Objectives. 0 Address everyone s disorientation. 0 Describe service policies. 0 Call Rooms 0 Conference Policy 0 Miscellaneous

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2 Objectives 0 Address everyone s disorientation. 0 Describe service policies 0 Wards 0 Cross Cover Policy 0 MICU 0 CCU / Cards Wards 0 Consults 0 Call Rooms 0 Conference Policy 0 Miscellaneous

3 Wards

4 Wards: On call Teams A,B,C 0 One resident + two interns 0 Resident call is 6:30am 10:30am (28 hours) 0 Cross Covers for other teaching services on weekends and holidays (A,B,C and Geri), NOT TEAM D they check out to the hospitalist service. 0 Day/AM Intern 6:30am to 7:00 PM. Should have last patient by 5:00pm 0 Night/PM Intern 6:30 pm to 10:30 am (16 hours max) Cross covers for their team overnight. 0 Admission cap 10, team cap Non call days, receive checkout from Float resident at 6:30 AM.

5 Wards: Team D 0 One resident + two interns (Hospitalist Attending) 0 Call schedule 0 Same as other teams 0 Non Call days 0 Receive checkout from overnight hospitalist 0 Give checkout to attending at 5:00 pm 0 Team cap is 20, admission cap is 10 0 Your backup is the attending that you are on call with

6 Hermann Wards: Rounding 0 Use the rounding rooms for patient privacy 0 Team A C Team B C Team C C Team D C Multidisciplinary Rounds (MDRs): 0 One member of team must be present 0 Everyday (10:30 11:00 AM) 0 Okay to break away from your rounds... Attendings aware of this 0 Update the interdisciplinary team about 0 CURRENT diagnosis 0 BARRIERS to discharge 0 System Based practice is an ACGME core objective.

7 Hermann Wards Call days 0 UT Sound Hospitalist Group (MHUTS SpectraLink x42742) triages all 0 ER admissions 0 MICU transfers 0 CIMU/CCU downgrades 0 Geriatric Admissions 0 Gen Med Clinic Admissions 0 Bounce backs to MHUTS are w/in 7 calendar days w/in the same month 0 PLEASE DO NOT ARGUE ADMISSIONS: 0 Residents can discuss level of care (floor vs MIMU vs MICU) at patient bedside with Hospitalist On Call after evaluating the patient. 0 If you still have problems, call us (pgr 22001) or Dr. Harbison ( ). Your attending or chief resident on call is your backup for decisions such as this. 0 Please use the flow sheets, on the chief s corner. Keep track of the time of your admissions, so we can help collect the data.

8 Herman Wards Caps 0 Time cap for on call team is 2am 0 Resident cap per call is 10 admissions 0 Intern Cap per call is 5 0 Total team cap is 20 0 Night float admits one per hour between 2 5 am for a total of 3 admissions

9 Hermann Wards:Order Writing 0 If indicated, please make sure that daily labs are ordered the day before 0 Confer with your Upper Level/ Attending 0 When cross covering follow consultant s recommendations

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13 Herman Wards: Acting Interns 0 As an upper level with an AI you are expected to: 0 See every patient assigned to the AI on the day of admission and write a full H&P. 0 Write a full progress note daily on each of the AI s patients. This includes vitals, physical exam, labs, assessment and plan. Do not wait for the AI s note to be in the chart. You are expected to write your note independently. 0 Review diagnostic and treatment plans with the AI every day prior to rounds. 0 Review the AI progress notes, giving feedback to the AI. Co sign all progress notes. 0 Assume complete responsibility of the AI s patients on their day off. 0 AI may not checkout patients or update the checkout list (resident or interns only) 0 You are responsible for all dictations including Admission H&P s and Discharge Summaries. Do not ask the AI to do any dictations for you. 0 Teach the AI how to do basic procedures. They can only do a procedure if they have seen one first and are under the direct supervision of an upper level. 0 Give them patients!!! 0 Do not assign this role to interns, AI works directly with the upper level resident.

14 Geriatrics 0 New structure Interns have a 2 week block with ACE, consults, and Palliative 0 For Geriatrics admission, please use Geriatric template when dictating/typing your H+P. 0 This is for billing purposes, but may be a good idea to use for all your elderly patients (even if they are not on the Geri service) it will allow you to cover everything specific to elderly patients. 0 Weekends duties 0 Work 1 of 2 weekends 0 Patient called before noon must be seen by the resident 0 No new admits after noon 0 No new consults after noon 0 Leave when the work is done OR 4 pm at the latest

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16 Medication Reconciliation 0 0 That includes you MICU/CCU

17 Medication Reconciliation

18 Medication Reconciliation

19 Hermann Wards: Checkout...Checkout...Checkout 0 Use IPASS Format Focused and problem based 0 Keep lists current CODE STATUS, room numbers, med list 0 Mistakes can be life threatening to your patients 0 It should be done by Interns & Residents Only 0 For the post call team: The resident should run the list with the post call cover intern. The Resident on call will be the intern s backup if needed. 0 For the non call teams, ACE Resident, Resident/Intern: Weekdays may checkout to the float resident at 5:30 pm. 0 The ACE Resident takes admissions until 4:30 and covers their inpatients until checkout (M F). 0 Weekends may checkout to the on call resident at 2pm

20 Weekday Cross Coverage Float 0 Float resident will continue all previous float duties, including arriving at 5:30 pm to get checkout from medicine and Geri teams, cross covering, and checking out to teams in the morning at 6:30 am. 0 At 2 am or when the on call team caps, the on call resident will pass the SpectraLink to the float resident to take up to 3 admissions until 5 am (up to 3 admissions from 2 5am, or 2 admissions from 3 5am, or only 1 admission from 4 5am) 0 The float resident will manage the new admissions until they are handed off to the POST POST CALL RESIDENT in the morning. Patients will be staffed by the post post call team attending. 0 Do not need to present at Morning Report post float

21 Weekday Cross Coverage Float 0 Geriatric admissions to night float resident 0 All Geri admissions to float residents between 2 5 am will have an H&P and admit orders by the float resident. 0 In the morning, the patient will be checked out to the Geri intern/resident who will staff the patient with the Geri attending.

22 Weekend Cross Coverage 0 A, B, C and Geri teams checkout to the on call resident 0 Team D checks out to hospitalist 0 Checkout occurs at/after 2PM

23 Cross Coverage Misc. 0 Please keep track and let us know if you re getting overwhelmed!! 0 Called for palliative patients (virtual hospice)? Tell nurse to call hospice company listed on chart, or palliative attending on call if hospice is not returning call. You are not responsible for pronouncing death for virtual hospice patients.

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25 Jeopardy Backup 0 New Float/Jeopardy block: 0 Float is now a set of shifts, 2 5 consecutive nights 0 Jeopardy will be assigned educational objectives 0 Independent learning topics for interns Yale, MKSAP 0 Daytime clinical assignments for upper levels 0 If you need to call in (verbal communication with CMR): 0 Must provide documentation for why you re not at work e.g. doctor s note 0 Must call chief pager to let us know you will not be in! 0 Also, notify your clinical team and attending

26 Jeopardy Backup 0 Keep your pager with you the day before your jeopardy call starts! 0 Since interns can only do 16 hrs...an upper level may be pulled for an intern s shift (including ER)

27 MICU

28 MICU 0 In House Fellow for Backup 24/7 x Residents On call q4 0 Call days 7am 11AM 0 Non call days 6am 4pm 0 Interns On call q4 0 Call days 7pm 11am 0 Non call days 7am 7pm (no exceptions) 0 4 days off per 4 week block (NOT every post post day, you are here to learn, and rotations are shorter, we are keeping track)

29 MICU 0 Conferences: 0 You have received an about critical care conferences. 0 Documentation 0 All daily progress notes are written by the overnight team 0 Clearly document code status in transfer note and ensure appropriate documentation 0 Ensure updated information on the Transfer Orders 0 Procedures: 0 Residents oversee all procedures 0 Log procedures on a daily basis in GMEIS 0 Finger sticks always take your time, protect yourself, and REPORT incidents to or OUCH (24/7)

30 CCU

31 CCU 0 Conferences: 0 PLEASE ATTEND CCU ORIENTATION 0 Noon Conference mandatory for day team 0 Notify Admin CMR via if you attend the Cardiology GR 0 Resident Duties: 0 RESIDENTS ATTEND ALL ADULT CODE BLUE (ALL OF THEM) 0 Carry the Code pager and Chest Pain/STEMI pager 0 Work with your Fellow 0 Days Off 4 days per 4 week block

32 0 CVICU HVI Other Services 0 Patients transferred to CVICU will continue to be seen by CCU team as consults. 0 Patient seen in clinic by UT interventional Cards admitted to CVICU will also be followed by CCU team. 0 EP Service 0 The residents will not write notes on patients admitted to the Primary EP services. 0 House staff will see these patients if admitted to the CCU team teaching service with an EP consult.

33 HVI Other services 0 Advanced Heart Failure (5 HVI): 0 Housestaff will not write notes on admits to Primary AHF service 0 Housestaff will see patients admitted to the CCU teaching service with a AHF consult 0 Private admissions by UT Interventional Cardiologists (Smalling, Sdringola, Anderson, Iliescu): 0 These patients will be seen by the CCU resident/interns 0 Individual attendings MUST make rounds with the CCU residents EVERY day in person to provide teaching. 0 CCU fellow cross covers and admits for: 0 EP, Heart failure, White service (Private Non UT Cardiologists), CCU, Cards Consults 0 Be considerate of their time

34 Cards Wards 0 Duties 2 Cards Ward Interns 0 No overnight call 0 Rounds after CCU patients are seen/staffed 0 Round on and presents non critical care patients 0 May admit to CIMU/COU until 3pm. 0 Division of Labor CCU v. Cards Wards Team 0 On call resident assigns patients to team on day prior to rounds. 0 Team/patient Cap for Cards Wards Team 14 patients (7 per intern) 0 Rounds 0 Post call Resident/Interns patients should be presented first 0 All other patients are presented afterward. 0 On call resident and pre call intern do not pre round that day. 0 Days Off 0 4 days off per 4 week block (1 in 7)

35 Call Rooms 0 There is a card system for entry into the call rooms one card opens all the doors. These cards are available to the residents in the Physician Staff Services Office, which is located on the 1st floor of the Cullen Pavilion. Please refer any questions or problems with these cards to this office. Please, DO NOT use any call room that is not assigned to you. 0 Cullen 240: MICU Fellows Room 1 0 Cullen 242: MICU Resident Room 2 0 Cullen 244: MICU Intern Room 3 0 Cullen 246: Medicine Ward Team Resident 0 Robertson 539: Ward Resident/Intern 0 Robertson 631: Ward Resident/Intern 0 Robertson 675: Ward Resident/Intern extra 0 Robertson 676: Ward Resident/Intern extra 0 HVI 2nd floor CCU Resident 0 HVI 2nd floor CCU Intern

36 Consults Troponins are positive. Please see patient

37 Consultation Etiquette 0 Consults should be requested/called by the Upper Level Resident for the first few months 0 Please identify yourself by NAME/SERVICE when calling a consultant 0 Have a clearly defined Consult Question 0 Be prepared to give pertinent clinical history 0 Please do not be rude Good communication is part of professionalism 0 Leave a call back/pager number for follow up once your patient has been seen by the Consulting Service

38 Consult Services 0 Caps: 0 no more than 8 old and 4 new consults per day 0 total cap: no more than 12 patients at a time 0 last consult of the day at 5:00 pm 0 consults rec vd after 5:00 pm to be seen by Fellow/Attending 0 Must have a 10 hour duty free period between shifts 0 Weekends: last consult by noon, and out of hospital by 2pm. Must be rounding with the attending. If not please let us know. 0 DO NOT carry a fellow s pager at any time! 0 Last time we checked, you are not a fellow. 0 Clinic Duties: 0 Endo, Rheum, Onc, Heme, and Pulm have one ½ day of clinic per week 0 ID will have one ½ day of clinic per month 0 Clinic assignments will be given by the Attending

39 Consult Services 0 FOLLOW UP PLEASE! 0 Please call the primary team via the team pager once you have staffed patient 0 Discuss the recommendations and orders you want. Once you ve agreed on a plan either decide whether the primary team or the consulting team will place orders. 0 Communication skills are an ACGME core objective!

40 Consult Weekends Off? 0 Many consult team structures have changed 0 General days off rules apply 1 day per week, average 0 Work the details out with your team. 0 Please let Chiefs know if there are problems

41 Conferences

42 Conference Calendar

43 Conferences Monday Tuesday Wednesday Thursday Friday 7:30 8:30 Board Review Orlander MR (post post call resident) 12 1:00 Core Curriculum Intern conference Faculty led case conference Arias MR (post post call resident) Grand rounds Consultant case conference PLEASE BE ON TIME, 12 noon. 0 Attendings should release you at 11:45 am

44 0 Core Curriculum Lecture Conferences 0 lecture given by faculty covering high yield topics 0 Faculty Case Conference 0 Interactive session led by faculty focusing on workup and management 0 Intern Conference 0 Interns present a case from wards service 0 Interns and student attendance only 0 Consultant Conference: 0 Interns/resident present a case from consult service with subspecialty faculty attendance 0 Board Review: 0 15 MKSAP questions presented by 3 rd year resident 0 Ethics: 0 Interactive case discussion with Dr. Boisaubin. 0 Med/rad case conference: 0 chief/residents prepares cases to be discussed with radiologist

45 Case Based Conferences 0 Chiefs need to know the case and teaching topic 3 5 days in advance. 0 Please provide PPT 1 2 days in advance 0 We are happy to help with preparation 0 Choosing a case 0 Teaching point 0 Review PPT slides

46 IC Intern Conference 0 Interns present 2 cases 0 Present H&P and physical; Bring with you all labs minute presentation at the end of the case answering a FOCUSED clinical question 0 Paradigm: diagnosis, prognosis, management, epidemiology 0 i.e. Why is hydroxyurea used as chronic therapy for sickle cell and what is the evidence to support this practice? 0 Focus on: 0 presentation skills 0 physical exam findings 0 interpretation of labs 0 developing a differential 0 basic management issues 0 Moderators: 0 CMRs, Ward Attendings, Core Faculty 0 No Zebra cases please bread and butter cases are best for this conference

47 Post post Call Morning Report with Dr. Orlander 0 Weds 7:30 to 8:30 0 MSB B PLEASE, BE ON TIME! 0 Post post call Resident presents 0 Problem/Diagnosis Card System: please contact the chiefs if you are not familiar with the card system 0 See The Morning Report Card Article by Dr. Fred on Blackboard

48 Post Call Morning Report with Dr. 0 Thursday 7:30 to 8:30 Arias 0 Kirkendall Library (MSB 1.150) 0 Post post call Resident presents 0 Card should include ONLY: 0 Chief complaint 0 Initial vital signs in the ED 0 Each patient should have a chest x ray 0 Another resident review the CXR and give a differential diagnosis

49 Willerson Morning Report Saturdays per month at 6:30 A.M. (BE ON TIME!) in Kirkendall Library 0 Who should be there? 0 EVERYONE in the hospital that day. 0 Post call resident presents a case 0 Bring EKGs and other important info on the patient

50 Consequences of Poor Attendance 0 This is your educational opportunity CME for residents 0 Expectation is to attend ALL conferences 0 Minimum acceptable attendance is 75% of all conferences 0 1 st Delinquency 0 Call from or meeting with Dr. Orlander 0 2 nd Delinquency 0 Friday night float 0 3 rd Delinquency 0 Presented at Competency Meeting

51 Outside Rotators 0 Residents from other services (Family Practice, Emergency, Psychiatry) should be coming to medicine conferences while on our services. 0 They should not be compromising clinical duties to go to other specialty conferences.

52 Days Off 0 You must have 4 days off per 4 week block! 0 Schedule these at the beginning of the block be aware of conference presentations, etc. 0 If your co intern is off and has a lot of patients, your resident should help you out with those patients. There is no rule that residents can t write notes. 0 Residents, don t take your day off on the last 2 days of a block! You are there for continuity!

53 Pain Service 0 Attendings: 0 Dr. Yefim Bogomolny, Director 0 Dr. Jaideep Mehta, Acute Pain Medicine Chief 0 Dr. Mahammad Hussain, Regional Chief 0 All consults may be called 24/7 to spectralink ext Consults called after 15:00 M F will be seen the following day. 0 Consults called after 12:00 noon Saturday and Sunday/Holidays will be seen the following day. 0 To obtain a consult: two steps 1. Call In the EMR order: then type consult: then select: Consult Pain Center Inpatient 0 Pt's on APM consult service that are being discharged please notify APM service ext prior to 12:00 noon Sat/Sun/Holiday for prescriptions of Schedule 2 (triplicates); prior to 15:00 M F 0 No sickle cell crisis patients, No chronic pain

54 Hygiene... 0 Please WASH YOUR COAT! 0 Free Laundry Services available at MSB If too soiled they will not wash, so wash first then place there to be washed and pressed. 0 Remember to Wash your Hands!

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56 Feeling Burned Out?

57 EAP Employee Assistance Program UT Counseling & Work life Services 0 Confidential Services Free of Charge 0 Contact: Services Include: 0 Solutions for childcare 0 Eldercare 0 Stress management 0 Wellness and more 0 Professional Development skills for productive employees 0 Legal and Financial Advice

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59 Final Word 0 Not my patient 0 Carry your pagers if on Jeopardy 0 Return pages promptly 0 Replace pager batteries promptly

60 To Contact Us: 0 Chiefs office 0 MSB CMR Pager after hours ext Have A Great Block