Orientation to the Pediatric Emergency Medicine Rotation

Children’s Healthcare of Atlanta @ Hughes-Spalding

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Welcome!

The Pediatric Emergency Center (PEC) & Pediatric Urgent Center (PUC or “Walk-In”) offers a unique opportunity to participate in the care of sick and injured children.

The spectrum of disease & variations in severity is unmatched in any other pediatric rotation.

You will be directly managing patient care under the supervision of a faculty member of the Division of Emergency Medicine in the Department of Pediatrics of Emory University School of Medicine.

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This Orientation

General Expectations Nuts n’ Bolts of your shift Trouble shooting: where to turn when

challenges arise

NOTE: This orientation is an introductory overview. All learners must review the resources found on our

website under “Teaching Portal”: www.pediatrics.emory.edu/divisions/emergencymedicine

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Expectations

What to expect of the faculty (attendings and fellows)

What the faculty expects of you

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Expectations of Faculty

Faculty will: give you the opportunity to examine,

assess and present patients.

assess your patients and provide feedback on areas of agreement and disagreement.

explain their recommendations and decisions.

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Expectations of Faculty cont’d

Faculty will: teach and supervise procedures.

provide feedback to you on perceived strengths and weaknesses during the rotation.

provide end of rotation evaluation.

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Expectations of the Learners (outline)

Before you begin the rotation Attendance Dress Code Professional Behavior Documentation Patient Care

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Expectations of the learners:

Before you Begin

Obtain your schedule www.amion.com. Password: emupeds

Activate your name on the Teaching Portal website: www.pediatrics.emory.edu/divisions/emergencymedicine Donna Stringfellow should be emailing your login/password

to the Teaching Portal prior to the start of your rotation donna_stringfellow@oz.ped.emory.edu (404) 785-7142

Review/complete all pertinent material and links: Orientations, PreTest, Learning Modules

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Expectations of the learners:

Before you Begin

Make sure the following have been arranged by your program coordinator: Parking ID Badge Computer access to Grady “Citrix” & “Ultra C”

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Expectations of the Learners (outline)

Before you begin the rotation Attendance Dress Code Professional Behavior Documentation Patient Care

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Expectations of the learners:

Attendance

Begin on-time (your peers are waiting!) Find coverage for unexpected schedule

conflicts and clear it with your program/chief resident

Notify your program/chief resident of special requests > 3 months in advance

Follow your schedule: make sure you are in correct location (i.e. PEC vs PUC)

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Expectations of the Learners

Before you begin Attendance

Dress Code Professional Behavior Documentation Patient Care

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Expectations of the learners:

Dress Code

Business casual Scrubs OK (well-fitting, clean and fresh) No open-toed shoes, artificial nails No denim, capris, or hem-line above knee No short blouses, low necklines, tight clothing

Please refer to CHOA/Emory guidelines for more details:• CHOA Policy 4.11 • www.med.emory.edu/GME/house_staff_policies_section25.cfm

Above all, be neat and presentable!

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Expectations of the Learners

Before You Begin Attendance Dress Code

Professional Behavior Documentation Patient Care

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Expectations of the learners:

Professional Behavior

Confidentiality • non-healthcare providers should not be able to hear

discussions with & about patients Respectful

• Interact courteously with families & staff Sensitivity to length of stay

• update your patients ~ every 30 min, even if brief De-escalate tension

• Approach potential or actual conflicts in a constructive manner

Please refer to the Family Centered Care power point for more complete guidance!

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Expectations of the learners

Before you begin Attendance Dress Code Professional Behavior

Documentation Patient Care

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Expectations of the learners:

Documentation

Completion of the chart: History and Physical Impression & Reassessments Order Page Procedure note Respiratory Orders Medication Reconciliation Discharge Instructions Disposition: condition & time

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Documentation: History & Physical

Date & Time Chief ComplaintTargeted HPI Relevant ROSPast Med/Fam/SocPhysical Exam with

available Vital Signs (includes pain & weight)

Legible signature

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Documentation:Impression

Document your assessment including a differential diagnosis list.

(This is key for presenting the case and helping others understand what you were thinking!)

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Documentation:Reassessments

Who to reassess:All patients with orders,

interventions or abnormal

vital signs.

Examples of what to reassess: Pain Respiratory distress Abnormal vital signs Alertness Ability to take PO

Time each reassessment! Write down lab results and

radiology readings. Write down d/w consults.

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Documentation:Order Page

Initial & time each order

Initial & legibly sign in designated space

Use separate Physician Order sheet for: pharmacy orders extra orders

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Documentation:Procedure Note

Examples: Splints Laceration repair Incision & Drainage Lumbar Puncture

Not required: Pelvic exam Flourescein study

Remember to date, time, and legibly sign your note!

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Documentation:Respiratory

Respiratory Orders Fill in date, time, weight Initial & time each order Initial & legibly sign in

designated space

Reassessments: Condition Date & Time Initials & legible signature

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Documentation:Radiology

Select desired test Pt sticker on each

page Indicate reason for test Sign, date order

• Include PIC or callback number

For CTs: call to put pt on Grady CT list.

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Documentation:Medication Reconciliation

Review and sign on presentation: note date & time

Review and sign on discharge: note date & time

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Documentation:D/C Instructions – Rx

LEGIBLE Include allergies &

weight Note concentration of

suspensions Doses in ml (not mg) Sign & print name, NPI

#, DEA # (if applicable) & date

Cross out unused Rx lines

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Documentation:Discharge Instructions

LEGIBLE Avoid medical

jargon • (5th grade reading level)

Useful information: Appropriate follow-up

(default: call PCP’s in the morning)

Criteria for return Appropriate handouts

Review with discharging nurse if possible

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Documentation:Discharge Time & Condition

Review & sign : Condition on

discharge Disposition Time Disposition

Location

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Expectations of the Learners

Before you beginBefore you begin AttendanceAttendance Dress CodeDress Code Professional BehaviorProfessional Behavior DocumentationDocumentation

Patient Care

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Patient Care: Day #1

Try to arrive 15 minutes early on your first shift

Introduce yourself to the attending and let them know it’s your first day

You will have an orientation with one of the nursing staff

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How-To care for patients in the Pediatric Emergency Department

Identify yourself to the attending, staffIdentify next patient to be seenPerform and document history & physicalPresent case to attending, fellow or charge

residentPlace orders (magnet system)Monitor status of ordersReassess patient (and document)Make final disposition

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Step 1: Identify yourself to staff

Who am I?• name, year of training

Where am I supposed to be and when? • PUC vs PEC (check hourly schedule posted in

MD workroom)• shift you are working

Write your name, shift, location (PEC vs PUC), on the designated board

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Step 2: Identify next patient

Look for patients on board without a physician assigned (yellowyellow magnet)Check “time to room” for longest waitingSee EMERGENT patients first (blue or red

magnet by complaint, e.g. sickle cell with pain/fever, respiratory distress)

Look for charts in circular rack @ the central nurses station

Apply patient labels to History & Physical Exam form

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Step 3: Perform and Document H&P

You are representing the attendingIdentify yourself to the patient and familyExplain processProfessional behavior

H&Ps in the ED are more focused and should take less time than in-patient H&Ps.

Most assessments should take < 10 minutes.

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Perform and Document H&P: Team Approach to Care

Nursing staff also complete initial evaluation on patients• May occur simultaneously with physician evaluation• If a nurse is in the room: ok to enter the room, introduce

yourself & ask them if you may start your evaluationBe polite: do not interrupt, ask that they stop their

assessment or leave the room. COOPERATION & TEAMWORK are the goals

Patient Access staff may be interviewing your patient briefly: wait for a break in the conversation and ask if it is ok for you to begin your interview• PAS staff understand families are there to see the doctor

and do their best to work around us• Remember: patients have to be registered!

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Perform and Document H&P: Caregiver initiated protocols

Nursing /ancillary staff have standing protocols to start care for certain patients• Asthma• Sickle cell pain & fever• Vomiting• LET (topical anesthetic) to lacerations • Analgesics

You can interview families/obtain history while IV is placed, labs are drawn, or breathing treatments given

Ask the nurses or RCPs where they are in the process if you have questions

Remember: We share the chart – put it back where it belongs!

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Step 3: Perform & Document H&P (cont’d)

Non-English speaking families• Must use qualified medical interpreter (staff or

language line) when historian has difficulty understanding questions due to language barrier

• Ask your attending or charge RN for language line phones.

Students may document only on the following aspects of the patient chart: Review of systems Past Medical/Family/Social history

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Step 4: Present the case

Seek out the attending, fellow or charge resident to present your case ASAP.

Begin with the chief complaint: why are they here? Often this isn’t clear until the end of your encounter! Parent chief complaint & our primary concern may not be the

same.

HPI should be focused with a succinct summary of the quantifiers and qualifiers of relevant symptoms (e.g. duration, severity, frequency, quality)

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Step 4: Present the case (cont’d)

Summarize the case briefly (should be able to do in 1 breath!)

Present Differential Diagnosis with rationale Most likely & Most serious conditions Not a laundry list

Present your Plan with rationale

NOTE: This is where the learning is at!

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Step 5: Place orders (see slide 20)

Write clearly, using only approved abbreviations

Special order forms:• Respiratory orders (slide 22)

• Radiology orders (slide 23)

include your pager #!

• Pharmacy orders (meds not available in ED) include patient weight & allergies!

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Step 5: Place orders (cont’d)

Orders to be completed

Respiratory Orders

Needs to be seen

Financial Counseling

Discharge

Admit

Magnet System

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Step 5: Place orders (cont’d)

Place red magnet on the board for nursing orders. Tell the RN for the patient about the orders. CT scans & ultrasound: call Grady to place patient on list. Unit clerk will use ASCOM phone to notify RN of order.

Place blue magnet on board for respiratory orders Tell the RT for the patient about the orders (the unit secretary

will call them on their ASCOM)

Place chart with orders in rack in front of unit clerk.

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Step 6: Monitor status of orders

Were orders were taken by nurse?check chartask nurse

Check to see if the lab has received specimen (UltraC) call the lab for results if none in the

computer after 30 minutes.

Call Radiology for special studies: ultrasound, CT call for CT results if haven’t heard from

radiology in 30 minutes.

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Step 7: Monitor Status of Patient & Document

Document a reassessment after any intervention (slides 19, 22):

breathing treatment fluids medicationse.g. : If you don’t document that a dehydrated patient took PO

and improved during their ED visit then it will appear as if you sent home a dehydrated patient!

RETURN CHART TO DESIGNATED PLACE IN CIRCULAR RACK AT CENTRAL

NURSING DESK AFTER USE!

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Step 8: Final Disposition (see slide 27)

Discuss with attending, fellow or charge resident

Remember an attending (or overnight fellow) must see all patients!!

Patients without a final disposition at the end of your shift should be signed out to another resident

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Step 8: Final Disposition: Admitted Patients

Admitted patients need sign-out to admitting resident (404) 225-1969

& document

bed sheet w/ accepting attending & “obs” vs “inpatient” status

give completed bed sheet to charge nurse

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Step 8: Final Disposition: Home

Patients discharged from ED need Completed Medical Reconciliation form Completed Discharge form

meaningful advice note handouts provided

Documented time and condition at dischargeGreenGreen magnet on the board (chart completed)

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Tips for positive encounters

Establish a good relationship Make eye contact, smile, use their name, sit! Give your title & explain your role in the department

Prove you have heard them Summarize what they tell you Discuss the plan of care with them

Set time expectations Tell them when they can expect to see you again TIP: Overestimate the time Explain delays

Answer questions verify understanding solicit regularly

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Additional Patient Care issues

Clean hands before and after every patient encounter

Patients without insurance should be offered financial counseling

Turn around time goal: 139 minutes

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Charge Resident

Senior pediatric resident identified when possible for each shift

Functions as “junior attending” attention to patient flow attention to sickest patients

Precepts and supervises students and junior residents (including procedures)

Makes arrangements for admissions

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Trouble shooting: Scheduling Questions

I have a conflict with a scheduled shift. What should I do?

Alert the Emory peds chiefs and Dr. Patel via email.

Can I take vacation time during my rotation? Vacation requests should have been submitted to YOUR

program chiefs 3 months in advance.

I’m sick and can’t work my shift. Who do I call? Call your fellow residents (to switch shifts) and the

Emory peds chiefs. If you can, call the ED also and apprise them of the situation.

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Trouble shooting: Evaluation Questions

Who is my PEM program coordinator? Emory Pediatrics: Dr John Cheng Emory Emergency Medicine: Dr David Goo Morehouse Pediatrics: Dr Taryn Taylor Morehouse Family Practice: Dr Tiffany McKinnie Emory Transitional Residents: Dr Mike Ziegler Emory Psychiatry: Dr Debbie Young Emory Family Practice: Dr Debbie Young Emory School of Medicine (MS4): Dr Mike Ziegler Emory Nurse Practitioner Students: Dr Tracy Merrill Emory Physician Assistant Students: Dr Mike Ziegler

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Trouble shooting: Schedule contacts

Emory pediatrics chief residents www.amion.com

Password: emupeds Select “PEC” at the top Select appropriate block with arrow buttons Chief resident emails are at bottom of PEC schedules

Dr. Roshni Patel roshni_patel@oz.ped.emory.edu

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Trouble shooting: Working Environment Questions

How can I address challenges in working relationships with different members of the healthcare team?

Approach them directly when you can have an uninterrupted conversation in private

Discuss your concerns with the attending

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Have a great rotation in the

Pediatric Emergency Department!