Queens Medical Center Inpatient Medicine Orientation For Interns

Queen’s Medical Center Inpatient Medicine Orientation For Interns Academic Year 2014 -2015 Dennis Bolger, MD (Assoc. DME) Chief Medical Resident: Masayuki Nogi Revised Dec 2014

This is a J OKE http: //www. gomerblog. com/2013/09/cobra-kai/

Where can I get my curriculum? https: //www. new-innov. com/Login/Home. aspx

Goals of this rotation 1. Deliver patient care as a good team member and learn from patients Understand criteria for different levels of care “think about discharge from the day of admission” 2. Apply EBM to patient care Search for answers for your every-day clinical questions Take advantage of the daily rounds and high patient volume! 3. Facilitate the education of students/interns in a hospital medicine setting

On your Day 1 Know your patients Clarify expectations from each team members at the beginning– be explicit Check the Chain of command, exchange contact info Know when/how to ask for help

What you need to know as an intern

Team structure Team member Attending UL intern Sub-I Max 8 pts Cap 8+1 Avg. 35 pts UHS attending MS-3 Cap 8+1 MTC attending Max 1 pts Avg. 2 -4 pts • • UHS: University Hospitalist Service MTC: Medical team care

Patient Acquisition Schedule Overnight Transfer New ICU downgrade Late ⑦⑧ 12 pm-6 pm ①② AED 　− − − ①②③④ 6 am-12 pm − Early ⑤⑥ 6 am-12 pm − Short ①②③④ 6 -10 am − ⑤⑥ 10 am-6 pm ①② Transfer Week end Lw if E team capped Rounds will get busy on “Early call” and “someone’s clinic day”

Unexpected Re-admissions AKA “Bounce backs” Patient will return to the previous team regardless of your shift schedule. If ANY note is filed from ANY of your team member (within the same block)

CAPs 9 Total census New admission/day 2 transfer/day New admission/48 hour s

Work hour rules 80 Per week (on average) Continuous working hours * Work hour survey will be collected weekly via Google form 10 Should have between shifts 8 MUST have between shifts

Extended working hours… Extended Duty Episodes Chief and DME will inquire about these episodes and get a count of episodes and the reasons Acceptable reasons…. 1. Required continuity for severely ill or unstable patient 2. Academic importance of events transpiring 3. Humanistic attention to the needs of patient or family 4. Finishing up on one patient before leaving ** purpose is to help / identify ways to be more efficient, not to get you in trouble!

I-PASS Handover Electronic Hand-over in Carelink, should be updated daily! Verbal handover (Phone) Night team @ 6 pm (THIS IS NOT PAGER CALL) Your verbal and written I-PASS handover will be evaluated by either NF resident or CMR/faculty IZ QU What does I-PASS stand for?

The I-PASS Mnemonic I Illness Severity Stable, “watcher, ” unstable P Patient Summary statement; events leading up to admission; hospital course; ongoing assessment, plan A Action List To do list; timeline and ownership S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen S Synthesis by Receiver summarizes what was heard, asks questions; restates key action/to do items © 2013 I-PASS Study Group/Boston Children’s Hospital. All Rights Reserved. For Permissions contact ipass. study@childrens. harvard. edu

. IPASSIM Filter with“Residents

Pager rules Keep pager ON, and respond until 7 pm on regular work days SAS sessions (Tues PM) Continuity clinic How to change greeting message 1. 2. 3. 4. 5. 6. Call your pager No. Hit * Enter PIN number Hit 3 -0 Record message Hit 1 L team intern carries the “X-cover pager” 6 am-6 pm

Intern Morning Report Thursday 7: 30 am – 8: 15 Every am @ Iolani 5 How to prepare? 1. 2. 3. Discuss with UL about suitable case You can team-up with your co-intern (case presentation vs didactic) Notify CMR one day prior (MRN and topic of didactic) How to present? Case presentation 30 min – accurate content, confident delivery “Talk to the audience” – make it lively Didactic 10 min – focus, take home message * Make a focused didactic!

Case of the month Based on… -content of the case presented -quality of the presenter & didactic -value of the information & importance of disseminating to one's peers Grand Prize winnings: Certificate Name etched into our I-5 Hall of Fame Board Starbucks Gift Card ($25) Bragging Rights (Priceless) Case to be published in the UHIMRP newsletter

Noon conference Thurs. 12: 00 pm– 1: 00 pm @ Every Iolani 5 BYOL What? Case based learning modules for inpatient topics Neurology lectures Cardiology lectures Infectious disease conference Pain & palliative care workshop Diabetes management Quality improvement report (4 th week) * PIZZA for week 1 !

Radiology Rounds Every Friday 7: 45 -8: 00 am @ Radiology X-ray files room Time to ask and discuss interesting imaging findings.

Evaluations Please evaluate… MS 3 (mid-term & final), Ms 4 Peers Attendings You will be evaluated from… CMR (chart audits) Med students Peers Attendings 9 reporting milestones (among 22) with the following criteria: Critical deficiency/Early learner/Mid-level learner/Ready for unsupervised practice/Aspirational/Not observed

Suggestions for Admission H&P HPI Include the ER course and reason for admission. PMH/Meds/SH/FH Insert “Above table was reviewed by me and confirmed to be accurate. ” when using auto-populated smart phrase.

Suggestions for Admission H&P (2) ROS Write “complete ROS was obtained and was negative otherwise mentioned in HPI” “ 10 -point ROS” are no longer acceptable! Physical exam Write >2 elements for each system Write >8 systems

Suggestions for Progress note Assessment Plan Document “present on Include admission” for any latent dx other source of information Status of established diagnosis “possible” “probable” Well controlled vs poorly “suspect” “likely” are controlled acceptable if workup mentioned. Patient education plans Document all treated dx Comment as “resolved” Discharge goals Whom the consultation(referral) was made Review of labs, radiology

Suggestions for final diagnosis Bad Preferred “Insulin dependent DM type 2” “NSTEMI type 2” “CHF” ACS AKI, renal insufficiency Chest pain AMS Urosepsis Hypertensive emergency CVA DM type 2 on insulin treatment Troponin elevation due to sepsis (or CHF, Afib, dehydration) Acute on chronic systolic HF due to ischemic cardiomyopathy Acute initial STEMI to LAD AKI with lesion of the tubular necrosis Chest pain secondary to possible musculoskeletal or GERD Acute delirium due to metabolic encephalopathy Sepsis due to UTI Accelerated HTN resulting in encephalopathy Acute intracranial hemorrhage to left internal capsule

CLABSI assessment

This is a J OKE

Tips for a successful rotation

No time to search for review articles ? ! Trouble with Care Link ? ! * Missed a morning report !? Username: residents / password : residents

RIME model Reporter MS-3 / MS-4 accurately gather information through H&P, and can accurately report the information through presentations or write-ups Interpreter MS-4 / intern understand the clinical significance of the information obtained , and can generate a short differential diagnosis and prioritize problems Manager resident generate a reasonable diagnostic plan to deal with outstanding questions, and a therapeutic plan to solve problems. Educator CMR/ fellows risen to the level where they can identify knowledge gaps in others and effectively fill those gaps. Pangaro, L. (1999). A new vocabulary and other innovations for improving descriptive in-training evaluations. Academic medicine : journal of the Association of American Medical Colleges, 74(11), 1203– 1207.

A day in the life: Interns 5 -6 am Arrive, get hand-over from NF intern. Pre-round. Noon-1: 00 Noon conference (TH) 1: 00 - 7: 45 am Radiology rounds (F) 7: 30 - 8: 15 am Morning report (TH) 8: 15 -9 am Meet with the team. Contact MTC attendings & consulants 9: 30 -11: 30 UHS attending round. D/C orders by 11 am Finish up work, prepare disposition for next day & dictations. 4 pm update IPASS form Can leave hospital, answer pages until 6 pm (THIS IS NOT “PAGER CALL”, we are just letting you leave early 6 pm Night team calls you for Phone handover. Pager off. 8 pm Late team finish.

You will need a nice organizer (check list) RULE #1 Write down everything! Make sure to clarify orders with UL (or attending)

Ex) Organizer http: //medfools. com/downloads. php Traditional version

Carelink version Ex) organizer Family contact Med list 1) 2) Make a new patient list Copy “UHS organizer 2014” Consultant list Problem list The columns are easy to customize

Rule #2 Understand the time frame of each task. Phone calls take time Page wait talk Seek help to UL New order > stopping order Admission > Discharge Writing H&P > progress note

Time management tips “Eisenhower Matrix” 1. Phone calls 2. Orders 3. Procedures 1. 2. 3. Pagers from unit Phone calls Going to bathroom 1. 2. 3. Documentation Preparation for conference Meals 1. 2. Check E-mails Social media

Miscellaneous Stuff

QMC map SAS Queen Emma tower “ewa” (west) “diamond head” (east) east GR mountain ocean DH ewa G: Clinic, coffee stand 1: radiology, lounge, cafeteria, hospitalist office 4: med ICU, neuro ICU & surgical icu 5: neurology 6: cardiac ICU/ telemetry 7: oncology & *resident call room. 8 &9: med/surg pts 10: labor & delivery Pauahi- west side of QET. west Goes up to 7 th flr. 1: ER 2: dialysis & CDU 3: cardiac noninvasive & cath lab 4 -7: tele/med/surg pts

Reminder about HIPAA: Health Insurance Portability and Accountability Act of 1996. first federal law aimed at protecting the privacy of health information. Be careful to protect Patient’s health information do not talk about patients in the elevators taking clinical pictures needs a consent do not take pictures or send information of patient’s information on personal phone or email Don’t lose/leave your papers in public areas

Miscellaneous 1. 2. 3. 4. 5. 6. Verbal Orders (In-Basket): MUST be signed within 24 -48 hours Changing Code Status: Only upper or attending Call room, Iolani 5: 4 -3 -5 -1 ER code: 2 -4 -6 -8 -* Meal Debit: $18/call Meal card problems: call Stacey Teramae x 4381 Scrubs ok to wear daily except on Clinic days

Needlesticks/ occupational exposure QMC Blood/Body Fluid Exposure Policy 24 -hr confidential hotline: 6914004 Don’t wait! Based on the risk, the exposed person may need immediate care and follow-up Alternative = Call ER

Summary of Duties (interns) 1. 2. 3. 4. 5. 6. 7. Help/Guide/Teach the medical students Pre-round on all patients, and staff with UL prior to rounds. Present case during round, put in orders that are discussed Progress note should be done no later than 2 -3 pm Discharge summary within 24 -48 hrs, H&P within 24 hrs. Follow up labs, imaging, consultant up-dates in the afternoon. Up-date Carelink sign-out by 6 pm, and communicate with Xcover NF resident

Intern orientation quiz ACGME requirement My cap is ( ) new pts per day, and I can carry total of ( ) UHS and ( ) MTC pts per day. I am allowed to work ( ) hours straight. I am allowed to work ( ) hours per week. Do I take “pager call”s ? Y / N Our standardized hand-off system is ( )

Intern orientation quiz ACGME requirement My cap is ( 5 ) new pts per day, and I can carry total of ( 8 ) UHS and ( 1 ) MTC pts per day. I am allowed to work ( 16 ) hours straight. I am allowed to work ( 80 ) hours per week. Do I take “pager calls” ? Y / N Our standardized hand-off system is ( I-PASS )

Intern orientation quiz Work related I should come to the hospital by ( ) am to get sign-out. As an intern, I am responsible for writing ( , , ) for all of my patients My upper will write 2 notes for me on my ( ) day. I will write my H&P within ( 24 ) hours, Discharge summary within ( 48 ) hours If I get paged by the nurse for an uncertain matter, I will ask my ( ) first. If my UL is gone for clinic on my Late call day, I will admit MTC patients with the ( Early ) call UL. I can get free coffee at ( ).

Intern orientation quiz Work related I should come to the hospital by ( 6 ) am to get sign-out. As an intern, I am responsible for writing ( progress note , H&P , Discharge summary ) for all of my patients. My upper will write 2 notes for me on my ( clinic ) day. I will write my H&P within ( 24 ) hours, Discharge summary within ( 24 -48 ) hours If I get paged by the nurse for an uncertain matter, I will ask my ( upper level resident ) first. If my UL is gone for clinic on my Late call day, I will admit MTC patients with the ( Early ) call UL. I can get free coffee at ( Morgan’s Lounge ).

Intern orientation quiz Required conference I must attend intern morning report on ( Thursday ) morning. If I am assigned, my presentation should be ( lively ) and my didactic should be ( focused ). I must attend Radiology round on ( Friday ) morning. I must attend Noon conference on ( Thursday ) noon. I must attend SAS on Tuesday unless I am on ( Late ) call schedule. I am encouraged to attend Queens Grand Round on ( Friday ) morning.

Intern orientation quiz Required conference I must attend intern morning report on ( Thursday ) morning. If I am assigned, my presentation should be ( lively ) and my didactic should be ( focused ). I must attend Radiology round on ( Friday ) morning. I must attend Noon conference on ( Thursday ) noon. I must attend SAS on Tuesday unless I am on ( Late ) call schedule. I am encouraged to attend Queens Grand Round on ( Friday ) morning.

On your Day 1 Clarify expectations for each team member at the beginning– be explicit Check the Chain of command Know when/how to ask for help Know your patients

Are you Ready? Keep this Power. Point in your email or on file for future reference. uhmed. org/chiefblog training site QMC orientation packet Any questions or concerns this month: - Contact the Chief Medical Resident (M. Nogi) or DME (Dr. Bolger)