An initiative to help decrease stress and frustration in the workplace. An anonymous survey designed for small and easy fixes that can be resolved in a timely manner depending on the type of submission. We hope it adds to the quality of life in the ED!
How do I submit a response?
Through this form or the QR code (to right), you can submit a quick 3 question survey which will go to ED leadership.
Where are the physical QR codes?
QR codes are located in the ED nursing station, staff bathrooms and break room.
We will report back regularly with any positive changes we can address or make from this.
What are some examples of appropriate “pebbles” to submit:
Public Health Law governing disposition of fetal remains has changed reccently. Families are no longer required to bury fetal remains over 20 weeks gestation. In general, GYN should be consulted, and the new consent form (see below) must be completed and scanned in to the EMR.
From the Desk of Michael Nimaroff, MD, MBA, Senior Vice President, OBGYN Service Line, Northwell Health
There are important changes to the NYS Public Health Law governing disposition of fetal remains. Previously, the families of products of conception delivered in our facilities outside of New York City were required to bury all products of conception for any remains over 20 weeks gestation. This requirement has been eliminated and now families are not required to bury fetal remains of any gestation.
For all sites in New York State and outside the New York City limits, families must be given the option to opt-out of self-disposition of products of conception over 20 weeks gestation. Our Pathology departments will manage fetal remains less than 24 weeks gestational age/26 weeks since last menstrual period (LMP). Discussions are underway with funeral directors and county coroner leads for mechanisms to dispose of the remains above the gestational age limits noted above. As we move to comply with this change, for families who choose not bury the products of conception, the remains will be held in hospital morgues. (Pathology departments are aware of the change).
The change requires a revision to our current Disposition of Products of Conception consent. As this revision moves through the formal approval process, we have been advised by the Office of Legal Affairs to implement the changes immediately and have attached the updated consent to replace the current disposal of fetal remains consent document. Inclusion of the revised form is being expedited to Vital Docs, for the immediate timeframe please use the attached consent.
Management of fetal remains does not change for any of the Northwell facilities in New York City (Queens, Staten Island, Manhattan, Bronx or Brooklyn), although all sites will use the new form.
Please note, that these changes do not apply to live births but only to pregnancy loss resulting from spontaneous miscarriage, stillbirth, or any termination of pregnancy.
Charge Nurse assigns the team and pulls the provider for an evaluation
EMS stops in front of the charge desk where the patient is evaluated by:
Registration
ED nurse
ED provider
Assess that patient is having stroke symptoms requiring stroke work up (brief neuro exam, NOT full NIHSS)
ED provider and RN go through check list to ensure
Vital signs stable for CT transport
Glucose safe for CT transport
Airway intact
Patient goes to CT scan on EMS stretcher, transfers to NWH weighted stretcher, weight is checked outside of CT scan. RN enters weight and allergies.
RN calls charge NR or ED provider to advise that weight and allergies are entered
ED provider enters the stroke orders (This means that after you evaluate a code stroke in the hallway, 2 or 3 minutes later, you’ll be notified to place the orders. So please do not immediately get involved with a complex situation until you have entered the stroke orders)
Patient returns to the assigned room and usual stroke care follows.
You are all probably aware that the service line is invested in having all of us trained and placing femoral nerve blocks for hip fractures. These blocks provide significant analgesia for 24-36 hours and minimize the complications of opioid medications that we have traditionally given. This is especially true of our elderly patients who are obviously most likely to suffer a hip fracture.
Education:
We have an educational process in place.
You should have the opportunity to practice nerve blocks at your next Bioskills training.
You can spend time in the PACU with our local block expert Attila Kett. Text me and I can slot you into a week. Usually we touch base with him on Mondays and the most high yield day is Thursdays when a lot of ortho cases are going. It is a nice day – meet in the PACU at 7am. I would stay until all the ortho cases were done – about 6 hours.
Call anesthesia – they will bring their equipment down to have the block done, but are willing to walk you through a block.
If anesthesia is unable to come to the ED for your hip fracture, call me. If I can make it, I’ll come in and do the block with you so you can teach the next person.
For ultrasound savvy folks, 2 observed blocks are required per EMSL guidelines, and for the novice, 10 blocks are required.
Order Set
For the procedure itself, there is an order set in meditech, titled ED: Nerve Block. The orders for anesthetic are here as well as for Intralipid in the exceedingly rare case of a patient with LAST (local anesthetic systemic toxicity). You can use this order set for any other local or regional blocks you are doing should you suspect LAST.
Procedure Cart
The new procedure cart should have a Nerve Block Kit, probe sheath and block needle which you will need for the procedure.
Documentation
You can document the procedure using the .usnerveblock or .usblock dotphrases/quicktexts. This can be anywhere in your note, but would be appropriate to place in the “ultrasound” tab.
Complications
Again, complications are very rare. There is always the possibility of hematoma, or infection when you go through the skin. These patients will be on the monitor to screen for signs of LAST toxicity. LAST may begin with tinnitus, perioral numbness, and then cardiac signs – tachycardia, hypertension. These may progress to seizure > coma > death. Again this is exceedingly rare and the treatment is in the pyxis with dosing in the order set if needed. Nursing education has done a great job of bringing our nurses up to speed.
Hit me up with any questions, but especially if you want to spend time in the PACU – our new chief is going to be one of the first to spend time up there!
DATE: 07/22/2024 TO: Healthcare Providers, Healthcare Facilities, Clinical Laboratories, and Local Health Departments FROM: New York State Department of Health (NYSDOH) Wadsworth Center and Division of Epidemiology, Bureau of Communicable Disease Control (BCDC) The purpose of this advisory is to provide guidance regarding surveillance for influenza (including highly pathogenic avian influenza A(H5N1)) in patients with severe respiratory illness and the submission of specimens to Wadsworth Center. Summary
In response to the ongoing and extensive global outbreak of highly pathogenic avian influenza (HPAI) A(H5N1) in wild birds, poultry, and dairy cattle, the Centers for Disease Control and Prevention (CDC) is encouraging year-round testing for influenza among persons with severe respiratory illness.
NYSDOH and the CDC request that respiratory samples from persons hospitalized with laboratory confirmed influenza, particularly patients receiving intensive care unit (ICU) level care, be promptly forwarded to the Wadsworth Center Virology Laboratory for additional testing, including subtyping, whole genome sequencing, and antiviral resistance testing.
Laboratories, hospitals, and clinical providers should recognize that adherence to recommendations for influenza testing and sample submission are important steps for human HPAI A(H5N1) surveillance in the United States (U.S.), especially during the summer when influenza testing may not be routine and exposure to poultry, cattle, and swine may increase during agricultural fair season.
If you suspect a patient has a novel influenza A virus infection based on an influenza A positive laboratory result in combination with clinical history and exposures, immediately contact the NYSDOH at 518-473-4439 or 1-866-881-2809 after hours and the local health department (LHD)1 where the patient resides. 1 https://www.health.ny.gov/contact/contact_information/ Health Advisory: Influenza Testing among Persons with Severe Respiratory Illness During Periods of Low Influenza Virus Circulation Please distribute immediately to: Clinical Laboratories, Hospitals, Local Health Departments, Physicians, Physician Assistants, Nurses, Nurse Practitioners, Facility Staff in The Departments of Emergency Medicine, Infectious Disease, Infection Prevention and Control, Epidemiology, Laboratory Medicine, Medical Directors, Directors of Nursing, and all patient care areas Page 2 of 3 Background Public health agencies in the U.S. and clinical partners continue to monitor and respond to the global outbreak of HPAI A(H5N1). As of July 18, more than 100 million poultry have been affected in 48 states in the current U.S. outbreak, the largest domestic outbreak of avian influenza in poultry in recorded history. Additionally, HPAI A(H5N1) has been detected in more than 163 U.S. dairy cattle herds in 13 states and sporadically in other animals2 . The currently circulating strain of HPAI A(H5N1) poses a low risk to the health of the general public. However, to date, nine human cases of A(H5N1) infection associated with the outbreak in U.S. dairy cows3 and poultry4 have been reported. While the number of human cases nationally remains small, influenza viruses are known to be unpredictable and highly mutable with the potential for a rapid change in tropism and transmission, which is a concern given the extent of spread in birds and novel detections in dairy cows and other animals. Please visit https://www.cdc.gov/bird-flu/situation-summary/index.html for the most up-to-date information. Recommended actions:
Submit to Wadsworth Center year-round all positive influenza samples from hospitalized patients requiring ICU care.
Conduct enhanced influenza surveillance during months when seasonal influenza incidence is typically low (May through September).
Continue ordering influenza testing and subtyping on patients with respiratory illness.
NYSDOH recommends increased levels of clinical suspicion of influenza in patients with respiratory illness who are at higher risk for contracting avian or novel influenza, such as those with a history of exposure to dairy cattle, wild birds, poultry, or swine (pigs).
If you have a patient with conjunctival symptoms (with or without respiratory symptoms) and who is at high risk for contracting avian or novel influenza, such as recent exposure to dairy cattle, contact the local health department (LHD)5 where the patient resides for testing guidance. If unable to reach the LHD where the patient resides, contact the NYSDOH Bureau of Communicable Disease Control at 518-473-4439 during business hours or at 866-881-2809 after hours.
Submit to Wadsworth Center all influenza positive samples detected in hospitalized persons NOT requiring ICU care until December 31, 2024, for subtyping, sequencing, and other specialized analyses, as well as potentially forwarding to CDC for their repository.
In the event of an outbreak, please contact the NYSDOH at 518-473-4439 for guidance. Specimen and shipping instructions
Specimens acceptable for influenza testing at Wadsworth Center include nasopharyngeal swabs (NPs), oropharyngeal swabs (OPs), and nasal swabs (NSs) in viral transport media (VTM) or universal transport media (UTM).
Flocked swabs are preferred. Sterile Dacron® or rayon swabs with plastic or metal handles may also be used. Do NOT use cotton or calcium alginate swabs or swabs with wooden sticks. Place the swab in liquid VTM or UTM. The swabs and media used for routine SARS-CoV-2 or influenza (polymerase chain reaction (PCR)) testing can be used. Do NOT use saline or dry swabs.
Specimens MUST be kept cool until they reach Wadsworth Laboratory. Refrigerate OR store specimens in cooler with frozen gel packs until ready to ship. Specimens should be shipped 2 https://www.cdc.gov/bird-flu/situation-summary/index.html 3 https://www.cdc.gov/media/releases/2024/p-0703-4th-human-case-h5.html 4 https://www.cdc.gov/media/releases/2024/p-0715-confirm-h5.html 5 https://www.health.ny.gov/contact/contact_information/ Page 3 of 3 overnight on frozen gel packs.
Specifics regarding influenza specimen collection and shipping to Wadsworth Center can be found at: https://www.wadsworth.org/programs/id/virology/services/specimen-collection
A shipping manifest from an electronically submitted Remote Order OR an Infectious Disease Requisition (IDR)6 form requesting influenza testing with subtyping should accompany all specimens sent to Wadsworth.
For questions about shipping on holidays or weekends, please call 518-474-4177.
Please ship specimens to: David Axelrod Institute Virology Laboratory Wadsworth Center New York State Dept. of Health 120 New Scotland Ave. Albany, NY 12208 Infection Prevention Considerations Standard, Contact, and Airborne precautions, including the use of eye protection, are recommended for the collection of respiratory and other specimens and medical evaluation.
Patients with suspected HPAI A(H5N1) infection who present to a healthcare facility should be placed in an airborne infection isolation room (AIIR).
If a patient presents to a healthcare facility at which an AIIR is not available, the patient should be instructed to wear a facemask and should be placed in an examination room with the door closed until discharge or transfer to a facility with an AIIR.
Additional infection prevention and control guidance for healthcare facilities with or without an AIIR, including additional patient placement information and cleaning and disinfection steps, is available7 . NYSDOH appreciates your continued support in this effort to prevent and control influenza, and the partnership with laboratories, hospitals, and providers to immediately identify and contain potential human cases of novel influenza in the U.S. Resources and Questions
Questions regarding submission of specimens to Wadsworth Center can be directed to wcid@health.ny.gov.
Questions pertaining to enrollment to Wadsworth Center CLIMS for access to remote ordering and access to electronic test reports can be directed to climsoutreach@health.ny.gov.
General questions about suspected A(H5N1) cases can be directed to the NYSDOH BCDC at 1- 866-881-2809 evenings, weekends, and holidays or by email at BCDC@health.ny.gov.
NYC based clinicians should contact the healthcare provider access line at 1-866-692-3641
General questions about influenza infection control in hospitals, nursing homes, and diagnostic and treatment centers can be sent to icp@health.ny.gov
Additional NYSDOH guidance for clinicians regarding Highly Pathogenic Avian Influenza A(H5N1) is available at: https://commerce.health.state.ny.us/hpn/ctrldocs/alrtview/postings/NY_Advisory_- _HPAI_Identification_of_Human_Infection_2024_1712853441619_0.0.pdf
General NYSDOH avian influenza information is available at: https://www.health.ny.gov/diseases/communicable/influenza/avian/ 6 https://www.wadsworth.org/programs/id/idr 7 https://www.cdc.gov/bird-flu/hcp/novel-flu-infection-control/?CDC_AAref_Val=https://www.cdc.gov/flu/avianflu/novel-flu-infection-control.htm
