Hospitalist Program Inpatient Orientation Daniel Robitshek, MD UC Irvine Medical Center

Hospitalist ProgramInpatient OrientationHospitalist Program

Inpatient Orientation

Daniel Robitshek, MDDaniel Robitshek, MD

UC Irvine Medical CenterUC Irvine Medical Center

Attending Information (example)Attending Information (example)

• Daniel Robitshek, MD– Pager: 506-2267– Cell: 658-0440– Office: 456-5726 (Christal Wright)– Email: [email protected]

Daily AM ActivitiesDaily AM Activities

• Weekday Morning Rounds– 7:00-9:00 Team pre-rounding without attending

• or Short Call rounds w/attending

– 9:00-11:00 Attending work/teaching rounds• 9:00-9:10 Morning debriefing

– Urgent/overnight issues– Discharge planning

• 9:10-11:00 Patient/Bedside Rounds, includes radiology rounds

– 11:00-11:20 Didactic Teaching rounds– 11:20-11:55 Team Work rounds

• Noon conference– 12:00-1:30 Daily– Mandatory on-time attendance for all house-staff

Daily PM ActivitiesDaily PM Activities

• Afternoon– House-staff/student Work Rounds

– Afternoon specific• Admissions• House-staff PC Clinic• Post-Hospital F/u clinic• Family meetings• F/U on Lab/diagnostic test/consultation• Afternoon attending debriefing• Clinical Vignettes (students)• Course didactics (students)

• End of day (time varies)– Senior Resident (or designate)

• Check-out rounds with attending either at end of routine day or at end of call– In person, over the phone, at bedside/conference room

Team goalsTeam goals• All team members will provide the highest quality patient

care• All team members will provide patient-centered empathic

care• All team members will foster an atmosphere of teaching

and learning that is patient-based and team oriented• House staff and students will develop confidence and

progressive autonomy in the care of patients• All team members will implement a cost and time-

efficient model of care, while ensuring the highest quality with minimal risk

• All team members will foster a positive inclusive approach with nursing staff, case-management, social service and chaplains/spiritual care team

ResponsibilitiesResponsibilities

• Attending responsibility– Assume final responsibility for overall patient care– Ensure the highest quality of evidence-based medical care– Ensure optimal risk, time, and cost management– Conduct formal daily teaching rounds

• Ensure optimal educational experience of students and house-staff in an open and non-threatening environment

• Be available 24-hours daily as consultant and mentor to team, nursing staff, case manager, patients and families

– Role model the practice of an Internal Medicine hospitalist– Role model the practice of patient-centered compassionate care– Role model excellent communication skills with patients,

families, colleagues, house-staff, students, nursing, case-management and other ancillary staff-members


• Senior resident responsibilities:– Responsible for overall team management, organization and

supervision of patient care – Provide leadership for and supervision of interns and students

• Leads teaching activities during pre-rounds, pm work-rounds and on-call

• Actively participate in attending teaching rounds and work rounds discussions

• Discusses and or assigns pertinent evidence-based topics and articles to team

– Provides positive role-modeling to interns and students– Ensures orders, tests and consultations are carried out

expeditiously and results are addressed in a timely fashion– Recognized by the patients and families as the leader of the

house-staff/student team

ResponsibilitiesResponsibilities• Senior resident responsibilities (cont’d):

– Ensure that medical records are accurate, timed, dated and signed by Interns and/or Students

– Ensure attending is made aware of any significant results or changes in clinical status of patients in a timely fashion

– Dictates all admission H&P’s at time of admission (excluding short-call admissions)

– Dictates all D/C summaries for all patients ideally on day of but certainly within 24 hours of discharge

– Perform 1 CEX with each MS3– Ensure 1 observed CEX is performed by the attending– Be available during reasonable working hours (7am-7pm) daily

or later if necessary except designated days off and other arranged times for any patient or team-related issues

– Inform Primary Care Provider of admission and updates as appropriate


• Intern and Sub-Interns– Responsible for day-to-day assessment and care of

patients– Responsible for timely implementation of care-plans,

orders, diagnostic tests, consultations– Develop rapport with and trust of patients and families– Demonstrate/develop history taking skills and physical

examination techniques– Develop focused and organized case presentation

skills– Develop broad understanding of DDx and care plans– Develop technical/procedural skills– Dictation of death summaries within 24 hours of death


• Intern and sub-intern (cont.)– Understand and demonstrate proficiency at evidence-based,

cost-effective ordering of labs and diagnostic tests– Be available to attending, resident, nursing staff and case

managers during reasonable working hours(7AM- 7PM) daily or later if necessary except designated days off and other arranged times.


• Medical Students (MS-3)– Responsible for day-to-day assessment of designated patients– Develop rapport with patients and families as care-giver and

advocate– Demonstrate compassionate whole-person care of patient and

family– Ensure that patient assessment and test results are discussed

with intern/senior resident and/or attending in a timely manner on rounds and throughout the day.

– Refine and demonstrate proficient history taking and physical examination skills.

– Develop an understanding of the recognition, patho-physiology, differential diagnosis and practical management of common disease states and syndromes.

– Develop focused and organized case presentation skills


• Medical Students (MS-3)– Full written H&P given to attending for evaluation and

feedback: 2/block– 1 observed CEX by senior resident per block– 1 observed CEX by Attending per block– Case-based literature search/presentations: >1 per

week.– Attend all designated conferences, lectures, clerkship

meetings.

DocumentationDocumentation

• Senior Resident:• Dictated H&P for all new admissions (excluding short-call

admissions)• Responsible for reviewing and co-signing all Medical Student

H&P and progress notes• Responsible for ensuring medical record and medication

reconciliation documentation is accurate, dated, timed, signed and without any unapproved abbreviations

• Intern/Sub-Intern• Responsible for medication reconciliation on all patients• Comprehensive History and Physical must be written for all

admissions.• Documentation must be dated, timed, signed and without any

unapproved abbreviations

Initial PresentationInitial Presentation

• PCP name (If applicable)• CC, HPI, PMHx, PSHx, Allergies, Meds,

Social Hx, ROS• Physical Exam, Labs, Diagnostic tests

– EKGs/rhythm strips should be available at time of presentation

– Radiographic studies reviewed at time of presentation

• Assessment and Plan with DDx

Follow-up SOAP PresentationFollow-up SOAP Presentation

• S: events from overnight and/or need for continued hospital stay; new sxs, f/u on old sxs

• O: focused including all vitals and pertinent diagnostic data

• A/P: problem based• Include in addition

– Lines, catheter necessity– DVT/PUD Prophylaxis– Antibiotic day/anticipated treatment length– Skin/integument evaluation– Nutritional assessment and plan– Disposition/Prognosis and outcome planning

Medication ReconciliationMedication Reconciliation• Purpose: Patients are most at risk during transitions in

care (hand-offs) across settings, services, providers, or levels of care.

• It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.

• Ambulatory care• Outpatient procedural areas• Emergency and urgent care• Inpatient services • Post-hospital care

Discharge Med ReconciliationDischarge Med Reconciliation• This process is required for ALL discharges.• This includes discharges from the acute inpatient setting to ARU

(acute rehabilitation unit), inpatient Psychiatry, SNF (skilled nursing facility), or hospice.

• This includes discharges from ARU or inpatient Psychiatry to the acute hospital.

• Shortcuts such as “continue previous home medications” or “no change in home medications” are not acceptable.

• This process will be audited for compliance.

“Do Not Use” Abbreviations“Do Not Use” Abbreviations

• "U" – mistaken as 0– write Unit

• "iu"– mistaken as iv– write international unit

• "Qd, qod" – mistaken for each other– write every day, every other day

• "MS, MSO4, MgSO4" – confused for one another– write morphine sulfate or magnesium sulfate

• "tiw" – mistaken for three times a day or twice weekly– write 3 times weekly

• "as, ad, au" – confused with os, od, ou– write left ear, right ear or both ears

• "Trailing zero (3.0)" – decimal point is missed– never use a trailing zero

• "Lack of leading zero (.3)" – decimal point is missed– always use a leading zero

• "ug" for microgram – mistaken for mg– write mcg

Heart FailureHeart Failure• “A”

– ACEi or ARB must be prescribed at the time of D/C • If not, reason for NOT prescribing the ACEi/ARB must be clearly documented in chart

– Aldosterone blockers should be prescribed in the appropriate HF patients.• “B”

– Beta-blocker must be prescribed at the time of D/C• If not, reason for NOT prescribing the Beta-Blocker must be clearly documented in chart

• “C”– If on Coumadin f/u INR and Coumadin clinic/physician appt required

• “D3”– Discharge instructions– Diuretics– Digoxin

• “E”– Ejection fraction must be documented in chart

• study type, date, EF%; if no evaluation within last 1 year must provide f/u EF evaluation (appointment or phone number)

Heart FailureHeart Failure• Discharge instructions: All 6 items listed below are mandatory for

HF Patients.• All 6 items must be entered on all D/C instructions in TDS• Can begin D/C instruction entry at any point during hospitalization.

“D” = Diet as appropriatei.e. Sodium restriction 2 gm daily, low fat, low Cholesterol, Fluid

restriction 2L daily“A” = Activity instructions“W” = Weigh self daily“M” = Medications

name, dose, freq of all new and old meds that will be continuedlist all prescription and non-prescription medslist all discontinued meds

“S2” = Symptom management & smoking cessationi.e. “call doctor if you gain > 3lbs/day or >5lbs/week

“F/U” = f/u appt for HF mgmt provided on D/C instructionsHeart Failure clinic 456-6699

Heart FailureHeart Failure• Please notify any of the following of all Heart

Failure admissions:– Cardiology consult fellow (consults)– Nathalie De Michelis (CV Program mgr) p9088– Molly Nunez (HF NP) out of office until 3/08– Beth Westberg (Cards Research RN) x7945– Dawn Lombardo (HF Cardiologist) p4150

PneumoniaPneumonia

• Smoking Cessation counseling should be offered to all patients who have a smoking history in the last 12 months

• All patients admitted to the hospital should be evaluated for the need for Pneumovax and Influenza Vaccine

• All patients admitted to the hospital with a diagnosis of pneumonia or who subsequently are diagnosed with pneumonia– MUST be evaluated for the need for a

PNUEMOVAX and this clearly documented in the chart

FormsForms• Consult request forms must be signed by attendings

prior to requests if possible• DNR forms must filled out on the day it is discussed with

patient/family and signed by the attending within 24 hours.– Attending should be present at all DNR discussions or be

notified immediately of any such discussion.• Nursing Home transfer form must be filled out and

reviewed with the attending prior to patients’ discharge

Discharging a PatientDischarging a Patient

• All discharge meds, instructions and follow-up plans should be reviewed with the attending PRIOR to discharge

• Case managers can help with authorization for post-hospital specialty follow-ups

• Discharging a patient in TDS requires three steps:– Entering a Physician Discharge Summary note– Entering Discharge Instructions for the patient– Entering an order to discharge patient today,

tomorrow, etc.

Discharge InstructionsWhat Should be Included?

Discharge InstructionsWhat Should be Included?

• The screens will guide you through the instructions that need to be entered on your patient, such as– Condition– Diet– Self-care– Activity– Follow up/clinic appointments– Specialty Instructions– Medications needed (this includes the medication reconciliation

process!)

Post-Hospital Follow-upPost-Hospital Follow-up

• Patients should be scheduled for post-hospital f/u with their/a Primary Care Provider preferentially– The date and time of the follow-up appointment should

be given to the patient/family PRIOR to discharge– The PCP should be contacted at the time of discharge

and de-briefed about the hospital course and f/u plans– A copy of the d/c dictation should be forwarded to the

PCP– If the patient has no PCP, the inpatient resident/intern

caring for the patient will become the PCP (if appropriate insurance and agreed to by the patient)


• Only if no appointment is available in a timely fashion with a PCP– The patient should be scheduled into PHFU clinic by

contacting Jessica Ellis-Mills [456-3962/506-0599] or Primary Care clinic [456-7542]

• If no f/u appointment is necessary urgently and the patient has no insurance– A list of community clinics MUST be provided to the

patient and follow-up instructions clearly given and documented


• Where to send the patients for labs or imaging studies– Patients with Cal-Optima Direct , Medicare or Medi-cal can

come to UCI for primary care, lab tests and imaging studies – Others:

• Quest Labs

• Radnet (714-288-5400, fax 714-532-3738) or West Coast Radiology Santa Ana/Tustin Center (714-835-2323) or Irvine Center (949-753-0900)

– MSI Patients have to go to Quest for outpatient lab tests

Other issuesOther issues

• Transfers– For any patients requiring transfer from floor

to intensive care unit, this must always be communicated to the attending prior to transfer

• Procedures– Consent must be obtained prior to any

procedure and the procedure discussed with and approved by the attending

Other issuesOther issues

• Co-management– All ONCOLOGY patients are admitted to the Internal

Medicine service, including NEURO-ONCOLOGY patients

• the oncology fellow should be notified immediately of all admissions AND communicated with daily

– All GI patients (including post-procedure patients) should be admitted to the Internal Medicine service

• communication with the GI fellow/attending daily– Most PULMONARY (USUALLY POST-

PROCEDURE) patients are managed privately by Dr. Colt and his fellow in partnership with the Internal Medicine resident/student team BUT NOT the Medicine attending

Evaluations and FeedbackEvaluations and Feedback

• Informal evaluations are conducted at any time during the month and include two-way communication of any observations, commendations or concerns between attending, house-staff and students

• Formal two-way feedback sessions are conducted at mid-block and at the end of the block

• Written evaluations are completed by attending/house-staff at the end of each block

Documents

Hospitalist Program Inpatient Orientation Daniel Robitshek, MD UC Irvine Medical Center