The goal of this webpage is to be a resource during your rotation in the MGH and BWH Emergency Departments, both on shift and off. This page is accessible both on the computer and on your phone at the same URL. Please use the tabs on the left (on PC/Mac) or below (on mobile) to navigate.
Created and compiled by:
Christopher J Nash, MD
Farah Z Dadabhoy, MD
Daniel S Choi, MD
We Are a Team
A sink or swim component of your first several shifts (and the rest of residency) hinges on your communication skills—effective communication (especially closing the loop) is critical in any emergency department. Don’t forget to keep your attendings, senior residents, and nurses up to date on the status and plans for your patients. Additionally, patients and patients’ families should be kept as up to date as possible, especially if treatment will be initiated, admissions will be made, consultants will be involved, or clinical statuses have changed.
Order of Operations:
- Sick patients!
- Dispo-ing patients (admit, OBS, discharge)
- New patients (unless sick–see number one)
Do rate-limiting steps as soon as possible. This includes doing pelvic/rectal examinations, performing your procedures, and calling your consults as soon as feasible! Side note: these are not good things to pass off to the next resident at the end of your shift.
You may find that you’re more effective with Dragon dictation than you are at typing or that you find your notes are done faster if you make more macros. Don’t forget to chart while you are on shift! The most efficient way is to write your HPI, ROS, and physical examination (i.e. things you may not remember the next day) right after you see a patient. ED course [workup tab in Epic] can be updated during the course of the patient’s time in the ED using the workup tab. MDM can be written at any time, but if you have the time to write it concurrently with the other parts of the note do it! It seems to be the easiest thing to fill in after the shift is over.
Ask your senior residents how they maximize their efficiency. As you spend more time in the emergency department, you will find your own ways to become more efficient.
When to Call for Help (From Intern Handbook)
When faced with a sick patient or a new procedure, there is no shame in asking for help if you feel you’re getting in over your head. In fact, your senior residents and attendings will be quite annoyed at you if you don’t ask for help and they have to clean up your mess later. Whether in the MICU, or the ED – nobody will ever fault you for calling your senior and saying, “I’d like to discuss a patient with you: Mr. Smith is getting more SOB and is breathing in the mid 20s now. I had his nurse re-vitalize him and now his vitals are _____ and he’s sat’ing 92% on RA. So I put him on some O2, ordered a portable CXR, an EKG, and some nebs but still pretty tachypneic. Do you mind taking a look at him?”
Additionally, if and when your senior or attending asks you to perform a procedure, it’s okay to say “I’ve done three arterial lines before so I understand the technique, but would love it if you could supervise me and give me some feedback.” As a junior, it’s never a bad idea to have someone senior in the room to help you troubleshoot or give you advice for improvement. This is not a sign of weakness, it’s appropriate patient care.
Lastly, if you are at MGH and you think you have identified a patient who is under-triaged (e.g. in Fast Track but you think is sick and would like to move to Acute), feel empowered to make this change. Discuss with your attending, ask the nurse to move the patient (they will arrange for the physical transport), and pass off the patient to the other pod.
On shift resources:
The beauty of emergency medicine is the breadth of complaints and pathology we see on a daily basis. That being said, that also means that you will encounter complaints, presentations, or even procedures that you are less familiar with or have not cared for in some time. Never be afraid to reach out to your senior residents or attendings if you have questions, however there are also useful on shift resources that may help guide your initial workup and care (note: these are just suggested resources, not formally sponsored resources).
General differential building and initial workup:
- WikEM – www.wikem.org – search by a complaint or diagnosis and this tool provides background, possible differentials, and initial workup
- ALiEM Cards – https://www.aliem.com/category/emergency-medicine-clinical/pv-card/
- Quick EM app
- The MGH Whitebook – https://mghwhitebook.app/home
- Brigopedia – https://brigopedia.partners.org/index.php/Management_Guidance
- Orthobullets for orthopedic complaints – www.orthobullets.com
- ED Resources in the Epic Handbook
Procedures and Miscellaneous:
- EMRA demonstrations of procedures – https://www.emra.org/students/advising-resources/skill-demonstration-videos-and-topics-pertaining-to-em/
- UCSD Ultrasound – https://emultrasound.sdsc.edu/index.php/curriculum-2/
- CORE EM procedures – http://coreem.net/procedures/
- NEJM Videos in Clinical Medicine procedures – https://libraryhub.nejm.org/wp-content/uploads/2020/04/covid-19-videos-in-clinical-medicine.pdf
Presentations help build the picture of your differential for your attending or the senior resident you’re presenting to. List data by differential piece in your HPI.
Don’t forget to discuss EMS course and vitals!
When it comes time to present your differential the “SPIT” mnemonic is helpful. Present the serious possibilities (1-3 “can’t miss diagnoses”, ex: ACS, PE, and dissection for chest pain). Present the plausible/possible presentations (1-3 of the “most likely causes” for presentation, ex: costochondritis, pneumonia, muscle strain for chest pain). Present any interesting possibilities for presentation (may not always present this, but sometimes interesting and relevant to include the “zebra” that also may cause the presentation). Finally, discuss your plan for treatment including workup.
How to call a consult:
To page for a consult from Epic, you’ll use the phone directory, available at either http://ppd.partners.org/ or in the upper right-hand corner of Epic. Click the below button for a visual tutorial:
When the consulting services Call:
The recipient of your consult will have certain expectations when you contact them. You should always:
- Identify yourself
- Have ready the patient’s name, MRN, and location in the ED
- The consult question
It is often helpful to put the above in your first sentence or two to help orient the person you’re consulting before launching into the patient’s story
“Hey, thank you for getting back to us. This is [Name] in the ED, I paged about Mr. Doe. He’s a 78yo male with a SDH on CT, and we’re consulting you for surgical evaluation. ”
For each service there may be very particular details they will want to know. Have at the ready:
|Cardiology||Know history of CAD, whether or not stented, most recent ECHO (especially EF). Know today’s EKG. If anticoagulated, know the regimen and why (e.g. Plavix for stent, Coumadin for AFib or mechanical valve).|
|Infectious Diseases||Know prior micro data (can find this in Epic under the “60 Day Micro” tab.|
If they have HIV, know CD4 count and their antiretroviral medicines
|Neurology||Stroke: time of last normal, anticoagulation medications, INR (and other tPA contraindications), neuro exam, stroke scale|
Epilepsy: description of seizure activity, length of seizure, if abortive medicines given, home AED regimen
|Neurosurgery||Anticoagulation (including aspirin), GCS. Neurosurgeons often want both PT and PTT to be ordered.|
|OB/GYN||Gs & Ps (TPAL), LMP, pregnancy status (how far along by U/S or LMP), Rh status, pelvic findings on speculum and bimanual examinations|
|Oncology||Patient’s oncologist, type of cancer, whether or not they are on chemotherapy/radiation|
|Ophthalmology||Visual acuity (for both eyes), IOP (if suspicious of glaucoma)|
|Orthopedics||XR of injury ± imaging of joint above and below, CSM distal to injury, whether the injury open or closed|
What is the ED Observation Unit?
In order to understand this, it’s helpful to know something about billing. An admission is not considered a hospital admission technically unless you spend two midnights in the hospital. Many patients do not fit the criteria for a full hospital admission; however, it may also be inappropriate to discharge these patients straight from the ED after several hours.
The ED observation unit is a great place to send patients if you feel that they are not safe to discharge home or if you anticipate that their ED workup may take longer than ~ 6-8 hours, but less than 24-36 hours. Some examples of reasons to admit a patient to the ED observation unit include:
- Awaiting cardiac stress test or CT coronary angiogram
- Awaiting for isolated IR guided procedure
- Provide IV pain medications or IV antibiotics with the goal of transitioning to PO
- PO challenge, IV fluids and monitoring vitals
- Awaiting for particular imaging such as MRI/MRA of the brain (since it can take hours to do and get results)
- On evening shifts, patients may often be placed into ED observation so that certain services such as addiction medicine, pain management, physical therapy, case management, or social work can be consulted the following morning
While the ED observation unit is great for many patients, as noted above, there are definitely certain criteria that should warrant a hospital admission instead. Patients that require very close monitoring, have elevated cardiac enzymes, abnormal EKG’s, or need frequent pain medications(>2qh) should not be admitted to ED observation.
When you are ready to admit a patient to ED obs, just let your attending/senior resident know, and you can place the observation orders yourself. Click on the observation tab on the top column. In order for a patient to go to ED obs, you must 1. Place the bed request 2. Place ED obs orders 3. Write and sign (with attending co-sign) an initial obs note- may vary by site (see images below for guidance).
1.Place Bed Request
To place the bed request, go under the Observation tab, and click Obs Bed Request followed by clicking either ED Obs unit (usually No Pref button unless indicated to click a site in Brigham) vs ED obs stay in the ED. Then you must hit close for the request to be taken. Note: Prior to placing them in Obs stay vs unit ask your attending/colleagues what they think would be the most appropriate location. Behavioral health patients will require obs stay if they are agitated.
To place the bed request, just select the appropriate box as noted below depending on ED Obs unit vs ED obs stay in the ED. Note: at the Brigham, you can do ED obs stay vs. ED obs unit downstairs vs. ED obs tower. Ask your attending/colleagues what they think would be the most appropriate location.
2.Place Obs Orders
Once the bed request is in, you should then place ED obs orders, generally by clicking Obs Orders (under the ‘place orders” tab see image above). You will then be given a view to continue current medications, order home meds and other order sets. You should generally continue all existing orders, and order the most essential home medications under the review/reconcile meds tabs. Make sure you order time sensitive medications such as seizure medications, blood thinners or heart medications (unless they need to be held). Example -Hold beta blockers prior to ETT ( ok for MIBI) or hold AC if procedure is pending. Then under the Order Sets tab click ED Observation – General Complaint to open an order set. You must click ED Place in ED Observation, add diagnosis and attending name. Focus mainly on the basic orders, i.e. vital signs, NPO vs PO, getting out of bed vs assistance, pain medications, imaging orders (MRI, Stress, or TTE) and PT or other consults. You don’t need to place orders as thoroughly as a medicine admission/hospital admission.
Once you’ve completed the above two steps, the patient square on the far left column should now turn dark green and say “ED observation”. If you do not complete this step, the Obs bed request will not be complete!
3. Observation Initial Note
Next you will create an ED Observation initial note. Click the “Obs Initial Note” ( see above for location of this tab) and the following option will appear.
You should be succinct and focused, and make sure that you include any pertinent information regarding consult recommendations/plans/contingency plans.
Each institution has different pathways for how you create your note and also when you create a note. Based on what site you are at, please see below.
After clicking Obs initial Note, you should use the blank note template and type “.mghedobs” under the smart phrase search bar, and you will see the proper note template needed.
You will always complete a note while at MGH. The provider taking the patient will read this note and click pass off on the board, and the patient will then be moved. If the accepting provider has questions they will call you. Important to complete this note as soon as you place them in Obs in order to get them accepted by other providers.
After clicking Obs initial Note, you click on the focused initial ED obs note, as seen above. Or you can start a blank note and use the dot phrases: EDOBSINITIAL, .EDOBSPROGRESS, .EDOBSDISPO
You may not always need to write a note and add medical orders depending on what section of the ED the patient will be going to and the timing.
- If the patient is going to Fairfield Obs, you will not need to write a note or med reconciliation as you will give a verbal pass off to the 24/7 PA. When you place the patient in obs and they are assigned to Fairfield find the PA to pass off.
- If the patient is going to Dartmouth from 11A-11P on M-F or 10A-10P on weekends, there is PA coverage therefore you can pass off verbally after being assigned. That PA stops taking pass off an hour before, therefore in the evening you will have to keep the patient and at the end of your shift pass off to the 3rd year in Exeter, your senior will assist with this step.
- Outside of the PA coverage you will be responsible for doing the initial note, medication reconciliation and ordering home medications.
- You will also start a Sticky note and use the dot phrase .EDOBSSTICKY and complete as indicated in the template and check off that med rec and dvt ppx has been completed. You can start a sticky note under Snapshot in the review chart (see image below). This helps the provider taking over know more about to do’s for the patient.
- More Pro Tips for BWH
- There are 3 sites for Obs Fairfield, Dartmouth or Stay in Bed
- Fairfield Obs preferred for behavioral health patients, agitated patients should stay in bed
- If no Obs bed assigned within 30 minutes contact ED Flow manager or NIC (talk to your senior or attending)
- There are 3 sites for Obs Fairfield, Dartmouth or Stay in Bed
Now that you’ve passed off your patient, you can now “green out” your patient by going back to the ED trackboard area, and clicking on the MD handoff tab above, and selecting ED obs handoff complete! ( see below)
As you go through your first few shifts, you will notice that many of the ED patients we see at both MGH and the Brigham require a medical or surgical admission. There is an anticipation that these patients are likely to spend more than one midnight in the hospital (unlike ED Obs).
How do I admit a patient to a medicine service?
The admission process at our two institutions have notable key differences:
- If you are planning to admit a patient to level 1 or level 2 medicine at MGH, you can put a bed request in without speaking with the medical triage senior.
- For cardiology & ICU admissions you will need to contact the DOM triage medical senior via Voalte. Just provide a quick summary of the patient and a brief reasoning for the admission. They will then let you know what type of bed you can order for the patient.
- If the patient has an MGH cardiologist and likely needs admission to cardiology, it is often recommended to page/call the outpatient cardiologist prior to speaking with the triage senior.
- For oncology, you always want to include the outpatient oncologist in patient care. If admission is recommended, Include his/her name under “Receiving Attending” for the bed request after you have their approval for the admission.
- Sometimes you may have difficulty getting in touch with the outpatient provider (e.g. for oncology). You can then page the fellow on call if you need assistance with the admission process.
- When placing a bed request, you may indicate whether they may follow the prompts to determine whether your patient is appropriate for home hospital/NWH transfer. You can also ask your senior resident/attg if the patient may be appropropriate.
- If you are planning to admit a patient at the Brigham, there is no “Med Senior” to contact. Instead, just let your Attending/PGY-4 know and he or she will sort out the bed situation and place the request. This is mainly for general medicine, cardiology, & ICU (see oncology next).
- For Oncology, you need to page/call the outpatient oncologist and have them approve of the admission before being able to place the bed request. You will need to include his/her name in the “Receiving Attending” when placing the bed request.
How do I admit a patient to a surgical service?
The admission process for any surgical service (general, trauma, ob/gyn, neurosurgery, urology, orthopedics) is generally the same at both hospitals. Once you consult the appropriate service and they have seen/staffed the patient with their attending, you can ask them for the attending’s name and place the bed request yourself.
How about neurology?
This is also generally the same – you just consult neurology and once you have the attending’s name, you can place the bed request yourself.
Discharging a Patient
When it is time to discharge a patient, there are a few steps involved in the Discharge Tab. In the ED trackboard view, this can be accessed by clicking open the right sided sidebar, and clicking the dispo tab located in the top right of the screen
It can also be accessed by opening the patient’s chart and clicking the tab with the door icon (usually located on the right side, but may be in a different location depending on your EPIC configuration).
After you have selected this tab, you must fill out various parts of the tab. From top to bottom, you must be sure to put in an ED Clinical Impression (i.e. the diagnosis for the visit). If there is diagnostic ambiguity at the end of the visit it is perfectly acceptable to put the general complaint (e.g. abdominal pain). You may also add multiple impressions if appropriate.
Prescribe any post-discharge medications for the patient by clicking the “New Order” tab next to the RX header. This will open a sidebar for placing orders similar to placing orders in other contexts. If the patient has a preferred pharmacy, most medications can be e-prescribed. If your patient prefers a paper script (or if it has to be a paper script, e.g. for controlled substances), you can change to print as opposed to e-prescribe. This is also where you will order outpatient referrals to specialty clinics. If you need to make a referral (e.g. to ortho for a one-week follow-up after a fracture), the easiest way to do this is to type in “ambulatory” followed by the service of choice. Make sure you refer to the correct hospital’s service!
Arguably the most important part of the ED discharge is the discharge instructions. There are many dot phrases for this in circulation, and it is highly recommended to copy one from an ED resident. Regardless of the exact format, all discharge instructions should contain a summary what happened in the ED including any pertinent results (e.g. normal EKG and CXR for chest pain patient), specific prescription instructions if you are adding new medications or changing existing medications, and explicit return precautions. Other things that are useful, but not strictly necessary, to include are follow up appointment information, and OTC pain medication instructions.
You were seen in the emergency department for **
Your evaluation showed ***
*** Acetaminophen (Tylenol) and ibuprofen (Advil/Motrin) can be taken together to control pain.
Take acetaminophen 500mg (Tylenol Extra Strength) – 1 pill every 6 hours as needed for pain.
Take ibuprofen 400-600mg (Advil) – 2 or 3 pills with food every 4-6 hours as needed for pain. Do not take naproxen (Aleve) while you are taking ibuprofen.
You can also apply lidocaine patches which are available over the counter to any focal areas of pain
Please follow up with ***
We also recommend that you follow up with your PCP after discharge regarding your recent visit for further evaluation, particularly if you have any persistent symptoms.
If you ***, we recommend you return to the emergency department.
Be sure to keep any upcoming appointments listed below.
It was a pleasure meeting you and a privilege caring for you.
-The Emergency Department
In addition to (but NOT instead of), you can add pre-prepared discharge information that will auto populate once you enter a clinical impression. These can be helpful, but before the read/skim them because they may contain information that is extraneous or inappropriate for the clinical situation.
If you are making an ambulatory referral, it is often useful to include a phone number for the patient to use if they are not contacted by the clinic in 2-3 business days. This can be done in the follow up tab. The “Other – Lookup” tab is notoriously difficult to use. It is often easier to use the free text option. You can usually find the phone number for the appropriate service easily by simply googling the service. It is common to also have the patient follow up with their PCP (especially for wound checks), and instructions for that can also be placed in this tab.
Note: This does not place a referral order, it simply provides information for the patient. Referals must go through the discharge orders section.
If your patient requires a work/school note, it can be made from the excuse tab. You can simply click through it to have a complete letter, and you can write in specific comments if necessary. You can then print the letter to sign it.
Finally, in order to formally discharge the patient, you need to click “Discharge” under the “Disposition” tab. Note also that you can select other dispositions, such as AMA or Elope if appropriate (and can add additional comments if necessary). If a patient is leaving AMA, the supervising resident and/or attending should be involved in the conversation, and can provide assistance with documentation.
In order to print the AVS (after visit summary), click the “preview AVS” button under the Chart Status tab. Then, you can print the form. You must hand these papers to the nurse in order for the patient to be truly discharged and leave the ED.
How do I pass off patients to the medicine service (including oncology, cardiology, & ICU)?
You should first check the trackboard, and look for the “to be admitted” tab. All the patients that are being admitted from the ED will be listed here. Once you find your patient based on the appropriate ED pod/room/pt name, you can then look to the far right where the “dispo” tab is located.
Once you see the “dispo” tab, you can hover over the little bed icon with a green check or plus sign to see the bed status (i.e. occupied, cleaning, ready). Either way, look over to the “Team” tab to the left where you see highlighted green boxes. Hovering over that box for your patient will reveal which medicine team will be admitting the pt. If that box is red, that means that the team has not yet been assigned and you cannot pass off yet. Boxes that are highlighted orange indicate that this patient has been waiting at least 2 hours for a bed and is now considered a “boarding” patient.
When you know which team is taking the patient, then go to your phone directory, click the “on call directory”, and look up medicine teams (see image below). Page the appropriate team pager listed on the directory. For ICU patients, you can just call directly to the floor coordinator (dial zero and ask for the appropriate building/floor), who will then transfer the call over to the ICU admitting resident for direct pass off.
There is a boarder service that after 2 hours will pick up some of these patients and they will either assign themselves or page you to let you know that you can give pass off.
You will start to develop your own style for passing off patients, but keep in mind the basic structure which usually involves: 1. Brief HPI 2. Vitals 3. Exam 4. Pertinent Labs/EKG/imaging 5. ED interventions 6. Work-up/treatment needed (optional)
You will start to develop your own style for passing off patients, but keep in mind the basic structure which usually involves: 1. Brief HPI 2. Vitals 3. Exam 4. Pertinent Labs/EKG/imaging 5. ED interventions 6. Work-up/treatment needed (optional)
The pass off process is standardized for Brigham with the Ipass, which replaced verbal pass off. You can place the Ipass at the end of your note or if you took over a patient start an update note and type the dot phrase .edipass. Complete the sections with brief HPI, significant events, remarkable labs, interventions and reason for admission. Once you sign or share the note, page the provider who assigned themselves to your patient (this will happen once the patient is assigned a team). The page can be “Hi, ipass complete, please call with questions”. They will have 20 minutes to call back with questions after you page, and then you can green patient off if they do not call.
I-pass does not work with patients being transferred to BWH Faulkner, You will get a page with a phone number and provider name, you can call and give Ipass then. You will need to complete an EMTALA form found under the disposition tab. You click through and print it and hand it to the nurse.
What do I do once I’ve given the pass off?
Once you are done with pass off, you can go back to the ED trackboard and “green out” the patient by going to the MD handoff tab, and clicking the appropriate box (see image below).
This can be an intimidating, sometimes confusing task at first. You will be fighting the urge to just stay and dispo everyone yourself versus wanting to go home ASAP at the end of your shift. In the ideal world, you end up signing out at a reasonable time and giving your oncoming colleague a minimal amount of work to do.
When signing out to the oncoming resident, give a thorough, organized presentation of the highlights of HPI, PMH, vital signs, exam, etc. Tell them what you’ve done or ordered for the patient and any results that are back. Make specific emphasis on pending labs or radiology results or pending consultations so the oncoming resident has an idea of next steps.
Make a clear point about tentative disposition for all patients and qualify conditions to change the dispo. Usually patients’ dispos will depend on tests or imaging that are still pending; therefore, your dispo plan that you sign out should be something like “if the CT is positive, the patient will be admitted to X service. If negative, the patient can go home with PCP follow-up and prescriptions for oxycodone and ibuprofen.”
At the end of your signout, the oncoming resident should have a good idea of the patient’s clinical picture (vitals trend, pertinent physical exam findings), know what things they need to follow (radiology reads, labs, consultant recs), and a good-faith effort at a dispo plan.
Sometimes surprise results will come back and the dispo plan will have to be re-evaluated after you leave; if this happens, no worries. You can’t predict the future but the point is that you did your best at giving the oncoming resident a straightforward sign out.
If you’re anticipating a discharge, it’s nice for you to have filled out the discharge paperwork. If you’re admitting a patient, try to have them passed off to the team upstairs.
*Pro Tip: Use the Sticky Note feature in Epic to create a short and sweet summary of patients you are signing out (this is especially helpful as a quick reference when you are assuming care of many patients at once). Things to include would be one-liner, vital signs, exam, labs, imaging, EKG, impression, and plan. Some of the residents (Chris Nash’s .CJNSTICKY) have great smart phrase templates for this, worthy of stealing.
OK To Sign Out:
- Imaging results – especially abdominal CTs, MRIs, etc. These can take forever.
- Labs – usually aren’t a huge issue because they come back fairly quickly.
- Consultant recommendations – if they need to talk to their attending/senior and you think it’s going to take a while. Just make sure to tell the consultant who the new contact person is for your patient. Make sure you communicate what the question is you wanted to ask the consultant. It’s also helpful to give a general time estimate of the last time you spoke with the consultant so the resident taking over know when to re-page the consultant for an update.
- Patients that are getting rehydrated, doing a PO challenge, getting treated for migraine, etc. Anything that involves waiting around to see if they improve. Be sure to have an attending-approved dispo plan in place in case they don’t improve when you do sign them out.
NOT OK To Sign Out:
- Pelvic exams, rectal exams, checking under the pannus etc. Common sense.
- Presentation to attending. Again, common sense.
- Calling a consultant. If the decision to consult neurology has been made at the time you are ready to sign out, call the consult. You are the one who knows the patient best at this point and will be able to tell the story better than anyone else.
- Giving pass-off to the team upstairs if they have a ready bed. If you are at MGH and your patient is 34th in line for a Bigelow bed, go the hell home. You can pass off the patient tomorrow when you return for your next shift (kidding … sort of).
- Procedures – unless the oncoming resident is psyched about doing the Pilonidal cyst drainage, you should wrap up procedures before you sign out (or at least before you go home). They are time-consuming and you should stick around to finish out of courtesy for your colleagues.
- Dispo paperwork – if you anticipate that someone will be discharged, do the discharge paperwork, prescriptions, etc., and put it in the patient’s chart or hand it to the nurse. Not a big deal if you forget but generally a nice thing to do.
- Floor team pass-off – Same as mentioned above. You know the patient better than the person taking your sign-out, so try to have the pass-off done before you leave. If the bed is available and ready, you should page at least once or twice and wait for 15-20 minutes. If there’s still no call back, don’t wait just for this, your oncoming colleagues can also do your pass-off for you. In this case, do your best to have your note as updated and thorough as possible to reflect your clinical judgment and decision making. It sucks having to defend someone else’s decision to CT PE an 81 year old with a creatinine of 3.
Unlike medicine rounds we all participated in during our third and fourth years of medical school, the purpose of ED rounds (at shift change) is to communicate the relevant information to the oncoming team while not delving into unnecessary detail. If more detail is needed, the oncoming team will ask questions.
There are many right ways to convey the information. What matters is that you are clear, concise, and consistent. More information is needed for undifferentiated patients, or patients where the disposition remains unclear. Patients with a diagnosis and clear disposition won’t need their whole story re-hashed – the ED course, important diagnostics, and pertinent interventions will typically suffice. Remember, while sign-out is a valuable time for you to think about all your patients, it is even more valuable for the oncoming team.
One script is as follows:
- Start with who they are and either chief complaint or, if data is back, their diagnosis. As in the House of God, “placement comes first.” Be sure to include the patient’s disposition, or if unclear, anticipated disposition.
- “Mr Jones is a 57 yo male here with chest pain”
Or if you already have a diagnosis…
- “Mr Jones is a 57 yo male being admitted to cardiology for an NSTEMI.”
- You can move on to relevant PMH (if you are worried about PE, mention the h/o CA or the OCP use. If you are worried about aortic dissection, mention the smoking and HTN, etc.). It’s also okay to include this in the one-liner.
- “He has a long h/o poorly controlled DM and HTN.”
- Summarize the HPI without extraneous details. It can sometimes be helpful to state why the patient came in today (more pain than normal, not getting better, etc.). More complex stories require more retelling than straightforward ones.
- “He developed 10/10 chest pressure at rest today, associated SOB, and nausea. He took 2 NTG, no relief, so he called EMS. EMS gave him an ASA, and by the time he arrived here, the pain was gone.”
- Recount the vitals. Don’t say the vitals are normal unless they are actually normal.
- “His HR was 60, but he was hypertensive to 180/110, satting well on room air. He had some crackles at the bilateral bases, and 2+ pitting edema, rest of exam unremarkable.”
- Talk about the EKG, assuming one was done. It is better to say what it actually showed, rather than “it was normal,” – actually describing the EKG will force you to think about it, and make sure you know what it looks like.
- “His EKG was a NSR with some lateral T wave flattening – no change from his prior in 2006.”
- Summarize pertinent studies. Make sure you talk about labs, chest X-rays, CT scans, anything the patient had done. Again, stick to relevant (the white count of 9 in this patient tells us nothing).
- “He had a CXR that showed mild pulmonary edema. His labs came back with a BNP of 1005, and a troponin of 207.”
- Summarize the ED course – in essence, spell out what’s happened since the patient arrived to the ED.
- “We put an inch of NTG paste on his chest, but his pressure plummeted. He responded to removal of the paste, and didn’t need a bolus, so we are just using morphine for pain. He got heparin, and we talked to his cardiologist, who agreed with management.”
- Conclude with any details of conversations with PCPs/specialists about further plans (e.g. if they plan on cath in the morning) and re-cap the disposition.
- “His cardiologist said that he will be able to fit him into the cath schedule later this afternoon, so keep him NPO. He’s in for a Cardiac Step-Down bed, and can go up before the cath, should one become available.”
When you are done with your story, it is very appropriate for the incoming team to ask questions. This is especially important in complicated patients, those with a plan in flux, etc. Please do not be offended if you are asked a lot of questions – this is just a part of good hand-off! Also, don’t be embarrassed if the oncoming colleague thinks of something that you didn’t realize – this is just part of the advantage of a fresh pair of eyes. Try to answer their questions as best you can, but do not be afraid to say, “I don’t know.” It is far better to admit that you can’t remember an EKG or didn’t see it at all than to assume it was OK and tell the oncoming team such. If you are honest and offer to print out a new EKG or run back to radiology to get the read on a CT, etc, everyone will be most appreciative.
Brigham and Women’s Hospital
|ED MAIN 25636|
|Radiology Reading Room||28592/27176|
Massachusetts General Hospital
|ED MAIN 44100|
|RADIOLOGY (ED MAIN) 63050|
|Body Reading Room||41533|
|Neuro Reading Room||68188|
|Neuro Rad MD||P39991|
|OBS (ED) 63800|
|Bigelow 7 NP||P23296|
|Bigelow 12 NP||P13467|
|ED MED SENIOR 62333×75360|