Pediatric Ward Orientation

1. Pediatric Ward Orientation For Clinical Clerks Welcome to MacPeds!

2. CTU Structure • Team 1 & 2: • General Pediatric Inpatient Teams • Patients located on 3C +/- ER • Team 3 • Chronic complex care team • 4C consults

3. A Day in the Life… • 7:15 or 7:35 Morning Handover • 8:00 Morning Teaching • 9:00 Patient Care • 10:15-12:30 Rounds – Walk around • Afternoon – Complete notes, Consults, Update List • 15:00 – (Depends on day) Subspecialty or Bedside Teaching • 16:40 or 17:00 Evening Handover

4. Morning Teaching • Morning (8 – 9am) • Monday: Gen Peds Grand Rounds (4E20) • Tuesday: Resident teaching (1A3) or RRT (3A14) • Wednesday: Heart-to-Heart Cardiology Rounds (1J7) - 1/month • Thursday: Pediatric Grand Rounds (MDCL 3020) • Friday: Case Based Learning (3E26)

5. Protected Time • Please let your attending and senior resident know at the start of your rotation when you have protected teaching time. Please write these times beside your name at the top of the handover list. • Attendance at all teaching sessions is mandatory! If you are attending to a sick child, please notify the staff or senior resident that you have protected teaching time so they are able to take over their care. • Update the list and touch base with your team before leaving!

6. Multidisciplinary Rounds • Team 1: Tuesday 13:00-13:30 • Team 2: Tuesday 13:30-14:00 • (Team 3: Thursday 13:00-13:30)

7. AM Handover • AM handover starts promptly at 7:15 or 7:35am • AM handover on weekends start at 8:30 • Team on take that day has the later AM & PM handover times • Ensure you print a list and bring it to handover • The on call residents/clerks will briefly review new admission and any overnight issues • Team 1 admits on ODD days, Team 2 admits on EVEN days

8. Guide to presenting new consults • Spend 2-3 minutes on each new patient and discuss • Name, age, main presenting complaint • Brief HPI focusing on pertinent positives/negatives • Brief summary of objective findings (physical exam, investigations) • Admitting diagnosis and plan

9. PM Handover • PM handover occurs at 16:40 or 17:00 • Remember that JPRs may cross cover CTU and may not know the patients from the ward • Day team is in charge for printing 2 updated patient lists for the night time team • IPASS format for handover!

10. PM Handover – iPASS

11. Handover - Sample

12. Team Lists • Team lists are located on the Citrix handover site • Please update the lists everyday and include any overnight / weekend instructions • Don’t wait to the last minute to update a list as there can only be one checked out list at a time • Be sure to check your lists back in so that others can edit them • Remember: The patient lists contain confidential information! Do not leave printed copies in the handover rooms or on wards! Dispose in confidential waste bins at the end of the day!

13. How to access the Handover List

14. Appscriber- Search for ‘service Handover’

15. Open the Clinical folder

16. Open Service Handover

17. Choose your team list

18. Check out to Edit

19. **Save and Check in before you exit **

20. Press OK

21. Documentation • Every patient requires a daily progress note • Exact details (ie labs and vital signs) are part of the electronic chart. It is important to capture these by documenting trends and providing interpretations. • The most important part of your note is the impression and plan: • Make sure you detail the rationale for pursuing one treatment versus another or reasons for changes in mgmt. • Include working diagnosis or differential diagnosis. • Important to include a disposition plan

22. Documentation • On Fridays, each patient should have a more detailed note outlining the treatment plan for the weekend, especially if the patient is a predicted discharge • Please try to have planned weekend discharges organized (prescriptions written, appointments arranged, CCAC arranged etc.) • You are responsible for the discharge dictation if the patient has been admitted for longer than 48hrs

23. CTU Scut Sheet

24. ROUNDING • Efficiency is KEY! • How can you help? • Make sure the charts are on the cart by 10:15am • If you are not presenting a patient, someone should have the chart and write down orders/fill scripts/DI req’setc as the plan is being decided for the patient • Use the rounding checklist to help guide you when presenting your patients. Feel free to ask JPRs/SPRs for feedback.

25. Rounding • Presenting on rounds: • Step 1: Patient ID – Age, gender, reason for admission with pertinent past medical history (if relevant) and POST if any? • Step 2: Prioritized issues list • Step 3: Overnight issues • Step 4: Present Issues/updates according to issue list • Ex. Bronchiolitis – any O2 requirements, last fever, last puffer use? • Ex. Gastro – Any IVF requirements, ?po intake, last emesis or diarrhea, last anti emetic • Step 5: Comments on feeding is not previously mentioned • Step 6: Physical Exam – fever? O2? Changes in PE? Ins/Outs? • Step 7: Monitoring – CRM, BW, PRN meds etc. • Step 8: Assessment – 1 line summary of current patient status and diagnosis • Step 9: Plan for Day

26. Rounding Resource

27. Dictations • Every Consult and Discharge requires a dictation within 24-48hrs • Exception – PICU transfers do not need a dictated consult note • When dictating, ensure you indicate the relevant staff (the one who reviews the consult with the senior/fellow or you) and please SPELL their name • Dictations should be done AFTER review with staff to incorporate all information and decisions • The Pediatric Survival Guide can be used for templates for dictations • Make sure you write down the dictation number on your consult note, or on the discharge face sheet

28. Discharges • Face sheet must be filled out for every patient at the time of discharge • Please put the dictation job ID on the face sheet once the dictation is completed • Chronic patients will have a “chronic patient checklist” that must be completed before discharge • Ask your SPR if you think your patient might qualify as chronic

29. Who to call if you need help • Senior Resident (or any other resident on the team) • The SPR is available for any questions or to be support if you are concerned about a patient • NEVER feel worried to get a more senior member of the team if you are feeling uncomfortable about a patient • REMEMBER – there is always either a SPR or staff carrying pager 1645

30. PACE • PaediatricAssessment of Critical Events • Call paging or page 75030 • Team includes: • PICU resident and fellow • PICU nurses • RT • PICU staff • Activation criteria available on PACE cards • ANYONE who is concerned about a patient based on these criteria can call PACE

31. On-Call • Arrive to handover at 4:30pm to introduce yourself to the team • You do not need to print team lists • You may be dismissed from handover to start seeing consults • Throughout the evening, the SPR will page the clerk/JPRs as they receive consults • The SPR will see the patient briefly to ensure they are stable • If you are concerned about your patient at any time, page the SPR, get the ER MD or activate PACE • All consults need a written and dictated note • While waiting to review, write your note, and start an admission order set

32. Admission Order Writing • Please use the Pediatric Admission Order Set when admitting patients • Look for the “order set” icon on your citrix, and search under the pediatric tab on the right • Be aware or ask your fellow residents if there are specific order sets that you should be using ie. bronchiolitis, asthma, DKA, UTI etc. • We encourage you to try to start the order set on your own if you are waiting to review

33. Meditech access

34. Select “Live Applications”

35. Remember HAH!!

36. Enter your username and password

37. Choose Patient Care Inquiry

38. More than one way to find your patient • Search by Name, Number • Search by Location – scroll down to MI-3C

39. Recent Investigations

40. Meditech Patient Flowsheet for Vitals, Ins/Outs

41. Patient Flowsheet • Hit ‘F12’ • *If it asks you for a facility – type in ‘M’

42. Flowsheet

43. Vital signs – Pain Mgt

44. VS – Graph

45. Intake and output

46. Cumulative I/O

47. Useful Resources • Website, CTU handbook, Scut sheet, rounding and handover guide and articles: http://www.macpeds.com/general_pediatrics.html

48. Have a great rotation! • We want to create a positive learning environment for you so please give us feedback on how we can make things better!