Workflows 

Acute Aortic Dissection 

• For EM transfers of acute aortic dissections (atraumatic), refer to this guideline. 

Ambulance Offload 

• Our current goal is to get our APOT times under 25 minutes. The nursing team and provider team are to work together to meet this goal. Click here for the APOT workflow. 

Bed Escalation 

• Follow this link for the internal guideline regarding bed request escalation. 

Dialysis 

• There is now a dialysis hotline available for all dialysis needs. You may reach the hotline 24/7 at 951-486-4960. 

• All routine STAT dialysis 

• Hemodialysis (HD) 

• Continuous renal replacement therapy (CRRT) 

• Prolonged intermittent renal replacement (PRRT), or peritoneal. 

Difficult Airway 

• There is a difficult airway cart located in the trauma bay. 

• Inventory List *** 

• Photo of the cart 

Field Delivery 

• When a baby is born in the field and arrives to our ED, please call the neonatologist right away so that they can place admission orders. Do NOT discharge the patient in EPIC. The rest of this workflow is directed toward the MUCs, RNs, and NICU team. There is nothing else to do from the "provider" standpoint. 

General Surgery Pathway 

• Consult the surgery team if a patient has had a recent procedure, surgery, or was discharged from their service within 30 days and is returning to the ED for a related chief complaint. 

• General Surgery Pathways 

  • Appendicitis ​

  • Diverticular Disease 

  • Gallbladder 

  • GI Bleed (Critical) 

  • Hernia 

  • Pancreatitis 

  • SBO/Bowel Perforation 

Hip Fracture Pathway

• Follow this link for the Hip Fracture Pathway. 

Homeless Care Plans 

• By law, homeless patients require: 

• Medical Screening Exam 

• Referral to behavioral health when needed. This may be an outpatient referral, but screening and follow-up plan must be documented. 

• Provided with a prescription for necessary medications. 

• Documentation that the patient is stable for discharge. 

• Make sure the following care decisions and good documentation for every homeless patient are met: 

  • Medically stable ​

  • Have mental health resources when needed 

  • Have the capacity to be discharged (alert, awake, and able to care for themselves). 

• The RUHS Social Services teams are working on further protocols to ensure all other facility requirements are met and hardwired. The patient does not need to stay in an ED bed while other arrangements for discharge planning are being made. 

• The hospital has many other requirements they will be working to meet. More details for the CAL ACEP website can be found in this link. 

Hyberbaric Oxygen Chamber 

• See this link for the hyperbaric oxygen workflow.  

Intranasal Versed 

• Attached is a set of guidelines for the use of intranasal Versed. Please note that when this medication is used on its own, it is not considered procedural sedation, however, if it is used along with opioids, it is then considered procedural sedation. 

Non-Accidental Trauma 

• Regarding Pediatric Forensics: RUHS Forensic Pediatricians are always on call (either Dr. Grant or Dr. Massi), and the operator should know who is on call and should have their information. They would like to be called for any uncertain cases. 

• NAT Pathway 

Outpatient Follow-Up Visit from Triage 

• *** 

Opioid Use Disorder 

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Palliative Care 

• Emergency Medicine team role and goals: 

• Will work to discuss end of life goals with then patient (prior to intubation/deterioration) and next of kin whenever possible to document this.

• Review available POLST prior to intubation/MICU admission whenever possible. Work to ensure patient's plans are consistent with the level of care requested. 

• Will convey patient/family wishes (when known) to the admitting team during handoff. 

• Will place palliative consult for any patient with anticipated potential death within 6 months (e.g. most PCU and MICU admissions; most COVID+ PCU and ICU admissions over 60 years of age). 

• Palliative Care Pathway 

Radiology Guidelines 

• Refer to the RUHS Intranet for full radiology guidelines. 

• Quick Guide for ED radiology 

SART 

• SART patients requiring Medical Clearance prior to Forensic Medical Examination

• Patients presenting to the Emergency Department prior to reporting a sexual assault to law enforcement (self-presenting) 

• Patient presenting to the Emergency Department via ambulance 

• Patients presenting to the Emergency Department for a Forensic Medical Examination who have medical complaints including pain, bleeding, strangulation, and/or are intoxicated upon presentation.

• Pediatric patients

• SART patients presenting for the sole purpose of receiving a Forensic Medical Examination will receive a Medical Screening examination by the SANE Department of Nursing - Sexual Assault Response Team Page 2 of 2 Subject: Medical Screening/ Medical Clearance Document No. SART-102 

• SART patients with emergent/urgent medical needs or conditions will be referred to the Emergency Department following Forensic Medical Examination for further evaluation and/or treatment. 

• SART also can assist in management of domestic violence cases. 

• SART can be contacted by calling the hospital operator and requesting a page.

• Complete SART Screening Guideline 

Service Agreements 

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Sports Concussion 

• For all adult and pediatric patients seen in the ED with a concussion, please refer to Sports Medicine. 

• Place a discharge order for an "Ambulatory Referral to Sports Med"

• Click on "Referral Override" 

• Select "Perris Clinic", Dr. Uziel Sauceda 

• Regardless of insurance type, Dr. Sauceda will arrange follow-up (including Kaiser). 

• You can also message Dr. Sauceda directly through EPIC 

• Excuse patient from sports for a minimum of 7 days and require medical clearance prior to return to sports. 

• *** Make the picture for here into a document or something 

STEMI Program 

• Internal STEMI guidelines

Strangulation 

• Strangulation Evaluation Guidelines

• Strangulation workflow

Stroke 

• Use the stroke order set 

• Do not admit until LVO has been ruled out 

• Go to CT with patient if within TPA/TNK window (look at CT head to ensure there is no ICH and start calling neurology/pharmacy for TPA/TNK) 

• LKWT must be within 24 hours for patient to qualify for neuroIR and 4.5 hours for patient to qualify for TPA 

• Pediatric Stroke Pathway 

Trauma 

• Trauma Activations 

• MICN will activate field calls if criteria is met 

• ED Attending should, when in doubt, activate pre-arrival (err on the side of activation) 

• Trauma and ED senior need to make sure introductions are made when possible prior to major trauma arrival and tasks are assigned by the Trauma Senior and understood by the team. 

• If the trauma senior or attending is not present, the ED senior should coordinate roles. 

• If patient's condition changes in the ED, activation should me made or upgraded as appropriate. Life threatening injuries should be activated as major traumas. 

• If a patient does not meet activation criteria but requires a work-up (CT scans) to investigate for traumatic injuries, when appropriate, the ED will expedite the care (e.g. bypass labs for CT if indicated, expedite CT, etc). 

• When appropriate, trauma activations can/should be used outside the protocol to facilitate expedited care as well (access additional nursing, lab, CT, and other resources). 

• For medical arrests with associated signs/suspicions of trauma, trauma activation will occur (e.g. elderly fall with significant bruising/trauma)

• For cardiac arrest in custody, if there is no clear medical indication (e.g. asthma, chest pain prior to arrest, ingestion), it should be activated as a trauma. If the cause is unknown (found down), activate. 

• Consult/minor trauma: place a consult and call trauma nurse (ext. 18132) and ask for a "minor trauma consult". See consult criteria. 

• All trauma transfers out of our facility to be approved by trauma service/attending. 

• If patient meets criteria for stroke or RRT/Sepsis, please activate in parallel to trauma activation/work up. 

• ​

Transfers

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