Initiative #7: PEDrU (EDRU for Pediatric ED)

On September 6th, we will launch some exciting new PEDrU process improvements, including the PEDrU SWARM and PEDrU Page. We will also review some key clinical pathways.

The SWARM is a rapid bedside assessment by a nurse and a senior-level physician to determine if a pediatric patient needs immediate intervention. It is used to rapidly alert physicians of potentially ill or deteriorating patients and improve communication between physicians and nurses on the care team.

A PEDrU page is an alert sent out to the rest of the Emergency Department and ancillary services of an active resuscitation in progress. It is to be used for critically ill patients that required the maximum resources within the Pediatric ED.

Initiative #6: E-CPR Initiative

We've been formally offering E-CPR during business hours (8-5 M-F) for almost 1 year. Through everyone's collective effort we are saving the lives of a subset of cardiac arrest victims who are refractory to standard ACLS. We've made great progress but can always get better through review of the process and simulations. Please familiarize yourself with the most recent version of the E-CPR inclusion & exclusion criteria below (revised 8-18), and watch the videos reviewing the delivery system in place. You can go to the Resource page for more great E-CPR education. Have fun resuscitating!

Follow the link to read the most recent version of the E-CPR inclusion and exclusion criteria.

E-CPR from UNM Health Sciences Center on Vimeo.

ECPR Lecture Part 1 from UNM Health Sciences Center on Vimeo.

ECPR Part 2 CODE Response and Room Setup from UNM Health Sciences Center on Vimeo.

ECPR Part 3 RESUS-TECH from UNM Health Sciences Center on Vimeo.

ECPR Part 4 ACLS Captaining from UNM Health Sciences Center on Vimeo.

ECPR Part 5 Resuscitation Leader from UNM Health Sciences Center on Vimeo.

ECPR Part 6 Line Doc from UNM Health Sciences Center on Vimeo.

ECPR Part 7 Precision CPR from UNM Health Sciences Center on Vimeo.

ECPR Part 8 from UNM Health Sciences Center on Vimeo.

Go to Learning Central, log in and search for EDRU to be credited for finishing this course.

Initiative #5: Trauma Re-Org

Our New Year's Resolution:
Let's bring our "A game" to each and every trauma resuscitation.

To kick off EDRU improvements in 2017, we are excited to rollout a new process for running our TAP traumas in collaboration between EM physicians, Trauma surgeons and all ED staff.

Broadly, the goals are to improve our collective trauma team culture and management process.

Specifically, the goals are:

  1. To establish a culture of sociability and solidarity between the many stakeholders of the trauma care process
  2. To improve teamwork and communication among all trauma team members
  3. To improve leadership skills of the Trauma Team Leader (TTL)
  4. To implement a process with defined roles and responsibilities among team members
  5. To implement a process where all communication and orchestration of patient care goes through a single trauma team leader (TTL)
  6. To implement a rotation of the TTL and other roles between EM physicians and surgeons

Components of the initiative:

  1. Continued training with joint simulation sessions both in the BATCAVE sim center and in-situ, in the trauma bay. We will approach every live trauma case as an opportunity to rehearse and improve.
  2. Revive monthly joint EM/trauma surgery conferences; these will be held on the 3rd Tuesday of every month at noon. Attendance will get you internal Trauma CME for your continued education. Topics and locations to be announced routinely.
  3. A multi-disciplinary and multi-professional Trauma-Resuscitation committee was formed to continuously work on global improvements to our trauma care systems. For any ongoing feedback, please send an email to the group via UNMH-trauma@salud.unm.edu
  4. Intermittent social events

EDRU initiative #5 requirements:

  • The requirements for this one are simple; watch the Re-Org video and pass the quiz in Learning Central.
  • The bigger challenge comes with continuously working on our own teamwork, communication and leadership skills in an effort to improve our culture and make the new process work.

Where can I review the new process? On the EDRU Initiative Resource page.

Initiative #4 - RUSH Exam Initiative

After watching the video, go to Learning Central, log in and search for EDRU or CE 600 to complete the quiz.

Purpose of the initiative:

  • To improve your comfort level and expertise with the RUSH exam.
  • To facilitate making the RUSH exam a routine component of the evaluation of hypotensive patients in the EDRU
  • To get faculty on their way to privileging for this exam

HIMAP RUSH Ultrasound Exam Episode 1 from UNM Health Sciences Center on Vimeo.

RUSH FEST Promo Part 2 from UNM Health Sciences Center on Vimeo.

RUSH Initiative Requirements and FAQs

To successfully complete the RUSH initiative requirements and remain eligible to work EDRU shifts YOU MUST DO THE FOLLOWING:

  1. Either have attended the live RUSHFEST didactic lecture, or watch the video and then pass the quiz on Learning Central. Both the video and quiz can be accessed on the EDRU website. Even if you attended the session, you are encouraged to watch the video that was so well-done by our excellent videographer. It will help you to revisit some key points you may have forgotten.
  2. You must then complete 3 entire RUSH exams that have appropriate images saved, and submit to Q-path to be QA'd by our department sonographers. The QA team will assess if these images are adequate (Image Quality categories 4 or 5, indicating that minimum criteria met for diagnosis and all structures imaged well) and provide feedback. The first completion due date will be March 1st, 2017 which will give everyone plenty of time to get it finished.
  3. To stay current and eligible for EDRU shifts, you will need to complete 3 new RUSH exams every 6 months moving forward until you have completed enough for credentialing.
  4. You should save exams as separate components (or separate them out in Q-path into their individual components) of; 1. Cardiac + IVC, 2. FAST, 3. Aorta and 4. Pleural, since that is what is required during your training by ACEP since there isn't a specific RUSH category. UNM faculty will now have an advanced privileging category called the RUSH privileging (explained below).

What are the requirements for me to be credentialed for RUSH exam utilization?

When hired as UNM faculty after EM training, you are credentialed for FAST exam and procedural ultrasound use. We have designed a next level of privileging referred to as the RUSH level credentialing. To attain this, you will need to add some components to your already completed FASH exams (understood to have been completed during your residency training). That means you need to add the cardiac (+IVC), aorta, and pleural components. The credentialing requirement set forth by our department is 25 cardiac exams, 25 aorta exams and 10 pleural exams.

***If you only did the 3 exams every 6 months as required by the EDRU, it would take you around 5 years to meet these credentialing requirements. The hope is that we all complete our requirements for credentialing much sooner. But at the very least, the expectation to work in the EDRU is that you demonstrate that you are on the path to credentialing, by way of only 3 exams every 6 months.

I'm too busy during an actual shift to methodically perform and save a comprehensive RUSH exam. What should I do?

There are four excellent options to help you get the above requirements done.

  1. Come in to scan on your own in the ED or ICUs.
  2. Complete RUSH exams in 1 on 1 sessions with Tamara
  3. Schedule some time with any of your EM/CCM colleagues in the ICUs...always available patients with excellent pathology. We also have 2 faculty who are Echocardiography certified (Marinaro and Wray), and 3 others on their way to Echo certification (France, Isaac and Todd).
  4. Please feel free to ask any of the RUSH instructors (Barret, Baty, Macias, Doyle, Wachter, Reilly, Dettmer, J. White, Musleh, Glass, Tawil, Braude, Keiler-Green) to help you scan or provide guidance to complete your requirements. It's a great team of knowledgeable RUSH experts here to help make this easy for everyone!

When I do a RUSH exam clinically, how can I chart it?

There is a new RUSH Macros that you can use. Thanks Dusadee and Gillian! It is attached here.

How else can I get good at utilizing the RUSH exam?

The RUSH initiative resource page is full of excellent video tutorials, podcasts and literature to get you on your way! If you spend a couple hours going through this page, I have no doubt it will serve as an excellent supplement to your bedside scanning.

Thank you all for helping us to improve the critical care and resuscitation we provide in the EDRU!

EDRU: Year 1 in Review

Initiative #3 - Vascular Access Mastery

Purpose of this initiative: The purpose is to improve your expertise and comfort with all things related to emergency vascular access; to include central venous, arterial, and intra-osseous lines. Specific areas of improvement are...

1. Central Venous lines:

  • Mastering the technique of ultrasound guided subclavian, IJ, and femoral vein placement
  • Mastery of site selection tailored to each critically ill patient
  • Implementation of real time checklist use for every central line in the EDRU

2. Arterial lines

  • Timing: Expediting safe arterial line access early in hemodynamically unstable patients
  • Mastery of arterial line transduction set-up
  • Mastering ultrasound guided line placement in the Common Femoral Artery

3. Intra-osseous lines:

  • Timing: making this the first line in pulseless patients and unstable patients with difficult peripheral access
  • Mastery of anatomic site selection and placement

Initiative #2 - Airway and Ventilation

Purpose of this initiative:

  1. Improve intubation practices through the routine use of a new intubation checklist
  2. Improve and standardize the initial mechanical ventilatory settings for all intubated patients
  3. Improve collaboration with respiratory therapy to manipulate ventilatory settings based on patient gas exchange, physiology and comfort
  4. Improve respiratory care through utilization of ETCO2 for all intubated and mechanically ventilated patients
  5. Introduce a guideline for Emergency Department Extubations

Airway/RSI Checklist: We will prepare for all intubations using a "pre-flight" checklist to assure that we are addressing each component of the process.

ETCO2 Utilization: The goal is to use quantitative capnography to confirm ETT placement (replacing qualitative capnometry), assure adequate minute ventilation for critically ill patients and correlate with an arterial blood gas PCO2. Additionally, we will use ETCO2 during CPR to evaluate efficacy of compressions, identify ROSC and assist with prognostication.

Mechanical Ventilation Order Sets: The new mechanical ventilation order sets will provide a standardized starting point for all intubated and ventilated patients. By using an ideal body weight based tidal volume, appropriate PEEP and FiO2, we will assure that our patients are on a lung protective ventilatory strategy. Each patient's ventilatory settings and overall care will be revisited by the physician and respiratory therapist using ETCO2 and blood gas PCO2. Additionally, the order sets will address other important aspects of care including head positioning, gastric decompression and post-intubation sedation orders.

ED Extubation Guideline: For those uncommon circumstancces where a patient is appropriate for extubation while in the ED, we will introduce a previously studied guideline, and enlist the support of our intensive care faculty and respiratory therapists to assure this goes smoothly in the busy EDRU environment.

Initiative Completion Requirements: All EM faculty and residents must either attend the CME lecture or watch the video on the site and then complete and pass the brief quiz through Learning Central by Feb 4th, 2016.

Initiative #1 - Neuro-Resuscitation

1. NIH Stroke Score (NIHSS) Certification:

Due Date: All faculty and residents are to complete this certification by November 5th (3 months time). Faculty and residents are expected to complete the NIHSS in the stroke or TIA powernote. Compliance goal is 100%, we are currently below 10%.

Purpose of this Certification: Demonstrates an expertise in assessing ischemic stroke patients, calculating and NIHSS, which is fundamental to the evaluation and management of ischemic stroke patients. With improved compliance in documenting NIHSS, we will improve our eligibility to become a comprehensive stroke center.

Logistics of Completion:

Access the National Stroke website at: https://secure.trainingcampus.net/uas/modules/trees/ windex.aspx?rx=nihss-english.trainingcampus.net, set up an account and take the free training. the tutorial takes between 1-2 hours depending on how fast you go through it and the testing takes another hour. You will qualify for CME for this and obtain a certificate of completion. This certificate should be emailed to Marisol Deleon at MdeLeon1@salud.unm.edu.

2. Neurocritical care resuscitation powerplans/order sets:

These new ED guidelines and order sets will facilitate standardized triggers and strategies for managing patients with CNS emergencies including severe TBI, spontaneous ICH, and aneurysmal SAH. The power plans include blood pressure goals for each with orders for titratable gtts to attain these goals, prophylactic anti-seizure med orders, RSI meds, ETCO2 goals for herniating and non-herniating patients and osmolar therapy guidelines for the herniating patient. It will be one-stop shopping for catastrophic CNS injuries! This will standardize practice between the ED and ICUs.

3. Ischemic Stroke process improvements:

These new processes for rapid notification and assessment of the ischemic stroke patient will hopefully improve our door to thrombolytics or IA therapy timing. The goal is also to improve our completion of the stroke timing sheets. Compliance goal is 100%. This will improve our eligibility to obtain certification as a comprehensive stroke center.