Embedded Files
The ED schedule is published month by month and will be updated on Momentum as soon as it is available. If you have any questions about the ED schedule please reach out to the chiefs.
The care paths are algorithms of diagnosis and management for some common presentations like DKA, Osteomyelitis, MIS-C etc. The J drive will give you access to everything from your desktop.
UB PEM PROCEDURES WEBSITE!
All procedures and how to perform them are listed there!
Thank you Dr Territo and PEM fellows for this!!
ED Rotation Expectations and Quick Reference Sheet
Goals for the rotation:
1. Obtain knowledge about acute care medicine
2. Learn how to stabilize a patient
3. Obtain the skills necessary for various pediatric procedures
Location: Main/1st floor of the hospital (behind Tim Hortons)
Shift duration: 10 hours
Attire: Scrubs and comfortable foot wear.
Tools needed: It is a good idea to have you PALS card handy, trauma shears if you have them, and obviously, your stethoscope is a must
Patient Load: There is not a set minimum or maximum number of patients that one should take. Take as many as you can handle. Patients are given an ESI (emergency severity scoring) number while in triage. Level 1s are the most serious (i.e. traumas) and 5s are the least serious. Please signup for any level of patient (an intern can take a 1 or 2 if you have interest in doing so). If multiple patients need to be seen, make sure the higher acuity patients are covered first (i.e. 1s and 2s) before the lower acuity (4s and 5s).
Day to day information:
-There is a secure locker room in the back (with badge access) where you can keep your stuff if you do not feel comfortable keeping it at the desk
-There is also a refrigerator in the back as well for your convenience
-Make sure you grab your own ASCOM (again found in the back) – each resident should have their own personal number
-The EMR used in the ED is FirstNet: when signing in make sure you assign a color for yourself and place your ASCOM number after your name
Go to people/resources to help:
-Feel free to ask other pediatric or ED residents at any time
-The PEM fellows are also a great resource of medical knowledge and procedural help
-The attendings are very approachable, so don’t hesitate to ask them your questions
-If you need any help with suturing/stapling, I&Ds, etc… the NPs are an excellent resource. They do the majority of these procedures, so they have really perfected these skills
-There is a pharmacist in the ED, so use them – they are extremely helpful. If they are not there or it’s a simple dosing question, reference Lexicomp off of Kaleidascope
-There is an iPad and cordless phones when a translator is needed, these are both behind the workspaces. Follow the directions on the respective electronic device.
-The ED medical assistant can help you track down supplies you cannot find in the store room, they are also another helpful hand when you need an EKG done, or extra holding for suturing
-The ED secretary will be able to download outside imaging to the EMR via the disc sent by the OSH. Make sure this is done so you can see all of the images for yourself.
Role during a trauma:
-The senior is responsible for running the code if the fellow is not available or not in the ED (i.e. from 10pm – 12pm overnight) – this usually entails airway management and head to toe assessment
-Anyone is allowed in the code/trauma rooms (located at the back of the ED, near the break room). You must badge in for the doors to open to the trauma area.
-Typically, the role of the resident, including interns is to order the necessary imaging, labs, and medications needed
-There are Level I and Level II Trauma order sets that are very helpful
-If you do not decide to partake in the code/trauma, make sure you are helping out in the ED. There should be one attending in the code and one helping to run the rest of the ED. If it is overnight with only one ED attending, please continue to see new patients as they come in, even if this means you have multiple people to present to the attending at once when they are free.
Presenting:
-Feel free to present to any attending who is available
-For the majority of the time there are two attendings on, except from 2am to 8a when there is only one
Placing calls
-Surgery has their own ASCOM, so you must call them directly when placing a consult
-The ED secretary will help make all other calls if you place the order to do so (found in the ED order sets)
When Admitting:
-ALWAYS call the patient’s PMD BEFORE you admit the patient, do not place the admission order before you have done this
-The patient’s PMD can be found in the EMR: Patient Information >> PPR summary
-If the patient is a Towne Garden or Niagara Street Pediatrics patient then the clinic does not need to be called to inform them of the admission (attending names: Kaufman, Archer, Lucy Holmes, Parmington, Yu, Kuo, Messina, Hays, Vergos)
-Please use the PCP Physician relation lookup on Kaleidacope. This tool will tell you if the PCP admits under their own service or if they admit to the pediatric hospitalist service (PHS)
-If the patient is being admitted under a private attending, family medicine (i.e. Jericho Road), or subspecialty service make sure the attending accepts the patient before you admit them
-The on call list on Kaleidascope will give you the admitting physician for PHS and Family Medicine – this physician will be the one you need for the admission order
-Green triangle (i.e. okay to be transported to the floor/CDU) should be placed only after the admitting team has said so, please don’t assume that just because the team came down to the ED, they will take them. The patient may need a higher level of care, or may not even need to be admitted.
Procedures:
-You should be doing all the procedures that are necessary for the patient’s care
-That means LPs, suturing, stapling heads, removal of foreign bodies, etc… are yours for the taking, plus you need them to graduate, so make sure to do them
-Do not forget to log your procedures in medhub and send them to the attending for approval
J-Drive
-WCHOB ED folder has a lot of great care paths to help out: closed head injury guidelines, what to do with a sickle cell patient who has a fever, psychiatry resources, etc…
-You can obtain access to this via Kaleidascope
Tips:
-The ED ordersets are key to success. Make sure you have these set up so they can help!
-If your patient is in respiratory distress make sure you get them the treatments they need before you get all of the ancillary history (i.e. social/surgical history is not as important as an asthmatic who needs albuterol-ipratropium)
-Ideally, all your notes should be done within 24 hours, this way you won’t forget pertinent information and they won’t start to accumulate to overwhelming numbers
-The ED attendings do our evaluations with input from multiple people in the department (i.e. fellows, nurses, etc…), so work hard and it will get noticed)
Last Updated: August 9, 2021
Pediatric ER Cheat Sheet
Welcome to the OCH Pediatric Emergency Department! Here are some cheat-sheet notes to help you get through your first month.
The Basics:
1. Starting of your shift:
Get a resident ASCOM from the lounge
Find a computer and log onto First Net using your login ID
Pick a color, put your first name and your ASCOM number for everyone to see on the board
Ask if anyone is leaving and needs to sign off any patients
2. Seeing patients:
Always sign up for a patient you are going to see… get the color off the board.
See the more acute ones first! (Red> Orange> yellow> Green > Blue)
Do not sign up for multiple patients at one time
If you think the child is sick – come find someone (fellow, attending, or charge nurse) for help. DO NOT wait until after you talk to them, examine them, write your note, grab a coffee, etc, you get the point!
Click on the ED summary box prior to evaluating the patient
This will allow you to see chief complaint, patient vitals, and other prior ED notes
Always present the case to an attending before placing orders (labs, x-rays, etc.) We will come up with a plan together
Please discuss and come up with a plan with the attending prior to giving the family the plan
3. Placing Orders:
Place orders from your note or the tracking shell
Try not to open more than one chart at a time to prevent errors!
Always place orders from the ED favorites
If you are not sure of something (i.e. how to order a med, how to calculate doses, whatever…) please ask! We are here to help you
Most medications can be rounded up – instead of 323.5 mg or mL– round it to 325, especially with IV fluids… you will score major points with the nurses!!
4. Writing Notes:
After writing your note, PLEASE send it to the attending you presented the case to. If you finish notes later, I suggest you write down which attending you worked with so you don’t forget and send the note to the appropriate attending. (there is an area mid -way through the note that says “case presented to” this may help remind you)
Please try to complete admitted patient notes by the end of your shift
You MUST complete PICU notes immediately
Try to complete discharged patient notes within 24 hours
Please remember to keep the family updated! It is nice to give the family an expected time frame to complete the initial plan (labs, studies, etc). This should include summarizing what studies, consults, etc we plan to do on the (Dry Erase) "White Boards" in the patient room.
When results come back
If another test/procedure needs to be done
If another consulting service is coming
At time of discharge
If you are unclear about how long something should take - ask the attending before setting (what could be) an unrealistic expectation with the family.
Expects:
Every so often you will hear “There is an expect on 7330”.
This means a PMD is calling to let us know about a patient they are sending into the ER.
You are allowed to answer this call but PLEASE FOLLOW THIS PROTOCOL:
Answer the call
When you are looking at First Net in the upper left hand corner there is an ambulance icon – click on it – this is where you type your expect
Always fill in the name of the patient, age and why they are coming
If the patient is over 21 – place on hold and notify the adult provider
Ask who is calling, which doctor office – and a number we can call them back at
Write a brief summary of what is going on
If there is anything in particular the PMD wants us to do
ASK if the patient is admitted to they use the hospitalist service
ALWAYS mention the expect to an attending or fellow
If the kid sounds sick – run it by the attending before hanging up the phone
If it is NOT a PMD but instead an URGENT CARE OR OTHER HOSPITAL put the call on hold and let an attending or fellow know. These calls should be directed to the transfer center… Residents are NOT allowed to accept transfer calls
How to admit a patient:
When the decision is made to admit a patient it is a complicated process but stick to these steps:
1. Determine what kind of admission this is.
There are 4 kinds of admissions – medical, subspecialty, PICU, surgical
Medical
1. Check if the PMD admits privately or to hospitalist service - look on the PCP look up on Kaleidascope
2. Decide if patients meets criteria for observation or inpatient admission (see J drive)
3. Request a bed – under the order tab – click on “ED admit Inpatient or ED admit Observation” depending on step number 2.
You will see the order in the tracking shell - heart=obs; bed = inpatient
4. While you are waiting to find out what floor the patient is going to contact the patients PMD.
Let them know that the patient will be admitted, what we have done for the child, any lab results and what floor they are going to.
5. Once a floor is assigned the red triangle will be launch next to the admission order
6. Medical team will come to the ED for sign out and to examine the patient
7. When the team is comfortable with the admission they will tell you to green triangle!
Right click on tracking shell next to admit bed/heart -- find MD Admit complete
This tells the nurses patient is ready for transfer out of the ED
If needed, Put in holding orders – under the orders tab – Click on “ED Holder Orders” and complete.
Surgical admits (general surgery, ENT, urology, Neurosurgery) or PICU
You do not need to sign out to the floor resident or place holding orders – Just launch a bed and place the green triangle
If patient is going to surgery - Admit to Ambulatory Surgery Status
How to Sign-Out a Patient:
I: Introduction - Individuals involved in the handoff identify themselves, their roles and jobs
P: Patient - Communicate the patient name, identifies, age, sex, and location
A: Assessment - Present the patient's chief complaint, vital signs, symptoms and diagnosis
S: Situation - Communicate the current status and circumstances, including code status, level of certainty or uncertainty, recent changes and response to treatment
S: Safety Concerns - What are the critical lab values and reports? Any socioeconomic factors to be aware of? Any allergies or alerts (ex: risk for falls)?
**An attending or fellow will walk you through putting in all of these orders your first couple of times**
Discharging a patient:
Please discuss the discharge with attending and family then:
When discharging consider:
Are the meds being sent to the correct pharmacy?
When should the patient follow up with their pediatrician or other doctors?
Does the patient or family need an excuse form?
Fill out the discharge instruction using the discharge icon on first NET
Go to depart section
Go to patient education
Select “all”
Type “Form/Kaleida- ER OCH” in the search bar
Right click and add to “personal favorites”
Go to “personal” with star symbol and use selected instructions
Please make sure the discharge attending listed on the document is the same as the one you worked with for the patient
Print the instructions -- secretary will place on the clipboard
Pediatric Medication doses you have to know:
Tylenol 15mg/kg with max of 650 mg
Motrin 10 mg/kg with max of 600-800 mg
Ceftriaxone 50 mg/kg with max of 1-2 grams
Normal Saline bolus 20 ml/kg max of 1000 ml
Other Helpful Stuff:
If you need to order an ultrasound (or MRI) after hours you must page the tech
If you are not sure when after hours are – just ask (hours are different for weekends, weekdays, holidays, full moons, etc…)
If you order a respiratory treatment you also need to call the respiratory therapist
Call RT on your ASCOM– and tell them you need - ex racemic epinephrine, albuterol, oxygen, hi- flow
THE RED PHONE – When you hear the red phone ring – DO NOT answer it!!!
It is out medical direction phone – only attendings and fellows can answer
Note tips:
Please follow these tips so that we don’t have to send your note back to you!
1. Always click the date and time you first evaluated the patient
2. Write a concise HPI – if using dragon PLEASE re-read… the dragon can make for some interesting stories…
3. Under Review of Systems
DO NOT click “unable to obtain due to age”
Click negative or positive for each item – AVOID the “negative except HPI” button
4. PMH, PSH, FH, SH – if you click the button include medical history and nothing is reported– nothing will carry over… this mean it is left blank!
So if it is negative click negative
If there is something that is not already in the note add it
Remember for social history you can always (well usually) click “lives with parents”
IF YOU DO NOT FOLLOW THIS WE WILL SEND THE NOTE BACK TO YOU!!!!
5. Please copy all lab results and imaging results into your note
6. Diagnosis – please make sure it is included in the note (not just the discharge instructions)
7. It is nice to give a summary of care at the end of the note – remember these notes are sent to the patients primary pediatrician.
For example – Suzie is a 15 month old who presented with a fever without a source. Her urine was positive for leuks and nitrates – we sent a urine culture and treated her for a UTI. She was given one dose of ceftriaxone 50mg/kg prior to discharge and was sent home with a prescription for cefzil for 10 days. She looked well at the time of discharge – her fever resolved and her tachycardia improved with Motrin.
Last Updated: August 9, 2021
QI Project: Anticipatory Guidance
GOAL:
TO IMPROVE THE ANTICIPATORY GUIDANCE GIVEN IN THE ED
Where to find the anticipatory guidance documents?
Go to depart section
Go to patient education
Select “all”
Type “Form/Kaleida- ER OCH” in the search bar
Right click and add to “personal favorites”
Go to “personal” with star symbol and use selected instructions
Google Sites
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