Ambulances & EMTALA

Please read or re-read the information below that I sent out in June. The blue part is what I want to emphasize most. If a patient arrives by foot, ambulance, helicopter, donkey, or in any form onto our property and requests treatment, we must see them and can not turn them away. There is no opinion or decision to be made once they are on our property; they must receive an MSE then stabilized and transferred appropriately.

During this recent season where the main ED is having many hours/days of diversion, it is conceivable that AMR but more likely outlying community ambulance services could attempt to bring patients to the FEDs either after being told or having foreknowledge of the diversion at main. We want to increase and encourage more ambulance traffic to the FEDs; however, we only want this to happen in cases that are safe and do not pose a delay in needed care for the patient.

Therefore, when receiving report from an ambulance and there are conditions and vital signs (i.e. major trauma) that make you question the FED as the appropriate location for a patient, find the physician asap and give a quick report. The physician will decide to accept or divert the patient on a case by case basis. Make every effort to do this on your initial radio interaction with the ambulance; it would be advisable to attempt to find them and have them listen from the onset of most reports when possible. On the ambulance log, note the physician and reason for diverting and send me and Dr Poage an email about the situation. The reason must be based on the condition of the patient.

PLEASE NOTE THE FOLLOWING – once the ambulance has arrived on our property we can no longer divert them. It is an EMTALA violation to do so. There are additions to 489 below that make it clear that an FED counts in these guidelines. The physician on duty can personally be held responsible and fined as well as the hospital. This applies to any means of arrival. For example, if a pregnant female arrives and seeks care for abdominal pain and we don’t check her in but tell her that she needs to go to the hospital and they will take her up to OB… this would be an EMTALA violation. We are obligated to stabilize and transfer.

§ 489.24 Special responsibilities of Medicare hospitals in emergency cases.

(a) Applicability of provisions of this section.

(1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must -

(i) Provide an appropriate medical screening examination within the capability of the hospital's emergencydepartment, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of § 482.55of this chapter concerning emergency services personnel and direction; and

(ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section.

Link for more reading: eCFR :: 42 CFR 489.24 -- Special responsibilities of Medicare hospitals in emergency cases.

Please let me know if you need any clarification or have questions!
Thank you,
Andrea DeLoach

Breaking Records!

Wow, that was a record breaking week! Thank you all for your amazing teamwork, you did an amazing job although I know it didn’t feel amazing for those who worked this week ! Please read the following updates carefully and let me or Melissa know if you have any questions.

1. Call the Transfer Center (TC) aka Bed Board at 1233 for all transfers. If the TC does not have a bed, THEY will call the ER to get an ED bed so you no longer have to call the CN yourself. The TC should call you back and tell you what bed or lobby or hall etc! We will still have to call for an ambulance and call with report. I believe this will be very helpful to us as the TC calls are recorded, they keep a log of all calls and will eliminate some of the untoward interactions that we have had in the past. Also, the TC will escalate issues appropriately to upper management so that all are aware of the FEDs holding.
   

2. Since Wednesday afternoon, the yellow plus triage on minor’s will not go away even when all the “forms checklist” items appear to be complete. It is also requiring a Humpty Dumpty fall assessment that was never asked for prior to Wed. I have placed a ticket with corporate for them to look into and correct this.
   

3. I’m a firm believer in staying current / up to date on charting. While the initial triage is the main priority, the rest of the yellow + and the assessment should be completed asap. We have had several shift changes lately where these were not complete on a lot of the board. Please make every effort to have these done, especially before shift change or include why they aren’t completed in your shift report to explain. We all understand those times when it feels like a Greyhound bus dropped off Amarillo in the lobby at shift change…we just need to communicate that.
   

4. We met with the CP coordinator and found out some details on what is being audited. Be looking for that, but I wanted to go ahead and make you aware that if a patient doesn’t say “chest pain” but has other s/s in their chief complaint like weakness, SOB, dizzy, hurts to breath, palpitations etc and the doctor orders a cardiac workup…. This is counted in the CP audits. Therefore, the door to EKG time will be measured. I recognize that this is a physician responsibility, however, you might let them know that they are supposed to write the TIME on the EKG to indicate when they viewed it as well as a signature.
   

5. When a patient is registered by mistake or if they LWOT….as long as they remain on the board the red plus continues to count against our wait times. Please assist registration in removing these asap.
   

6. Reminder to please bring your stuffing donations to Georgia Street !!! (and brownie mixes to TSQ) Boxes have been placed at both sites.
   

7. Please know that we are diligently trying to cover all the call-ins, we are having 1-2 per day but it is very difficult to get these covered. We do have several employees who will be starting in the next few weeks. Also, a third traveler will be here 1/1/22 and I got approval for a 4th. I recognize the tremendous physical and emotional strain it places on those working to have to work understaffed and am trying to resolve this issue as much as I can. I am believing for better days ahead and ask for your patience and assistance with this !
   

Thank you for all you do !!!
Andrea

FED Holds & Attendance

FED Admission Holds

This is becoming an issue again; I wanted to review our transfer process. Please review the flow policy which actually has the patient transfers to be out of units in 30 minutes; however, this was pre-covid with issues that we have never faced before. FED patients will be given room assignment priority.

<CLICK HERE TO READ THE FLOW POLICY>

The physician will put a decision to admit in Cerner

Either the physician will call the transfer center or they may ask the nurse to call and ask if a MS/ICU bed will be available in the next 4 hours.

IF YES – physician will admit per usual process by securing an admitting physician and place the AOT order in Cerner and the RN will be in contact with the inpatient RN and call the ambulance for transfer as soon as the room is available.

IF NO – physician can pursue transfer to other facility: ED to ED or Direct Admit beginning with BSA

If no other admission avenue is available and the patient is appropriate for NW Services, the physician will admit to NW and the FED CN will work with the ED CN to initiate an ER to ER transfer. It is an expectation that both CNs will act with courtesy and respect in working out a transfer plan.

If the ER to ER transfer is not going smoothly, the RN will call the house supervisor for assistance. The house supervisor will assist in a transfer plan and/or escalate the issue to the AOC as needed.

Call-Ins

We have seen a tremendous increase in call-ins lately. Please review the NW Attendance policy, and want to encourage you to have a responsible attendance record. I am not encouraging showing up ill as that will cause more call-ins but please be proactive to find replacements and alternate forms of care for family as this places a tremendous burden on your coworkers. Also, with the addition of the third nurse per shift, it may seem of no consequence to call in; however, this position is important if we want to retain staff and practice safe patient care. This excerpt is out of the attached policy and will be followed:

<CLICK HERE TO READ THE NW ATTENDANCE POLICY>

Progressive Disciplinary Guidelines
A. A preventative counseling will be issued to an employee with three (3)
unscheduled absences in a twelve (12) month period.
B. The first written counseling will be issued to an employee with four (4)
unscheduled absences in a twelve (12) month period.
C. The final written counseling, with possible suspension without pay
issued to an employee with five (5) unscheduled absences in a twelve (12)
month period.
D. When the employee has six (6) unscheduled absences in a twelve (12) month period, termination of employment may occur at the facility’s discretion based on the employee's previous work record and the circumstances surrounding
the absences.

Updates

1) Registration now has a chair in the hall at GS so they can bring patients back and have private conversations. We are working on a plan that will use Cerner to communicate when the physician has seen a patient and when registration is complete in order to indicate they can be discharged…more to come.

2) Reminder to techs: even with the 3rd nurse coming up front we will keep it where nurses stock the back and rooms and the techs clean and stock the front please do this every shift as these areas are small and can become chaotic quickly (i.e. copies of forms, cleaning, stock swabs and tubes)

3) Nurses, please look in the boxes on the bulletin board walls to see if you have any Chest Pain or Stroke audits.

4) This is such a busy time of year, several have talked about and agree that we should have a Winter Party in mid-January…. Let me know if you’re interested in helping to plan this!

5) Please do the initial triage on patients as quickly as possible so we know what we have in the lobby and checking in (red plus). The rest can be done later if others are waiting, this is a priority !

6) ESI levels: Tiffany just had a great class on how to assign ESI levels. You can review the ESI handbook that will answer any questions you have about this process. As a whole from what I have seen, the FEDs tend to assign lower ESI scores than the ENA ESI indicates. Please ask if you have any questions!

<CLICK HERE TO READ ESI HANDBOOK>

EKO Stethoscope Discount

http://ekohealth.com/

I recently purchased an EKO 3M Littmann Core Digital Stethescope, and it is amazing! It blue-tooth connects to your phone and shows rhythm strips, HR, and can help with murmurs. You can also do a recording and send it to your favorite cardiologist. Feel free to take advantage or add it to your Christmas Wish List. - Dr. Poage

Print Transfer Report From Cerner

It was brought to my attention that many of you do not know how to print a transfer packet / report of care from Cerner. We send almost everyone to main and this task is not necessary for that so it is understandable. Please see the instructions HERE on how to do this.

Updates

Greetings!

I am out of town Sat Nov 6 – Tues Nov 9. I will have intermittent cell service and will be checking my work email; otherwise, for more immediate needs Melissa Talley (ext 6990 or cell 806-678-1088) will be available.
Regeneron: I received mixed messages about Regeneron… the final answer is that the NW pharmacy has it and will make it up as needed. It will have to be couriered over and will be a slow process. They don’t have the kind we can stock in our fridge anymore. If the FED Dr orders it and the patient is willing to wait the allotted time, we can do it. However, if they don’t want to wait, the FED physician can write an order and fill out the paper (physicians were emailed the form) for them to get it at the city infusion clinic.
New Charge Nurse: Denise Ramos has accepted the position of Day CN at TSQ !!! WOOHOO!!! This leaves her Float Day ED (between main and the FEDs) position open. Tell anyone who might be interested!
Payroll: Melissa will be coming up to do payroll early Sunday morning, please make sure all entries are in and correct by the end of Saturday night, thanks
Front End Process: please read HERE and comment back to me and Melissa if you don’t understand something or have a better idea…we are certainly open to suggestions. It’s a bit wordy but I couldn’t express the full intent with just bullets. We will review this one-on-one and I will soon schedule a staff meeting to review. On the next schedule sign up we will be going to 3 RNs per shift but will no longer have a mid-shift. We are working out the details of this and will send out more information.

Thank you for all you do !!
Andrea

Updates

Greetings! Hope all is well with you and your families!

As we enter into the holiday season, please know I believe in a work life balance and it is important for you to maintain that ! Melissa and I also have to fill shifts in order to create a safe work environment so you will likely get a number of texts about openings but I don’t want anyone to feel bad about saying no; it is very helpful if you will let us know “yes, no, or let me check” so we know what possibilities remain rather than ghosting us!

PAYROLL – we have to have payroll completed on Sunday by 2pm since this is a holiday week. Please check your timecard for accuracy and if you have some education from the last couple of weeks, we will need to enter it asap.

TIMECHANGE – from payroll: Daylight Savings Time – Employees clocked in at 2:00 am (Sunday, November 7th) will have their time cards adjusted appropriately for the “fall” back one hour. If possible, please make sure employees are not clocked out at this time (for evening break) so the system can auto adjust appropriately.

RESIGNATION: Daytime Charge Nurse at TSQ, Chelsea Galbraith, told me some time ago that she was going to the VA. She gave notice last Tuesday then a couple of hours later became quarantined r/t exposure so she didn’t get to finish her shifts and have a proper send off! There will be a basket with NW stationary at each site for you to write a note and to collect any items you may want to voluntarily contribute to a gift basket for her. Please have notes/items in by 10/10/21

TSQ Day CN position open: send Andrea and Melissa a message that you are interested in it and attach a resume by 11/3/21 5pm.

STAY UP TO DATE: It is an expectation that you will stay up to date on reading your email every shift. Also, we will be sending out frequent notices about HealthStream. Should you have any difficulty completing these during regular hours let us know as we would approve time before or after shifts to complete these items. Thanks!

REFERRAL BONUS: Remember there is referral money if you talk a nurse into hiring on at NW…..we need night nurses FT, PT, prn !

SCHEDULE: PLEASE READ CAREFULLY, a schedule sign up ShiftHound reminder will be sent out the Sunday night that starts sign up week. If you miss your sign up time and fail to sign up by the Sunday night following the schedule sign up period; you will be assigned your required FTE amount of shifts on Monday morning. For example, the next sign up period starts November 14 and goes through November 20; on Monday 11/22 we will assign shifts to anyone who did not sign up and any open shifts will be available for all staff.

Durable Medical Equipment: Starting next month, any missing durable medical equipment that does not have a completed form and facesheet in the folder (do not send it to medical records) will be charged to NW. Doing this process was part of skills day so please let me know if you have any questions!

I know there have been some items that we have been without for a while that we thought were ordered…. Monitor cords, otoscope heads, etc. I am meeting with CS tomorrow to try and rectify this.

Thanks for all you do !

ED FED BH MSE PROCESS

I received the new policy for the ED and FED MSE Process for BH Patients. This is effective now please read HERE !