Welcome to John D. Dingell VA Medical Center

1. Welcome to John D. Dingell VA Medical Center Pradeep Kathi and Walid Ibrahim Chief Medical Residents

2. Background • 267 bed facility. • One of the largest VA hospitals. • Provide primary health support to Veterans. • Affiliated with WSUSOM/DMC. Provide significant portion of residents’ salary. • In-patient: Medicine, Surgery, Psych and ICU. • Also NH, extended care, hospice

3. Floor structure • Four (Blue, Green, Red and Yellow) medical teams. • Each team consists of 1 resident, 2 interns, 1-2 medical student(s), and social worker.

4. Typical Day • 6:45 arrive and get sign out • 7-7:30 see your patients • 7:30-8: Pre-round with your senior • 8-11:00: Rounds with medicine attending • 11:00-11:50: Discharge Arrive before 7 to get sign-out from Night float

5. Floor structure & Typical day • 11-12pm : Morning report (only in July) • 12-1 PM : Noon Report (Morning Report) • 12-5:30PM- Academic Half day- every Thursday • 1-5 PM- Finish work (including new admissions), exit rounds and sign outs.

6. Admissions Flow • NP’s on Weekdays will transfer/carry Medicine admission pager # 9775 to him/herself from 8am - 1pm • NP is responsible for triaging, assessing pts. and putting basic orders on weekdays from 8am-1pm

7. Admissions Flow • From 7am to 8am the on call senior (not the team senior) should transfer the pager to him/herself and triage patients. • Any pending admissions between 7-8am should be distributed to the teams by on call senior before NP takes over. • NP will mark on the board outside the room when they get an admission. • Resident comfort- when to get sign out from NP.

8. Admissions Flow • On the Weekend on call senior will transfer the admission pager #9775 to him/herself • On call senior will get sign-out from the ER, then inform the accepting team senior about the admission ASAP • Accepting senior will be responsible to evaluate the pt. ASAP in the ER (preferably in less than half an hour)

9. Consults (weekday) • 8 AM – 4.30 PM: Consult attending will see the consults (schedule available @ clinical call schedule) • After 4:30 PM: STAT consults- MOD should be contacted. If MOD decides the patient to be seen by resident team, please see the consult and count it as a hit (flow similar to new patient) ROUTINE consult: Please take information regarding the consult and let the consult attending & NPs know the next day about the consult.

10. Consult (weekend) STAT consult: • MOD is responsible for STAT medicine consult. If MOD decides the patient to be seen by resident team, please see the consult and count it as a hit (flow similar to new patient) • If resident team see the patient please staff it with MOD. ROUTINE consult: • Routine consult is seen by on-call attending • If your attending wants you to see the consult, you can count it as a hit. • All consults seen should be staffed over the phone with your on call attending same day

11. Calls on Medicine consults patients • For patients who are already being followed by medicine consult service (example ENT, Ortho, Urology, Gyn pts): In case of any medical issue after hours MOD is responsible for addressing those issues. • If the MOD decides that the patient needs to be transferred to Medicine service, see the patient and take it as a hit.

12. Call System • Team on call Q4, every 4th day • On call team gets total of 9 new admissions • Non call teams gets up to 3 new pts each per day • Post call team gets no new pts. • Each day on call senior will start admitting patients to him/herself after 2 pm • Or whenever the other teams are capped meaning 6 admissions to medicine team whichever comes first.

13. Call System • On call team will start admitting at 2pm (changed from 3pm) to allow the team adequate time to work up all the patients and leave on time • Non call teams can sign out at 3pm ( not 2pm as they can still get bounce backs until 3pm but not new admissions after 2 pm) • Total number of patients for the team will be 9 patients over • On call team will admit 5 patients till 6pm (will be at senior resident discretion how the patients get distributed between the interns) • On call team will stop admitting new patients at 6pm to prevent violating mandatory short break

14. Night float • From 6pm MOD (Available from 5pm) for the day will start admitting till night float takes over at 8pm • Night float will admit total of 5 patients • NF can get patients from MOD, but MOD should have taken at least 50% or more of the patients admitted to MOD irrespective of number of admissions and time of admission. • EX: if MOD gets 6 pts , NF can get a maximum of 3 (not 4 pts) • If MOD gets 7 pt: NF gets a maximum of 3 only ( not 4 pts) • If MOD gets 2, NF can get 1 pt from MOD • If MOD gets only 1 pt ( even if it is at 7.50pm), it can not be given to NF.

15. Once the night float team reaches the cap of 5 patients, MOD will again admit rest of the night • Night float cut off-6.15 AM

16. NF coverage • NF Seniors : same as the old NF system (3days on/1day off), no new changes are made to seniors schedule. • NF interns: 5 + 2 system (beginning this academic year) • NF interns: Sunday – Thursday night only • Friday and Saturday: On of the floor team interns will do 24 hrs call. Each intern will get one 24 hr call in the entire block.

17. On intern 24h call days • One intern from on-call team will stay back over 24 hours with 4 more hours to wrap up work next morning (LONG CALL INTERN) • Long call intern will admit the first 2 patients starting at 2pm or earlier based on the day (senior can decide whom to give admissions). • After his/her admissions process is completed, they will be able to rest until starting call at 8PM with night float senior. • Seniors: We would like you to cover the intern pager for 2-3 hours for them get some rest • Long call intern admits maximum of 5 patients/24 hrs. (2 with day senior , 3 with NF senior)

18. Admissions Flow • As the total team cap is 9 patients, the on call team will receive 4 patients from night float the following day to meet the total number of 9 patients • The other patient admitted by night float and any patients admitted by MOD will become overflow to be distributed to the NP/non call teams based on NP patient load. • Post-call senior responsible for admission log to be submitted to NP at 8AM

19. Admissions Flow • New admission typically comes from ER • Also can come from clinics, direct admissions, physician will page #9775, will give you sign-out as well as put delayed orders, Admitting Physician ( not the on call resident) is also responsible to call Bed Control and precertpt except in CLC transfers • Outside transfers- CMR/MOD (After 5pm and weekends) • Residents can also get pt. from CLC or NH located in 6th floor, again same process. But residents are responsible to call bed control in this case, and put the transfer order.

20. Admissions Flow • In the event the on call team gets total of 9 patients before 5pm, the senior resident is expected to have admissions orders in for all 9 patients and call the MOD at 5pm to hand off the other 4 patients to be admitted by MOD.

21. Admissions Flow • Night float senior + intern will admit up to 5 patient overnight. • Any additional admission after both on call team/night float reaches cap, will go to the MOD on call. • Total team cap is 20 pts. • Senior will hand over code blue pager to NF senior resident. • NF intern carries the another code pager and hands it over one of the on call intern next day

22. Bounce Back • Same block • Irrespective of intern • If before 3 pm, will go to original team NOT counted as a hit. Unless the team is post call and can’t take patients goes the next admitting team or on call team. • Admitting team will round on bounce back patient next day, write progress note and then give back to original team immediately (do not wait until 3pm to sign out).

23. Bounce Back • NF/MOD bounce back- goes to original team irrespective of team cap. • NF takes bounce back as a hit. • Bounce back admitted by MOD/NF cannot be a hit for call team in any case. • Patients discharged by NP- Not considered bounce back to the team

24. Cross Coverage • Medicine Team cross cover other medicine team (NP is part of team) • Pt. admitted by MOD is cross covered by MOD till 6:30am the following day then signed out to night float senior

25. Codes • Codes (blue and grey): Keep pagers with you. Let CMR know ASAP if they’re malfunctioning. Respond to calls from other services and call THEIR attending. Code blue from CLC DO NOT go to ER, only falls do. • Code White: only afterhours and all day weekend • You are required to put code grey/white note in CPRS and call attending, in the case of code white it’s the neurology attending on call. • ICU is responsible for writing code blue notes, but if incase a senior resident runs the code you are responsible for writing the notes. • Code Blue Test paging system • Please don’t lose code pager, you will be held responsible for it. Each one costs 350$. • Please return test page, dial 0 to call the operator and inform them code pager is working

26. Responsibility: • Transfers: nursing home, other VAs, outside community. Accept but do not count until they reach the floor. • Once capped  inform ED and MOD ( please check CCS). • Once capped, MOD takes over admission. MOD will sign out to Night float senior at 6:30 am (must be face to face) • If on-call team caps before MOD arrives (5 PM), let your attending and CMR know.

27. Certain services are not available in VA Detroit: Neurosurgery, and any solid organ transplant patients ( ex: Renal, Liver) • In case if you get a call from ED which you think requires neurosurgery evaluation, please discuss with ED regarding the same.

28. VA Medicine Department • Associate Chief of Staff for Medicine: Dr. Patricia Brown • Associate Program Director : Dr. Kareem Bazzy • Chief Medical Residents: Dr. Pradeep Kathi (Clinical) Dr. Walid Ibrahim (Q&S)

29. House staff coordinator: Beverly Greene, Dial 576-1000 then ext. 63334 Responsible for all medicine divisions

30. Unique to the VA • Meals during call days (1-2 meals). • Call rooms - (6th floor/semiprivate bathroom).1-9-2-1 Only for Medicine residents. • Exceptional computer/EMR system (paperless system) + connected to all other VAs. • Patients are mainly in A3 Med, A4 Surg and A4 S/D • Paging system- Call 61135- Enter VA Pager number, DMC pager – 91-313-745-0203 • Nursing home/hospice unit – considered outside facility. If pt is already hospice, should be admitted as hospice.

31. HIPAA privacy • It is imperative to respect privacy of our patients in public places, outside patient rooms and on phone. It is being monitored very closely every day. • Duty hours should not be violated. If there is some concern, please approach your senior/attending/CMR.

32. VA pt. info • Don’t share VA protected health information PHI outside of the VA system. Don’t share via: • @gmail, @yahoo.com etc, @med.wayne.edu (not even by using {secure}) • SMS, iMessage. • Non-secure voicemail, e.g iPhone. • Drop Box, Google Drive, icloud • May use @va.gov e-mail by sending a secure message: To automatically set up – just open Microsoft Outlook.

33. OFF days • 4 days off per block. Work ahead. • Can not take on-call days off. • No day off on the first day or last day of rotation as this is critical for effective handoff. • Seniors should not be off - Post call days. • Please inform attending about off days • Please try to avoid days off on code grey simulation days as it is important to have participation from all residents. It is a good opportunity to test your skills and learn.

34. Morning Report • Purpose: Educational, scholarly activity • Your purpose it teach others and respect their valuable 1 hour time. • Please keep that in mind when you are preparing the morning report • Bedrock of Inpatient Academic Medicine around the world

35. Morning Report • Long Case by 1 intern. • Each intern presents at least once. Discussion – Senior • Do not have to be 'Zebra'. Plenty of great teaching points on common cases too. • Send your presentation at least 48 hours in advance. No exceptions. No rough draft on 48th hour (12 PM) • It will be the responsibility of the senior to go through case and correct / add to it before 48 hours. • All cases must be from the VA, please send Pt. last Initial and Last 4 72 hours prior.

36. Morning Report • 25-30 slides total. 5-7 lines per slide. • Ideal font size: 24-28 • No cut and paste/screen shots of up-to-date tables. • Focused teaching points • Should get something out of every teaching slide • Should have a reference slide in the end

37. Morning Report

38. Morning Report- Example • Vancomycin should be changed to a penicillinase-resistant semisynthetic penicillin antibiotic (oxacillin or nafcillin). The patient's blood cultures indicate infection with a methicillin-sensitive Staphylococcus aureus (MSSA) isolate. The β-lactam antibiotics are more rapidly bactericidal than vancomycin and are therefore the preferred class of antibiotics for treating serious S. aureus infections. Because this patient is not allergic to penicillin, oxacillin or nafcillin are the best choices. Vancomycin is associated with worse outcomes when used to treat MSSA infections. Empiric therapy with vancomycin is appropriate for patients in whom infection with methicillin-resistant S. aureus is a consideration. However, therapy should be modified as appropriate as soon as culture and antimicrobial susceptibility results are available. • Combination antimicrobial therapy (such as vancomycin and rifampin) for the treatment of S. aureus bacteremia does not improve clinical outcomes. Therefore, it would not be the most appropriate management choice for this patient. • Vancomycin therapy is monitored by serum trough levels, not serum peak levels. When vancomycin is used in the appropriate setting, the usual goal for the serum trough level is 15 to 20 µg/mL. • Definite or probable thrombosis occurs in approximately 70% of patients who have central venous catheter–associated S. aureus bacteremia. Imaging of the previous intravenous site is not necessary unless suspicion exists for suppurative thrombophlebitis (pain, swelling, palpable cord) or a fluid collection that would require drainage.

39. Resident Recognition • Discharge Efficiency Award • Nurses’ select “Intern of the month” • Nurses’ select “Resident of the month”- not awarded every month. • Resident Luncheon last day of block

40. Resident supervision policy after hours Senior residents on call, must call their supervising physician/CMR (Hospitalist on call for that 24 hour period) for update, review, and advice concerning any patient in the following situations: • Admission to the Step Down Unit, or transfer (or possible need to transfer) of patient to SDU/ICU • Code Blue or Grey called on a Medicine patient

41. Resident supervision policy after hours • Serious change in medical status on the Medical floor or SDU (including, but not limited to: blood pressure; respiratory, cardiac or neurological status) • Concern that the ED is inappropriately admitting a patient to Medicine floor when he should go to ICU or to the SDU.

42. The 3 essential EMR tasks • Covering physician order + flag must be added on every admission and transfer. • Medication reconciliation: Use the H&P template when admitting a pt. and make sure to indicate whether or not there is a discrepancy between home meds and meds that are listed in our EMR. Must use Medication Reconciliation tool • Change Anticipated discharge date and flag it

43. The 3 essential EMR tasks 3. Change encounter location: Make sure to select a new encounter location BEFORE adding your note (DET INPT GEN MED). Important measures Place anticipated discharge date Goal Discharge of 30% by 12pm

44. Proper Discharge Process • Rounds must end by 11:00 AM. • Place your discharge order BEFORE 11:00 AM and make sure you inform you nursing staff • Use the discharge menu. • Don’t place a text order “D/C IV and D/C patient” • Afternoon rounds to discuss possible discharges the next day.

46. Hospitalist menu

47. Team names should be standard: Red Team block 1 2018

48. Occupational Health • In case of a blood or body fluid exposure, or any injury while caring for a patient at the JDDVA Medical Center please report immediately. • Employee Health (located C1783) : Monday-Friday  8:00 am-4:30 pm • Emergency Department : after hours, weekends, and holiday.  • In addition to the care you will receive at the VA, please report the incident as soon as possible to Employee health at DMC/ your home institution

49. Access Issues • Intellispace and Essentris- Please check VA email • If unable to place Medication orders- Call NSD service desk – 1-855-673-4357 Option 2 and Option 0 • WSU email and DMC-VA email

50. Other Important Points • CM and SW huddle at 8AM every morning on weekdays • Didactic Attendance: On call senior and long call intern • Sub-Is • VA badges • Hospitalist menu and MRSA swabs • Flag- Anticipated discharge, Covering physician