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Emergency Department

Orientation Part I

Developed by:

Lori Baker, RN, BSN

Mission and Goals

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See Orientation Notebook

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Your Orientation Notebook

• Most of your orientation material will be found on Quia (pronounced key’-ah) in an effort to do our part in saving the environment

• Some copies have been made of the material you will use more often so it will be close at hand during your orientation

• We will review both electronic material and hard-copy material during orientation so always bring your notebook with you

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Beyond Orientation – Any Questions?

• Employee Health• Infection Control• Restraints• Wound and Pressure Ulcer

Management• VTE and SCD• Hyper/Hypothermia

Systems• Telemetry/Cardiology

• Body Safety and Patient Transfers

• Codes• LifeNet• IV Therapy• Pain Management• Informed Consent• Blood Administration • Swallow Screening

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Become Familiar with Your Department

• Acute, MEC, and Triage• POCT• Breakroom, Locker room• Utility rooms• Patient rooms• Core• Storage rooms• Ancillary departments

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Kronos

• Clock in and out NO MORE THAN 7 MINUTES before or after your scheduled time

• No meal must be signed by charge nurse• PTO and sick time should be put in by the

employee (when possible)• Overtime must be approved• Exception log is located at the charge

nurse desk – use if badge does not work, you were at a meeting somewhere other than the hospital, etc – must be signed by charge nurse

Remember…

•If you clock in after your assigned start time you are still late

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Scheduling

• “Wish list” in breakroom • NOT guaranteed

• Sign up for your weekend or holiday• May use an “R” one time per 2 weeks• May not be actual schedule when it comes

out – check it!!!• Masters, daily's, and sign-ups are in the

schedule book at the charge nurse deskSee tip sheet

on QuiaDuring your orientation, you are to work your preceptor’s schedule unless other arrangements are made. For consistency, please make every effort to adhere to this arrangement unless absolutely necessary.

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Holiday Rotations• Full-time and part-time – one major and

two minor, alternate with two major and one minor

• OPT – one major and one minor per year• Work your usual shift• You will be assigned to group “A” or group

“B”• NSER-215 scheduling of Weekends-

Holidays is the policy listing what is considered major and minor holidays

See tip sheet on Quia

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Call in procedure

• For sick calls, call Nursing Administration at 304-264-1000 ext 1782

• Call-ins are considered unexcused

• Put in your own sick time in Kronos

• Please refer to…

for details

NSER-216 Sick Call-InsSee tip sheet

on Quia

Education

• General Hospital Education• NetLearning

• ED Specific Education• Quia

• Instructions in orientation notebook• You will be given a specific

username and password for this

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Mandatory Education• Intranet>Departments>Education

• Accu-Chek• Blood administration• Braun IV pumps• Blood culture collection

• Fill out and send to hospital education department via email

• Mandatory every 2 years: BLS, CPI, ACLS, PALS• Mandatory every 4 years: TNCC

• TNCC is done through the ED, not the hospital education department

• This is counted as hours worked – don’t forget to clock in for these

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One day per month

0715 and 1400 in dept.See tip sheet on Quia

•Must sign off on 100% or staff meeting minutes

•Minutes are in a book at the charge nurse desk

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Huddles

• To be done every 12 hours by clinical coordinators at the beginning of the shift

• It is your responsibility to to be at the charge nurse desk on time

• The object is to disperse up-to-date ED pertinent information

• Changes weekly• Huddle book at charge nurse desk

See tip sheet on Quia

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Dress Code• Colors

• Primary-navy, white and gold for nurses• Any combination• Prints acceptable, only in these colors• Techs – burgundy with gray accent color

• NO thermal or denim fabric• NO T-shirts

• A thin T-shirt of department colors may be worn under the scrub top

• NO logos or pictures visible• May NOT hang below the scrub top

• If a cover-up is needed it MUST be a uniform scrub jacket• NO sweatshirts, hoodies, sweaters, etc.

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Dress Code

• Holiday Scrubs• Appropriately themed holiday scrubs may be

worn for the following holidays ON the holiday• Christmas – may wear the week before

through New Years Day• Thanksgiving• Valentines• Easter• 4th of July• St. Patrick’s• Memorial

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Dress Code• “Free Friday”

• Alternate colors/patterns of scrubs may be worn on Fridays

• Still NO denim, flannel, or thermal material• Must be professional and of uniform style (i.e.

no fatigue patterns, etc.)• With all uniforms

• Tight fitting clothing is inappropriate• Underwear should never be visible (even when

bending or stooping)• Tattoos must be fully covered• Hair should be up off collar and out of face• Beards and mustaches should be neatly

trimmed

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Dress Code• Shoes

• No open toed shoes allowed• Shoes should be able to be washed or

autoclaved• Athletic-style shoes may be worn

• Keep in mind all the fluids you may be exposed to

• NO body piercings other than 2 earrings per ear should be visible

• No artificial nails, tips, wraps or other type of extension

• No perfume or cologne• Make-up should be minimal and in good taste

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Vocera

• Vocera• Hands free communication device• MUST WEAR EVERY SHIFT • Part of uniform-NOT an option• Issued own personal device to keep• Batteries in breakroom

See tip sheet on Quia

HIPAA

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Confidentiality

• Electronic information• Minimize screens• Only use EMR for appropriate use• Do not look up any patient you are not directly

taking care of (including relatives and friends)• Verbal

• Clinical information for patient care• Be careful who, what and where• Be very cautious using the Vocera (DO NOT use it

in or near a patient care area)

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Other Access

• EPIC• Meditech• Omnicel

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REVIEW TIME!!!

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ED Documentation

• Most documentation is done through EPIC on the computer

• Exceptions are the following, which will be done on paper forms:• Traumas• Codes• Suicide risk assessments• Disposition of Body Form• Waiver of medical screening• AMA/Refusal to TreatSee tip sheet

on Quia

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Computer Downtime

• Appendix F in downtime procedure manual (link is on Quia ED Orientation page)

See tip sheet on Quia

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Consents

• Types• Informed – fully explained – sign• Implied – ex. Cardiac arrest• Phone consent – document reason and

2 witnesses• No mind altering drugs before getting

consent

See policies on Quia

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Telephone Consent

• If parent, MPOA unable to give written consent, can consent over phone

• Documentation:• MPOA ( write name of representative)

is unavailable to sign an informed consent because (write the reason), but has consented over the telephone for (write the procedure)

• Two witnesses to sign, date, time• Please refer to the following policy for

all consents:• CH ADM-301-Consent Policy

See policy

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Consent of Minors

• Minor – under age 18• Emancipated minor - <16; court declared

or married• Mature minor - >16; deemed mature by

physician• Minor consent must be given by parent

otherwise• Exceptions: pregnancy, birth control, STD,

substance abuse• Minor can give consent for own child

See policy

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EMTALA

• Emergency Medical Treatment and Active Labor Act

• Require medical screening• Stabilize and transfer if appropriate• Need receiving MD name and a bed• Consents to treat signed• Medical chart sent with patient • Nurse-to-nurse report• DOCUMENT

Policy on Quia

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Triage• QUALIFICATIONS:• Licensed in West Virginia• ACLS, PALS, [TNCC and CEN preferred]• Demonstrated competence evidenced by completion of a triage

checklist and preceptor evaluation. A formal class will be provided.

• Effective 1/1/03, nurses that have worked 6 month in ED with prior experience can Triage OR 1 year without prior ED experience. However, all nurses must attend the class prior to being assigned to triage.

• Effective interpersonal and communication skills and the ability to work collaboratively and effectively interact with public

• Flexibility/adaptability to rapidly changing situations • Ability to use decision-making skills

• Excerpt from ED Operational Guidelines/Triage Nurse

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Triage

• ESI V Level Triage• Emergency Severity Index• Separate class will be scheduled once

you meet the qualifications

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Immediate Bedding

• Trial began June 3, 2013 (still ongoing)• Patient presents to front desk• Pivot nurse directs patient to a bed by

chief complaint and general rapid assessment

• Bedside nurse performs “triage” assessment

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Advanced Triage Protocols (ATPs)

• Pre-set procedures to follow for patients presenting with the following:• Abdominal pain• Flank pain• Sore throat• Pyrexia/Pain• Orthopedic• Chest pain• Psych complaint• Suture removal• Chest pain

Please refer to the specific protocols on Quia

See separate Quia page for

ATPs

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Code STEMI

• EMS or walk-in

• 12 lead EKG to be transmitted from EMS, otherwise, EKG within 5 minutes

• Physician calls Code STEMI

• Unit secretary calls 1-911 to page the Code STEMI

• Cath lab nurse and Hospitalist transport patient to cath lab

• Door to cath goal 90 minutes (or less)

• Document time accurately!!!• Please refer to the handouts in your orientation

notebook

See orientation notebook

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Ten-minute EKG

• For all chest pains of patients >16 y/o• If they present to triage, place them on

a stretcher and do the EKG BEFORE bringing them back to a room

• As soon as the EKG is done, show it to a provider immediately (and document that this was done.

• Place ALL chest pain patients in a wheelchair as opposed to walking them to a room

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Code Stroke

• Notification from EMS (or walk-in)• Page for Code Stroke initiated by

physician• Draw labs if not done by EMS• Send to CT • Vitals and repeat fingerstick glucose• NIH stroke scale• Contraindications to thrombolytics• Please refer to the handouts in your

orientation notebook

See orientation notebook

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REVIEW TIME!!!

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Admissions Process

• Admitting physician enters orders in EPIC• Nurse views admission orders• Nurse enters a bed request• Page or call for bed• Call report• Transport patient to assigned bed

• Discharge from ED• See policy on Quia

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Gateway Admissions (Psych)

• Crisis worker evaluates patient in ED• ED medically clears• Same admission process• When admitted, patient is escorted to

Gateway with crisis worker and security guard

See tip sheet on Quia

Policy also on Quia

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Suicidal/Homicidal Risk Assessment

• Suicidal/homicidal pts should change into paper scrubs. Belongings out of room.

• Ensure room clear of IV tubing, wires, etc.• Notify security only if needed

Policy found on Quia ED Orientation Page

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Commitment• Involuntary• Clear and present danger to self or others• Deprives patient of rights and freedoms• Petition filed at county clerks office • Patient to ED for evaluation by

psychologist• Hearing takes place• Decision by mental hygiene commissioner• Patients pending a commitment hearing

will have PD at bedside at all times for duration of hold order

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Restraints

• RN may initiate but physician order must follow

• Identify alternatives to physical restraints first

• Monitor circulation, measure dignity, behavior, loosen every 2 hours, provide hydration, elimination, passive ROM every 4 hours

• Document on restraint documentation

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Abuse - Reporting

• Mandatory reporting of child and incapacitated adult abuse is to be made to the DHHR

• Domestic violence is not mandatory reporting in WV• Provide community resource

information

Policy on Quia

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Blood Alcohol

• If it is to be used as legal evidence• Law enforcement requests level to be

done• Consent is to be signed by officer and

patient• Individual kits• Lab may draw the specimen• Please refer to ED Operational

Guidelines/Blood Alcohol Testing WV CodeSee guideline

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POCT (Point Of Care Testing)

• Located next to triage• Become familiar with their policies

• Intranet>MCN Policy Manager>Lab>Point of Care Testing

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•Accurate weight

•Obtain vaccine and Ig from pharmacy

•Rabies form (see example on left)

•When first vaccine is complete, make 3 copies

•Patient

•Triage

•Chart

See guideline on Quia

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Interpreter Service

• Hearing Impaired• DT Video Interpreting Services

• (housed in care management department on 3rd floor)

• DEAFNET(301) 791-9025 or

• Policy: CH ADM-320 Obtaining Interpreter and Other Services...

See policy

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Interpreters

• INTERPRETER’S FOR NON-ENGLISH SPEAKING… See CM Policy for same which lists the following:

• LANGUAGE LINE, LLC• Telephone # - 1-866-237-0173• Language ID Code - 25401

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Precipitous Delivery

• Call OB charge nurse• Notify physician• Overbed warmer from supply room

which has to OB pack in it• Any patient at 18 weeks or beyond

with complaints of abdominal pain, call OB

• We keep under 18 weeksSee guideline

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Workplace Violence

• Zero tolerance• Verbal or physical• Incident report• Patient or staff involvement

See policy

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Valuables Policy

• To secure patient valuables call control center (3-1430)

• Security officer and patient sign (or witness if patient unable)

• One copy to chart• Admissions need “Patient Valuables

Record” completedSee policy

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Safety and Security

• Become familiar with the hospital policies pertaining to safety and security• Intranet>MCN Policy Manager>Safety

and Security• Be aware there is a silent alarm at triage,

MEC, and Acute care areas that go directly to the control center

• Call ext 3-1430(control center) for security• If PD is deemed necessary, the control

center will notify them

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Forensics

• Evidence collection/preservation• GSW, stab wounds• Sexual assault

• SANE• Chain of custody

See policy on Quia

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Law Enforcement Issues

• Patients under arrest• Law enforcement stays with patient at

all times (prefer 2)• Restriction of rights up to the officer (i.e.

visitors)• Notify security of patients arrival• Forensic restraints to remain on (i.e.

handcuffs)• Unarmed officer at bedside, armed

outside the room

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Law Enforcement Issues

• Scenario• An officer asks you to call PD when a

patient is discharged, so that an arrest can be made

• What to do…• Such a notification poses a violation of

patient confidentiality. Therefore, the officer must explain options to the patient

• If patient consents, document with patients signature, officer signature, and hospital staff witness

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Reporting Deaths

• Organ/Tissue donation• 1-866-LIFENET• ALL deaths are reported• Potential imminent death, such as severe brain

trauma, call for possible organ donation• Documentation

• Coroner Notification• County medical examiner• Sudden, unexpected death (i.e. suicide,

homicide)• Leave all tubes in place• Disposition of body form

See several policies

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Post-Mortem Care• Secure valuables• Death certificate• Notify LifeNet• Eye care• Notify medical examiner (see policy on Quia)• Notify funeral home • Do not remove any drains, IV’s, catheters if

this is a coroner’s case Wash body if needed• Shroud and tags• Removal of body• Disposition of body form

See policy

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