Transcript PGY-2 to Be Retreat 2015 Presentation by Chief Residents

PGY2-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.*
Overview
4:00-4:30PM
Snacks and informal discussion
4:30-6:00PM
Didactics
Giving feedback
Milestones
Student teaching - clerkship directors
6:00-7:00PM
Dinner & Small Groups
How to be a ward resident Q&A
7:00-9:00PM
Administrative issues/changes for next year/chief residents
New for next year: MICU, CICU, & Ambulatory changes
Electives
Jeopardy
Transition dates
Team caps/duty hours
Staffing/new roles
Coverage/schedules
Moonlighting
Professionalism/conferences
In-training exam
Night float
Codes
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 PGY2 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)
Your New Role
Be a Manager:
•Print out daily patient list for attending at UH
•Enter team attendings in the EMR
•Lead rounds
•Review active medications and orders EVERY DAY!
•Direct intern work flow
•Help with discharge summaries!
•Have teaching topics
•Maintain a white board and saved list of patients
•Review discharge profiles
Your New Role
Be a Teacher:
•Great teachers are motivators, respectful, and treat their
students as colleagues/equals
•Take time to critically evaluate presentation skills
•Find your own method of teaching
Your New Role
Be a Steward of Sign-outs:
•What is important? What changes management?
•What is not important?
•Observe signouts early
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
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.
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: 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 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!)
VA Nightfloat Resident
•
•
•
•
Works from 8 PM to 8AM
Cover the VACR pager (medicine consults)
Run codes
Evaluate CARES Tower 6 patients
– If patient needs more evaluation then direct admission
(DO NOT GO TO THE ED)
• VA chief will page you in the morning to distribute patients
• Discuss Code status of patients
• Change team assignment in CPRS (admission order: team)
The NIGHTFLOAT TEAM
NACR
Nightfloat Resident
Rotating MSIII
Nightfloat Intern
Rotating MSIII
Nightfloat Resident
Nightfloat Intern
Nightfloat Intern
UH Nightfloat Resident
• Works from 8 PM to 8AM
• Meets the NACR in the KACR
• Admit patients overnight, works with the nightfloat intern to
help answer questions/manage ill patients.
• NACR is always available if you need help
• Two nightfloat residents, each resident either gets Saturday or
Sunday off (must have 1 nightfloat resident each night)
• Must go to all Code Whites during the first 6 months with
intern
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.
Running Codes
Notify attendings at night of any Code Blue
• Page the attending let them know the outcome
(either of transfer to ICU or death)