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Here’s a helpful bit of news from the ICUs.

In the evening and overnight there is ONE Nursing Administrator covering all the ICUs.

The direct line is: 646.385.5937.
They are available to help out with bed management. They can contact ICUs about bed availability and identify open ICU beds. If there are issues with ICUs blocking beds, they are told to contact the VPs office for guidance.

So, if you have that patient that all agree belongs in an ICU (usually the MICU) but they have no beds, this ICU Nursing Administor can help you figure out which units have capacity. You will still need to contact the doctors covering that unit, but at least this helps streamline that process.

Please let me know if this is helpful, or if the process doesn’t work.

Peter

Hello all,
As you may have noticed, there is a new note type in the “Attending note” field titled “Disposition decision note”. As the name suggests, this template will help you document your decision to admit as painlessly as possible. (see screen shots provided by Nick below).

I have broken the decision to admit into a few categories (i.e. severity of illness, risk to decompensate, etc.) Your clicks will be used to populate a paragraph of text that will appear in the chart. Please fill out this template on every admission and click as many boxes as apply to your patient (be generous). Let me know if you have concerns or ideas to improve it…

And thanks as always for your help!

Luke

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)

If you have a patient you are admitting to medicine:

1. Sort patients into stable / low demand (non-teaching with fewer providers to patients) and less stable / high demand (teaching service where there are more providers per patient) using the following criteria as guidance for who should be teaching:

a. HR > 125

b. RR > or = 30

c. O2 sat < 90% (despite 4L NC) d. BP < 90 or > 200

e. New AMS in setting of abnormal VS

f. Severe laboratory abnormalities requiring frequent (THREE OR MORE TIMES A DAY) bloodwork (e.g.

DKA, GIB, Hyponatremia, Hypernatremia) – excludes PTT for patients on heparin drip

(There is no absolute requirement for any data but do realize that if you underestimate the complexity of the patient and they are assigned a team (i.e. non-teaching) and subsequent lab work or study shows significant abnormality (i.e. trop of 20, Na of 115, CT with appendicitis, etc), the patient may have to be re-assigned which ultimately slows down the process.)

2. List patient in EPIC as you normally would to medicine service

a. (hospitalist of the day for general medicine and ADS attending of the day for cardiology unless the patient has a primary who will act as the admitting physician).

b. In the text box put the zone phone of the ED provider who will provide verbal hand-off to the admitting team.

3. Either speak directly to or call the MAPA / MAR- provide a brief overview of the case, and ask that a team be assigned.

a. In general this should happen on the spot (the MAPA / MAR should not repeat a history / physical exam of said patient unless they have specific questions you can’t answer).

4. Expect a call from the admitting team to allow verbal hand-off the patient.

If there are any issues / speed bumps. Don’t expend a lot of energy trying solve in real time. Forward the case to me and I will send to Dr. Radbill and the medicine chiefs.

FAQs about Geriatrics for ER residents/attendings:

Bottom line from Makini: Please, when you call AMAC to page “geri,” do not say “Please page geri.” Be specific. IE, Ask for the pt’s actual PCP, ask for the MACE or phone call fellow when appropriate, or if you are calling a proper consult, you can ask for the geri consult fellow. Seriously, this is more complicated than most of our consults/provider calls, so please refer to this email.

Thanks, Makini

From Dr. Blachman:

What is the MACE team? This is the inpatient geriatrics service, comprised exclusively of Coffey geriatrics patients and residents of the Jewish Home nursing home.

How do I know if my elderly patient is a Coffey geriatrics practice patient? If you look at notes on EPIC, they would have notes from a geriatrics office visit. The person who wrote the note is the PCP.

Who do I call about a geriatrics MACE admission if it’s Monday at 9 am-Friday 5pm, at ALL hours? The PCP (found in EPIC).

What if the PCP does not call back? Please scroll down on amion (password mssm) and see if the PCP is on vacation. The covering attending will be listed, and you can contact them directly. If no one responds to your pages, please call our geriatrics call center operator at 212-659-8552.

Who do i call about a MACE admission on the weekend (Friday at 5pm til Monday at 9am)? The fellow listed under “phone call coverage” (see amion, mssm, search under geriatrics). Please do not call the general “geriatics consult” number since this is held by the other fellow.

On a weekday, why would you call Concurrent/consult fellow? If you want a consult in the ED between 9am and 4pm on weekdays.

On a weekday or weekend, why would you call MACE fellow? If you have already spoken to PCP but want to alert MACE fellow about an admission during the day (note that this is not necessary as PCP or weekend phone call fellow usually contacts MACE fellow directly).

Are the geriatrics and palliative care fellows the same? No, we are in two separate fellowship programs, taking care of different patients.

What is the Coffey practice? This is the outpatient geriatrics practice at the Martha Stewart Center (1440 Madison)

Nina Blachman via Makini

The following describes patient groups, which are appropriate for telemetry monitoring on 11-West, 9-West, 10-West. These patients do not require specialty care provided on cardiac units. These criteria are meant as a guide and do not override clinical judgment.

1. A patient with history of CAD who presents with typical or atypical chest pain and does not have high-risk features (Ischemic EKG, low systolic blood pressure, decompensated CHF, history consistent with unstable angina) requiring a cardiac unit.
a. Patients who already have 2 consecutive negative troponins or at least one troponin 6 hours after the onset of chest pain are unlikely to benefit from telemetry

2. Patients with syncope who have high risk features for cardiac cause, including low systolic blood pressure, CHF, CAD, or advanced age(<65). 3. Medication or drug toxicity wit potential arrhythmogenic consequences. a. Examples include monitoring after overdose of a tricyclic antidepressant or digoxin or cocaine toxicity. 4. Electrolyte imbalances. a. Example includes hyperkalemia with ECG changes. 5. Patients with atrial fibrillation/flutter who are hemodynamically stable but are actively being managed for rate control. 6. Tachyarrhythmias requiring continuous intravenous therapy that can be managed by the nursing unit (e.g. IV cardizem). 7. Symptomatic bradyarrythmias. 8. Selected stable patients post procedure from heart hospital at discretion of attending (11 west only, managed by ADS nurse practitioner) 9. Any patient requiring continuous heart rate monitoring that is not otherwise specified above but is deemed medically indicated by the clinician.

(last update: February 27, 2008)

o High risk acute coronary syndromes characterized by a clinical history suggestive of ischemia and one or more of the following:
? Electrocardiographic evidence of acute or recent myocardial infarction
• Pathologic Q waves in two or more leads (new or not known to be old)
? Electrocardiographic evidence of acute myocardial ischemia
• ? 1mm ST depression in two or more leads (new or not known to be old)
• T wave inversions in two or more leads (new or not known to be old)
? Positive biomarker for myocardial ischemia (troponin I)
? Systolic BP < 110mm Hg ? Crackles above the lung bases ? Recent coronary intervention or coronary bypass surgery ? Worsening of established anginal pattern in the setting of known ischemic heart disease o High risk congestive heart failure (CHF) characterized by one or more of the following: ? Systolic hypotension ? Ventricular arrhythmias ? Persistent hypoxemia ? Significant hyponatremia (sodium < 130) ? Renal insufficiency (stage IV-V chronic kidney disease or acute renal failure ? stage III) ? Requirement for IV vasodilator or inotrope therapy ? Known or suspected severe aortic or mitral valvular stenosis ? CHF secondary to an acute coronary syndrome o Syncope with high suspicion for a cardiac etiology characterized by one or more of the following: ? History of CHF ? History of ventricular arrhythmia ? Acute coronary syndrome ? Significant aortic or mitral valvular stenosis ? Electrocardiograph with arrhythmia/ prolonged QT/ bundle-branch block or acute ischemia ? History of myocardial infarction ? Prior implantation of pacemaker or ICD ? Second or third degree heart block o Tachyarrhythmias requiring continuous intravenous therapy o Symptomatic bradyarrhythmias o Patients who require urgent invasive cardiac procedures o Patients who require observation immediately following invasive cardiac procedures o Patients receiving chronic infusions of vasoactive medications o Other patients who, in the judgment of the treating attending cardiologist, require specialized cardiac care Depending on the clinical scenario, individual patients meeting the above criteria for admission to cardiac telemetry may be appropriate for admission to the Cardiac Care Unit (CCU) instead.

Please see this policy:

Diabetic Foot Ulcer Policy

Foot Ulcer Policy

Under 12 without a known MD goes to Peds Associates.

Under 12 followed by peds assoc, med/peds, known voluntary is assigned as such.

12 and over not followed already by peds assoc, med/peds, known voluntary or already followed by adolescent should be admitted to adolescent.

Subspecialty pts should be assigned to the appropriate team after discussion with them, if not then the rules above apply.

For all sickle cell admissions for pain only (no concern for infectious/ischemic or other complication of sickle cell disease), no longer call the hematology fellow. Admit to medicine service, lead hospitalist. Call the chronic pain cell phone upon admission (646-592-0145). The chronic pain service will see the patient promptly and write admitting analgesic orders. Call the heme-onc fellow if there is an emergent need for a hematologist.

For sickle cell pain crisis admissions, the chronic pain service wishes to be called instead of the hematology fellow. They will come down 24/7 to write analgesia orders. The resident/fellow covering this service carries a cell phone:

(646) 592-0084

If a sickle cell patient has another reason for admission (e.g. medically ill with an infection, chest crisis, hemolytic crisis, etc.) the case should be discussed with the heme fellow.

The procedure is very straightforward and well established. Dr. Himmel is intimately involved with the Vascular Service. He directs the Vascular Clinic. He has considerable clinical acumen and when he makes a determination that a patient requires admission to the Vascular Service the patient should be admitted to the faculty member on call for the faculty practice. I regularly admit patients that Dr. Himmel has determined require admission to the Vascular Service.

I will address this issue with the Vascular team and Dr. Divino will instruct the General Surgery house staff.

In the future if the ED staff are having any difficulty with the disposition of these patients, do not hesitate to contact me directly. My page # is 917-205-0504 and my cell # is 646-300-4239.

Thank you for bringing this matter to my attention,

Peter Faries

Peter L. Faries, MD, FACS
Franz W Sichel Professor of Surgery
Chief, Division of Vascular Surgery
Mount Sinai School of Medicine
Telephone: (212) 241-5386
Facsimile: (212) 534-4079

From: Chang, Dennis [mailto:dennis.chang@mountsinai.org]
Sent: Fri 2/18/2011 5:45 PM
To: Chasan, Rachel (MSSM-Imail); Sadikot, Sean; Matloff, Jeremy (MSSM-Imail); Sachdev, Darpun (MSSM-Imail)
Cc: # DHM Hospitalists; # HMP NP (MSH)
Subject: Orthopedics Admission Guidelines

Evening,

So we met with the orthopedics department and attached are the guidelines for admission to medicine and orthopedics. A copy was given to the MAR today but if you guys could distribute this to all the MARs going forward that would be great. The orthopedics residents also received an email today. There was some confusion over the guidelines today but that was because the orthopedic residents didn’t read the guidelines thoroughly. This was cleared up today but there may be some confusion in the future. Thanks! Have a good weekend.

Dennis

Dennis Chang, MD
Co-Director, Medicine-Geriatrics Clerkship
Director of Medical Consult and Peri-Operative Services
Assistant Professor, Division of Hospital Medicine
Mount Sinai Medical Center

Orthopedic Admission Guidelines

Situations in which patient in ED with primary Ortho complaint should go to Medicine Team with Ortho Consult:
o ACUTE CHEST PAIN (for rule out MI, requiring Telemetry)
o ACUTE STROKE (Medicine or, more likely, Neurology)
o SYNCOPAL EPISODE CAUSING FALL (for rule out MI, requiring Telemetry)
o Hypertensive urgency (requiring Telemetry, IV antihypertensive drips)
o Severe ELECTROLYTE DISTRUBANCE (e.g. Hyponatremia)
o Other unstable comorbid condition (e.g. significant COPD or CHF exacerbation) not listed above

Situations in which patient in ED with primary ortho complaint should go to Ortho Team with Medicine Consult:
o ANTICOAGULATED PATIENT
o PTS NEEDING CARDIAC WORKUP PRIOR TO SURGERY
o MULTIPLE COMORBIDITIES (>5) RENAL, PULMONARY, CAD, CHF, DM, HIV – ALL OF WHICH ARE CONSIDERED STABLE AT THE TIME OF ADMISSION
Orthopedic Admission Guidelines

In order to ensure prompt, safe, and efficient throughput from the Emergency Department to the medicine department, the following have been agreed as the minimum required tests or procedures prior to admission to the department of medicine.

ALL admissions require:

• Venous panel
• CBC

Patients with fever:

• Chest X-ray
• Urinalysis

Patients with chest pain or shortness of breath:

• Chest X-ray
• Troponin
• ECG

Patients with abdominal pain:

• Abdominal panel (this may be pending but not resulted at time of triage to medicine)

Patients taking anticoagulants (coumadin)

• PT/INR

Patients with liver cirrhosis and ascites need a cell count for ascitic fluid before triage if any of the conditions below are met:
• Massive ascites in need of a large volume paracentesis
• Acute kidney injury
• Confusion
• Fever
• Abdominal pain

New Admission/Triage Policy – Effective March 1, 2011

1. Triage
• ED decides to admit vs. discharge patient
• The ED attending /resident enters order in IBEX (not a formal bed request) which acts as a signal to the MAR that the patient is a potential medicine admission
• MAR should immediately evaluate this patient and assign a team
• If MAR agrees with admission to medicine, the MAR will assign an appropriate inpatient team/accepting attending
• If there is any disagreement between the MAR and ED that cannot be resolved so that the patient can be triaged, this must be escalated to the MAR’s supervising attending (Medicine Consult attending or on call hospitalist)

2. Listing with Bedboard and Hand off
• After Medicine team assignment, MAR will submit bed request to Bed Mgt
• The MAR will then provide AMAC with the patient’s name and the admitting team contact info
• AMAC will connect the inpatient team with the ED team caring for the patient to facilitate direct verbal communication and proper handoff
• Direct verbal communication and proper handoff must occur before a patient is transferred from the ED to the floor

3. Transition of care
• The accepting inpatient team will evaluate the patient and write admission orders
• Once orders appear, this is a signal to ED that the transfer of care has occurred
• Until this hard signal exists, the ED team remains responsible for the care of the patient
• The time frame from the ED’s admission request (order entered to signal MAR to evaluate) to the completion of the inpatient admission orders must be 3 hours or less
• This time frame assumes no discrepancy between ED and MAR regarding appropriateness of admission and the availability of appropriate data. If there is any disagreement between the MAR and ED concerning necessary available data that cannot be resolved, this must be escalated to the MAR’s supervising attending (Medicine Consult attending or on call hospitalist)
• If there is a decompensation in a patient’s condition requiring emergent intervention while the patient is still in the ED, the ED team will manage the resuscitation
• BUT the team currently responsible for the care of the patient at the time of his/her decompensation remains responsible for that patient and must work with the MAR or TR to arrange proper inpatient placement
• After direct verbal communication and proper handoff between the inpatient team and the ED team, a patient may be transferred from the ED to a bed on the inpatient floor at which point the inpatient team is responsible for the care of the patient (even if inpatient orders have not yet been completed)

4. MAR role
• The MAR will perform a focused assessment to determine the inpatient team
• The MAR will not place orders for medications, laboratory testing or consults
• Any recommendations or requests along those lines will be communicated to the ED provider who will place the order
• If the MAR feels that an ICU consult is warranted, they will communicate this to the responsible ED resident or attending who will then request a consult as they see fit
• Any discrepancy which may arise between the Emergency Medicine attending or resident and the MAR regarding the need for an ICU consult should be resolved via discussion between the ED attending and the MAR’s supervising attending
• The chain of command for the MAR will be the Medicine Consult Attending listed in AMION. This will clarify attending to attending communication as needed.

Important Numbers
Bed Board: 47461
AMAC: 43611

From: Jasmine Koita
To: “Patel, Vaishali”
Date: Wed, 11 Aug 2010 15:09:12 -0400
Subject: Fw: [Interdept] Interdepartmental Meeting 8/10/10 Minutes– *Importantcorrection re: LGIB/UGIB patients*
Please note the following corrections:

Patients with lower GI bleeding: These patients should always be admitted to a surgical service unless there are specific other recommendations made by the attendings involved.

Patient with upper GI bleeding: These patients should always get a prompt surgical consult, however they do not necessarily require admission to a surgical service.

—
Malini D. Sur, MD
House Staff
Department of Surgery
Mount Sinai Medical Center

All
If you have a Jewish home pt that needs to be admitted please admit them to the “Mobile ACE attending”

In am i on
Click on Geriatrics and Palliative care
Look for
Mobile ACE Attending

Thanks
kevin

If a patient does not have a known MSH internist, and you need to admit a patient, please try and discuss with the MAR first.

then look in AM I ON

List the pt under the “lead hospitalist of the day”

Dr Kathuria is no longer at MSH!

Kevin Baumlin

Please note that a new policy with tcc will be starting this weekend.  Please email me if you have tcc pts arrive without a call in.
Thanks

Kevin M. Baumlin

—–Original Message—–
From: Lechich, Anthony
Sent: Friday, January 15, 2010 4:41 PM
To: TCC MEDICAL ADMINISTRATION; TCC NURSE MANAGERS-ANCC; TCC NURSE MANAGERS-DISCRETE; TCC NURSE MANAGERS-SNF
Cc: Frenkel, Cheryl; Carey, Kathy; Sussingham, Robert; Baumlin, Kevin; Dunn, Andrew; Southwick, Robert
Subject: FLOW SHEET TO BE FOLLOWED UPON TRANSFER OF TCC RESIDENTS
Importance: High

Please note the attached flow sheet. For all patients transferred to Mount Sinai Hospital for possible admission the steps indicated on the FLOW SHEET must be followed. The physician or Nurse Practitioner must inform the concierge operator in accordance with the proceedure outlines below. When the MD is off site the nurse relaying the information on the patient must do so thoroughly so that the MD can convey a proper clinical picture to the Emergency Room Staff.

FLOW SHEET TO BE FOLLOWED UPON TRANSFER OF TCC RESIDENTS

EFFECTIVE DATE: January 15, 2010

Step 1
MD/NP directing transfer calls the concierge number: 212 241 3611.
States ( to the concierge operator)  own name and that this is regarding a patient of Terence Cardinal Cooke Health Care Center.
Cell number (best) or beeper # that will work to reach him/her for the next 12 hours or, if going off duty, the next covering MD/NP.
States: name of the patient; brief summary of the patient’s baseline; statement of the reason for transfer and suggested workup, issues, other info such as family contacts,issues; advance directives;
States (to the best extent possible) service to which the patient, if admitted, should go to.

Options are: >65 geriatric= Dr. Winik (Cell 917 837 0147)
<65  geriatric= Hospitalist service (Beeper # 7217(Mon-Fri 8AM-6PM); 3989 (Nights weekends)
HIV cases=Hospitalist for ID  reachable at www.amion.com login mssm and click infectious diseases to find the two HIV  attendings.
Pure ESRD issues: MSH  Renal team must be notified. (All patients from TCC on dialysis need MSH renal notified even when admitted for non-renal issues so that dialysis may be arranged during their stay.

TCC MD/NP must remind nursing in charge of the transfer to include all of the items in the INTERACT II envelop and clearly mark on the transfer form that the patient is from TCC and instructions are included in the dictated information on the concierge record.
If the patient is over 65 geriatric the TCC MD/NP should call Dr. Winik and inform him of the admission. (We will need to confirm with Dr. Winik how to handle this when he might be away, w/e etc.

_______________________________________________
Mssmemfaculty mailing list
Mssmemfaculty@mssm.edu
http://mm-2.mssm.edu/mailman/listinfo/mssmemfaculty

Please note that there has been a change in mechanism for disposition of patients treated with therapeutic hypothermia.  In the past, the CCU had been taking all patients, but we have come to the agreement that disposition will be based on etiology not therapy.

Obviously, it may be difficult to determine the most likely etiology of arrest in some patients.  To expedite the ICU triage process for the patients who do not have a clear etiology of their arrest, the units have agreed to have the neurology hypothermia consultant (Frontera or Gordon) in consultation with the ED, decide which unit will take the patient.  The pulmonary and cardiology fellows should be aware of this change.

If there are any difficulties with this process, please notify phil.

We do not have to transfer often from Mt Sinai so this is what is necessary when we do:

-A transfer form must be completed, scanned  to the chart and given to the transfer team. This is found under copies in the lt hand column. This includes receiving facility/accepting physician info.  That being said, there also used to be a consent form under that same heading and it printed as a packet.  The consent form is probably important legally- I’m not sure why it is no longer there.

-You must also include a written exam (repeat exam) within in 1 hr(or something similiar) to transfer- to show the patient was stable prior to transfer. (I noted this on the transfer form and timed it- it could also be done as a dr note on the chart)

-A copy of the completed chart (with full H&P and attending note)

-Copies of any labs (just make sure you enter them into the chart from “results”)  or imaging studies(hard copy or cd- This can be made at the film library- way down the hall past the ED CT scanner on the right; there is a sign posted. I imagine during off hours the ED rad techs could do this.)

Feel free to add anything I may have forgotten. Anyone know why we no longer have the written patient consent for transfer- (I do think it is important)?
-Lori Montagna

If you encounter patients being admitted for weight loss bariatric surgery, all information regarding contact lists, pre-op work up, utilizing proper body mechanics, the surgery itself, complications and sensitivity to the patients can be found on the intra-net.
Go to home page- medical services-on left Surgery, then Bariatric Clinical Guidelines.
If you need a bariatric bed; ask your coordinator or go to Nursing P&P Bariatric
There will be a survey for the Bariatric Program Wed. Oct.28.

Given the current difficulty in obtaining single rooms (particularly airborne isolation – negative pressure rooms), we wanted to remind everyone that patients with suspected or confirmed influenza require only Droplet Precautions (not airborne precautions) and can be admitted to any single room. (Of course, if TB or varicella/zoster is present or on the differential, then airborne isolation would be required.)

We have had a few patients waiting in ED for negative-pressure room who required only a single room. Thus, this clarification with staff may reduce ED waiting times for admitted patients.

Multum update–  the end result of this means that your med service and rx quick lists may be a bit different… of note toradol and lasix have changed… sorry, these updates .. we are required to take…

bed request– “none” is no longer autopopulated in the isolation question…. UGGGH.. i know… but hopefully this will decrease the re-listing for isolation pts that seems to happen daily.

bedboard overview– now has an additionally column for mrsa/vre– this is pulled through from cerner– (meaning the pt has had a mrsa/vre positive cx in the past.  this should help decrease confusion as to who is and who isn’t iso, and for what reason.

current medications  please put this on your tool bar and check pts med lists!

Obs– for pts 8+ hours and overnight obs pts– fill out the new “hpi” template

Peds ROS– working on it

Studer– AIDET— bottom line is, its not enough to take great care of your pts.  you need to do it with a smile, introduce yourself, manage expectations and say thanks for coming….

-kb