Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page

KCHC Pediatric Emergency Department

A Message from the director
Pediatric Emergency Medicine (PEM) is a division of Department of Emergency Medicine. The Pediatric ED at KCHC is the only state –designated level 1 trauma center in Brooklyn, and operates 24/7. The Pediatric ED is a gold mine of pathology and provides tremendous opportunity to serve the children of central Brooklyn. The purpose of this outline is to provide brief administrative aspects of the functions of the Pediatric ED. It is a privilege to serve children and we hope you will enjoy exercising this privilege!
Administration
Dr. Binita R. Shah is the Director and Dr. Jose Jule is the Associate Director. Drs. Shah and Jule as well as Dr. Agoritsas provide a liaison with the Department of Pediatrics. Ms. Rosamond Payne is the Administrative Nursing Director for the Dept. of Emergency Medicine. Pediatric and EM faculty staff the Pediatric ED. Residents from the departments of EM, Pediatrics, Family Medicine, combined EM/IM program rotate through the Pediatric ED. 3rd year and 4^th year medical students as well as PA students also rotate through the Pediatric ED.

About 30,000 sick and injured children are seen in the Pediatric ER annually.

ED description
Clinical Services operated by the Pediatric ED include: Asthma Room, Main Emergency Room, and CCT.
In-patient wards
Pediatric In–patient wards (total beds: ) are D-6 south and D-6 North (in-patient tower / “D” building 6^th floor). PICU (8 beds) is located also on the D-6 north. There are also 3 observation beds (“stepped –down” unit) located on the D-6 north.

Neonatal ICU is located on D-5 (“D” building 5^th floor) along with regular nursery.

Triage

• 
  When the patient first comes to the Peds ED, he/she is first evaluated by the triage nurse who will determine if the patient needs to be seen immediately or if stable, to be triaged. Simultaneously, the clerical staff will log on patient. The area clerk will do full registration later. The triage nurse will then assign acuity of visit (ESI). Triage policies can be obtained from the Pediatric ED Nursing office.
  

• 
  All patients brought by EMS are triaged at the EMS receiving area.
  
• 
  Patients presenting with acute asthma are seen by the triage nurse at the front desk or by the main EMS triage nurse and brought immediately to the asthma room for treatment. Nebulization treatments are given by the nursing staff assigned to the asthma room.
  

Medical patients

Regular rooms are used for evaluation of physical/sexual abuse, GYN and short procedures. Room # 6 is dedicated for moderate sedation and room # 7 for surgical procedures. Cubicles are used for short ED visits. There is also an isolation room equipped with negative pressure and has its own bathroom. Any patient with exposure to measles, chickenpox or other infectious disease will be placed in the isolation room and evaluated there by the physician.
Critical patients

• 
  If a patient is critically ill, they are to be taken to the Pediatric CCT area.
  
• 
  The charge nurse and the attending-on-call or the senior EM resident is responsible for assigning the roles during the resuscitation.
  
• 
  Please visit the CCT Pediatric Trauma Room and get to know where equipment and materials are located. In the CCT Pediatric Trauma Room, there is a Broselow cart that contains all necessary airway equipment.
  
• 
  After patient stabilization, if needed, patient can be escorted to the X-Ray room. However, portable X-Ray is available in the CCT area.
  

Surgical and trauma

All surgical / trauma patients are triaged to the acute area. These patients are seen by the ED staff, and pediatric surgery is available for consultation (up to 13 years of age for major trauma).
OB
Less than 20 weeks gestation is to be seen in the Pediatric ED. More than 20 weeks gestation to Labor and Delivery Suite after initial triage and ED stabilization.
Telephone triage
We do not give advice over the phone. Parents calling from home seeking advice are advised to seek treatment at the KCHC walk-in clinic, ED or their primary medical doctor.

Age-limit criteria

• 
  Please use age limit criteria as just guidelines and do not let patient suffer because patient is presenting in a “wrong ER with a wrong age”.
  

1. 
   Medical emergencies up to 18 years of age = Ped ER
   
2. 
   Minor blunt trauma up to 18 years of age = Ped ER
   
3. 
   Major blunt or penetrating trauma up to 13 years of age = Ped CCT
   
4. 
   Major blunt or penetrating trauma after 13 years of age = Adult CCT
   
5. 
   Surgical Emergencies up to 13 years of age = Consult Pediatric surgery
   
6. 
   Surgical emergencies in patients older than 13 years of age = Consult Adult surgeons
   

• 
  If a patient is followed-up regularly by one of our subspecialty clinics (e.g. asthma or sickle-cell clinic), then we will see such patient who may be even older then 18 years of age (usually we will see such patients up to their 21^st birthday).
  

• 
  For all cases, where there exists a question as to the appropriateness for triage, the Pediatric ED attending will be consulted and the attending on call will then use his/her discretion to accept or transfer the patient.
  

• 
  Under NO circumstances, patients should be moved between the adult ER and Ped ER just because they are “slightly” either older or younger than the age limit criteria (e.g. a common scenario: a 19.5- year- old patient not followed by any pediatric subspecialty clinic presents to Ped ED with fever and sore throat—please just take care of patient in Ped ED and DO NOT send him/her to adult ED!).
  

• 
  You may also be asked to assist in stabilization of extramural delivery of a neonate who is usually brought to adult ED along with the mother. The neonatal attending will also come and participate in such stabilization.
  
• 
  There is a policy book in the Nursing Office. Please refer to it for any policy
  

questions. Several policies are also available on the HHC intranet.

• 
  There will be an EMS notification to pediatric ED if a pediatric critically ill patient is brought to CCT. However in absence of notification, such patients will be attended by CCT attending and Peds ED will be notified. Pediatric staff is expected to assist in the pediatric resuscitation.
  

Age of consent

• 
  Any person 18 years or older or any person who is parent of a child, or who is
  

married may give consent for medical, dental, health and hospital services for

himself/herself and for his/her child.

• 
  In an emergency, consent is not required if a delay would lead to immediate life threatening events to the person’s health or life. This must be documented on the medical records and signed by the physician.
  

• 
  A “Minor” is defined as an individual under the age of 18 years who has not been emancipated.
  
• 
  In a sexually active adolescent, “consent” is not required when presenting for sexually related conditions.
  

Nursing
A charge Nurse is assigned 24 hours a day. She is responsible for knowing the general status of the ED at all times. She can help coordinate admissions, discharges and transfers. The nursing staff is comprised of clinical nurses, nursing support technicians and unit assistants. Each patient, once registered, is evaluated and a primary nurse is assigned. Emphasis is placed on collaborating with the nursing team for patient care and decision-making. This will definitely lead to cordial work environment and best patient

care. Remember, nurses, clerks and the support people do not rotate at the end of the month and have an interest in providing excellent care. If they suggest a particular way of doing something, most often it is the way it has worked best in similar situations in the past.

Discharge instructions
Before each patient is discharged, they must have an exit interview that will help reinforce your discharge instructions with the family. Computerized Discharge Instructions and patient education materials can be printed out directly from the Micromedex ^R system and MD consult ^R available through the computers at caregiver stations. The parent should sign a copy of disposition note before being discharged. Statements like “preprinted discharge forms given to mother - she understands” shows that communications did occur.

It is very important that you document the following on all discharge instructions:

1. 
   When to Follow up: Many discharged patients require mandatory follow up. These include fractures, pregnancy, wound or burn care, or first urinary tract infections. Other patients do not warrant mandated follow up and thus the disorder will simply run its natural course. However, it is important to advise “as needed” follow up when it is appropriate to do so. If the condition improves as expected, no follow up is necessary. However, the instructions must clearly and specifically state that if the condition persists or worsens or some other problem develops, follow up is necessary.
   
2. 
   With Whom and where to follow up: Specify a date, time, location and with which specialty the patient is to follow up. Depending on specific insurance issues, the patient may require a referral. Please advise the parent to seek additional assistance with their primary care provider regarding the referral process.
   
3. 
   Provide instructions in plain, simple language.
   
4. 
   Avoid the use of medical abbreviations and medical lingo. Please write in a clear language that the patient or parent can understand. For example, instead of “q” write “every” and for ‘P.O.’ write “by mouth”.
   
5. 
   Provide discharge instructions in the language of the speaking patient/parent.
   
6. 
   Document that a translator was utilized when discharging a patient with the assistance of a translator. Always record the name of the translator on the discharge instructions or in the medical record of the ED visit.
   
7. 
   Document a discharge diagnosis, even if it is an impression.
   
8. 
   Provide specific instructions regarding home care for the patient’s injury or illness. These instructions can range from brief instructions such as PRICE (Protect, Rest, Ice, Compression, Elevation) after an orthopedic injury to extensive information with computerized discharge instructions. When you provide a patient/parent with instructions from Micromedex ^R system or MD consult ^R , then document in the ED discharge instructions that the parent was provided with them. (Ex: Micromedex instructions on asthma in children given)
   

Social work
Remember: Social worker can call ACS (Administration for Child Services). There is NO RULE that only physician can call ACS !!!. Social worker can also help in providing referral to community resources and agencies. Usually a 24-hour coverage and assessment is available for child abuse and neglect cases. If a social worker is not available (e.g. mid night-AM shift), please page AOD and they will get a social worker on the phone to assist / guide you.

Physical and sexual abuse

• 
  Patient 18 years and younger fall under child protective services/specialist (CPS) laws and therefore, should have a pediatric consult. The Pediatric ED must ensure proper referrals to CPS, Social Services and appropriate counseling.
  
• 
  There is a Polaroid camera available in the Ped ER to document the signs of abuse. Please speak to the head nurse for assistance. You must document the name, MR# and who took the picture on each photo. Also, if you are documenting signs of physical abuse, place a ruler or another object (quarter) next to the physical finding in order to provide a perspective on the severity of the injury.
  
• 
  From the ED, all the patients (especially sexual abuse cases) are required to follow up at the sexual abuse clinic.
  
• 
  Dr. Dipasquale is also available at beeper (917)-760-1156 if you need a second opinion regarding any case.
  

• 
  Sexual Abuse Follow- up Clinic
  

1. 
   This clinic runs every Monday, 12p-4pm at E- Building 4^th floor as well as Thursday morning.
   
2. 
   Appointment can be made through the clerical staff of either Ped ED or registration (REMEMBER : ALL the clerical staff has been trained to make an appointment)
   
3. 
   Tel # of clinic: (718)-XXXXXXX
   

4. If you have difficulty making an appointment, ask the social worker for assistance

Sexual Assault in Sexually Active Pediatric Adolescent Patients

• 
  Consult Sexual Assault Coordinator through the page operator (# 3141). Sexual assault coordinator for such cases can be paged through the operator all the times (SART Team).
  

Consults

• 
  The information bulletin bears the name and beeper number of the fellow/resident on call for different sub-specialties.
  

• 
  The attending/resident will type the consultation note in the computer after direct communication with the ED staff.
  
• 
  If the patient is to leave the ED for consults to dental, ophthalmology, ENT, Gyn, the chart will remain in the ED, and make sure that patient is sent with a nurse’s aid.
  
• 
  Please make sure also that patient does not get discharge directly by the sub specialist. You must co-ordinate discharge and follow-up with the consultant service.
  

Psychiatry consultations

• 
  There is child psychiatry consultation to the Pediatric ED at Kings County
  

between 9 a.m.- 5 p.m. Instructions on how to contact psychiatry are posted in the bulletin board.

• 
  Patients need to be medically cleared before psychiatry consult is called. If the patient is to be transferred to G-ER, the psychiatry internist is to be called for clearance.
  

• 
  If the child can go home, it is important that we refer them to the walk-in clinic in J building (corner of Albany & Winthrop), open M-F 9:00a.m. – 2:30 p.m.
  
• 
  REMEMBER: Medical clearance in the Ped ED does not automatically mean routine blood tests like CBC and CMP. Patient can be medically cleared just by a history, and well-performed physical examination. Blood tests are ordered only when indicated.
  

Admitting Process

• 
  Once you have decided to admit, let the child’s nurse know.
  
• 
  Communication with the referring physician, if indicated, is very crucial. Please notify the unit clerk to request the bed for this patient.
  

• 
  Patients are admitted to the pediatric team. The “Red Team” or “Green Team” no longer exist. Call the pgy 2 resident for any admission (917-760-1301). The beeper numbers of the team is also posted in the Peds ED.
  
• 
  Call the admitting senior resident on the assigned floor and give your sign-out. All diagnostic work-up, including labs, intravenous access, and first dose of antibiotics, (if indicated) are to be done in the ED. However, there is nothing like a routine lab tests that are required for admission except Hgb/Hct (thus, a child getting admitted for Status Asthmaticus who is not dehydrated does not need BMP just because you are admitting him or you have extra blood drawn by a nursing staff).
  
• 
  Admission to the ICU requires speaking to the Chief Resident/Attending in charge of the PICU.
  
• 
  All the admissions to PICU need to be accompanied by the nurse and a physician. A physician-to-physician communication and nursing –to- nursing communication must be done in detail at the time of admission.
  

Remember: NO one from the in-patient service or PICU has a right to refuse an admission (provided there is a bed available). If you think that patient needs an admission, and if in-patient team disagrees with you, it is still ultimately your decision. You can discuss differences of opinion in a non-threatening manner with the in-patient team, but ultimately YOU ARE RESPONSIBLE FOR THE PATIENTS who are in the ED. No one from in-patient team should ever make a decision without actually examining the patient. Under these circumstances, please do not transfer the patient to another facility as per suggestion of in-patient team. Please page the AOD, and director of service (if required), if you have any difficulty admitting patients.
Transfers

• 
  All calls should be directed to the attending in charge.
  

• 
  If the patient is an inpatient at another hospital, please guide them to speak to the appropriate subspecialty or the Pediatric Chief Resident.
  

• 
  Any trauma patient should be referred to Pediatric Surgery or Neurosurgery as indicated. Do not accept patients on behalf of sub specialist.
  
• 
  ED physician should NOT accept a transfer from an in-patient service at another institution. Refer all the calls to appropriate subspecialty or to Pediatric Chief resident. Inpatient transfer can be directed to the Pediatric Chief Resident on call for direct admission.
  

Documentation

• 
  Your documentation in the ED chart has been called “the final letter to the Jury.”
  

• 
  Please make it legible. You may be the best physician but if you don’t document, no one will believe you. YOU MUST USE YOUR STAMP to sign all your notes.
  

• 
  Please ensure that all residents and medical students write the name of the attending that have discussed the patient with (e.g. “discussed with Dr. -------“). Since there are usually two attendings working in the Ped ED majority of the times, it is very hard to figure out who was the attending involved with the case from a chart lacking such documentation.
  
• 
  All the spaces in the chart have some meaning to it. Please, complete all applicable areas before the patient goes home.
  
• 
  Document any difficulties, altercations or interaction between Parent or Guardian/patient and you. It will help if a complaint arises later on. Please write the time the patient was seen and the time patient was sent home.
  

Follow up- pediatric clinic

• 
  DO NOT schedule patients to return to ER for follow-ups.
  
• 
  If patients are to be recalled in 24 hours for follow-ups, they can be asked to return to the Pediatric Urgent Care or PMD.
  
• 
  Appointment for PCP can be made by the clerical staff of Ped ED or by calling the clinic appointment desk at telephone # [phone].
  
• 
  The PCP can only make all sub-specialty follow-ups. Patient needs a referral paper (prior authorization) from the PCP. Thus, always refer the patient back to the PCP (e.g. a patient with chest pain who needs cardiology clinic follow-up for Holter –send such patient to PCP first who will in turn will make an appointment with cardiology).
  
• 
  There is a schedule (time/day) of all the clinics with their telephone numbers posted in the ED.
  

Follow up- Culture

• 
  For those of us working overnight...
  
• 
  The cultures for that day will print out at approximately 4 am on the computer printer (1/P 172.25.140.131).
  
• 
  Please do not throw this away
  
• 
  The 7am attending will assign a resident to look up these culture reports. When you put in the medical record number in patient search the first page where you pick the visit has the phone number at the top of the page. The cultures are listed by patient name, MR # and ordering MD.
  
• 
  We do not need to follow up the urgent care cultures. If unsure just follow it up- or if you get a call during off hours then it is our responsibility after contacting the patient/family. Please make a notation in the computer.
  
• 
  Under the patient name please click on "documentation/notes". Click on Recall Note and then the reason for the recall (Micro result). Click either in person or telephone- put down the person's name that you spoke with and it will go to "word" where you can put down further documentation like: antibiotics prescribed, the pharmacy where you called, or parent will pick up rx etc...
  
• 
  Please place the printout sheet in the new culture notebook.
  
• 
  You should confirm the phone number in the chart/computer is the correct one or
  

enter it in the discharge note so it can be pulled up again in case the number in the registration is incorrect.

• 
  If you send off PCR studies for Chlamydia or Neisseria in the ED and then treat the patient with oral antibiotics and a “shot”, you must document that the patient was treated in the ED. This will allow the follow up of the positive culture to be aware of what happened in the ED and if a follow up phone call is required.
  

Helpful hints

• 
  If you get overwhelmed in Ped ED (multiple injured or ill children), you can always call Adult ED and speak to the attending in charge. He /she can always send some help whenever possible (REMEMBER : This is one department and we always work a team—like wise if Adult ED is very busy and need any help, please send ED attending or resident to help.
  
• 
  Please DO NOT give fluid boluses, if not indicated (it is Not fashionable to give every one fluid boluses without proper indication and we are teaching wrong medicine to our trainees.
  
• 
  There is NO “SIGNING OUT AGAINST MEDICAL ADVICE” in Ped ED. Be advocate for a child and always try to resolve the differences of opinion with parents in such a way that a child’s health does not suffer.
  
• 
  Parents are not allowed to leave children of any age alone. We will try to relieve them, if possible.
  

• 
  The computer generates all lab slips. Each specimen must be labeled and placed in individual bags. Almost all specimens can be sent to the lab via the pneumatic system.
  

• 
  Procedure notes must be written for each procedure done. Always obtain consent prior to performing procedures (e.g. Procedural sedation). Always document Time Out when indicated.
  
• 
  Residents or attendings performing the procedure are expected to discard the used items after the procedure.
  

• 
  No patient can be discharged until the patient is presented to the Attending who will then complete the chart. Please ensure that all the residents/ medical students / PA students working with you are aware of these.
  
• 
  Equipment failure or any other problems during the shift (e.g. lack of adequate nursing staff) need to be addressed on the same day either by calling Drs. Shah or Jule (if the problem is serious and need to be addressed emergently) or leave a note in either Dr. Shah or Jule’s box.
  
• 
  
  

IMPORTANT PEDIATRIC PHONE NUMBERS

Pediatric ED 3638/3860/3866

Page Operator 3142/43

Admitting 4326/4488 (after midnight)

PICU 7028/7029

D6 South 7033/7034

D6 North 7023/7024

NICU 7020/7016/7048

Social work 3661/62/63

Peds ED 3636/3638

Peds Chief 917-760-0089

Peds admitting pager 917-760-1301

Pediatric Core Faculty

1. 
   Dr. Binita Shah; Director Ped ED; pager [phone]
   
2. 
   Dr. Jose Jule; Associate Director Ped ED: pager [phone]
   
3. 
   Dr. Rachel George; Assistant Professor; pager [phone]
   
4. 
   Dr. Ambreen Khan; Assistant Professor; pager [phone]
   
5. 
   Dr. Gus Agoritas; Assistant Professor; pager [phone]
   
6. 
   Dr. Jennifer Chao; Assistant Professor;
   
7. 
   Dr. Noordin Tejani; Director ACRC, SUNY Downstate Medical Center;
   

cell [phone]

UHB EMERGENCY SERVICES

Introduction
The purpose of this orientation manual is to orient you to the UHB Emergency Services and to help you prepare for your rotation through our department. It is assumed that by this time you have received your clinical shift schedule and spoken with/met with Dr. Kifaieh or Dr. Flood to prepare for the rotation. You will receive a tour of the facility highlighting the physical plant and a description of the available resources and supplies (including airway medications and supplies, resuscitation carts, etc.). In addition, you are expected to be familiar with the UHBES Policy and Procedure Manual, a copy of which can be found on the unit or in the Medical Director’s office.
The University Hospital of Brooklyn
UHB is a 400-bed tertiary care hospital located in the Flatbush section of Brooklyn, New York. The hospital is affiliated with SUNY--Downstate Medical School, with a graduating medical school class of 200 physicians/year. The hospital’s capabilities include all surgical sub-specialties, dialysis, cardiac catheterization, OB/GYN, NICU, and transplant surgery.
Description of Unit
UHBES is a comprehensive Emergency Department . Our physical plant has expanded to a 9,000 square-foot unit with dedicated pediatric, adult and fast track areas. The annual census of the department is approximately 62,000 patients generating greater than 13,000 admissions to the inpatient wards. The unit is a FDNY EMS-designated 911 receiving center and is able to accept both BLS and ACLS ambulances from both the FDNY and private ambulance companies.
Roles and Responsibilities of Resident Physicians
The role of the Resident Physician in the ED is to provide excellent, timely and courteous medical care to our patients. In return, the resident can expect to experience fast-paced Emergency Medicine with a focus on quality medical care. The resident will encounter a “community-type” setting amidst a tertiary care atmosphere. Residents are expected to discuss all patient interactions with a faculty attending physician, and all medical decision-making must be initiated in concert with the attending’s supervision.

Patient Flow
All patients who present to UHBES will be triaged based on severity of illness and receive an appropriate medical screening exam for their stated medical complaint. It is the policy of UHBES that all patients are to be triaged within ten minutes of presentation. Financial information may be obtained during the medical screening process but may not impede the completion of the medical screening exam. All patients will receive a medical screening exam to determine if an emergency medical condition exists. Patients who are determined to have an emergency medical condition will be stabilized utilizing the full resources of the institution irrespective of the patient’s ability to pay. After notification of the inpatient service the attending physician may admit patients who require admission. You must discuss all admissions with the faculty attending physician prior to initiating the admission process. Patients who require services not provided at UHB will be offered transfer to an appropriate facility.
Consults
Specialty consultations are available in all services offered by UHB. The consult policy mandates that all emergency consultations be answered by phone within 10 minutes and in person within 30 minutes. It is expected that the physician requesting the consult will complete and sign the required green consultation form (UHB 44). Urgent consults may be seen within 3 hours. If, as the resident physician, you are having difficulty contacting a given service, you are to discuss this immediately with the ED faculty attending of record for the case. Obstetric consultation for all stable pregnant patients will take place in the Labor and Delivery unit (NS 33)—you do not need to inform the OB service prior to sending stable pregnant patients upstairs. However, you must discuss the status of the patient and the faculty attending must examine the patient prior to the patient leaving the unit. The details of the consultation policy may be found in the UHBES Policy and Procedure Manual. Patients may only be sent to outpatient suites [dental, ENT, GYN (suite G)] for emergent consultations at the discretion of the attending physician, and only if accompanied by qualified medical personnel. In addition, patients may not be sent for follow-up care at outside institutions (i.e. KCHC, etc.).
Admitting Process
At the time it is determined that a patient requires admission to the hospital, you must discuss the case with a faculty attending physician. Either you or the faculty attending physician must discuss the admission with the appropriate inpatient service attending physician. Patients without an attending physician at UHB are to be admitted to the attending-on-call for the required service. Residents may act as proxy to accept admissions but may not refuse admissions. All admissions must be discussed, either in person or by phone, with the admitting attending of record or his/her proxy. No patient is to be admitted to any service without prior appropriate notification. Monthly call schedules for all UHB services are to be found in the blue on-call book. The details of the admissions policy may be found in the UHBES Policy and Procedure Manual. The resident should document in the medical record with whom the case was discussed (Private Attending, On-call house-staff, consults, etc). The Department of Medicine has in place a hospitalist program to provide medical coverage for patients who are to be admitted who do not have a personal physician.
Boarders
Patients who are admitted to the hospital but who do not have beds are to be cared for by the admitting service. The transition to the in-patient team takes place at the time admitting is called and the team notified, NOT at the time a bed is assigned. The inpatient team is expected to write admitting orders and provide care. The ED attending is expected to intervene if any emergency arises or the patient’s status changes. The details of the boarder’s policy are in the UHBES Policy and Procedure Manual.
ICU Admissions
The respective unit must accept patients who require admission to either the MICU or CCU. If a dispute arises about the ICU admission the discussion must be attending-to-attending and all involved services must be part of the discussion. Currently there is an intensivist in-house 24-hours daily. If the ICU cannot take the patient because of operating above capacity, the ICU team may accept the patient as a boarder and care for the patient in the ED. If the ICU will not care for the patient the director of the ICU, the administrator on duty, and UHBES Medical Director are to be notified.
Transfer Agreements
Transfer agreements are in place and protocols approved for the following inter-facility transfers once initial stabilization has been achieved:
Burn: Patients requiring burn unit admission are to be transferred to NY Hospital, Cornell University or Staten Island University Hospital.

Hyperbarics: Patients requiring hyperbaric therapy are to be transferred to Jacobi Hospital.

Trauma/Pediatric Psychiatry: Patients requiring admission to either of these services are to be transferred to King’s County Hospital Center.
All transfers must be discussed with an accepting physician at the receiving institution, and prior to transfer, all patients must have a transfer form (UHB #7-83) completed by the Attending Physician, including reason for transfer and the name of the accepting physician at the receiving institution. In addition, the UHB AOD is to be notified prior to transfer.

Pediatrics
Pediatric patients comprise approximately 30% of the UHBES patient census, and as such will comprise a significant portion of your clinical duties. Our new facilities provide a dedicated pediatric ED, including full-time pediatric triage, nursing and physician and physician-extender coverage under the direction of Dr. Nooruddin Tejani, Director of Pediatric Emergency Services. During periods when there is not a dedicated pediatric attending or pediatric resident, you will be expected to care for pediatric patients. Pediatric admissions (NS 42) are to be discussed with the pediatric resident on-call, who can be contacted by calling the pediatric unit. Any child who you feel requires ICU or step-down monitoring must be discussed with the pediatric chief resident. A large segment of our pediatric population is primarily cared for by Downstate Pediatric Associates (718-998-5076) who request that they be notified of all patients affiliated with their group who present to the ED for care. The pediatric ED also keeps a log of all cultures that are taken on a daily basis. The residents will be expected to help follow up the culture results and call back patients as needed.

UHB Administration

• 
  John La Rosa, MD President, SUNY-Downstate Medical Center
  
• 
  Michael Lucchesi, MD Chairman, Emergency Medicine, Interim
  

Medical Director – SUNY Downstate

• 
  Roger Holt, MD Director of Emergency Services
  
• 
  Nooruuddin Tejani, MD Director of Pediatric Emergency Services
  
• 
  Nizar Kifaieh, MD Associate Medical Director
  
• 
  Russell Flood, MD Assistant Medical Director
  
• 
  Judy Drummer, RN Assoc Director of Nursing, ED
  
• 
  Vikki Small Administrator
  

Ancillary Staff
Ancillary services in UHBES are provided by the EKG technicians and Healthcare Assistants (HCA I and II). The EKG technicians’ responsibilities include phlebotomy (but not intravenous access), performing EKG’s, patient transport and clerk relief. The HCA’s responsibilities include patient transport, lab delivery, and patient care assistance. As a Resident Physician, it is expected that your time here will be spent on direct patient care, rather than ancillary duties. All IV access is to be obtained by either the RN or the MD. Techs and HCA’s can NOT obtain IV access. In addition, there is a dedicated ED phlebotomist in the ED from Noon-8p on weekdays (Ms. Lisa Dorce).
Information Systems

At present, UHBES employs several information technologies. We went live with an electronic medical record (T-system) in September ’07. You will be inserviced during your orientation month. Please see Dr. Kifaieh or Dr. Flood if you have any questions about the use of this system. The CERNER system is for lab entry and retrieval, and RIS for radiological procedure entry and retrieval. Prior to your starting in the ED, you should obtain your IS in-service. For RIS, see Mike Vaughn (x4613), and for CERNER see Dr. Kifaieh. It is absolutely imperative that you NOT share your log-in or passwords with your fellow residents, as this is a serious breech of hospital and departmental policy. If you need to renew or reset your password, please see Dr. Kifaieh or Dr. Flood.

Nursing
The UHBES nursing staff is composed of one charge nurse, two triage nurses and at least eight RN’s per tour. UHBES nurses are all BLS/ACLS/PALS certified, and as such are qualified to provide care for Emergency Department patients. Intravenous access is to be obtained by the nurse assigned to that patient. Please be diligent in actively involving the nursing staff in your on-going management decisions regarding patient care. Many of the newly-hired staff are young and eager to learn, but may need guidance in Emergency Medicine patient management.
Radiology Services
The Department of Radiology has made a commitment to our department to provide efficient, full-service radiology services. “Wet readings” of films may be obtained by paging the radiology resident on call during off hours or calling the radiology department during the day. We are currently evaluating a system to provide real-time attending radiology readings of all radiological studies. All plain films are to be reviewed by yourself and the attending physician of record on the PACS system, located in the ED. The radiology department is in the process of transitioning to a 24-hour unit and there may be times on off-hour tours that a technician may need to be called in to perform certain studies. Recently, the nuclear medicine division has pledged 24-hour coverage for emergent nuclear studies (V/Q, HIDA, etc). The senior radiology resident on call should be contacted to discuss all off-hour specialty studies, and the page operator should be utilized to page the technician. If there is difficulty contacting the technician, the AOD is to be notified and the radiology administrator is to be paged. Any persistent difficulties in obtaining studies should be referred to the attending radiologist on-call. All radiological studies are available 24 hours a day, 7 days a week, 365 days a year.
Laboratory Services
Lab studies are available 24-hours daily. It is your responsibility to discuss all lab test results with the faculty attending of record prior to disposition of the patient. Whole blood analysis for blood gases, chemistries, metHb and COHb are presently available on a STAT basis (turnaround time in minutes) 24 hours daily. In addition, BNP is available (must be sent in a separate lavender tube).
Physician Documentation
All patients who present to UHBES are required to register and undergo triage, at which time a chart will be generated. Currently, we utilize the electronic T-system charting tool. It is expected that you will complete the patient chart, providing all pertinent historical, physical, and laboratory/radiological/EKG interpretive information—both positive and negative—prior to patient disposition. All patients must be discussed with a faculty attending physician. It is your responsibility to note on the chart which attending was involved in your supervision of the care of this patient (i.e. “d/w Dr. Smith, etc). If a patient is to be discharged, all patients must have specific discharge instructions (“exit-writer”), including time and place, return instructions, and any medication/care instructions.
Follow-up Appointments
UHB utilizes the EAGLE system for clinic/outpatient appointment scheduling. Any patient who does not have a PCP or any patient for whom you feel a follow-up appointment is necessary should be given a specific outpatient appointment scheduled in the EAGLE system prior to discharge from the ED. All clerks have been in-serviced on this system and are capable of making appointments for all clinics currently on the EAGLE system. The only clinics not using the EAGLE system are General Surgery, Urology, and Orthopedics. These patients are to be given a specific appointment scheduled by the consultant service prior to patient discharge. Several of the outlying satellite clinics (Suite B, Midwood and Throop) are actively recruiting patients for their services, and have very short (one or two day) lag times. In addition, Dr. Zenilman, Chairman of Surgery, asks that any patient requiring a surgical follow-up appointment be given his phone number (x1421) so that the patient may schedule an appointment through his office.

Protocols
Chest Pain: Currently, UHBES is utilizing a formatted chest pain protocol to facilitate prompt, aggressive, standard-of-care treatment for these patients. A standardized order sheet has been developed and it is expected that you will utilize this form in evaluating and caring for all cardiac chest pain patients.

Congestive Heart Failure: All patients admitted to the hospital with a diagnosis of CHF must have a CHF pathway form completed by the physician (either yourself or the attending). It is imperative that these forms be completed and included in the chart to maximize patient care.

Community Acquired Pneumonia (CAP): All patients that are admitted to the hospital with the diagnosis of pneumonia will require CAP pathway. It is to be used to order all ancillary/nurses services and antibiotics. The national guidelines recommend that all patients admitted to the hospital for pneumonia receive their first dose of antibiotics within 4 hours of arrival.

Code H: We have a STEMI pathway (called “code H”) that is to be initiated IMMEDIATELY upon presentation of any patient with a STEMI. Initiation of the cascade is to be signaled upon notification by FDNY EMS that a patient is en route with a suspected STEMI. The pathway is posted in the ED (outside the resus room). Please make sure that the attending is involved immediately in any STEMI case.

Scheduling
ALL SCHEDULE REQUESTS ARE DUE AT LEAST FOUR (4) WEEKS PRIOR TO YOUR STARTING DATE. This is to ensure timely completion of your schedule and maximum clinical benefit from your rotation. All schedule requests should be emailed to [e-mail]. No written or verbal requests will be honored. You will be assigned a number of clinical shifts (usually ten hours in length, 8 hours for overnight) in accordance with your clinical requirements as dictated by the Department of Emergency Medicine. (Please note any religious commitments well in advance when making your schedule requests).
Of course, you are expected to be on time and to stay in the clinical area at all times. You must stay in the clinical area until your relief has arrived to ensure appropriate patient “sign-out”. The Director or Assistant Director of UHBES must approve all scheduling changes and “covered shifts” in advance. In addition, in the case of a personal emergency or illness, you MUST contact Dr. Holt or Dr. Kifaieh, as soon as you know you will not be able to attend your shift. You must also contact Ms. Stephanie Lane, the Chief Resident on-call and the Residency Director, Dr. Doty. All missed shifts will be made up.
Dress Code
As a representative of UHBES, it is expected that you will dress professionally in the clinical area. As such, “scrubs” are not permitted during daytime shifts (but are permitted on overnights).
PMD Notification
UHBES is committed to fostering a close, professional, and efficient relationship with the primary care physicians in our community. In an effort to enhance this partnership, you are asked to be diligent in your effort to discuss your care and disposition plans of all patients with known PMD’s who present to the ED. This includes both admissions and discharges. Please document on the medical record the name and time of the attending with whom you discussed the case. Please pay particular attention to the patients who are followed by the Family Practice service. They do have an inpatient service at UHB, and are almost always willing to accept admissions for their patients. The FP outpatient service is located in Suite B
Ground Floor Response
In accordance with the EMTALA regulations, UHBES has accepted the responsibility to respond to all calls for assistance originating from the basement, ground floor of the hospital/medical school, and within a 250-yard perimeter of hospital/medical school grounds. The attending physician is expected to provide medical coverage for these calls in conjunction with the “code team” response unit. This policy is outlined in the UHBES Policy and Procedure Manual. You may be asked to accompany the attending physician on one of these calls during your rotation.
Resources
UHBES is dedicated to providing the resident physician with the most up-to-date, clinically relevant Emergency Medicine resources available. To that end, internet access is available in the clinical area to allow you to research current guidelines in diagnostics and therapeutics.
Summary
In summary, we welcome you to our rapidly expanding ED and look forward to working with you to develop your clinical skills and to facilitate patient care in our ED. We feel that our facility will provide you a unique Emergency Medicine experience, combining a community atmosphere with a tertiary care setting. Please remember that we are very open to suggestions on ways to improve our rotation—we want to work with you. Your feedback is very important to the success of your rotation, especially if you discuss your concerns in real-time--please do not wait until the end of your rotation to voice a concern or raise a suggestion. Again, welcome to UHBES.
Useful Phone Numbers
Roger Holt, MD Bpr: [phone]

Email: [e-mail]

Fax: [phone]

Nooruddin Tejani, MD Bpr: [phone]

Email: [e-mail]

Russell Flood, MD Bpr: 917 219-6411

Email: [e-mail]

Nizar Kifaieh, MD Bpr(917) 761-1287

Email: [e-mail]

Joneigh Khaldun (Chief Resident)

Email: [e-mail] (Cell)215-307-0207

Aquila Lewis [phone]
Page Operator X2121

UHBES IMPORTANT NUMBERS

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  CATH LAB x4282, x4278
  
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  Chest pain unit (NS 41) x8716
  
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  Vascular ultrasound (daytime, weekdays, 5^th fl.) x2515. Send pt with green consult sheet.
  
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    Off-hrs (Mon-Fri till 9p) call x2515 leave message or page tech Diana Palterman 917-219-4749
    
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  GYN ultrasound (weekdays 9-4) speak with Dr. David Sherer, Director of MFM at x3901 or page at 917-761-1039. Please be sure to speak with Dr. Sherer prior to sending patient upstairs.
  
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  ON CALL SCHEDULES are located in the BLUE ON-CALL BOOK
  
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  MICU consults x2701 to speak with resident/fellow/attending
  
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  Neurosurgery: Mon-Fri 8a-5p (PA on-call) 917-760-1374. Other times contact attending directly.
  
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  General Surgery follow up appointments:
  
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    Zenilman x1421 (Marisa)
    
  • 
    Schwartzman x1791 (Lana)
    
  • 
    Breast Health Partnership 718-270-8846
    
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  Urology appointments
  
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    Adult x2554, x1406, x2429, x4448, Dr. Macchia—Chair x3237 or 917-760-1075 any problems
    
  • 
    Peds x1958
    
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  Dental clinic Dr. Susan Pugliese. x1884 (dental clinic, behind Suite H); (bpr) 888-341-6219
  
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  OMFS Dr. John McIntyre cell (preferred) 718-809-7712, beeper 917-219-8164
  
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  Hospitalist’s Office x7303
  
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  GI clinic appointments 718-282-7234
  
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  PA service Office x2549, x2999
  
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  Radiology reading rooms: Dr. Shwarzberg office x1603, Radiology resident on-call beeper 917-760-1124
  

Room MD and/ or Service Telephone

B2-324 Neuro, Dr Nath 7212

Body CT, Dr. H. Zinn 7209

Chest, Dr Waite 5061

Body, Dr. Choi

Resident Stations 7211, 5081

A2-610 Body CT, Dr. H. Zinn 4134

Neuro, Dr. Nath 4645

A2-605 Sono (6730)

Peds, Dr. Amodio (6730)

Mammography, Dr. Corsaro 4273

Resident Station (on Wall) 4133

A2-621 Nuclear, Dr. Strashun 1902

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  Blood Bank for all EMERGENT blood products x4630. In addition, page the on-call blood bank resident. Attending: Dr. Gloster 917-760-1428; Supervisor: Irene Swiderski 917-218-2407
  
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  ED Psychiatry on call (24/7) 917-218-1353
  
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    DMHA (outpatient psych) 287-4806
    
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  Staten Island University Hospital Burn Unit [phone]; appt desk [phone]
  

Affiliate Phone Numbers

THE BROOKDALE HOSPITAL ED

Meeting Place: Brookdale ED

One Brookdale Plaza

Brooklyn, NY 11212
Daily Rounds: 7am and 7pm daily

Shifts: The Brookdale ED shifts should be the same in number and length as at KCH.
Introduction:

The Brookdale Hospital Medical Center is a 595 bed urban teaching institution and a fully integrated site for the Emergency Medicine Residency Program at SUNY Brooklyn. The Emergency Department is a designated Level I Trauma Center with approximately 104,000 visits per year.

Working in the Emergency Department at Brookdale Hospital is both challenging and rewarding. The atmosphere is highly charged and the spectrum of illness and pathology is staggering. Although a private hospital, the Emergency Department experiences are similar in volume and congestion to typical other public, inner city hospital. The Brookdale Hospital Medical Center serves a minority and immigrant population from the Brownsville and East New York sections of Brooklyn.