Welcome to MSK

1. Welcome to MSK Resident Orientation

2. Orientation Overview • Team Structure • A Typical Day • Time to Learn • Being on Call • Code/Consult Resident • Admissions • Weekends at MSK • Details, Details…

3. MSK Structure: Teams • Our patients are admitted to one of nine medical oncology teams • Leukemia A or B • Lymphoma • Breast • Genitourinary • Gastrointestinal A or B • Head/Neck & Melanoma/Sarcoma Service (HMS) • Allogeneic Bone Marrow Transplant • Thoracic (Lung) • Autologous Bone Marrow Transplant • General Medicine

4. MSK Structure: Sister Teams • Each team is paired with a sister service for on-call admissions and weekend cross-coverage • Leukemia (A + B) • Gastrointestinal (A+B) • Lymphoma + AlloBMT • Genitourinary + Breast + GenMed • Auto/Thoracic/HMS (all NP services)

5. Team Composition • Most teams have the following structure: • Service Attending (1) • Oncology Fellow (Leuk A, Lymphoma, GU, Allo) • Nurse Practitioners (Leukemia, Lymphoma, GU, Allo) • Residents (2) • Interns (2 or 3) • Sub-Intern (0 or 1) • Three teams are staffed by nurse practitioners only (no house officers): • Thoracic (Lung) • Head/Neck & Melanoma/Sarcoma (HMS) • Autogeneic BMT / Hematology / Myeloma

6. About Fellows • Most teams have the following structure: • Service Attending (1) • Oncology Fellow (Leuk A, Lymhoma, GU, Allo) • Nurse Practitioners (Leukemia, Lymphoma, GU, Allo) • Residents (2) • Interns (2 or 3) • Sub-Intern (0 or 1) • Fellows do: • address daily management questions • supervise new patient admissions • supervise house staff procedures • Fellows do not: • work on Sunday

7. About Nurse Practitioners • Most teams have the following structure: • Service Attending (1) • Oncology Fellow (Leuk A, Lymphoma, GU, Allo) • Nurse Practitioners (Leukemia, Lymphoma, GU, Allo) • Residents (2) • Interns (2 or 3) • Sub-Intern (0 or 1) • Nurse practitioners do: • admit and care for most patients admitted for chemo • Nurse practitioners do not (usually): • admit patients from the Urgent Care Center • work on weekends (their patients are covered by a moonlighter or the resident)

8. About Sub-Interns • Most teams have the following structure: • Service Attending (1) • Oncology Fellow (Leuk A, GU, Allo) • Nurse Practitioners (Leukemia, GU, Allo) • Residents (2) • Interns (2 or 3) • Sub-Intern (0 or 1) • Sub-interns do: • maintain their own census of up to five patients • preround and write notes on their patients daily • take call with one of their residents • Sub-interns do not: • Write solo orders or do admissions on their own for the team

9. A Typical Day

10. Time to Learn

11. Being on Call • Residents take call roughly every 4th day • you may have q3 or q5 calls as well • Posted at amion.com, password ‘sloan2’ • Weekday call: • ~3-4 PM till 8 PM • admit new patients (usually 2 - 3 patients) • Weekend call: • 7 AM to 8 PM • admit new patients (usually 2 - 4 patients)

12. Code/Consult Resident • You are the code leader (you run all codes on all patients – except UCC and ICU). • How to be a code leader: • Clearlyidentify yourself as the code leader • Make sure the patient is not DNR • Assign people, by name, to specific tasks (chest compressions, bagging, line placement, …). You should not be doing these tasks yourself • Focus on the big picture: formulate a differential diagnosis, direct team members, ensure adequacy of resuscitation efforts (compressions, ventilation). • Announce the type of code being run to help orient team members (e.g., “This is a PEA code”) • NPs from ICU will be there – will guide code as well

13. Code/Consult Resident • You are the consult resident for non-medicine services: • surgery & surgical subspecialties • gynecology • neurology • pediatrics (if the patient is not tiny) • MICU (called ‘ICU’ here, it is run by anesthesiologists, not internal medicine MDs) • General medicine service (only has interns) • NP-covered medical oncology services • thoracic (lung) + autogeneic BMT + HMS • Types of consults you may be asked to do: • cardiology (e.g., rapid atrial fibrillation) • renal (e.g., acute renal failure) • general medicine (e.g., pre-op clearance)

14. Code/Consult Resident • You are NOT responsible for the following: • Follow-up consults • If the patient is already being followed by a consult service, the consulting resident must call the attending directly. • Medicine team consults (GI, leukemia, GU etc) • Residents must do their own service or sister service consults.

15. Code/Consult Resident • If you’ve been called for a consult: • see and evaluate the patient • treat urgent/emergent issues first • perform a full history & physical, document your assessment & plan in a consult note. • speak with the appropriate on-call attending • call the operator (2000) and ask which attending is on call for (renal / cardiology / general medicine) • page and discuss your assessment/plan with the attending • document your consult note, assessment & plan • please record the name of the attending you spoke with in your note • If you have a question about the appropriateness of a consult, please page the chief resident (1050)

16. Admissions • Admissions come from: • the Urgent Care Center • clinic or a procedure area directly to the floor • the ICU or another service directly to the floor • You will primarily admit patients to: • your own service • your sister service • You may also be asked to admit patients to: • any other non-NP service (if the on-call intern or resident have too many other admissions) • All residents admit every day! Early (before 4 PM) admissions are preferentially assigned to residents who will not be on call later that day or in clinic (whenever possible).

17. Admissions • Your admission note must include: • chief complaint • history of present illness • oncologic history* • past medical history • social & family history • chief complaint • history of present illness • oncologic history* • past medical history • social & family history • review of systems* • list of current medications* • allergies • exam, including lymph nodes* • assessment & plan • review of systems* • list of current medications* • allergies • exam, including lymph nodes* • assessment & plan * IMPORTANT !!!

18. Admissions • You must ensure that newly admitted patients are appropriately handed off to the covering night float intern when you leave • Patients admitted to your service during the day should be added to one of your interns’ lists and signed out to night float with their other patients • For any other patients you admit: • Make a copy of your admission note for night float • Review your note with the night float intern, paying particular attention to any required follow-up • For patients you admit to another service, be sure to present your admission to that service’s resident the following morning at 7AM in the DOM library.

19. Weekends at MSK • There are no ‘golden weekends’: everyone works either Saturday or Sunday  • The schedule for the upcoming weekend is posted on the chiefs’ office door early in the week. • When you arrive in the morning: • RESIDENT: pick up the list(s) for any interns who have the day off • pick up the list of NP patients, if there is one. • divide pre rounding/notes among yourself and the intern(s) so that everyone does an equal share of the day’s work

20. Resident Night Float • None! • Now performed by nocturnalist MDs hired as full time staff by the hospital

21. Rapid Response Team (RRT) • The RRT consists of specially trained NPs and MDs, available to assist you from 7 PM to 7 AM • Call ‘5000’ for any of the following: • Anytime you are worried about a patient • Acute change in heart rate (ex HR < 40 or > 120) • Acute change in systolic BP (ex SBP < 90 or > 200) • Acute change in oxygen saturation (sat < 90%) • Acute change in respiratory rate (RR < 8 or > 36) • Acute change in neurological status • Failure to respond to treatment for an acute problem

22. Patient Deaths • Complete a ‘death note’ in the chart • Complete the MSK ‘Expiration Sheet’ • Complete the ‘Department of Health Certificate of Death’ • If the patient is eligible for eye donation, you must contact the nursing supervisor • You must contact: • the patient’s family • the service attending (the operator can assist you) • please do not forget to tell the primary intern when he/she returns to pick up their list in the morning

23. Progress Notes • Write legibly, please • Computer notes now available for H/P and daily progress notes. • Computerized Event notes and procedure notes still being developed • Date and time every note • Always sign each note and include your name and pager number • PROHIBITED: error-prone abbreviations, e.g.: • avoid ‘qd’ → use ‘daily’ • avoid ‘MSO4’ → use ‘morphine sulfate’

24. Medication Reconciliation… • Is a JCAHO National Patient Safety Goal, designed to eliminate medication errors during transfers of patient care • You must document a complete list of your patient’s current medications whenever: • your patient is admitted • your patient is transferred to/from another service • your patient is discharged • Complete means: • name of medications • dose • route of administration • timing of administration • for prn medications, a clear indication for use

25. Infection Control • Clean hands save lives! • Use the Purell sanitizing lotion before and after entering any patient room • Wash your hands whenever: • they are visibly soiled • you have come into contact with any patient with proven or suspected clostridium difficile • Abide by the precautions posted on every door • a mask, gown and gloves may be required routinely for certain vulnerable patients

26. Glycemic Control • Tight glycemic control reduces morbidity and mortality in critically ill patients (NEJM 2001;345:1359) • The order entry system includes an inpatient insulin algorithm, which should be utilized for any patient with a glucose > 200 mg/dL • Exclusion criteria: • < 18 years of age • Weight < 40 kg • Severe insulin deficiency • Type 1 diabetes • Diabetic ketoacidosis • Total pancreatectomy • C-peptide level < 0.5 ng/mL • Use of a continuous subcutaneous insulin infusion • Blood-glucose ≥ 400 mg/dL (call Endocrine)

27. Questions? Ask the Chiefs. We are available 24/7 to addressyour questions or concerns office: 212-639-6732 or 6733 pager: 212-639-3329, #1050