Intern Survival Guide: Ward/Night Float Edition
Introduction Schedules Prep work Division of labor Where things are When things happen AM Sign-Out Work Rounds Morning Report Attending Rounds Private PMDs Orders Admissions Progress notes Discharges Running the List/Updating Medical Students/Teaching PM Sign-Out Weekends and Holidays Night Float Misc tips, tricks and advice Outline
So you’re starting the floor… • The pediatric ward is located on 11N, to the left of the elevators. • The resident call room is the first room to the left as you walk through the double doors onto the floor. Please ask one of the seniors or the chiefs for the code. • Dress code is business attire ± white coat. If you’re on call on a Friday night, you can change into scrubs before sign-out. If you’re on over the weekend, it’s all scrubs, all the time.
Floor Intern • For 3½ months, you belong to the 11N floor team as their intern. The rotations are labor intensive (and very intimidating at first!) but can be very rewarding. • The floor team will consist of medical students, 4-5 interns (usually 3 or 4 pediatric interns + 1 family medicine intern) and 2 seniors. • Patients will be split as evenly as possible, but expect to carry at least 4-5 per day on average. During the busier months, this number can easily double. Time management will likely be the most important thing you learn your intern year. • Remember – you play an active role in your pediatric education, of which the inpatient rotation is an important piece. Please feel free to ask ANY AND ALL questions you may have.
Scheduling • During each month of floor rotation, your work hours are officially 7am (AM signout) – 6pm (PM signout). • For every four weeks that you’re on the floor, you’ll work a 24-hour Friday, a 24-hour Saturday and a Sunday (7am-7pm) • Be prepared to push the 80-hour work week limits. Sleep when you can, eat when you can, and don’t forget to keep yourself hydrated.
Schedule Access To access your personal schedule, go to: New Innovations: https://rms1.newinnov.com/Login/Login.aspx After logging in, hit View: Take a couple of hours one day and just browse through new innovations. It does take some getting used to.
Preparation • Before you start the floor, familiarize yourself with where everything is. During orientation week, take the time to really be nosy and look around at everything. • Get a sturdy binder or clipboard, black and colored pens and a small calculator (Staples has cute keychain calculators for $1.) • The day before you start, one of the other interns will sign out their patients to you. Make sure that you know everything about each one of those patients: take notes during the verbal sign-out, comb the chart for pertinent information (H&P and off-service notes are key, if the latter is applicable) and go through the computer for current orders, latest labs and previous discharge summaries, if there are any.
Flow Sheets • Flow sheets are found either in the big cabinet on 11N or @ pedsportal. fellinahole.com under “chart data.” • They exist to have all pertinent information, past and present, at fingertips and facilitate good signout. • Most interns like to use them and you should receive one for each patient you are signed out, but there are no guarantees. A good rule is to make a new one for each patient you’re signed out, as well as new patients you’re assigned. • You should hand them off to another intern whenever you need to sign out (to night team, when you have clinic, off-service). Make sure they’re legible!
Where Things Are: Charts • Red Charts are usually found next to the clerk. In them you’ll find: • Patient stickers • Completed H&P with growth chart • Progress notes • Completed consults • ED and outside records • Blue Charts are found bedside. They house only asthma scores. • Powerchart: our electronic medical record • Orders • Meds/MAR • All vitals (including height, weight and HC) and I/Os. • All patient results including radiology (PACS) and old records (Eclipsys)
Where Things Are: Miscellaneous • Forms/Paperwork: • The big gray cabinet in the core houses most of the blank forms you’ll ever need, including blank H&Ps, flow sheets and discharge paperwork. • If you need paperwork not found in the gray cabinet for any reason, ask a clerk or your senior. • Other Items in the Core: • Big bulletin board • Frequently called phone numbers • Frequently written orders/fluids • Printer/Fax machine
Pre-Rounding • When you’re ward intern, what time you arrive at the hospital is usually dependent on how many patients you carry. Plan on being there at approximately 6am. • Find the night intern and nurses to get sign-out on overnight events. • Obtain vitals (including ranges if abnormal), ins and outs, asthma scores, new labs, etc. Look at radiology studies done overnight (don’t just read the report). • See all of your respiratory kids and as many other patients you can before AM sign-out. Patients with acute issues should have priority. If the patient is sleeping, you do not have to wake him/her for a full physical, but when pertinent, do a focused exam. • Tip: Organize yourself while pre-rounding in order to prepare for work rounds. Either on your flow sheet or your own sheet, write a one-sentence summary about each patient, vitals and labs you’ve collected and current medications. Start a checklist for what you foresee to be the day’s plans.
AM Sign-Out • AM sign-out begins promptly at 7am in the 11N conference room across from the call room. It’s extremely important to be on time for every scheduled event, including this one. • Assigning patients: As the night intern presents new admissions (more information on this later), the seniors will assign them to interns based on current patient numbers. Take note of any service/staff patient you’re assigned, as those require a little more work.
Work Rounds • The entire team (including night intern and senior) round in the conference room in the morning as an introduction for the day. • Presentations should be short, with a brief introduction to the patient, any overnight events, ROS by system, pertinent physical exam findings if you examined the patient, pertinent vitals, assessment and plan for the day. • Tip: When presenting vitals, include asthma scores, ranges (if pertinent) and UOP in cc/kg/day (this is especially important in our nephrology patients). • On Wednesdays, work rounds are conducted one intern at a time in the 11N conference room in order to make sure everyone can get their pressing work done and make it to Grand Rounds on time.
Senior Sign-Out • Tip: Try to structure your presentations for work rounds by systems as laid by the senior’s sign-out sheet. • “Patient BC is a 10-month-old male with rotavirus + AGE, hospital day 2. No overnight events. Patient is on a regular diet and ½ maintenance fluids. Tolerating PO well, no vomiting. No respiratory or cardiovascular issues. Vitals are [here, including the weight and change], with a UOP of 2cc/kg/hr. Had 3 episodes of diarrhea overnight, which is improved over yesterday. Plan is f/u stool studies, heplock his IV today, monitor Is/Os, discuss with Dr. Baram possible d/c.” • Be prepared to move fast – the team has to round on the entire floor before morning report. • If rounding is not complete by 8am, rounds conclude after morning report in the 11N conference room, one intern at a time.
Morning Report • The goal of morning report is to provide an interactive forum for house staff to develop skills in presentation, diagnostic evaluation and patient treatment. • It is run by the chief resident with multiple faculty, including Dr. McGovern, present. • Cases are usually selected by the chiefs with input from the current seniors. Seniors should share their knowledge with the interns and the interns should feel free to ask questions and offer responses. • As a new intern, you will not be expected to present. In your last six months of internship, however, the baton will fall to you. Therefore, you should pay attention to your seniors – how they prepare, present and respond to criticism. • In general, presentations should include the chief complaint, a chronologic HPI (what happened at home, then at the outside hospital, then at our ED), past history, chronologic physical exam (did yours look different from the outside hospital?), any and all labs/diagnostic done. • Comprehensive treatment of entire topic is not necessary but all possible entities in the differential diagnosis should be discussed based on the facts of the case at hand.
Morning Report: Running the List • Before cases are presented, the chiefs will run the list of patients who have new and/or interesting radiographs. • After cases are presented, the chiefs will prompt the interns to run the entire list. • For either of these situations, be prepared to give a one-liner about your patients: “Patient JJ is a 7-year-old male admitted with a left surpacondylar fracture after falling from a trampoline, now s/p CRPP.” (Tip – always include mechanism of injury). • On Mondays, we run all admissions from Friday through Sunday. If you are on over the weekend, keep a list handy (usually taped to the cabinet above the senior computer) of patients you admit. Tip - Don’t forget about the patients admitted Friday night that are discharged on Sunday!
Attending Rounds • After morning report, you should get all time-sensitive work done: discharges (should be done before 11am if possible), calling consults, seeing newly admitted patients (with service patients getting priority) and reading their charts thoroughly, and seeing all service patients. • Attending rounds are bedside and family-centered with presentations either outside of the patient’s room or inside with family present. • If the patient is established, your presentation will be the same as work rounds, except your emphasis will be on physical exam, assessment and plan. • If the patient is a new patient, you will have to present the entire H&P. Tip – Because the hospitalist will physically take the H&P from a newly admitted patient’s chart to write on, you should either photocopy it or take good notes from it before rounding. • You should defer all presentations to your medical students if they are following a patient with you (this is true of work rounds as well). Make sure to go over with them the correct format and help them in their areas of weakness.
Private PMDs • Some community pediatricians have admitting privileges. If a patient is admitted under a private PMD service, that PMD is their attending. • The physician “on-call” to the hospital will usually round in the morning (usually at exactly the time of work rounds). They will drop by the conference room to pull out the night intern/senior in order to impart the plan for the day. • Because there are no formal attending rounds with private PMDs, you should have a low threshold for calling them during the day when any situation arises. • For a list of PMDs and their contact information, check out fellinahole at http://fellinahole.com/peds/pmd.html. • Tip: Most will appreciate being updated at least twice during the day – once in late morning and once in late afternoon.
Orders • All order writing is now done electronically through our CPOE system. Please refer to your PowerChart training for more specific instructions. • You should notify the patient’s nurse of any new orders, especially if the order is written as STAT. • Lexi-Comp online (http://online.lexi.com/crlonline) is our hospital approved reference for medication. • Since CPOE has eliminated order rewrites, it is prudent and necessary to check every order every day to make sure that you haven’t hit a soft stop or fallen off of the MAR. • Compare active orders to what the patient should be getting to exactly what the patient is getting (MAR) every day.
More Orders • Orders that need to be renewed daily: Restraints, 1:1 orders. • Orders for phlebotomy need to be put in for the exact times of 6:00am and 11:00am (when the phlebotomy team rounds). These orders should ideally be put in the night before, but if that is not possible, make sure to give the phlebotomists enough time to see your order. • If you are too late for phlebotomy or would rather have the nurses collect blood for you, put in the order as a “nurse collect” and tell that patient’s nurse. • Our nurses are very professional and will place IVs, draw blood and place catheters for urine when necessary.
Radiology • After putting in orders for desired study, call the appropriate department in order to make sure they are aware. Try (and it may be difficult) to get an estimated time that the study will be done. • If contrast is to be given, obtain parental consent and place it in the chart. • You should discuss with your senior resident whether the patient should be NPO for the study, but in general: • Patients who need studies under anesthesia and patients who need CTs with contrast will need to be NPO for a certain amount of time before the study (usually 4-6 hours). • MRIs usually do not require a patient to be NPO. • If a patient requires anesthesia, call the anesthesia coordinator and he or she will help you arrange the study.
Prescription Writing • Use the hospital DEA number (AU9053125) and your personal suffix at the top of the script. Always stamp at the top. • Medicaid patients require an attending license number to be written at the top. License numbers can be found here: http://www.health.state.ny.us/professionals/doctors/conduct/ • Prescriptions do not need to contain any math but they do need to specify what the concentration is of any suspension or tab/pill you write for: Amoxicillin 400mg/5ml suspension Sig: 6mL PO BID for 10 days Disp: QS
Consults • When arranging for a consult, page the resident or fellow covering for that service. If there are no residents or fellows, page the attending directly. • Exception #1: If there are no ophthalmology residents seeing pediatrics patients, consults are attending-to-attending. • Exception #2: ENT consults are always attending-to-attending. • Exception #3: Cardiology and child pysch consults are arranged via their main offices. To consult either one of these services, have the operator connect you to their main office. • Tip: Before calling a cardiology consult, you should obtain an EKG and 4-limb blood pressure. They are always helpful! • Fill out the top part of the consult form and leave it in the chart. • Never call a consult without attending approval. • Never initiate a plan proposed by a consultant without attending approval.
Admissions • Patients who are admitted during the day to a general pediatric service (service, private PMD, non-surgical subspecialties) will require: • A complete history and physical, after which an H&P packet needs to be completed. • Growth chart and BMI • Admission orders • PMD notification • PMDs need to be notified of admission both when they are the attending and when they are not. • Any private pediatrician of a service patient or patient from another service (ie surgery, ortho) should be notified of admission. • Medication Reconciliation (if not done by nurses) • A flow sheet
Admissions: Other Services • Surgical services • We “co-follow” pediatric surgery, orthopedic, OMFS (etc) patients. When they are admitted, a full H&P is not required – only an accept/post-op note is required. • Daily SOAP notes are also required. • Patient issues or questions about plan of care should be discussed with the primary team. • Orders should not be written on their patients without their approval, but you should check to make sure they are correct. • The reverse is also true: surgical teams should not be writing orders on service or private patients that they may be consulting on. Please contact your senior or chief if this happens. • We are involved with surgical patients as we are on the floor 24/7 and they are often in the OR when situations arise.
Admissions: Other Services • Neurosurgery • Same as surgical services. The only difference is that the pediatric neurosurgery service often requires a “pediatric” consult. • Tip – Write youraccept/post-op note on the consult forms. • Any questions should be directed toward your senior or Nancy Strong, the pediatric neurosurgery NP. • ENT • ENT patients are often admitted under the hospitalist service. Therefore, they do require an H&P packet, daily SOAP notes and orders (though they should not be written without ENT attending approval). • You are not responsible for discharging or dictating the patient. A surgical resident will complete the discharge paperwork and dictate.
Admissions: The H&P • You are responsible for doing admissions with the senior resident and medical student (if you are assigned to one.) • At that time, you will ask the questions regarding the history. (After your medical student has watched you do this once or twice, you should pass the baton to him or her.) • You will all complete the physical together. • Tip – Don’t forget the oto-ophthalmoscope to examine the ears and the pharynx. Check to see if there are pediatric otoscopic specula (the smaller ones) and tongue depressors with the scope before you go in. • Your H&P format will be laid out for you in our easy-to-use pre-printed intern packet. • Tip – Sticker every page, back and front. • Tip – Until you get comfortable writing a chronological, sensible HPI, take notes on the back of the intern flow sheet. You can transcribe it later and have the extra bonus of having an HPI at your fingertips on the flow sheet.
Progress (SOAP) Notes • There should be a progress note in the chart for each patient every day. • Exception: If the H&P of a new patient admitted overnight is dated after midnight, a SOAP note is not required. • In the first line of the note, remind the reader why the patient was admitted: “7-year-old with reactive airway disease exacerbation and hypoxia.” • The SOAP format: • S (subjective): How the patient did overnight, any events, any complaints. • O (objective): Physical exam including ALL vitals (weight, I/Os), labs, radiology. • A (assessment): Summary of status. • P (plan): Goals by systems • Tip – It helps to arrange your systems by the order they are laid out on the senior signout sheet. (FEN, Resp, Cardio, ID…) • Date, time, stamp and sign every page of your progress note. • All notes by medical students should be reviewed, discussed and co-signed before being place in the patient’s chart.
Discharges • To discharge a patient, you must complete a discharge summary (found in the gray cabinet in the core), write necessary prescriptions, and arrange follow-up with PMD. • Contact all consulting services at point of discharge and ask if they would like follow-up if not addressed in their note. • In theory, the discharge paperwork should be started as soon as the patient is admitted so that completion does not delay discharge. • Keep incomplete summaries in the top left desk drawer in the core. • Make sure there is enough information on each summary so that a resident covering you over the weekend or while you are at clinic is able to discharge the patient successfully. • Make sure to write your name under “responsible dictating resident.” • The discharge sheet serves as the progress note for the day. • After the patient has been seen by the attending, sign the discharge summary and put discharge orders into the computer.
Discharges If a patient is going home on an unusual medication, call the outside pharmacy and make sure they will have it available in a timely manner. If the pharmacy is closed or will not have the medicine in an acceptable period of time, see if there is a spare dose in the patient’s drawer to get them through the day and/or the next morning. The pharmacy supervisor is also sympathetic to the realities of these situations and will sometimes agree to send up an extra dose or two before discharge. Magical pharmacies that seem to have very unusual medications are Stony Brook Pharmacy (no affiliation) and Fairview Pharmacy.
Dictations • All patients admitted for more than 48 hours will require a dictation. • Tip – Try to dictate patients in a timely fashion, optimally before the charts leave the floor. After that, you must head up to the 13th floor to medical records and have your charts pulled for you to dictate. • The rules: • You may have no more than twenty on your list until January 1st(then no more than ten thereafter). • You may not have any chart older than 30 days on your deficient list. • If any of these rules are broken, medical records will contact Elaine and put a letter in your mailbox threatening suspension of medical privileges, fines and other bad things. In addition, the chiefs may be forced to give you an extra call. • The bottom line is – get your dictations done.
Transfers Accepting a Transfer Usually from the PICU Read through chart thoroughly, including the other service’s transfer note. Talk to the patient, get history, do physical. Double-check already written orders. Write an accept note. Make sure to include the hospital course until the time the patient is transferred to your service. Transferring to Another Service Usually to the PICU You MUST write a transfer note, which is SOAP note format with more detail. Include a brief HPI and hospital course until time of transfer. Write transfer orders in PowerChart Reconcile meds using the “transfer” option. Sign-out to the resident accepting the patient.
Off Service Notes • Off-service notes should be written for complicated/chronic patients, as well as patients who have been on the floor for more than 3-4 days with no discharge plans. • The off-service note is a more comprehensive SOAP note, including problem list, brief HPI and hospital course since admission. Be very detailed in physical exam and assessment/plan.
Running the List/Updates • During the course of the day, update your senior (and your patients/families) frequently. • Tip – Parents should not be asking the night team about long-term plans! If they are, that is a clue that you should be more on top of updating your families. • At 5pm, you should be prepared to give your senior final updates for the day. This is key to leaving the hospital on time. • Before evening sign-out at 6PM, you should have obtained the most recent vitals for your patients and have a good idea of what the night team should expect overnight.
Medical Students & Teaching • Medical students will be assigned to you when they come on service. Typically, they will follow 2-4 of your patients during the course of the week, after which they will follow a different intern and a different student will follow you. • Med students should be seeing patients and writing notes. They should also be presenting during work rounds and attending rounds. • Be sure to take time to teach, even if it’s only pearls here and there, or tips and tricks for internship. • Constructive criticism is especially important in history taking, physical exam skills and note writing. Before co-signing medical student notes, they should be reviewed and discussed.
PM Sign-Out • Evening sign-out begins at 6PM in the 11N conference room. • Presentations to the night team should be brief, but they should also include any and all pertinent information about your patients that would be important to know overnight. • Report by systems, including your updated vitals. • Briefly list important medications. • Finish with a summary of night issues/things to look out for or accomplish overnight, as well as labwork expected in the AM if there is a value that needs to be watched for. • If necessary, also sign out if anyone needs to be called for a specific parameter (ie, calling the endo fellow with urine ketones and d-sticks at 10PM.)
Night Float • The night intern rotation consists of two two-week blocks of nights in which you will work Sunday through Thursday, 6pm through 8am. • Your day will start with PM sign-out. Make sure to listen carefully about anything pending overnight, taking notes on the sign-out sheets if necessary. Both the floor team and heme/onc will sign out to you, so it can seem like a lot. Feel free to ask for clarification if something is unclear. • Depending on the night senior and number of pending admissions, many night teams will do night rounds, which consist mainly of introducing yourself to the patients and families and asking if they have any problems or concerns. • For the rest of the night, your job is admissions. Have lots of blank H&P forms and flow sheets readily available for use.
Night Float: Admissions • Whenever your senior gets paged for an admission, ask him or her to tell you about the patient, too. It’s nice to know what’s coming. • When a patient first comes up, grab the chart. Thumb through all of the records already there, such as outside hospital or ED records. You should have your HPI in chronologic order, and that includes what was done for them before they got to the floor. • You will need a lot of stickers. • All PMDs need to be notified of admission, even if it’s 3am. • Private attendings need to be spoken with in order to solidify plans for their patients. • Pediatricians of service patients and surgical patients need to be notified but not necessarily spoken to. Talk to their service and leave a message for the morning. This is important because private attendings (especially of surgical patients) will already be in the hospital to round in the morning and can stop by to see those new admissions.
Night Float: Overnight • Check vitals and labs frequently. If something looks suspicious or impossible (respiratory rate of 0, for example), get clarification! Make sure to have the nurses or CAs repeat any abnormal looking vital signs. • If you are called to the bedside for whatever reason, write a 2-3 line event note in the chart stating why you were called, what you did, and what the resolution of the event was. • Eat (deli opens at 12), sleep (seriously) and go to the bathroom when you can. • Before signing out in the morning, get the vitals and labs on all of your new admissions, listen to your respiratory kids and put all your paperwork together. • Interns will start showing up around 6am. Update them on what happened to their patients overnight.
Night Float: AM Sign-Out & Beyond • AM sign-out begins with the night intern presenting new patients. Presentations should consist of • A brief HPI including what was done for them, if anything, at outside hospitals, the ED, and on the floor • PMH pertinent to HPI • Significant labs/radiographs • Pertinent physical exam findings • Brief assessment/plan. • It will take awhile to finesse, but these presentations should only be 2-3 minutes long. • It is always good practice to ask for feedback from your seniors about how your presentations are going and what you can do to improve. • After sign-out, the night team joins the day team on work rounds. Monday through Thursday mornings, your day ends at 8PM. On Fridays, you should attend morning report.