1. Orientation to the Pediatric Emergency Medicine Rotation Children’s Healthcare of Atlanta @ Hughes-Spalding

2. 2 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.

3. 3 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 www.pediatrics.emory.edu/divisions/emergencymedicine

4. 4 Expectations  What to expect of the faculty (attendings and fellows)  What the faculty expects of you

5. 5 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.

6. 6 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.

7. 7 Expectations of the Learners (outline)  Before you begin the rotation  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

8. 8 Expectations of the learners: Before you Begin  Obtain your schedule  www.amion.com. Password: emupeds www.amion.com  Activate your name on the Teaching Portal website: www.pediatrics.emory.edu/divisions/emergencymedicine 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 donna_stringfellow@oz.ped.emory.edu  (404) 785-7142  Review/complete all pertinent material and links: Orientations, PreTest, Learning Modules

9. 9 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”

10. 10 Expectations of the Learners (outline)  Before you begin the rotation  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

11. 11 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)

12. 12 Expectations of the Learners  Before you begin  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

13. 13 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!

14. 14 Expectations of the Learners  Before You Begin  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

15. 15 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!

16. 16 Expectations of the learners  Before you begin  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

17. 17 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

18. 18 Documentation: History & Physical  Date & Time  Chief Complaint  Targeted HPI  Relevant ROS  Past Med/Fam/Soc  Physical Exam with available Vital Signs (includes pain & weight)  Legible signature

19. 19 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!)

20. 20 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.

21. 21 Documentation: Order Page  Initial & time each order  Initial & legibly sign in designated space  Use separate Physician Order sheet for:  pharmacy orders  extra orders

22. 22 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!

23. 23 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

24. 24 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.

25. 25 Documentation: Medication Reconciliation  Review and sign on presentation: note date & time  Review and sign on discharge: note date & time

26. 26 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

27. 27 Documentation: Discharge Instructions  LEGIBLE  Avoid medical jargon (5 th 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

28. 28 Documentation: Discharge Time & Condition Review & sign :  Condition on discharge  Disposition Time  Disposition Location

29. 29 Expectations of the Learners  Before you begin  Attendance  Dress Code  Professional Behavior  Documentation  Patient Care

30. 30 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

31. 31 How-To care for patients in the Pediatric Emergency Department  Identify yourself to the attending, staff  Identify next patient to be seen  Perform and document history & physical  Present case to attending, fellow or charge resident  Place orders (magnet system)  Monitor status of orders  Reassess patient (and document)  Make final disposition

32. 32 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

33. 33 Step 2: Identify next patient yellow  Look for patients on board without a physician assigned (yellow magnet) Check “time to room” for longest waiting See 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

34. 34 Step 3: Perform and Document H&P  You are representing the attending  Identify yourself to the patient and family  Explain process  Professional 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.

35. 35 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 evaluation  Be 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!

36. 36 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!

37. 37 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

38. 38 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)

39. 39 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!

40. 40 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!

41. 41 Step 5: Place orders (cont’d) Orders to be completed Respiratory Orders Needs to be seen Financial Counseling Discharge Admit Magnet System

42. 42 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.

43. 43 Step 6: Monitor status of orders  Were orders were taken by nurse? check chart ask 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.

44. 44 Step 7: Monitor Status of Patient & Document  Document a reassessment after any intervention (slides 19, 22): breathing treatment fluids medications e.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!

45. 45 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

46. 46 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

47. 47 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 discharge  Green  Green magnet on the board (chart completed)

48. 48 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

49. 49 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

50. 50 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

51. 51 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.

52. 52 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

53. 53 Trouble shooting: Schedule contacts  Emory pediatrics chief residents  www.amion.com 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 roshni_patel@oz.ped.emory.edu

54. 54 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

55. 55 Have a great rotation in the Pediatric Emergency Department!