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.
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. As you learn to navigate the different hospitals in this residency, don’t forget to keep your attendings, senior residents, and nurses up to date on the status and plans for your patients.
Order of Operations:
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 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 older 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 “Sorry to wake you up but 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.
The recipient of your consult will have certain expectations when you contact them. You should always:
Have ready the patient’s name, MRN, and location in the ED
The consult question
For each service there may be very particular details they will want to know. Have at the ready:
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).
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
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
Anticoagulation (including aspirin), GCS. Neurosurgeons often want both PT and PTT to be ordered.
Gs & Ps (TPAL), LMP, pregnancy status (how far along by U/S or LMP), Rh status, pelvic findings on speculum and bimanual examinations
Patient’s oncologist, type of cancer, whether or not they are on chemotherapy/radiation
Visual acuity (for both eyes), IOP (if suspicious of glaucoma)
XR of injury ± imaging of joint above and below, CSM distal to injury, whether the injury open or closed
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: waiting for a cardiac stress test or CT coronary angiogram, waiting for isolated IR guided procedure, providing IV pain medications or IV antibiotics with the goal of transitioning to PO, providing IV fluids and monitoring vitals, and waiting for particular imaging such as MRI/MRA of the brain that may take many hours for the test and results to be reported. Especially during the 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, or have elevated cardiac enzymes or abnormal EKG’s, or need frequent pain medications 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 side 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 (see images below for guidance)
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.
Once the bed request is in, you should then place ED obs orders, generally by using the ED Obs order sets for guidance (under the “new orders” tab). You should generally continue all existing orders, and order the most essential home medications under the review/reconcile meds tabs. Focus mainly on the basic orders, i.e. vital signs, NPO vs PO, getting out of bed vs assistance, any pain medications or imaging orders such as 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”. Now you should go place your ED Observation initial note. Again you should be succinct and focused, and make sure that you include any pertinent information regarding consult recommendations/plans/contingency plans. For MGH 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. At the Brigham you can just click on the focused initial ED obs note.
Once you see any text in the dispo section of your patient, you can then “E-PASS off” your patient to the accepting NP or PA.
For MGH, just type the appropriate building/floor i.e. bigelow 7 or 12 and page the responding NP for that floor.
You can just page – “Ready for pt EPASS off, please page when ready to send pt up” – and leave your number in case they need to ask questions
EPASS off means that the accepting provider should just read your ED obs note for pass off, without needing formal verbal pass off
For BWH, if your patient is going to ED obs unit downstairs, you should physically walk over and pass off verbally to the PA. If your patient is going to the Tower unit, then you can page for the PA/NP provider for EPASS off
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!
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. These patients generally require a much more comprehensive work up, intervention, or close monitoring than what the ED observation unit can offer (see ED Obs unit section). There is also an anticipation that these patients are likely to spend more than one midnight in the hospital.
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 at MGH, you need to call Med Senior through a Voalte phone or ask for the direct number from a colleague. This includes all general medicine, cardiology, oncology, & ICU admissions. 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.
For cardiology in particular, you may also need to page/call the outpatient provider to figure out if the patient should go to the Cardiac Step Down Unit vs Cardiac Access (which is for patients with private cardiologists)
For oncology, you always want to include the outpatient oncologist in patient care, as well listing as his or 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.
Whether you talk directly first with the Med Senior, or speak with the outpatient provider, you should let the Med Senior know right before placing the bed request order.
If you are planning to admit a patient at the Brigham, there is no “Med Senior” to contact. Instead, just let your Attending 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.
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.
When it is time to discharge a patient, there are a few steps involved in the Discharge Tab.
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). Thereafter, ensure that you have given the patient appropriate written instructions. Oftentimes it is useful to summarize the pertinent results from the encounter (e.g. normal EKG and CXR for chest pain patient) as this can be helpful for the patient’s follow-up PCP visits. Specific instructions should also be given, especially with return precautions. You may also want to give instructions on how to go to follow-up appointments as well. You will find that many residents have dotphrases that they use for these sections — be on the lookout for good ones you can steal from the other residents or from the PAs.
There is a section below this entitled Healthwise Instructions. These are premade discharge instructions purchased by Partners to be inserted into the discharge instructions. It is generally good to include one of these if a pertinent one exists for your type of encounter.
Discharge orders are done in this orders tab, specifically useful for discharge medications and ambulatory referrals. 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. 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!
You may populate follow-up information into the discharge instructions as needed. If your patient requires a work/school note, it can be made from this tab as well. You can write in specific comments if necessary by clicking on the icons that look like pieces of paper.
Finally, you discharge the patient by clicking the Disposition section and choosing the Discharge radio button. Note also that you can select other dispositions, such as AMA or Elope. At BWH, you then need to print the AVS and give it to the nurse (or discharge the patient yourself). At MGH, the nurses will print the AVS and discharge the patient themselves (though still good form to communicate the discharge to them).
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.
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 much simpler at the Brigham. Just wait until you see a responding clinician name/pager when you hover over the “dispo” tab with the little bed icon. You can then page that clinician directly for pass off.
What do I do once I’ve given the verbal 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).
Click complete under inpatient care for any admitted patient including medicine/surgery/etc., except for ED observation patients (see ED Obs section under bootcamp), and “covered boarder” patients. Boarder patients are just patients who have been waiting at least 2 hours for a bed, and one of the hospitalists may take over care temporarily until the patient is able to go upstairs. Usually they will contact you directly or their name will become available in the bed icon area or under responding clinician.
How do I pass off patients to other services (neurology, surgery, urology, ortho, neurosurgery, etc.)?
For both hospitals this is very simple. Once you’ve consulted and informed the consultant about your patient, they will start the admission process if they are planning to admit the patient. You can then place the bed request as noted in the prior Bootcamp section, and wait until the bed icon turns green under the dispo tab.
You can green out patients going to neurology as soon as the bed is ready
You can usually green out patients going to urology, neurosurgery, or ortho as soon as the bed is ready, unless the consultant mentions otherwise
You may wait to green out the surgery patients until the surgery consult gives you the thumbs up and has placed admission orders
Note: often times surgical patients should have pre-operative labs ordered prior to being passed off. This generally includes: CBC, BMP, PT-INR, (PTT for neurosurgery), (sometimes ESR & CRP for ortho), Type and Screen, EKG, and sometimes a CXR
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, know what things they still need to follow (rads 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 always 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 panus etc. Common sense. Enough said.
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 bed ready. 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 CTPE 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 ED rounds (at shift change) is to communicate the relevant information to the oncoming team while not delving into unnecessary detail.
There are many right ways to convey the information. What matters is that you are clear, to the point, and consistent. Remember, while sign-out can be a very valuable time for you to think about all your patients, it is even more valuable for the oncoming team.
One “script,” if you will, is as follows:
State who they are, and why they are here – or if you already have data back and a diagnosis, what they are here with.
“Mr Jones is a 57 yo male here with CP” or if you already know this, “Mr Jones is a 57 yo male here with an NSTEMI.” Unlike a good movie, your audience should not have to endure plot twists and await the final conclusion.
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, sating 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 index 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 with the dispo and any details of conversations with PCPs/specialists about further plans (e.g. if they plan on cath in the morning).
“His cardiologist said that he will be able to fit him into the cath schedule later this afternoon, so keep him NPO. Also, 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.