- CDU Notes Which patients can go to the CDU (so far)? Hospitalist patients Or patients of PCPs who admit to hospitalist Unassigned patients Pinto patients Or patients of PCPs who admit to Pinto “Admitting” the patient in Cerner Identify patient appropriate for CDU Criteria on SharePoint Case Management will help Status: Choose “Observation” Admitting physician: Choose YOURSELF Bed type: Enter “CDU” Staff will then depart the patient from ED to CDU Patient will only be visible on CDU tab Sending a Patient to the CDU Order Sets in Cerner Complete and close ED note Ensure patient is “tucked in” for the remainder of your shift Sign over care to your colleague Home Medication Ordering: Workaround Enter PowerChart through My Apps Main -> Erecord-> Core Power chart If Chart does not load, choose patient from alphebetized list Go to Matrix orders If med history was obtained, green check box will appear Choose Reconciliation - > admission Choose meds to continue/not continue, then click “reconcile and sign” Who is responsible for the CDU? 7a-9a: M1 9a-12p CD1 (round 9a-10a) 12p-5p: CD2 (round 12p-2p); ST2 assists 5p-1a: CD3 (round 5p-6p) 1a-7a: M5 Plus backup MD PRN ED Physician to ED Physician Communication Sender owns patient until end of their shift, then signs out to CD MD Receiver gets signout on existing patients, then signs over to next physician who then assigns them self to the patient in First Net CDU signout: CD1-> CD2-> CD3 -> M5 -> M1-> CD1 ED Physician Communication: Receivers CD1: Get report from M1 at 9a CD2: Get report from CD1 at 12p ST2: Get report from CD2 at 2p CD3: Get report from CD2/ST2 at 5p M5: Get report from CD3 at 1a M1: Get report from M5 at 7a ED Physician to ED Physician Communication: Senders (at the end of shift) M1: 2p to CD2 physician M2: 6p to CD3 physician M3: 12a to M5 physician M4: 1a to M5 physician M5: 7a to M1 physician Receivers (CD shifts only) Receive signout on existing CDU patients Round on active patients Respond to questions/issues on CDU patients Secure dispostions Contact PCPs Final exam/ OBV note Also If patient examined Also if changes in plan/additional orders Discharge instructions/medication reconcliliation Documentation Requirements E/M documentation PLUS Length of time in OBV (must be >8, < 24 h; clock starts at triage) 2nd physician attests they saw the patient Progress and/or discharge note Must include family history: 3/3 instead of 2/3 for personal/family/social history If absent, downcoded to E/M Elements of discharge note A final examination Clinical course in the unit – results, decision making, diagnosis, etc. Preparation of discharge (or admit) records Instructions for continuing care EWS template (“Dictaphone Observation”) Summary: Role of CD MD CD1 Receive signout from M1 at 9a Round in CDU 9a-10a Manage CDU issues 10a-12p Work in [26-32 + ST] pod 10a-6p CD2 Receive signout from CD1 at 12p Round in CDU 12p-2p Manage CDU issues 2p-5p (ST2 MLP to assist) Assist in North Track/ST/ERC 2p-8p Facilitate departure of NT1/CD1 MDs (pick up new NT pts 4p-6p) CD3 Receive signout from CD2 at 5p Round in CDU 5p-6p Work in [26-32 + ST pod] and manage CDU issues 6p-1a PCP Notification Notify at the point of disposition if they have a private PCP Whether or not Mercy affiliated MHC patients do not apply Benchmark: Patients who will require urgent outpatient follow-up Most CDU patients will fall into this category Discharge Process First Net instructions Print Discharge Medication reconciliation Highlight patient in First Net Choose task -> reports from top of First Net screen Discharge Process Check “Med Reconciliation OP Discharge” box Click Print Check on form meds to resume or discontinue Form goes with patient instructions Safe discharge packet prepared by RNs Management of Chest Pain Patients CDU Entry Criteria Normal or unchanged ECG Hemodynamically Stable Pain Resolved Stable Comorbid Conditions* If H/O cardiac disease, most recent event >6 months prior *Note: If cardiac event more recent or comorbid conditions not stable, the patient may be placed into the hospital under observation status, but is not a candidate for the CDU. Management of Chest Pain Patients 6 hr troponin (time 0 performed in the ED) Next AM ECG (if in CDU overnight) Nitropaste (unless contraindication) Beta Blocker (unless contraindication) Exercise treadmill w/nuclear imaging Stress Testing In its current configuration, the stress lab is only able to start stress testing between 7a and 3p. (i.e., patients who present after 9AM with chest pain will need to remain in the CDU overnight for next AM study - would need 2nd troponin back by 3P to be eligible for same day stress test). This may result in CDU LOS exceeding 23 hours. In selected patients (i.e., those who can obtain urgent PCP follow up) discharge after negative time 0 and 6 hr troponin with urgent outpatient stress testing is an acceptable alternative. Discharge Criteria: Acceptable VS Stable symptoms No serious cause of symptoms identified Normal serial cardiac markers Normal or unchanged ECG Negative provocative test or cardiac imaging for ACS – no ischemic or reversible defects identified Admission Criteria Unstable VS Positive cardiac markers or EKGs Positive provocative test – ischemic or reversible perfusion defect CDU or personal physician discretion Serious alternative diagnosis, e.g. PE, aortic dissection