TRIAGE
When a patient walks into the UMHS ED, he/she is first seen in the registration and triage area. Patients who are acutely ill and in need of immediate medical attention are brought directly into the treatment area. All others register with a clerk and are seen by a triage nurse. The triage nurse obtains a set of vital signs, a chief complaint with a brief history of present illness, a list of current medications, and an abbreviated past medical and surgical history. Each patient is assigned to a triage classification from 1 to 5, where 1 is the most and 5 is the least ill. Patients that arrive by ambulance may be brought directly to the ED or sent to triage depending on their level of illness severity. Relatively minor complaints or rapid visits may be sent to MECA between 1:00p and 1:00a, where they are seen by a Physician’s Assistant (PA).

THE PHYSICAL PLANT

The adult Emergency Department has 24 rooms and numbered hallway slots, and the CES (Children’s Emergency Services) has 11 rooms (1-11). All rooms have an ophthalmoscope, otoscope, oxygen, suction, ECG, automated blood pressure and pulse oximetry monitoring capability. There are three resuscitation bays (A-C) where unstable adult and pediatric, medical and trauma patients are seen.   Beginning during the 2010-11 Academic Year, the UMHS Adult ED will be undergoing an expansion to add additional triage and patient care space with an anticipated completion of December 2011. 

Currently, the adult ED is divided into 2 teams, Maize and Blue during most of the day.  An attending physician is also leading a resident team seeing patients primarily over in the Medpath area.  Several faculty are also assigned to see patients individually.  The ED CT scanner and the ED radiology reading area are in rooms adjacent to these bays. A portable ultrasound machine is permanently stationed in the resuscitation area. Basic supplies (gowns, sheets, urinals, hem-occult, etc.) are kept in each room. Other portable carts are stationed around the ED and can be moved to any needed location.

                        CARTS           TYPE                          LOCATION
                        Yellow             Suturing cart            Trauma bay, outside room 20, medpath
                        Green              Gyn                            outside room 20, medpath
                        Blue/purple    IV cart                        outside room 14, 16, 22, 8, medpath
                        Red                 Crash cart                 outside room 22, 8, medpath, trauma bays
                    

CHILDREN’S EMERGENCY SERVICES (CES = peds ED)

Children’s Emergency Services provides 24 hour coverage by either a pediatric emergency physician and often a PEM fellow. There is a separate waiting room.  The new Children’s Hospital is anticipated to open in November 2011.
 

WEST WING

The West-Wing is currently being used for patients with an extended ED stay or who are assigned to an ED observation protocol.  ED patients with specific diagnostic or therapeutic goals may be admitted for ≤ 23 hours with the approval of the ED attending.  Protocols exist for the low-risk Chest Pain, pyelonephritis, asthma/COPD, pneumonia, hyperemesis, and cellulitis.  In order for a patient to be admitted to protocol, orders must be completed, report given to the PA, and dictation completed.  Suitable patients are those with a clear plan of care, require minimal nursing assistance, and who are expected to be able to be discharged within 24 hours of admission.

ORDERS
Orders are written on the communication document. Student orders must be countersigned by a resident or attending before they can be executed. Radiology orders are written on a separate form and handed to the clerk for submission.  When an order is written, the nurse will be cued by turning on the “O” icon on any tracking board.

PORTABLE (SPECTRALINK) PHONES
Portable phones are assigned to each physician/resident during their shift in the ED and are not available routinely to students.

THE TRACKING BOARD
Patients are listed by their initials, room assignments and chief complaint. Their time of arrival and triage classification are also listed. Type “Last Name”, M4 into the notes box when you pick up a patient to see or take over the care of a patient (as a sign-out from another student).  No resident or student should ever sign out patients directly to a student. They will be passed from resident to resident, attending to attending.

Patients on the waiting board are arranged in order of priority and then by length of stay.  Students MUST initially preview the case with the resident/attending with whom they are working PRIOR to going into the patient’s room. Your supervising physician will help determine what is an appropriate case.  Once you are assigned a patient, print a goldenrod form and use it to take notes on your patient. 

DOCUMENTATION
All ED patient visits are dictated with real-time transcription into CareWeb. Students do not dictate during this rotation, but should assist their supervising resident/attending by providing them with comprehensive notes from each patient assessed. Students are able to complete discharge and admission paperwork on their patients.

ED PERSONNEL
Nurses: navy scrubs.  

• Triage Nurse: The Triage Nurse is usually the first member of the health care team to come in contact with the patient. This nurse will determine whether or not the patient requires immediate medical attention. If so, they will be brought into the ED suite where another nurse and a physician will assume responsibility for the patient and initiate whatever care is necessary.
• Throughput Nurse: When volume and wait times are high a nurse will be assigned to initiate orders on waiting patients in consultation with the Attending physician. This nurse also works to expedite patient flow through the ED.
• Staff Nurse: All the nurses in the ED are RNs. They can all start intravenous lines (IV’s), perform venipuncture, draw arterial blood specimens, and administer medications through any route. They are ACLS and often ATLS certified.  Each nurse will be assigned to specific rooms. The assignments are listed on the main board.
• Charge Nurse: The Charge Nurse on each shift is responsible for coordinating the nursing care in the ED. He/she is also responsible, in conjunction with the Attending Physician, for maintaining organized patient care and a smooth flow through the ED. They are located at the clerks’ desk in the main ED.

ED Techs: They wear olive green scrubs. They are all paramedics, often with significant field experience, who help with a variety of patient care tasks. They are assigned to a specific RN and work as a team to deliver care. ED techs cannot take verbal orders, and cannot administer medications but can perform a wide variety of procedures including blood draws, foley placement, EKGs, and splinting. 
ED Clerks: They wear cranberry scrubs. They are responsible for putting through all the requisitions for studies and handling in-coming phone calls.
Registration Clerks: They wear khaki scrubs.
Medical Social Worker: There is an MSW assigned to the ED 24 hours a day and they are an extremely valuable resource with any aspect of the patient’s/family’s social situation. They can help set up care for patients discharged to home, as well as help patients and their families cope with their illness/injury.
Unit Hosts: They were purple scrubs. They act as patient/family-physician liaisons and maintain the flow of information. They may ask you the status of a patient’s work-up and pass it on to those waiting. They may alert you when patients need to see you or when family has arrived.
Security Guards: One guard is posted at the Emergency Department entrance and more are available for assistance if needed. Never enter a dangerous situation without assistance. Always inform the attending about potential problems, or if you feel uncomfortable with a situation.  

CONSULTS
Some ED patients require involvement of a consultation service. You need to discuss calling a consultant with the Attending before doing so. Ask the clerk to page the consultant for you. Remember that consult services are called to assist with patient care, but the ultimate responsibility for the patient is still yours. Consultants cannot discharge patients. They should relay their findings and plans to you or the attending.

CONFIDENTIALITY
You should keep in mind that even when the ED is busy, patients and family members can hear everything that is being said in the ED and at the desk. Never discuss a patient’s case outside of the treatment area. Be mindful of how you describe your patients. Never argue with a nurse or anyone else while you’re in the Emergency Department. If you have a disagreement with someone, get the attending physician involved and retreat to a private forum.

ED MANAGEMENT TEAM
The ED Management Team is made up of:

William Barsan, MD: Department Chair
Peter Forster: Administrative Manager
Jeffrey Desmond, MD: ED Operations Director
Marie Lozon, MD: CES Director
Jennifer Gegenheimer-Holmes, RN, BSN: Manager, Clinical Nursing Services

Their names are provided for your general information. If you should encounter difficulties while working in the ED, you may address them to either the Attending Physician or the Course Director.

Please go to the following website for additional rotation information:

http://www.med.umich.edu/em/education/rotation.htm

Look to the right of the screen for:

• Goals & Objectives
• Forms (procedure/patient complaint log, clinical evaluation)
• Articles (by topic)