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My .02 in the PIcu.   Do what’s best for the patient and what’s within your training, comfort level and available resources.   My threshold would be mighty low for transfer if no picu RN or picu md availability.  

On urgent care etc., is anyone fostering discussion on the big picture of pediatric emergency medicine?  25 years in, seems pem needs a broader discussion of where this field is and where it should be going.    Training, research, volume demand, longevity, distribution of resources, psych shortage, the list goes on. 
Just curious. 


Mick Connors



> On Jan 7, 2018, at 12:00 AM, PED-EM-L automatic digest system <[log in to unmask]> wrote:
> 
> There are 4 messages totaling 291 lines in this issue.
> 
> Topics of the day:
> 
>  1. PED as PICU overflow unit (2)
>  2. George Koburov: PED as PICU overflow unit
>  3. Pediatric Urgent Care Fellowship
> 
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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> 
> ----------------------------------------------------------------------
> 
> Date:    Sat, 6 Jan 2018 05:06:05 +0000
> From:    Camel chav <[log in to unmask]>
> Subject: Re: PED as PICU overflow unit
> 
> This is wrong on multiple levels
> Even if ED MD providing care
> 1. Floor patient coming to ED  - Billing as an ED physician - wrong
> 2. Liability issues: ED insurance will not cover you as it will likely be proved that it was not covered under your insurance
> 3. ED busy place and inability to basically to do intensivist/hospitalist work-increase risk
> 4. Would say a categorical no to this!!!!
> 5. Surprised your legal department is letting this happen ( Tney might be like Trump administration- Mad house)
> 
> Kamal
> ________________________________
> From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Melissa M Tavarez <[log in to unmask]>
> Sent: Friday, January 5, 2018 4:33 PM
> To: [log in to unmask]
> Subject: Re: PED as PICU overflow unit
> 
> At our institution, For times when the PICU full, overflow patients are
> usually placed in PACU beds with, I believe, PICU nurses and they are
> covered by the ICU physicians.  We may occasionally board an ED patient for
> a few hours if beds are not available, even if they are intubated, but I
> have never seen a deteriorating inpatient transferred to the ED as a step
> up in care.
> I echo that particularly from a nursing perspective, it is not appropriate
> to have the ED be the pop off valve for this situation.  It is too much to
> ask them to care for a patient who requires ICU level care and also have
> 2-3 other patients, overall it is just a set up for errors when folks are
> that taxed.
> I don't think it's unreasonable to board and manage primary ED patients,
> but getting kids from the inpatient unit seems like a very poor solution.
> I commend your group for being such great colleagues, but it's less about
> physician expertise and more about all the resources that are needed to
> provide high quality care, and abusy ED is just not the ideal place for
> these inpatients, because if you think about it, if they had presented that
> way to the ED, they would go straight to the PICU!
> 
> just my thoughts
> 
> Mel
> 
> 
> On Jan 5, 2018 9:30 AM, "McDonnell, William" <[log in to unmask]>
> wrote:
> 
> Because our PICU is increasingly at capacity and "closed" to additional
> patients, our hospital has begun designating the ED as "PICU overflow."
> Hospital inpatients who deteriorate on the floor are taken to the ED, and
> handed off to the ED physician for management. Our ED physicians are
> comfortable with immediate resuscitation, but are unhappy with managing
> ventilators and ventilator sedation for extended periods, as well as trying
> to manage these often-complex patients with multi-system issues, all the
> while running a busy ED. Are other hospitals using the PED as a PICU
> overflow for deteriorating in-patients? If so, do you place any limits on
> who manages these patients, for how long, and with what assistance (e.g.,
> co-management with hospitalist or critical care doc)?
> 
> Thanks for sharing your thoughts and/or experiences.
> 
> Bill McDonnell
> 
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> ------------------------------
> 
> Date:    Sat, 6 Jan 2018 11:28:04 +0000
> From:    Gill Winnik <[log in to unmask]>
> Subject: Re: PED as PICU overflow unit
> 
> Not done here
> I would be concerned also with the legal risks where you are managing ( and billing) as an Intensivist while it may be out of your qualifications.
> 
> Giora Winnik/ Maimonides Brooklyn
> 
> Sent from my iPhone
> 
> On Jan 5, 2018, at 10:26 AM, McDonnell, William <[log in to unmask]<mailto:[log in to unmask]>> wrote:
> 
> Thanks Mathew.
> In our experience, there has NOT been any PICU fellow, PICU resident, or PICU attending involved.
> 
> From: Mathew George [mailto:[log in to unmask]]
> Sent: Friday, January 05, 2018 8:39 AM
> To: McDonnell, William
> Cc: [log in to unmask]<mailto:[log in to unmask]>
> Subject: Re: PED as PICU overflow unit
> 
> Will there be a PICU fellow or resident staying with the patient in the ED with PICU attending backing or are you completely responsible for thr care. If its former , it is not too bad
> 
> On Jan 5, 2018 9:30 AM, "McDonnell, William" <[log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]>> wrote:
> Because our PICU is increasingly at capacity and "closed" to additional patients, our hospital has begun designating the ED as "PICU overflow." Hospital inpatients who deteriorate on the floor are taken to the ED, and handed off to the ED physician for management. Our ED physicians are comfortable with immediate resuscitation, but are unhappy with managing ventilators and ventilator sedation for extended periods, as well as trying to manage these often-complex patients with multi-system issues, all the while running a busy ED. Are other hospitals using the PED as a PICU overflow for deteriorating in-patients? If so, do you place any limits on who manages these patients, for how long, and with what assistance (e.g., co-management with hospitalist or critical care doc)?
> 
> Thanks for sharing your thoughts and/or experiences.
> 
> Bill McDonnell
> 
> For more information, send mail to [log in to unmask]<mailto:[log in to unmask]><mailto:[log in to unmask]> with the message: info PED-EM-L
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> ------------------------------
> 
> Date:    Sat, 6 Jan 2018 23:26:01 +0000
> From:    DocMatter <[log in to unmask]>
> Subject: George Koburov: PED as PICU overflow unit
> 
>    
> Our hospital suggested this and we flatly said NO.  It is not in the interest of anyone patient included.  IF a new patient shows up to the ED who needs PICU and they are full we may hold them if we think we will get a bed in reasonable amount of time (4-6 hours).  If not, we transfer them out to another institution.        
>        
>        
> George Koburov MD            
> Direct Reply: https://www.docmatter.com/georgekoburov           
> Chief, Pediatric Emergency Medicine            
> University of Missouri        
> Columbia, MO  USA        
> 
>       
> 
> This is a reply to the discussion started by William M. McDonnell MD, JD:         
> 
> Because our PICU is increasingly at capacity and "closed" to additional patients, our hospital has begun...        
> Full discussion:           
> https://www.docmatter.com/dm/svc/links?link=8D742C2C304C4342F7C014C50ECBC8FF&tk=eo_60f1e285-d8c3-4abf-af0c-0fc3e19138f9_yOckJzh1SAqgmkFgfn3ON4s2WmDPnVbiW5P9         
> 
>         
> ===============================================================                    
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> ------------------------------
> 
> Date:    Sat, 6 Jan 2018 17:46:35 -0500
> From:    Chris Ramsook <[log in to unmask]>
> Subject: Pediatric Urgent Care Fellowship
> 
> Phoenix Children’s Hospital is proud to offer a new Pediatric Urgent Care Fellowship for the academic year 2018-2019 in Phoenix, Arizona. Given the increasing number of pediatric urgent care centers nationally, most pediatric residents graduate without adequate exposure to the urgent care experience and the career opportunities that it offers. This is the perfect opportunity for someone interested in acute care pediatrics including procedures but not the high acuity and complicated 
> patients of a pediatric emergency room. We are offering a 1 year program designed to train graduating residents and general pediatricians to practice in this high acuity, fast-paced environment. Our goal is to create experts in the emerging field of pediatric urgent care medicine who will become leaders in the field. Phoenix Children’s has four urgent care centers at 4 corners of the city that sees over 50,000 patients per year combined at all sites. The urgent care centers function with the backup of an emergency department that is readily accessible and has over 85000 annual visits as well as a tertiary main campus for inpatient and subspecialty care. The fellows will receive their training/ supervision by general pediatricians and pediatric emergency medicine faculty/ fellows who all cover the urgent care sites. The entire spectrum of subspecialists are on call for both urgent care as well as the emergency department. 
> 
> Summary of the Program Structure and Overview
> 
> Rotations               Duration in Weeks                  Clinical UC hours per week
> Core UC rotations     28                                                   32
> PTO/CME                      4                                                    -
> ED                            4 (2 main, 1 ext, 1 RMA)                 -
> General Surgery    2                                                   20
> Plastic Surgery            2                                                   20
> Orthopedics            2                                                   20
> Sports Medicine      2                                                   20
> Radiology                    2                                                   20
> ENT                            2                                                   20
> Ophthalmology        2                                                   20
> Dermatology            2                                                   20
> Total                          52                                               1216
> 
> This fellowship is anticipated to produce well trained and motivated urgent care physicians for whom the demand is expected to increase both internally and externally. We hope to hire as many as possible with a competitive compensation package that recognizes the formal urgent care training and experience upon completion of fellowship. Interested candidates can email the program director, Chris Ramsook MD at [log in to unmask] or call 6029331910 for additional information.
> 
> Chris Ramsook MD
> Attending Physician, Emergency Department
> Phoenix Children's Hospital
> Director, Urgent Care Services
> Phoenix Children's Hospital 
> 
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> ------------------------------
> 
> End of PED-EM-L Digest - 5 Jan 2018 to 6 Jan 2018 (#2018-5)
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