Transcript Slide 1

PGY-3 to Be Retreat
June 11, 2013
Sumit Bose
Crystal Lantz
Kamal Shemisa
Claire Sullivan
Navin Vij
Congrats!!! You are entering your last year of
Internal Medicine residency !
“Don’t count the days,
make the days count”
-Muhammad Ali
Overview
5:30-6
Dinner
6-7:30
Changes for next year
-CICU schedule
-New Ambulatory Model
Patient Safety/Quality Externship
Clerkship issues
Miscellaneous administrative issues
Boards
Noon conferences
Board review series
License, jobs/procedures
Senior talks
Dictations
Professionalism/RECC
In-training exam
Weekend coverage/handoffs
Reading elective
7:30 - 8:00
DACR/NACR Orientation
Gen Med Consults
8-8:30
Questions
Changes for Next Year
 New ambulatory model
 New CICU schedule
Current Structure of the CICU Team
* Rounds with CICU attending start at 8 AM. Heart failure
rounds (separate attending) usually start at 10 AM.
 Attendings rotate in one week blocks
 4 residents do overnight call every fourth night
 May have rotators from Emergency Dept. as well
 No nightfloat system
 Sometimes admit MICU overflow patients
 Cardiology fellow not in-house at night (though staff
admissions with fellow on the phone and if patients sick,
fellow comes in)
 Drawbacks to this system: only one resident at night, can be
challenging to leave post-call by 11 AM if busy night
The New CICU for Interns
*2 interns scheduled in the CICU:
-Day intern: works 7 AM-7 PM. May follow/admit one
to two patients under supervision of senior resident.
-Night intern: works 7 PM-7 AM. Helps with cross-cover,
gains valuable night ICU experience including procedures,
and possibly allows for on-call resident to take a quick nap.
*Interns will do one week of nights and one week of days during
two week rotation
*Both interns have Sunday off (accommodate switch days and
transition from nights to days)
The New CICU for Senior Residents
 5 senior residents
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On-call
Post-call
Regular day
Day call
Pre-call
 Days off will be Pre-call day between Thursday and
Monday
 Signout should occur after evening fellow rounds (4-5
PM) to overnight resident
The New CICU for Senior Residents
 Every fifth night is overnight call, but resident does
not come in until 4 PM that day. Resident then
presents the following morning on rounds and leaves
hopefully by noon (20 hour call), with wiggle room to
prevent duty hour violations.
 After post-call day, resident has regular day (til 5 PM).
No admissions this day.
 After regular day is day call where resident is
responsible for admissions from 7 AM- 4 PM (when
overnight resident arrives). Day call resident works
until 7 PM.
 After day call is pre-call day without admissions.
The Current State of
Continuity Clinic & Ambulatory Blocks
Weekly continuity clinic during inpatient wards,
electives, and ambulatory blocks
Two 1-month Ambulatory Blocks comprised of
didactics, medicine subspecialty clinics, VA UCC,
Psych CL, and continuity clinic
New Ambulatory Model
 Four 2-week Ambulatory Blocks
 Morning VA subspecialty clinics
 For 1 week you will have 5 consecutive afternoons of Clinic
*Green Road 5 clinic sessions over 2 weeks including morning sessions
*Residents must turn in sessions to Amb Chief
 For the other week you will have 5 afternoons of VA UCC and
subspecialty clinics
 2 Clinics during Electives
 PGY2 = 8 weeks
 PGY3 = 14 weeks
Pros of New Ambulatory Model
 No continuity clinic during Wards!!!
 Precept with different attendings each day of week
to get different clinical perspectives
 Improving the outpatient experience of our program
and limiting extended periods of time on wards
 Continuity with patient panel: guaranteed clinic
q8weeks for chronic disease management (CDM) and
preventative health
New Ambulatory Model
 The ambulatory schedule is
fixed
Ambulatory blocks cannot be swapped
Elective rotations cannot be switched
Summary…
 The new ambulatory model is proposed to decrease stress of
balancing inpatient and continuity clinic responsibilities
 Opportunity to improve continuity with panel of patients and
develop QI projects
 Greater autonomy
 Increased engagement in the clinic environment
 Resident feedback throughout the year is strongly encouraged
and leads to continued improvements in your ambulatory
rotation!
Fellowship Timeline
• Applications should be in by July 1; ERAS token can be
requested June 18th
• Have faculty working on your letters of recommendation
• Another meeting with KBA June 18th at 6 PM
•July 15, 2013: programs begin downloading applications
•Deadline for completed application varies but is as early as July
31st; check with program and be prepared
• August - November 2013: interviews conducted
• First Wednesday in December 2013: Match results available
*KBA will perform mock interviews upon request
REMINDER: Residency Reading List
*Primary care and subspecialty specific
*Both landmark and review articles
*Case Medicine website  Residents  Education 
Residency Reading list
Research Day
 Research poster is a requirement for those who take two or
more weeks as a research elective
 Can present subspecialty research done during electives
 Establish connections with a mentor
 Chief residents are available to help find mentors and research
opportunities
 Research Day is usually in May
Transition Dates
• New intern orientation 6/13/2013
• Last day of work for current PGY-1’s 6/23/13
• Transition week (Block 0) starts 6/24/13
• First day as PGY3 is 7/1/13
Team Caps
 UH ward teams cap at 10 patients per intern except
for the Seidman teams which cap at 8
 VA ward teams cap at 8 patients per intern
 No short call on weekends
 No shorts if intern has 8 patients (but AI/intern pair
with 2 seniors can go to 10 patients on short day)
 Intern + AI @ VA = 10; AI+AI paired together =12 (if 2
seniors, 10 when one senior)
 Intern + AI @ UH = 12 when 2 seniors; 10 when 1 senior
Duty Hours
 Long:
 Medium:
 Short:
3 patients until 7:00 stay until 9:00
2 patients until 4:00 stay until 7:00
2 patients until 12:00 UH and 1:00 VA
 MICU transfer/NF only at UH, can be new patients at the VA
 No short patients on clinic days or if intern already has 8 patients
ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!
 Senior Resident:
 On call residents stays until 9:00
 Staff patients available to be seen anywhere in the hospital until
4:00 (Monday-Sunday)
 Weekend team covering resident staffs until at least 1:00PM
Staffing
 On call senior resident must stay till 9:00 PM must leave by
11:00 PM
 Starting Block 4-5 you will be staffing orphan interns on
other teams as well when on call
 See and examine EVERY patient
 No staffing note required for ICU 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:
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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
 ***Please note, even if you are not on call, you
must staff all patients who are available to be seen
if they are assigned to your team before 4 pm (even
on the weekend)
 Weekend coverage resident should staff all patients
until 1pm
Patient Safety and Quality Improvement
* Introduction to quality improvement during DACR
rotation
-Hand-washing audits
-CLIPPS
-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
 Each PGY3 resident identifies and completes a quality improvement
project as one of the requirements by ACGME
 Work in groups of ideally 3 (no less than 2, no more than 4)
 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
Timeline for QI Project
 General Timeline:
 Mid-August to early October: define objectives, collect
background information, plan an intervention
 Mid-October: schedule a meeting with project chief to review
objectives and plan
 Late October through January: implement your intervention
 January through February : collect and analyze postintervention data and schedule meeting with project chief to
discuss results
 March through April: write-up project and finalize poster;
submit poster for printing to be presented at Research Day
To Admit vs. Observe
 All low risk chest pain, sickle cell pain crisis,
gastroenteritis in a young patient, syncope is an
observation patient
 Please follow ER description on blue sheet
 Instead of admission order, click the “Place in
Observation” box
 Please keep your UH care team lists up-to date!
 Quality center is tracking admissions by diagnosis
 Obs vs admit is related to clinical criteria and not
expected LOS!
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
 Referral to RECC
 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
 While on elective, you are expected to attend all Grand
Rounds and M&M’s
 Please note that when you are on elective, you are back up
jeopardy!!
 You are expected to have your pager turned-on throughout
your elective rotation
 If you are going out of town for the weekend, please notify
the ambulatory chief prior to leaving
 Elective should not be treated as vacation
 Please email Barb 2 weeks prior to starting your electives
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
Be on time!
Noon conference:
UH: Mon-Wed-Thurs
VA: Mon-Thurs-Fri
Grand Rounds on Tuesday: UH & VA
M&M Fridays @UH, Wednesdays @VA
Professionalism: Ambulatory
Conference Attendance
• Ambulatory conference attendance is mandatory and
tardiness and absences are extremely disrespectful to our
educators
• 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 will be assigned
• Any MISSED conferences without prior approval by the
ambulatory chief will result in weekend coverage
Professionalism: Discharge Summaries
 Do them the day of discharge
 Do them for your intern
 Do them for your friends
 Do them for your patients
 Weekend coverage is responsible for
discharge summary
Coverage and Schedule Switches
 All coverage arrangements and schedule switches
must be approved by the Ambulatory chief
 Switches must be arranged before 1 week of
rotation starting
 Weekend Coverage switches before 48 hours of
day
 NO SWITCHING AMBULATORY OR ELECTIVE
BLOCKS!!!
Talks
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Senior Grand Rounds
-Start in late August
-Dr. Mourad is the APD in charge.
-Email learning objectives to assigned faculty
mentor and ambulatory chief resident two
weeks prior to talk
-Evaluation process will be in place
-Should be evidence-based
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Research
-All residents doing away and research electives
must present at Research Day
BOARDS!!!
 Register by December
 Plan ahead…costs about $1,365 (more if you sign up
late)
 Noon Conferences to include more board prep
sessions
 Intense June weeklong session for board review
 Can use ITE exam results to help guide studying
 In-service Exam Dates are Oct 4 – 19th
 Remember: no Moonlighting if ITE < 30% of your peers
Medical License
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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!!!
VACR
 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
The NACR as Ombudsman
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Distribute admissions to teams on call in AM
Enforce geographic localization
Run codes
See medicine consults at night (Ortho co-management)
Cover emergencies in CF patients on RBC 7/Lakeside and Hanna
House
 Cover flex patients at night
 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 surgery
*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
Reality
“The Book” according to the ED…
Medicine
Surgery
Fam Med
Neuro
Ortho
Transplant
ENT
How the ER views the world
Appropriate Service?
Is the
patient
stable for
the floor?
No
MICU/CICU/NSU/SICU
Yes
Yes
Appropriate
for FP?
PCP an
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)?
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Physician Portal (summary page, physicians)
Previous discharge summaries
EMR patient info clinical summary (visit history)
Ask the patient!
Hints as NACR
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Be proactive – keep an eye on the ED board
Admissions require bed assignment
Figure out PCP (verify with patient if possible)
Quick visit history/portal search for past visits
Assign patient to NF or house doc (consider team in the
morning for geographic localization)
 Call admitting with location and ER with pager (or place
it in EMR)
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. Can take liver to a cap of 3 (but
flexible) if Post/Gholam patients
• Fang service: newly renamed HVI.
• 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
 MICU transfers followed by renal consult team
-If chronic  Eckel
-If acute  gen med with renal consult
Non-Teaching Services
 Reaffirm census/open spots in the morning and afternoon
 Medical NPs will call in evening with open spots for the next
day
 Berger NPs will email the night before with spots
 Hospitalist A (NPs), B, C, and D will call the Admissions
Coordinator with next day’s open spots (make sure they are
written in the book)
 Fang Service - Just call them
NPs
 Medical Nurse Practitioners
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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)
 Berger Nurse Practitioners
 Stable patients who do not need procedures: sickle cell, pain
management, hospice, routine chemo admissions
Hospitalist B, C, & D
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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 up to their cap
 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
The NIGHTFLOAT TEAM
The NIGHTFLOAT TEAM
NACR
Nightfloat Resident
Rotating MSIII
Nightfloat Intern
Rotating MSIII
Nightfloat Resident
Nightfloat Intern
NIGHTFLOAT TEAM
Nightfloat Intern
NACR specifics
 8pm – midnight:
 Meet Admissions Coordinator in KACR to get sign out
 Start NACR sheet, Admissions Coordinator will be holding the book and pagers til midnight
on most days so this is prime admitting time
 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, print out new board (on medicine.case.edu; UH
resources ), get intern census
 Talk to NFs regarding admits and appropriateness for teams vs. NPs vs. flex
 6:30-8am
 Review admits with KBA and V-BLSS
 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
Chief Resident may call you to check in on your first NACR night
ED Issues
 Neurology
 Strokes go to neurology
 Seizures – try neuro first
 General Surgery: insist (politely) that they take SBO’s, 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 orthopedics
 We follow along with ortho patients; they don’t need a
“question”
 You can put in orders dealing with medical issue
Transfers to Medicine
 All transfers to medicine must be approved by medicine
consult attending (not Dr. Whelan), chiefs, or KBA
 Consults for transfer to medicine:
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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 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
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DACR = 0800 – 2000
NACR = 2000 – 0800
MAN = 0800 - midnight
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
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
 Call the family
 Use the Code Note EMR, all Code nurses have it and should be
available in the ICUs
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
Questions?
We are looking forward to a great year together!!!
-VBLSS