Transcript PGY-3 to Be Retreat 2015 Presentation by Chief Residents

PGY 3/4 to Be Retreat
*Due to a lack of available conference
room space, the 2015 retreat will not be
at the Four Seasons Bora Bora, it will
instead be on Tower 11. We will return to
Bora Bora in 2016.*
Changes for Next Year
• Interns will take overnight call in the MICU
• Adoption of the MICU call structure in the CICU
• Implementation of intern ambulatory blocks
(goodbye weekday resiterning!)
• Friday Ambulatory Academic Half Day
UH MICU new for next year
Interns will take Q4 overnight call with their
paired senior resident.
Last day of rotation their call day will end at 11PM.
Return to 2 attendings, 2 teams.
UH MICU
• Overnight Call – Post Call – Helper Day – Pre Call
• Senior residents get pre-call day off between Friday and Monday (interns
get helper day off during same days)
• Five senior residents in the MICU (plus rotators)
• Senior will be paired with intern. Senior “supervises” their intern, but
intern “staffs” new patients with the MICU fellow.
• New: interns will take Q4 30 hour call with their residents (iCOMPARE
study). Last day of rotation they will leave by 11PM.
• Helper day = supervise the post call intern (their senior will leave by 11am)
and help out on-call resident until at least 7 PM
• Note: Our program is responsible for the care of a very sick MICU. Things
are always happening. Other than post-call residents/interns, no person
should sign out before 4PM. Signing out early adds another thing to the oncall team’s plate.
UH MICU Nights
• May have 2 weeks as MICU night resident (have Friday and Saturday nights
off that are covered by MICU moonlighter)
• MICU night resident responsibilities
– Comes at 9 PM
– Cross-covers unit at night
– Alternates admissions with resident on call until 2 AM, then does all
admissions after 2 AM
• Patients admitted by NF will be distributed by the MICU fellow in AM
• NF residents sometimes stay to present patients on rounds (complex
patients)
• Post-call resident will present and leave, sign out to the post call intern
and helper resident
UH CICU new next year
In response to feedback that:
1. There were too many handoffs in the CICU
2. There were too many cross-coverages in the CICU
Brainstorm: ideas regarding cause; possible remedies.
Intervention: trial run of the MICU call model in the CICU. The
feedback from this pilot was that the residents preferred the
new format (MICU call model) to the current CICU call model.
We will therefore adopt this change for next year.
Ambulatory Model 3.0
• Friday Morning Educational Half Day
– 8AM-Noon: Didactics, Journal Club, Workshops organized by system
– Systems chosen by gaps in other parts of the program
– No clinic or UCC requirements during Friday mornings
• No 8AM Conference, though VA clinics and UCC start at 8
(DMC start time TBD)
• Tues and Wed AM DMC Clinic. Decreasing wasted travel time
between VA and UH.
• Challenges
– Ambulatory blocks are fixed (cannot trade)
– Clinic days are fixed throughout the year, allows improved scheduling
continuity
Ambulatory blocks for interns
• All categorical interns will
have one primary care
block and 2 ambulatory
blocks with the senior
residents.
• No Clinic on Wards/ICU!
Resident no longer will
have to cover interns in
the afternoon who are in
clinic (exception for
Med/Peds)
Ambulatory Model 3.0
Example Schedules
Changes at the DMC
• Tuesday and Wed AM Clinics.
• Ongoing efforts to improve continuity
• New Attendings: Dr. Crystal Lantz and Dr.
Babak Moini. 2 resident favorites back as
outpatient teaching attendings!
Changes at the VA
• Clinic names changing, talk with your
preceptor if you need to change your list
• Alerts
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
• If you present at a national meeting…travel money!
• 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 & Jeopardy
• Elective is not vacation
• You are expected to be in town and available - if you need
to leave town, please let the Ambulatory chief know
• Everyone on elective is back-up jep any given day, but we
will assign people on specific days to be the first called so
you know when to have your pager with you. Look for the
doodle poll email so you can choose your days.
• If you are on backup jep and do not answer your pager in
15 minutes, you will be assigned extra weekend
coverage!
Jeopardy
• Please carry your pager 24/7 Monday thru Friday
• Failure to respond to pages within 15 minutes will result in extra
weekend coverage.
• Use of jeopardy is tracked for training/support purposes
• Those getting jepped from electives will be tracked as well
– Those jepped off elective multiple times will move down the list on
future electives
– 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
– When on the jep rotation, covering sick colleagues is the job. There is
no pay-back for this coverage.
Transition Dates
•PGY1 end date: 6/23
•Block Zero: 6/24 – 6/30
•Block One: 7/1 – start of your PGY3 year!
Team Caps
UH Wards:
• 10 patients per intern for all services except Ratnoff & Weisman
which cap at 8 (with rolling cap for Long & Med call)
• 2 Senior teams (Intern+AI or Intern/Intern): 12 patients; 10 patients
for Ratnoff & Weisman.
• 1 Senior teams (Intern+AI or Intern/Intern): Same rules as per
individual intern caps; 10 patients for all wards except Ratnoff &
Weisman (where cap is 8)
• Short call day caps at 8 (based on the number of patients you
start the day with, not a rolling cap).
VA Wards:
• 8 patients per intern
• Intern+AI or Intern/Intern: 10 patients
Team Caps
Special circumstances:
1.
2.
3.
4.
Hellerstein Short gets only 1 short admission.
No Eckel short admissions.
No weekend short admissions.
AIs can get new admissions on short call.
Admissions
• Long Call:
– 3 patients (4 if paired with AI) until 7 PM
– Max of 2 patients if after 5 PM
– Max of 1 patient if after 6 PM
– Anesthesia interns should leave by 9PM, work up admissions accordingly
• 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 or ICU transfers)
• Senior Resident:
– Residents on call MUST stay until 8 PM when the NACR and NFs arrive.
– Weekdays: ward seniors staff any patient assigned 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 the first 3 blocks, longer
for some services. There will be minimal orphan coverage in
the first few blocks
• See and examine EVERY patient
• No staffing note required for ICU transfers or inter-service
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
• Daily AI notes: need a progress note for you, unless the
attending is also writing a full daily progress note
(Naff/Wearn)
Moonlighting
• FLEX – when your team is capped and a patient is in need of your
specific team. Senior residents should be open to flexing. It’s paid, it
helps the nightfloat, and it keeps patients on the team that will provide
the best care. A win-win-win.
• PRN SHD – admit 3 patients
• Early and Late SHD – admit 3 patients
• Admitting LHD – admit 6 patients from 6 PM – 6 AM
• Cross Cover LHD – cross covers hospitalist, NPs, and admit 1 patient (3 if
overnight NP present), work from 8 PM – 8 AM
• MICU/CICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for
alternating admissions with resident until 2am, then all admissions
• No moonlighting during wards or ICU
Professionalism: Attire
• Men
• Shirts and ties
• Women
• Professional
• Keep white coats clean –
department pays for dry cleaning
• Scrubs: long call, weekends, nights,
and ICUs
• No denim
• Closed toe shoes
• No fleeces to morning report or on
rounds (unless under a white coat)
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: weekday swaps
• Swapping weekday coverage of ward and ICU teams
will not be routinely permitted.
• Where weekday absences would be needed for
events such as weddings, reunions, conferences, or
interviews, residents should swap full blocks rather
than weekday coverage.
• Exceptions may be granted for academic pursuits
when only full block swaps cannot reasonably
arranged
• Exceptions will need pre-approval by the ambulatory
chief resident and will be on a case-by-case basis.
Professionalism: 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 2 weeks before rotation
start date, ideally sooner
Professionalism: Reading Electives
• Residents on reading elective are expected to attend
morning reports and journal clubs at the VA
• Must attend Grand Rounds and M&M 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 will be
assigned specific days of back up jeopardy – you must
have your pager on these days. Failure to answer a page
within 15 minutes when you are on jeopardy will result in
extra weekend coverage.
Professionalism: Discharge
Summaries
•If you put in the discharge order, you do the
discharge summary
•Do them the day of discharge
•This is a great way to lead your team by
example and show your intern that you (1)
care and (2) are not above helping with the
scut work.
Professionalism: Conferences
•Be on time.
In-service Training Exam
•
In-service Exam Dates are in September – exam is
completely computerized this year
•
•
Includes all PGY2/3, PGY1’s?
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!)
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 2 weeks before rotation
start date, ideally sooner
Issues Unique to 3rd year
•
•
•
•
•
•
•
Fellowship
Boards
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!
• https://www.erasfellowshipdocuments.org/
• Request ERAS token
• Ask for letters of recommendation…if you haven’t yet, this is
your week!
• Personal statement
• July 15, 2015: first day to submit application AND programs
begin downloading applications. Have everything in place.
• 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: Late August - Early November First
• MATCH: first Wednesday in December
*KBA will perform mock interviews upon request
Fellowship Timeline
BOARDS!!!
•Register starting in December
•Plan ahead…costs about $1,365 (more if
you sign up late)
•Can use ITE exam results to help guide
studying
In-service Training exam
•
In-service Exam Dates are in August and September –
exam is completely computerized
–
•
Includes all PGY2/3, PGY1’s
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 later summer($430)
• State licensing ($335) can often take 5-6 months.
• DEA license is much quicker but more expensive ($740)
• Plan ahead, it takes 5 months at a minimum, and usually
longer from start to finish.
DACR / NACR / VACR
Your education in systems-based practice
VACR
• Many PGYIII’s will have this rotation, not all
• Perform medicine consults.
• VACR service often takes 2-3 straightfoward
patients early to middle of the week.
• Be available to help out ward teams as needed
• VACR talk: prepare EBM lecture on a topic of
choice 2nd Tuesday morning report
• Attend all morning reports
• One Saturday 24 hour VA MICU coverage
DACR/NACR Hours
•DACR = 8am – 8pm
– Come to morning report, Grand Rounds, and
M&Ms
•NACR = 8pm – 8am
•Admission coordinator = 8am – 12am (8pm on
Saturday and Sunday)
DACR
• Quality curriculum (EQUIPS)
• PRN SHDs
• Flex Service
– D Brown patients
– Pulmonary patients
– Overflow of heme/onc patients
• Consults
– Sometimes there is an anesthesia resident to help
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
• You will now also get QI teaching during your
ambulatory block
• You’ll learn about the QI project in your first
ambulatory block
• Present quality poster at Research Day
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; 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)
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
– 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)
• Dworken: GI patients (abdominal pain anyone?). Can take
liver to a cap of 4 (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
 ***If you are slammed with heme/onc patients,
uncomplicated sickle cell patients should be admitted to
Tower and go to the Hospitalist service
 HIV patients go to Carpenter
-When Carpenter is not admitting, give them one a day early
or have resident flex
 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 Berger
• Hospitalist B, C, and D will call the NACR at 8am to
get assignments
• Fang Service – Call with admissions in AM; NP on
service will tell you if they can accept the patient
• 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
• Straightforward medicine patients without
complicated social issues
• Try to give them patients with likely short stays
• Cannot take ICU transfers that were in unit >48h
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!)
• No admissions after 0600
• 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!
• No admissions after 0400
• Appropriate patient selection for the house doc is key
ED Issues
• Neurology:
• Strokes go to neurology
• Seizures – try neuro first
• General Surgery: for patients with recent surgery, have the ED
consult the service who performed the surgery
– Make the resident call their attending to refuse all patients and
document attending name in their note
• VA: far better to transfer BEFORE admission
• Ortho: Medicine co-manages ortho patients if desired (NACR/DACR
consult)
Medicine Consults,
Comanagement, Transfers to
Medicine
Medicine Consults
•DACR and NACR
•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 issues
Co-management Memos
• ENT and Ophtho have specific comanagement pathways
– On the bulletin board in the KACR room
Transfers to Medicine
• All transfers to medicine must be approved by
medicine consult attending, 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
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
• “Too many chefs spoil the soup”
• One person leads the code
• Make sure interns are involved: Never kick an intern out of
the room during a code, they will be running it next year!
• Maintain a calm quiet atmosphere
• Keep the ACLS cards in your pocket
• 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
• Call the ICU nurses by their name, closed-ended communication
• Assign someone to call the family
• During a crisis, people want to feel like soldiers, not victims. Given them a job
“please draw up 1mg of epinephrine” and things will fall into place.
HAVE A GREAT YEAR!!!