Mount Sinai Hospital Monthly In-Patient Orientation Update: November, 2003

1. Mount Sinai HospitalMonthly In-Patient OrientationUpdate: November, 2003 Minerva Galang MD Jose-Luis Velazquez MD Chief Medicine Residents Ermias Tilahun, MD, FACP Site & Associate Program Director Assistant Professor of Medicine Chicago Medical School

2. Time punctuality Pre-round for interns: 7:00AM- 7:30 AM Sign-in for floor teams with CMR at OS 653 - Monday, Tuesday, Thursday: 7:30- 7:45 - Wednesday: 8:30 –8:45 - Friday: 7:00 – 7:15 Teaching rounds: 8:00- 9:00 (except wednesdays)* Morning report at Noon (MRAN): 12:00- 1:00pm Sign-out Rounds: 4:00 pm (fridays at 3:00 p.m.), OS653, except mondays held at 9th floor. Bed side rounds with Dr.Gall: 4th Monday. 11:00- 12:00. Team assignment in call schedule Ethics Rounds: every Thursday from 11:00- 12:00 on 5N with Dr. Sokol Grand Rounds: Wed. at 8:00 am Tumour board in Conference Rm C- 3rd Thursday from 12:00- 1:00 PM Continuity clinic:1:00 pm Community free clinic: 2nd and 4th Thursday of every month at 6:00 pm- residents to be assigned from electives *varies in some teams according to attending clinic’s schedule

3. Conferences • Attendance required for > 80% of the conferences (M-F @ noon, Wednesday @ 7:30 a.m. and Friday at 7:00 a.m.). IMPORTANT PART OF YOUR MONTHLY EVALUATION!. • Attendance has to be on time (5 min. tolerance) to be considered, late arrivals are marked as absent. • ICU and CCU resident attendance is optional. • Morning report(MRAN): Case to be discussed according to specialty of the day (check conference schedule at web site) • Questions raised during the morning report are due in 2 days.

4. Schedule & webpage www.amion.com Password: chimed

5. Amion.com examples Full Month Schedule Includes Jeopardy, Sinai and VA schedules

6. (your name) Amion.com, monthly schedule

7. Amion.com who’s on call?

8. Websitecms.velcec.com • Conference schedules • Jeopardy, team structure • Bulletin board • Download forms (sign-out) • THIS PROCEDURES/ ORIENTATION • Journal club articles

9. Web site, conference schedules

10. NEW:Weekday Long Calls (1) • Call starts at 11:00 • cross-coverage until 9:00 p.m. • Admit until cap of 10 or midnight • Interns: 1 intern stays in the hospital (gets early admissions), 1 goes home (usually the intern that has clinic next day, should go home at 9:00 p.m.). The H&P’s are to be filed in the chart before going home if possible or early next morning. BOTH INTERNS STAY IN THE HOSPITAL ON FRIDAY, SATURDAY AND SUNDAY. • Seniors: Stay over-night in the hospital (1 Senior from MSI team). Leave next day at NOON. Clinic will be cancelled on post-call day(s) – not morning clinics (yet!). • If you have Clinic the same day On Call, Leave Satellite Clinic at 3:00 p.m. and 4 p.m. at Kling. Make sure to notify the attending when you are going to be on call (at least the day before, if you notice some reluctancy, please notify the CMR the day before).

11. NEW:Weekday Long Calls (2) • The team admits until CAP (10 patients) or midnight • Night Float crosscover from 9:00 p.m. (regardless of cap status, early or late) • Consults will be done by the person carrying the pager at the time the consult is received. If patient is away for a procedure, consult should be done when the patient is back by the person who received the consult

12. NEW:Weekends Long calls Saturday • Call start at 11:00 a.m. until 11:00 a.m. of Sunday (long call team come to the hospital for sign-out). • Regular Saturday work (writing notes, calling attendings, but starting from 11:00 a.m.) • Cap of 10. • Trigger point for calling the NF is 8 pt on the floor by 8:00 pm. • NF (if called) will admit/do consults and will not cross cover. • Overflow from NF or long call will be admitted by moonlighter. • After the moonlighter admits 4 patients, SMR, NFR and the moonlighter will alternate.

13. NEW:Weekends Long calls Sunday • Call starts at 11:00 a.m. (no need to come to the hospital before this time) • Admit until 7:30 a.m. Monday morning • Clinics will be cancelled in the post-call day • Monday is a normal working day for the team (sign-out at 4:00 p.m.)

14. NEW:Weekdays short calls • Week days: from 7:30 a.m. to 11:00 a.m. • Cap of 8 patients. • Over night cases admitted by NF and moonlighter will go to the short call team • Redistribution policies are flexible and the final decision will be made by the CMR depending on individual situation.

15. NEW:Weekends short calls • Saturdays and holidays: admits overnight cases and until 11:00 a.m. with cap of 8 patients. • Overflow go to the long call team temporarily, pending distributing them to the team on short call Monday • No short-call on Sundays • On Mondays you accept the overflow pt from Sat. and or Sun. • Overflow of Sat night must be endorsed to Sunday long call for coverage

16. Cross Coverage • It is carried out by long call team from 4:00 pm until 9:00 PM • Floor cross coverage by the interns: • Floors 5 & 6 and 2 & 3 floors • You should get good clear endorsements at sign out round and during the weekends • Any cross coverage even must be documented in the chart • Must be endorsed to the team in the sign in rounds

17. Week days night float • Week days: 9:00 p.m.- 9:00 a.m. • Admit from 9:00 p.m. until 7:30 a.m., unless called early or SMT (long call) still admitting. • Cross-coverage of the non-teaching service from 8:00-9:00 AM. Also from 5:00 p.m. to 8:00 p.m. • Cap of 8 pt, 4 each, overflow admitted by moonlighter

18. Weekends night float • They will be called by the long call team when there are 8 pt on the floor by 8 pm • One person should come in if the NF is to be called, and he will have a cap of 4 without doing any cross coverage • The 2nd person will be called in the following day if NF is to be called in again or as arranged between the NF • Overflow should be admitted by moonlighter. • After the moon lighter admits 4 patients, the senior resident, NF resident and the moon lighter will take alternate admissions in that order.

19. Community free clinic • Community free clinic, on either the 2nd or 4th Thursday of every month. • Residents in electives at Sinai (check your schedule!) Address: 2611 W Chicago Ave Time: 6:00 PM

20. General Medicine Consults • Should be done by whoever is carrying pager 1555, For short call 7:30 until 11:00 a.m. unless they cap early • Long call 11:00 a.m. until pager given to Night Float (9:00 p.m.). • Attending list on consultation (as per current policy- MOX) Username: MSH Password: policy

21. Continue Consults: • All consults for medicine should be seen by whoever is carrying pager 1555, regardless of the patient condition and this resident decides whether the patient needs ICU, CCU or floor and get in touch with appropriate person (ICU or CCU resident on call) • The exception for the above rule is that Family Practice and Dialysis unit will call MICU directly. • Also the person carrying pager 1555 will be responsible for D/Cing Tele beds. • If you want to place a surgical consult (regardless of the specialty), you can do that by paging the surgery consult team on pager 1456.

22. General communication • Check your MOX often! • Check your e-mail every day! • Make sure that the CMR has your UPDATED/CURRENT e-mail! • Check your mail box often, if possible every day! • Check the web site for schedules

23. Patient care communication • Communicate with your nurse every stat order, any overnight events. • Label your chart at any time you admit new patient or change the service of a patient, and put it back in its right place. • Communicate with your senior any events for your patients • Communicate with CMR any problem with your intern, senior, patient’s attending, nurses, teaching attending, or any house staff members • Communicate with the primary care attending everyday especially on Sat. for any change in the status of your patient health (ICU, Death, Tests, Consults, Procedures, Admission, Discharge, Transfer)

24. Delay a decision if consensus is not possible. Involve all stakeholders in the decision making process, if possible. Acknowledge that there legitimate firm differences in opinion Do not let the disagreement overwhelm the real goal of the discussion. Tips for better communication and conflict resolution:(By Dr Tilahun) • Always communicate face to face whenever the opportunity arises. • Be direct in communication, but respectful of differences. • Learn to negotiate. • Be agreeable and positive. • Appeal to shared values.

25. Dictation • Clearance form: by the end of the rotation you must submit the clearance form from the medical records signed by the manager and cosigned by the chief residents and submitted to Trina. • No pending dictations are to be left at the end of the rotation (strictly monitored). • MSI team must dictate their patients and the seniors should make sure they are doing so. • If there is a transfer of patient’s care either from ICU or at the end of the rotation from the previous month intern, You will dictate all the patients who were under your care for at least 2 days and if less than 2 days will be done by the previous intern.

26. Sign off patients SMR (Team decision) Discuss With CMR Discuss With Attending agree agree Endorse patient to non-teaching service disagree • Relabel chart • Sign off order • Reflect in note disagree Notify the floor Nurse Manager

27. Violent and abusive patients • If you think your patient is abusive, or harassing you whether verbally or physically, get out of the room immediately , and call the security and activate code green and report to CMR, Nurse manager on that floor immediately • Get a witness if you can • Signing off that patient will be considered • The hospital official policy regarding this matter is now in progress

28. Dealing with an Angry person(by Dr Tilahun) • Never lose your cool. • Keep your distance and do not touch. • Do not comment on the other person’s anger. • If possible, speak first-you will set the tone for communication. • Listen to the outburst without interrupting. • Empathize by paraphrasing the other’s concern’s. • Control the dialog by asking thoughtful questions. • Conclude with assurance that something will be done.

29. New admission • All the orders must be written within the first 30 min of patient being on the floor. • All the primary attendings should be informed as soon as possible by the interns at all times day or night. Follow attending preference of contact during night time (page Vs. phone) • Full H&P must be written in the first 24hrs. • If the patient was admitted within one month of the current admission, you might copy the previous H&P and add addendum and full dictation is required at the time of discharge.

30. 24 hrs. observation • If you think a patient could be observation, ask the attending to change the admission status upon admission, ONLY the attending is authorized to make this decision. • Stable patients under Subspecialty services (could be admitted from ER, direct admission or for chemotherapy and after or before a procedure as Renal biopsy & Cardiac cath & Liver biopsy) • If during working hrs; All admission issues, follow up and discharge orders will be done by that subspecialty service. • After working hrs; 24hr observation patient needs a brief H&P only with no dictation at discharge, and does not count as an admission • Cross coverage after hrs for emergency situation will be carried out by floor coverage on call and should be communicated to the subspecialty next day. • Document any coverage in the chart, as this is very important.

31. Bounce back • Patients transferred to the ICU will return to the original intern upon transfer back to the floor. • Night float will sign out the patient the same morning. • Short call will not take a patient if the team is in the hospital and it is before 2:30 p.m. • Long call team will take any patients admitted after 2:30 p.m. and sign out to the original team the next day morning. • Patients discharged home and getting re-admitted are bounce back if the PGY-1 is still in the rotation. MSI team= goes by senior.

32. Sign out to surgery service • All patients admitted by the team will be followed by the admitting team every day (except on Sundays and bounce backs). Patients transferred to SICU or surgical service may be signed out to surgical service/ attending after discussing with the CMR and the attending and with a sign out note and order.

33. Jeopardy • You should be available 24 hrs via pager while you are in jeopardy. • It is a pay back call (exceptions as decided by SMR) • If you are in Jeopardy and CANNOT take call, be aware that you are also calling Jeopardy yourself, so you will also owe a call to the 2nd or third person called. • You may cover the CCU, ICU or the floor, as in case of the unit resident being pulled for CC-ER orientation or in case of in-service exam, or urgent leave. • If you are going to be absent for any reason you need to notify the CMR ASAP. • No exams are allowed to be scheduled while on inpatient rotations.

34. Patients admitted with fractures(conflicts) • Simple fractures which need orthopedic surgery in a patient without other medical problems under medicine attending will not be admitted to medicine, but might need medicine consult • Fractures which need surgery in a patient with multiple medical problems will be admitted by medicine if the patient is under medicine attending, and to be followed by orthopedics • Preoperative consults are to be done on the same day of admission

35. ER Boarding • If a pt is admitted from the ER and accepted to ICU or the floor, and there is no bed, he should be seen and followed by the moonlighter. • Medicine resident will not follow or write orders as long as they are in the ER

36. Days off • Rule of 4 days every rotation (1/week) usually Sundays. • If a weekday: Should not be on short call or long call or any switch day either junior or senior and CMR should be informed. • Only one senior from the floor is allowed to be off on any particular day. • A MOX should be sent to MED.ALL about the day off. • CHANGE YOUR VOICE MAIL MESSAGE (even if it is only for one day) • Notify the CMR (seniors day off), only after approval by CMR you are allowed to take the day off. • Should not be more than one member of the team on the same day. • If you are on call on Sun, you will be off on Sat, your senior will cover you and he will take one week day off. • Exams should not be scheduled when you are on a floor or MICU rotation. • No more than 2 weekdays off in one particular floor rotation. • YOU MUST notify the CMR if you are planning to leave town on your days off while you are on a floor or ICU rotation, except for emergencies.

37. Leave requests • For leave requests, you should fill out the special form; get the appropriate approval; remember to cancel your continuity clinic before you go on leave (must be one month in advance or ASAP)

38. MSI team and students • Must not call for any surgical consult • No week days off if they are on call on Saturdays • If one MSI is missing their long call cap will be 10 as usual and their short call will be 8 • Be sure to fill their blue evaluation form for any MSI or any students on your service before the end of your rotation • MSI must sign out their patients at 4:00 pm like any other intern as well as attend the sign in round at 7:30 am for any cross coverage issues • Any problem, please contact Dr. Kumar • All orders, consent etc must be co- signed by a senior. • Make sure that they dictate their patients at the time of discharge • Do not forget to feed them, remind them to move their cars at 4:00 pm to the regular parking lot when they are on call

39. ICU calls • Week days: Call starts at 4:00 pm till 7:00 AM. • Week ends: Call starts at 7:30am till 7:30am of the following day. • ICU/CCU team must be in the ICU no later than 7:00 AM and relieve the on call team for the residents sign in at 7:30 a.m.

40. ICU senior duties • Senior: See all the consults promptly, and admit after the intern caps at 5 pt. Help presenting and writing notes during the weekends if the ICU intern has more than 8 pts to cover and to present during rounds • Leads the code in the ICU, and provide help during codes on the floor. • ER consult should be seen within 30 min of the consult placement, and if you are busy please communicate with the ED physician and explain the reason for the delay. • Inform the ER staff about your decision and recommendations. • To admit patient to ICU initiate contact with the charge nurse in the ICU so a bed can be made. • Communicate with ER regarding lack of bed/staffing issues • Perform focused HPI and PE and call the fellow/attending with the information that would be useful in the decision to admit /not to admit to ICU • An ICU attending need to be called for all major events like death, unexpected worsening of patient’s condition or if there is a disagreement between the resident and the fellow.

41. ICU junior duties • Junior admits up to 5 pt with the senior while on call • Call the primary attending for new admission, transfer in and out the unit, or any dramatic events for their patients • Present patients and write notes: up to 8 during the weekend coverage (if you x-cover your co-intern) • Will accompany the patients to xrays, procedures etc… if the patient is critically ill, who is on 2 pressors, requires high peep and high fio2, or if the nurse requests it

42. ICU conferences and clinic attendance • ICU intern must attend the intern morning report on (Wed, and Thu) • ICU and CCU residents attend optionally as long as it does not interfere with their work in the unit • ICU Interns will go to their clinic if it is at Sinai. Please inform the clinic about the days that you’re not able to attend. • There must be one intern in the ICU all the time.

43. Post-ICU call • Home early by 1:00 pm after the noon conference, this also applies to the ICU & CCU teams after assuring appropriate coverage ( i.e. the ICU resident can cover the post-call CCU resident and vice versa.) • Let your attending and your fellow know that you will leave early at least one day in advance • Make sure you sign out your patients to your attending or to the fellow before you leave

44. CODE BLUE • Leadership is the key • Avoid fighting, crowd-control • Team leader: on the floors by the senior medical residents or whoever is carrying the pager 1555. • Cover both medicine and family practice patients • Any abnormal behavior should be reported • Medicine territories are everywhere but Surgery and Ob-Gyn floors which include Cafeteria, Psychiatry ward, elevators, lobby and parking lot. • No coverage for Schwab

45. Writing orders • Clear, precise orders avoiding duplicate ones • Correct dose, route • Time your order with date and hr:min • Appropriate stat order, flag chart red, and communicate with the nurse. • Check the results of your order • Before you sign out to check the results make sure your order is already there • If you do not know a dose or how to write an order; check your pharmacopeia ask your senior, your attending or the pharmacy.

46. Notes • All notes should be stamped, or signed with your full name(legible), pager and dated. You must mention the name of the Attending whom you discussed the case with. Please use the signature stamps that you are provided. • All notes written by 3rd year students should have addendum and a co- signature.

47. Safety and hospital policy • If you wear scrubs , adhere to the appropriate policies • Wear only Mount Sinai scrubs • Keep your lab coat fully buttoned over green scrubs • Do not leave the hospital or come from home wearing scrubs • Refrain from eating, drinking in patient care areas • Pay attention to fire alarms and follow the safety procedures, assist patients and visitors • Know the closed exit stairwell, fire alarm, fire extinguisher, and where the “what IF” boxes are located • Remember the emergency procedure: R A C E, RESCUE, ALARM, CONTAIN, EXTINGUISH • Follow Hand washing policy • Follow up the isolation procedures • Do not disclose the key code to anyone or write it down on the wall