chairman’s welcome - department of medicinemedicine.case.edu/images/current_residents/intern...

Chairman’s Welcome

To our interns: Our residency training program is the keystone for the educational mission of the Department of Medicine. It is top priority. Here, medical students, specialty fellows and faculty interact with housestaff in a stimulating learning environment that centers on high-quality compassionate patient care. Tailored programs prepare our residents for careers that include leadership roles in academic medicine, physician scientists, practicing generalists or specialists. The balanced and diverse admixture of career goals among our housestaff catalyzes an intellectual atmosphere which is second to none. Defined inpatient workloads and innovative ambulatory programs exist against a backdrop of a medical school and department which are in the top 10 for biomedical research in NIH funding in a world-class hospital system. We believe that the physical resources of our University Hospitals Case Medical Center and the adjacent Veterans Affairs Medical Center are unparalleled. Our faculty is justifiably proud of their initiatives in medical education in general and housestaff training in particular. These ingredients make our program one of the best. It gives me pleasure, on behalf of our faculty, to welcome you to our program and to participate in your professional development.

Richard A. Walsh, M.D.John H. Hord ProfessorChairman of Medicine

Case Western Reserve University Director, Department of Medicine

University Hospitals Case Medical Center

1

Program Director’s Foreword

The Faculty in the Department of Medicine wishes to make your internship year a productive, stimulating, and rich in educational experiences. In an effort to focus your learning, our faculty has identified major learning objectives for many of our rotations. They are enclosed in this booklet. We recognize that this year will be busy and that you will have limited time to study. It is my hope that these objectives will help you use your study-time efficiently.

There are other important items in the booklet pertaining to the evaluation and feedback. We hope that you find this material useful. Do not hesitate to ask, if you have questions or concerns.

Keith B. Armitage, MDVice Chair for EducationResidency Program DirectorProfessor of Medicine

2

TABLE OF CONTENTS

Housestaff InformationBlock Schedules..........................................................................4Residency Calendar.....................................................................5Miscellaeous Information.............................................................6Department of Medicine Conferences...........................................7

Elective TimeReport Form..............................................................................10

PoliciesUncovered Patients...................................................................12Duty Hours / Workload...............................................................13Order Writing............................................................................15Patient Care Responsibilities......................................................16Moonlighting.............................................................................18Attending – Housestaff Interactions............................................19Dress Code................................................................................21Conference Attendance..............................................................25Definition of Internal Medicine and Goals of Training Program.....26

Tips for the VA....................................................................27Tips for UHCMC....................................................................38(Preparing you for your first day on each ward and service)Service Excellence Standards...............................................64Ten Ways to Make Your Life Easier.......................................67Library Access Issues...........................................................80ACGME and Competencies....................................................81Banded Abbreviations………………………………………………………82

3

Academic Calendar 2013 – 2014Block 0 6/24-6/30Block 1 7/1 – 7/30 Block 1A 7/1-7/16 Block 1B 7/17-7/31

Block 2 7/31 – 8/27 Block 2A 7/31 – 8/13Block 2B 8/14 – 8/27

Block 3 8/28 – 9/24 Block 3A 8/28 – 9/10Block 3B 9/11- 9/24




Block 7 12/18 – 1/14/14 Block 7A 12/18 – 12/28Block 7B 12/39-1/14/2014

Block 8 1/15 -2/11 Block 8A 1/15 – 1/28Block 8B 1/29 – 2/11



Block 11 4/9 – 5/6 Block 11A 4/9 – 4/22Block 11B 4/23– 5/6

Block 12 5/7 – 6/3 Block 12A 5/7 – 5/20Block 12B 5/21– 6/3


Annual Residency Calendar

July ABIM Applications (for PGY 3 residents)USMLE Step III

4

AugustFellowship interviews (Aug-Oct)SeptemberGrand Rounds StartAgre SocietyOctoberHoliday Schedule PlanningIntraining examSenior Grand RoundsNovemberHoliday Days offRecruitment Begins- Noon Lunches@ UHCMC and DinnersDecemberRecruitment continues- Noon Lunches@ UHCMC and DinnersFellowship MatchJanuaryRecruitment continues- Noon Lunches@ UHCMC and DinnersFebruaryIntern Recruitment EndsMoral WeekMarchIM Match ResultsAprilChief Resident RetreatMayHousestaff Dinner Spring DinnerDepartment of Medicine Research DayBronson DayJune Future PGY 3 and PGY 2 RetreatSpring PicnicNew Intern OrientationERAS Fellowship Applications for PGY 1 and PGY 21 week vacation before beginning PGY 2

Miscellaneous Information

Xerox machine available at UHCMC across from the Carpenter room- Lakeside 3108

5

Instructions for the pager system:

Get dial toneDial “222”Wait for long beep, enter 5 digit pager numbersWait for a series of beeps, then enter your number, followed by the # sign (most residents and faculty “tag” their pagers by then entering the “*” key which adds a space, then enter their own pager numberWait for short beeps, and then hang up.If you make a mistake in the number you enter you can hit “*” three times and start over (this is a little known pearl!)From outside the hospital including the VA: 216-207-7244; then follow the above directions.

Swipe cards are given to each house officer annually to be used for meals at UHCMC. It is given in a lump sum according to the number of call nights for the academic year. It is refilled January 1st of each year and funds on the card will be lost if not used by December 31st of each year. At the VA, food will be available when on call.

Resident mailboxes are located at UHCMC outside the Carpenter Room, Lakeside 3108.Please check regularly and keep them uncluttered

Conferences

Department of Medicine ConferencesAll of the conferences listed below offer Continuing Medical Education (CME) credit unless otherwise noted. CME credit is available without charge to physicians who attend any of our conferences.

6

Morbidity and Mortality ( M & M) ConferenceThe M & M conference is held weekly at noon on Fridays in the Kulas Auditorium on the 5th floor of Lakeside. The Chief Medical Resident selects one or two cases for the presentation. Following the case presentation by the housestaff, the Chairman moderates the discussion around the issues of disease prevention, differential diagnosis, and management. This conference is often lively and interactive; comments and discussion from physician participants are welcome and encouraged.

Grand RoundsGrand Rounds are held weekly at 12-1pm on Tuesday in the Kulas Auditorium on the 5th floor of Lakeside from practitioners of Internal Medicine. Generally one topic is presented during the hour, with a 45minute presentation and 10-15 minutes for questions. We simulcast to UHHS affiliated hospitals

Infectious Disease Case ConferenceTuesday afternoon from 4-5:30pm in Lerner Tower Room 2060

Infectious Disease Fellows Didactic LectureFoley 306Monday Noon -1pm.

Infectious Disease Fellows Journal ClubFoley 306Thursday, Noon-1pm

Rheumatology Grand RoundsThursday morning 8-9am on the second floor of the Foley Building room 216 (excluding July and August)

Pulmonary/Critical Care Grand RoundsFriday morning 8-9am in the RB&C Amphitheater.

Pulmonary Case ConferenceThursday at 7:30-8:30 am VA Medical Center, Rockefeller Gardens Conference RoomCARES Towers, Room 1F 160

Multi professional Critical Care Lecture Series Wednesday, Wearn 6th floor Conference Room 618

Sleep Medicine Grand RoundsTuesday 8-9am Wearn 6th floor Conference Room 618

Pulmonary Research ConferenceMonday, Noon-1pm Cardiovascular Institute, Mather 1735

7

Topic in NephrologyTuesday afternoons May-September 5-6pm in Humphrey Conference room 2628

Endocrine Grand RoundsWednesday afternoons October-May 4-5pm in The Carpenter Room, Lakeside 3108

Cardiovascular Medicine Grand RoundsThursday 12 noon-1:00pm September-June in The Wolstein Reasearch Building, Room 1413. September-June

Cardiovascular Clinical Case ConferenceWednesday morning 7:30-8:30am Lakeside 3108. August - June

Cardiovascular Medicine- Cath ConferenceTuesday 5:30pm Lakeside 3108. August-June

Cardiovascular Medicine Fellows Core LecturesTuesday and Thursday 7-8am Lakeside 3068. August-June

Cardiovascular Medicine EP Conference Monday and Friday 8-9am Lakeside 3068. August-June

Cardiovascular Medicine Echo ConferenceMonday, 12:30-1:30pm Lerner Tower 2060. August-June

Topics in GeriatricsFriday mornings 8-9am in Room K119 at the VAMC

GI Division Med-Surg ConferenceTuesday 4:40-5:30pm September-June in the RB&C Amphitheater

Frontiers in Gastroenterology1st and 3rd Thursday 4:40-5:30pm in the Frohring Auditorium (BRB 105)

Hematoolgy ConferneceMonday 1-2pm in the Wolstein Research Building Room 2136

Hematology/Oncology Division Research ConferenceWednesday 8-9am in the Radiology Oncology Conference Room (Lerner Tower B-151)

Hematology/Oncolog Fellows Conference Friday 8-9am July-June in the Wearn Conference Room 137

Hematology/Oncology Morphology Conference- (alternates every other week) Friday 2-3pm Pathology Building Room B-20 andFriday 1-2pm Wolstein Research Building Room 2136

8

MEMORANDUM

TO: Medicine Interns and Residents

FROM: Keith B. Armitage, M.D.

9

SUBJECT: Elective Time

DATE:

In order to receive credit by the ABIM, we must be able to verify where/how you spend your elective time. You are asked to submit your written intentions via email to [email protected] for elective by the Monday of the ½ block prior to commencement of the elective. Failure to do so will result in an individual meeting with your designated Program Director.

We need to receive this sheet completed PRIOR TO YOUR ELECTIVE.

If you would like to do an elective at another institution, you need to discuss this with me initially, and upon my approval Deena Segal needs to be notified BEFORE committing to the elective. Additional paperwork needs to be completed besides this form, and the elective needs to be approved by both institutions BEFORE the elective begins.

Please complete the information below and return it either in electronic form or hard copy to Aurelia Rios-Ortiz at the Louis Stokes VA

Name _________________________________________________________________

Month _________________________________________

Elective/Site _________________________________________________________

Attending _____________________________________________________________

What you would like to achieve during this time:________________________________________________________________________

RESIDENT ELECTIVE MONTH ROTATION: GOALS AND EXPECTATIONSDEPARTMENT OF MEDICINE

UNIVERSITY HOSPITALS CASE MEDICAL CENTERVETERANS AFFAIRS MEDICAL CENTER

Revised 6/6/11

10

mailto:[email protected]

GOALS:Throughout your residency, you may take electives to acquire and enhance the knowledge and skills necessary to become a competent scientist and or practitioner of internal medicine.

EXPECTATIONS:In order to meet this goal, you are expected to attend and actively participate in all scheduled conference, lectures, specialty, urgent care, and grand rounds during your rotation. In addition, you are to identify a preceptor/mentor with whom you will work during the month and who will be required to evaluate the extent to which you achieved your educational objectives for the month. The program director, associate program director and chief residents can help you to identify a mentor.

ATTENDANCE:Attendance at electives is mandatory. Residents on electives should have their pagers on from 8:00am to 5:00pm. Residents on jeopardy must have their pagers on 24 hours/day. Residents on elective are allowed to use this time for job or fellowship interviews but must notify a Chief Resident in advance when they will be out of town.

EVALUATIONS:Your evaluation will be sent to you and your preceptor/mentor by MyEvaluations.com at the end of your elective month.

There are no reading elective for Interns.

Case Western Reserve UniversityInternal Medicine Residency Program

Policy on Uncovered PatientsRevised 5/27/09

11

1. The on call senior resident ("NACR/DACR") is responsible for responding to emergency calls (ie Code Blue/Code White) on all uncovered medical patients, including Bone Marrow Transplant, Hanna House 4, RBC 7/CF patients. All non-urgent calls should go to the primary physician or service.

2. No resident should do routine work (such as drawing blood, filling out requisitions) on any uncovered patients.

3. The Chief Medical Resident will decide which patients will be transferred from the uncovered to the covered medical service should the primary physician request it.


Policy on Duty Hours and Work Load for Interns and ResidentsRevised 6/06/13

12

1. Interns on all services are limited to 3 admissions per long call day, 2 per medium call and 2 for short call day.

2. Residents on all services are limited to ten new patients and two transfers per long call day.

3. Interns on all services may not have more than 10 patients under their care at one time.

4. Short and medium call admissions will be limited based on the number of patients carried by an intern. There will be no short call admissions on the intern’s clinic day.

5. Interns with an excessive number of complex patients may have their patient load reduced at the discretion of the Chief Medical Resident. Residents are encouraged to notify the Chief Resident if the patient load on a team is suboptimal for education or patient care.

6. Residents must not be responsible for the ongoing care of more than 20 patients.7. Admissions will be limited if the intern or resident feel that the work load might

compromise the 80-hour rule.8. All residents must comply with the ACGME duty hour rules including working a

maximum of 80 hours a week, 24 + 4 hours for residents, 8-10 hours between duty periods and 1 day off in 7 averaged over a 4 week period. The maximum consecutive duty hours for interns are 16 hrs.

9. Any duty hour violation must be reported to the IM program director.10. A detailed duty hours audit will be completed the 2nd week of each bock, and all

residents on ward and ICU rotations must complete the audit. All residents must be aware of the ACGME duty hour requirements.

11. ACGME Requirement : Duty hours are limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities, including moonlighting.

If a resident suspects or anticipates they are in danger of exceeding those limits for any reason, those concerns must be brought to the attention of the Program Director.

12. ACGME Requirement : Residents are provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period.

Residents’ schedules are designed such that all services allow for one full weekend and at least 2 other weekend days off per month. Residents must report to the Chief Residents if the schedule calls for less than 1 in 7 days off on average. All schedules are created for 1 in 7, and the potential for less than 1 in 7 would only occur when there are ½ blocks back to back with different days off schedules.

13. ACGME Requirement : Adequate time for rest and personal activities is provided by an 8-10-hour time period provided between all daily duty periods.

Daily schedules are created such that work hours regularly end at between 5 and 6 PM and start at 7:00 AM. In the instance of q4 call when the PGY2 or 3 resident hands off to night float; residents are allowed an 8-hour period as long as it is not routine and the

13

schedule is created for 10 hours, and time between duty periods of less then 10 hours must be monitored by the program director.


Order Writing PolicyDepartment of Medicine Teaching Service

14

Revised 6/02/09

In accordance with ACGME policy, all orders on patients on the teaching medical service should be written only by the house officers (intern or resident) assigned to that patient or on night float or cross coverage duty. Attending physicians may write orders on patients on the teaching medical service under circumstances where the order will significantly expedite patient care (e.g.; the intern and resident are at a conference, the attending is seeing the patient and an order needs to be written.) In these circumstances the intern or resident must be notified that the attending is going to write an order or has just written an order. The Chief Medical Resident will notify attendings that violate this policy and Program Director and consistent violation will lead to termination of admitting privileges to the Teaching service.

Orders may be written by medical clerks (third year medical students) or acting interns (fourth year medical students) who are assigned to a patient, but at all times must be co-signed by the intern or resident assigned to that patient before they can be taken off.


Patient Care Responsibilities on the Teaching Medical ServiceUniversity Hospital and Cleveland VA Medical Center

15

Revised 6/06/12

1. InternsInterns have primary care responsibility for all patients assigned. These responsibilities include performing a complete admission history and physical and formulating a diagnostic and therapeutic plan in conjunction with the senior resident and attending. The admission history and physical must be in the patient’s chart within 24 hours of admission. The intern is responsible for all day-to day management issues, which must be reflected in a daily intern progress note [the note may be written by the resident or the attending for post call and day off interns]. Copy and paste of a patient note without daily editing is discouraged. All patients assigned to the intern are to be examined by the intern every day. Interns are responsible for discharge summaries on all non-private patients on the Teaching Service. Discharge summaries on days off are to be done by the Resident. When working with 3rd year medical students, all H&P’s by intern must be completed as well as daily progress notes by interns.

2. ResidentsResidents are responsible for all patients assigned to their service and are responsible for supervising all patient care activities of the interns. They are to perform a history and physical on all admissions which take place while they are on duty and write a brief resident admit note within 24 hours of the patient being admitted. With the assistance of the attending physician, they are responsible for aiding the intern in formulating a diagnostic and therapeutic plan on all patients admitted. They are to make rounds on all the patients assigned to them every day. When working with AI’s, Residents should complete initial H&P with physical exam; can sign daily progress notes with small addendums

3. AttendingsAttendings have ultimate responsibility for all patients assigned to their service. All new admissions must be seen within 24 hours of admission. The attending is responsible for co-signing the admission note and the daily progress note of the intern. The attending is to aid the resident and intern in developing a diagnostic and therapeutic plan for patients assigned to their service. The discharge summary of private patients assigned to the teaching service will be dictated by the attending.

4. ProceduresAn attending or resident who is credentialed in that specific procedure must supervise procedures. Residents are considered credentialed (and available to supervise) after documentation that they have successfully completed the prescribed number of supervised procedures (see procedure card or website for specific number needed for each procedure.)

5. Acting Interns

For all acting interns, a resident must complete an initial H&P, in addition to that completed by the acting intern. For daily progress notes, residents may

16

sign the acting intern’s progress note and write a small addendum.

6. Third Year Medical Students

For all third year medical students, both H&Ps, as well as daily progress notes, must be written by the ward intern in addition to those notes written by the 3rd year medical student.

Moonlighting PolicyRevised 6/06/11

17

1. Moonlighting during Ward, ICU rotations is not allowed. 2. Moonlighting during other rotations at approved sites is allowed with prior

approval provided the moonlighting does not interfere with the activity of the assigned elective. Current approved moonlighting sites include Lakeside Housedoc and Flex at University Hospitals, and VA Urgent Care.

3. The Program Director should be notified in advance about moonlighting at non-approved sites.

4. Total duty hours of combined moonlighting and residency-training activities must not exceed 80 hours per week.

5. Residents should report total weekly moonlighting hours to the program director if the total moonlighting and resident duty time exceeds 80 hours.

6. Residents who do not attend at least 60% of required conferences or who score <30% on the in-training exam are not allowed to moonlight.

Guidelines for Attending/Housestaff Interactions

18

Admissions of patients to housestaff covered services at University Hospitals carries with it important responsibilities for our Attending staff. In exchange for around the clock in house care of their patients, Attendings should follow these guidelines:

1. Attending physicians should conduct themselves in compliance with the rules of the Residency Review Committee (RRC) for Internal Medicine. The written RRC Requirements for training states that:

“On inpatient rotations resident’s responsibilities must include development of diagnostic strategies, planning and decision-making commensurate with resident’s abilities and with appropriate supervision by the attending physician.”

2. The RRC requires that all orders on patients under the care of housestaff be written by the housestaff; the RRC states that:

“Residents must write all orders for patients under their care, with appropriate supervision by the attending physician. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident’s patient, the attending or subspecialty resident should communicate his or her action to the resident in a timely manner.”

With the rapid pace of patient care in the hospital it may not be possible to contact the housestaff before an urgent order is written, communication about the order should take place when possible.

3. Attending physicians should treat the housestaff as junior colleague. While all final decisions on patient care rest with attending physicians, Attendings should engage in discussions of patient care issues with housestaff, allowing housestaff to voice their input. Attending physicians should engage and interact with the housestaff in a teaching capacity.

4. Contentious interactions on the part of the housestaff or faculty should be avoided and conflicts handled professionally.

5. Attending physicians and housestaff should mutually readily be available to discuss patient care issues.

6. Attending physicians are expected to call housestaff at the time a patient is admitted. The Senior admitting Resident (pager 30512 24 hrs a day, 365 days a year) can be called to clarify housestaff assignmentsif needed. The housestaff is expected to call Attendings after evaluating a new patient, and whenever there is a significant change in patient’s status

7. Attending physicians who are unable to comply with the guidelines will be referred to the Faculty-Housestaff Liaison Committee. Repeat non compliance may result in the loss of housestaff teaching service admission privileges. All decisions are subject to the approval of the Chairman of the Department of Medicine.

19

8. Nonteaching services that offer an equivalent level of coverage will be maintained. These services will offer nurse practitioners to aide in the management of patients during normal working hours and a house doctor to cover patients during evening and nighttime house. Patients may be admitted to the non-teaching service when the admission quotas of the housestaff teams (as defined by the RCC) have been met. Under these circumstances specific requests for housestaff coverage should be referred to the Senior Admitting resident or Chief Resident (pager 31250)

20


Revised 6/6/11

Dress Code for Department of Medicine Residents

Patients have a right to feel comfortable with their health care providers. A sensitive and compassionate doctor will recognize that appearance affects how patients feel about him/her and the experience the patient has in the hospital. We have avoided elaborate specific guidelines and expect common sense to prevail. Our litmus test is the following: if you grandmother was in the hospital, would she be comfortable with your appearance?

Simple guidelines: 1. Blue jeans and sweatpants should not be worn during patient care. 2. Scrubs are OK on call days only, but a white coat should be worn over scrubs

when doing patient care. 3. Appropriate professional attire should be worn on non-call days.

All health care providers should have a name tag visible to patients.

CLINICAL RESEARCH STUDY

21

What to wear today? Effect of doctor’s attireon the trust and confidence of patientsShakaib U. Rehman, MD,a,b Paul J. Nietert, PhD,b,c Dennis W. Cope, MD,d,eAnne Osborne Kilpatrick, DPAfaRalph H. Johnson Veterans Affairs Medical Center, Charleston, SC; bDepartment of Medicine and cDepartment ofBiostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina, Charleston, SC; dUniversity ofCalifornia at Los Angeles (UCLA) San Fernando Valley Program and eOlive View-UCLA Medical Center, Sylmar, Calif;fDepartment of Health Administration and Policy, Medical University of South Carolina, Charleston, SC.ABSTRACTPURPOSE: There are very few studies about the impact of physicians’ attire on patients’ confidence andtrust. The objective of this study was to determine whether the way a doctor dresses is an importantfactor in the degree of trust and confidence among respondents.METHODS: A cross-sectional descriptive study using survey methodology was conducted of patients andvisitors in the waiting room of an internal medicine outpatient clinic. Respondents completed a writtensurvey after reviewing pictures of physicians in four different dress styles. Respondents were asked questionsrelated to their preference for physician dress as well as their trust and willingness to discuss sensitive issues.RESULTS: Four hundred respondents with a mean age of 52.4 years were enrolled; 54% were men, 58%were white, 38% were African-American, and 43% had greater than a high school diploma. On allquestions regarding physician dress style preferences, respondents significantly favored the professionalattire with white coat (76.3%, P _.0001), followed by surgical scrubs (10.2%), business dress (8.8%),and casual dress (4.7%). Their trust and confidence was significantly associated with their preferencefor professional dress (P _.0001). Respondents also reported that they were significantly more willingto share their social, sexual, and psychological problems with the physician who is professionallydressed (P _.0001). The importance of physician’s appearance was ranked similarly between male andfemale respondents (P _ .54); however, female physicians’ dress appeared to be significantly moreimportant to respondents than male physicians’ dress (P _.001).CONCLUSION: Respondents overwhelmingly favor physicians in professional attire with a white coat.Wearing professional dress (ie, a white coat with more formal attire) while providing patient care byphysicians may favorably influence trust and confidence-building in the medical encounter.© 2005 Elsevier Inc. All rights reserved.KEYWORDS:

22

Physician attire;Physician dress;Patient trustThe patient-physician relationship is the foundation for allpatient care. Research has demonstrated that a patient’sinitial consultation plays a vital role in the development ofthis relationship.1 During this consultation, a patient willdevelop a first impression of his or her physician2 basedupon the physician’s verbal and nonverbal communication,as well as personal attributes like clothing, grooming, andcleanliness. This article examines respondents’ preferencesto their physician’s attire, one component of this first impression.Sociologists and psychologists have long recognizedthe effect of one’s appearance on important life ex-This work was supported in part by Department of Veterans AffairsResearch Services.Requests for reprints should be addressed to Shakaib U. Rehman, MD,Ralph H. Johnson Veterans Affairs Medical Center, Medical University ofSouth Carolina, 214 Historic Drive, Mount Pleasant, SC 29464.E-mail address: [email protected]/$ -see front matter © 2005 Elsevier Inc. All rights reserved.doi:10.1016/j.amjmed.2005.04.026The American Journal of Medicine (2005) 118, 1279-1286periences such as interpersonal relationships and job-relatedsuccesses.3-6 In fact, the importance of physician dress onthe patient-physician relationship can be traced back toHippocrates, who stated that the physician “must be clean inperson, well dressed, and anointed with sweet-smelling unguents.. .”7Even in ancient societies, the way healers dressed playedan important part in rituals of healing.8 More recently, onecan find a variety of personal opinions about the dress andappearance appropriate for physicians as reflected in editorialsand letters.9-27 Review of the existing literature aboutphysicians’ dress style revealed conflicting findings. Manystudies found that patients favored a more traditional dressstyle for physicians, yet there are studies showing thatpatients preferred physicians in a more casual outfit. In apioneer study in 1987, Dunn et al reported that 65% of 200patients wanted their physicians to wear a white coat duringa consultation, and the majority believed that physiciansshould wear formal dress.28 Many studies reported similaroutcomes and the traditional items of attire such as formaldress, a name tag, and a white coat were suggested byrespondents as appropriate attire for physicians.6,29-35 In onestudy, a majority preferred their doctor to wear a white coat,be free of political badges, and for men to have conventionallength hair; however, most patients did not mind a maledoctor with an earring, a woman in trousers, or a manwithout a tie.35 A study performed among teenage patientsactually measured patient attitudes after encounters withphysicians whose dress varied from “very informal” toformal; the results were that dress style made no statisticaldifference in patient attitudes toward their physician.36 Inother studies, most of the patients claimed that the attire ofthe physician had no influence on their choice of familyphysician37 or satisfaction.38 The two studies that assessedthe impact of dress in actual patient encounters found it to

23

be an insignificant factor overall.36,38 However, very fewstudies have examined the impact of physician attire andappearance on the confidence and trust in physicians bypatients. No studies have assessed the effect of physicianattire on patient adherence to prescribed regimens. In addition,no studies have assessed patient preferences for physicianattire in an internal medicine outpatient setting. Thepurpose of this study was to determine whether the way adoctor dresses is significantly associated with patient selfreportof their trust and confidence in physicians.MethodsSubjects were administered a survey to assess the selfexpresseddegree of patient trust, confidence in physicians,and adherence to prescribed regimens. The study used arandomized cross-sectional design, which made use of surveymethodology. Before the administration of the surveysto the study subjects, the survey’s reliability and validitywere tested. Two researchers familiar with instrument developmentand clinical research assessed the questionnaire’scontent validity. After a slight revision, the questionnairewas then administered to the clinical staff and nurses toassess clarity and ease of use. Ten volunteers took thesurvey and expressed that they did not have any troubleunderstanding the survey questions and would not hesitateto take the survey again if needed. The questionnaire wasadministered to the same group again after a month to testthe reliability and consistency of answers. This pilot testingproduced a reliability of 90%. The study was approved bythe institutional review boards of the participating VeteransAdministration (VA) and the University.After determining that the instrument was valid andreliable, a convenience sample of patients and visitors in thewaiting room of internal medicine outpatient clinics at theRalph H. Johnson VA Medical Center participated during a6-month period in 2003, from January through June. If apatient was accompanied by one or more persons, only oneof them was selected to participate. We did not recordwhether the subject was a patient of that clinic or an accompanyingvisitor. However, because we wanted to ensurethat approximately half of the subjects were female, andbecause most of the VA clinic patients are male, it is highlyconceivable that the majority (but not all) of the femalesubjects were not clinic patients and that the majority (butnot all) of the male subjects were clinic patients. Subjectswho were demented, noncommunicative, or blind were excludedfrom the study. Demographic information was collectedon each participant. Subjects completed the questionnaireafter reviewing pictures of physicians attired in avariety of styles (Figure 1). Questions were asked abouttheir preference for physician attire within the context ofseveral scenarios as well as their trust and willingness todiscuss sensitive issues with their physician.The prespecified sample size chosen for the study was400 respondents to ensure high (_90%) statistical power todetect significant differences across groups. Respondentswere randomized into 1 of the following 4 groups:

24

● Respondents who were shown the photographs of a“white male doctor” dressed in 4 different styles as describedbelow (Figure 1a).● Respondents who were shown the photographs of a“white female doctor” dressed in 4 different styles asdescribed below (Figure 1b).● Respondents who were shown the photographs of an“African-American male doctor” dressed in 4 differentstyles as described below (Figure 1c).● Respondents who were shown the photographs of an“African-American female doctor” dressed in 4 differentstyles as described below (Figure 1d).Each patient saw only one set of photographs, comprising4 photographs of one of the above doctors (ie, the samedoctor) in each of following styles of dress:● Business attire (suit with neck tie for male physician,either tailored trouser or skirt for female physician)1280 The American Journal of Medicine, Vol 118, No 11, November 2005


Policy on Conference AttendanceRevised 5/27/09

1. Attendance at 60% of required conference is necessary for successful completion of the training program.

2. Required conferences include Grand Rounds, M & Ms, Noon Conference and Morning Report.

3. Attendance at Grand Rounds, M & M, Noon Conference and Morning Report is expected during “Reading” Elective.

4. Failure to comply with the conference attendance policy may lead to loss of elective time, moonlighting privileges or annual Educational Allowance.

25

Definition of Internal Medicine and Goals of the Training Program Definition of Internal Medicine:

“Internal medicine is the discipline encompassing the study and practice of health promotion, disease prevention, diagnosis, and treatment of men and women from adolescence to old age, during times of health and through all stages of acute and chronic illness. Intrinsic to the discipline are the application of the scientific methods of problem solving, decision making, and an attitude of caring driven by humanistic and professional values. The practice of internal medicine requires comprehensive knowledge of human biology, behavior, and spirit; an understanding of the epidemiology and pathophysiology of disease; and the mechanisms of treatment. Internal medicine requires a mastery of clinical skills in interviewing, physical examination, differential diagnosis, diagnostic testing strategies, therapeutic techniques, counseling, and disease prevention.” Goals of the IM residency- at the end of 3 years of training:

1. Residents demonstrate a broad understanding of medical problems in adults and learn a rational approach to medical problems in adults.

2. Residents understand the science behind the etiology and therapy of common

medical conditions that affect adults.

3. Residents comprehend principles of efficient and cost-effective practice, and system based practice.

4. Residents demonstrate competence in the history and physical exam of adults,

and receive additional training as needed.

26

5. Residents demonstrate professionalism and comprehend common ethical and legal issues and the psychosocial aspects of the practice of medicine.

6. Residents recognize how to apply the evidence in the medical literature to

medial problems in adults.

7. Residents learn to critically evaluate the medical literature.

8. Residents formulate a research question and produce a plan for carrying out research.

9. Residents demonstrate the fundamentals of teaching internal medicine.

10. Residents will develop a basic understanding of patient safety and quality and how it relates to core competencies.

Your First Day on VA wardsHere is some info to help you throughout this month:

1. Rounds. Rounds will be at 8:00AM in your work room. The Green and Blue work rooms are on Ward 4B and the Orange and White work rooms are on Ward 4A. Your patients will be located on Ward 4A, Ward 4B, PCU (telemetry) or occasionally the 5th floor. Blue and Green are considered 'sister services' because these teams are on call on alternate days, and they cover each others patients when you are on call. Similarly, Orange and White are sister services as well.

2. Call. There will be two interns on each ward team. Call will be as follows: Long call, medium call, short call and then no call on 4 consecutive days. The cycle will then repeat. Call is from 7AM to 10:30pm with last admission assigned by 7:00pm. One intern will take long call with the senior resident, while the other intern will be the ‘orphan’ and will be covered by a senior from the other on-call team. Short call consists of two (2) admissions before 2:00 PM with the following exceptions:

a. If you have clinic on your short call day, you do not get admissions.

b. There is no short call over the weekend. Medium call consists of two (2) admissions before 4:00pm

Long Call consists of three (3) admissions before 7pm a. As a general rule, you cannot carry more than 9 patients at

a time at the VA. There are certain circumstances where an intern may be asked to accept an additional patient or two however these situations are rare.

3. Signouts: The signout at the VA is still done by making a table on Microsoft Word/Excel with Patient ID and info, summary statement

27

and active issues, allergies, medication list, code status, and to do list. Signouts can be accessed on the “S” drive and then clicking on the folder corresponding to your team. When you signout at the end of the day, if your co-intern is on call, you should sign out to him or her. Someone from each team should be present at the hospital until at least 4:00pm.

4. An important rule of thumb at the VA is that nothing happens unless you talk to someone about it. What this means is that if you order an imaging study, you should call down to radiology (x4301) and confirm that they got the order. If you order a urine sample for the floor to collect, you should talk to the patient's nurse and make sure they know to collect it.

5. Phlebotomy and IVs. There are phlebotomy rounds 8 times a day and daily IV therapy rounds. There is a physician supply room on each floor that contains supplies for phlebotomy and IVs. After midnight, IV therapy/Labs on Demand may be asked to draw urgent labs. Phlebotomy and nurses occasionally will draw stat labs if they are asked nicely during the day.

6. Consults. If you need to call a consult, page the consulting fellow. Some services (ie Psychiatry) may ask that you enter a consult in the computer as well. You should try to call all consults before noon, if possible. The consulting service will then see the patient that day and give final recommendations within 24 hours. You can get a list of the consulting services for each month from the Resident Program Office.

7. On-call Meal. There is a locked refrigerator and cabinets in the call-room suite stocked weekly with food for the on-call residents. There is also a second refrigerator there to store food if you want to bring meals from home.

8. Social Work. Blue/Green: Social worker is Stephanie (pager 440-562-0589) and discharge planner is Sue (x6714, pager 440-562-0702). Orange/White: Social Worker is Sarah (x4238, pager 440-562-0631) and the Discharge Planner is Lucie (x6713 pager 440-562-0678).

Please include them in your discharge planning as they can be of a lot of assistance in SNF placements. The discharge planners will often round with the post call teams each morning. If you have a renal (dialysis) patient, then you need to work with Denise Green (phone x4248,pager 440-562-0315). If you have a oncology patient, your social worker will be Miranda Payton (x4258, pager 440-562-1491.) If you have a patient being placed on hospice, you need to contact Beth McIver (x3277, pager 440-562-1749)

10. Discharge Planning. Before a patient can be discharged the following five items need to be addressed:

1. Discharge medications need to be put in the computer (preferably 24 hours in advance). This is typically done after completing a “Anticipated Discharge Note” that is reviewed by the ward pharmacist for completeness and accuracy. An

28

effort should be made to complete this note 24 hours prior to discharge.2. Travel arrangements need to be made. If requesting transportation through Travel services you need to enter a Travel Consult. If a patient is brought by ambulance, they will often qualify for travel services at discharge.3. Discharge instructions in computer4. Discharge summary done and in the computer on day of

discharge5. Discharge Order (under Admissions/Discharge/Transfer

order set)11. Radiology After Hours (evenings and weekends).

a. If you need a stat portable X-ray, you should enter it in the computer and then call x4301. If no one answers, have the operator page 'X-ray' overhead to call your extension.

b. If you need a CT scan done after hours you have to call the operator. They will page the radiology technician who will call back to your extension. Explain to the technician the urgency of the test and they will then come in to perform the test. The films will then be sent over to UH and you can page 32494 to speak to the radiology resident on-call at UH to read the CT scan.

c. If you need an MRI or other specialized radiological test after hours, you must transfer the patient to UH. You must call UH transfer center to arrange this. Then, you must place a Non-VA Special procedure in CPRS.

12. Expiring Orders. Certain medication orders will expire on a timed basis. You must renew them periodically otherwise they will not be given. These medications are:

a. IV fluids, IV drips, TPN - 1 dayb. Nebulizer solutions, IV ranitidine, class II narcotics - 3 daysc. Coumadin, lovenox, inhalers, antibiotics - 7 daysd. Class III through Class V narcotic drugs - 14 days

13. Consents. All consents for procedures and blood transfusions are to be completed electronically on CPRS. Each team has a portable laptop that is equipped with an electronic signature pad. You can access the consent program in CPRS under “tools”, then IMED consent. You can enter in “phone consent” into IMED as well.

14. DNR orders. You can enter a DNR order that is good for the first 24 hours. After that, a new order must be written by the attending. There are two types of DNR orders:

a. DNR comfort care: this order is active as soon as it is written and the focus of this is order is to ease pain and suffering. There are no resuscitative efforts taken to initiate or sustain life

b. DNR comfort care -arrest: this order is not activated until patient experiences an arrest. The goal is to provide all indicated treatment until the patient experiences an arrest.Note: You have to fill out both a DNR order set from the order menu AND a DNR progress note. The DNR progress note must be cosigned by the attending in the morning.

29

15. Phones: To reach an outside local line, just dial ‘9’ and then the number. To call UH, dial ‘86’ and then the extension.

16. Pagers: VA pagers generally are 440-562-xxxx. Simply dial this number, when you hear a beep, enter your callback number and press ‘#” when done. To page a UH pager, dial 9-207-7244

17. Codes: Codes at the VA are called ‘Dr. Heart.’ They are announced overhead as well as sent to the code pagers. It is expected that all on-call interns should go to codes and help out in whatever way they can.

18. ICU Transfer: ICU Transfers are coordinated between the ward intern/resident and the ICU resident/fellow. Transfer notes must be written on all patient transfers to and from the ICU

19. Conferences: There are conferences every weekday at the VA, the schedule is:

Day Monday Tuesday Wednesday

Thursday Friday

Conference

Noon Conf.

Grand Rounds

Morbidity & Mortality Conf

Noon Conference

Noon Conference

Location K119/4th

Med conf room

K119 K119 K119/4th floor med conf room

K119/4th floor med conf. room.

K119 Auditorium is on the first floor, past the cafeteria, the rec hall and the library.

In addition, on Thursday there is also intern morning report at 10:00AM in the Department of Medicine conference room

Your seniors are always available to help. The only stupid question is the one you did not ask.

30

WARD 4A & 4B HELPFUL HINTS: TIPS FOR THE VA

DISCHARGE PLANNING: An anticipated discharge note should be completed by the intern 24 hours prior to discharge and includes medication reconciliation. This note will be reviewed by the ward pharmacist for completeness and accuracy and will be forwarded back to the discharging intern.

o Discharge orders MUST be written in CPRS before the discharge process can begin.

o Check to see if the patient needs a Pneumovax or Flu Vaccine prior to discharge.

o Communicate with the discharge planner as soon as a decision has been made concerning a patient’s discharge.

o Discharge planners can assist with travel, supplies, follow- up appointments, home care and IV antibiotics. Order prescriptions on the computer with pharmacy at least ONE DAY BEFORE discharge.

A Medicine anticipated discharge note should be included in the chart for review by a discharge pharmacist.

Make sure that the Medical Record Discharge Instructions agree with ordered Rxs.

o Once it is known that the patient will need travel at discharge complete TRAVEL REQUEST in CPRS. Travel restricted to patients who qualify and/or transfer to CARES. If in questions, call the Travel office.

Note if the patient has special needs, ie wheelchair or oxygen. Travel is generally restricted to non-ambulatory, wheelchair

bound, and ambulance patientso Allow 3-5 days for delivery of necessary prosthetic (durable medical

supplies). You may order as an electronic consult to W Prosthetics.

31

o IV antibiotics/hyperalimentation must be ordered thru consultation to HBPC/Community Primary Care. Allow a minimum of 48hrs to obtain from pharmacy. An ID consult must accompany home IV antibiotics.

o Notify the VNA coordinator 24 hours in advance for needed VNA, HBPC, or Hospice Care. Fill-out appropriate referral form, ie Nursing Care Referral Form

o Must complete the discharge summary and discharge instructions in lay terms prior to the patient’s discharge.

o CARES TOWER TRANSFERS Charts must be coded prior to the patient’s transfer so please notify

the Discharge Planner and CARES Intake about CARES transfers one-day prior to discharge.

Physician to Physician report must be called to the provider at CARES on the morning of the transfer

Notify the patient’s nurse about the transfer as soon as possible so that she can make arrangements for transfer.

PPD status must be determined prior to transfer to CARES or any community nursing home.

STANDARD ORDER RENEWALSo IVFs - 24hrso Narcotics - 72hrso Respiratory treatments - 72hrso Oxygen – 72hrso IV zantac - 72hrso Oral anticoagulants - 7 dayso Restraints (soft wrist and posey) - 24 hours, and this must be done on the special order form.o Fluid orders with potassium – 3 dayso IV heparin – 24hrso SQ heparin – 7 dayso TPN & PPN – 24hrs, before noon

MANDATORY LINE CHANGESo Peripheral – 4 dayso Femoral (central venous catheter) – 4 days or change to another site sooner (highest infection rate

with this site so avoid continuous infusion)o Arterial Line – 3 dayso Central Lines – No time limitation but site must be inspected daily and may be changed over a

wire if no infection is present. (Generally, changed every 5-7 days)o If a line is left in longer that the above policy then a note must be written daily. (ie line site clean,

no other evidence of infection; will leave line in place and monitor.) Remove all lines that are not needed

BLOOD DRAWS AND COLLECTION TIMESo 0600 collection with cutoff time of 0500o 0900 collection with cutoff time of 0830o 1100 collection with cutoff time of 1030o 1300 collection with cutoff time of 1230o 1430 collection with cutoff time of 1400o 1700 collection with cutoff time of 1600o 1900 collection with cutoff time of 1830o 2100 collection with cutoff time of 2030

32

INFORMED CONSENT

Patients must sign informed consent forms prior to receiving: Blood products Or undergoing thoracentesis, paracentesis, lumbar punctures, central venous

catheter placement, and arterial line placement. * As a general rule, anytime skin barrier is compromised.

The witness may be anyone not on the team. Nursing staff may co-sign as a witness on a permit; however, they must be present for your discussion with the patient.

All consent form must be completed via I-MED consent. Include a procedure note in CPRS.

Include the name of the procedure and its indication, as well as the patient’s attending and the name of the residents performing the procedure.

Consent remains viable for thirty days.

The patient must initial and sign the consent as well.. If you can’t obtain a signature due to an emergency then a comprehensive progress note must be written.

The order of surrogates: durable power of attorney for health care, legal guardian, next of kin (wife, adult child, sibling, close friend contact social worker)

Consent in emergency cases may be obtained from the chief of staff if no surrogate is available. The administration or social services will assist in locating the patient’s surrogate.

A procedure note should accompany all situations requiring informed consent, and it should include comments related to the patient’s competency and discussion with the patient/surrogate about indication, risks, benefits, and alternatives to the procedure.

BLOOD PRODUCTS: Consent should be signed prior to the administration of blood products except in emergencies. One consent form is good for all blood products needed in a 30-day period.

SOCIAL WORK

The firm’s social worker will attend morning rounds with the ward team that is post-call.

Nursing Home Care Unit (NHCU) @ CARES TOWERSo Place a consult to B NHCUo Administrative coordinator for the NHCU is Helen Ferrer, B# 388-1284o Requirements for transfer: PPD placement required; discharge summary completed; discharge

order placed with time specified; travel request sent; doctor-to-doctor report and RN-to-RN report called.

CLERK and patient’s RN must be notified of discharge in advance. COMMUNITY NURSING HOME PLACEMENT REQUIREMENTS:

private pay, medicare, and Medicaid forms per social work instructions. Transfer back to the same facility:

o NHCU contact Ms Ferrer, and complete doctor-to-doctor verbal report, discharge summary, discharge orders, and travel request

o COMMUNITY NH and OHIO VETERANS HOME NH form, discharge order, and travel request complete. NH transfers must occur within 14 days or the patient’s bed will be lost.

DOCUMENTATION

HISTORY & PHYSICALo Use the Admission Boiler Plate (admission BP)

33

Must complete each field in order to sign the admission BP. If the patient presents with Chest pain, use the Chest pain BP.

Medical student H&P may not be used or cosigned as the official H&P

Advance Directives must be addressed in the admission H&P. See DNR.

Reference to discharge planning must occur in the plan of the admission note (DISCHARGE PLANNING SHOULD BEGIN ON ADMISSION)

o A complete physical exam should include documentation of breast, pelvic, genitourinary, skin and lymph node exam.

o Addressing social issues, ie living situation, nursing home resident, drives or takes a van, guardian, etc, will assist with discharge planning.

PROGRESS NOTEo Avoid the CUT & PASTE phenomenon, or in other words update your noteso Co-sign and/or place an addendum to all medical student notes. There is no need to write a

separate note.o Acknowledge consultants, abnormal labs, radiology, and therapeutic responseso Daily, unless the patient is on intermediate care then it can be every other day.o Document anything that is taught to the patient and/or their caregiver, and their responses.o Refer to discussions with attendings (Seen and discussed with Dr …)

ORDERSo Co-sign all medical student/AI orders and verbal orders ASAP.

OTHER IMPORTANT TIPS

Notify the nurse caring for the patient immediately after writing a “NOW” or “STAT” order. DNR orders must be co-signed by the patient’s primary attending in order for them to be valid. Paper Charts that are not being used should be returned to the nursing station. Nurses do not perform guaiac tests or electrocardiograms and they do not titrate oxygen. Non-PCU nurses

will only perform ECG’s in emergent situations (e.g. pt with active chest pain) Verbal orders cannot be accepted except in emergency situations. Allergy assessments need to be entered on all patients. Labs on Demand: any lab that is STAT; peak and trough levels; blood cultures; ABGs CONSULTS: Place requests in CPRS except for those consults you personally phone to a provider to have a

patient seen on the ward, ie general surgery, cardiology, etc IV Therapy to assist with IV placement from overnight 7 days a week; you can make requests by paging B#

388-0599, however the nursing staff and ward clerks generally do the paging. If the IV nurse is unavailable other options include nursing supervisor, ICU nurse, or a resident.

Escort Services: to assist with lab specimen, blood bank requisition, and stat lab specimen pick-up 24hrs a day, 7 days a week; also, to assist with patient transport; for assistance call ext 5095 from 0800-1630 or page 388-0647 // 388-1018 from 1630-0800

AFTER HOURS EMERGENCY RADIOLOGY

CT scan, Angiography, and MRIo Call the VA operator for the number of the radiologist on callo It the patient is to be transferred outside the VA, then complete the “request for non-VA services,” and

the Chief of Radiology, Dr Naheedy, must sign this on the next working day.

34

Patients with IVs will need a minimum of a paramedic attendant and unstable patients may require ground ICU transport.

o The radiologist on-at UH will read the film if the team does not feel comfortable interpreting the film.o If consent is needed for a procedure and the patient is unable to consent then discuss the procedure with

the surrogate and have that individual stay near the phone to provide consent.o If considering an MRI then determine if the patient has any metallic prosthesis or internal shrapnel

prior to scheduling the procedure.

Nuclear Medicine attendings should be called if a nuclear procedure is required after hours. The attending comes into the hospital to interpret the study after it is completed.

INFECTION CONTROL

BLOOD/BODY FLUID EXPOSURE (needle stick, splash, etc) Wash affected area and notify supervisor Report to personnel Health during administrative hours and at all

other times report to the Acute Treatment Room Prophylaxis for high-risk needle stick injury should begin ASAP

(within fifteen minutes). Patient HIV counseling is done by an AIDS team member

Avoid bending, breaking, and recapping needles. If recapping is required use the one-hand technique

Follow Infection Waste Management guidelines. Use red bags, sharp containers, etc, appropriately.

The following are available through Personnel Health: Hepatitis B vaccine and antibody testing, PPD testing, Flu vaccine, Varicella titers, and Varicella vaccine

BLOOD CULTURES: Draw two sets of peripheral blood cultures or one set from a central line and one set peripherally when obtaining the initial set of blood cultures from a patient. Place 7-10cc of blood in each bottle and do not cover bar code with label.

INFECTION CONTROL NURSE: Liza Eckstein, RN ext 4791 B# 648-2139

PERSONNEL HEALTH: Dan Tinman, MD ext 4445

ADVANCE DIRECTIVES/DNR

DNR orders must be co-signed by the attending physician in order to be valid.o Use pre-printed order form and progress note to document DNR.o These orders must be reviewed when a patient has a change in their

medical status, on admission or discharge from an ICU and every 30 days. In addition, they must be rewritten on transfer.

o Limitations must be specified in the orders.

35

o In order to preserve the right of the patient to choose among treatment options, DNR orders will not automatically be cancelled when a patient goes to the OR.

o The attending physician or resident must document the discussion, as it relates to DNR, with the patient and/or surrogate in the chart.

o Ohio portable DNR should be on the chart during transfers

Use advance directives to clarify end of life care, except DNR.o They must be reviewed at every hospital admission, per patient request,

change in mental status, admission to ICU, and annually in long term care patients and outpatients.

o These discussions should be documented in the admission note or progress note, acknowledging the Advanced Directives and clarifying any care limitations.

o If a patient desires to make an Advanced Directive or designate a durable power of attorney for health care (DPAHC) then call social services or a chaplain.

o A member of the medical team cannot witness the form.

END OF LIFE DISCUSSIONo Include the following in the discussion with the patient: diagnosis,

prognosis, treatment options, comfort care, and hospice care.o PALLIATIVE CARE

Write specific comfort care orders, ie oxygen, suctioning, analgesia, and sedation

May refer to the palliative care team (Beth McGyver) for: terminal illness comfort care and patient/family emotional distress.

o ORGAN DONATION can be discussed/addressed when asking about advanced directives

Contacts: Coroner 721-5610 & LifeBanc 752-5433

DICTATION FORMATS

USE THE DISCHARGE SUMMARY BP WHEN TYPING DISCHARGE SUMMARIES ON CPRS.

DICATATE EVERY ADMISSION REGARDLESS OF THE PATIENT’S LENGTH OF STAY

OXYGEN THERAPY

Obtain a pulse oximetry or ABG prior to and within 6hrs of initiating oxygen Reason for oxygen must be documented either in progress notes or with the order

36

Order to be renewed every 3 days Consult Wendy Dukes for home oxygen therapy

o Patient must have pulse oximetry < 88% or PaO2 < 55 on room air and this must be documented in the patient’s record.

o Values must be obtained within one-week of discharge

SHORT STAY UNIT (extension 5714)

Located on Ward 52 Nurse manager Marion Yowler (B# 388-0699) Social Work coordinator is by service, ie medicine, renal, palliative care, HIV, etc Patients may only be admitted to ward 52 and stay for 23 hours. If the patient’s length of stay increases then

he or she must be admitted to the medical service on ward 42 or 44. All charting to be completed on the short stay tri-fold, including the discharge summary. Barbara Adams (ATR and ward 3A) and Margaret Harris (ward 3B), from quality management and

utilization review, can assist with questions regarding patients that may be appropriate for the short stay unit. Examples of appropriate admissions include: pain control, blood transfusion, peri-procedure

(thoracentesis, paracentesis, PEG tube placement, lung or liver biopsy), and other diagnosis or symptoms requiring a brief observation period.

HOPTEL This is a service rendered to Veterans and families of hospitalized veterans who live greater than 60 miles from Wade Park so that they have a place to stay in Cleveland while undergoing treatment. The VA currently contracts with a local hotel until such time that the hoptel facilities at Wade Park are renovated. Arrangements can be made for Family members by contacting Carla Reed at ex 5700. There is a 2 business day turn around time for hoptel requests. If an urgent request is required, please call Carla Reed at ex 5714

ICU TRANSFERS

Resident- Resident report is critical and performed between the PGY2/3 ICU resident and floor resident at the time of transfer.

Unless the ICU is full and a bed needs to be made available. Urgent floor to ICU transfers are always available.

37

Your First Day in the UH MICU

The UH MICU is a very busy month and can be very intimidating to start. Just remember that there is a very steep learning curve and that there are always upper level residents and the MICU fellow around to help you. Here is some more info to help you throughout this month:

1. You will be paired with an upper level for your MICU call. Talk to the senior on the day prior to starting to determine which patients on which you should pre-round.

2. Never be heard saying, “That’s not my patient.” Remember, while you may not be the primary care giver for a particular patient, you should know about every patient in the MICU. If it is something simple like a nurse asking you to replete potassium, then you should place the order and tell the resident who is responsible for that patient. If it is something more complicated like a family meeting, help the nurse find the resident who is responsible for that patient.

3. Rounds will start at 8:00AM in the back of the MICU. Radiology will be reviewed on all the patients in the MICU. Try to review all the films taken in the past 24 hours on your patients prior to rounds. Especially note where the central lines are located and whether the ET tube is in proper position. You will be asked to interpret the films in front of the team on rounds so take the time to review the films so that you are prepared for rounds.

4. For call, you will be paired with an upper level resident. Interns will stay until 9:00pm. It is up to the discretion of the resident to determine how the patients will be distributed while on call. Even if you are not writing the admission note, you should be aware of all the patients that are admitted, as you will have to cover these patients when the resident is off.

38

5. The MICU team on-call is responsible for attending all Code Blues in the entire hospital. As the MICU intern, you should make your way into the room and be an active part in the code (ie doing chest compressions, getting ABGs, etc). Keep the ACLS algorithm cards in your pockets at all times while in the MICU.

6. Trust the opinions of the senior nurses and respiratory therapists. They have been doing this much longer than you have and know what to do when a patient is sick.

7. You should be involved in as many procedures that are done in the MICU as possible. Have the resident or fellow walk you through how to do a procedure and review the items in the pre-packaged procedure kits. After you have seen a few lines placed, you should have the fellow help you place a line. Be sure to have a signed consent form in the front of the chart and write a procedure note (using the pre-printed stickers) after every attempted procedure. Document all your procedures on my evaluations!!!!

8. Remember to address code status with every patient admitted to the MICU.

9. There are two nurse practitioners in the MICU. They are very helpful for everything from helping with lines and procedures to taking patients. Any patient that is chronically vented or from a LTAC should be picked up by the NP in the morning. The NPs will also help covering the patients of the intern or resident who are off.

10.Please call the DACR to notify them of any patients that you are sending out of the MICU to the floor. IT is helpful to know the patient’s primary care provider and if they have any medical problems (ie HIV, ESRD, cancer) that necessitate a particular team assignment. The DACR will then assign the team and give you an intern to call report.

11.There is plenty to learn about mechanical ventilation, pressor support, ARDS, CVVH, etc. Do not feel like you need to know everything before you start, but if you want to get a headstart, the reading list can be found on casemedicine.com if you click on the link called “UH MICU” or Resident Reading list under Pulmonary.

**REMEMBER: There is a MICU fellow who is available 24-hours per day. The only stupid question is the one you did not ask!

39

Your First Day on Carpenter

Here is some info to help you throughout this month:

Rounds will be at 8:00AM in the Lakeside 60 conference room. Ideally, the majority of your patients will be located on Lakeside 60, 65 and 20; however they can be located anywhere in the hospital.

There will be two interns on this ward team. Call will be as follows: Long call, medium call, short call and then no call on 4 consecutive days. The cycle will then repeat. Call is from 7AM to 9:00pm with last admission assigned by 7:00pm. One intern will take long call with the senior resident, while the other intern will be the ‘orphan’ and will be covered by a senior from the other on-call team.

Short call consists of two (2) nightfloats or ICU transfers before 2:00 PM with the following exceptions:



Long Call consists of three (3) admissions before 7pm

As a general rule, you cannot carry more than 10 patients at a time on UH wards. There are certain circumstances where an intern may be asked to accept an additional patient or two however these situations are rare.

40

On the weekend, there is no short call, only medium and long call. You will occasionally have a 3rd year medical student working with you on this service. They can carry a maximum of three patients and they should pick up a patient on each call. They will write an admission note and you should co-sign their note and write a full admission note of your own. Try to pick patients that are interesting and present a good learning experience. The third year medical students also do not take overnight call so try to get them a patient early in the day, if possible.

When the team is on Long/Short call, the intern on short call should sign out to the intern on long call at the end of the day. The long call intern will then sign out the entire team by 10:30 to the nightfloat intern. When the team is on medium call, the medium call intern will stay until 7:00 pm and sign the team out directly to the intern nightfloat. In the morning, you should pick up your signout from the night float intern on tower 5 promptly by 7:00am.

The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor conference room to distribute the nightfloat admissions from the previous night. If you are on short-call you should check to see if you have any nightfloat admissions. On the days that you are on short call you should get there at 7:00 am to allow yourself time to see nightfloat patients before rounds. You do not have to write a full admission note if the nightfloat has already written a note. You simply have to write an acceptance note that contains a paragraph briefly summarizing the nightfloat’s note and then the remainder of the note is the same as a daily progress note.

Some months on Carpenter, there is an ID fellow on service. They are there to assist you in the management of your staff patients and can help supervise procedures as well.

While performing your history for an HIV patient, you must find out the following:

a. Where do they get their HIV care and who is their HIV doctor?b. What is their last CD4 count and HIV viral load?c. What HIV medications are they on and have they missed any

doses?d. Have they ever had an opportunistic infection (PCP, MAC,

toxoplasmosis, Cryptococcal meningitis)?Note: the easiest way to get this initial info for HIV patients who see physicians at UH is to call the Special Immunology Unit (SIU) at x41585 and have them fax over this info from their chart at the SIU.

e. Perform a thorough pulmonary, skin and lymph node exam. In addition, you should perform a Mini-Mental Status Exam if there is any question of mental status changes.

When performing a physical exam on an HIV patient, you should always examine the skin for open blisters or sores, look for thrush or ulcers in their mouth, and perform a thorough neurological exam.

41

HIV patients are on prophylactic antibiotics for opportunistic infections and you need to determine if they have been compliant with this medication. Here is a list of common prophylactic regimens:

As you may know, the war on HIV/AIDS is being won by early introduction of highly active anti-retroviral therapy (HAART). Typically the three components of HAART triple therapy are three drugs from at least two different classes. Typically, this translates into two nucleoside reverse transcriptase inhibitors (NRTI), plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). A few points about HAART therapy:

Patients should definitely be on HAART if their CD4+ count is <200, and it should be considered if the CD4+ count is 200-350. In addition, if their HIV RNA level is >100,00 copies/ml, they should be on HAART.

It is ESSENTIAL that patients are compliant with their medication regimen and adhere to the dosing schedule. This is the only way provide durable viral suppression and to prolong the time to development of resistance.

The HAART medications have some unique toxicities including nephrolithiasis, hyperbilirubinemia, vivid dreams/nightmares, and hypersensitivity syndrome. In addition, these drugs can also cause more typical side effects, such as nausea, vomiting, malaise and diarrhea. Furthermore, many of these medications are metabolized by the cytochrome P450 enzyme and can lead to drug-drug interactions with other medications.

42

If side effects or drug interactions become a problem and it becomes necessary to change medications, it is ESSENTIAL that you do not simply stop one or two HAART medications. This is due to the fact that viral resistance can develop quickly to a one or two drug regimen. It is better to stop all three medications than to have the patient taking just one or two medications.

Amphotericin and other ‘big gun’ antibiotics are often restricted and you must obtain approval from the Pharmacy Antibiotic Approval person on-call. You must page 30316 and explain your rationale for prescribing this restricted antibiotic.

The team pager for the Carpenter team is pager 32661. The nurses can use it to contact you from 2:00 PM until 8:00AM the following morning. It is also a text pager and you should encourage the nurses to use this function if they just want to send you a piece of information (i.e. – your patient’s family has arrived, the evening blood pressure, etc…). The team pager is also a code pager. You should carry it with you at all times when you are on call and hand it off at rounds the following morning. It also needs to be handed off to cross cover when signing out to them.

Your seniors are always available to help. You can also check the ID reading list on the website. The only stupid question is the one you did not ask.

43

Your First Day on DworkenRevised 6/6/12


Rounds will be at 8:00AM in the Lakeside 55 team room. Ideally, the majority of your patients will be located on Lakeside 55 however they can be located anywhere in the hospital.


Short call consists of two (2) nightfloats or ICU transfers before 2:00 PM with the following exceptions:







The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor conference room to distribute the nightfloat admissions from the previous night. If you are on short-call you should check to see if you have any nightfloat admissions. On the days that you are on short call you should get there at 7:00 am to allow yourself time to see nightfloat patients before rounds. You do not have to write a full admission note if the nightfloat has

44

already written a note. You simply have to write an acceptance note that contains a paragraph briefly summarizing the nightfloat’s note and then the remainder of the note is the same as a daily progress note.

The team pager for the Dworken team is pager 32299. The nurses can use it to contact you from 2:00 PM until 8:00AM the following morning. It is also a text pager and you should encourage the nurses to use this function if they just want to send you a piece of information The team pager is also a code pager. You should carry it with you at all times when you are on call and hand it off at rounds the following morning.

The admission diagnoses accepted to the Dworken team are as follows:1) GI bleeding: must include either:

melenahematochezia, and/orhematemesis

Anemia with guiac + stool is NOT acceptable

2) Established diagnosis of IBD with GI symptoms

3) Acute pancreatitis: Diagnosis established by 2 of 3 criteria: amylase/lipase levels 3x normal, upper abdominal pain with nausea and vomiting or CT scan showing pancreatic inflammation

4) Established diagnosis of chronic pancreatitis with GI symptoms

5) Primary diagnosis of acute or chronic diarrhea (including malabsorption)

6) Established diagnosis of acute diverticulitis (CT confirmed)

7) Obstructive jaundice or cholangitis or choledocholithiasis (including dilated bile ducts on imaging)

8) Primary diagnosis of dysphagia

9) Esophageal/gastric/pancreatic/colon mass (if malignancy established pt should go to Heme/Onc)

10) Foreign body or food impaction

Many of the patients you will admit to the Dworken team will have gastrointestinal bleeding. Here are some tips to help you with the initial management of these patients.

History and physical exam: The history obtained from a patient with a suspected GI bleed should include: The age of the patient, any history of previous GI bleeding, any previous surgeries (esp. AAA repair), medical comorbidities especially any history of liver disease, any history of previous endoscopies (MUST obtain these reports), what

45

specific symptoms the patient is suffering from and a complete medication list (NSAIDs). The physical exam should be focused on identifying stigmata of liver disease, evoking any abdominal tenderness and a rectal exam. ALL patients with suspected GI bleeding should have a rectal exam done by the admitting intern (even in one was already done in the ED).

Venous access and Resuscitation: All patients with GI bleeding must have adequate IV access. This includes 2 large bore peripheral IVs, a triple lumen catheter (ICU) or a “Cordis” (ICU). Orthostatic vital signs should be checked on all patients. Resuscitation can be done using crystalloid (IVF) or colloid (blood products) and coagulopathies should be reversed. Remember a patient has to have an adequate blood pressure to undergo sedation for endoscopy.

NG lavage: An NG lavage should be completed on any patient with as suspected upper GI bleed and should at least be considered on patient’s with suspected lower GI bleeding unless the source of lower GI bleeding has already been determined. Your senior resident can help you with this procedure.

Laboratory evaluation: Laboratory evaluation for a patient with a suspected GI bleed should include: CBC, renal function panel and a coagulation panel. Additional labs may be indicated depending on the individual patient situation.

Medications and definitive treatment: The medications given to a patient with a suspected GI bleed will vary depending on what the suspected source of blood loss is. Please work with your senior resident and the GI fellow to determine the best medication regimen for your patient. Always make these patient’s NPO overnight unless you are sure there will not be an endoscopy the following day. You will work with your senior resident/GI fellow to determine which patients need to receive bowel prep on admission.


Your First Day on Nightfloat

46

Revised 6/6/11

Here are a few tips to help you out:

There will be 3 interns on a two-week nightfloat rotation. There will be 2 interns per night, 7 days/week.

Your nightfloat coverage begins at 7:00 p.m. when you take signout from the medium call intern in the Tower 5 medicine room.

The signout session between the medium call/long call intern and the nightfloat intern will be facilitated by the upper level night float resident or NACR.

Between 7-10:00pm, the on-call interns will be signing out their own team to the NF interns. By 10:00pm, all patients should be signed out to nightfloat team.

Each nightfloat intern will be responsible for admitting up to 2 patients between 10:00pm and 5:30am at the discretion of the NACR

At 7:00 a.m., formal signout rounds of all the medical teams will occur in the Tower 5 medicine room.

During your time of coverage, you will be working as a team with the PGY-2 nightfloats as well as the NACR. Any questions or concerns regarding patient care should be addressed with them. The senior resident should always be involved in the case of any patient who needs an upgrade of care to an ICU-setting.

When called about a significant event, it is important to make a brief note about the event and what was done in the patient’s chart so that the primary team and consultants are aware. Additionally, make a note of it on the signout to facilitate communication.

Rule: If you go see a patient for ANY reason, you must document this in the chart!

Your First Day on EckelRevised 6/06/12

47


Rounds will begin at 8:00 AM in the Lakeside 50 team room. Your hemodialysis and private patients can be located anywhere in the hospital. However, most of your peritoneal dialysis patients will be located on Lakeside 50 because the nurses are trained in how to use the equipment. You are expected to pre-round on your patients even if they are already in the hemodialysis center (across from Lakeside 20).

There will be 4 interns on this ward team. Call will be as follows: Long call and medium call on 2 consecuative days, followed by 2 days of no call. The cycle will then repeat. Call is from 7AM to 9:00pm with last admission assigned by 7:00pm. Two intern will take long call with a senior resident, while the other two interns will be the ‘orphan’ and will be covered by a senior from the other on-call team.

Short call: There is no short call on Eckel Medium call consists of two (2) admissions before 4:00pm



You will occasionally have a 3rd year medical student working with you on this service. They can carry a maximum of three patients and they should pick up a patient on each call. They will write an admission note and you should co-sign their note and write a full admission note of your own. Try to pick patients that are interesting and present a good learning experience. The third year medical students also do not take overnight call so try to get them a patient early in the day, if possible.

The long call intern will then sign out the entire team by 9:00pm to the nightfloat intern. The intern on medium call intern will stay until 7:00 pm and sign the team out directly to the intern nightfloat. In the morning, you should pick up your signout from the night float intern on tower 5 promptly by 7:00am.

The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor conference room to distribute the nightfloat admissions from the previous night. If you are on short-call you should check to see if you have any nightfloat admissions. On the days that you are on short call you should get there at 7:00 am to allow yourself time to see nightfloat patients before rounds. You do not have to write a full admission note if the nightfloat has already written a note. You simply have to write an acceptance note that contains a paragraph briefly summarizing the nightfloat’s note and then the remainder of the note is the same as a daily progress note.

Eckel is a very data-oriented service and daily labs are very important. Unfortunately, dialysis patients are often difficult for phlebotomy to draw labs from. Make sure that you have ordered labs every day and call to make sure

48

they were drawn. If the labs could not be obtained, you will need to draw labs yourself. On the days that your patient is in dialysis, it is easiest and most reliable to have labs drawn in dialysis. This can be done through the dialysis order set in the EMR. In a crunch, you can call the HD unit and ask one of the nurses/techs yourself.

Keep in mind the indications for acute (emergent) dialysis:o Severe volume overload causing pulmonary edemao Severe metabolic acidosiso Refractory hyperkalemiao Acute uremia causing mental status changes, pericardial

effusion with tamponadeo Toxin removal

Emergent dialysis during regular hours is done by calling the dialysis nurse practitioner. After hours, the renal fellow on-call must be called.

While taking your history for a dialysis patient, find out the following:o Who are their nephrologists?o Where do they get their dialysis (i.e. CDC East, VA, UH,

etc…)?o What days do they get their dialysis? (Mon, Wed, Fri –OR-

Tues, Thurs, Sat)o Have they missed a dialysis appointment recently? When was

his/her last dialysis?o What is their access (fistula, graft, temporary catheter) and

when was it placed?o What is their “dry weight?”

Once you have admitted your patient, you should call their dialysis center (if you are unsure of the phone number, the HD unit at UH has most of them on file) and ask to have the following faxed to UH, preferably directly to the dialysis unit (x48975) if it is still open:

o The patient’s last three run sheets – from these you can find out useful information, e.g., whether a run was terminated early, if a patient became hypotensive or febrile on dialysis, how much fluid was removed

o The “monthly packet”, which includes routine dialysis labs (among other things)

o You should also call the patient’s dialysis center to follow up on blood cultures drawn prior to admission.

Dosing of medications in renal patients must be adjusted for creatinine clearance. A rough estimation of creatinine clearance can be obtained by using the Crockroft-Gault equation or it can be calculated accurately by a 24 hour creatinine collection. For a dialysis patient that is anuric, their creatinine clearance is 0. ALWAYS check every medication for dosage adjustments (calling the pharmacy x 42016 is sometimes the best way to find out).

o Crockroft – Gault: CrCl = (140-age) x (lean body weight in kg) x (0.85 in

49

women) (serum Cr in mg/dl) x 72

o 24 hour urine collection:CrCl = (urine Cr in mg/dl) x (volume of urine in ml) (serum Cr in mg/dl) x (minutes)

The dialysis techs are your friends! If you ask nicely and put in the orders the following things can be done while patients are on dialysis :

o Labs can be drawno Blood cultures can be drawn from lines (phlebotomy can

draw peripheral blood cultures during regular hours)o Blood products can be administered – this is particularly

useful in these fluid-restricted patients, since extra fluid can be removed to compensate

o Antibiotics are often best given at dialysis and should be dosed q dialysis.

Pain control in dialysis patients is a tricky issue. It is preferable to use small doses of Dilaudid (hydromorphone) over morphine because Dilaudid is metabolized by the liver. Morphine is a poor choice because it can accumulate causing respiratory depression and mental status change. Similarly, for anxiety, Ativan can also accumulate. Haldol may be a better choice.

Potassium is another tricky issue. Hemodialysis patient have a tendency to get hyperkalemic (especially if they miss a dialysis session). Peritoneal dialysis patients tend to be hypokalemic. Be careful about aggressively repleting potassium in your hemodialysis patients – it is ok if it is a little low. You should also avoid repleting potassium based on labs that were drawn immediately post-dialysis: the value will be falsely low for a few hours while the patient’s body re-equilibrates. At discharge, make sure your hemodialysis patients understand that they must follow a renal diet and avoid foods with high potassium.

Be careful with your fluid management on your dialysis patients. Too much fluid can send a patient into pulmonary edema. Too little and they can be hypotensive. You will not be able to use your BUN/Cr to determine if a patient is volume depleted. Therefore, you must rely upon your physical exam, checking orthostatics and a CXR to determine if someone if hypo-, hyper-, or euvolemic. Comparing a patient’s current weight to their “dry weight” can also be helpful in this assessment.

There are very helpful dialysis nurse practitioners who can arrange emergent dialysis during regular business hours and act as the liaison between our service and the Transplant Surgery service that is responsible for placing, maintaining, and repairing dialysis access (i.e. – fistula or graft) in our patients.

Patients requiring temporary access will need this placed in Angiography. You will need to have coagulation profile in the computer with an INR of 1.2 or below and the patient must be able to consent for the procedure or have a

50

power of attorney that can consent for them. Also, if they have a contrast dye allergy they need to be prepped accordingly.

The team pager for Eckel is 33559. It is also a text pager and you should encourage the nurses to use this function if they just want to send you a piece of information. The team pager is also a code pager. You should carry it with you at all times when you are on call and hand it off at rounds the following morning.

Eckel may or may not have “golden weekends” (i.e. off Sat and Sun), this will be at the discretion of your senior residents. If you have an important event that requires a golden weekend, please speak to your seniors prior to starting your month on Eckel so they can plan accordingly.

Always ask questions, the only stupid question is the one you did not ask!!!!

51

Your First Day on Elective


Elective is your opportunity to explore career interests, pursue research projects or gain additional knowledge in a specialized area of medicine. There are a variety of clinical electives you can choose from. The most common clinical electives are consult services. You can arrange these by finding out which attending is on the consult service for the month and asking them if you can do an elective with them. You will work with the on-service fellow and any medical students doing elective on the service as well. Other clinical electives are also available and as long you can arrange a preceptor to supervise you, it is possible to do almost any type of rotation. Examples of other types of clinical electives people have done include rotating though the CICU or MICU, working in a community physician’s office, anesthesia, dermatology, radiology, echocardiography and ophthalmology.

All electives need to be approved by your program director and reported to Chris Myers at the VA . This should be done before your first day of service.

While on elective, you will be asked to cover a VA nightfloat Saturday shift to cover the day off for the VA nightfloat intern.

Electives are also a great time to do research. If you have an area of interest, talk to attendings in that department to see who is doing research in your area. In addition, the chief residents and senior residents can also recommend good research mentors. If you do research at any time during the year, you will be required to present your work during the spring research talks. This is a great opportunity to gain experience in presenting your work as well as a chance to get some feedback on your project.

Residents have also done away electives in other cities or even other countries. In the past, residents have done projects such as working at the NIH, volunteering in Africa and rotating at another hospital. You need to set this up several months in advance and identify a preceptor who will supervise you. All away electives must be approved by the Program Director. If you are planning an away elective the Ambulatory chief must be informed at least 30 days in advance to arrange clinic coverage. If you inform the chief less then 30 days prior to leaving for your elective you must arrange your own clinic coverage.

You are expected to attend Grand Rounds, Morbidity and Mortality Conference, Noon Conference and clinic, unless you are doing an elective outside of the Cleveland area. You are also required to attend morning report at the VA daily.

When you are on elective, you may be on jeopardy call (this will be indicated on your schedule as consult/jeopardy), which means you can be called to cover an intern on the floor who is sick or has a family emergency. Interns on elective may be pulled to cover for VA Saturday Nightfloat coverage. As a result, you must keep your pager on you at all times and stay in the Cleveland area. If you must leave the area, you must notify the chief resident right away.

52

Again, the most important thing about elective is that you must turn in an elective form that identifies what you did for your elective and who your preceptor is. The forms are located in Barb’s office and they must be turned into her. If you do not indicate your elective plans in a timely manner, you will be required to meet your assigned program director.

Elective is also a time to get caught up on your sleep and take care of the smaller details in your life. Enjoy yourself!

53

Your First Day on Hellerstein


Rounds will begin at 8:00AM in the Tower 5 conference room. Most of your cardiology patients will be located on the telemetry floors, Tower 3, Tower 5, and Tower 7. You may have some patients on the observation unit on Lakeside 50. Your cardiac patients that no longer require telemetry and private patients can be anywhere in the hospital.

There will be 4 interns on this ward team. Call will be as follows: Long call, medium call, short call and then no call on 4 consecutive days. The cycle will then repeat. Call is from 7AM to 9:00pm with last admission assigned by 7:00pm. Two interns will take long call with their senior residents, while the other interns will be the ‘orphan’ and will be covered by a senior from the other on-call team.

Short call consists of one (1) nightfloats or ICU transfers before 2:00 PM with the following exceptions:a. If you have clinic on your short call day, you do not get

admissions.b. There is no short call over the weekend.

Medium call consists of two (2) admissions before 4:00pmLong Call consists of three (3) admissions before 7pm




The telemetry nurses are great and are very experienced in dealing with cardiac patients. They will draw AMI panels on cardiac patients located on telemetry and coagulation panels on patients on heparin

54

protocol. They are not required to draw any other routine labs, but occasionally they will do so if you ask nicely.

You can get echocardiogram and cardiac catheterization reports online via the Physician Portal. (On the Portal homepage, select “HeartLab” from the “Cardiology Systems” menu on the left and enter your UHHS system signon and password.) You should obtain the most current echo and catheterization reports for all of your patients. You can also access these through the EMR.

Telemetry is a precious resource and beds are always limited. If your patient no longer requires telemetry, do the honorable thing and discontinue it. The nurse manager may approach you and ask if tele is necessary on all your patients. The most common indications for telemetry are:

o Patient being admitted to rule out MI who has NOT had three negative AMI panels

o Patients with significant bradyarrythmias or tachyarrythmias that are not rate controlled

o Patients with significant hyperkalemia and concerning ECG changes

o Patients with a recent STEMI or NSTEMI who require monitoring for ventricular arrhythmias

o Patients with documented ventricular arrhythmias or history concerning for ventricular arrhythmias

o Patients with newly placed pacemakers or admitted for evaluation of pacemaker firing or possible pacemaker malfunction

o Patients admitted for syncope workupo Heart failure patients undergoing significant diuresis and/or

initiating ionotropic therapy On your first day of Hellerstein, become familiar with the monitors on

the telemetry floors. Learn how to review your patient’s last 24 hours of telemetry monitoring and ask the nurses at the monitoring stations if any events happened overnight. Most of the time, abnormal telemetry strips will be in bedside vitals chart. If any events happened, ask the nurse to print a copy of the tracing and bring this to morning rounds. Checking with telemetry is a mandatory part of your pre-rounds on this service and you should include this info in your presentation each morning.

There are two classic types of admissions you get as a Hellerstein intern: 1) chest pain-rule out MI and 2) heart failure exacerbation. There are certain things you should determine for each type of these admissions.

When taking a history for a patient admitted with chest pain:i. When did the chest pain start and how long did it last?

What was the patient doing at the time when the pain started?

ii. Where is the chest pain located? Does it radiate anywhere?

55

iii. Are there any exacerbating or relieving factors? Is it associated with exertion and relieved with rest or nitroglycerin?

iv. Have they had any associated symptoms such as dyspnea, diaphoresis, or nausea?

v. Have they had an MI in the past? If so, did they have a heart catheterization? If so, what was the result and where was the procedure performed? Did they have a stent placed?

vi. Have they had a CABG in the past? If so, how many vessels were bypassed? Where and when was the surgery done?

vii. Have they had their cholesterol checked? Were they placed on cholesterol lowering medications?

viii. Have they ever had an abnormal ECG or stress test? Have they had an echocardiogram?

ix. Do they have a family history of heart disease? Anyone ever died suddenly without explanation?

x. Do they have social history or smoking, alcohol abuse, drug use or sedentary lifestyle?

While taking your history for a patient admitted with heart failure exacerbation, you must find out the following:

xi. Have they had any chest pain? (see above)xii. Have they had any prolonged immobility, recent surgery

or a history of a DVT? Did they have an acute onset of dyspnea?

xiii. Have they had a cough, fever, worsening dyspnea, or sick contacts?

xiv. Have they had any palpitations or has their defibrillator fired?

xv. Have they been compliant with their medications and/or diet?

xvi. Are they anemic or have they had a recent GI blood loss?These questions pertain to the 6 most common causes of heart failure exacerbations: MI, PE, pneumonia, arrhythmia, medication/dietary noncompliance and anemia.

The ACC/AHA has a published guideline entitled ‘The Management of Patients with Acute Myocardial Infarction.’ According to this guideline, for each patient being evaluated for possible MI, the following should be given (unless a contraindication exists):

o Aspirin 325 mg PO daily (main contraindication: allergy, GI bleed, bleeding diathesis)

o Metoprolol 25 mg PO q6 hours (main contraindication: reactive airway disease, significant bradycardia or hypotension)

o Lisinopril 5 mg PO daily or Captopril 3.125 mg PO q8 hours (main contraindication: allergy, angioedema history, renal insufficiency)

56

o Statin: Atorvastatin 80 mg PO daily(main contraindication: allergy, pregnancy, severe liver disease)

o Lovenox 1 mg/kg SC bid for creatinine clearance >30 or 1 mg/kg SC daily if the patient has a creatinine clearance <30. Unfractionated Heparin for patients whose weight exceeds 150kg or with a creatinine clearance <10.(main contraindication: allergy, active bleeding, thrombocytopenia)

****Remember these few things while putting in orders on patients:o Echocardiogram (if indicated)o Daily ECG’s. o NPO after midnight for cardiac catheterization (if indicated)o Empiric pharmacotherapy: see above #8

*****For patients admitted for heart failure exacerbation, o Echocardiogram o Admission BNP o Follow-up chest x-rays o Daily diuretic regimen

If a patient has had a cardiac catheterization, abnormal stress test, or CABG surgery in the past, you MUST obtain the report as soon as possible, preferably on the night of admission. If you are planning on sending someone who has had a CABG surgery for a cardiac catheterization, it is IMPERATIVE that you get either the operative report or a post-surgery catheterization report that details the patient’s anatomy, PRIOR to sending the patient for cardiac catheterization. In addition, if a patient has had any sort of vascular bypass procedure it is essential to know exactly what was done PRIOR to sending that patient for a heart catheterization. It is also essential to determine if a patient has an allergy to IV contrast dye and if so, the patient needs to be properly prepped with the steroid prep. If a patient has acute or chronic renal insufficiency, they must also be properly prepped with fluids and Mucomyst prior to the procedure. For a patient with ESRD, arrangements must be made to dialyze the patient after the procedure. In each of these situations, the risk of the procedure must be weighed against the potential benefits before the catheterization is scheduled.The team pager for the Hellerstein team is pager 32605. It is also a text pager and you should encourage the nurses to use this function if they just want to send you a piece of information The team pager is also a code pager. You should carry it with you at all times when you are on call and hand it off at rounds the following morning.


57

Your First Day on Naff/Wearn


Rounds will begin at 8:00 AM in the Lakeside 65 conference room (Naff) or the Lakeside 450 conference room (Wearn). Naff and Wearn are the general medicine “sister teams.”


Short call consists of two (2) nightfloats or ICU transfers before 2:00 PM with the following exceptions:a. If you have clinic on your short call day, you do not get

admissions.b. There is no short call over the weekend.

Medium call consists of two (2) admissions before 4:00pmLong Call consists of three (3) admissions before 7pm



58


The Naff/Wearn teams were established as hospitalist teams to provide inpatient general medicine care for patients who have their own PCP. The idea is that these PCPs will turn over the care of their patients to the hospitalist while the patient requires hospitalization and then the hospitalist will help transition care back to the PCP when the patient is ready to go home. Therefore, you should arrange for every patient to have follow-up with their PCP upon discharge and either you or your attending should call the PCP at discharge to summarize the patient’s hospital course and let them know if any medication changes were made while the patient was hospitalized. You should also send the PCP a copy of the discharge summary; if the PCP is not in the UH online directory, include the physician’s fax number or office address in your dictation to ensure that a copy gets to them.

Since these are both general medicine services, you may be calling consults more frequently on this service. It is recommended that you try to call the consults early in the day (before noon), so that the fellow has a chance to see the patient and staff it with their attending that day. If you call the consult late in the afternoon, the fellow may be upset and they may not have a chance to see the patient until the following day.

The team pager for the Naff team is pager 33726, for Wearn pager 32654. It is also a text pager and you should encourage the nurses to use this function if they just want to send you a piece of information. The team pager is also a code pager. You should carry it with you at all times when you are on call and hand it off at rounds the following morning.


59

Your First Day on Ratnoff/Weisman


Rounds will begin at 8:00AM. Ratnoff will begin rounds on Seidman 3 and Weisman will begin rounds on Seidman 4. Your patients will primarily be located on floors 3 and 4 of the Seidman Cancer Center however, you may have some patients on Seidman 6 or at Case Medical Center.

Call. There will be two interns on each ward team. Call will be as follows: Long call, medium call, no call and no call on 4 consecutive days. The cycle will then repeat. There is no short call on Ratnoff or Weisman. Long call is from 7AM to 9:00pm with last admission assigned by 7:00pm. One intern will take long call with the senior resident, while the other intern will be the ‘orphan’ and will be covered by a senior from another on-call team.

Medium call consists of two (2) admissions before 4:00pmLong Call consists of three (3) admissions before 7pm.

When you are on call, you will primarily be admitting patients who established with the Seidman Cancer Center. Often, these patients will be direct admissions from home or a clinic that have been seen as an outpatient that day.

When you hear that a patient is being admitted, you can find a great deal of information about that patient by looking in the Physician Portal under the outpatient Heme/Onc notes. It is always helpful to review several of the most recent discharge summaries.

Some sickle cell patients have “Coordinated Care Notes” which are viewable only through the Physician Portal. Please be sure to ALWAYS check for these notes for any sickle cell patient being admitted as they contain important information from the outpatient care team.

60

There is a nurse practitioner service that runs in conjunction with the Ratnoff and Weisman services and handles many routine chemo admissions, admissions for complications of chemotherapy, and some sickle cell admissions. There are times that you will be responsible for the cross cover of these patients.

The Seidman nurses are excellent and are very experienced at dealing with Heme/Onc patients. For the most part, they tend to have good instincts and are used to handling sick patients. They will draw labs on patients and are trained in providing chemotherapy.

Chemotherapy orders are written by the attending physician ONLY. Only attendings can stop, change or delay a chemotherapy order. The nursing staff knows to contact the attending directly about chemotherapy questions or concerns. When taking a history from an oncology patient, find out the following:

Who is their oncologist and their primary care provider? Where do they get their chemotherapy, what chemotherapy do they

receive and when was their last cycle? Have they ever had a fever or sick contacts since their last oncology

appointment. Have they been compliant with their home medications?

When taking a history from a sickle cell patient, find out the following: Where is their hematologist and their primary care provider? Have they had fever, cough, UTI symptoms, GI symptoms or sick

contacts in the past week? When was their last blood transfusion and how often are they

transfused? Are they on iron chelation therapy? Have they been compliant with their home medications? What pain medications do they use at home? What is the character of their pain and is it typical for their “crisis

pain?” For women, are they pregnant? Did the ED to a type and screen?

There are 4 must know admissions for the Ratnoff/Weisman intern: Sickle cell crisis, neutropenic fever, rule-out spinal cord compression and hypercalcemia of malignancy.

Sickle Cell Crisis: There is a care protocol for sickle cell patients posted in each team room. There is also a sickle cell admission template in the EMR which should be used.

Fluids: If the patient is hypovolemic, hydrate with NS at 300-500ml/hr until they are euvolemic. If the patient is euvolemic, hydrate with D5W1/2NS at 75-125ml/hr

Lab/Radiology: CBC with diff, reticulocyte count, renal function panel and hepatic function panel. All women should have a B-HCG. Blood

61

cultures, UA and urine cultures can be drawn if needed. CXR if not done in the ED.

Transfusion: Transfuse PRBC if the Hgb is < 3g below baseline. Transfuse PRBC for any symptomatic anemia (dyspnea at rest or on exertion, orthostasis, etc.). Sickle cell crisis is NOT a symptom of anemia.

Pain Medications: All narcotics should be give as IVPB. If the patient does not have IV access, analgesics may be given IM or SQ. If the patient is on long acting narcotics at home, continue that medication for the hospitalization.

For initial pain relief, give morphone 5-10mg IVPB and repeat Q1H PRN until pain improves or give hydromorphone 1-2mg IVPB Q2H PRN until the pain improves.

Once adequate pain relief is achieved with bolus narcotics (should be in the first 2 hours of admission), begin a PCA pump with morphine or hydromorphone 0.2-0.4mg demand with a 6 minute lockout.

If the patient is not on chronic long acting narcotics, consider adding a basal rate per hour of 4 times the demand dose.

Breakthrough pain medications should be equivalent to the 1 hour demand dose if needed. Give a breakthrough medications in 1 time doses. If frequent breakthrough doses are needed, consider increasing the PCA demand dose.

If there are no contraindications to NSAIDs (renal dysfunction, GI bleeding, PUD, GERD etc.) you can add ketorolac 30mg IV Q6H.

Reassess the patient frequently. Increase PCA doses by 25% if needed.

Respiratory: Incentive spriometry is very important. Routine use of supplemental oxygen is not recommended unless Sa02 is <90%.

Ancillary medications: Tylenol for fever >38, diphenhydramine 25-50mg PO Q4-6 hours or hydroxyzine 25-50mg PO Q6H PRN itching. Add antibiotics and other home medications as appropriate.

Special Situations: Acute Chest Syndrome presents as new pulmonary infiltrates on CXR, hypoxia and chest pain and may require exchange transfusions. If exchange transfusions are required, a transfusion medicine consult is required. PRBC can be given for mild symptoms.

Neutropenic Fever: In an oncology patient, the main concern is for a bacterial infection (e.g. line infection, PNA, UTI, bacteremia etc.).

Pan culture the patient: Obtain 2 peripheral blood cultures and cultures from any lines, urine culture and sputum culture

Daily CBC with differential and calculate the ANC.

ANC = (Wbc count x 1000) (% neutrophils + % bands)

An ANC of ,1000 is considered neutropenia and, in the setting of fever, requires antibiotics. IV antibiotics are required for a fever with an ANC of <500.

62

The patient must be covered for gram negative organisms. Multiple agents are acceptable including Zosyn, ceftazidime, cefazolin, imipenem etc.

Vancomycin is not necessary initially unless the patient has a suspicious indwelling port or line or has severe mucositis.

Rectal exams are CONTRAINDICATED in neutropenic patients. Consider starting G-CSF (Neupogen) at 5mcg/kg/day SC daily

Suspected Spinal Cord Compression Secondary to Metastasis: Start decadron 6mg Q6H along with a PPI and an insulin sliding scale STAT MRI for the appropriate spinal level (s) based on your neuro

exam. This is one study that MUST happen stat and often you may have to call the radiology resident to make this happen. You also MUST get a “wet” read (prelim read) that night.

If the imaging shows cord compression, you must call the radiation oncology team to initiate XRT.

Hypercalcemia of Malignancy: On admission, order PTH, PTHrp, 25-OH vitamin D, 1,25 di-OH vitamin

D, ECG, CMP, urine calcium and daily ionized calcium Initial therapy for severe hypercalcemia includes simultaneous

administration of saline, calcitonin, and a bisphosphonate. IV hydration, usually at an initial rate of 200-300 ml/hr is needed

(depending on the patient) and then can be readjusted to 100-150ml/hr

Calcitonin 4 units/kg IM Q12H. This can be increased to 6-8 units/kg Q6H

Zoldronic acid 4mg IV over 15 minutes. Be sure to discuss the rare but possible side effect of jaw osteonecrosis.

Pain control in Heme/Onc patients is of paramount importance. There is a conversion chart for narcotics that can help you when switching from one narcotic to another or from IV to PO formulations and vice-versa. People with intractable cancer pain or sickle cell crisis pain have a very high tolerance for narcotics and will require more frequent dosing of these medications. If you cannot adequately control a patient’s pain with PRN morphine or hydromorphone, consider placing them on a PCA pump. You can use this to titrate a patient’s pain medications to a dose that allows them to be comfortable with less danger of overdose. As the patient improves, you can gradually reduce the amount of pain medication and calculate the total daily narcotic requirement before converting the patient to an oral regimen. This can be done using the narcotic conversion chart and will likely consist of a long acting pain medication and a shorter acting breakthrough medication. Remember that every patient who is on a narcotic regimen should also be placed on a bowel regimen. The Palliative Care team is a great resource for helping optimize a patient’s pain regime. Their pager number is 35614.

Often patients are admitted who may be in need of hospice and/or palliative care services. If the patient is appropriate for hospice services, please contact the Heme/Onc social worker to facilitate a family meeting and hospice discussion with you. The social worker can place the actual hospice

63

referral. Please note that we do not have a hospice agency or hospice floor located within University Hospitals or the Seidman Cancer Center.

CODE STATUS must be addressed with EVERY oncology patient on admission. If you get in the habit of having this discussion early in your training, it will serve you well. If DNR or durable power of attorney paperwork has been completed, this needs to be copied and placed in the chart.

Any DNR and/or hospice discussions need to be communicated to the outpatient oncologist/PCP upon discharge.

The Ratnoff team pager is 33306 and the Weisman team pager is 33970. Nurses utilize these pagers throughout the day in order to contact the team. For reference, the Hematology consult fellow pager is 31251 and the Oncology (solid tumor) consult fellow pager is 31600.

Lastly, these can be very emotionally draining services. Please take care of yourself and be aware of the toll that the service is taking on you. There is nothing wrong with taking “time-out” for a few moments or finding a corner to have a good cry. As always, please let you senior resident know if you are feeling overwhelmed.

SERVICE EXCELLENCE STANDARDS

University Hospitals Cleveland Case Medical Center (UHCMC) physicians, employees and volunteers follow four service standards that demonstrate UHCMC’s commitment to ensuring the best possible outcomes and experience for our patients and their families. UHC MC employees are committed to our core mission; To heal, To teach, To discover.

Our Service excellence standards are based on the following key concepts:

Patient Centered Accountability Communication Teamwork

Patient Centered

We value the unique qualities and needs of individuals and are committed to understanding and respecting the diversity of cultures, opinions and experiences that patients, families and hospital staff bring to our environment.

64

Respect the customer’s knowledge of their medical condition. We ask, “Is there anything I need to know about your child’s/your medical condition?”

Show concern for the customer’s privacy by closing the door before asking personal questions.

Demonstrate awareness of cultural differences and respect for other people’s opinions and experiences.

Keep our voices down and refrain from personal conversations in patient areas.

Do not ignore patients or speak about them as if they were not there.

65


Accountability

We take responsibility to know, understand and perform in a professional and competent manner and we extend ourselves, asking, “What more can I do?” to ensure a positive outcome. We:

Provide explanations in clear and understandable language to customers of the services/treatments they are going to receive.

Inform patients about any schedule changes that may impact the patient. Take ownership of complaints or requests and follow through to resolution. Take care of equipment and facilities and report all problems immediately. Maintain a professional appearance and demonstrate pride in our work

and our jobs.

Communication

The purpose of communication is to provide clear, accurate information and to achieve mutual understanding by active listening and open, respectful dialogue.

Always knock and ask permission before entering a patient’s room All employees introduce themselves upon entering a patient’s room

including name, title and role. Acknowledge patients and families by smiling, making eye contact and

offering assistance. Address families with a formal greeting (Mr. /Ms.) unless asked to do

otherwise. Ask patients and families for permission by saying, “Are you ready?” or,

“Shall we go ahead...?” Always ask permission to discuss patient’s medical condition in front of

others in the room. Do not discuss the patient’s condition as if they are not present. Use language and terms the customer can understand and offer an

interpreter when needed. Listen attentively to the customer and check for understanding. We ask,

“Have I answered your questions?" Always keep the patient informed about what can be expected. Ask, “Is there anything else I can do for you” before leaving the patient’s

room.


66

Teamwork

We work collaboratively, valuing the specific and necessary contributions of each member of the team. We work together with a shared goal of achieving excellence in addressing patient needs, one patient at a time by:

Encouraging participation from all team members (patients, families, physicians and other caregivers and co-workers).

Daily patient rounds as a team including all caregivers. Communicate daily goals to all team members. Offering to help co-workers before being asked and asking for support

when we need it. Working with others collaboratively in problem solving and decision

making. Giving positive feedback publicly; give constructive criticism thoughtfully

and in private. Initiating, promoting and adapting to change and the process of

continuous improvement.

67

Ten Ways to Make Your Life Easier as an Intern at UH:

1. Be Organized.a. Develop a system to keep track of your patients’ admission info, daily vitals,

labs, studies and “to do” list. You need to have this information at your fingertips at all times and don’t want to be fumbling through scraps of paper for 20 minutes. One system that most people use is to photocopy your admission H&P and fold it in half and write your daily vitals, labs, studies and “to do” list on the back. Another system is included on the website and consists of an admission template that serves as the basis of your H&P and a daily patient tracking sheet that has spaces for your vitals, labs, studies and “to do” list. There is also patient tracking software for use on a PDA. Find a system that works for you and stick with it.

2. Show up and get your notes started before rounds.a. Once rounds are done, you will have a list of things to do that is a mile long.

It is often difficult to get your notes done between calling consults, putting in orders, talking to families, etc…If you get to work a little early, you can preround AND get a large chunk of your note done before rounds. This has the following benefits:i. After rounds all you have to do is enter the labs and polish up your plan

and then put your note in the chart.ii. You will have a chance to assimilate the data and put down a plan. You

should try to come up with your own plan each day. It does not matter if the plan is wrong! You can always change this after rounds. The important part is that you are learning and growing as an intern and your attending will be impressed that you are coming up with your own plan.

iii. Your presentation will be more smooth and organized because you will have all your data handy and you have thought through the plan already.

iv. You will be less stressed during the day and you will save time at the end of the day. After rounds you can concentrate on doing your work and then when you are done, all you have to do is signout. Since your notes are done before rounds, all you have to do is make an addendum if anything changes and then put your note in the chart. There is nothing worse than writing notes when you are tired at the end of the day. There is an old saying among interns: “The longer your stay, the longer you stay.” What this means is that when you have to stick around to do stuff at the end of the day (e.g. writing notes) it is inevitable that something will come up that will require you to stay longer.

3. Ask for help when you need it and work together as a team.a. On a given day there is an inequitable distribution of work among interns –

one intern has a lot of patients while the others have less. One intern is post call and has a lot of work to do, while the others have less to do and are fresh. This inequitable distribution is not only an inefficient way to accomplish

68

work, it is bad for resident morale. If everyone chips in to help each other out and redistribute work, it has the following advantages:i. The post-call intern feels less stressed and can leave by 1:00 PM.

ii. The total amount of work on the team can be completed more efficiently. iii. The other interns on the team will learn more about each other’s patients,

which make rounds more interesting and make it easier to cross-cover these patients at night.

4. Try to see your new admissions while they are still in the Emergency Department.

a. If you have the chance to see new patients in the ED, you can save a lot of time and get a lot done. The ED chart has a lot of information that you can put into your H&P before you even see the patient : information on allergies, medications (especially if they came from a nursing home), past medical history, PCP, admission vitals, admission labs, radiology results, new and old ECGs, and ED course (medications given, progression of vitals). Between the ED chart and the discharge summaries on in Portal, you can collect a substantial amount of useful information before you even see the patient. In the ED, it is reasonable to collect this info before you see the patient since the ED attending is technically responsible for managing the patient while they are still in the ED. Once the patient arrives on the floor, you are responsible for “eyeballing” the patient and ensuring that they are stable and any immediate needs are addressed before proceeding with collecting admission information for your history and physical.

b. While the patient is still in the ED, you can get additional labs drawn and medication delivered that will take substantially more time once the patient is on the floor. For example, there will be many occasion when you will want additional blood cultures, urine cultures, urinalysis, ABG, AMI, ECG, or coagulation panels done that the ED staff can do if you ask nicely. In addition, id you think an investigation is warranted, talk to the ED attending – if you ask nicely and make a cogent argument for your study, they will often order it in ED. The advantage of this is that nay study ordered in the ED is first priority, while any study ordered from the floor is last priority, even if it is ordered STAT.

c. Once you have seen and examined your patient in the ED, you can also enter admission orders in the EMR under “pre admission on hold.” MAKE SURE YOU DO NOT ENTER YOUR ADMISSION ORDERS UNDER THE REGULAR ORDER SET, OTHERWISE THIS WILL ALL DISAPPEAR ONCE THE PATIENT IS MOVED TO THE FLOOR. Once you have entered the orders in suspend mode and written your note, you have done 95% of your work before the patient has left the ED. When the floor pages you to let you know that your patient has arrived, simply tell the secretary to tell the nurse to activate your orders from suspend mode. The only thing you have left to do is to put your note in the chart and staff the admission with your senior. When you can do this consistently for your admissions, you really feel like you are ahead of the game and your call-night stress is significantly reduced.

69

5. Try to get old records on the night of admission.a. When patients come from outside hospitals or they have had previous

admission at outside hospitals, it is very helpful to get those records as soon as possible. For patients who have had previous admissions at UH, you can get records from medical records sent up to the floor – just ask the secretary (nicely) to call for them. There are usually laboratory studies, diagnostic investigations or procedures deon that are relevant to the current presentation. If you can get these records on the night of admission, it has the following benefits:i. The information you obtain may change your management on the night of

admission. If a patient had a similar presentation in the recent past, it is helpful to see how it was handled at that time.

ii. It may prevent unnecessary duplication of studies and labs (i.e. – if a CT scan, echo, or endoscopy was done recently, it is often unnecessary to repeat these).

iii. Patients will often omit or misunderstand the course of events at an outside hospital, so it is helpful to verify their history with actual records.

b. Every hospital has someone who has access to medical records 24 hours a day. Do not be discouraged if the hospital tells you that their medical records department is closed. You simply insist that you need these records tonight and they can call in a supervisor to get the records. Obviously, do not abuse this and only ask for records that will be pertinent to your management that night or the following day.

6. Think about discharge planning every day.a. There is a motto among senior residents: ‘the day of admission is the day you

start discharge planning.” The reason for this is that the process of discharge planning takes time and if you do not start this process early it is inevitable that a patient’s hospitalization will be delayed. This frustrates everyone and allows your services to swell unnecessarily.

b. A patient can be discharged to home, home with home care, nursing home, SNF, hospice or another service (i.e. surgery). Each discharge, regardless of disposition, requires the discharge document in the EMR.i. Home:

1. Make sure patient has a ride who can take them home and a way to get into their home. Many patients have had to stay an extra day in the hospital because no one could pick them up or they did not have a key to their home.

2. Make sure the patient has a follow up appointment that is listed in their discharge instructions and prescriptions/refills for all their medications.

ii. Home with home care:1. Patients need a gold form done and faxed to home prior to the day of

discharge so that home care can be in place when the patient is ready to be discharged. The gold form must state that the patient is

70

homebound and requires RN. The social worker will often fax this form if you complete, sign and place it in the chart.

2. The patient or family member must be reachable and physically able to assist with the home care. Home care will only come out once a day and only for a limited number of visits. The objective is to transfer care to the patient or patient’s caretaker. Therefore, the patient or their caretaker must be able to learn how to handle basic wound care or IV antibiotics.

iii. Nursing home/SNF:1. If someone comes from a nursing home/SNF and you intend on

sending them back to a nursing home/SNF, then that patient will need a gold form. The earlier you get it done, the earlier the social worker can get it sent out and the earlier the patient will leave. Also, make sure that the patient/family is agreeable to returning to the same facility – some people hate their nursing home and refuse to go back, however, they neglect to tell you this until the day of discharge.

2. If the patient came from home and you have the slightest suspicion that the patient may need placement, then you should order a PT and/or OT consult as early as possible (preferably on the night of admission). This evaluation will determine if the patient goes to a nursing home, SNF or the patient is safe to return home.

iv. Hospice1. If you are going to make a patient DNR-comfort care only, they need

to have hospice involved. Once this decision is make it is imperative that you contact hospice as soon as possible to set up a meeting with the family. The hospice worker can explain the details of home hospice or hospice care in a facility and can help the family decide between these options. The hospice workers frequently cannot come out the same day, so the earlier you call, the better. A patient going home with hospice will need a gold form and the gold form must state that the patient is DNR and that a hospice worker is required (under the home care section). You must also discontinue any medications on the gold form that the patient does not need (typically hospice patients only have oral pain medications and other ‘comfort medications such as ativan, haldol and sleeping aids).

v. Another service (i.e., surgery) – for a patient going to surgery you have to at least consider the following well in advance of the date of surgery:1. Do they need a type and screen? If so, how many units of blood do the

surgeons want the patient to be crossmatched for?2. Is there any coagulopathy present and has this been sufficiently

reversed? Do they need Vitamin K, fresh frozen plasma, etc…?3. Is there an order in PCOSS to make the patient NPO after midnight for

the day of the procedure?4. Are there medications that should be held in advance of the surgery?

For example, if the patient is on aspirin, coumadin, or lovenox, how long prior to surgery do these need to be held?

71

7. Identify the main family contact person early and have them help you keep the rest of the family informed.

a. Talking to families is one of the most rewarding things that we do as physicians, however, it can also be the most time consuming. For patients with large families, you cannot spend every day repeating the patient’s progress to several individuals. Instead, have the family appoint a spokesperson who will be accessible to you as well s the other family members who can help you to disseminate information. If the family cannot agree upon a spokesperson, at least have them agree on a time to meet so that you can talk to everyone at once.

b. Some patients are not competent to make decisions about their own care and different family members have different options about what should be done regarding a patient’s care. You need to determine who has durable power of attorney for healthcare as early as possible. If no one has been made legally responsible, then you need to determine who the next of kin is. If this is not clear, then you need to have a family elect someone to make decisions. If there is any question as to whether or not a patient is competent to make their own decisions, you will need to call a psychiatry consult for competency assessment

8. Do your discharge summaries on the day the patient is dischargeda. The average discharge summary should take you no more than 5-10 minutes

to dictate.

9. Be nice to the nurses, secretaries, CTAs and phlebotomists and they will be nice to you and can make your life easier.

a. The ancillary staff in the hospital exists to assist with patient care land can really make your life much easier. Remembering people’s names and treating them with respect will to a long way toward making friends and getting assistance down the line. Here are the kinds of things you can get help with.

b. Labs – All nursing staff will draw admissions labs on a patient.. Nurses on all floors should draw coagulation panels for patients on heparin protocol, too. Tower 3 and 5 nurses will draw AMI panels, however sometimes they will also draw other labs if you put them in at the same time as AMI panels land. Similarly, Tower 6 nurses will draw labs on staff Heme/Onc patients as well, particularly if they have a mediport and you let them know what labs you want before the port is accessed. The other floors typically do not draw labs, however, sometimes people are nice and will draw an occasional lab for you.

c. Blood cultures –All nurses will draw blood cultures but please ask them nicely.

d. Contacting people or other ancillary services – It is not inappropriate to have a secretary page another physician or page another services for you while you are rounding or busy with patient care. This can save you from waiting by the phone. In addition, the secretary can page respiratory care, social work or physical therapy for you as well.

72

e. Conveying information to and from family members – Sometimes it is impossible to be in two places at once and the nurses can often help you convey information to a family member as well as obtain information for you as well.

10. Do you discharge prescriptions on EMR if possiblecoming soon

73

Ten Ways to Make Your Life Easier as an Intern at the VA:

1. Be Organized.b. Develop a system to keep track of your patients’ admission info, daily

vitals, labs, studies and “to do” list. You need to have this information at your fingertips at all times and don’t want to be fumbling through scraps of paper for 20 minutes. One system that most people use is to photocopy your admission H&P and fold it in half and write your daily vitals, labs, studies and “to do” list on the back. Another system is included on the website and consists of an admission template that serves as the basis of your H&P and a daily patient tracking sheet that has spaces for your vitals, labs, studies and “to do” list. There is also patient tracking software for use on a PDA. Find a system that works for you and stick with it.

2. Show up and get your notes started before rounds.a. Once rounds are done, you will have a list of things to do that is a mile long.

It is often difficult to get your notes done between calling consults, putting in orders, talking to families, etc…If you get to work a little early, you can preround AND get a large chunk of your note done before rounds. You can print this out from CPRS and use this to present with on rounds. This has the following benefits:i. After rounds all you have to do is enter the labs, [olish up your plan and

sign the note.ii. You will have a chance to assimilate the data and put down a plan. You

should try to come up with your own plan each day. It does not matter if the plan is wrong! You can always change this after rounds. The important part is that you are learning and growing as an intern and your attending will be impressed that you are coming up with your own plan.

iii. Your presentation will be more smooth and organized because you will have all your data handy and you have thought through the plan already.

iv. You will be less stressed during the day and you will save time at the end of the day. After rounds you can concentrate on doing your work and then when you are done, all you have to do is signout. Since your notes are done before rounds, all you have to do is make an addendum if anything changes. There is nothing worse than writing notes when you are tired at the end of the day. There is an old saying among interns: “The longer your stay, the longer you stay.” What this means is that when you have to stick around to do stuff at the end of the day (e.g. writing notes) it is inevitable that something will come up that will require you to stay longer.

3. Ask for help when you need it and work together as a team.a. On a given day there is an inequitable distribution of work among interns –

one intern has a lot of patients while the others have less. One intern is post call and has a lot of work to do, while the others have less to do and are fresh. This inequitable distribution is not only an inefficient way to accomplish work, it is bad for resident morale. If everyone chips in to help each other out and redistribute work, it has the following advantages:

74

i. The post-call intern feels less stressed and can leave by 1:00 PM. ii. The total amount of work on the team can be completed more efficiently. iii. The other interns on the team will learn more about each other’s patients,

which make rounds more interesting and make it easier to cross-cover these patients at night.

4. Try to see your new admissions while they are still in Urgent Care.a. If you have the chance to see new patients in the Urgent Care Center (UCC),

you can save a lot of time and get a lot done. By talking to the UCC resident/attending you can get a lot of information that you can put into your H&P before you even see the patient: information on allergies, medications (especially if they came from a nursing home/CARES), past medical history, PCP, admission vitals, admission labs, radiology results, new and old ECGs, and UCC course (medications given, progression of vitals). In the UCC, it is reasonable to take your time going through old discharge summaries to collect information before you actually see the patient since the UCC attending is technically responsible for managing the patient while they are still in the UCC. Once the patient arrives on the floor, you are responsible for “eyeballing” the patient and ensuring that they are stable and any immediate needs are addressed before proceeding with collecting admission information for your history and physical.

b. While the patient is still in the UCC, you can get additional labs drawn and medication delivered that will take substantially more time once the patient is on the floor. For example, there will be many occasion when you will want additional blood cultures, urine cultures, urinalysis, ABG, AMI, ECG, or coagulation panels done that the UCC nurses/staff can do if you ask nicely. In addition, id you think an investigation is warranted, talk to the UCC attending – if you ask nicely and make a cogent argument for your study, they will often order it in UCC. The advantage of this is that nay study ordered in the UCC is first priority, while any study ordered from the floor is last priority, even if it is ordered STAT.

c. Once you have seen and examined your patient in the UCC, you can also enter admission orders in CPRS under suspended order management. MAKE SURE YOU DO NOT ENTER YOUR ADMISSION ORDERS UNDER THE REGULAR ORDER SET, OTHERWISE THIS WILL ALL DISAPPEAR ONCE THE PATIENT IS MOVED TO THE FLOOR. Once you have entered the orders in suspend mode and written your note, you have done 95% of your work before the patient has left the UCC. When the floor pages you to let you know that your patient has arrived, simply tell the secretary to tell the nurse to activate your orders from suspend mode. The only thing you have left to do is to put your note in the chart and staff the admission with your senior. When you can do this consistently for your admissions, you really feel like you are ahead of the game and your call-night stress is significantly reduced.

5. Try to get old records on the night of admission.a. When patients come from outside hospitals or they have had previous

admission at outside hospitals, it is very helpful to get those records as soon as possible. For patients who have had previous admissions at the VA, you can

75

get records directly from CPRS. If the patient was at another VA hospital, you can access their information remotely by clicking on “REMOTE DATA” on the top menu bar and then selecting which location you want to get information from. Next, you click on the “REPORTS” tab and then click on the “Health Summary” on the left hand menu and then you can select if you want to look at Progress Notes, Laboratory, Medications, etc… Once you make a selection, it take some time to load up the data, so be patient. In general, the most relevant document to read is the discharge summary from previous admissions. In addition, there are also usually laboratory studies, diagnostic investigations or procedures done on prior admissions that are relevant to the current presentations. If you can get these records on the night of admission, it has the following benefitsi. The information you obtain may change your management on the night of

admission. If a patient had a similar presentation in the recent past, it is helpful to see how it was handled at that time.

ii. It may prevent unnecessary duplication of studies and labs (i.e. – if a CT scan, echo, or endoscopy was done recently, it is often unnecessary to repeat these).

iii. Patients will often omit or misunderstand the course of events at an outside hospital, so it is helpful to verify their history with actual records.

b. Every hospital has someone who has access to medical records 24 hours a day. Do not be discouraged if the hospital tells you that their medical records department is closed. You simply insist that you need these records tonight and they can call in a supervisor to get the records. Obviously, do not abuse this and only ask for records that will be pertinent to your management that night or the following day.

6. Try to do your discharge summaries on the day the patient is discharged. a. It is infinitely easier to do a discharge summary on the day of discharge while

the patient’s hospital course is fresh in your mind and the information is in front of you.

7. Start to plan your discharge on the day of the admissiona. There is a motto among senior residents: ‘the day of admission is the day you

start discharge planning.” The reason for this is that the process of discharge planning takes time and if you do not start this process early it is inevitable that a patient’s hospitalization will be delayed. This frustrates everyone and allows your services to swell unnecessarily.

b. You need to do 5 things before a patient can be discharged from the VA:i. Discharge medications entered in CPRS – it takes pharmacy several

house at least to get medications together and bring them up and go over them with the patient. You should enter these first because this is often what holds up a patient the longest and it frustrates the patient and the nurses. If it has been a while since you entered the medications and the pharmacist has not arrived, and you may want to call to the pharmacist and encourage them to expedite the request and inquire how much longer it will be before they can bring up the medications.

76

ii. Travel request or travel arrangements – if you are sending someone via VA travel, try to get your request in early because it can take some time before arrangements can be made. If the patient’s family is going to pick up the patient, try to set a time when this will happen. It is not recommended that you arrange a morning pickup by either family or travel, unless you plan on getting the patient their medication the night before. In general, you should arrange to have travel come after you know that the patient’s medications will have arrived.

iii. Discharge Instructions entered in CPRS – You should do this next, so that the nurses can go over these with the patient once the medications arrive. The nurses will start to give you a hard time if they do not see instructions in the computer after a few hours. On the discharge instructions, you need to specify any follow-up care, appointments and special instructions in the appropriate sections as well as ensure that the list of medications is correct. This is also the time to ensure that you have adequate follow-up for your patient: if the patient is seeing their PCP you need to try to arrange a date and time; if they are going to follow up in the Firm clinics or a specialty clinic you need to make sure the consult has been entered.

iv. Discharge orders in CPRS – Next you should enter a text order that states “Discharge patient to _______ (place) today at ______ (time).” This is the one thing that interns most often forget to do.

v. Discharge Summary – If you are sending a patient to CARES (see below), you need to have this done before the patient leaves the ward. They are also starting to require that even patients going home should have this done on the day of discharge as well. To be honest, it is probably better for you in the long term because it is much less painful to do the discharge instructions at the time discharge while the information is all fresh in your mind.

c. A patient can be discharged to home, home with home care, nursing home, SNF, hospice or another service (i.e. surgery). Each of these destinations requires different preparations.i. Home:

1. Make sure patient has a ride who can take them home or a travel request in CPRS 24 hours ahead of time. The patient also needs a way to get into their home. Many patients have had to stay an extra day in the hospital because no one could pick them up or they did not have a key to their home.

2. Make sure the patient has a follow up appointment that is listed in their discharge instructions and prescriptions/refills for all their medications.

ii. Home with home care:1. Patients need a Community Home Care form completed in CPRS at

least the day prior to the day of discharge so that home are can be in place when the patient is ready to be discharged. You need to notify home care by phone. The form must state that the patient is homebound and requires RN.

77

2. The patient or family member must be reachable and physically able to assist with the home care. Home care will only come out once a day and only for a limited number of visits. The objective is to transfer care to the patient or patient’s caretaker. Therefore, the patient or their caretaker must be able to learn how to handle basic wound care or IV antibiotics.

iii. Nursing home/SNF(Brecksvills):1. The vast majority of VA patients that require placement in a nursing

home or SNF will be placed at the CARES VA. Helen Ferrer is the coordinator of the nursing home care unit at CARES. Basically, she determines if your patient meets criteria for placement at CARES and if so, when a bed will be available. You need to be as nice to Helen as you can, because she can determine if you have a large service full of patients awaiting placement or a small service of only acute care patients. If your patient will require placement in another facility (e.g. – Ohio Veteran’s Home) you will need to involve social work. When you know someone will need placement, the earlier you contact the social worker or Helen Ferrer, the better your chance of finding a place. Also, if your patient came from a facility and you plan on sending the patient back to the same facility, make sure the patient/family is agreeable to returning to the same facility; some people hate their nursing home and refuse to go back, however they neglect to tell you this until the day of discharge.

2. If the patient came from home and you have the slightest suspicion that the patient may need placement, then you should order a PT and/or OT consult as early as possible (preferably on the night of admission). This evaluation will determine if the patient goes to a nursing home, SNF or the patient is safe to return home.

iv. Hospice1. If you are going to make a patient DNR-comfort care only, they need

to have hospice involved. Once this decision is make it is imperative that you contact hospice as soon as possible to set up a meeting with the family. The hospice worker can explain the details of home hospice or hospice care in a facility and can help the family decide between these options. The hospice workers frequently cannot come out the same day, so the earlier you call, the better. A patient going home with hospice will need a Ohio DNR form completed prior to their discharge. You must also discontinue any medications on the gold form that the patient does not need (typically hospice patients only have oral pain medications and other ‘comfort medications such as ativan, haldol and sleeping aids).

v. Another service (i.e., surgery) – for a patient going to surgery you have to at least consider the following well in advance of the date of surgery:1. Do they need a type and screen? If so, how many units of blood do the

surgeons want the patient to be crossmatched for?2. Is there any coagulopathy present and has this been sufficiently

reversed? Do they need Vitamin K, fresh frozen plasma, etc…?

78

3. Is there an order in CPRS to make the patient NPO after midnight for the day of the procedure?

4. Are there medications that should be held in advance of the surgery? For example, if the patient is on aspirin, coumadin, or lovenox, how long prior to surgery do these need to be held?

8. Identify the main family contact person early and have them help you keep the rest of the family informed.

a. Talking to families is one of the most rewarding things that we do as physicians, however, it can also be the most time consuming. For patients with large families, you cannot spend every day repeating the patient’s progress to several individuals. Instead, have the family appoint a spokesperson who will be accessible to you as well s the other family members who can help you to disseminate information. If the family cannot agree upon a spokesperson, at least have them agree on a time to meet so that you can talk to everyone at once.

b. Some patients are not competent to make decisions about their own care and different family members have different options about what should be done regarding a patient’s care. You need to determine who has durable power of attorney for healthcare as early as possible. If no one has been made legally responsible, then you need to determine who the next of kin is. If this is not clear, then you need to have a family elect someone to make decisions. If there is any question as to whether or not a patient is competent to make their own decisions, you will need to call a psychiatry consult for competency assessment

9. Be nice to the nurses, secretaries, and phlebotomists and they will be nice to you and can make your life easier.

a. The ancillary staff in the hospital exists to assist with patient care land can really make your life much easier. Remembering people’s names and treating them with respect will to a long way toward making friends and getting assistance down the line. Here are the kinds of things you can get help with.

b. Labs – The nurses at the VA typically do not draw labs, unless it is in the ICU. However sometimes people are nice and will draw an occasional lab for you.

c. Blood cultures – Similarly, if someone spikes a fever at night, you usually have to draw the blood cultures yourself, but occasionally a nurse may help you our if you ask nicely.

d. Contacting people or other ancillary services – It is not inappropriate to have a secretary page another physician or page another services for you while you are rounding or busy with patient care. This can save you from waiting by the phone. In addition, the secretary can page respiratory care, social work or physical therapy for you as well.

e. Conveying information to and from family members – Sometimes it is impossible to be in two places at once and the nurses can often help you convey information to a family member as well as obtain information for you as well.

79

10. Put in orders for each other on rounds.a. You should make it a habit to round with one of the laptop computers that has

CPRS access. You and your co-intern can both log-on to CPRS under separate windows of the application. While one intern is presenting, the other intern should be on the computer looking up labs, radiology or consult notes to help answer that come up on rounds. As a plan is discussed on rounds, you should enter the orders on your co-intern’s patients. In this manner, when rounds are over both of you have all of your orders done and nothing gets missed. Don’t forget to double-check each others orders after rounds. The additional advantage of this method is that you learn the plan on each other’s patients.

80

LIBRARY ACCESS ISSUES: There are several ways you can increase your home access to journals. The easiest, as mentioned, is getting VPN installed on your computer. The VPN (virtual private network) is a piece of software (Cisco) that you install and set up to provide a network link of your choosing. In this case, either Case Western Reserve or UH, if desired. Essentially the program gives your computer network access, which also gives you seamless access to most library resources as if you were either on campus or on-network. To get the vpn you can do two things, call the Case help desk at 216-368-HELP to get information on downloading the program and importing the correct profile to connect you via Case (you will need to give them your Case information - usually a username and/or pin), or you can call the UH help desk and ask for the VPN software / UH profile. While the UH profile will only get you access to the UH network, you can use the same Cisco program to import a Case profile and connect to either at your choosing. More information for getting your Case information (pins, etc.) Is available from our website at: http://intranet.uhhs.com/corelibrary/OHIOLINK.asp. Aside from the VPN, you can also access a number of Case resources through ohiolink (more information is available through that link). As for UH resources, there is the VPN, as well as links from the physician portal and an ejournals page. The VPN for either institution, though, is definitely the easiest to use once set up and running. Our webpage here: http://intranet.uhhs.com/corelibrary/REMOTEACCESS.asp has more information on off-campus access. Please feel free to contact us anytime if you are having trouble with this or any other issue. I hope this helps. -- Jennifer Staley, Librarian, Core Library

81

http://intranet.uhhs.com/CoreLibrary/REMOTEACCESS.asp

http://intranet.uhhs.com/CoreLibrary/OHIOLINK.asp

ACGME and Competencies

Practice-Based Learning and Improvement Residents are expected to be able to use scientific evidence and methods to

investigate, evaluate, and improve patient care practices.o EBM, literature searching, information technology, teaching

Interpersonal and Communication Skills Residents are expected to be able to demonstrate behaviors that reflect a

commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society

Professionalism “a commitment to carrying out professional responsibilities, adherence to ethical

principles and sensitivity to a diverse patient population” Residents are expected to demonstrate behaviors that reflect a commitment to

continuous professional development, ethical practice, and understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.

Increasing emphasis in licensure Like pornography- “easy to recognize but difficult to define” How physicians meet their responsibilities to individual patients and to

communities ABIM- “comprises those attitudes and behaviors that sustain the interests of the

patient above one’s own self interest…and entails altruism, accountability, commitment to excellence, duty and …respect for others”

Systems-Based Practice “manifested by actions that demonstrate an awareness of and responsiveness to

the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value”

Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

Understand, access and utilize the resources, providers and systems necessary to provide optimal care

Understand the limitations and opportunities inherent in carious practice types and delivery systems, and develop strategies to optimize care for the individual patient

Apply evidence-based, cost conscious strategies to prevention, diagnosis, and disease management

Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care

Medical Professionalism National focus on defining and measuring professionalism Physicians subordinate their own interests to the interests of others Physicians adhere to high moral and ethical standards Physicians respond to societal needs

82

Banned Abbreviations

Abbreviations that May Not Be Used in the Medical RecordThe abbreviations below have been banned from use in the medical record:

Abbreviation Potential Problem Preferred TermMS Can mean morphine or

magnesium sulfateWrite Morphine Sulfate

MSO4 “ Write Morphine SulfateMgSO4 “ Write Magnesium Sulfate

IU Misread as IV (intravenous) or 10 (ten)

Write International Unit

1.0 Misread as 10 if decimal is not read

1Do not use zero after

decimal.5 Misread as 5 0.5

Use a zero before a decimalQD q.d Period after Q or tail of the

q misread for I or a oWrite Every Day

QOD O misread for I Write Every other dayU (for unit) Read as a zero or four

causing overdoseWrite Unit

83

chairman’s welcome - department of medicinemedicine.case.edu/images/current_residents/intern...

Documents