Traumatologist
Urology
Interventional Radiology
Vascular Surgery
Cardiothoracic Surgery
Neurosurgery
Pediatric Surgery
OBGYN
Cardiac
Critical Care/Pulmonary
Gastroenterology
Teleneurology 24/7 for stroke
Intermittent Coverage
Neurology
ENT
Nearly Continuous Coverage
Pediatric Cardiology
Pediatric Neurology
Pediatric Endocrinology
Pediatric Heme/Onc
Pediatric Nephrology
In Community, No Dedicated Coverage
OMFS
Plastic Surgery
Nephrology
Ophthalmology
Dentistry
Podiatry
Dermatology
Rheumatology