I forget…what did that email say? oh yeah, its at

Archive for the ‘Elmhurst’ Category

EHC Cardiac Room Presentations

Reminder to attendings/residents in Critical Care area:

When cases are presented to you from triage

1) Cardiac Room (CR) attending must see/examine patient if the patient is to be sent to the team
2) CR attending signs the EKG (if one is available) before “refusing patient”
3) RN represents patient to the Team (A/B) attending
4) A/B attending ALSO signs the EKG (when one is available) before scanning into HMED
5) A/B attending personally speaks to the CR attending if there is a disagreement about where is safest for patient to be evaluated.

PGY-4 (Pre-attendings) residents:

1)Cardiac room resident can accept patient but cannot be the only one to refuse them.
2) Team senior resident can evaluate these patients and, if the resident has a concern, discuss the case with the team attending.
3) The team attending discusses the case with the CR attending when there is a disagreement.

Phil (Fairweather)

Written by phil

December 26th, 2012 at 5:23 pm

EHC Direct Admissions

Ms. Suri has asked me to remind everyone that the ED staff should not accept direct admissions from the clinics – even when there are no “available beds” on the floors. She assures us that the bed coordinator (4-6505) is always able to make arrangements for these patients. These patients shouldn’t have to board in the ED or come to the ED “just for blood draws”. Please advise those providers to refer the patients to the TR and to the bed coordinator.
Thank you,

Phil (Fairweather)

Written by phil

December 26th, 2012 at 5:21 pm

Posted in Admitting,Elmhurst

EHC Facial Trauma

The service covering facial trauma (ENT, Plastic Surgery or OMFS) covers ED calls from 7 am to 7 am and is responsible for the patient based on the patient’s registration time not the time the consultant is called. Thanks,

Phil (Fairweather)

Written by phil

December 26th, 2012 at 5:20 pm

Posted in Consults,Elmhurst

UTI resistance at Elmhurst

There has been increasing resistance to Cipro for urine cultures sent from Elmhurst ED. Cephalexin and Macrobid currently have lower resistance rate. Bactrim continues to have high resistance for treatment of UTI.

Sheree Givre, MD, FACEP
Associate Director
Department of Emergency Medicine
Queens SART, Medical Director

Written by phil

November 29th, 2012 at 7:53 pm

Posted in Antibiotics,Elmhurst

Elmhurst DNR Forms


HHC has significantly simplified the DNR/DNI process (I know, I can’t believe it either).

Here is the deal:

Pt is making his or her own decisions and wants to be DNR and/or DNI:
Have pt sign a pink DNR form and if he or she wants DNI, a refusal of treat form
this is unchanged

For everything else, including proxy, surrogate, DNR, DNI, withdrawal of care you just need to use one form
It is in the cardiac room form rack or here:

You need to identify the family member who is the proxy or surrogate on the form, but he or she doesn’t need to sign (huge win for pall care).

Email me if you have any questions


Written by phil

July 8th, 2012 at 2:50 pm

Posted in Elmhurst,Policy

Elmhurst Bellevue Hospital Transfers

Dear Colleagues,

We just finished a conference call with Bellevue Hospital Administration (ED, Admitting and Transfer Office) regarding Riker’s Island inmate transfers. The following is the agreement which is EFFECTIVE IMMEDIATELY:

1) For all transfers and 24 hours/day: call the transfer office at 212-562-6458 or 646-772-2415
2) Give the patient’s name, DOB, Diagnosis, Presumed Accepting Service and our attending’s cordless number (DO NOT GIVE THE GENERAL ED NUMBER). This ensures direct/expedited contact with us.

The transfer office will locate an accepting attending. That accepting attending is expected to call us for report and call the transfer office back when the contact with us is made. That attending cannot refuse to take the patient if we determine the patient is a RI prisoner and is stable for transfer.

3) They have 30 minutes to call us for report
4) If no call back is received within 30 minutes call and transfer the patient to the ED the way we have done it in the past and inform them that the above has failed.

**No need to call Dr. Bud Heyman at any time.**



Stu and I just had another conference call with the Bellevue ED medical director, transfer services director and medical inpatient hospitalist service director regarding transfers. The following was agreed to:

1) We make one telephone call to the transfer office to inform them of the transfer
2) Give them the cordless # of our attending so they can make direct contact with our staff
3) The transfer office is responsible for locating the inpatient service physician at Bellevue and will give their doctor the number to call us
4) We should get a call back within 30 minutes

***If there are no inpatient beds the patient will be accepted by the Bellevue ED (call the ED)
###There is no expectation that the patient waits in our ED for 6 hours until a bed comes available
@@@They have at times had difficulty getting in touch with our attending so please make sure we are available to receive the call from their doctors

Please continue to send me and Stu emails with details about the difficulty you have with these cases. Please get names of people in the transfer office who you have disagreements with regarding the above agreement.


Written by reuben

July 4th, 2012 at 3:00 am

Posted in Elmhurst

These guidelines are to be used in determining the most appropriate service to which a patient shall be admitted. Clinical circumstances may, on occasion, require the responsible ED attending to make an admission decision that overrides these guidelines.

Patients with the following primary diagnoses are to be admitted to the Surgery Service.

• Lower GI Bleeds
• Pancreatitis with gallstones or if the patient requires an lCU admission.
• Diverticulitis (with or without abscess)
• Appendicitis
• Bowel obstruction (large or small bowel)
• Bowel perforation.
• Cholecystitis
• Cholangitits / choledocholithiasis
• Liver abscess
• Post-operative complication (including DVT) within 30 days of surgery goes to service that operated on the patient.
• Animal bites (except to upper extremity distal to elbow, which goes to service covering hand)
• Frostbite / burns (except to upper extremity distal to elbow, which goes to service covering hand)
• Acutely Incarcerated Hernia
• Spontaneous primary pneumothorax. (This excludes those patients with
underlying pulmonary disease as the probable cause ofthe pneumothorax, such as
COPD, TB, PCP or other HIV-related disease)
• Perirectal abscess
• Cellulitis to be admitted on an alternating basis with medicine (except for upper
extremity cellulitis distal to the elbow, which gets admitted to the service covering hand)

Admissions Criteria Regarding Trauma Patients

Patients with traumatic injury requiring admission are to be admitted as follows: Red Trauma: Surgery (Trauma Service).*
Traumas other than Red Traumas (Yellow Traumas and non-activated traumas)
• More than one organ system injury: Trauma Service.
• Syncope with significant trauma**: Trauma Service.
• Syncope with isolated intracranial bleed**: Neurosurgery Service or Trauma
• Isolated facial trauma not requiring ICU: Service covering facial trauma.
• Isolated genitourinary trauma: Trauma Service
• Isolated upper extremity fracture: Orthopedic Service (Social goes to Medicine)
• Isolated lower extremity fracture: Orthopedic Service.
• Pelvic Fracture: Hemodynamically unstable and / or accompanied by significant
blood loss: Trauma Service. Otherwise, Orthopedic Service.
• Altered mental status (or post-concussive syndrome) after mechanism of trauma except for syncope (i.e. pedestrian struck, assault, motor vehicle crash): Trauma
service, even if trauma work up is negative.
• Rib fractures: Trauma Service
• Isolated vertebral fractures after trauma: Service covering spine.
* These patients may be discharged ONLY IF the ED attending agrees and the senior surgical resident and / or surgical attending writes a progress note that can be scanned into HMED to document this decision. They should not be downgraded to Yellow Trauma prior to discharge.
** Syncope patients with a traumatic injury should only be admitted to Medicine if they are suspected to be at risk of serious cardiac dysrhythmia or cardiac ischemia as determined the ED attending.

Trauma and General Surgey Admission Guidelines

Written by reuben

April 3rd, 2012 at 6:11 pm

Posted in Elmhurst,Surgery

Elmhurst Tonopen

I believe most of us have, at one time or another, noticed that we cannot get the Tonopen to work. Well, apparently it does.

The Biomed rep went through the calibration process with me, to be done each time you turn it on:

1. Press the main button and hold it down for 15 seconds, you will hear a beeping sound.

2. Keep holding down the button, the screen will then say “Dn” which means orient the Tono-Pen downwards, for approximately 15 seconds while continuing to hold down the button.

3. You will then see the screen say “Up”, which means orient the Tono-Pen upwards for 15 more seconds while continuing to hold down the button.

Essentially, you will be holding down the button throughout the entire process and will be prompted by instructions on the digital screen.

After this process is complete, the Tono-Pen should work. If not, call Biomed.

The Tono-Pen is kept in Dr. Kessler’s office, in the cabinet above his desk.

You can ask Security to get access to it at night in cases of emergency.


Written by reuben

March 15th, 2012 at 10:58 pm

Elmhurst Reminders

A few Elmhurst-related reminders to keep in mind…

1) Discharge instructions:

– please select appropriate dc instructions in the appropriate language
– the instructions can be modified and should be modified to reflect the specifics of your patient
– ALL instructions should include 1) Return to ED if you develop worsening symptoms etc. 2) When to follow up at PMD
– If available provide some diagnosis-related reading material.
– Do your best to provide culture/language-sensitive verbal discharge instructions – (use your discretion – the more potentially dangerous the diseases is – the better understanding a patient should have)


– We may lose the option to use the template – if used inappropriately
– if you are using a template, modify it to meet the specific patient, and delete the part of the exam that you are not performing.
– Write a progress note – it shows quality care was provided
– Write an assessment and plan – its the classy thing to do, and it shows you have used your 200 000$ brain cells for a good cause
– Remember to complete as many elements as possible: including social history…there are a number of other elements – try your best to fill them out, but there is a tab for non-contributory.

4)ID Clinic:

Follow up for sexual assault victims at ID clinic should be 2 to 3 days later (NOT THE NEXT DAY). This gives the patients time to deal with other legal and personal issues they need to follow up with. Also, ID clinic wants to observe any side affects from the HIV medications which usually doesn’t take effect until 24 to 48 hours later. In addition, ID clinic appointments are available Monday thru Friday 9:00 a.m or 9:30 a.m which can be made by the ED clerk. If patients show up at later times it interferes with the scheduled ID clinic appointments already made and it makes it harder to get the PEP medications from pharmacy.

5) AMA:

IF patients are sent home AMA, remember that they are still our responsibility. We must ensure that they receive the best care possible – medications, and follow up. Please document that you pleaded with them to stay and discussed fully the need for admission and that they are at risk for disability and/or death by leaving AMA.

6) Riker’s Island discharges:

Print the Riker’s Island discharge summary and send it with the patient/CO.

Approximately 10% of RI patients who are discharged back to RI are done so without a discharge summary.

A percentage of them are sent back to EHC for further eval as a result.

Remember to print the RI Chart when discharging a RI patient ( either back to RI, or transfer to another hospital) and put them in an envelope with the discharge papers. Hand the envelope to the RI Officers to take back to RI.

To print the RI Chart:
1) Go to “Chart Review”
2) Top left of the screen: Pull down to Rikers Island Chart
3) Bottom right screen “print”

NB: Don’t write assessment and plan information in the “Progress Note” section. This is not printed in the RI version of the chart. Write it in the “Assessment and Plan” section under the Dispo tab.
To print a consult to go back to the RI MD’s or Bellevue in “Chart Review” at the bottom right click “advanced print” then “scanned documents” then “consults” then ” print”.
Medications and follow up instructions for RI MD’s can be bolded to emphasize: highlight then “control B”.

7) Discharge Diagnosis:

– PGY1 & PGY 2 should discuss the discharge diagnosis with the Attendings or PGY4s (its not classy to send a patient out on the streets in Queens with EHC paperwork that says AMS)

8) Consultants:

If the service has a wireless phone, call the phone.If the phone is not answered or not turned on then call the 41111 operator. All other services call 41111. Do not call clinics directly.If the phone is not answered or not turned on then call the 41111 operator. All other services call 41111. Do not call clinics directly.You need to give them – Patient’s name and medical record #. Your name and wireless number or extension (fast track/cardiac/trauma room) The Attending’s nameDocument in HMED the consultation request.If the 4111 operator doesn’t get a response from the consult in 5 mins they will re-page that person.After an additional 5 minutes if there is no response they will page the chief resident.If there is no response from the chief resident in 5 minutes they will page the Attending. If the Attending is called the communication should be Attending to Attending.After an additional 5 minutes if there is no response they will page the chief resident.The consult is expected to arrive in ED within 30 mins. If they cannot arrive within 30 minutes this should be communicated to you, If they cannot come within 60 mins they should have a back up plan.After arrival the consult should evaluate and speak to senior etc., within 45 mins. They should give you a verbal consult and document within 45 mins. (In the future we want all services to document in QMED).

9) If possible, avoid presentations to attendings/seniors with less than 40 minutes to the end of their shifts.

10) Paisa: 718-478-7700
– we have an agreement with the car-service
– more info is on / policies

11) If you have any problems with Elmhurst, please let me know…
– examples are: a particular CT tech consistently giving you a hard time, a particular issue with a nurse, issues with a consultant…
– it always helps to have names, dates and MRNs
– you can either address it to me directly, talk to one of your seniors, or if you’d like to be completely anonymous…there is a feedback for on the mainpage of…

12. Blood Orders
– Reminder that you can now place all blood orders in HMED
– This includes types AND blood products
–> You do NOT need to use quadramed anymore!

Also, remember that:
– Patients getting transfused need 2 samples total, and an old specimen counts as one.
– Patients new to Elmhurst need 2 fresh samples. Everyone needs at least 1 fresh sample.
– You can’t draw 2 types at the same time/site
– If you draw a type, you must LABEL and SIGN the tube

This information will also be posted in a google doc ‘Mount Sinai / Elmhurst Rotation Guide’ as well as several other resources – if it hasn’t been shared with you…let me know.

Daniel Lakoff MD

Written by reuben

February 16th, 2012 at 4:47 am

Posted in Elmhurst

A plea re: hypothermia


I know this is beating a dead horse, but some of us are still cooling patients that are inappropriate and will not benefit from the therapy. The other day I walked in to a patient being hooked up to arctic sun pads that was 83 y/o, with dementia, and possible sepsis. We discontinued hypothermia, signed a FHCDA and got palliative care involved. The patient went up to the floor and was terminally extubated with all of the family present.

This case brings up the need to reiterate the following:

Please don’t cool patients with dementia or sig. cognitive decline.
Please don’t cool patients who can’t manage their ADLs independently
Please don’t cool patients with poor baseline status
Please don’t cool patients with a significant downtime unless they were found in v-fib/vtach
The default is not to cool patients >=80 y/o. I have left this as relative b/c if you have an 80y/o who looks 50 with none of the above, you may want to cool, but the DEFAULT is not to cool these patients
Each use of the arctic sun costs about $2000 in pads; in addition if the ICU continues cooling, the pt will be in the ICU for 5-7 days unnecessarily.

Now let’s say you just can’t handle making this decision. You can’t handle withholding care from ANYONE; it just isn’t in your practice pattern. You have some recourse:

Email Me; if I am around I will call you back immediately and I am happy to take the burden of withholding this therapy
If it is a borderline case, use ICED SALINE and the BLANKETROL machine instead of the arctic sun. If the ICU decides to continue, then they can switch over to arctic sun. If they don’t you have only wasted $100 instead of $2000
Please send me your thoughts and comments.


Written by reuben

January 27th, 2012 at 9:10 pm

Posted in Elmhurst,Hypothermia

These patients should always be admitted to the Surgical Service

Dear Colleagues,


With input from the Department of Surgery we are in the process of revising the earlier admission guidelines.  Going forward please admit these patients to the Surgical Service NOT the Medical Service:


Diverticulitis with and without abscess


Cholangitits (NOT MEDICINE)

choledocholithiasis (NOT MEDICINE)

Liver abscess

Post-operative complication within 30 days of surgery including DVT (go to the service that operated on the patient)

Spontaneoous pneumothorax

Pancreatitis (except alcohol induced)





Written by reuben

December 22nd, 2011 at 7:54 pm

Posted in Elmhurst

Patients who have an initial evaluation by NP/PA/Attending

ED Attendings:


Remember to use the “Initial Evaluation” status button on the bottom tool bar when you speak to patients after reviewing their EKGs, order medications or have other patient encounters that satisfies you that a patient is stable for the team or for fast track evaluation.  This is especially important for our intoxicated patients who are in the department for 8 to 12 hours.  It’ll establish your early assessment of them and help to continue to drive down our “time to initial evaluation”.  Our median time to initial evaluation has decreased 25% (to about 30 minutes) and we have shaved about 10 minutes off of our total throughput time for discharged patients.  Remember that when you click on the “initial evaluation” button your name appears in the right column and the “Needs Exam” button changes to blue.  You can clear your name by transferring to “blank”.


The progress note macros are useful to quickly document this encounter and list your interventions.


Please also be aware that patients who have an initial evaluation by a PA, NP or attending (with or without labs/radiographs/medications) and then leave before a team provider is assigned  have left “BEFORE DISPOSITION” not “LEFT WITHOUT BEING SEEN”.  This initial evaluation at triage or on the team constitutes a meaningful assessment of the patient’s stability and qualifies as a screening exam.  Attendings, PA and NP are qualified to provide this screening evaluation but residents are not.  Therefore, if the senior resident does the initial evaluation and the patient is not later seen by a NP, PA or attending we will continue to document the disposition as LWBS.




Written by reuben

December 22nd, 2011 at 6:51 pm

Posted in Elmhurst

HIV Testing at Elmhurst ED

HIV testing the ED

We talked about this yesterday at our attending meeting and I know there’ll be more to discuss. If you’ve worked this week you’ve probably noticed the HIV icons on the tracking board.

In order to adjust to a hospital funding change and start complying with a new New York State regulation requiring 24/7 HIV offer/testing in ED we had to change how we provide this service. The new funding source has the specific expectation of an expanded testing program throughout the hospital. We are not ready to offer testing 24/7 but will now have 16 hours of additional testing on the weekend. Unfortunately we will no longer have HIV counselors weekday evenings (between 4 and 11 PM). Instead a phlebotomist will staff these hours and can order and enter results in QMED but cannot counsel patients. An important aspect of the change for us then is, during these hours (weekdays 4 to 11pm), a doctor/PA/NP has to give the patient the test result and document the conversation in HMED.

Here is how it should work:

1 ONLY AMBULATORY patients get an HIV fact-sheet at mini-registration (“FORM A”)

2 At triage the patient is asked if they want free HIV test:
a. “YES” response gets the new icon with a check mark in the center
b. “NO” response gets the icon with a “minus” sign
c. “Strike through” (not applicable) goes to patients who have been recently tested, are positive or are arriving by ambulance

3 Consent is signed along with general consent form at registration.

4 Hours of testing:

a. Monday to Friday 9 AM to 4 PM and Saturday/Sunday 11 AM to 7 PM: HIV counselor performs test, gives result and counsels patient. They also document post-test counseling in HMED.

b. ***Monday to Friday 4 PM to 11 PM: Phlebotomist performs the test and enters result into QMED but cannot give result to patient, counsel patient or document in HMED.

i. Tech will give result to Resident/PA/NP if one is assigned
ii. Tech gives result to attending if no Resident/PA/NP is assigned

5 Post-test counseling:
a. NEGATIVE result (>99%):
i. Inform the patient
ii. PRN follow up

b. POSITIVE result (<<1%):
i. Counsel patient
ii. Page ID fellow and give fellow the patient’s contact information
iii. Advise patient to return the next morning, with the test result sheet, to speak to the counselor and set up ID clinic follow up
iv. If the patient is admitted the in-patient team will contact ID/HIV counselors

6 Document counseling
a. HMED progress notes have pre-set statements that are self explanatory
b. HIV counselor document in a different section of the HMED chart

If you have any questions please call me 917-533-2660.


Courtesy of Scott Goldberg:

There is some reasonable information on the CDC website. However, the material can be vague and refers back to "following your institutions guidelines."

The CDC RESPECT-2 site ( has some excellent information and scripts on what to do with a NEGATIVE result, and on how to counsel patients PRIOR to the test. The script for counseling a patient on a HIV Positive Script. It is useful, but limited.

There is also some useful information on positive test result counseling here: It includes information including the sensitivities and specificities of our rapid tests (appendix), allowing an educated discussion about what this test means with our patients.

Also, remember that at Sinai any positive should get a call to social work for counseling 24/7.


Written by reuben

December 8th, 2011 at 7:29 pm

Posted in Elmhurst,HIV

Elmhurst NP Role

Please see attached details.

Some of the KEY POINTS:
1) Must be present at morning and evening rounds
2) Must participate in morning report
3) Perform advanced triage function on the A/B teams
4) Are to be assigned straight forward cases when there are no evaluation to be done
5) When they are leaving on break they are to tell you when the will return, how many patients are pending initial evaluation and let you know the status of the patients they are seeing primarily.
6) Tell you when they have returned from break
7) Assist in the Fast Track in the morning if there are no patients to be seen on A/B. Those cases should be presented to the A/B team attending (not the cardiac/trauma attending).
8) Assist in FT if, during the day, that attending request assistance (through the charge nurse). This should be for a short (about 1 hour) periods.

Nurse Practitioner Revised Role_2011

Written by reuben

November 18th, 2011 at 8:10 pm

Posted in Elmhurst

EHC Optho Cases

Optho residents want to be contacted for all patients that are referred to their clinic that aren’t booked in the computer. In the past on occasion we have given a discharge sheet with a f/u appt “according to/as per Dr. Eye Resident on call’s name” without that resident having been contacted. This was typically given for patients that they see the next day in clinic, i.e. corneal abrasions.
According to their residency site director the optho “residents are happy to see patients after hours.” So please call them. They feel a liability if their name is used without seeing the patient.

Please forward this to PAs and residents.

Sheree Givre

Written by reuben

November 14th, 2011 at 6:57 pm

HHC Policy on Taking Pictures of Patients

Written by reuben

October 5th, 2011 at 10:48 pm

Elmhurst: Clarification of SICU admission policies

At a meeting today with the heads of General Surgery, Trauma Surgery, SICU, Neurology and Jim Harris the following was agreed to and will be added to the ICU admission policy shortly:

1) All RED and YELLOW trauma patients needing ICU care MUST be admitted to the SICU with the Trauma Surgery as the admitting service.

That means patients with isolated neuro-surgical or orthopedic injuries, for example, who would have in the past gone to the SICU on the NS or ortho service should now be admitted to the to the SICU on the trauma service. Understand that this is new and the surgical residents may not know of this policy for a few days.

2) Critical surgical patients needing SICU care should be admitted to the unit whether or not the attending or fellow in the unit has discussed the plan of care with the admitting surgical team.

That means, after you have come to an agreement with the admitting team or you decide it’s best for the patient that they are admitted to the unit, you don’t have to wait for the unit fellow/attending to track down the chief resident of Surgery, ENT, Orthopedics, etc. before admitting the patient and sending them upstairs. If there is a bed available the ED nurse staff should give report and get them upstairs ASAP.

3) Neurology cases needing an ICU should first be admitted to the RICU with neurology as a consultant. If the RICU is full then they should be admitted to the SICU under the neurology service as the primary team.

That means neurology patients managed in the SICU the same way that current surgical patients are managed.

4) NO more waiting in the ED for repeat CT at “6 hours” for patients with traumatic intra-craninal hemorrhages. They must all be admitted to neurosurgery and sent to the unit or step-down.


Written by reuben

August 12th, 2011 at 1:53 am

Posted in Elmhurst

Elmhurst Consults: 4-1111

Dear Colleagues,

We are trying to document how long it takes consultants to (1) respond to pages (2) come to evaluate patients in the ED and (3) submit their assessments. The next Rapid Improvement Event (RIE) begins January 24th and will deal with the issue of consultation delays. Before we start though we need to know the baseline times. After the first Consultation RIE, about 1 1/2 year ago, some services got cordless telephones which helped us contact them directly but prolonged waits continue. So, for the next couple of weeks the telecommunication department has assigned an operator to help us gather this information:

The Plan:

1) Call 4-1111 for all consults
2) Give the operator the pt’s name, MR#, your name, your phone number (NOT 3054) and consultant needed
3) She will call/page the service and connect them to you
4) Speak to consultant
5) Consultant calls the operator when they arrive in the ED from the RED PHONE on the wall in the A Area’s Nursing Station
6) We call back operator when consult is completed ( defined as: when the consultant’s input permits you to make a disposition or diagnostic decision)

Please help us with this effort because there are no easy ways of getting this information and we do better if we can quantify the problem more exactly.


Written by reuben

January 11th, 2011 at 10:28 pm

Posted in Elmhurst

EHC ED Admission Guidelines

with one comment

Admission Criteria for A7 – NP, non-teaching service

This unit is for “obs” type patients who are expected to have 0-1 clinical decision points in their inpatient care and a brief stay.

Patients appropriate for the unit include:

Low – Intermediate risk chest pain with negative enzymes
Minor Cellulitis
Uncomplicated Pyelonephritis
Simple cases which require little clinical evaluation or intervention

The unit should not get any:

Social Admissions
Patients with active psych problems
Patients who may have a placement issue
Prisoners or restraints
Patients in or at very high risk of withdrawal
Patients with complicated medical problems
Patients requiring active management for secondary medical issues (eg. diabetes is ok but hyperglycemia is not)

Suggested Indications for A4/CCA:

All downgrades require attending approval

ALL patients on continuous drip medications EXCEPT for heparin, nexium, acetadote (NAC) and octreotide MUST go to A4 or an ICU (nursing)
Patients requiring FSBS Q1-2 hours ongoing (nursing)
Patients requiring Q1-2 hour neuro checks or VS checks (nursing)
UGIB – melena or unstable VS
Respiratory Support – intubated patients, patients requiring Bipap proximate to admission or patient with tenuous respiratory status
Severe Etoh withdrawal. (DT’s will be triaged to the ICU at the discretion of the ED attending)
Medicine subspecialty request – GI, Renal, Cardiology, Pulmonary, etc.
Selected overdose patients not going to the ICU – after discussion with poisons or toxicology
Hemodynamic instability not going to the ICU
Potential ICU patients judged stable for A4
At the discretion of the ED attending

Patients that generally should not go to A4:

Low-intermediate clinical suspicion patients with trop <0.5
Patients who had a single lactate >4 which normalized and pt otherwise does not meet above criteria

Patients not appropriate for A4:

Patients with an a-line (nursing) must to go an ICU
Actively dying patients with DNR/DNI not otherwise meeting any of the above criteria should go to a regular floor bed

Written by reuben

December 21st, 2010 at 12:10 am

Posted in Elmhurst

Withholding Life Sustaining Treatments in the ED at EHC

Hi folks,

As some of you may know, the recently passed Family Health Care Decision Act allows the withholding and withdrawing of life sustaining treatments in patients who lack capacity, even in the absence of a health care proxy.

This is an enormous step forward for palliative care.

However, the procedure to do this is rigorous and exacting. I have gone through HHC’s 30 page policy and I have created a 3 page summary. It is absolutely critical that we follow all of the steps completely. If we half-ass this, I am sure there will be greater administration involvement. Once that happens, it becomes more difficult to give our patients the palliative care they deserve. Please, please comply with HHC’s policy.


Withholding Life Sustaining Treatments under FHCDA

Question 1- Does the patient have capacity to make the decision on the particular life sustaining therapy?

An attending physician must make the initial determination that the patient lacks decision-making capacity.
The note should include language similar to: I have determined, to a reasonable degree of medical certainty, that the patient lacks the ability to understand and appreciate the nature and consequences of proposed health care, including the benefits and risks of and alternatives to proposed health care, and lacks the capacity to reach an informed decision.

A concurring attending must make the same determination and document it in the chart as well.

If mental illness is the cause of the lack of capacity, one of the two attendings must be BC/BE in Psych or Neurology.
If mental retardation or developmental delay is the cause of the lack of capacity, call risk management to get involved.
If the patient has any ability to comprehend, you must tell them of the decision that he or she lacks capacity. If the patient objects to the determination of lack of capacity, call risk management and do not continue.

Question 2 – Did the Patient State His or Her Wishes Previously?

Statements that are acceptable for this purpose are:
A Living will
Written statement regarding their wishes
Prior medical orders pertaining to the particular life sustaining treatment (DNR or DNI signed at the same.) Document the nature of these prior statements, and if possible include a copy in the chart. If the patient stated their wishes in one of the above forms, the attending can honor them. If the patient did not state their wishes, then a surrogate will make the decisions regarding life sustaining treatment.

Notify the surrogate (if one is available) of the prior statement of wishes, if the surrogate objects, call risk management.

Question 3- Is there a surrogate who is reasonably available, competent, and willing to serve?

Search for one person from the following list who is reasonably available, willing and competent to serve as surrogate: (The list goes from highest to lowest priority class)
1. A guardian authorized to decide about health care pursuant to Mental Hygiene Law (Call risk management before making any decisions using a guardian)
2. Spouse, if not legally separated from the patient, or a domestic partner;
3. A son or daughter eighteen years of age or older;
4. A parent;
5. A brother or sister eighteen years of age or older;
6. A close friend. A close friend is any person, eighteen years of age or older, who is a close friend of the patient, or a relative of the patient (other than a spouse, adult child, parent, brother or sister), who has maintained such regular contact with the patient as to be familiar with the patient’s activities, health, and religious or moral beliefs. Such person must write and present a signed statement to that effect to the attending physician. This statement should be added to the chart.

Patient Objection to Choice of Surrogate
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to the choice of surrogate, the patient’s objection must prevail until Risk Management becomes involved.

Surrogate Designation of Another Surrogate
If the surrogate designates any other person on the surrogate list, such person designated will be the authorized surrogate, provided no one in a class higher in priority than person designated objects. If there is such an objection or disagreement, the attending physician must promptly refer the matter to Risk Management.

Document the surrogate in the chart.

Question 4 – Is there a situation which would allow a surrogate to make decisions to withhold or withdraw life-sustaining treatment?

In order for a surrogate to withhold or withdraw life sustaining treatments, one of the following must be satisfied:
1. If the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
2. If the patient is permanently unconscious, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
3. If the patient has an irreversible or incurable condition, as determined by the attending physician with the independent concurrence of another attending physician, the provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or extraordinarily burdensome under the circumstances.

If the decision revolves around the provision of artificial nutrition or hydration (unlikely in the ED), then you should consult risk management.

Duty to Give the Surrogate Information
Health care providers must provide the surrogate information necessary to make an informed decision, including information about the patient’s diagnosis, prognosis, the nature and consequences of proposed health care, and the benefits and risks and alternatives to proposed health care.

Expression of Decisions
The surrogate must express a decision to withhold or withdraw life-sustaining treatment either orally to the attending physician or in writing.

Three conditions above was present as a progress note. The concurring attending must write the same sort of note as a progress note.

Patient Objection to Surrogate’s Treatment Decision
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to a health care decision made by a surrogate the patient’s objection prevails until a determination is made by risk management.

Standard Forms
If the decision revolves around DNR, the surrogate should sign a DNR form. If the decision concerns intubation, vasopressors, dialysis, etc.; then documentation should be done in a progress note by the attending and the concurring attending.

Health care decisions for adults without available, willing, and competent surrogates

***Consult Risk Management for these decisions***

Written by reuben

November 1st, 2010 at 9:55 pm

Residency Disaster Plan

MSSM Emergency Medicine Residency Emergency Response Plan
I. Upon notification of an activation of the Medical Center Plan E or Elmhurst Hospital Center the Residency Leadership will activate its emergency response plan. The plan is initiated by the Residency Director, Site Directors or Chief Residents.
II. Each site chief should contact the Residency Site Directors to coordinate staffing.
III. The Residency Site Director will coordinate with Mount Sinai or Elmhurst Emergency Department’s Administrative Staff during normal business hours or an Attending physician on duty during evenings to determine the Department’s staffing needs.
IV. In the event that additional resident staffing is needed, the Chief Residents will coordinate to contact the off-duty residents, beginning with the residents who are on sick-call.
V. During a crisis, the Chief Residents may designate the responsibility of contacting the off-duty residents to another resident or residents [utilizing the telephone/pager contact tree]. Off-duty residents will be contacted through the following means:
a) Pager
b) Home phone
c) Cell phone
d) E-mail
e) Someone may go to their home address
VI. In the event of an emergency during which telephone or e-mail communication is possible, off-duty residents should either contact, or wait to be contacted by a Chief Resident, prior to reporting to the hospital. This will enable the Departments to allocate staffing appropriately between Mount Sinai and Elmhurst, prevent staffing surges, and permit planning in the event that increased staffing is needed for a prolonged period of time.
*Note: In the event of an emergency, off-duty Emergency Medicine Residents who are assigned to other, essential, services such as the RICU, CCU, or Surgery, should report to their respective services. Off-duty residents, who are assigned to non-essential blocks such as OB/Anesthesia, Toxicology, or electives, will be considered available to provide staffing coverage in the ED.
**Note: Residents who are on-duty in the ED when the emergency response plan is activated must stay on-duty until relief arrives. All shifts will be 12 hour shifts with a one for one relief. Residents who are schedule for next shift after plan activation should plan to report for that shift and notify chief residents of availability, Senior residents originally assigned to eight-hour shifts will work twelve-hour shifts when plan is activated and until emergency response plan is demobilized.

External Disaster Assignments/ Set up

1) Clear ED of all patients ASAP (to OR/ ICU/ floors/ Psychiatry/ Dx Clinic/ D/C)
2) Assign 2 people to Decon Closet to start setting up external triage/ warm and cold zones.
a) Tape off between warm and cold zones, area for walking wounded staging and undressing, area for litter and ambulatory decon.
b) Set up external triage point in warm zone with triage tags.
c) Set up sawhorses in warm zone litter decon (4 horses; 2 for each backboard)
d) Put out undressing supplies in front of decon areas (walking wounded undressing area, litter and ambulatory decon.
e) Put down sides of decon shower.
f) Put out redressing supplies in cold zone for decon’d walking wounded, litter and ambulatory decon

3) People should be assigned to start getting into PPE (minimum 4 to decon but ideally 4-8 to decon, 1 nurse and 1 PA or resident assigned to external triage).
4) Assign med student to go to Emergency Management closet to information on WMD event and photocopy/ distribute information to staff.
5) Assign PA or resident to Diagnostic Clinic if closed +/- an attending (ideally medicine resident). Assign at least one ED PA/ resident to each room (ie: cardiac/ trauma/ A/ B room). Assign additional Medicine/ Surgery/ ENT/ Ortho/ NSG/ Anesthesia residents to each room as staffing becomes needed (remember senior representatives of each service should be in ED facilitating patients to be moved out of ED as soon as stabilized).
6) Escort to bring stretchers/ wheelchairs/ team 700 cart to cold zone.
7) Assign a nurse to cold zone ED entrance to direct decon/ tagged patients to appropriate rooms in ED (ie: cardiac, trauma, B, A, Diagnostic Clinic).
8) Disaster carts will need to be placed somewhere. They are very large. Likely hallway outside of fast track is best place to position them until they are needed. (ie: Biomed cart, Respiratory Therapy cart, Central Sterile cart. There is also a linen cart in holding, blackout cart and food cart).

Key to Decon Shed (EMS ramp outside): Hospital Police “Key #8”
Key to Decon Cage (hallway radiology corridor): Dr. Kesslers Office/ Shelf over desk
Key to Dr. Kessler’s Office: Hospital Police

Key Points during a disaster: Chain of Command

1) The Executive Director (AOD) in consultation with the Department of Emergency Medicine Director of Service (or designee) will determine the need for initiating the External Disaster Plan.

– once notified of a possible External Disaster, the Director of Service of the Emergency Department or the senior Emergency Medicine attending physician will consult with the AOD whether to activate the External Disaster Plan, usually activated when 10-15 casualties are expected.

2)Executive Director calls Telecommunications to signal the DISASTER SIGNAL
(4-4-4) and notify the telephone operator of the External Disaster Plan declaration.

3) Executive Director/ AOD consults with the Director of Service in the ED about:
-Site of Disaster?
-Type of Disaster?
-How many casualties?
-Types of injuries?
-Present status of the ED (# critical, noncritical, staffing levels).

4) The Command Post A1-15 (alternate site E1-49) gets set up (Activated by the AOD). The Telephone extension for either site is 41423. From here on out anything the ED attending needs (staff, supplies, updated info within hospital or outside hospital) is to be gotten/ requested through the Command POST.

Physicians in the Emergency Department:

1) The Director of Service of the ED or senior EM attending organizes/ supervises the medical care of all External Disaster patients. He/ She assigns and reassigns attendings and house staff to all rx areas.

2) Assign a physician to establish and operate a triage area at the ambulance entrance. If decon is needed these people need to be in appropriate PPE.

3) Refer non-emergency patients to the DX Clinic if open. If not open assign a physician to the DX Clinic.

4) Sort patients appropriately to:
-the ED/ Psychiatric ED
-Post Anesthesia Care
-Diagnostic Clinic
-Patient Care Units
5) Coordinate transfer to:
-Burn Units
-Hyperbaric Units

6) Rule of thumb: Stabilize the acute life threatening emergencies in the ED then move ASAP to appropriate unit or area. Ambulatory patients send to Diagnostic Clinic.

7) If you need more staff call the Command Post to have staff called in. Those staff members report to the command post for red arm band to gain ED access.

8) Know your Universal Triage Tag categories (red = emergent; yellow = urgent; green = walking wounded; black = expectant).

Nurses Duties

1) Call Command Post (CP) to give update on personnel, # pts awaiting exam/ undergoing rx/ awaiting admit.
2) Call CP to request supplies/ staff.
3) Ensure readiness of ED/ Trauma/ Cardiac room
4) Supervise gathering of stretcher at ambulance entrance
5) Assign nurse to assist triage (NOTE: senior ED attending directs triage)

Obtaining and Assigning Necessary Personnel/ Equipment

1) Charge nurse calls CP if needs nurses
2) Call CP for stretcher bearers and aides to transport pts
3) Patient property collected by admitting clerks with HP. Direct patients to bag own property especially if need decon. (Valuables bagged separately and kept with patients). LABEL BAGS. KEEP NONVALUABLES OUTSIDE UNDER HP SUPERVISION. THIS IS CONTAMINATED. THIS IS EVIDENCE FOR NYPD.
4) Most senior Medicine, Surgery, ENT, Ortho, NSG, Anesthiology, Bell attending report to CP for red arm band and report to ED for help getting patients to OR, ICU’s, floors, etc.
5) Clerks create disaster charts and staple corner of Universal triage tag to chart or copy #.


1) AOD is contacted if the ED or CP determine that arriving patients are possibly contaminated with hazardous materials. AOD instructs HP to direct all persons or vehicles possibly contaminated to Decon area.
2) Set up warm and cold zones and CLEARLY MARK these areas. Only personnel in proper PPE shall operate in warm zone.
3) Do not allow patients to wander. Patients directed to undress themselves COMPLETELY and remove all valuables/ put in separate bags (both labeled. Valuables remain with patient, rest says outside under HP watch).
4) The AOD determines need for diversion/ additional FDNY/EMS resources and makes appropriate call.
5) ED attending and AOD determine need to deploy portable decon shower inside or outside building (if inclimate weather set up across from family room. 2 fans blowing toward decon set up on either end of corridor and +/- shut down ventilation system).
6) Ed attending detail triage team to cold zone
7) ED attending detail medical staff member as resource person to gather and disseminate info (STAT copies from ED/ decon closet or Emergency MGMT Closet for medical management of the particular WMD event taking place)
8) Contact Poison Control as needed (212-POISONS).
9) Escort should bring adequate stretchers, wheelchairs, and Team 700/ Disaster cart to cold zone.
1) 80% of patients from WMD event will self refer to hospital. Detail screening team (HP and medical staff) assigned to each entrance WITH BULLHORN to redirect THROUGH THE OUTSIDE OF BUILDING to decon area.
2) If possibly terrorism related:
– perpetrator(s) may be harmed and may now be in the ED intent to cause more harm
– keep all clothing outside, labeled, under HP watch for NYPD arrival and safety inspection
– If law enforcement need room HP to set up B1-13.
3) At the conclusion:
– All those in level B/C suit need medical screening
– If interior decon was done only AOD can turn on air handling equip.
– Salvage drums with haz mat water held under F-wing for DEP.
– Safety director inventory supplies and equip to repair, replace, replenish as soon as incident secured. Return to state of full operations ASAP.

Chief Resident Job Action Sheet
?Immediate Actions:
?1) Contact all residents w/ other chief residents to alert of incident & assess safety
2) Assess need to activate Resident Recall Plan in concert with ED Leadership
3) If Resident Recall Plan is activated, edit resident schedules for Sinai &
Elmhurst, to increase all shifts to 12 hrs, and provide adequate Department
4) If maintenance of communication is a concern in a city-wide event, the Chief
Residents may be expected to share alternating 24hr coverage from the ED
5) As coordinators of resident coverage during mass casualty, the chief resident
may assist in assigning residents to new treatment areas including: Triage, Immediate Treatment Area, Delayed treatment Area, Minor Treatment Area, and Decontamination Area.
6) Send Home those residents who are working beyond their scheduled shifts, or who “just show up” at the ED site, as the goal is to provide adequate coverage for the full extent of the casualty situation
Intermediate Actions:
An ‘on duty’ Chief Resident, must continuously monitor fellow ‘on duty’ residents, Attendings, and support staff for:
a) Food Breaks
b) Water Breaks
c) Rest
d) Mental Health/ Stress related to the mass casualty
When the ED team takes breaks, and communication access is available, the members of the care team should also be encouraged to contact their families and loved ones outside of the hospital to re-assure them of our safety within the site of a mass casualty area

MSSM Emergency Resident Job Action Sheet[1][1]
Emergency Response Plan-MSSM Emergency Medicine Residency[1][1]

Written by reuben

September 21st, 2010 at 4:46 pm

Posted in Disaster,Elmhurst

Elmhurst Central Line Bundle Kits

Hi folks,

HHC has gone to a new vendor and changed our central line bundles.

There are two major changes:
1. The syringes are now in a separate pack and the syringe wrappings ARE NOT STERILE. The syringes and the fluid is sterile. But you can not drop the syringe packages themselves on to your field. You must open each of the three syringes and drop them on to your field. THIS IS ANNOYING AND INEXPLICABLE.

2.  The drape is different
Look for the guy on the attached picture, he is next to one of the two openings
The guy represents the right-neck side of the drape
His head points to the head portion of the drape
The drape unfolds to the feet first and then the head (the opposite of the previous drape)

write me with any questions



Written by reuben

September 3rd, 2009 at 2:25 am

Posted in Elmhurst

EHC ED Wireless Consult Project

Attached are the wireless #’s to contact the ED Consultants and the algorithm to use.
The #’s are also in AMION and posted in the ED.
Please let me know if you are having any difficulties (wireless numbers not being correct or not in AMION, etc).
Don’t forget to log the consult times and drop them in the boxes in the A and B room so we can have #’s to back it up if this does work well.  Indicate if you made contact via page or wireless as well.


Written by reuben

May 9th, 2009 at 7:53 pm

Posted in Elmhurst

Isolyte (Elmhurst)

Hi folks,

In the IV fluid cart in the trauma room, we are stocking a fluid called isolyte.
It is very similar to lactated ringers with three exceptions:
1. It does not contain lactate so it will not affect lactate levels in shock patients
2. It is a true isotonic solution, so it can be used in head injury patients
3. It has no calcium, so it is compatible with blood products

This begs the question: why don’t we just replace LR with isolyte.
Problem is that it costs twice as much, which when you talk about fluid bags still is not very much money, but it adds up.
At this point, the appropriate patient pop. to use this fluid is preexisting acidosis (bad DKA, sepsis, etc.) where NS will make things worse and you still want to send lactates.

Scott Weingart

Written by reuben

April 8th, 2009 at 5:12 pm