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Welcome to DRH

Welcome to DRH. Rick Bloomingdale Chief Medical Resident. General Structure. Teams Structure. Team Structure. Q4 Calls. Day Structure. Call days. Post-call days. General Structure. Teams Structure. Q4 Calls. Q4 Calls. Day Structure. Call days. Post-call days. General Structure.

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Welcome to DRH

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  1. Welcome to DRH Rick Bloomingdale Chief Medical Resident

  2. General Structure Teams Structure Team Structure Q4 Calls Day Structure Call days Post-call days

  3. General Structure Teams Structure Q4 Calls Q4 Calls Day Structure Call days Post-call days

  4. General Structure Teams Structure 7 am 8 am 10 am 11 am 12 pm 3 pm 8 pm Preround ER/IM Teaching Round Q4 Calls D/C MR Non-call days Day Structure Non-Call teams 1 pm Call days On-Call team Post-call days

  5. General Structure Teams Structure Code Blue: On-call team will cover the code blue pager and respond to codes from 7 am to 8 pm. The whole team is expected to show up for codes and be active. Code Blue pagers: Two code pagers are available. A test page will be sent at 10 am. Please respond and confirm your availability. Admission structure discussed later Q4 Calls Day Structure Call days Call days Post-call days

  6. General Structure Teams Structure Inherit patients from the night float (up to 5) No new admissions (except the bounce backs) Sign out to the on-call team (not before 3 pm). Q4 Calls Non-call days Call days Post-call days Post-call days

  7. Weekends There is no difference in the flow between weekends and weekdays. Cut off for taking new admissions, bounce backs, and sign out time is still 3 pm

  8. Admission Process The admission pager is 0997 7 am – 1 pm: ER/IM 1pm – 8 pm: On-call resident 8 pm – 7 am: night resident Whenever the patient cap is reached for admissions (daytime or call team), please forward pager to Med B at 5755 – send a courtesy page letting them know pager is forwarded and include your pager number or cell phone if they have questions or issues

  9. Admitting Resident Role • The admitting resident covers the admission pager. • He/ She accepts new admission, place basic orders and distribute to the non-call teams. • The teams should be notified verbally and not just by text page. • ER/IM resident will cover senior residents when they are off or have pm clinics. • There is no ER/IM on Sundays, and on-call resident should cover admission pager from 7 am.

  10. Admissions Introduction Introduction 7 am: ER/IM resident will take over the admission pager (0997) They will admit 3 patients for each non-call team; This is total of 6 new patients. 1 pm: the on-call resident will take over the admission pager. Once 6 patients are admitted, the admission pager should be transferred to the Medicine B. 3 pm: the on-call team will start taking new admissions. Total cap for on call team is 7; they will admit 3 patients or until 6:30 (whichever comes first). The rest of the patients will be seen by the senior residents and necessary orders will be placed by him/her. until night float arrives and assume care for those patients. After admitting 7 patients please transfer the pager to medicine B and notify them. 8 pm: Night float team arrives and takes over ER MICU Transfers 3T Upgrades Medicine Consults Misc

  11. Admissions Introduction Be Professional & Courteous Please provide the attending name when contacted by ED without delay. All patient must be assessed within 15 -30 minutes from the time of ER contact. If you are concerned about the level of care, you can ask the ER staff to give you 15 minutes to evaluate the patient before giving the attending name. After assessing the patient, if you think that a higher level of care is needed, discuss with ER staff. If you are still concerned and would like the MICU to assess the patient, place the consult and talk to the MICU personally. Admissions from ER ER MICU transfers 3T Upgrades Medicine Consults Misc

  12. Admissions Introduction Please provide the attending name when contacted by MICU without delay. The MICU team will continue the manage the patient as long as he/she is physically there. You can’t place orders until he/ she comes to the floor. Place a covering physician order and sign out the patient who is still in the MICU. ER MICU transfers MICU Transfers 3T Upgrades Medicine Consults Misc

  13. Admissions Introduction 3T upgrade should go to the non-teaching service. If you are contacted by 3T attending, please re-direct them to medicine B (5755). Medicine B might give you some of those patients if they feel that they are good teaching cases. You should accept those patients. ER MICU transfers 3T Upgrades 3T Upgrades Medicine Consults Misc

  14. Admissions Introduction There is a medicine consult team during the day. After hours (around 4 pm), they will sign out the consult pager to the on-call senior resident and leave. Senior resident is responsible for cross coverage for medicine consult patients after hours. If there is any new routine consult; place the patient on the consult list and patient will be seen the following day. Stat consults need to be seen by the on-call resident and staffed with the medicine B attending. They are not counted as hits and only a brief note is needed. Please add the patient to the consult team list as well. ER MICU transfers 3T Upgrades Medicine Consults Medicine Consult Misc

  15. Admissions Introduction NICU (or other services) transfers: Go through medicine consult (YOU after hours) to determine appropriateness HUH ER Admissions: Patient will have a different FIN when admitted to DRH. You will need this to see the current location and place orders. Please contact Admission for the new FIN. Do not assign to teams until patients hits the floor. Transfers from outside hospitals: Get sign out and call back number, then call CMR and your attending. Then call back with the attending name. Do not assign to teams until patients hits the floor. Direct Admissions: (from UPG clinics); should go through CMR. If contacted for direct admission, get the call back number and contact your CMR. Psych Unit: they might call you for medical emergencies, please assess patient and facilitate transfer to floor/ MICU. ER MICU transfers 3T Upgrades Medicine Consults Misc

  16. Bounce Backs • Bounce backs are re-admission within the same block • Those are usually admitted to the same team who discharged the patient within that block. Regardless of the call status. So even post-call and on-call team take bounce back. • The only exception is when the bounce back patient comes after 3 pm, then the on-call team will admit the patient, count him as a hit, and then give the patient back to the original team after rounding the following day. • The night float will admit up to 2 bounce backs. They will staff with the bounce back team attending over the phone in the morning and sign out to the bounce back team senior (or intern when senior is off) who will be responsible for the formal presentation during the round. • NF needs to email CMR of all bounce backs

  17. Pulmonary misc • Dr. Saydain patients – esp the pHTNpts – all need a pulmonary consult and also the team needs to call Dr. Saydain, no matter what time the consult comes • Dr. Kissner -- all of her patients need a pulmonary consult as well

  18. Caring For Patients Basic Orders Basic Orders All patients should have the following orders: Covering physician order: assume responsibility and taking care of the patient, people need to know who to contact if something happen. Code status: after proper discussion) Diet order: placed as soon as patient is admitted; imaging starving for 3 hours for no good reason) DVT prophylaxis: should be placed within 24 hours of admission, but preferably as soon as patient is admitted. If any contra-indication, please document that in your note. Always check the clinic system (NextGen) for any records. Placing Orders/ Consults Lines/ Foley Telemetry Discharge Planning Documentations

  19. Caring For Patients Basic Orders Orders/ consults can be placed as: stat (meaning within 20 minutes of placing the order), now (one hour) and routine. This should be determined exclusively based on medical necessity and patient care. Just because you want something done before your attending asks or social worker goes home is not a good reason. Stat orders/ consults: placing the order in the computer doesn’t mean it’s done. If you need a stat lab/ imaging/ or consult, please place the order and then communicate with nurses/ consult teams to make sure they are aware. When placing orders for medications, place them as “now”. Otherwise, they will be scheduled for the following day if placed after 9-10 am. Daily labs: please only order if necessary, there is no need to do daily labs unless you are monitoring something specific. Please don’t place them as “stat” Placing Orders/ Consults Placing Orders/ Consults Lines/ Foley Telemetry Discharge Planning Documentations

  20. Caring For Patients Basic Orders Central lines (CVC and PICC) and midline cannot be used for lab draws. You can only place a midline or PICC if you have a patient with poor venous access but even in those, you still CANNOT use the line for lab draws as this is associated with higher incidence of CLABSI which has adverse outcomes. CVC/ PICC/ midline require a provider order prior to placement. Please assess the need for those lines/ catheters on a daily basis and remove as soon as possible. Placing Orders/ Consults Lines/ Foley Lines/ Foley Telemetry Discharge Planning Documentations

  21. Caring For Patients Basic Orders Please evaluate the need for telemetry on a daily basis and d/c when no longer needed. Indications include (but not limited to): Suspected myocardial ischemia: discontinue after 24 hours if no positive troponin Syncope suspected to be of cardiac etiology: discontinue telemetry if no event after 24 hours. Drug overdose due to an agent with potential cardiac toxicity Atrial Fibrillation (New onset or RVR); discontinue telemetry if rate is controlled for 24 hours Hyperkalemia (potassium > 6.0); discontinue telemetry when potassium < 6.0 CHF patients with either 1) recent chest pain, or 2) syncope, or 3) ICD firing, or 4) serious atrial or ventricular arrhythmias, or 5) serious electrolyte abnormalities Non lacunar CVA with any ECG abnormality new or old; any TIA requiring admission; discontinue telemetry if no event for 24 hours Placing Orders/ Consults Lines/ Foley Telemetry Discharge Planning Documentations

  22. Caring For Patients Basic Orders D/C planning starts on the day of admission. Talk to the SW/ CMS and involve PT/OT in a timely manner to avoid delaying the discharges. Please update the nursing staff daily after the round of your d/c plan (including pending SW/CMS needs…) and ask them to update the “unit boards, AKA tempo boards” with the date and your initials. They will help you expedite the discharge process. Place discharge orders before 11 am. This will require starting the process from day 1 and not on the day of discharge. When your patient is medically stable, please place d/c order. Even if the patient is waiting for placement. Placing Orders/ Consults Lines/ Foley Telemetry Discharge Planning Documentations

  23. Caring For Patients Basic Orders Please avoid copy/pasting as much as possible. When copy/pasting, review and edit as appropriate Complete your progress note early during the day to enable other providers to be aware of your plans. Discharge summary should be done within 24 hours. It can be used as your progress note for the day if written during the same day and “objective/ physical exam” parts are included. If you will delay the d/c summary until the next day, please write a progress note for that day. Placing Orders/ Consults Lines/ Foley Telemetry Discharge Planning Documentations

  24. VTE • Please select the correct relation to your patient ( responsible resident, covering resident, fellow, home physician etc) on opening the chart each time. • Note that VTE Risk Assessment/Screening and Prophylaxis / Management is a Core Measure which needs to be completed on all admitted patients within 24 hours. • The provider who is responsible for initial admission orders is also the first responsible person to order this. • Please be aware that you need to complete VTE Risk Assessment even if your patient is admitted with a DVT or PE or if they are receiving anticoagulation for another reason like A. Fib. • Develop a daily routine to check on your patients safety/quality measures.

  25. VTE • The correct Order for VTE assessment is “VTE Risk Screening”. • After evaluating the patient, review the alert, choose the appropriate prophylaxis/therapy/contraindication based on your assessment and click on “Submit” to capture the risk assessment. Then please sign the appropriate orders. • Please note that the EMR based tool is only to assist you and is solely based on the information entered in CIS. Always use the best judgment based on your complete patient assessment and document the reason in the chart. • Also note that some of the patient information pulled by the tool may be duplicate or no longer relevant. • If you need more information, please refer to DMC Perfect Care Widget on your Desktop or App.

  26. Sign Out • Interns A  on-call intern A  NF senior • Interns B  on-call intern B  NF intern • Seniors  on-call senior (sick pts)  NF senior • Med consult  on-call senior (sick pts)  NF senior • Please give verbal + written sign out; ask questions when receiving sign out and if necessary go to the bedside and assess the patient with the other provider • Seniors are expected to observe their interns sign out in the first few months

  27. Morning Report • Starts at 11:00 am. You must arrive on time. • Cases will be 1 hour long each. Interns will present the history and physical, seniors will do the majority of the teaching. • Senior residents will need to submit a question related to the case to be used in Jeopardy at the end of the month. • All cases need to be provided to the CMRs 48 hours in advance for both long and short cases, with the FIN number of the patient. If the case is not submitted in time, the senior resident will have to run the morning report (for his/her intern and him/herself) • Any absence at MR must be explained in person to the CMR. Case dx and FIN should be sent 72 hrs in advance

  28. Days Off • Please discuss days off ASAP • Seniors cant take days off on the same days as their interns • Seniors shouldn’t take on-call days or post-call days off. Interns can be given post-call days off when necessary. • Please try to coordinate your day off with the other seniors • Please email the list of days off to the CMR, other senior residents and the ER/IM • Students and Sub-Is get one day off per week as well

  29. FAQs • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry?

  30. Social Work and CMS • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry?

  31. Family History • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry? Please document the family history using the widget (not free texting)

  32. Family History is a now a Meaningful Use Measure per Tenet. Please make sure that at least one family member has something documented. If Family History has been documented it will cross encounters. If patient has family history already showing (pulled from previous encounter), all you will need to do is to click on “Mark all as Reviewed”. It will show your name and date of review If all family history is Negative - you do have that choice by clicking the negative box on the top right hand side. Shows last review of Family Hx If no family history is showing click on ADD and then click in box of correct medical history box for each immediate family member. You can double click on “+” to add more specific family member information **Free texting family history with in your note will not meet this measure. If you make a mistake selecting the wrong family member history or when reviewing history – you can right click and clear the entry

  33. 2. 3. 1. 4. 5. 6a. To add a new family member unlisted problem to the list  1. Click on the magnifying glass, 2. Type in problem i.e. Murmur, 3. Click on search by name, 4. Select problem by double clicking on it, 5. It should show up on Scratch Pad at bottom, 6a. Click on “OK”

  34. The new problem will form a new row and then you can select the family member that has history of it. If you want to enter more information specific to that family member, 6b - double click on the “+” and a form will open to enter that information. When all family history has been entered, 8.- Click on OK You will then see a list of family members and family health issues listed for each member. If some thing is incorrect all you need to do is hit the ADD button and go in and correct it (Rt click on “+” and clear it) 6b. 8. 7. Fill in information as needed on form and Click “OK” 7.

  35. Pager Etiquette • As before, double check covering physician orders • Sign out pagers to night float (or call team) when leaving, be sure to re-open your pager in the morning when you arrive • On your off days, forward your pager to your senior, don’t make it unavailable • Don’t use passwords on your pager • Return pages ASAP, 15 minutes at longest

  36. Other stuff • Telemetry • 11-noon pages • Care transitions • Healthcare preference • Side effects • Appointments/location and phone number • Hypertensive Urgency on Floors • Rapid repsonse team • Falls • No pass zone/call lights • Tempo Boards

  37. Bedside Rounding Initiative • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry?

  38. Bedside Rounding Initiative • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry? • Goal: • To introduce a paradigm and standard of patient-centered, interdisciplinary bedside rounding for all Internal Medicine Teams, and to, eventually, extend this practice to all rounding teams in the hospital

  39. Bedside Rounding Initiative • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry? • Background: • Patient Centered Bedside Rounds have been linked to improved care team communication, lower pain scores from patients, shorter rounding times, and decreased length of stays. • Detroit Receiving Hospital would benefit from patient-centered bedside rounding • Team communication is a continued challenge at DRH and could improve with Interdisciplinary Patient Bedside Rounding

  40. Bedside Rounding Initiative • Rounding Structure: • Teams round from 8:30 until 10:30 AM • Each team has a specific starting location and will move through the hospital in the same fashion as to minimize the chances of more than 1 team being on a unit at a time (to facilitate nursing attending rounds) • Each team is responsible for finding their patient’s nurse prior to entering the room to ensure that he/she can be present for the bedside rounds • If a nurse cannot come at the onset of the bedside rounds, then when they do join the team, the resident who is the primary resident for the patient and who is running the bedside round should segway to allow nursing input as soon as possible such that the nurse can get back to clinical care duties. • Round will take place bedside with patient input. • What do I do on Wednesdays? How about Grand Rounds? • Is there a difference between weekdays and weekends? Is there an ER/IM on Sundays? • Can two seniors be off on the same day? • I am post call and I am done at 1 pm; can I sign out and go home? • I have a stat medicine consult at 6 pm; do I count it as a hit? • NICU called me with a transfer at 6 pm; what should I do? • I have a patient who I think has the flu; what should I do? • Can my patient travel without telemetry?

  41. Final Words • Welcome aboard! • Enjoy your rotation • Do not hesitate to call me with any questions

  42. Thanks

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