MLP ORIENTATION

WORKSHOP 1

Objectives

• Orientation overview• Department orientation• Work flow• RACE team• RME• Fast Track• Physician consults• Charting and documentation

Orientation Overview

• Business Office orientation• Hospital Orientation • New Employee Orientation (guideline)• Epic MHS training + provider oreintation• Workshop 1• Workshop 2• Shadow + Mentorship shifts

New Employee Orientation

Workflow

• Sign into Epic• ASCOM phone• Huddle with charge RN and attendings• Objectives shift specific / location specific

TG Workflow

Tacoma General 10-8p

• 1000 – 2000• ESI 4 and 5 patients in Fast Track

– Signs up as attending • Waiting room RME of patients

– Signs up as attending then “end assignment” in Treatment Team tab– Turns patient RME status on track board

• Physician extension tasks – Laceration repair– Procedures– Consultation– Dispositions– Re-assessments

Tacoma General 2p-12a• 1400 – 0000 (Huddle) • RME WTBS patients in main ED (sickest first) if unable to be seen

by physician – Signs up as attending, gets taken over by attending

• RACE Team– Signs up as attending then “end assignment” in Treatment Team tab– Turns patient RME status on track board– ESI 2, then 3 by LOS– If all 2 and 3 done, treat and street ESI 5

• Assist with Fast Track ESI 4 and 5 patients • Co-management of patients with physician in main ED • MLP signs up as PA or ARNP in MLP column

RACE Tacoma General

RACE Allenmore

RACE Covington

Rapid Medical Evaluation

• Assign as attending• Label as RME• Brief H&P• Labs + Imaging• Comfort

medications• Consult as needed

Fast Track

• Verb… not noun• Goal evaluation <80 min• ESI 4 + 5• Seen independently, consult prn • RN + tech• Focus on oral medications and limited

workups

Co-manage patients

• Initially assigns as attending• Perform H&P• Initiate labs + imaging• Consult attending early• Change assignment to PA

or ARNP once consulted• Re-consult after workup

complete to discuss management

Mandatory Consultation

• ESI 1 or 2• Unstable VS – HR >110 or <50– SBP <100 or >220/120– RR >24 or <8– Pulse ox <95% (unless baseline)– Abdominal pain >50 yrs old– Altered mental status

• Active / uncontrolled bleeding• Anaphylaxis• Chest pain >35 yrs old• CVA / TIA• Joint dislocation (other than digits)• Falls associated with near syncope / syncope• Open fractures

Mandatory Consultation

• Pregnancy with abdominal pain or bleeding• Post surgical complications• Procedural sedation• SOB with abnormal vital signs• Telemetry indicated• Unexpected (non-follow up) return visit• Pediatrics <12 mo, or <3 yr with fever

Mandatory Consultation

Consultation

• Start with reason for consult: run it by you, ED consult, asking for admit.

• ED presentations: ok to not be sure• Concise presentations• Other consultants: specific questions.• Know what you want

Consult case 1

• 22yo M c/o abdominal pain. Constant, began 4 hours ago, radiates to R testicle.

• No PMH/PSH/meds/allergies• VS 140/92, HR 115, RR 30, T 37• Exam: R testicle swollen and painful.• Labs: normal. US no flow to R testicle

Consult case 1

Dx:• HPI:• Plan for care?• Reason for consult?• Present to the ED attending• Present to consultant.

Consultation case 2

• 51 yo man c/o left lower leg pain and swelling for 4 days.

• PMH: DM, HTN• PSH: none• Meds: insulin, lisinopril• VS: 130/80, HR 130, RR 22, T 38.2• Left leg swollen, red, hot to touch. • WBC 20, lactate 4, glucose 600, AG 30, Co2 10

Consult case 2

DX:• HPI:• Plan for care?• Reason for consult?• Present to the ED attending• Present to Consultant. Recommends discharge

after insulin bolus and single dose of IV antibiotics.

Consult case 3

• 25yoF presents to c/o back and leg pain that began several hours after an intense crossfit workout.

• No PMH/PSH/meds/allergies• HR 90, BP 120/80, RR 18, T 37• Exam: uncomfortable. Moderate paraspinous

tenderness. Neuro exam normal.• Labs: CBC/CMP normal. UA +heme, no RBC, CK

4,000

Consult case 3

DDX:• HPI:• Plan for care?• Reason for consult?• Present to the ED attending

Consult case 4

• 45F HA x3 days. Sudden onset 12 hours ago. +vomiting and photophobia. Worst HA of life

• PMH: migraines• VS: 192/120, HR 88, RR 20, T 37• Exam: uncomfortable, otherwise normal• CT head: negative• LP: +xantochromia, + 100,000 RBC

Consult case 4

Dx:• HPI:• Plan for care?• Reason for consult?• Present to the ED attending• Present to consultant.

Specialist Consult

• Consult ED attending first• Medicine– More detailed information– Tell the story of the patient’s problem– Review recent admissions, clinic visits, imaging

• Surgery– Ask your question first– Brief presentations– Review prior surgeries, admissions– Cedar group is different than ACSS

Charting and Documentation

• Chart at appropriate level (3 – critical care)• Don’t forget PMH, PSH, FH, Soc, etc…• HPI: OPQRST• MDM– Initial impression, DDx– Workup and impression of objective data– How this supports / refuts your DDx– reassessment– Final impression and treatment plan

Resources

• PSR website– EGO charting tips and tricks– Pdf of previous education lectures

• Textbook– An Introduction to Clinical Emergency Medicine

• Education Website– Tecpedu.net

• Fundamentals of Emergency Medicine• Resident Page• Procedures• CME• Blog

From Here

• Workshop 2– Procedural

• Select evaluation dates– 30 day, 90 day

• Reach out to mentors / sponsors – Set date and agenda

• Review onboarding materials

Questions

• Epic questions– Dot phrases– Preferences– Macros

• Workflow