Policy and Procedure Manual Reviewed/Revised …

1 Policy and Procedure Manual Reviewed/Revised March, 2012 _____ _____ Mark Henry, MD Chairman, Department of Emergency Medicine _____ _____ Alison Rowe, RN Nurse Manager _____ _____ Eric Niegelberg Administrative Director for Emergency Services Reviewed/Revised March, 2012 Emergency Department Policy and Procedure Manual Stony Brook University medical Center Stony Brook, New York Emergency Department (ED) Classification of Capability Patient Assessment and Care Community-based Emergency Plan Emergency Department Design Patient Initial Screening Exam Chief of Emergency Services Assistant Chief of Emergency Services Attending Physicians in Emergency Medicine medical Staff Coverage Physician Assistants ED Director of Nursing (ADN) ED Nursing Staff ED Nursing Staff-Orientation Emergency medical Services ED Nursing Station Clerks and Clinical Assistants ED Nursing Station Clerks-Orientation ED Clinical Assistant (CA)- Orientation ED Scribes Continuing Education Disaster Plan Flu Pandemic Plan Blood-Location, Storage and Procurement Equipment and Supplies Equipment Loan Equipment Failure Power Failure Electrical Safety Fire Plan Security/Traffic Control Interhospital Transfers Laboratory Down Time Procedure Panel Screens Decontamination-Possible Anthrax Exposure Warmer (Fluid/Blanket) Consent Confidentiality of Patient Information Triage Private Physician (PMD)

2 Notification Critical Care Area Patient Belongings and Valuables Standing Orders Laboratory Services Integration of Diagnostic Radiology with ED Integration of Operating Rooms (OR) with ED Integration of Special Care Units with ED Reporting of Criminal Injury Invasive procedures (Physicians) ED Observation Patient Transport for Special procedures Admission Return of Admitted Patients to the Emergency Department Length of Stay in the ED Greater than 8 Hours Injury Prevention of Unconscious, Confused or Irrational Patients Radiation Accidents/Radioactive Contamination Social Work Services Consultation Rape/Sexual Molestation Rape Kit/Maintaining Evidence Release of information to the medical Examiner (ME) Animal Bites Notifying the Dept. of Health Pesticide Poisoning Notifying the Dept. of Health Patient Discharge Infection Control Bloodborne Pathogen Exposure in Patients Presenting to the ED Bloodborne Pathogen Exposure in Prehospital Response Employees Visitors medical Records Patients Pronounced Dead in the Emergency Department Poisonings Pediatric Immunizations Tetanus Prophylaxis Rabies Prophylaxis Major Adult Trauma Major Pediatric Trauma Adult and Pediatric medical Resuscitations Documenting Waste of Prehospital EMS Medications Pediatric Medication Administration ED Control Register (ED Log) Quality Control Follow-Up Program - Call Back Patient Follow-Up Procedure Telephone Advice Transportation Vouchers Continuous Quality Improvement (CQI)

3 Identification and Treatment of Domestic Violence Emergency Contraception Reviewed/Revised March, 2012 Emergency Department Policy and Procedure Manual Stony Brook University medical Center Stony Brook, New York Admission Adult and Pediatric medical Resuscitations Animal Bites - Notifying the Dept. of Health Attending Physicians in Emergency Medicine Bloodborne Pathogen Exposure in Patients Presenting to the ED Bloodborne Pathogen Exposure in Prehospital Response Employees Blood-Location, Storage and Procurement Chief of Emergency Services Community-based Emergency Plan Confidentiality of Patient Information Consent Continuing Education Continuous Quality Improvement (CQI) Critical Care Area Decontamination-Possible Anthrax Exposure Disaster Plan Documenting Waste of Prehospital EMS Medications ED Clinical Assistant (CA)- Orientation ED Control Register (ED Log) ED Director of Nursing (ADN) ED Nursing Staff ED Nursing Staff-Orientation ED Nursing Station Clerks and Clinical Assistants ED Nursing Station Clerks-Orientation ED Scribes Electrical Safety Emergency Contraception Emergency Department (ED)

4 Classification of Capability Emergency Department Design Emergency medical Services Equipment and Supplies Equipment Failure Equipment Loan Fire Plan Flu Pandemic Plan Follow-Up Program - Call Back Identification and Treatment of Domestic Violence Infection Control Injury Prevention of Unconscious, Confused or Irrational Patients Integration of Diagnostic Radiology with ED Integration of Operating Rooms (OR) with ED Integration of Special Care Units with ED Interhospital Transfers Invasive procedures (Physicians) Laboratory Down Time Procedure Laboratory Services Length of Stay in the ED Greater than 8 Hours Major Adult Trauma Major Pediatric Trauma medical Records medical Staff Coverage Nurse Practitioners Observation Panel Screens Patient Assessment and Care Patient Belongings and Valuables Patient Discharge Patient Initial Screening Exam Patient Transport for Special procedures Patients Pronounced Dead in the Emergency Department Pediatric Immunizations Pediatric Medication Administration Pesticide Poisoning Notifying the Dept.

5 Of Health Patient Follow-Up Procedure Physician Assistants Poisonings Power Failure Private Physician (PMD) Notification Quality Control Rabies Prophylaxis Radiation Accidents/Radioactive Contamination Rape Kit/Maintaining Evidence Rape/Sexual Molestation Release of information to the medical Examiner (ME) Reporting of Criminal Injury Return of Admitted Patients to the Emergency Department Security/Traffic Control Social Work Services Consultation Standing Orders Telephone Advice Tetanus Prophylaxis Transportation Vouchers Triage Visitors Warmer (Fluid/Blanket) _____ Manual Code: _____ Subject: Emergency Department (ED) Classification of Capability _____ Effective Date: Reviewed/Revised as of: Scheduled Revision: July 1, 1989 March, 2012 March, 2013 _____ Policy : 1. The Emergency Department (ED) of Stony Brook University medical Center is a Level 1 ED offering comprehensive emergency care 24 hours a day.

6 2. An attending physician in Emergency Medicine is on-duty in the ED 24 hours a day. 3. Attending physicians in Anesthesiology and Psychiatry are in-hospital 24 hours a day and available for consultation. 4. Senior-level resident physicians in Internal Medicine, Family Medicine, Surgery, Orthopedics, Obstetrics/Gynecology, Pediatrics, Anesthesiology and Psychiatry are in-hospital 24 hours a day and available for consultation. 5. Resident physicians, fellows and attending staff in other subspecialties are available for consultation within 30 minutes. 6. On call rosters for specialty consultation are available in the emergency department as well as being readily available via the page operator. _____ Manual Code: Page 1 of 2 _____ Subject: Patient Assessment and Care _____ Effective Date: Reviewed/Revised as of: Scheduled Revision: July 1, 1989 March, 2012 March, 2013 _____ Policy : 1.

7 All patients who come to the ED for emergency medical evaluation or treatment will receive care by qualified personnel in a timely manner consistent with the acuity of their illness. 2. Evaluation and care will be rendered to all patients regardless of age, sex, race, creed, national origin, criminal status, immigration status, type of medical illness or ability to pay for care. 3. Patients presenting to the ED will be evaluated by the ED staff under the supervision of the attending physician. The ED attending physician will be responsible for determining the appropriate treatment and disposition of the patient. 4. The assessment will include, but not be limited to, the following: a. The initial assessment of the patient s physical, developmental, and psycho-social status. b. The appropriate treatment setting. c. The patient s desire for treatment d. The patient s nutritional and functional status.

8 E. The appropriate work up and assessment of possible victims of abuse. f. An appropriate discharge planning process to include medical , developmental, psychological, and functional needs of the patient. 5. All patients seen in the emergency department must be registered in the emergency department and assigned a medical record number and an emergency department encounter number. The only exceptions involve pregnant patients who may be triaged directly to the Labor and Delivery area or CPEP. (see Policy # ) _____ Manual Code: Page 2 of 2 _____ Subject: Patient Assessment and Care _____ Effective Date: Reviewed/Revised as of: Scheduled Revision: July 1, 1989 March, 2012 March, 2013 _____ Policy : 6. Patients presenting to the emergency department with hand injuries, head trauma, poisonings, and burns will be evaluated by the emergency department staff under the supervision of the attending physician.

9 The reporting of burn injuries will be as stated in the Stony Brook University medical Center Administrative Policies and procedures Manual #RI:0027. _____ Manual Code: _____ Subject: Community-based Emergency Plan _____ Effective Date: Reviewed/Revised as of: Scheduled Revision: July 1, 1989 March, 2012 March, 2013 _____ Policy : 1. The Stony Brook University medical Center ED staff and the attending staff in Emergency Medicine are dedicated to participating in the organization, operations and continuing education of the pre-hospital care providers and the EMS system of our community. _____ Manual Code: _____ Subject: Emergency Department Design _____ Effective Date: Reviewed/Revised as of: Scheduled Revision: July 1, 1989 March, 2012 March, 2013 _____ Policy : 1. The ED is designed to facilitate the safe and effective care of patients.

10 2. The ED is on the same level as the emergency entrance. 3. The ED ambulance and pedestrian entrances are well lighted, clearly identified by signs, and protected from bad weather. Ramps are provided for patients in wheel chairs or on stretchers. 4. The ED ambulance and pedestrian entrances are wide enough to safely accommodate patients, attendants and equipment. 5. Stretchers and wheelchairs are stored in the area immediately adjacent to the ambulance entrance and do not obstruct this entry. 6. A waiting area, lavatories and telephones are provided for patients, families and individuals accompanying them. 7. Unauthorized individuals are prohibited from entering the ED treatment area ( Manual code ). Public Safety will assist the ED staff in traffic control. 8. The Critical Care area of the ED is the receiving areas for all seriously ill or injured patients.