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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Administrative Issues : Pediatric Emergency Services Operations

Pediatric emergency care is available 24 hours a day, seven days a week, in the Pediatric Emergency Department adjacent to the Adult Emergency Department ("1 West"). It is staffed by a pediatric attending 24 hours a day.

Children arrive in Pediatric Emergency Services from three main sources:

  1. self-referral or walk-in;
  2. by EMS or other ambulance service;
  3. referral for care from another health care source.

Each patient is screened (triangle assessment) on arrival. This initial screening by staff is to identify any child who needs immediate care. If immediate care is needed, the child is taken into an exam room, the resident and/or attending physician is called, and the child is immediately evaluated and diagnostic and treatment process initiated. If immediate care is not needed, the child is triaged and further assessed by one of our nurses. Vital signs are taken, and chief complaint and pertinent historical information is obtained and recorded on the ED record. If, at this time, a more careful assessment reveals that the child is more seriously injured or ill than initially appreciated, the above immediate management will occur. The parent or caretaker fills out the registration information. The child is then taken to an examining room. The chart is placed in the rack in the nursing station. Chart order is based on urgency of need first, then by time of arrival.

Take the first chart from the urgent rack (if no "urgent" charts, take the first "non-urgent" chart) and review the available information. DECODE THE VITAL SIGNS AND CHIEF COMPLAINT and READ THE NURSING NOTE. The exam room number is on the clipboard holding the chart. Write your initials on the board in the column for MD. Take a history and examine the child. Record your history and physical examination on the Encounter form. Be sure all charting is done with a black or blue ballpoint pen, and sign the chart as soon as you write on it. Present the patient to the senior resident or attending. The attending physician needs to see every child before that child leaves the ED.

If the patient requires lab work, x-ray studies, IV hydration, consultation, procedure(s) etc., write the orders in the chart and tell the nurse caring for the patient about the orders. Perform the procedures yourself when possible. Either give the chart to the nurse or place it in the "orders" slot in the chart rack. Write a succinct but complete procedure note on all procedures that you do. Be sure to document response to any treatment given (e.g. VS after fluid bolus, breath sounds after aerosol medication, etc.) and the time of the reassessment.

Whenever you are not working with the chart place it in the appropriate slot in the chart rack in the nursing station so the nurse can have access to the chart. Please try to keep the entire chart together on the clipboard.

Admissions
Please contact the upper-level resident on-call to tell them about the admitted patient. With some exceptions, most subspecialty patients and general pediatric patients are admitted to the hospitalist service. Some private groups and family medicine admit to their own services. Also, hematology/oncology admit to their own services as well. Please ask other residents or attendings if you have any questions regarding this process.

Discharge Instructions
When the patient is ready for discharge, complete the necessary prescriptions, discharge instructions and school/work excuses. With a few exceptions, we can only give a school excuse for the day of the ED visit; the primary care provider can provide further excuses if needed. Discuss discharge and follow-up instructions with the parent/caretaker. When discharging a patient from the Emergency Room, it is crucial that the parent(s) or caretaker understand and can recall the instructions you have given them.

Write all prescribed and/or recommended medications in the appropriate spaces in lay terms with simple instructions (no abbreviations).

Most important, give the patient clear verbal and written instructions about needed care. Document criteria for return both chronologically (e.g., follow-up in 2-3 weeks, return in 3-4 days if not improving, sooner if condition worsens), and for signs and symptoms (e.g., return if persistent vomiting or anytime if blood is seen in the vomitus/stool).

Discharge instructions are available for a number of common pediatric problems. Computer based instructions in English and Spanish are available, both on PAIGE and in MD Consult. Preprinted forms for some conditions are also available in a drawer in the nurses' station. When using these forms, document in the discharge instructions that you have given a copy of and reviewed the contents with the parent/caretaker.

The chart is placed in the discharge slot in the rack for the nurse to discharge. This gives the parent another opportunity to ask questions, and also gives the nurse an opportunity to do her discharge assessment. If the nurses are busy, a resident or attending may discharge the patient. A medical student should not discharge the patient. Give a copy of the instructions and handout(s) to the parent/caretaker after having the parent sign a copy of the discharge instructions. RECORD THE TIME OF DISCHARGE ON THE DISCHARGE INSTRUCTION SHEET. If the patient has a private physician or goes to another clinic for health care, refer the patient to that source for follow-up. If follow-up is urgent, i.e., within 1-2 days, call the patient's health care provider. In addition, check off the "fax immediately" box on the chart completion form on the chart and notify the secretary that the chart needs to be faxed immediately. All other charts will be faxed to the primary care provider automatically when the chart is scanned into our records system. If the resident discharges the patient, put the completed chart in the "MD to complete" slot in the chart rack.

Make sure that every child who leaves our ED has an appropriate follow-up care provider. If the child does not have a primary provider, a few options are available: 1) you have the option of taking the patient into your continuity care clinic; 2) you can refer the patient to the Pediatric Faculty Practice (the medical student pediatric outpatient experience); 3) one of our medical home practices either in Moncks Corner or in North Charleston; or 4) for patients living in North Charleston or Summerville area, you can call the family medicine resident on call and refer the child to their continuity clinic at the Trident Health Center. Family medicine also has a practice downtown. In any case, every child who leaves our ED has to have a medical home identified for follow-up care.

Please try to get the name and contact information (phone/fax) of the primary care provider for those children who are from out of town. We would like to get the information about the visit to their physician/clinic if possible.

On the discharge instruction form, there is a sentence that says:

"For any questions call 792-2123 (hospital operator) and ask her to page _________________________ on call for ____________________ service."


There should be a service listed in this blank only if this patient is followed by an MUSC primary care provider or this visit was related to a subspecialty here at MUSC. If the patient has a private pediatrician, DO NOT WRITE ANYTHING IN THIS AREA, LEAVE IT BLANK! Your follow-up instructions will have addressed this issue.

For patients who you are referring to a subspecialty clinic, consider filling out an "ASAP form" located at the nurses' station and faxing it as instructed on the form. This form will help get the patient into the appropriate clinic faster. Orthopedics requests this form be filled out on all patients to be followed in their clinic from the Peds ED.

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