WELCOME Orientation to Harper University Hospital

1. WELCOMEOrientation toHarper University Hospital Courtney M. Moore-Luibrand Chief Medical Resident

2. Changes at HUH • Q12 overnight call for Interns/Sub-I’s/Students • Full schedule on wsumed.com • Advance Management Resident (ER/IM)

3. TEAM STRUCTURE Medical Students  Two MS III 1 Sub-S (MS IV)

4. In General: A Day on Harper Floors On-Call (Q2) 7 am AMR carries admission pager Floor residents get signout from night float/intern overnight (pager!) Evaluate your patients Pre-round with your senior Pre-round with students Round with your attending Attend morning report 1 pm Admission pager is carried by short-call senior Work on your patients’ cases Short call senior and intern admit patients 3 pm Check on your patients again before signing out Other team signs out to long call = cross coverage(pagers!) Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients Long call team begins admitting patients 8 pm Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!) If it is the night float intern day off on call floor intern and students stays overnight 7 am next day Return to get sign-out about your patients (pagers!) If Night float team is here they stay to round with the team and present the patients they admitted overnight If on-call intern stayed overnight they remain in house to round with attending but does no admit patients (the new on-call team does) Non-Call (Q2) 7 am • AMR carries admission pager and admits to other team • Floor residents get sign out from night float/intern overnight (pager!) • Evaluate your patients • Pre-round with your senior • Pre-round with students • Round with your attending • Attend morning report 1 pm • Work on your patients’ cases 3 pm • Check on your patients before signing out • If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!) 7 am next day • Return to get sign-out about your patients (pagers!) • You’re now on-call!! --Refer to that side of the slide  **YOU MAY ADMIT PATIENTS TO YOU TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

5. In General: A Day on Harper Floors On-Call (Q2) 7 am AMR carries admission pager Floor residents get signout from night float/intern overnight (pager!) Evaluate your patients Pre-round with your senior Pre-round with students Round with your attending Attend morning report

6. In General: A Day on Harper Floors On-Call (Q2) 1 pm Admission pager is carried by short-call senior Work on your patients’ cases Short call senior and intern admit patients

7. In General: A Day on Harper Floors On-Call (Q2) 3 pm Check on your patients again before signing out Other team signs out to long call = cross coverage(pagers!) Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients Long call team begins admitting patients

8. In General: A Day on Harper Floors On-Call (Q2) 8 pm Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!) If it is the night float intern day off on call floor intern and students stays overnight

9. In General: A Day on Harper Floors Non-Call (Q2) 7 am • AMR carries admission pager and admits to other team • Floor residents get sign out from night float/intern overnight (pager!) • Evaluate your patients • Pre-round with your senior • Pre-round with students • Round with your attending • Attend morning report 1 pm • Work on your patients’ cases 3 pm • Check on your patients before signing out • If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!) 7 am next day • Return to get sign-out about your patients (pagers!) • You’re now on-call!! --Refer to the previous slides  **YOU MAY ADMIT PATIENTS TO YOU TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

10. In General: A Day on Harper Floors On-Call (Q2) 7 am AMR carries admission pager Floor residents get signout from night float/intern overnight (pager!) Evaluate your patients Pre-round with your senior Pre-round with students Round with your attending Attend morning report 1 pm Admission pager is carried by short-call senior Work on your patients’ cases Short call senior and intern admit patients 3 pm Check on your patients again before signing out Other team signs out to long call = cross coverage(pagers!) Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients Long call team begins admitting patients 8 pm Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!) If it is the night float intern day off on call floor intern and students stays overnight 7 am next day Return to get sign-out about your patients (pagers!) If Night float team is here they stay to round with the team and present the patients they admitted overnight If on-call intern stayed overnight they remain in house to round with attending but does no admit patients (the new on-call team does) Non-Call (Q2) 7 am • AMR carries admission pager and admits to other team • Floor residents get sign out from night float/intern overnight (pager!) • Evaluate your patients • Pre-round with your senior • Pre-round with students • Round with your attending • Attend morning report 1 pm • Work on your patients’ cases 3 pm • Check on your patients before signing out • If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!) 7 am next day • Return to get sign-out about your patients (pagers!) • You’re now on-call!! --Refer to that side of the slide  **YOU MAY ADMIT PATIENTS TO YOU TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

11. LEAVING BEFORE 3 PM • ONLY THE OVERNIGHT POST-CALL FLOOR INTERN/NIGHT FLOAT INTERN/SENIOR CAN LEAVE AFTER ROUNDS (and they must sign out their patients) • NO OTHER RESIDENTS SHOULD LEAVE BEFORE 3 PM • Work on patients management, discharges, morning reports, etc.

12. A Few General Floor Notes Rounds should begin by 8:30 so that there is time to discharge patients before morning report You should be identifying patients for potential discharge at least the day before and completing paperwork early so that on rounds you can just place the discharge order Participate in the TEMPO boards on a daily basis and notify nurse daily and directly of patient plans/dispo plans .

13. AMR aka. ER/IM • AMR (ER/IM) carries admission pager from 7 am – 1 pm • While you’re rounding and in Morning Report • AMR will: • Arrive at 7AM in 7 Brush lounge • Assign the admission pager (0092) to themselves • Admit patients to the on-call team • When the ED calls them for an admission they’ll take sign-out, briefly review the chart, ask the ED physician any questions they might have, provide the attendings name and go evaluate the patient immediately or at least within 15 minutes. • They will place the following orders: • Covering physician order • Basic orders until the primary team evaluates the patient (which should be after morning report) • Short-call team should begin carrying the admission pager from 1 (until 3 pm at which time the long-call team carries the admission pager) • When senior is off: typically, AMR staff with that intern • Won’t leave until after team signs-out

14. Long Call Team Notes • Long call team will cross cover the other teams’ patients from 3pm until 8 pm • Stay and provide sign out to the night float team at 8 pm Don’t forget to forward your pager to the covering resident • Long Call team accepts admissions and writes full H & P’s until 6:30 pm (unless capped) • Admissions between 6:30 pm and 8:00 pm will evaluated by on call senior who will admit the patient, add the patient to the list, place a covering physician order and place basic orders • Seniors must sign these patients out to night float!!! • Full admission note to be done by the night float team • Admissions from 6:00 am to 7:00 am will be evaluated by the night float senior who will admit the patient, add the patient to the list, place a covering physician order and place basic orders • Full note to be done by the on call team

15. Night Float and Intern 24 +4 • Night call 8 pm - 7 am • Patient cap to admit overnight is currently 10 patients • Cross-coverage of patient continues; sign-out occurs at 7 am next morning • 4 nights: Night Float intern + Night Float Senior • 2 nights: Floor interns stay overnight (in-house from 7 am that morning until after round the next day) with Night Float Senior • 24 + 4 hours • 24 hours = accept new patients (but remember; short call will be helping until 3 pm • 4 hours = post-call wrap up (rounding, notes, etc) • Night float senior rounds with you too

16. When You Arrive at 7 AM Post-Call • Please change the covering physician in the morning • Day residents are expected to be at there by 7am AND transfer their pagers to them!! Be punctual!!

17. ADMISSIONS

18. Admission from ED • On-Call Senior will carry the admission pager (0092) on AMR days off or after 3 pm • When the ED calls them for an admission take sign-out, briefly review the chart, ask the ED physician any questions you might have, provide the attendings name and go evaluate the patient immediately or at least within 15 minutes • Place the following orders: • Covering physician order • Basic orders until the primary team evaluates the patient (which should be after morning report) • Always evaluate the acuity of your patient’s illness; determine if they are stable for the floor or need evaluation by the ICU • Admissions can not be refused. If you believe the patient does not need admission, staff with your attending and your attending will decide whether to discuss this with the ED.

19. Admission from ED • Please do not review patient chart to decide if the patient needs to go to different attending before accepting new admission. • First you accept the admission and staff with you attending the next day who will decide if the patient needs to be transferred to different team (the attending has to sign the transfer order) • You do not have to wait for the patient to receive a bed on the floor to work them up. Evaluation and orders can be completed in the ED.

20. Admission from MICU • One quick note: • Cannot place orders on the patient until they physically have left the unit • Communicate with MICU team if you’d like something done/cancelled

21. Direct Admission and Facility Transfer • Admissions from the clinic/outside are direct admissions. • If you accept an admission from the clinics, it is your responsibility to check which floor the patient is going to be admitted to. - Your attending physician must accept transfers from outside hospitals first. If you are called to accept a transfer, talk to the transferring physician and obtain the following information • provisional diagnosis • history • vital signs • pertinent physical examination • pertinent work-up • reason for transfer • phone number of transferring physician • Make sure the patient is stable for transfer and management on the floor. Discuss this with your attending physician before accepting the transfer. • Bed assignment number: 51387

22. In House Transfer • Floor to ICU transfers: • The floor resident is responsible for calling the MICU/CCU fellow on call for any transfers to the critical care units. • ICU to floor transfers: • Transfer order will be entered by MICU team. • Non-ICU transfer to medicine: • Patients transferred to your team from another service if you have not taken care of that patient before. • The Medicine Consult service must FIRST to approve this transfer, pager 5501.

23. Rule of 6 CODE STATUS!!

24. Team Cap • The total is 24-28 patients per team • Typically, you only admit new patients on call days • Once the on-call team caps: • Before 6:30 pm  page Dr. Saker, Safwan who will take over the admission pager until 8 pm when the night team arrives and start admitting to the other team • YOU CANNOT LEAVE THE HOSPITAL! YOU MUST CONTINUE TO CROSS COVER PATIENTS, SIGN THEM OUT TO NIGHT FLOAT AND TELL NIGHT FLOAT TO TRANSFER THE PAGER AND ADMIT TO THE OTHER TEAM • After 6:30 pm  on-call senior admits patient to the other team, places covering physician orders, evaluate the patient, places basic orders, signs the patient out to night float who will continue the workup and do the full H & P • If both teams capped > admission goes to Dr. Saker, Safwan

25. Bounce Backs • Bounce backs are admitted by the on call team (regardless of who the bounced pt belongs to). • The next morning, the team staffs the pt with the attending, writes a progress note, and signs out the pt to the team that the pt belongs to originally • If the patient is being discharged on the next day, the discharge will be done by the team that admitted the pt. • Email Courtney with FIN of EVERY bounce back and reason of bounce back • No bounce backs on the first and last days of the rotation

26. Discharges • Discharge before 11am • If it is not possible, you may still discharge in the afternoon. • Be pro-active, get discharge paperwork/process started early • Complete the discharge summary on the DAY of the discharge. • Remember that dc summaries count as progress notes • Must include • Subjective, PE and vitals!

27. Discharges By Covering Teams/Night Float • The covering/night float teams should confirm with the respective attending on the team before discharging any patients if asked to do so by the primary team • Also, the primary team should complete the departure process/discharge plan before leaving including: • Completing depart in computer • Making all discharge appointments • placing scripts in the chart • arranging for transportation • answering all patient/family/caregiver questions

28. Medicine Consults • After 4 pm on the weekdays and 2 pm on the weekendsthe medicine consult pager will be forwarded to you and you may need to see a HUH/RIM patient • SENIORS, after that time you must: • Evaluate STAT medicine consults • Conduct pre-op assessment on a patient • Staff over the phone with the DRH UPG Medicine Hospitalist (pager 5755) • Write a brief incident note (SOAP format) • Add patient to Medicine Consult list and page the team the next morning, give them a brief signout and they will do the full consult note • These DO NOT count as hits

29. Who Does Count as a Hit? • Patients seen, staffed and directly discharged from the ED • BUT MUST BE STAFFED WITH ATTENDING FIRST • Completed H&P but patient ends up going to a different service • Patients admitted to your team who you will be following on a daily basis • Patients transferred to your team from another service if you have not taken care of that patient before. • The Medicine Consult service must FIRST to approve this transfer, pager 5501.

30. Documentation • Always document lines • PIV • Central Line, Midline, PICC, ect • Foley • Date inserted and indication for ALL LINES • Code status, date discussed and any details • Family member/contact and RELATIONSHIP • Diet • Disposition (update DAILY!!) • Avoid copying and pasting • MUST update information!!!!!

31. Codes • On-call team responds to codes and actively participates (Senior, intern, students) • Other people/resources should be there too • If they are not, ASK FOR THEM

33. Days Off • Each resident must take 1 day off in each 7 days • All team members must be here on call days • Obviously, can’t have your assigned MR day off ;) • Seniors should avoid taking post-long call days off as much as possible and can only take days off when AMR is in-house….so please check the master schedule

34. AMR aka. ER/IMand Senior Resident Days off • AMR (ER/IM) • They are here TYPICALLY Monday-Saturday (off Sundays; but see below) • They will staff new patients with interns on days their senior is off • AMR does not round with the team (as they are still fielding admissions from ER) • SENIORS MUST ONLY TAKE DAYS OFF WHEN ER/IM IS IN-HOUSE • Typically in-house Monday-Saturday • Sunday’s off • JULY AMR SCHEDULE WILL BE DIFFERENT • AMR IS IN-HOUSE: • Saturday, July 1 - Friday, July 7th ; • Off July 8th/9th Email Courtney and other team with days off within the first 1-2 days of your rotation

35. Important Issues • All emergencies or change in clinical condition must be discussed with the attending physician • All procedures need to be supervised. If uncomfortable or not trained to do the procedure call your attending or Pulmonary team • Fill out death certificates (tips on wsumed.com) • No curb-side consultations (but advice ok) • Jeopardy: A CMR must be notified if jeopardy is activated, NO EXCEPTIONS

36. Important Issues Continued • When possible, place a midline rather than a PICC line • PICC lines should never be placed if anticipated use is <5 days unless there is a clear indication • If the patient already has central access, care should be taken not to order another central access

37. Important Issues Continued Every cystic fibrosis patient needs a Pulmonary consult Notify Drs Kissner and Saidan when their pts are admitted. I&O’s and Daily weights when needed!! Tempo board Daily SW/CM and quarterly PT/OT assignments to be emailed by CMR. Isolation orders: order with labs directly (e.g.: c diff pcr + contact isolation, influenza pcr + droplet isolation). DO NOT DELAY.

38. Telemetry • Renew after 48 hrs. • If not needed --> discontinue the order • If pt can travel w/o tele, pt doesn’t need tele (order can be discontinued) • If patient needs telemetry they cannot travel without it

39. E-Prescribing • Seniors will teach you how to access this • Controlled substances must be printed

40. Sepsis • ADDRESS sepsis alerts (accept or reject) • Utilize Sepsis PowerPlan

42. Pager Etiquette • When paging someone, always include: • Your name • Pager number • Call back number • Remember to “un-forward” your pager in the morning and make it “available wide area page” • Always forward your pager to SOMEONE • 3 pm = Long call team • 8 pm = Night float team • Day off = your senior resident

43. Education • Morning Report- combined at DRH • Morning report will start promptly at 11:00 am. • All residents are expected to attend MR except the senior who is on short call • 1 case per day • case presentation and teaching slides to be covered by the intern • Clinical quesiton, literature search and appraisal by the senior • Senior is responsible for case oversight and assisting intern • Review the MR schedule and guidelines on MR schedule

45. Morning Report Deadlines(can also be found on MR schedule)

46. Students/Sub-I • Third Year Medical Students/Sub-I’s will take 24 hour call • Sub-I’s • Admit 1-2 patients each call • They should carry between 2-3/4 patients at all times • Student Teaching: **USE YOUR POCKETPOINT CARDS** • Give students their patients early and go over the cases in more detail • You must co-sign the student orders • Make sure they get a good variety of cases (PP cards) • Seniors are responsible for Sub-I teaching

47. To Do • Email Courtney with days off within the first 1-2 days of your rotation • Email me with any bounce backs • Prepare morning reports and submit by deadlines

48. One last suggestion… • Make it FUN!!! • Team names • Say HI • Grab a snack/coffee/tea/water together

49. Finally… WELCOME TO HUH FLOORS! Don’t hesitate to contact me with any questions • Questions?