Transcript Slide 1

PGY 3/4 to Be Retreat
June 3, 2014
Scott Denstaedt
Marty Tam
Angel Qin
Khanjan Shah
Hoping for the best, prepared for the worst, and unsurprised by
anything in between.
-Maya Angelou
Overview
5:30-6
Dinner
6-7:30
Quality Center (Heidi et al.)
Milestones discussion (Dr. Arfons)
Ambulatory Changes
Medicine Clerkship (Dr. Leizman)
Changes for next year
Logistics reminders
Issues unique to 3rd year
Fellowship
Boards/ITE
Medical License
Senior talks
Patient Safety/Quality Externship
7:30 - 8:00
DACR/NACR Orientation
Gen Med Consults
Questions
8-8:30
Changes for Next Year
•Ambulatory
•Electives
•Jeopardy
Ambulatory Model 2.0
• 2013-2014: four ambulatory blocks and 2-4 clinics in elective
• 2014-2015: five ambulatory blocks and no clinic in elective (there is
a panel management day)
• “6+2” model
– 6 weeks of ICU/wards/elective
– 2 weeks of dedicated ambulatory
– 7 half days of clinic each block and 1 administrative half day
• Positive Effect
– Continuity: you and three other seniors make up a team (with two
interns) and see the same patients (great for you and the patients!)
– Electives Preserved: you can make more of your elective now!
– Curriculum: streamlined and less repetitive
• New Challenges
– Ambulatory blocks are fixed (cannot trade)
– Change is uncomfortable, but we do it to try and make things better
Ambulatory Model 2.0
Ambulatory Model 2.0
Team
Flight 1 (1A,4B,8A,10A,12A)
Flight 2 (1B,5A,8B,10B,12B)
Flight 3 (2A,5B,9A,11A,13A)
Flight 4 (2B,6A,9B,11B,13B)
VA 1 Red
Perihan
John S
Anodika
Prashanth
VA 2 Silver
Andres
Rachel
Abdullah Alm
Perica
VA 3 Purple
Alina
Katie
Philicia
Khadejah
VA 4 Yellow
Amhed
Wissam
Nupur
Lesley
DMC 1 M
Bryan
Jacob
Rania
Neetika
DMC 2 Tu
Stephanie K
Sadeer
John G
Nate S
DMC 3 W
Maya
Carine
Patrick
Gabe
DMC 4 Th
Ahmad
Dafina
Atallah
Vincent
DMC 5 F
Stephanie M
Brandon
Yosra
Chris
DMC 6 M
Roopa
Cassie
Won
Dhruti
DMC 7 Tu
Jack
Mo
Abdullah Alj
Hussain
DMC 8 W
Aniket
Anthony
Rishi
Shiv
DMC 9 Th
Bouchra
Priyam
Ning
Ziyad
Ambulatory Model 2.0
# Residents
1
2
3
4
5
6
7
8
BOX
BOX
Admin
# Residents
1
2
3
4
5
6
7
8
BOX
BOX
Admin
Mon
Team 1
Tues
Wed
Team 1
Thurs
# Residents
1
2
3
4
5
6
7
Fri
Team 1
Mon
Team 1
Team 3
Team 4
Team 6
Team 7
Team 9
*Intern 1
Tues
Team 2
Team 4
Team 5
Team 7
Team 8
Thurs
Team 2
Team 4
Team 6
Team 7
Team 9
Fri
Team 1
Team 3
Team 5
Team 7
Team 8
*Intern 2
Wed
Team 1
Team 3
Team 5
Team 6
Team 8
Team 9
*Intern 3
*Intern 4
*Intern 5
*Intern 6
*Intern 7
*Intern 8
*Intern 9
Team 2
Intern
Team 8
Mon
Team 1
Team 2
Team 4
Team 6
Team 8
Team 9
*Intern 1
Team 3
Intern
Team 9
Tues
Team 2
Team 3
Team 5
Team 7
Team 9
Team 4
Intern
*Intern 2
*Intern 3
Team 5
Intern
Team 1
Thurs
Team 1
Team 2
Team 4
Team 5
Team 7
Team 9
*Intern 4
*Intern 6
*Intern 7
*Intern 8
*Intern 9
Team 7
Intern
Team 3
Team 8
Intern
Team 4
Team 9
Intern
Team 5
Intern
Team 6
WEEK 1
WEEK 1
8
Mon
Team 1
Tues
Wed
Team 1
Team 1
Thurs
Team 1
Fri
WEEK 2
BOX
BOX
Admin
# Residents
1
2
3
4
5
6
7
8
Team 1
BOX
BOX
Admin
Wed
Team 1
Team 3
Team 4
Team 6
Team 8
Team 6
Intern
Team 2
Fri
Team 2
Team 3
Team 5
Team 6
Team 8
*Intern 5
Team 1
Intern
Team 7
WEEK 2
Electives
• PGY II: 8 weeks
• PGY III: 12 weeks
• Quality Chief will now be assisting Barb in keeping a running
list of what you are doing for elective
• For ACGME requirements each resident must have a specified
activity and supervisor for each elective
Example Elective Tracking
Electives
• Research Electives:
• Must have a mentor/PI for project
• If doing two weeks (or more) of research elective, you are
required to present a poster at Medicine Research Day
• Reading Electives:
• Requires approval, KBA is designated supervisor
• Required attendance at all UH noon conferences, UH
M+Ms, UH Grand Rounds, VA Grand Rounds
Elective Reminder
• Elective Professionalism
• Elective is not vacation
• You are back-up jep and expected to be in Cleveland
• If you are going out of town, please let the Ambulatory
chief know
• “Don’t you remember when you were a resident?”
• Having your pager on 24/7 on elective is unreasonable
• Everyone on elective is back-up jep any given day, but we
can assign people on specific days to be the first called so
you know when to have your pager with you
Jeopardy
• Minor changes to the jeopardy system will be made
• Use of jeopardy will be tracked for training/support purposes
– Make sure everyone is meeting minimum requirements
– Make sure we provide help and resources to those that need it
• Those getting jepped from electives will be tracked as well
– Ties into the “first call” back-up jep list, you move down the list after
getting jepped
– Makes the system more fair
• KEY Points
– Jeopardy still remains for emergencies and significant illness
– Unless there is excessive use of jeopardy (decided on a case by case
basis), you are not expected to pay back
– There is still a jep rotation, coverage here is not tracked and you do
not get paid back
Logistics Reminders
Transition Dates
•PGY1 end date: 6/23
•Block Zero: 6/24 – 6/30
•Block One: 7/1 – year of SMAK!
Team Caps
• UH Wards:
• 10 patients per intern
• 8 patients per intern on Ratnoff/Weisman
• Intern+AI: 12 patients if two seniors; 10 patients if one senior
• VA Wards:
• 8 patients per intern
• Intern+AI: 10 patients
• AI+AI pair: 10 patients
• Short Admissions:
• No shorts on weekends
• No shorts if intern has 8 patients
• Shorts for Intern+AI pair to cap of 10 patients
Duty Hours
• Long Call:
– 3 patients (4 if paired with AI) until 7 PM
– 2 patients if after 5 PM
– 1 patient is after 6 PM
• Medium Call:
– 2 patients until 4 PM
– Can sign out at 7 PM
• Short Call:
– 2 patients until 12 PM at UH (NF or ICU transfers)
– 2 patients until 1 PM at VA (NF, ICU transfers, new admissions)
– No short patients on clinic days
ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!
• Senior Resident:
– Residents on call MUST stay until 9 PM
– No matter what the call, ward seniors staff any patient the seen before 4
PM
– Weekend coverage seniors must stay and staff at least until 1 PM or longer
depending on how busy the other seniors are
Staffing
• UH wards will have double coverage Blocks 1-3
• There will be minimal orphan coverage in the first few blocks
• See and examine EVERY patient
• No staffing note required for ICU transfers or interservice
transfers
• Focused notes by the senior resident with detailed plan
• See PGY1 note for full H&P. Briefly, pt is a …
• Helpful to new interns:
•
•
•
•
Antibiotic doses
Description of imaging - With contrast? Without?
Medications to continue, medications to discontinue
CODE STATUS and Allergies
Staffing
• On call resident should notify the nightfloat resident of
tenuous patients
• Be proactive about staffing patients
Coverage and Schedule Switches
• All coverage arrangements and schedule switches
must be approved by the Ambulatory chief so it can
be noted in amion
• Switches must be arranged before 1 week of
rotation starting
REMINDER: Residency Reading List
• Residency Reading list:
• Landmark and review articles in all sub-specialties
• Last major update in 2011
• Looking a 20-40 year old resident who enjoys long nights
of Boolean searching to help update the site with new
landmark trials…
Professionalism
Professionalism: Attire
•Men
• Shirts and ties
•Women
• Professional
•Keep white coats clean
•No denim
•Do not show up to Morning
Report looking sloppy
Professionalism: Absences
• If you have to call in sick > 1 day, you will need a doctor’s
note from the Bolwell Family Practice clinic
• You will be able to get a same-day appointment
• If you are sick for > 2 days and do not have a doctor’s
note, you will be assigned extra weekend coverage
and/or weekend jeopardy
• Call-offs: You must PAGE 31529 the Ambulatory Chief
• DO NOT EMAIL
• DO NOT TEXT PAGE
• DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW
Professionalism: Electives
• Attend all Grand Rounds and M&M’s
• You are back up jeopardy!! = pager on
• If you are going out of town for the weekend, as a
courtesy please notify the ambulatory chief prior to
leaving
• Elective is not vacation
• Please email Barb 2 weeks prior to starting your
electives; Quality chief will be keeping track of electives
• Research for more than 2 weeks = present at Research
Day
Professionalism: Reading Electives
• Residents on reading elective are expected to attend
morning reports and journal clubs at the VA
• Must attend Grand Rounds at UH
• Your pager is expected to be turned on and on you during
the entire two weeks of elective
• All reading electives must be approved by KBA
• For PGY2s it can only be used to study/take step 3
• Please note that when you are on elective, you are back up
jeopardy!!!
Professionalism: Conference
Attendance
• Please be on time; our speakers usually have prepared a well
thought out talk/powerpoint, so please be respectful of the
time they spent
• Noon conference:
• UH: Mon-Wed-Thurs
• VA: Mon-Thurs-Fri
• Grand Rounds on Tuesday: UH & VA
• M&M Fridays @UH, Wednesdays @VA
• Conference attendance is part of your ACGME graduation
requirements
Conference attendance during
ambulatory
• Ambulatory conference attendance is mandatory
• Late Policy will be strictly enforced:
• Sign-in sheet will be available until 8:05AM
• At your 2nd instance of being late = extra weekend coverage
• Any MISSED conferences without prior approval by the ambulatory
chief will result in weekend coverage
Professionalism: Discharge
Summaries
•If you put in the discharge order, you do the
discharge summary
•Do them the day of discharge
•Do them for your intern
•Do them for your friends
•Do them for your patients
•Remember it is now easier than ever to do it
in UH EMR
Issues Unique to 3rd year
•
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Fellowship
Boards/ITE
Medical License
PGYIII QI project
Senior Grand Rounds
VACR
NACR/DACR
Fellowship Timeline
https://www.aamc.org/students/medstudents/eras/fellowship_a
pplicants/
• Please review this website! There are many new changes
this year
• https://www.erasfellowshipdocuments.org/
• Request ERAS token; June 11, 2014
• Ask for letters of recommendation…now!
• Start considering your future destinations for fellowship
• Work on your personal statement
• July 15, 2014: first day to submit application AND programs
begin downloading applications
• Special considerations (double check now):
• Sports Medicine
• Hospice and Palliative Care
Fellowship Timeline
• Deadline for completed application varies but is as early as
July 31st; check with program and be prepared
• Interviews: August - November 2014 First
• MATCH: first Wednesday in December 2014
*KBA will perform mock interviews upon request
BOARDS!!!
•Register starting in December
•Plan ahead…costs about $1,365 (more if
you sign up late)
•Noon Conferences to include more board
prep sessions
•Can use ITE exam results to help guide
studying
In-service Training exam
•
In-service Exam Dates are in October – exam is
completely computerized this year
•
•
•
Includes all PGY2/3, PGY1’s?
ITE during 2nd year is an important predictor of passing
boards
ITE remediation by percentile rank
•
•
•
>50% - no remediation, continue to study
31-49% - turn in in 60 multiple choice questions every 4
weeks to assigned APD for review; continue studying and
attend board review sessions
16-30% - high risk for ABIM failure multiple choice questions
as above with directed notes
•
If you are not already doing this PLEASE talk with us or your APD,
ABIM failure is no joke
• 1-16% - more intense remediation, urgent intervention
required (we are here to help!)
Medical License
• Remember to keep your BLS/ACLS updated
• Must have Step 3 results prior to license application
• Start FCVS by December ($430)
• State licensing ($335) can often take 5-6 months.
• DEA license is much quicker but more expensive ($551)
• Plan ahead!!!
Senior Grand Rounds
• Noon conference lecture for each senior resident, late
August (after intern boot camp has finished)
• Dr. Mourad is the APD in charge
• Email learning objectives to assigned faculty mentor,
ambulatory chief and Dr. Mourad two weeks prior to
lecture date
• Topic of your choice, should be evidence-based
• MORE INFORMATION TO COME!
Patient Safety and Quality
Improvement
•Introduction to quality improvement during
DACR rotation
• UH Care feedback
• Quality Assurance meetings
• Write-up cases for Medicine QA
• Attend ED/IM QA
• Attend Quality Patient Safety Committee meetings
• Mortality review, PASS reports, and Risk
Management meetings
Guidelines for Resident Quality
Improvement Project
• QI project for PGYIII required by ACGME
• Form groups of 2-4 (ideally 3) people
• Work with one of the chief medical residents and quality center to
develop project ideas and aid with data collection
• Start by identifying a quality issue, collect background data, design an
intervention, and collect post intervention data (Heidi and Meghan in the
quality center are good resources)
• Present quality poster at Research Day
• Select project/team in July, first meeting regarding the project occurs in
August
Timeline for QI Project
• General Timeline:
• July: select project/team
• August : meeting with assigned chieg resident and QI RN
(complete FOCUS PDCA) define objectives, collect
background information, plan an intervention
• September-November: collect baseline data (initial
survey)
• December: meet with chief resident and QI RN to discuss
baseline data and intervention implementation
• January through February : implement plan
• March through April: collect data post-implementation,
write abstract for research day, make research day poster
• May: present at research day
VACR
• Many PGYIII’s will have this rotation, not all
• Perform medicine consults
• Be available to help out ward teams as
needed
• Prepare EBM lecture on a topic of choice for
morning report
• Attend all morning reports
• One Saturday 24 hour VA MICU coverage
DACR / NACR:
Your education in systems-based practice
To Admit vs. Observe
•Arose out of for profit hospital chain fraud
•Requires attending to sign and admission
order that includes language that the
attending expects the patients medical
problems to require admission for two days
•Some logistical issues on getting attendings to
sign/place order
The NIGHTFLOAT TEAM
NACR
Nightfloat Resident
Rotating MSIII
Nightfloat Intern
Rotating MSIII
Nightfloat Resident
Nightfloat Intern
Nightfloat Intern
The NACR as Ombudsman*
•
•
•
•
•
•
•
•
Distribute admissions to teams on call in AM
Enforce geographic localization
Run codes
See medicine consults at night (ophtho and ortho co-management if
requested)
Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House
Cover flex patients at night and ?additional PRN SHD patients
Find out intern census from nightfloat interns for each team
Admit BMT and Transplant Medicine patients along with NF (must inform
BMT fellow and Transplant attending)
• Transplants within the past year should be admitted to transplant
surgery
*****Transplant service is not the Transplant
attending! MUST ASK OPERATOR FOR
TRANSPLANT ATTENDING!!!!******
*ombudsman – one who investigates complaints and
mediates fair settlements, especially between aggrieved
parties such as consumers or students and an institution
or organization
“The Book” as it should be…
Medicine
Fam Med
Neuro
Surgery
Ortho
Transplant
ENT
“The Book” according to the ED…
Medicine
Surgery
Fam Med
Neuro
Ortho
Transplant
ENT
ED
Admitting
Patient enters ED,
decision to admit
ED enters
admitting bed
request
ED pages NACR
for signout
Admitting pages
NACR with bed
request
NACR
OVERVIEW
Medicine
Yes
NACR calls
admitting and
makes appropriate
bed assignment
NACR assigns
admission to NF or
her/himself
No
Ask ED attending
to reconsider
triage of patient,
work-up, or
admitting service
NACR distributes
patients in the AM
with help of KBA
and chief
NACR
Medicine floor
admission
appropriate?
Appropriate Service?
Is the
patient
stable for
the floor?
No
MICU/CICU/NSU/SICU
Yes
Yes
Appropriate
for FP?
PCP in
FP?
No
Appropriate
for
medicine?
Yes
Yes
Have ED call FM (30116). If
capped, then ED calls NACR
back with admission.
FM capped
!?&*#@!
No
Stroke, SBO,
femur fracture, etc
Talk to ER, if attending from
appropriate service does not
accept, “Medicine will happily
accept the patient”
Appropriate Service?
• Look up the patient in Portal and EMR before assigning
• Patient’s PCP – Family practice patient? Private patient
(list of attendings available)?
• Fang Service does not have a cap per Dr. Oliviera; if they
have been seen in HF and are coming in w/ HF
exacerbation, have ED call the overnight admissions
person
• Physician Portal (summary page, physicians)
• Previous discharge summaries
• EMR patient info clinical summary (visit history)
• Ask the patient!
NACR
• The two most important things you can do as NACR:
• 1) Admit the patient to the appropriate service (never forget to look up
PCP/patient info/dc summaries)
• 2) Plan ahead and assign patient to appropriate floor based on available
spots/admitting diagnosis/co-morbidities ie. GEO LOC
• Be proactive – keep an eye on the ED board
• If the patient is unstable or you do not feel comfortable, it is okay to ask
for ED to either re-triage patient (ie MICU/CICU) or to set a goal for
admission to the floor (eg BP should be better than 240/120 for me to
admit this HTN urgency to the floor)
Before your first NACR night, you will have a more detailed orientation
with one of the chiefs at UH.
NACR specifics
• 8pm – midnight:
• Meet Admissions Coordinator in KACR to get sign out
• print out new board (on medicine.case.edu; UH resources)
• start NACR sheet, Admissions Coordinator will be holding the book and pagers until midnight on
the weekdays, so this is your PRIME admitting time
• Usually try to see most of your patients at this time; orders and notes can be done after the MAN is gone
• Midnight and after:
• Stay on top of the ED board
• Master the art of the NACR
• 5-6am
• Get organized, make copies of NACR sheet, get intern census
• Talk to NFs regarding admits and appropriateness for teams; biggest decisions are Hosp/NPs vs.
flex
• 6:30-8am
• Review admits with KBA and SMAK
• 8am hospitalists call for assignment
• Fax assignment sheets from day prior and overnight to admitting and hospitalist offices
• Call non-teaching services to assign patients (Fang/Transplant/BMT)
Chief Resident may call you to check in on your first NACR night
Types of Patients
• Private (PCP will attend) – Coviello, Schnall, D.
Brown, DeJoseph, Junglas, King, Tomm, Locke
• ER must call private attendings; but if the patient is on the floor
and the ER did not call, it is the DACR/NACR responsibility
• Assign to med NPs (private spots) during the day! If no spots,
then flex versus team (Eckel, Carpenter, or Gen Med; not
Ratnoff/Weisman/Hellerstein)
• D. Brown must be flex (not NP)
• Staff – NPs (no procedures), hospitalists (few
social issues low complexity), general medicine
teams
*Non-cardiology patients needing telemetry can go to
Hellerstein and hospitalists (not med NP)
Types of patients
Specialty services:
• Eckel: ESRD, hypertensive urgency/emergency. ESRD
transfers need to be accepted by Nephrologist.
• Ratnoff/Weisman: SCC with active issues
• Hellerstein: active cardiology issues (regardless of PCP)
• Dworkin: GI patients (abdominal pain anyone?). Can take
liver to a cap of 3 (but flexible) if liver attending accepts
• Fang service: HF issue who is seen by a HF attending
(Oliviera, El-Amm, Ginwalla, Effron)
• Patients with no right answer (HIV patient with ESRD and
chest pain followed in HF clinic) - most active issue prevails
Types of Patients
 HIV patients go to Carpenter
-When Carpenter is not admitting, give them one a day early
or have resident flex
 Pulmonary cases go to general medicine
-Pulmonary HTN and flolan patients need to be on T5 and goes
to Hellerstein/Gen Med
 MICU transfers followed by renal consult team
-If chronic  Eckel
-If acute  gen med with renal consult
Non-Teaching Services
• You or DACR will get an e-mail stating the number of
open spots for the next day for MNP, Berger
• Hospitalist A (NPs), B, C, and D will call the Admissions
Coordinator at 8am (make sure they are written in the
book)
• Fang Service – Call with admissions in AM; apparently
they have no cap…
• Transplant/BMT – Overnight admissions should have
been discussed with transplant attending or BMT
fellow; it is good practice to call in AM to make sure
the team is aware of the patient
NPs
• Medical Nurse Practitioners
• Patients who do not need procedures
• Patients who are not being ruled out for ACS
• CAN take syncope patients on tele
• They will take most private patients (not D. Brown)
• Can take very complex patients!
• Berger Nurse Practitioners
• Stable patients who do not need procedures: sickle cell,
pain management, hospice, routine chemo admissions
Hospitalist B, C, & D
•
•
•
•
•
•
Have a cap of 12 patients each
Straightforward medicine patients without complicated social issues
Try to give them patients whom you anticipate will have short stays
Unfilled spots rollover to the next day
Cannot take ICU transfers that were in unit >48h
Take bouncebacks, but count against cap
Fang Service
•Two NPs with Hellerstein fellow
•During the week, admit cardiology patients to
team cap
•Will take NF admits and CICU transfers
•“No cap”, but chief/KBA may need to speak
with attending in AM
•All Effron/Heart Failure patients
Moonlighting
• Cross-Cover Long House Doc: 8pm to 8am
• Cover the nurse practitioner, BMT, hospitalist services, and
Hanna House overnight
• Admits one patient per night (or three if NP on with them)
• Holds transfer pager (remember, don’t accept ESRD –
Nephrology must!)
• Early and Late Short House Doc
• Each admits three patients
• Admitting Long House Doc: 6pm to 6am
• Admits six patients
• Bomb the long house doc!
• Give them private patients that go to the NPs
• Must cap them!
• No admissions after 0400
• Appropriate patient selection for the house doc is key; in most
cases these patient should not come back to the housestaff the
next day
ED Issues
• Neurology:
• Strokes go to neurology
• Seizures – try neuro first
• General Surgery: insist (politely) that they take SBOs, etc
• Make the resident call their attending (or do it for them)
• VA: far better to transfer BEFORE admission
• Ortho: perhaps worth arguing, but Medicine co-manages most ortho
patients (NACR/DACR consult)
Other Duties: Medicine Consults
•See the patient in a timely fashion
•Write a note
• Leave at least a preliminary note in the chart
•Call the Gen Med consult attending if needed
•Co-management with orthopedicsWe follow
along with ortho patients; they don’t need a
“question”
• You can put in orders dealing with medical issues
Co-management Memos
• ENT and Ophtho have specific comanagement pathways (in handout)
• It is a good idea to review these prior to your
first NACR
Transfers to Medicine
• All transfers to medicine must be approved by
medicine consult attending (not Dr. Whelan), chiefs, or
KBA
• Your medicine attending can ONLY accept to general
medicine (Naff/Wearn, MNP etc); if the other service wants
to transfer to a subspecialty team (ie Dworkin), they MUST
consult the attending on call for the day
• Consults for transfer to medicine:
• If clear subspecialty issue, refer to appropriate attending
• If clear gen med transfer, no consult necessary
• If unclear, offer to do a consult and staff with attending
• Don’t accept inter-service transfers overnight
Outside Hospital Transfers
•Transfer Center
• 41111
• Attendings are supposed to call 67121 or page 30512 when
they accept a patient
•8 am – 8 pm – Rotating attendings
• M-W: Chief Resident and KBA
• Th-F: Dr. Chandra et al
•8 pm – 8 am – Cross-Cover Long House Doc
DACR/NACR Hours
•DACR = 8am – 8pm
•NACR = 8pm – 8am
•MAN = 8am – 12am (8pm on weekends)
•DACRs come to morning report, Grand
Rounds, and M&Ms
•NACRs have a staff attending on call
Running Codes
Code Whites (UH)
** 1ST six months – an upper level must go to
all Code Whites with an intern**
•Sick or decompensating patients on the floor
or Hanna House
•Initial response from ICU nurse, intern, and
PGY2
•DACR/NACR for level 2 code white
•If you want to transfer to MICU, call MICU
fellow
•Always write a Clinical Event Note!
Code Blues
• Check your own pulse first
• “Too many chefs spoil the soup”
• One person leads the code
• Make sure interns are involved
• Maintain a calm quiet atmosphere
• Keep the ACLS cards in your pocket until you are
comfortable with the protocols
• Make sure your BLS and ACLS are up to date
• CODE BLUE NOTE and notify family; DEATH NOTE if patient
passes; notify attending
Running Codes
• Rule #1: You are in charge
• If uncomfortable, defer to more senior resident
• Delegate, delegate, delegate – assign crowd control, chest compressions,
airway, etc.
• Use the DACR/NACR if you need help
• Don’t be afraid to ask people to leave the room
• Call the ICU nurses by their name, closed-ended communication
• Assign someone to call the family
• Use the Code Note EMR, sign code sheet
Running Codes
Notifying attendings at night
• Most attendings want to be paged and notified (either
of transfer to ICU or death)
• Can clarify with your attending on first day of service
what their preferences are
• Don’t get burned by not calling your attending- you
may hear about it the next day
We are looking forward to a great year together!!!
-SMAK
Questions?