Monthly Dispatch · Emergency Medicine
April 2026 ED Newsletter
🏥 Harbor-UCLA ED Department Newsletter · APRIL 7, 2026
Operations · Clinical · Billing · Joint Commission · Wellness
⚡ The TL;DR
📥 Direct Admits
Place the "admit request" order in Orchid — that's it. TEAMS Dr. Parmar/Roh/Chappell for issues.
🧠 Trauma
Full neuro exam on every trauma (GCS + motor/sensation). Repeat if abnormal. STAT MRI for persistent deficits. Don't sit on dispos.
Consult update for biliary colic patients (see Ops section)
🩻 IR Pathways
New emergent vs. urgent outpatient IR workflow is live. Use .harir autotext + Orchid consult. Schedulers will contact outpatient IR patients directly.
🦠 Sepsis Compliance
Numbers dropped significantly in Nov/Dec. Timestamp your ID, repeat lactates until downtrend, and stay close with nursing.
🫁 PERT/PE
Low-risk PEs don't need PERT. For arrest: tPA 50mg IV/IO without waiting. Don't activate PERT for isolated DVTs.
🧲 New MRI Order
MRI Acute Spinal Cord Compression protocol is now live in Orchid for ED & inpatient. Screens for cord compression in one scan — see IT/ORCHID section.
📋 Critical Care Billing
Note must include: time spent, concerns, actions, and exclusionary statement.
🏛️ Joint Commission
Window is still open. Review EMTALA scripts — know your role in the MSE process.
☕ Wellness
Jura is down but upgrade incoming. Power outage? Empty milk fridge + email Dr. Pedigo.
🏔️ Wilderness Med
Apply to be a WMS resident ambassador in Asheville, NC (July 19–22) by May 20. Free registration!
⚙️ Operations Updates
For Direct Admits
  • If a direct admit and they were boarding in the UCC but UCC is closing (~10pm)
  • The clinic teams trying to direct admit should be putting “Place for later” for admit orders
  • When the patient comes to the ED -- All you need to do as the ED provider is place the “Request for Admit” order (no note is needed)
  • If the patient is coming to the ED for an admit --> do the usual steps (these should be patients who require stabilization and/or pts being admitted from a specific service to a different specialty ie. Surgical service admitting to IM)
  • Issues? TEAMS Dr. Parmar / Roh / Chappell
Trauma Reminder

⚠️ Critical Reminders Do not 'sit on' dispositions. If there are significant injuries → get the patient admitted. ED Attendings: call Trauma Attendings directly if there are delays — they want us to call.
  • Perform and document an initial Neuro exam on every trauma patient
  • Document a repeat Neuro exam if the first is abnormal
  • Persistent Neuro deficits → get a STAT MRI
Biliary Colic Consults:
FYI, when you consult Trauma surgery for biliary colic patients — if they are going to discharge the patient they may instruct you to schedule the patient either in Trauma surgery clinic or Surg-Onc clinic (Dr. Hari as the attending) for outpatient follow-up (both clinics have capacity to care for these patients).
IR — Emergent vs. Urgent (Outpatient)
Copy the .harir autotext from Dr. Chappell via the "autotext copy utility" button on the FirstNet toolbar. 📎 WikEM: Urgent Outpatient IR Pathway
🔴 Emergent IR — Same-Day Procedures
  • Autopage "Consult to Interventional Radiology" in Orchid — pages the IR resident and places the consult order
  • Complete the .harir autotext and save to chart to expedite the consult
  • After hours / truly emergent (e.g., patient needs a Quinton for emergent HD and cannot be temporized overnight): ED attending must call the IR attending directly
🟡 Outpatient IR — Urgent Procedure within 48 hrs (Stable DHS patients)
  • Autopage "Consult to Interventional Radiology" in Orchid (after-hours separate order coming next month)
  • Use the .harir autotext — include: requesting team, contact #, attending, reason, procedure, priority (<48 hrs), outpatient status, ambulation status, and patient phone # for IR scheduler
  • Most recent labs auto-pull into template (CBC, Chem 7, INR, pregnancy test as applicable)
  • Patients will be contacted by IR schedulers and directed to OR 2nd floor surgery registration — they do NOT need to return to the ED
  • Please discharge with the "Harbor UCLA Interventional Radiology Pre Procedure Instructions"

📋 OOP Patients Call UM to explore in-network transfer or urgent PCP/specialist appointment. If care cannot be safely transferred in-network, request authorization to admit for next-day procedure.
Sepsis Compliance

⚠️ Compliance Alert We had a drastic drop in November and December — December was our lowest compliance month in 2 years. Identified areas for improvement below.
  • Timestamp your sepsis identification using the dotphrase. Without a timestamp, abstractors default to note start time.
  • Repeat lactates until they downtrend. If your patient has a rising lactate, abstractors count the highest as the first — you must repeat until it downtrends.
  • Communicate closely with nurses. We have several new nurses in the ED. If critical tasks aren't being done, escalate to area charge nurses or OCNs.
PERT Algorithm Update

📌 Summary Patient with PE? Risk-stratify per the 2019 ESC guidelines. Low-risk patients do NOT require a PERT consult — the ED team can manage and discharge them.

🚨 Crashing Patients If in cardiac arrest or extremis — do NOT wait for PERT. Give tPA 50 mg IV/IO over 2 min (0.6 mg/kg if <70 kg). Continue CPR for minimum 15 min post-infusion.
Quick Hits:
💉 Watch the Heparin Bolus
"Heparin Drip DVT/PE per Pharmacy" auto-includes a bolus. High bleeding risk? Manually uncheck the bolus box.
🧠 Malignancy Head CT
For underlying cancer: strongly consider head CT to rule out intracranial mets before starting anticoagulation.
🔁 PERT vs. Pulm
Do NOT activate PERT for isolated DVTs or chronic PE management. Call standard Pulmonary Consultation (p5194).
⏱️ 15-Minute Rule
PERT should respond within 15 min. No response? Re-page once, then escalate directly to Pulmonary attending via MedHub.
*See PERT documents uploaded in the Newsletter Teams channel.
Best Practice: Emergent vs. Urgent Endoscopy

🔴 Emergent EGDs ICU or redline to the OR

🟡 Urgent EGDs Stable GI bleeders, foreign bodies — admit and defer to GI/inpatient for timing/location
  • If boarding patient decompensates → inpatient team coordinates redline to OR
  • ED Attendings: use your discretion to intubate in the ED (e.g., foreign body removal)
  • Foreign bodies (daytime): GI can do in endoscopy suite (if no intubation needed). Emergent FB needing intubation → OR; non-emergent → admit
  • Foreign bodies (evening/overnight): ED Attending discretion — OR vs. in-ED procedure
One-Off Reminders
  • Ortho Glass splinting: Always close the full package after use — if left open, it will dry out and ruin the entire package
  • Please call Social Work for all cardiac arrests
  • Patient Financial Services — Daytime: Windows 6 & 7 in the waiting room | Phone: 424-306-6500 (option 3) | PFS Office: 1B1 (8am–4pm)
  • AED-specific issues → Dr. Jen Roh, AED Medical Director
  • Operations or ICE issues → Dr. Brad Chappell, VC of Operations

🎉 Resident Shoutout Doc boxes bulletin board gets a face-lift! Great job, Mai! (completed during her R4 Admin Rotation) ✨
💳 Billing + Documentation
Critical Care Documentation
A complete critical care note must contain all four of the following:
① Time Spent
How many minutes of critical care time were provided (exclusive of separately billable procedures)?
② Your Concerns
What condition/injury/sign/symptom triggered critical care? What were your specific concerns?
③ What You Did
Exam, diagnostics performed, treatments rendered to address those concerns.
④ Exclusionary Statement
"X minutes of critical care time, exclusive of separately billable procedures."
📄 Example Critical Care Dotphrase
From AliEM
I have discussed the case with the resident/mid level provider. I have personally performed a history, physical exam, and my own medical decision making. I have reviewed the note and agree with the findings and plan with the following exceptions: ____ (insert exceptions) ___.

Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to _(condition)_, which required my direct attention, intervention, and personal management.

I have personally provided ___ minutes of critical care time exclusive of time spent on separately billable procedures. Time includes review of laboratory data, radiology results, discussion with consultants, and monitoring for potential decompensation. Interventions were performed as documented above.

-- Your initials with time stamp

*This template is for educational purposes. Each note must accurately reflect the specific clinical presentation and care provided.
📎 AliEM: Critical Care Charting Guide
Questions or content to submit? Reach out to Dr. Manny Singh or Dr. Jen Roh.
🏛️ Joint Commission Preparation

🚨 Still Waiting — Window is Open The Joint Commission window is still open. Review the cheat sheets Charles and the Operations Team placed in doc boxes and the rounding room.
EMTALA: Know Your Role
EMTALA duty does not end until: (1) no EMC is identified, OR (2) an EMC is stabilized, admitted in good faith, or appropriately transferred.
👩‍⚕️ Triage NP Script: "How do you fulfill the EMTALA mandate?"
"EMTALA requires that every patient who presents to the emergency department receives a medical screening exam to determine whether an emergency medical condition exists, regardless of their ability to pay.
In triage, my role is to initiate the evaluation and identify any patients who may have an emergency condition. I perform a focused assessment, obtain vital signs, and assign an acuity level. If I identify any concerning findings, I immediately escalate the patient for rapid evaluation and placement in a treatment area.
I function as a qualified medical provider in triage — I can begin the MSE by initiating appropriate orders based on our protocols. However, triage alone does not replace a full MSE unless completed by a qualified provider.
We ensure all patients remain in the system until they receive a complete MSE. If a patient wants to leave before completion, we reassess, explain the risks, and document the encounter.
Overall, we follow a standardized process to ensure every patient is evaluated promptly, prioritized based on acuity, and receives an MSE in compliance with EMTALA."
🩺 Physician Script: "How do you fulfill your EMTALA mandate?"
"EMTALA requires that every patient who presents to the emergency department receives a medical screening exam to determine whether an emergency medical condition exists, regardless of their ability to pay.
As the treating physician, I perform and document the MSE for all patients — whether from triage or by ambulance. My evaluation is based on the presenting complaint and may include history, physical exam, and appropriate diagnostics.
If an EMC is identified, I provide stabilizing treatment within our facility's capabilities — including resuscitation, time-sensitive therapies, and consultants. Care is never delayed for insurance or payment reasons.
If the patient requires services beyond our capabilities, I arrange appropriate transfer: confirming capacity/capability at the receiving facility, obtaining physician acceptance, stabilizing the patient, and sending all relevant records.
If a patient leaves AMA, I assess capacity, explain risks and benefits, and thoroughly document the encounter.
Overall, every patient receives a timely MSE, appropriate stabilization, and safe disposition in compliance with EMTALA."
🩺 The Clinical Corner
With Dr. Ilene Claudius
Trauma Neuro Exams

✅ Document a Baseline Please document a thorough neurologic exam on all trauma patients, including GCS plus at least gross motor and sensation in the extremities. A baseline exam at time 0 is invaluable for identifying changes later!
Sepsis Compliance
  • Compliance dropped significantly in Nov/Dec — December was our lowest in 2 years
  • Use the dotphrase and timestamp when severe sepsis or septic shock was identified
  • Repeat lactates until they downtrend — abstractors count the highest lactate as the first
  • Communicate proactively with nurses; escalate unperformed critical tasks to charge nurses or OCNs
💻 IT / ORCHID Section
How to Insert Clinical Photos into FirstNet

📸 ORCHID Improvement You can now insert clinical photos directly into FirstNet. See the job aid for step-by-step instructions.
Thanks Jenn Fang! Questions? Contact Dr. Fleischman.
🧲 New: MRI Acute Spinal Cord Compression Order

📣 From Dr. Jack Brunner, MD, MBA — DHS Director of Radiology Orchid has gone live with an MRI acute spinal cord compression order. This will reduce imaging times, tech/radiologist workload, and costs (1 scan billed vs. 3 previously).
When to use it: ED and inpatient settings only. Intended for screening of suspected spinal cord compression — including nonspecific presentations where cord compression is a legitimate part of the differential:
  • 🦵 Nonspecific weakness — When cord compression is on your differential but presentation is not clearcut
  • 🚽 Incontinence / ↓ rectal tone — Screening before ordering full dedicated spine MRIs

✅ Workflow Screen with the acute cord compression protocol order first. If a significant abnormality is detected → follow up with targeted, complete imaging with and without contrast as recommended by Neurosurgery, Neurology, or Neuroradiology.
Please share with Emergency Medicine, Trauma, Neurosurgery, and Neurology colleagues. Also review and update any applicable PowerChart order sets.
Questions? Contact Dr. Fleischman.
☕ Wellness
Coffee Corner Updates ☕
Jura Status
The Jura is still out — but a little birdie says we're getting the next version up for free.
Department Beans Only
Department coffee beans only, please. No outside beans in the containers.
Keep It Clean
Keep the bean containers clean — no debris in the coffee bean holders.
Power Outage Protocol
Power outage? Empty the milk fridge immediately and email Coffee Master Dr. Ryan Pedigo.
Thank You!
Big thanks to everyone who has helped with Jura maintenance!
🏔️ Wilderness Medicine
WMS Resident Ambassador Opportunity 🌲

🎟️ Free Registration! Wilderness Medical Society Conference — Asheville, NC | July 19–22, 2026. Ambassadors receive free registration in exchange for working at the conference. Travel and lodging not included.
📑 In This Issue
📞 Key Contacts
  • Dr. Jen Roh — AED Medical Director — AED issues & newsletter content
  • Dr. Brad Chappell — VC of Operations — Ops, ICE issues
  • Dr. Manny Singh — Associate Program Director — Billing/documentation
  • Dr. Ryan Pedigo — Coffee Master ☕
  • Dr. Fleischman — IT/ORCHID questions
  • Patient Financial Services — 424-306-6500 option 3 | 8am–4pm | Office 1B1
📨 Submit Content
Have updates, patient stories, or reflections to share in a future newsletter?
🏥 Harbor-UCLA Emergency Department Newsletter
April 6, 2026 · Questions or submissions? [email protected]
Thanks for reading until the end! Have a fantastic rest of the month! 🌟