Updates & Reminders
2022/04/25 Updates
NW FED Spring Social: Please make an effort to join us! Click HERE to RSVP!
Patient Surges at Town Square
Town Square Teledoc Surge Support: Any time you have a volume-surge at Town Square, don’t forget that we have the Teledoc Surge Support process in place! If you are the on-shift physician, make sure you take over the note done during the televisit and do not start a new note. This is triage-independent and the sole goal is to decrease door-doc time and prevent LWOTs. If you would like to be included in the process, let me know. Click HERE to view the process in the “FED Provider Manual”.
Ortho
OTS: Ortho Trauma Surgery: NW is fortunate to now have two ortho traumatologists - Dr. Reddix and Dr. Potter.
for ALL ortho cases (except hand), we just need to the regular ortho on-call and then they will guide us if they can manage or if we should call the Ortho Traumatologist.
Pediatric Ortho Trauma: can call Dr. Potter (NW Ortho Traumatologist) Monday-Friday at 06:00 - 18:00. Otherwise, call the Pediatric Intensivist on the Call Roster and they will guide us if they can accept the patient.
Sepsis
Sepsis: We need to do better with out sepsis compliance. NW has fallen from #1 in all UHS to the bottom ⅓ in rankings on sepsis outcomes. I am working on a dedicated Sepsis section on tips and flow charts.
Lab
Culture Reports & Send-Out Labs: we are all responsible for following up on the culture reports and send-out labs. This is now available within Cerner. The labs will not be printing out reports. The day-shift physician and midlevels should review these at the beginning of each shift and make calls as indicated throughout the day as time permits. Click HERE to view the process.
Add-On Lab Orders: Effective immediately, when ordering additional labs, change the order status to “Add On STAT” instead of STAT.
NOTE: if a patient requests a test that is a send-out such as flu/rsv/covid pcr/respiratory panel, do NOT tell them to go to the main ED so they can get it faster. Simply inform them that we can do the test, but will have to either wait the several hours for the result or we can call them over the next 48 hours. I almost never order any of these tests as it will not change my management.
Medications
Lidocaine/Bupivicaine: We are no longer using the multi dose vials, but are moving to 10-cc single-dose vials. Please do not ‘save’ any vials after using them.
SGLT2 Inhibitors: NW has added two Sodium-Glucose Cotransporter Type 2 Inhibitors - Empagliflozin (Jardiance) & Dapagliflozin (Farxiga) - to the formulary. Click HERE to view the P&T Committees Executive Summary regarding these medications.
IMPORTANT WARNING: EUGLYCEMIC DKA: one of the subtle adverse events that can occur with SGLT2-i drugs is EUGLYCEMIC DKA. This requires a high degree of suspicion to catch, so pay attention to the CMP, anion gap, and bicarbonate levels - DESPITE a normal glucose level.
Policy Updates
NWTHS Provider Orientation Manual: the orientation manual that Delynn gives to every physician during on-boarding and training is now uploaded to the “Policies | Procedures | Processes” section of the newsletter. Click HERE to view
NWTHS Bylaws and General Rules & Regulations: these have been updated and are now available to review in the “Policies | Procedures | Processes” section of the newsletter.
2022/03/11 General Neurology Telehealth Consults
General Neurology Telehealth Consults are now available. The process is detailed in the “Provider Operation Manual”.
2022/03/08 Updates: FED Ambulance; Transfers to the Main ED; Covid19 Testing
FED Ambulance
I am excited that we now have our own FED-dedicated ambulance! We went live on March 1, and they will be working every day from 11a-11p. Their primary objective is transporting patients from the FED to the main campus, but can also be helping hands while not transporting. They will be based at GST, but can float to TSQ if they are needed.
FED-to-MainED Transfers
After discussing with Dr. Belaval and the main ED physicians, we have come to an understanding on transferring patients to the main ED.
Going forward, these will now be treated as a “Patient Hand-off” - similar to shift-change hand-offs - and the main ED physician will assume complete care for that patient. When we need to transfer FED-mainED, check the “ED Call Roster” and make sure you call and speak directly with the accepting physician at the main ED who has been on-shift the least amount of time, and give a complete verbal check-out. Also make sure to log that phone call in the “Consults” section under “Impression and Plan” in your note and that your note is completely done. The main ED physician will assume care and add an “Addendum” to the chart.
Dr. Belaval has ensured the main ED physicians are on-board, so there should be no push-back on this. Once the patient has left the FED and arrived at the Main ED, they are no longer our patient, but are then under the care of the main ED physician.
CoVID19 Testing
Starting today, we no longer need to test every admission patient for CoVID19. We only need to test patients with exposure or for respiratory type illnesses, as well as anyone going for a procedure. For patients with pyelonephritis, cellulitis, etc, we do not need to test them.
2022/02/04 Resume Outpatient CoVID19 Testing
NW resumed outpatient CoVID19 rapid antigen testing today.
2022/01/31 Ear Cleaning Kit
Ear Cleaning Kit
I bought ear cleaning kits for both FEDs and stocked them in the Pyxis under the title “Ear Cleaning Kit”. You can pull it yourself, or ask the nurse to pull it.
Preparation: use LUKEWARM water to mix:
1 part hydrogen peroxide or white vinegar
4 parts water
After use: Make sure you CLEAN IT with a purple-top wipe or Clorox wipe. Empty the bottle and place back in the kit-box. Return the kit to the Pyxis.
2022/01/27 Managing Patient Complaints and Grievances: Physician and Hospital Perspectives
As patient volumes have bounded back and hospitals are facing staffing shortages and long patient throughput times, overall patient complaints—and correlating risk—are on the rise. To minimize your risk exposure and enhance our overall commitment to excellence in patient experience, we are excited to bring you a live webinar prepared exclusively for APP.
"Managing Patient Complaints and Grievances: Physician and Hospital Perspectives" will be presented by attorneys John Floyd, Jr., Partner, and Lynn Audie, Partner, both from Wicker Smith, a firm that has focused on keeping healthcare providers apprised of legal and regulatory changes as well as how to mitigate potential risks for more than six decades. The webinar will focus on understanding the physician and hospital process for managing patient complaints, grievances, and family meetings. John and Lynn will provide real scenarios and risk mitigation tips.
Please save the date on your calendar and join us for this informative presentation
Wednesday March 9, 2022 10am - 11am CST.
Join on your computer or mobile app
Or call in (audio only): +1 629-216-4519,,699572795#
Phone Conference ID: 699 572 795#
2022/01/23 Down Codes
Overall, we are doing a very good job documenting; however, we still have some areas to improve - mostly with EKG and PFSH documentation. By not documenting appropriately, we are not getting compensated appropriately for the excellent care we provide our patients.
We had a total of 40 down-codes for November (most recent data) with 19 for no EKG documentation and 17 for inadequate PFSH (past family and social history). These charts have already went through billing, so nothing to correct.
If you don’t see an EKG section, you can add it by right-clicking on Medical Decision Making and then Insert Sentence, where you can select EKG.
2022/01/22 New Lab Tubes
We are switching labs collection tubes - the benefits are decreased hemolyses and decreased rejection rates, as well as smaller sample sizes.
COVID Tests Back In Stock
NW received over 900 CoVID-19 antigen tests yesterday evening, so we can restart testing for FED patients with antigen tests. We are NOT doing any ‘outpatient walk-in’ testing. Just for actual FED patients.
NW does not have any single PCR (Covid) or quad-PCR (Covid, Flu, RSV).
NW does have plenty of the 20-panel Respiratory PCR, and all machines are currently working, so results are typically within 24-hrs. However, the Respiratory panel literally costs $2,000, so I strongly advise caution when considering the respiratory panel. If it will affect your management for the patient, then go ahead. However, if it is for an otherwise healthy patient in no distress and not requiring an antibody infusion, then I would strongly consider diagnosing presumptively based on symptoms and exposure and providing the COVID19 Work/School Note with the "presumptive positive” check-box checked.
Admissions: continue current process:
if admitting for non-respiratory problem and have a negative antigen at the FED, then that’s fine.
if admitting for respiratory issue, or have a high-suspicion high-risk patient and have a negative antigen, then can order the respiratory panel. Lab will the main lab to rush the panel testing. You can still admit the patient as a PUI (patient under investigation).
Blood Product Shortage
Due to severe national blood product shortage, UHS is changing how to order blood products in Cerner. Click Here to View Handout
SHORTAGE: Antibody Infusions
The Amarillo Regional Infusion Center is currently out-of-stock of all antibody infusions for COVID19, with their next expected shipment not until Wednesday, Jan 12. NW does not have any infusions either.
EKG Date & Time Stamp
EKG
We must date and time and sign the EKG when we read it. Andrea has a Date & Time Stamp now for each FED that the nurses will be stamping when they pull the EKG.
PCR Test Shortage
As of today, 01/08/2022, lab informed me that NW only has 40 COVID PCR tests left. Additionally, they only have a single respiratory panel machine in operation and are currently 5 days back-logged for these.
Consequently, we need to cease ordering any COVID/Flu/RSV/Respiratory Panel PCRs. We only need to order COVID antigens at this time for patient that will be discharged. I will update this again once more things change.
For admissions, the process is the same as before - if covid antigen is negative, but have a high-risk, high-suspicion patient, then can order the PCR. Otherwise, the rapid antigen is sufficient for admissions.
Admission Call Overload
Call Overload!
When calling the hospitalist for admission, please only call once. If no answer, this means they are seeing a patient or on another call. Simply leave a message, and refrain from calling back-to-back.
Additionally, the hospitalists informed me that their caller ID shows ‘unknown’ when we call from GST - I have notified IT, so hopefully this gets fixed soon.
AMA
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. ___.
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.
FED Registration Flow
Watch the video below regarding the new FED Registration Flow we will be implementing on January 3, 2022. We have trialed this and it works very well and tremendously helps the flow and communication between registration clerks with nurses and physicians. Below is the process:
There will now be clipboards on the wall, under the light switch, in every room. These clipboards hold the form that registration needs to get the patient registered. When a patient is brought to the room, the tech/nurse/physician will hand the clipboard to the patient, instructing them to fill it out while they are waiting. This will cut out extra trips by the registration clerk just to hand the patient the form.
When the physician has seen the patient, they will click the drop-down under “BA (Bed Assignment)” column on the tracking board and select “MD Evaluating”.
This signals the registration clerk that they can now go see the patient to discuss billing and payment collection.
When the registration clerk has completed everything they need with the patient, they will click the drop-down under “BA (Bed Assignment)” column on the tracking board and select “None” - which makes that entry blank again.
This signals the nurse that registration is done with the patient.
When a patient is discharged and the house is on the board, nursing must wait until “MD Eval” has been removed by the registration clerk before the nurse can send the patient out.
It will take some getting used to for this process, but we have trialed it with different physicians, nurses, and registration clerks, and it has been universally praised for cutting down on extra trips by registration, cutting out the nurses having to ask registration if they are done, and improving our collections as well.