Welcome to Level 1 Group! We are excited to welcome you to our family. We have created this knowledge base to help familiarize new employees with the processes, procedures, and nuances of each hospital you may work at.
Texoma Medical Center #
TMC Main is a busy ER with monthly visits of around 5K per month (2023). Our shift structure is five doctors a day on Monday-Sunday (7-4, 9-8Pm, 12=9pm, 4pm-1am, 10pm-7am) with two midlevel shifts (9-6pm; 2-12am) Mon-Fri. On Thursday-Sunday, four doctor shifts are (7-5pm, 10-8pm, 3-1am, 9-7am). All TMC ERs (Main, Anna, Sherman) use Cerner. LVL1 operates their own scribe program- everyone gets assigned a scribe only at TMC Main.
Admitting #
Any medicine admission follows the same protocol as the main ER which entails calling x4378 during the times 7-5 PM. After 5 PM until 7pm, you must call the on-call hospitalist listed on the main call sheet for that day. After 7pm, the nocturnist is called. You must place a bed request through Cerner then add bridge orders. General Surgery admits ONLY simply appendicitis and occasionally healthy younger patients with cholecystitis/biliary colic. Otherwise, most surgery admits including SBO goes to the medicine service. Orthopedic surgeons do not admit to their service. Most traumatic fractures get admitted to the trauma service unless the underlying reason for the trauma is severe medical condition needing a medical workup.
Anna FSED #
Anna is a low-volume standalone ER 30 minutes south of the Main Dennison campus located in Anna, Texas. Anna is a rapidly growing community along the future high tech chip manufacturing corridor. Each month the volume increases with expected volume between 20-50 in a 24-hour period. Anna has the ability to do x-rays, CT scan, POC CBC, CMP, troponin, UA/pregnancy, influenza, RSV, SARS, and rapid strep. Ultrasound must be called from TMC main and takes much longer to complete. Admits follow the same protocol as the main ER which entails calling x4378 during the times 7-5 PM. After 5 PM until 7pm, you must call the on-call hospitalist listed on the main call sheet for that day. After 7pm, the nocturnist must be called.
Sherman FSED #
Sherman is a very busy freestanding ER with volumes that are much higher than Anna. Typical daily volume is above 50 and often 80-100 per day. The admission protocols follow the main ER. Sherman has similar point of care lab testing as ANNA with X-ray and CT scan capabilities. Ultrasound must be called from the main ER but typically doesn’t take as long as Anna due to the distance from the main ER.
Before First Shift #
Before your first shift, you will need to go to medical staff office and get your picture taken, ID badge with card to access the TMC doors and automatically login to computers, The staff office is located on the first floor near the cafeteria. If you cannot get to the office, you will need to call IT to get your login ID and password @ (903) 416-4555. You can also pick up the key fab that opens the TMC Main physician parking lot gate (located next to ambulance entrance.
Cerner #
When you arrive on your first day, use your login credentials to login to the local workstation. Upon logging in, you will need to launch this icon labeled First Net with Dragon.
After clicking on the icon, you’ll be launched into the main tracker with three tabs- one for main ER, one for Sherman, one for Anna. Click on the tab labeled TMC All Beds, ANN All Beds-Dr, or STC All Beds-Dr.
From there you will see all the patients in the department. To assign yourself to a new patient, right click on the patient and assign provider to sign up for the patient. After assignment, right click on the patient and click on open patient chart >ED Summary. At the top you’ll see Task, Edit, View, Patient, Chart, Links, Documentation, and help. Click on Chart > Documentation then hit +Add. This screen then allows you to start a new note.
Video Below Describing the login process and assigning to a patient. #
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Cerner Offsite #
To log in from home, use the following link Welcome to CernerWorks!
This will get you to the offsite login portal where you will input your Cerner username and password. The hospital uses dual authentication so you must download the Microsoft Authenticator application and input your UHS email and password which is different than your Cerner username and password. Login to the Cerner gateway and the authenticator will notify you to accept the request. Once accepted, it will bring you to the Cerner screen and click on the same icon as above to login to the system. You can login to the Cerner with Dragon and speak directly into your home computers microphone. Recently, IT has implemented a dual authenticator using provider’s phone number. You may use the code sent to your on file cell phone number to dual authentic.
Cerner Documentation #
After logging into Cerner, go the respective tracker for the facility you may be working and right click on a new patient and click assign provider. That assigns yourself to the patient and allows you to start the documentation process. After evaluating the patient, right click on the patient’s name and go to the following:
When you click on documentation, click add. From there, you’ll see six tabs. If you’d like to use a shared pre-completed chart then click on pre-completed; otherwise click on reason for visit and select a chief complaint based chart. Within the chart, the required field (time seen) is typically when you assign yourself to the chart. After completing the chart, make sure the MDM section is filled out. Below is an example of a shared macro that could be used to enhance your chart value based on the new billing rules.
Payroll Documents #
Stroke Protocol #
We would like to introduce you to Jenny Reeves (jenny.reeves@thcs.org) who is our incredibly energetic stroke coordinator. Jenny has an exemplary track record when it comes to ensuring we as a group continue to excel in our stroke care. TMC has the HIGHEST stroke facility designation.
To help you get acquainted with our stroke care protocols, we would like to provide you with some important information:
1. Jenny will personally assist you in inputting your stroke protocol orders, including Level 1/Level 2 orders and Intracranial bleeding order sets. Additionally, she will create the TMC stroke bridge orders that are necessary for all stroke admissions.
2. For Level 1 stroke or cases involving Large Vessel Occlusion (LVO), the charge nurse will make contact with you prior to the patient’s arrival at the hospital. It is expected that, in these situations, all ongoing tasks will be paused (if possible) so that you can meet EMS in the CT scanner promptly.
3. It is important to note that Neurology will not evaluate the patient before a decision is made regarding the administration of TNKase. Typically, the determination is made by the ER doctors, but it is customary to consult with the on-call stroke neurologist before proceeding.
4. While in the CT scanner, please ensure that you call the radiologist (the contact number is available in the CT booth) and inform them if you have a patient with a high probability of requiring TNKase. In such cases, a quick read is necessary (this applies only to obvious TNKase cases). We try to give the TNKase in the CT scanner!
5. When there are no contraindications, a verbal order will be given to the nurse to administer TNKase. In instances where the patient’s blood pressure is out of range, the nurses are proficient in administering IV labetalol in the CT scan area.
6. If a patient is identified as potentially having a large vessel occlusion but falls outside the TNKase window, they may still be within the thrombectomy window. In such cases, a CT perfusion scan is required. To assist these patients, please contact Tank, the interventional neurologist.
7. In the event of a potential large vessel occlusion with a normal CT scan, it is crucial to activate a code NEURO. You can inform the nurse directly or contact the hospital operator to initiate the code.
8. You always need to document a reason as to why TNKase or thrombectomy not given in the chart (even head bleeds… which is dumb but complain to Jenny). Most of us have macro statements.
 We wish you the best of luck as you familiarize yourself with our stroke care protocols. In the future, we hope to just provide a link to the LVL1 secure intranet for this information. If you have any questions or require further assistance, please do not hesitate to reach out to ghansen@lvl1grp.com will be more than happy to provide you with her cell phone number for convenient communication.Â
Sepsis Protocol #
We are thrilled to welcome you to the LVL1 group and aim to ensure a smooth transition for you. Building upon our previous education on stroke management, I would like to take this opportunity to address sepsis and introduce you to our interim sepsis coordinator, Tara Petty (cc’d on this email).
As a group, we recognize the need to enhance our approach to fluid resuscitation and consistently include the fluid re-evaluation note on all septic shock charts. To achieve this, it’s crucial to be aware of the following key points:
- Septic shock definitions- Lactic acid >4.0; SBP <90, drop of 40 points in BP
- Needs 30 ml/kg fluid bolus unless there’s a documented exception.
- Can use ideal body weight if obese.
- Needs fluid re-evaluation note added to the chart timed at least one hour later to give nurses time to complete the fluids.
- Macro to cover exceptions.
- 30ml/kg fluid bolus was given due to either the lactic acid being greater than 4.0 and/or SBP <90. I used ideal body weight for obese patients (when applicable) to calculate the bolus. When the fluid bolus calculates below 30ml/kg, we had a detailed discussion with the patient and/or family regarding receiving the full 30ml/kg fluid bolus and felt that the full amount would cause worsening CHF, fluid retention, or respiratory failure.
- Needs 30 ml/kg fluid bolus unless there’s a documented exception.
A focused fluid reassessment exam was performed after the bolus.
- Sepsis Order set
- UHS wants the doctors to use the sepsis order set that includes the “Antibiotic Advisor Module
- We made an executive decision that physicians most likely will use another order set on presentation and have created an ADD ON order set.
- During the on-boarding process, we will create your sepsis and sepsis add on order set.
- Broad spectrum Antibiotics (USE the UHS antibiotic advisor)
- Lactic acid/blood cultures for all SIRs patients
Once again, we look forward to having you as part of our private equity-free group owned by physicians.
Metrics #
UHS has a monthly ER wide tracking system with the following metric goals:
- LWBS rate less than 1.00%
- AMA/elopement rate less than 3.9%
- Arrival to Doctor exam 19 minutes or less
- Arrival to decision to admit 215 minutes our less for 80% of population
- This does not mean bed order; there’s a separate decision to admit toggle
- Discharge Length of Stay 190 minutes or less for 80% of population
- Door to house for MD 160 minutes
- ESI 3 LOS 180 minutes or less for 80% of population
- Door to house 150 minutes
- ESI 4/5 Length of Stay 100 minutes or less for 80% of population
- Door to house for MD= 80 minutes (nurses have 20 minutes to dc)
- Stroke- Door to TNKase less than 45 minutes
- Press Ganey 50 percentile or better
LVL1 tracks the above metrics and reports them via individual scores and aggregate data depending on how the hospital reports them.
We are excited to have you and look forward to many years of success!
LVL1 tracks the above metrics and reports them via individual scores and aggregate data depending on how the hospital reports them.
We are excited to have you and look forward to many years of success!
