Transcript PGY-2 to Be Retreat 2016 Presentation by Chief Residents

PGY2-to-Be Retreat
*Due to a lack of available conference
room space, the 2016 retreat will not be
at the Four Seasons Bora Bora, it will
instead be in the Tinkham Veale Center
Senior Classroom. We will return to Bora
Bora in 2017.*
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: CICU/MICU moonlighting, VA Cards nightfloat, VA
“Swing“ resident
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
• CICU/MICU nights meets moonlighting
• VA Cards night float
• VA “swing” resident during ambulatory blocks
• Discuss intern nightfloat at UH arriving at 6PM
UH MICU
(Same as last year)
• Interns will take Q4 overnight call with their
paired senior resident
– Last day of rotation their call day will end at 11PM
• 2 attendings
• 2 teams
UH MICU
• Overnight Call – Post Call – Helper Day – Pre Call
• Senior residents get pre-call day off if between Friday through Monday
(interns get helper day off if between Friday through Monday)
• 5 senior residents in the MICU (plus rotators)
• Each senior will be paired with an intern. Senior “supervises” their intern,
but intern “staffs” new patients with the MICU fellow.
• 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 the on-call resident until at least 7PM
• 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, you will be responsible for 6
nights a week (Saturday*-Thursday)
• MICU night resident responsibilities
– Arrive at 9PM
– Cross-covers unit at night
– Alternates admissions with resident on call until 2AM then does all admissions
after 2AM
• Patients admitted by MICU nights resident will be distributed to teams
(assisted by the MICU fellow in the AM)
• MICU night residents sometimes stay to present on rounds (for complex
patients)
• Post-call resident will present their patients and sign out to the helper
resident
UH CICU Nights
• May have 2 weeks as CICU night resident, you will be responsible for 6
nights a week (Sunday-Friday*)
• CICU night resident responsibilities
– Arrive at 9PM
– Cross-covers unit at night
– Alternates admissions with resident on call until 2AM then does all
admissions after 2AM
– CICU night resident may need to stay and present if a sick patient was
admitted overnight
• Any senior can get a night float admission. Use your judgment to
determine which senior should get the night floats based on how
many patients they are already carrying/covering for the day,
acuity/expected length of stay of the patient.
New! MICU/CICU Night Moonlighting
• Moonlighting opportunities still remain Friday and
Saturday night in the MICU/CICU
• Shifts available for moonlighting
– Friday evening MICU
– Saturday evening CICU
– Friday (CICU) and Saturday (MICU) will only be opened
once:
• Friday (MICU) and Saturday (CICU) shifts have been filled AND
• The night resident is OK with allowing a moonlighter to take their
paid scheduled shift
• MICU/CICU night residents are expected to work on
Saturday in the MICU and Friday in the CICU if no
moonlighters are available (You get paid for it!)
UH CICU
• Follows the UH MICU model for senior residents
• Interns are on either q2 or q3 day call depending on if
there are 2 or 3 interns.
• Intern "call" means they can admit new patients until
7pm. Max # of new admissions for interns on any day
is 2. Max intern cap is 3 (rolling cap).
– Interns in the CICU will alternate taking admissions with their
paired on call senior resident during the day
– Interns should take less complicated patients (e.g. post-cath,
post-TAVI)
UH CICU - Rounds
• A senior should always be on heart failure rounds if
the teams split, even if the patient is an intern's.
– If the senior who admitted the patient with the intern is
unavailable (off day, post call, rounding on their own
patient on the general cardiology team), the helper
resident should be present in their place.
• All interns should stay for evening rounds.
• Helper residents should stay at least through evening
rounds
New! VA Cards Nights
• Aim is to help offload excessive admissions for the oncall VA Cards resident and improve duty hours
• Nights resident arrives at 9PM and leaves at 7AM
• Responsibilities
– Alternates admissions with on-call resident until 2AM and
admits all afterwards, allowing on-call resident to have
protected sleep time
– Helps cross-cover patients
• Will be responsible for assigning overnight patients
• VA Cards nights resident will have Sat/Sun off
New! VA “Swing” Resident
• Aim is to help offload excessive admissions for
on-call VA senior  reducing stress/anxiety
• Assigned ~1 day every 1-2 ambulatory blocks
• Expectations…
– Arrive at 5PM
– Admit all patients assigned to NF (1st priority) until
8PM when NF arrives
– If there are no NF admissions, begin staffing orphan
team patients
– If admissions are minimal, help cross-cover
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 rest of the week, though VA clinics ,
DMC, and UCC start at 8
• 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 Flights
Example Schedules
DMC clinics
• Tuesday and Wed AM Clinics.
• Ongoing efforts to improve continuity
• New Attendings: Dr. Cassie Kovach
Changes at the VA
• Clinic names changing, talk with your
preceptor if you need to change your list
• Alerts- important to go through all alerts for
ambulatory patients before leaving every day.
If you ordered it- it is your responsibility to
follow it up!
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
–Enjoy the well-earned
week off!
• Block Zero: 6/24 –
6/30
• Block One: 7/1 – start
of your PGY2 year!
Block 1a
• Block 1 starts July 1st for Senior residents and
interns
• Block 1a- 7/1-7/19. Longer block due to 7/1
starting on a Friday
• Most noon conferences will be intern boot
camps
• Senior residents hold the interns’ pagers
during boot camps
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). Exceptions- intern/intern pair or intern/AI
pair have short call cap of 10 if on 1 senior team, 12 if on 2 senior
team.
VA Wards:
• 8 patients per intern
• Intern+AI or Intern/Intern: 10 patients
Team Caps
Special circumstances:
1. Hellerstein Short gets only
1 short admission.
2. No Eckel short admissions.
3. No weekend short
admissions.
4. AIs can get new admissions
on short call.
5. No short call admits for
residents with clinic that
afternoon (Med/Peds,
Family Practice)
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 (unless paired with an AI)
– 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
– Paired resident teams- one resident assigned to that team must be present each day during the weekend.
PLEASE CONTACT THE CHIEFS IF ANY QUESTIONS ARISE.
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
Acting Interns
• New Admissions:
– Need a FULL H&P from the senior
resident (includes ICU transfers)
• Daily Progress Notes:
– Need a short progress note for you
that must incorporate vitals,
physical exam, independent
assessment/plan
– Unless attending is writing a full
note (Naff/Wearn)
– Unless attending agrees to “as
scribed for…”
• Take the time to teach and to
mentor!
Your New Role – The Manager
•Print out daily patient list for
attending at UH
•Enter team attending into 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 – The 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 – Steward of Sign-out!
• Help your interns!
• What changes
management?
• What is not important?
• Observe signouts early- For first
three blocks, please observe each
intern’s signout to NF at least
once, and each AI until they feel
comfortable
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
Coverage and Schedule Switches
• All coverage arrangements and schedule switches
must be approved by the Ambulatory chief! This is
to ensure Amion is updated and there are no holes
in coverage – A major patient care issue!
• Switches must be arranged 2 weeks before rotation
start date, ideally sooner
Professionalism: Weekday Swaps
• Where weekday absences would be needed for
events such as weddings, reunions, conferences, or
interviews, residents should swap full blocks rather
than weekday coverage when possible.
• Exceptions may be granted 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: 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.
•Once the AI rotates off service, all remaining
summaries fall on the resident
Professionalism: Conferences/Clinics
•Be on time. Walking in late is often taken as a
sign of disrespect by the attending/presenter.
•If a pattern of lateness to ambulatory
clinics/ambulatory conferences develops, a
letter of professional misconduct will be
added to your academic record on file
In-service Training Exam
•
In-service Exam Dates are in September – exam is
completely computerized this year
•
Includes all PGY1/2/3/4 (Med peds)
•
•
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
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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)
Use ‘Night Float Admission Note’ and assign the VA chief as the cosigner
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
• Go to all Code Blues
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; always notify attending
• John Hornick has a .code note dot phrase
Running Codes
• Rule #1: You are in charge
• If uncomfortable, defer to more senior resident
• Assign Roles (Delegate!) – assign crowd control, chest compressions,
airway, etc.
• Use the DACR/NACR if you need help
• Call the nurses/interns/RT by their name, closed-loop! 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.
• After the code, regardless of the outcome, gather for post code debriefing to
discuss how the code went. Reflection will help hone code running skills!
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)