Resident Wards Orientation

1. Resident Wards Orientation

2. Team Structure • Attending • Senior Resident • Intern • Possibly a Sub-I • One or two 3rd Year Students

3. Duty Hours • Your Interns: • Must have 4 days off during their 4 week block. Give them one day off per week, including the first week! • Cannot work more than 80 hours a week, averaged over a four-week period. • Cannot work more than 24 hours (+ 4 hr transition) consecutively. • Must have 8hours off between each shift. • It’s your responsibility to ensure duty hours on your team are met. • Also applies to Sub-I’s.

4. Duty Hours • You: • Must have 4 days off during your 4 week block. • Cannot work more than 80 hours a week, averaged over a four-week period. • Cannot work more than 24 hours (+ 4 hr transition) consecutively. • Must have 8 hours off between each shift. • NOT ALLOWED TO TAKE POST DAY CALL OFF.

5. Duty Hours • Time spent on notes and documentation counts towards your duty hours. • Time spent covering the pager at home, does not count towards your duty hours unless you come in to the hospital to see a patient. • You must log your hours for the preceding week by Monday at 5PM in New Innovations.

6. Work Load • Interns can see up to 7old patients. • Interns can admit/transfer up to 5 additional patients. • There should be some degree of pager sharing between interns and residents • Relieve your intern from primary pager duty at least 2 days per week • Team cap is 12 patients. Bounce backs can take you over cap, but the attending is responsible for extra patients.

7. Call Cycle

8. Day Call • Weekdays: • 0700 – 1200: Silver admits to your team and gold. • Silver team admit to the day call team 4 patients or to a team cap of 8 (whichever comes first). All remaining patients are admitted to Gold and Copper back and forth up to 16 per team, then all further admissions admitted to Nickel. Day call will advise night float to back fill them to 12 if the day call team has not capped at the end of their call.  • 1200 – 1230: Meet Silver intern in the ED for hand off. • 1230 – 1800 (6:00pm): Triage new admissions for your interns and sub-I’s. • After 1800(6:00pm): Finish H&Ps, double check orders have been placed, f/u patients, round with attendings (usually). • Continue to take names for admissions during this time. • 1900 (7:00pm): Meet with NF to hand off The List. Sign out to OCD and go home.

9. Day call • Weekends: • 0700: Meet with NF in cafeteria to get The List. • 0700 – 0900: Round on old patients quickly or split from team to start seeing admits (work out with your attending). • 0700 – 1800(6:00pm): Take and triage new admissions from the ED. • After 1800(6:00pm): Finish H&Ps, double check orders have been placed, f/u patients, round with attending (usually). • Continue to take names for admissions during this time. • 1900 (7:00pm): Hand off to NF, sign out to OCD, and go home.

10. Triaging Patients • Appropriate Service: • When consulted for an admission, state “Who is their PCP?” • This is apart of the ED triaging responsibility. • Don’t evaluate a patient until you know they’re not FP. • A patient is FP if they identify their PCP as someone on the FP list (located on wiki). • Prior admissions DO NOT MATTER. • Where to locate PCP: • Prior Clinic Notes • Top of Powerchart (Sometimes) • Have the ED ask the patient (What’s supposed to happen every time).

11. Triaging Patients • Service Agreements: (Be Sure to Review) • Available for FP, CF, Neuro, Cards, MICU, Psych, Heme/Onc, Peds, Ortho, Surgery. • When in doubt, check the IMChiefs website. • ED Obs: • In general, applies to cards, placement, COPD, pyelonephritis, and cellulitis. • Caution with pregnant patients (get your attending involved if you have to admit).

12. Triaging Patients • PALS • Should be seen ASAP, at least within 1 hour of them arriving. • Have not been evaluated by a physician. • If you think they need a higher level of care, call the appropriate ICU. • Drop skeleton orders to get labs before heading upstairs. • MICU • If MOT gets > 4, they will triage the rest to your list. • If its after 1500, MICU will call you for transfers. • ED: • Sickest patients first. • Do a chart review on the patients and if you see anything alarming, i.e. meeting SIRS criteria, critical labs, critical vitals. • Make sure that any interventions you recognize are time sensitive at consult, are communicated to the ED team caring for the patient. • I like to let the ED know how long my list is and how long it probably will take before that patient is actually seen.

13. Day Call Bounce-backs: • Teaching Teams: • Within 21 days after discharge. • Follows Residents, Interns, Externs, and Sub-I’s, regardless of if that person was following patient previously. • Gold Medicine: • Next slide • Day call’s obligation to admit, regardless of bounce-back team. • Can contact team before 3PM to see if they want to admit the patient. • The Day Call team will care for the patient until OCD sign out. • It is the Day Call resident’s responsibility to sign out all admitted patients to the appropriate cross cover.

14. Gold Bounce-Back • Gold Medicine: • To enhance continuity, Gold bounce backs will remain at 14 days, but ONLY if an advanced practice provider (APP) discharged the patient. To determine if an APP discharged the patient, look at the discharge summary for one of the following names (also see additional important language under this list): • HusaynBIn-Bilal • Krystle Apodaca • Amanda Lechel • Radha Denmark • Amanda Woodards • Karla Enriquez • Barbara (Balin) Aronson • JoAnne Clinton • Lucas Miltenberger • NikolitsaVarvaresou • ** If one of the above APPs discharged the patient, then the patient will bounce back to Gold. If anyone other than those listed discharged the patient, then the patient will fall into the regular flow of admissions. • The Bounce Back rules apply to both MICU transfers and admissions from the ER. 

15. Admission Flow • DCT admits to themselves up to cap (12) . • DCT admits to tomorrow’s NAT up to cap (12) . • DCT admits 2 patients or up to 10 (whichever comes first, but no more than 2) to tomorrow's MOT. • DCT admits all remaining patients to Gold and Copper back and forth up to 16 per team then all further admissions admitted to Nickel. When in doubt, check the imchiefs.unm.edu

16. Admissions • Requirements on ALL patients: • Bed Request • Admission Order set • Medication Reconciliation • Code Status Note • History and Physical • Cache • It’s your responsibility to ensure these are completed.

17. Documentation • History and Physical • NEED TO INCLUDE: • PCP • Code Status • Contact Person with Phone Number • IMChiefs website for notes….. • Code Status • NEED TO INCLUDE • Your discussion with the patient • Surrogate Decision Maker with Phone Number • If “Presumed Full Code,” update as soon as patient has improved mentation or family can be reached.

18. Documentation Progress notes: • Every patient every day. • Attending addendums on the Night Float H&P counts as daily note for following day. • Discharge summaries dictated on the day of discharge counts as the daily Note. (Attending must include that they have made face to face contact with the patient).

19. Where to Find Sepsis Order Sets • Ensure Search Setting is “Contains” • Search Term “Sepsis” • Select this First Choice • Select the Appropriate Power Plan

20. Documentation • Discharge summaries: • Must be completed within 24 hours. • CC the patient’s PCP.

21. Discharge Summary • Essential Elements of a Discharge Summary • Date of admission and discharge • Final diagnoses • Brief description of reason for admission • Brief hospital course • Condition of patient on discharge • List of operations and procedures • Other significant findings and test results • Medication list on discharge • Follow-up appointments • Anticipated problems and suggested interventions • Pending laboratory work and test

22. MS3 (Phase II) Documentation • Procedure note is not billable • H&P in “Student Note” is not billable • Progress note • 1 note in “inpt progress note” is billable -> resident to addend (=resident+MS) -> attending to addend (=attending_MSandResident) • 1 note in “student note” in for education ONLY • NO Discharge/Transfer Summaries

23. Sub-I (Phase III) Documentation • H&P • in “H&P” is billable -> resident to addend (=resident+MS) -> attending to addend (=attending_MSandResident) • MUST BE DONE SAME DAY • Progress note • in “inpt progress note” is billable -> attending to addend (=attending_MSandResident) • Discharge/Transfer summaries • billable -> attending to edit and addend (=attending_MSandResident) • Transfer summaries should be edited and addended prior to patient transfer

24. MOT • You can receive 2 patients in the AM from NF. • Have your pager on early. • Perform up to 4 transfers from MICU in the afternoon. • Receive non-medicine transfers from Silver. • They should handle transfer note and orders. • Recap: • Can receive 6 total patients = 2 overflow + 4 transfers • If you do not receive any overflows, you can still only perform 4 transfers in PM.

25. MOT • MICU Transfers • 12 PM call from ICU or head there yourself. • Take all names of MICU transfers. • Ask MICU team to have problem-based progress notes • If >48 hr stay in MICU, ask MICU team to have interim summary • Triage and give any over 4 to DCT. • Don’t forget to have MICU team check PCP! • Cards Transfers • Your attending should be contacted regarding these and then contact you. • Non-Medicine Transfers (Neuro, Ortho, etc…) • Silver should handle these.

26. NAT • Before 0700: Residents and Interns (also Sub-I’s) preround on old patients. • 0700 – 0800ish: Meet in the Jemez Room at back of cafeteria to hear about new patients from night float residents. • After night accept rounds: Round as a team on new and then old patients.

27. Crosscover • OCD (CC1 and CC2) covers 1900 – 0700. • Intern or Senior Resident signs out at 1900 (7:00pm). • We all use IPASS now. • Cache determines the information that OCD first has to care for a potentially crashing patient, so make sure it’s UPDATED DAILY. • OCD should be in the 4 West workroom between 6:45 and 7:15 every morning for an in-person sign-out. • Someone from the team will need to be here by then every day.

28. Education • Afternoon Report at 2:00 pm every Monday, Wednesday and Friday. • Day Call Team is Excused • Attendings should hold/answer the pager. • M&M once a month on second Friday at 1200. • Grand Rounds/Thursday school activities start at 1230 every Thursday. • Day call/MOT are excused. • NAT intern is required to attend. • NAT resident can miss if necessary.

29. Afternoon Report • You will present on your NAT days. • Should Have 3 SMART Goals for each morning report. • Present a case for each morning report • …..unless you want to try something else? • Sign up for your topic at the beginning of the month • Email me and Reed your presentation w/ clinical pearls 48hrs prior • Check your email…

30. Students MSIII • Follow 2-4 patients, but START with 1-2 • Only write 2 notes a day in the chart (see documentation section) • One progress note is billable with addendum from resident & attending • Should have all of their patients seen by another member of the team prior to rounds every day. • One day off per week (usually non-call day). • 5 days off on “switch weekend” (usually Wed-Sun) • They will remind you when they have other commitments and needed to be off

31. Students • Passport: • You can sign their passport (except H&Ps). • Need to have attending sign off on required H&Ps • Didactics: • Tuesday afternoons. • Not expected to return to the team afterwards – even when on call. • Chief Rounds on Mondays 11:00 – 12:00 pm • Thursday after 1330 is protected study time if not on call.

32. Students Sub-Interns: • Should be performing the duties of an intern (but still not actually an MD) • Interns should not follow their patients • The resident is the primary contact for the sub-intern – Make sure they get an opportunity to carry the pager AFTER 1st week • Make sure either intern or resident has the other pager  – Give them feedback on documentation  – Opportunity to put in orders for resident co-signature • DO NOT ask sub-I to carry the pager during pre-round • Can perform billable H&P, progress note, discharge/transfer summaries (see documentation)

33. Days Off • Everybody gets 4 days off each month except for MSIII • Residents are NOT ALLOWED TO TAKE POST DAY CALL OFF. • Can take protected days, plus MICU accept if absolutely necessary. • Try to avoid Thursdays (TS, GR). • Your interns should have had one day off the first week. • You are in charge of team schedules. • Figure out the rest of the days off today.

34. What to do TODAY? • Schedule days off. • NOT ALLOWED TO TAKE POST DAY CALL OFF. • Avoid days off on intern/resident/attending switch days. • Print schedule and highlight days. • Give the interns and students your expectations. • How many patients they should see/admit • Who should carry the pager and when • Updating the list (using Cache) • Plan out talks that you want to give. • Plan out talks that you want your interns and students to give.

35. TigerConnect on Apple

36. TigerConnect on Android

37. IMPROVE-IT Quality/Safety Dashboard • Utilize during rounds • Available on Cache view • Fill out survey weekly if possible • https://ctsctrials.health.unm.edu/redcap/surveys/?s=7YX89AWYFF

38. Questions? Call or Email me: chchang@salud.unm.edu 808-675-8892 Come visit? Office across from Dr. Jernigan’s