Provider Orientation & Resources  

All Emergency Department Providers


Note: open ALL links and attachments that are applicable to your area(s) of practice.

Learn more about:

ED related strategic initiatives and core measures
Overview of all the system level strategic initiatives and CMS core measure sets with an emphasis of the role of the ED provider includes Patient Satisfaction, AMI- inpatient and outpatient, Pneumonia- Core measures and reduce variation in care initiative (avoid Chest CTs in pneumonia), Pediatric Asthma, Sepsis, Central Lines, Reduce variation in ED Brain CT for Atraumatic Headache (document medical necessity for CT scan for Headache), and brief overview of ED order sets available thru the EMR.

ED OB triage policy: Laboring and non laboring obstetrical patient triage assessment and disposition: presenting to the Emergency department or OB triage
Establishes guidance on triaging to most appropriate area (OB or ED) for pregnant patients over 20 weeks gestation presenting with potentially obestrical related complaints (mainly L&D), life threating conditions (mainly ED), and non-pregnancy related complaints (mainly ED). 

Emergency department standing orders policy
A set of medical staff approved standing orders that a ED RN may use to address injuries and/or medical problems ranging from critical and life threatening to minor and self limiting and establishing a layer of safety for patients presenting to the ED while determining appropriate treatment in a timely manner.

Split flow patient triage model
Describes the ED patient flow process thru triage between quick look (fast track) and acute care (main ED).

Clinical practice: Use of medical imaging for diagnosing appendicitis in pediatric patients
Outlines work-up of suspected cases of appendicitis in patients under 18 years of age including clinical exam, surgical consult, and if advanced imaging is indicated, to utilized ultrasound first (if available). Then if the ultrasound is equivocal or negative (or not available) and there is a reasonable index fo suspicion, a CT scan with IV and without oral contrast is recommended. 

Clinical practice: Appropriate use of CT imaging in pediatric head injury
This expected clinical practice states that all pediatric patients presenting with acute closed head injury will be evaluated to determine the need for head CT in order to avoid unnecessary imaging.This clinical practice outlines guidelines for performing head CT for children under two years old and those children over two years old based on Glasgow Coma Scale, presenting signs and symptoms and mechanism of injury.

Clinical practice: Use of emergent MRI - adult
The use of emergent MRI without requiring direct contact and subsequent authorization from a radiologist for adult patients presenting to Banner will be reserved for those patients where there is clinical indication of new or rapidly progressive neurological deficits suspected to be related to cord compression OR dural venous thrombosis with indeterminate CTV results and for pregnant patients. For other conditions where emergent MRI is deemed critical for patient care, there is to be direct contact with and subsequent authorization from a radiologist.

Clinical Practice: Diagnosis of spinal cord compression – adult
It is an expected clinical practice that all patients presenting with suspected spinal cord compression will be emergently assessed and undergo a whole-spine screening MRI utilizing an established medical imaging protocol which is ordered by choosing a designated order.  This clinical practice has been defined but not yet fully implemented.

Clinical practice: Behavioral health medical clearance
Guidelines for medical clearance for patients requiring inpatient psychiatric care including guidelines for lab work, vital signs, and general medical care needs.

Clinical practice: Pediatric fever evaluation and management
Outlines standardized approach and interventions to address all pediatric patients presenting with fever with emphasis on Neonates (0 to 30 days old), young infants (31-60 days old and 61-90 days old), and children (3-36 months old).

Clinical practice: Pediatric sepsis/septic shock management
Outlines standardized interventions of time-sensitive therapy based on the American College of Critical Care Medicine Guidelines for hemodynamic Support of Neonates and Children with Septic Shock including compliance with pediatric sepsis management bundle (screening for SIRS criteria, assessment protocols, and resuscitation/management goals).

Clinical practice: Pediatric bronchiolitis
Outlines treatment of patients with the diagnosis of acute viral bronchiolitis as recommended by the American Academy of Pediatrics.

Clinical practice: Pediatric asthma – inpatient and outpatient management
Pediatric asthma patients (age < 18) will be identified in any Ambulatory Care setting, Emergency Department, General Pediatric Ward or Pediatric Intensive Care Unit (PICU) or throughout the continuum of hospital stay and have standardized interventions of time-sensitive therapy utilizing an asthma severity score to identify patients with mild, moderate, or severe asthma.  The clinical approach to asthma in our pediatric population will focus on four components of asthma care: measures to assess (utilizing an asthma severity score) and monitor asthma, patient and family education, control of environmental factors and other conditions that can worsen asthma, and medications.  For chronic asthma care, management will be based on the 2007 National Health Lung and Blood Institute (NHLBI) recommendations, using a stepwise approach to assess asthma severity, in which rescue and controller medication doses or types are stepped up as needed and stepped down when possible.  All patients in the ambulatory setting and inpatient setting should be discharged with a standardized Home Management Plan of Care.

Clinical Practice: Screening and Treatment of Community–Acquired Pneumonia (Pediatric)
It is an expected clinical practice that all pediatric patients, three months to 17 years of age presenting to any outpatient department (including the Emergency Department) for evaluation of cough, difficulty breathing and fever will receive a complete clinical evaluation, assessment and treatment plan for simple primary community-acquired pneumonia (CAP).  This clinical practice outlines an approach for this assessment including guidelines for inpatient and outpatient management.

 Clinical practice: Identification and management of Suspected Child Physical Abuse and Neglect (SCAN)
It is an expected clinical practice that all pediatric patients suspected of being victims of child abuse and neglect will be stabilized and then evaluated, including a careful and well-documented history, physical examination with detailed documentation, and a thorough search for other signs that may suggest a non-traumatic cause.  Consultation with a child abuse pediatrician, pediatric specialist, or pediatrician experienced in this area, if available, may be helpful in determining the best way to proceed with assessment.

Clinical practice: Anesthesia administration
This clinical practice applies to all inpatients and outpatients in any setting for any purpose, by any route that receive anesthesia (including the use of short acting anesthetic agents for procedural sedation) in Banner Health facilities. All inpatients and outpatients within the Banner Health facilities receiving anesthesia will be administered anesthesia by appropriately credentialed providers based on evidenced based practice, or in its absence will practice within consensus guidelines to best serve the safety of Banner Health patients.

Clinical Policy: Procedural sedation for therapeutic/diagnostic procedure
This clinical policy applies to both Adult and Pediatric Patients and defines the circumstances under which procedural sedation may be administered and define responsibilities and parameters for the management of the patient requiring procedural sedation for pre-intra-post, short-term diagnostic, or therapeutic procedures including monitoring requirements.  This clinical policy has been defined but not yet fully implemented.

Clinical practice: Quantitative and qualitative exhaled carbon dioxide measurements during procedural sedation pediatric and adult patients
It is an expected clinical practice that all inpatients and outpatients of any age and clinical setting receiving anesthesia (moderate, deep, general and regional ((with sedation)) will, in addition to standard monitors, have the ventilation evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide.  This clinical practice has been defined but not yet fully implemented.

Clinical Practice:  Administration of nitrous oxide/oxygen sedation for pediatric patients
For pediatric inpatients and outpatients requiring minor procedures that cause anxiety and/or pain, nitrous oxide oxygen (N²O/O²) sedation can be used to provide minimal or procedural sedation. Nitrous oxide/oxygen is an analgesic, amnestic and anxiolytic. It is a recommended Clinical Practice that Nitrous Oxide/Oxygen sedation be used following the General Principles Nitrous Oxide/Oxygen Administration for minimal sedation for anxiety and pain management. If a second agent is given along with nitrous oxide/oxygen, additional patient monitoring guidelines and protocols will be utilized as applicable. Nitrous oxide/oxygen sedation will be utilized in cases with an anticipated length of no more than 30 minutes. This clinical practice has been defined but not yet fully implemented, and will not be available at all Banner facilities.

Clinical practice:  ED discharge instructions / transition record – adult and pediatric
All Emergency Department (ED) patients regardless of age or their caregivers will receive a transition record/discharge instructions at the time of ED discharge; including ED patients who are transferred out of the ED and those ED patients that are placed in observation.   The discharge instructions / transition record will include all of the following elements: 1) Major procedures and tests performed during ED visit, AND 2) Principle diagnosis at discharge OR chief complaint, AND 3) Patient instructions, AND 4) Plan for follow-up care (OR statement that none was required), including primary physician, other health care professional, or site designated for follow-up care,  AND 5) List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each.  This clinical practice includes all the required elements to meet the Hospital Outpatient Quality Reporting (OQR) Measure OP-19- Transition Record.

Clinical practice: ED acute pain treatment - adult
Adult patients presenting in the Emergency Department with acute pain, who able to self report, will be assessed with the Numeric Rating Scale (NRS).  Those patients with a pain level of 7 or greater (on a 10-point scale)  upon a provider’s order will be administered IV morphine according to an acute pain protocol.  Additional adjunctive medications will be available to address common side effects of morphine such as histamine release, nausea, and respiratory depression.

Clinical practice: Utilizing (Pulmonary Embolism Rule-Out Criteria (PERC) in diagnostic testing - adult
This clinical practice recommends that all adult Emergency Department (ED) patients who are deemed low risk by an ED provider for Pulmonary Embolism (PE) be evaluated for the possible occurrence of PE using the Pulmonary Embolism Rule-Out Criteria (PERC).  If all eight elements of the PERC rule are negative, no further testing (i.e. D-dimer or CT angiogram) is indicated.  The elements of PERC rule are as follows:  Age <50; Pulse <100; SaO2 > 94%; no unilateral leg swelling; no hemoptysis; no recent trauma or surgery; no prior PE or DVT; no hormone use.

Clinical practice:  Prioritizing ED to critical care admissions - adult
Patients requiring immediate high intensity care in the Emergency Room will be prioritized for transfer to critical care locations.  Those patients unable to be immediately transferred will receive critical care services to allow for high intensity management.  This clinical practice outlines the high priority clinical indicators and types of interim management for critical care level services in the Emergency Department.

Clinical Practice: Initial evaluation and treatment of patients presenting with Acute Ischemic Stroke or Transient Ischemic Attack, including the use of Thrombolytics
It is an expected clinical practice that all adult patients presenting to the ED with acute neurologic symptoms consistent with stroke will undergo emergent evaluation and treament, including high acuity assignment in triage, a standard focused history, a standard focus neurological exam, expedited diagnostics including continuous cardiac monitoring and a stat brain CT without contrast, and prompt control of blood pressure.  Includes guidelines for administration of thrombolytic therapy with intravenous tPA (Alteplase) to be administered within 60 minutes of patient arrival, or initial evaluation, to all ischemic stroke patienets who met established criteria within 4.5 hours of symptom onset, unless otherwise contraindicted.  It also outlines evaluation and mangament of patients presenting with Transient Ischemic Attacks (TIA) including guidelines for patient disposition.

Clinical practice: Initial evaluation and treatment of patients with hemorrhagic stroke - Adult 
It is an expected clinical practice that all adult patients with possible acute hemorrhagic stroke will undergo emergent evaluation and treatment, including a standard focused history and neurologic exam as well as diagnostic evaluations including continuous cardiac monitoring, stat brain CT without contrast, and prompt control of blood pressure.

Clinical practice: Dx and eval for syncope - adult 
All adult patients presenting to the emergency department with syncope will be risk stratified based on their history and physical exam, electrocardiogram (ECG), blood pressure measurement, age and cardiac risk factors.  Further testing to establish the etiology of the syncope will be based on the recommendations from the 2006 American Heart Association and the 2009 European Society of Cardiology.

Clinical practice: Prevention of pertussis - use of Tdap vaccine in ED and obstetrical patients
To improve immunity against pertussis, providers should not miss an opportunity to vaccinate people.  Patients who come to the Emergency Department with wound requiring tetanus immunization will be given the Tdap vaccine.  In these situations where a Td vaccine (Tetanus Toxoid, Reduced Diphtheria Toxoid Vaccine) would normally be given to an ED patient, all patients aged 10 years or older will be screened for substitution with the Tdap vaccine (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine).

Clinical practice: Diagnosis and evaluation for chest pain – adult observation patients 
It is an expected clinical practice that all adult patients with unspecified chest pain that is low risk, atypical, or an unusual presentation for acute coronary syndrome (ACS) and does not require immediate inpatient hospitalization and/or intervention should be considered for placement in observation status to further evaluate their cardiac risk.

Clinical practice: Heart failure exacerbation outpatient – adult
This recommended clinical practice states that all adult patients presenting in the Emergency Department (ED) with heart failure (HF) exacerbations will be assessed for acute conditions; and if they do not meet criteria for inpatient hospitalization, they should be considered for treatment in an outpatient/observation setting.

Clinical Practice: Management of Uncomplicated Deep Vein Thrombosis (Adult)
It is an expected clinical practice that all adult patients presenting to the Emergency Department with uncomplicated Deep Vein thrombosis (DVT) not requiring admission for other reasons will be discharged with anticoagulation and outpatient follow-up.  The management of Deep Vein Thrombosis (DVT) varies among providers.  With the use of low molecular weight heparin and oral Xa inhibitors it has been shown that patients can be safely and effectively be discharged home without increased risk for complications.  With this in mind, following a more structured and consistent approach to the management of patients with uncomplicated DVTs can lead to the safe discharge of this patient population reducing avoidable admissions.  This clinical practice has been defined but not yet fully implemented.

Clinical practice: Heart failure exacerbation outpatient – adult 
This recommended clinical practice states that all adult patients presenting in the Emergency Department (ED) with heart failure (HF) exacerbations will be assessed for acute conditions; and if they do not meet criteria for inpatient hospitalization, they should be considered for treatment in an outpatient/observation setting.

Clinical Practice: Management of fragility hip fracture in adults
It is an expected clinical practice that all adults presenting with low energy hip fractures will be medically assessed and complex medical issues addressed to facilitate surgery within 24 hours for non-critical patients. This clinical practice describes a multidisciplinary approach to management of these patients starting in the Emergency Department through post-operative care.

Clinical Practice: Approach to major burn patients in the Emergency Department – Pediatric and Adult
It is an expected clinical practice that all patients presenting to Banner Emergency Departments with major burns (greater than 20% of total body surface area) and/or high risk burns will undergo a rapid comprehensive assessment that includes vital signs, ABC (Airway, Breathing, Circulation), mental status and associated trauma or medical condition following Acute Trauma Life Support (ATLS) and ABA Advanced Burn Life Support (ABLS) guidelines. After initial stabilization burn patients meeting criteria for transfer to a Burn Center will be transported to a Burn Center.

Clinical practice: Use of medication for the reversal of anticoagulation - adult
It is an expected clinical practice that all adult patients presenting to a Banner facility (inpatient and emergency room department) in need of anticoagulation reversal to prevent or minimize negative outcomes (e.g., bleeding events) will be assessed to determine the most appropriate reversal strategy. This will include selection of the most appropriate medication/reversal agent based on the patient’s anticoagulation therapy.

Clinical Practice: Approach to adult sexual assault patients in the Emergency Department
It is an expected clinical practice that all adult patients presenting to Emergency Departments reporting a sexual assault are to be evaluated with a medical screening examination and if an acute injury is identified, appropriately treated.  Evaluation of all sexual assault victims should be performed by a trained SANE/SAFE, where available. A skilled Sexual Assault Team is further required for timely evidence collection, initial emotional support, teaching, and follow up care. Sexual Assault Team members may include forensic examiners, victim advocates, law enforcement, case management/social services, Emergency Department staff and other medical providers.

Clinical Practice: Management of asymptomatic pyuria and bacteriuria – adult
It is an expected clinical practice that adult patients with no symptoms of urinary tract infection (UTI) should not be screened for UTI with urinalysis or culture, including patients with indwelling foley or supra pubic catheter.  In the event that an asymptomatic patient is screened, a finding of pyuria and/or growth of bacteria or fungi should not lead to treatment with antibiotics based on IDSA (Infectious Disease Society of America) guidelines of 2005.  Exceptions are asymptomatic patients who are pregnant or are undergoing urologic surgery for which screening and antibiotic treatment may be indicated.

There are conflicting recommendations from expert specialty organizations regarding the treatment of asymptomatic bacteriuria in patients undergoing elective joint replacement surgery.  Therefore, physicians should weigh the risk of infection in these patients vs. the risk of antibiotic use on a case by case basis.

Clinical Practice: Delirium Identification, Prevention and Treatment  
It is an expected clinical practice that all adult Intensive Care, Medical-Surgical, Progressive care, and Emergency Department (ED) patients will have routine screening and interventions, such as medication management, orientation to the environment, early mobility, and promotion of sleep/rest cycles, to minimize the incidence, duration and negative consequences of delirium.  This clinical practice has been defined but not yet fully implemented.

Mandatory education on use of Anascorp in scorpion envenomations (Arizona ED providers only).
This presentation outlines a consistent process for administering Anascorp for appropriate patients with Grade 3 and 4 scorpion envenomations. The associated clinical practice outlines the assessment of patients presenting with scorpion envenomations, the grading scale based on clinical effects (Grade I-IV), and the treatment recommendations based on grade of envenomation including the appropriate use of Anascorp.

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