32. I Think My Patient is Coding...
- If your patient is poorly responsive or unresponsive,
ASK FOR HELP!
- Confirm DNR/DNI status
- Call/ask nurse or someone else to call RRT and/or Team 7000 (47000) and Anesthesia Airway Team stat. During the day have a team member notify the chief resident immediately. Overnight the senior surgical resident on call should be notified immediately.
- Call for the ambu-bag and crash cart to be brought into room
- If you are the first one there and CPR is indicated, do it!
- Airway → Start with chin-lift, jaw-thrust, ventilate the patient with the ambu-bag and be sure you are getting adequate chest rise, have oral airway in place, suction as needed
- Breathing → You may have an RN bag the patient if you know the airway is patent
- Circulation → If no pulse then immediately begin compressions, make sure patient has good IV access and bolus NS, get patient hooked up to a defibrillator.
- Send full set of labs including troponin and T&S
- Code team will help you with medication administration
33. Patient Deaths/D.A.V.E. application
Learning to cope with patient deaths and families of the deceased patients is one of most difficult tasks of residency. If they happen when you are on call, there are several things that must be taken care of.
- Notify your chief resident. He or she may call the attending, or have you call the attending directly. Either way, the attending must be notified immediately. (If it is not your primary patient, alert the primary team!)
- Clarify who will be calling the family to notify them about the death and ask for permission for autopsy.
- Complete a note in the chart with the death exam, the next of kin notified, and whether an autopsy request was granted. There is a template for this note in EPIC.
- All deaths within 30 days after surgery must be then referred to the Medical Examiner (212-447-2030). If the ME accepts the case, they will complete the death certificate. Make sure to record the ME case number.
- If the medical examiner rejects the case, or the death has not occurred within 30 days after surgery, you must complete the online death certificate. You can get help completing this online form by paging the nurse manager on call or going to medical records. You must know the cause of death—if you need help, call the ME and present the case and they will recommend an “official” cause of death.
So you have to do the D.A.V.E......
- Go to designated D.A.V.E. computer (marked on monitor, there is at least one on each floor)
- Go to original screen (not Citrix) try hitting windows key. Press the D.A.V.E button.
- Initial login/password: mtsinai/Mtsinai1
- Then use personal login/password for EVERS on left hand side.
- Fill out the “Death Start/Edit New Case”. License for Sinai is 42360.
- Autopsy should be requested for all patients and should be discussed with the family in an appropriate manner.
- Autopsies are performed either by the Dept. of Pathology at Mount Sinai or by the NYC Medical Examiner (ME).
- Clarify with your chief who should ask the next of kin for autopsy consent.
- Autopsy consent forms are available on Patient Works.
- Be clear about the benefits of autopsy:
- providing family & medical team knowledge about all the factors that may have contributed to patient's death
- sense of closure for the family
- potential knowledge about illnesses that may affect other family members.
- Autopsies can generally be performed within 24-48h and do not typically delay funeral arrangements. They also do not significantly alter the external appearance of the patient.
- Overnight, a completed autopsy consent form goes in the chart which goes to Medical Records the next morning.
- You should page pathology on-call to alert them to an expected autopsy.
- Funeral home and hospital morgue communicate re: transfer of the deceased.
35. Discharge Planning/E-Prescriptions
- Talk to patient and family on admission to assess living situation, mobility prior to surgery/ hospitalization
- Clarify with chief resident and attending anticipated discharge dates and patient needs so you can pass on information to SW
- Round with social work every day and follow up throughout the day to make sure paperwork is completed
Visiting Nurse Services
- If a patient needs wound care, drain care, IV antibiotics, TPN, Lovenox injections, etc. they will need VNS
- Home Health Aid: Patients have to qualify for this if they need assistance at home. HHAs help with things like cleaning, cooking, etc. They do not perform medical tasks.
- Place an inpatient PT consult through EPIC and then call PT to insure they received the consult. They check messages twice a day so call early. You can also call the BA and ask them to alert PT when they see them on the floor.
- Follow up to see what PT recommends re: no needs vs home PT vs acute rehab vs subacute rehab
Forms to know about and fill out early:
- Inter-institutional Transfer Form (ITT): for patients going to rehab/nursing facility after discharge
- Briggs Form: for patients who need VNS or home PT
- KCI form: for patients who need home wound VAC, takes ~2 days to arrive
- NY State requires prescriptions to be done electronically
- Confirm patient’s pharmacy, let them know you are sending prescriptions electronically there
- If prescribing Dilaudid, call pharmacy to confirm they have tab dose you want (2mg vs 4mg)
- Some pharmacies will not take general DEA that covers residents. Ask them to use the corresponding attending DEA. If they can’t, ask PA to e-prescribe.
Paper Prescriptions: If you do have to print a paper prescription then go to one of the computers on the floor that is designated to print on prescription paper and enter the order “Lab Rad” during discharge orders and make sure to designate ‘normal’ to print. This should cause the printer with prescription paper to print out a blank prescription to allow you to fill it out.
36. Leaving Against Medical Advice
If you are called that a patient wants to leave AMA, IMMEDIATELY go and assess the patient. Determine why they want to leave. Determine current clinical status (eg. Are they recently septic, are they currently delirious, etc). Next, quickly assess their capacity to make the decision to leave the hospital against medical advice.
Capacity consists of:
- Comprehension by the patient of their current clinical status. Do they understand what is currently happening with their medical course?
- Understanding of the risks of leaving against medical advice. Can the patient understand the potential risks of leaving the hospital before medically discharged?
- Free Choice. Determine if the patient is free from coercion or being forced to make the decision to leave AMA.
- Consistent over time. Does the patient’s decision and thought process remain stable over time?
After you have quickly assessed capacity IMMEDIATELY go and notify your chief with the update on their current clinical status and the results of your Capacity evaluation. The chief will direct you from there regarding speaking with the attending and whether a formal Psychiatry Capacity Consult should be called 4STAT.
If the patient is deemed competent to leave AMA then have the patient sign the ‘Unauthorized Departure Release Consent Form’ found in Patient Works. Then discharge the patient as normal with a discharge summary (noting the AMA status), discharge medical reconciliation (noting the AMA status again) with all correct prescriptions, and set up follow up appointments.
- If a patient leaves AMA you are still to provide them medications and follow up appointments as usual. Ref: Institutional Policy ‘Discharge Against Medical Advice (AMA)’ number GPP-206.
37. Consult and Paging Etiquette
Paging at Sinai: 41300 / Paging at Elmhurst: 41908
Enter the extension you are at followed by () and your pager number (i.e. 455333602). When you page someone who may not be in the hospital, only page to an extension starting with 4 so that they can call you back directly.
You can text page on www.amion.com BUT the text pages will not be forwarded. To forward your pager when in the OR or unavailable dial: 41200, your pager ID, 1, 7, covering pager number, #.
DO NOT text-page important information. Remember, if you don’t hear back after a text page, do not assume the person got the message!! (Conversely, always text “ok” to acknowledge that you received a message.) If your question requires a response, speak to the person directly. If nurses text page you about patients, call them back to discuss the issue and remind them that you do not always get text messages immediately (i.e. if you are scrubbed). The same goes for other services following your patients. Do not accept consults via text page! Call the team back and ask them to tell you about the patient over the phone. Alert your chief if this happens.
When calling a consult, ALWAYS CLARIFY with your chief/attending who exactly is to be called. Sometimes you will be directed to call the teaching service for that specialty (i.e. the pulmonary service); other times you will have to directly page a specific private attending, or their covering partner, in that specialty for the consult.
CALLING A CONSULT/ RECEIVING A CONSULT
- Call/Page/Answer the desired consult person/service.
- Speak politely
- Give/Acquire patient information in the following order:
b. Last name, First name
c. Patient current location
d. Specific reason for Consult
e. Callback number or pager
f. Patient story/background
- Thank the consultant for seeing the patient and find out when they expect to see the patient or follow up with you/team or let them know when you expect to see the patient.
Attending license numbers → http://www.health.state.ny.us/ professionals/doctors/conduct/license_lookup.htm
Call schedule for all services → http://www.amion.com
mssurg2018 for surgery
mssm for most non-surgical specialties
msmed for medicine residents
ehc for Elmhurst rotators
Case logs → https://apps.acgme.org/connect/login
Evaluations and work hour logs → http://www.new-innov.com
Levy Library, access to online textbooks, UpToDate → http://icahn.mssm.edu/about-us/services-and- resources/levy-library
MSH intranet page → http://intranet1.mountsinai.org
OR web schedule → http://intranet2.mountsinai.org/ms_schedule
ORWatch → http://www.orwatch.mountsinai.org
Resident homepage → http://www.mssurg.com
SCORE curriculum → http://portal.surgicalcore.org
Shuttle schedule → http://www.mshsshuttle.org
39. Computer Programs
EPIC: Used to view patient data, enter orders, update the list, write daily progress notes. Used at both Sinai and Elmhurst
OR Web Schedule: OR schedule (Access through “Applications-Web-Based” link on main intranet page, use “Future date” function for updated schedules). Use your EPIC ID and password
- The OR schedule can also be accessed on orwatch.mountsinai.org with your Epic login and then from the dropdown menu in the top right, choose “schedule”
- The OR schedule can also be accessed via the Status Board in Epic
PACS: Radiology images. login: ‘GILLEM03’, password: GREENDAY
Patient Works: Used to print forms like consents, progress notes, pre-op checklist. Only prints on specific printers.
40. Dictation Procedures
To dictate a report at Sinai:
From in-house phone: 89889 or if outside: 212.659.9889
Enter facility ID: 89#
Enter your 5-digit dictation code (ie 11111#)
Enter patient's 7-digit medical record number
Enter work type: 1=inpatient, 2=ambulatory
Begin dictating at the tone
3=Rewind & Play
4=End of file & Record
7=Beginning of file & Play
Dictation: 45061 in house or outside: 718.334.5061
- Soarian ID followed by # sign (from Glen)
- Work Type = 32 followed by #
- Patient CSN (next to MRN in EPIC)
- At the tone begin recording
- To note the job #, press 6 at the end. Document the job # in a brief EPIC note, as it may take a week for dictation to appear in the chart
- Press 8 between reports if multiple dictations
Operative dictations must be completed with 24 hours.
41. Shuttle Schedules
Shuttle schedule → http://www.mshsshuttle.org
42. The Glossary
AMA: against medical advice
ALC: Alternate level of care, only at Elmhurst. This means the patient does not need to be seen every day by the team. Used primarily for social admits or completely stable patients awaiting placement.
AOD: Administrator on duty, at Elmhurst. This is person available 24/7 who helps take care of disputes & delays in patient care and must witness telephone consents.
Blue-slip: Call the ER and ask them to notify you when the patient arrives in the ER.
CCU: Cardiac care unit (5E)
CTICU: Cardiothoracic intensive care unit (5C)
FPA: Faculty Practice Associates. All full-time faculty have their clinic/offices in the “FPA” located at 5 E. 98th Street.
HMP: Hospital Medical Practice. The non-teaching medicine services, run by attendings/hospitalists/NPs.
IDP: Implement discharge plan. An order in EPIC that should be written the day before a patient is/may be discharged. Allows patients the chance to appeal their discharge.
IMA: Internal Medicine Associates
LTM: liver transplant monitor, includes chem10 + LFTs
MAR: medicine admitting resident
ME: medical examiner
MICU: Medical intensive care unit (5E)
NSICU: Neurosurgical ICU (Ann8)
PACU: Post anesthesia care unit, where patients go post-op and stay overnight if waiting for a stepdown or ICU bed.
Phase II: Where ambulatory patients at Sinai go after PACU and prior to discharge home. Located on GP2.
Pink-slip: Go to OR/call OR desk to book for an emergency/add on case at Sinai or Elmhurst. As in, “pink slip the appy.” Actual pink piece of paper. At Elmhurst you have to order a ‘case request’ for the procedure.
POMA: PreOp Medical Assessment Form: required for all ASA 3+ nonemergent inpt cases. Page (POMA aka 7662) to complete.
PT: physical therapy
RRT: rapid response team; a critical care attg, fellow, and NP
SAR: Sub-acute rehab (a recommendation from PT)
Social Pool: The medicine service at Elmhurst can distribute patients to other services who are medically ready for discharge but cannot leave for social/placement reasons.
SICU: Surgical ICU (6E)
SNSS: Surgical Nutrition Support Service (Line service/TPN)
SQH: Subcutaneous heparin
Step-down: A 4 bed room with 2 nurses. Level of care between ICU and regular floor beds. Surgical stepdown is on 10E.
Team7000: A code
TCC: Terrance Cardinal Cooke, a nursing home that accepts many otherwise difficult to place patients (dialysis, wound vacs, TPN, etc)
TR: Teaching resident, PGY3 medicine resident on-call for curbsides or consults re: any medical issues, including general medical clearance.
VAT: Vascular Access Team for difficult IVs and long term IV access. p:2827
VNS: Visiting Nurse Service. Patient who are discharged home and need nursing care at home (i.e. wound care, dressings, ostomies, etc).