Harper University Hospital Orientation Malini Surapaneni New to

Harper University Hospital Orientation Malini Surapaneni

New to Harper… • Pager/sign-outs at 7 AM and 3 PM, no excuses • On Thursday, when there is educational half day, sign-out to long-call team is at 5 PM. No seniors or interns should be leaving before 5 PM • No Observation admissions, however if Med B contacts us for an upgrade we take the patient

New team structure Harper A 1 A 2 A 3 Senior 1 Senior 2 Intern 1 Intern 2

Team caps • Total team cap (for 2 seniors and 2 interns): 20 patients(including the bounce backs) • Intern cap: 10 patients (all encounters) • Intern new admission cap: 5 patients each day

Call days • Each team is on call Q 3 days. Within each team, one (senior + intern) sub-team will be on long call Q 6 days. • Entire call team will arrive at 7 AM. • Short call (7 AM to 3 PM) and long call (3 PM to 8 PM)

Call day • Short call team will admit patients from 7 AM 3 PM. • Short call team will also receive patients accepted by night float after 6: 15 AM

Call day • If short call team (one senior + intern) reaches their cap (10 patients) before 3 PM, then pre-call team(both seniors and both interns) will start admitting patients until 3 PM. • Pre-call team(for 2 seniors and 2 interns) new admissions cap is 5 patients.

Call day • At 3 PM, admission pager is taken by the long call team who will start admitting patients until 6: 30 PM. • After 6: 30 PM, patients are accepted, triaged and basic orders are placed by the on call senior. All patients accepted from 6: 30 -8 PM will signed off to NF senior at 8 PM. HPI and full orders will be done by NF team.

Hitting caps on call day • If the long-call team caps… Ø Before 6: 30 pm page Dr. Safwan Saker who will start taking the admissions until 6: 30 PM ü YOU CANNOT LEAVE THE HOSPITAL! YOU MUST CONTINUE TO CROSS COVER PATIENTS, SIGN THEM OUT TO NIGHT FLOAT ü The UPG admission pager stays on the on call resident who can inform the ED about reaching their cap and to direct the admissions to Dr. Saker until 6: 30 PM ü After 6: 30 pm on-call senior admits patients to the other team, places covering physician orders, evaluates the patient, places basic orders, signs the patient out to night float who will continue the workup and do the full H & P ü THE ON-CALL SENIOR MUST PLACE BASIC ORDERS ON THESE PATIENTS AND SIGN THEM OUT TO NIGHT FLOAT, LET THEM KNOW WHAT YOU’VE ALREADY DONE SO THEY CAN PICK UP WHERE YOU LEFT OFF ü At 8 PM the night float team arrives and receives sign out on patents admitted after 6: 30 PM. Ø If all teams capped > admissions go to Dr. Safwan Saker

Pre Call day • Entire team arrives at 7 AM. • Once the short call team caps, the pre-call team starts admitting patients until 3 PM. • Pre call new admissions cap: 5 new patients • Code blue are attended by On call team. Pre call does not have to respond to code blue unless it is YOUR patient.

Post Call day • Entire team arrives at 7 AM. • Night float rounds with your team on the new admissions from overnight. • Once night float leaves, please change covering physician on the new patients and you will assume care for the overnight admissions • Sign out at 3 PM. No bounce backs on post call day

Sign out • Sign out to long call team at 3 PM. ( Sign-out is at 5 PM on Thursday. ) • Long call team signs out to NF at 8 PM. • Sign out is now divided between intern ad senior equally. • Senior 1+intern 1 in every team will sign out to intern on long call, while the senior 2+intern 2 on every team will sign out to the senior who is long call

Night float and night admissions • • Cap overnight to call team: 10 patients NF Intern cap: 5 new patients. 3 nights on and 1 night off No 24 hours call for interns

Admission cut-offs • Admissions 6: 30 PM to 8 PM to be evaluated by on-call senior (admission and basic orders), H&P to be completed by night float team • Admissions 6 AM to 7 AM to be evaluated by NF senior (admission and basic orders), on-call team to complete H&P • Admission to short team: 3 PM

ADMISSIONS

From ED v On-Call Senior will carry the admission pager (0092) v When the ED calls for an admission take sign-out, briefly review the chart, ask the ED physician any questions you might have, provide the attendings name and go evaluate the patient immediately or at least within 15 minutes Place the following orders: Ø Covering physician order Ø Basic orders until the primary team evaluates the patient (which should be after morning report) Ø Patient presence in ED doesn’t stop you from managing/ordering v Always evaluate the acuity of your patient’s illness; determine if they are stable for the floor or need evaluation by the ICU v If you believe the patient does not need admission, please call your attending before refusing the patient.

From MICU v Take sign-out from resident or fellow v Cannot place orders on the patient until they physically have left the unit v Communicate with MICU team if you’d like something done/cancelled v Place covering physician order so that nurses page you once patient is on the floor v. Do not round on patients if still physically in MICU v. Sign out the patient to the on call teams even if the patient is in ICU (and let them know to be aware that patient might need few additional orders after they are on the floor)

From other services • Patients transferred to your team from another service if you have not taken care of that patient before. • The Medicine Consult service must first evaluate to approve this transfer, pager 5501.

Direct admissions and facility transfers v Admissions from the clinic/outside v If you accept an admission from the clinics, it is your responsibility to check which floor the patient is going to be admitted to. Bed assignment 51387 v Your attending physician must accept transfers from outside hospitals first. If you are called to accept a transfer, talk to the transferring physician and obtain the following information q q q q provisional diagnosis history vital signs pertinent physical examination pertinent work-up reason for transfer phone number of transferring physician Make sure the patient is stable for transfer and management on the floor. Discuss this with your attending physician before accepting the transfer.

Transfers to MICU • If you feel your patient needs a higher level of care, page MICU fellow at 6428 and consult • If accepted to MICU, fellow calls bed control for an MICU bed. Either you or MICU team place transfer orders

Bounce backs • Bounce backs are admitted by the on-call team (regardless of who the bounced patient belongs to). • The next morning, the team staffs the patient with the attending, writes a progress note, and signs out the patient to the team that the patient belongs to originally • If the patient is being discharged on the next day, the discharge will be done by the team that admitted the patient. • No bounce backs on the first and last days of the rotation

Discharges • Discharge process starts on day of admission • If patient to be discharged later in the day, make sure discharge meds, appointments, ambulance forms and order is placed by primary team

Medicine consults • After 4 pm on the weekdays and 2 pm on the weekends the medicine consult pager will be forwarded to you and you may need to see a HUH/RIM patient – SENIORS, after that time you must: • Evaluate STAT medicine consults • Conduct pre-op assessment on a patient • Staff over the phone with the DRH UPG Medicine Hospitalist (pager 5755) • Write a brief incident note (SOAP format) • Add patient to Medicine Consult list and page the team the next morning, give them a brief signout and they will do the full consult note • These DO NOT count as hits

Who counts as hit? – Patients seen, staffed and directly discharged from the ED • BUT MUST BE STAFFED WITH ATTENDING FIRST – Completed H&P but patient ends up going to a different service – Patients admitted to your team who you will be following on a daily basis – Patients transferred to your team from another service if you have not taken care of that patient before.

Codes • On-call team responds to codes in Harper • Do not respond to Karmanos codes

Days off • Each resident must take 1 day off in each 7 days • All team members must be here on call days • Obviously, can’t have your assigned MR day off • Seniors should avoid taking post-long call days off as much as possible

Morning report v Morning Report- combined at DRH – Morning report will start promptly at 11: 00 am. No excuses to skip – All residents are expected to attend MR except the senior who is on short call – 1 case per day • Case presentation slides to be covered by the intern • Senior is responsible for case oversight and educational slides – Review the MR schedule – Complete your case slides 48 hrs in advance and email to CMRs. – Late cases < 48 hrs will be moderated by senior

Responsibilities towards medical students • Please make sure you get in touch early on with your medical students. MS 3 can carry 2 -3 patients and Sub-Is can carry 3 -4 patients • Please allow time for your medical student to see the patient, staff with them and allow them to fully present to attending without interruptions. • Your medical students should be writing daily notes, and signing them to team senior for corrections

HAVE FUN!