Harbor:Administrative resident

Acting Senior (R2) Roles

• Lead rounds
• Take follows
• Take intern presentations
• Senior resident phone (once keys applied to all phones)
• Continue junior 5S duties

Background

ED Administrative Resident Orientation (Team A Resident)

First and foremost, the point of having R2s begin performing the administrative resident role in the emergency department before the end of the year, is so you can ask questions of the current senior residents about how to do things. Many of the finer points of being the administrative resident are not known to the attending physicians. Ask the senior residents lots of questions!

Things to Do Before Starting Rounds

1. Get everyone together to do 5S for a strict 5 minutes. Document on the 5S sheet.
2. Team B (Green team) R3: Prep airway equipment in the trauma bay
3. Invite the ED pharmacist to join rounds - they are part of the emergency department team and should be with us during rounds, and can answer many questions that come up about meds, drips, etc.

Patient Safety

• Your most important job is to make sure that all patients in emergency department have at least been eyeballed, and if needed have orders written, especially for pain medicine. Although each team is responsible for screening its own patients, you may have to screen the opposite team’s patients while they are in rounds.
• Ambulance patients are the responsibility of the Team A Resident to screen. Usually, the charge RN will overhead page you to go see the patient. Sometimes, they will call your phone (x23204). Patients will show up on the trackboard under ATri (on the 'Acute, Trauma, RME HAR track)
  • Triaging Ambulance Runs
• Another problem with ambulance patients in the middle of the room is that sometimes they sit there a long time with no care whatsoever, either waiting for the nurse to screen them, or waiting for an ED bed after the nurse has screened them. It's your responsibility to keep an eye on all these patients. If you notice an ambulance patient has been sitting awhile and no one has begun caring for the patient, screen the patient and find out what's going on from the charge nurse. If the patient is to stay in the treatment area, make sure a team gets assigned by the charge nurse and someone starts caring for the patient.
• In general, all patients should be screened within approximately 20 minutes. If you're getting really behind, talk to your attending to get some assistance.
  • If the patient you've screened requires immediate attention, make sure a physician starts seeing them right away if you cannot. All the members on your team work for you, and it is your prerogative to reprioritize them to a higher priority task when you need them to!
  • When you screen a patient, you can indicate this on FirstNet by completing the 'MSE' note. Not only does this count for measuring the “time to first provider”, but it also keeps any one else from duplicating your effort.
  • As a general rule, you (or the other R3 if you designate them) should screen all ED Traumas to make sure they do not meet higher level Trauma criteria. Look at the card!

Patient Flow

• Keep an eye on overall flow in the department. The better the flow, the safer the emergency department is and more patients get seen. There are several ways you can do this:
  • Orders: make sure orders are being written in timely fashion for patients who are admitted or on observation. Holding orders can be written for all Non-ICU patients when 2 hours have elapsed after the order “Request for Admit” has been entered in FirstNet, and you have notified the admitting team you are writing the orders.
  • Consults: Keep an eye on how long consults are taking. If you think the consult is taking too long, ask your attending for assistance. Always ask a consultant for an estimated time of arrival, so you know if they are overdue.
  • Downgrades – One of the best ways to move patients along is to get boarders downgraded as soon as possible. Whenever getting signout on a “follow”, know the (usually) single reason why that patient needs the PCU or ICU bed, and an idea of when that requirement will go away. When possible, discuss this directly with the admitting resident.
  • Interqual - Make sure that requests for Interqual are made as soon as you think the patient might be admitted. Also, have as much of this documented in your note as possible, this helps UR when contacting the patient’s insurance. Starting IQ early makes difficulties more likely to come up during your shift rather than having the next resident deal with them and second it ensures that the patient can be admitted here before you use up an admission slot. This does a lot to help flow and limit wasted admits.
    • Sometimes the actual insurance is different from the original registration info, and many times patients who are 'OOP' can still be admitted at Harbor.
    • Depending on who is working in UR, they may not start running interqual until there is a 'discharge' diagnosis in Orchid
  • Admissions: enter admissions and observations on their respective clipboards and call the teams as soon as the decision is made. This helps to avoid missed inpatient or observation slots.
  • Help your team to avoid time-consuming activities:
    • Consults - consults often take several hours. Do you really need that consult? Would a clinic visit suffice?
    • CTs/Ultrasounds - same goes for these. By policy all CT and US orders need to be approved by an ED attending
    • Surge Plan- Although we do not interact with this too often, be aware of what is in the Surge Plan. You're likely to encounter one wherever you end up after residency.
    • Transfers out to other facilities - If the patient has been admitted, the transfer should be carried out by the admitting team. No transfer should sit for more than an hour or two in the emergency department waiting to find out if the receiving facility has a bed. If no bed can be found within one or two hours, the patient should be admitted and wait on the inpatient side for transfer. Do not be afraid to push UR on this issue. If you decide that you want to transfer a patient yourself and the patient has been seen by a specialist, that specialist should talk to the receiving physician about their findings and plan of care (ie a patient requiring admission for a urological procedure).
  • Clinic patients-
    • These are not technically "transfers" - the clinic physician can send us patients whenever they want without an acceptance. You can however discuss the case with the clinic doctor and let them know what you think the patient needs. For example, if the problem is asymptomatic hypertension, let the clinic doctor know that you do not anticipate any specific therapy in emergency department. In the end, the clinic doctor gets to decide what he/she wants to do.
    • For on campus clinics, (as of 5/2015), policy is that all patients are brought to the AED
    • Stable Harbor clinic patients should not be sent to the emergency department for admission. The clinic doctor should use the direct admission process. If there are no beds in the hospital, stable patients can wait in clinic until a bed is found. If the clinic is about to close, they need to contact the Patient Flow Facilitator (PFF) who will either find them a bed, find them additional nursing staff to watch the patient in clinic, or direct them to send the patient to the emergency department. Only patients who need monitoring, or patients approved by the PFF, should come to the ED to await admission.
    • For all patients that you take calls about coming to the ED - create a pre-arrival/referral note in FirstNet. These are available from the trackboard near where you click to document procedures, ultrasounds, etc. Try to include:
      • Sending Doctors Name
      • Sending Doctors Contact Info
      • If another physician at Harbor was involved in the approval for transfer - put their name and contact info as well.

Patient Care

• Sad that this is so far down on the list, but that's part of being an administrative leader in the emergency department. Your job is to make sure that the environment is safe and working well so that everyone else in the emergency department can care for as many patients as possible.
• That being said, you're here to learn how to care for patients. You just have to find the balance between how many patients you can care for and how many you can follow and still get your first two priorities met. A couple of tips:
  • try to see patients either with the intern so they can do most of the work. Seeing patients with medical students will take you more time as you must write a separate note.
  • try not to overload yourself with too many complex or sick patients
  • when you have a patient with a procedure, do everything except the procedure, and get help from the intern or medical student to suture, etc. Tell them "I did all the scut work, and left the best part for you". They’ll love you.
• Airways
  • Trauma airways, by agreement with the Trauma Service, are performed by the R3/R4. You can run the TTA resuscitation, just not the airway. (Don't worry, you'll still get 24 months of TTA airways as an R3/4) So for TTA traumas the senior must be with you until it is clear that the airway is secured.
  • Airway management team response remains the responsibility of the R3/R4.

Other Administrative Duties

• Receiving phone calls
• Calls you SHOULD take
  • Clinics/Physicians wishing to send patients to the ED
  • Radiology results of patients discharged from ED
    • If they were admitted please ask them to notify admitting team
    • If patient is currently in ED please notify specific resident taking care of pt.
  • Pharmacy calls ONLY IF prescription written in ED and that physician is not currently working
    • Please check Orchid to verify (Urgent Care & MSE don’t qualify)
    • Otherwise please refer to appropriate resident/MSE/Urgent Care (call back when UCC open)
  • Positive Cultures
    • Check first if the patient was admitted to our facility, if they were (or were transferred after being admitted), do not take the report - inform the lab that the need to contact the patient's Harbor inpatient physician
    • If the patient was discharged from the ED you should contact the patient using our process under "Tips for Abnormal Lab Calls" on the page Receiving phone calls
    • If the patient was transferred to another facility from the ED (not from the inpatient service) - then contact the patient's inpatient physician at the facility the patient was transferred to
• Calls that generally AREN'T your responsibility:
  • Lab calls (hemolysis, critical value)
    • Should go to the nurse
  • Radiology reports for patients who are still in the ED
    • Should go to the specific resident taking care of the pt
    • Admitted patients - should go to the admitting team - if urgent you should assist with this process
  • Family member calls
    • Should be screened by nurse first. May request appropriate resident afterwards.
  • Calls unrelated to direct patient care provided in ED
    • Medical advice (notify we don’t provide this service)
    • Calls about clinic schedules, call schedules or medicine admission status
• Transfers from other hospitals: generally the Medical Alert Center (MAC) should not be contacting us directly, but should be going through the Patient Flow Facilitator, who will contact us to see if we have the space to accept a transfer. These transfers generally have already been accepted by a specialty service in the hospital. Ask your attending if you are open to transfers. We want to make sure that not only do we have space in emergency department, but there is an inpatient bed that the patient can go to from the emergency department. Any calls coming in from outside hospitals for transfers should be directed to the Medical Alert Center unless it is a critical emergency. At times, other hospitals considering a 911 STEMI transfer will call for advice. Get your attending involved. Enter them on the track in FirstNet
• Calls from Psych ED: Generally if the psych ED thinks a patient should be in the Medical ED, we should accept. They should never have really medically sick patients there – that’s not what they do. It also helps smooth out transfers in the other direction as well, which is what we want. You can always offer to just see the patient in the psych ED if you think its appropriate (be sure to use FirstNet Psych/AED consult process so the patient shows up on our board), but if they really want us to take the patient we should. You can always get input from the attending if you’re not sure what to do.
• “Follows” – or admitted patients should have moment to moment management by their admitting service. You should not write any but the most emergent orders on admitted patients. Please encourage nurses not to ask you for the “quick” order for this or that; it’s bad coordination of care, and may lead to dangerous duplication of orders. If there is an emergency however, we should step in until the admitting team can take over. Always call the admitting team ASAP to inform them of what you are doing. They may have important additional information. That being said, at signout you should get a detailed problem list and any baseline exam info (GCS, etc) or info about unstable issues which you might need to know if the patient does have an emergency. Pass off a PROBLEM LIST, it is much easier to remember and pass on with accuracy.
• Working with the ED Hospitalist – The ED Hospitalist was hired in large part to take workload off of the ED physicians. Know what they are here to do and use them! Some of their responsibilities:
  • Manage all Observation status patients in the ED
  • When the night hospitalist is more than 2 patients behind, the ED hospitalist is supposed to assist in seeing and admitting patients
  • Can help arranging follow-up for a medicine patient being discharged
  • Can answer IM related questions on ED patients (Hospitalist Consult)
  • Perform medical clearance when needed urgently on any ED patients (e.g. for surgery)
• Working with Nursing
  • This cannot be stated better than Stephanie Donald, a past resident, did:

    “Emphasize that they [the residents]should actively work on their leadership skills and establishing a positive working relationship with the charge nurse, and not be afraid to use the charge nurse to help facilitate patient safety and flow, and see themselves as 2 on the same team. Their goal is for the charge RN to see them as the leader of the department and one she/he can work with instead of just the triage person and she/he does their own thing in terms of flow, etc.”

  • Carry your phone and encourage nurses and clerks to contact you on it, as well as forward your calls to it. Have him or her call you to let you know when runs are on their way before the patient shows up
  • And finally – as the leader of the healthcare team in the ED, YOU set the tone for the department. Even if it doesn’t always seem like it, other housestaff, the nurses (most, anyway), clerks, nursing attendants, CT Techs, and even the housekeepers look up to you. If you are grumpy, everyone is, if you are positive and up beat, it’s contagious. “Do with a smile what you have to do anyway”

References

ED Administrative Resident - Running the Board- Orientation 3-18-14

See Also

Harbor: Harbor (Main)

Authors

Ross Donaldson, Neil Young