PGY-3 to Be Retreat

June 11, 2013

Sumit BoseCrystal Lantz

Kamal ShemisaClaire Sullivan

Navin Vij

“Don’t count the days, make the days count” -Muhammad Ali

Congrats!!! You are entering your last year of Internal Medicine residency !

5:30-6                 Dinner

6-7:30          Changes for next year-CICU schedule-New Ambulatory Model

                             Patient Safety/Quality Externship Clerkship issues                             Miscellaneous administrative issues Boards

Noon conferences Board review series

License, jobs/procedures Senior talks

                             Dictations                             Professionalism/RECC                             In-training exam                             Weekend coverage/handoffs                             Reading elective 7:30 - 8:00        DACR/NACR Orientation Gen Med Consults

                                                                                8-8:30                 Questions

Overview

New ambulatory model New CICU schedule

Changes for Next Year

* Rounds with CICU attending start at 8 AM. Heart failure rounds (separate attending) usually start at 10 AM.Attendings rotate in one week blocks4 residents do overnight call every fourth nightMay have rotators from Emergency Dept. as wellNo nightfloat systemSometimes admit MICU overflow patientsCardiology fellow not in-house at night (though staff admissions with fellow on the phone and if patients sick, fellow comes in)Drawbacks to this system: only one resident at night, can be challenging to leave post-call by 11 AM if busy night

Current Structure of the CICU Team

*2 interns scheduled in the CICU: -Day intern: works 7 AM-7 PM. May follow/admit one to two patients under supervision of senior resident. -Night intern: works 7 PM-7 AM. Helps with cross-cover, gains valuable night ICU experience including procedures, and possibly allows for on-call resident to take a quick nap. *Interns will do one week of nights and one week of days during two week rotation*Both interns have Sunday off (accommodate switch days and transition from nights to days)

The New CICU for Interns

5 senior residents On-call Post-call Regular day Day call Pre-call

Days off will be Pre-call day between Thursday and Monday

Signout should occur after evening fellow rounds (4-5 PM) to overnight resident

The New CICU for Senior Residents

Every fifth night is overnight call, but resident does not come in until 4 PM that day. Resident then presents the following morning on rounds and leaves hopefully by noon (20 hour call), with wiggle room to prevent duty hour violations.

After post-call day, resident has regular day (til 5 PM). No admissions this day.

After regular day is day call where resident is responsible for admissions from 7 AM- 4 PM (when overnight resident arrives). Day call resident works until 7 PM.

After day call is pre-call day without admissions.

The New CICU for Senior Residents

Weekly continuity clinic during inpatient wards, electives, and ambulatory blocks

Two 1-month Ambulatory Blocks comprised of didactics, medicine subspecialty clinics, VA UCC, Psych CL, and continuity clinic

The Current State of Continuity Clinic & Ambulatory

Blocks

Four 2-week Ambulatory Blocks Morning VA subspecialty clinics For 1 week you will have 5 consecutive afternoons of

Clinic *Green Road 5 clinic sessions over 2 weeks including morning

sessions*Residents must turn in sessions to Amb Chief

For the other week you will have 5 afternoons of VA UCC and subspecialty clinics

2 Clinics during Electives PGY2 = 8 weeks PGY3 = 14 weeks

New Ambulatory Model

No continuity clinic during Wards!!!

Precept with different attendings each day of week to get different clinical perspectives

Improving the outpatient experience of our program and limiting extended periods of time on wards

Continuity with patient panel: guaranteed clinic q8weeks for chronic disease management (CDM) and preventative health

Pros of New Ambulatory Model

The ambulatory schedule is fixedAmbulatory blocks cannot be swappedElective rotations cannot be switched

New Ambulatory Model

The new ambulatory model is proposed to decrease stress of balancing inpatient and continuity clinic responsibilities

Opportunity to improve continuity with panel of patients and develop QI projects Greater autonomy Increased engagement in the clinic environment

Resident feedback throughout the year is strongly encouraged and leads to continued improvements in your ambulatory rotation!

Summary…

• Applications should be in by July 1; ERAS token can be requested June 18th• Have faculty working on your letters of recommendation• Another meeting with KBA June 18th at 6 PM•July 15, 2013: programs begin downloading applications •Deadline for completed application varies but is as early as July 31st; check with program and be prepared• August - November 2013: interviews conducted• First Wednesday in December 2013: Match results available

*KBA will perform mock interviews upon request

Fellowship Timeline

*Primary care and subspecialty specific

*Both landmark and review articles

*Case Medicine website Residents Education

Residency Reading list

REMINDER: Residency Reading List

Research poster is a requirement for those who take two or more weeks as a research elective Can present subspecialty research done during

electives Establish connections with a mentor Chief residents are available to help find mentors and

research opportunities Research Day is usually in May

Research Day

• New intern orientation 6/13/2013

• Last day of work for current PGY-1’s 6/23/13

• Transition week (Block 0) starts 6/24/13

• First day as PGY3 is 7/1/13

Transition Dates

UH ward teams cap at 10 patients per intern except for the Seidman teams which cap at 8

VA ward teams cap at 8 patients per intern No short call on weekends No shorts if intern has 8 patients (but AI/intern pair

with 2 seniors can go to 10 patients on short day) Intern + AI @ VA = 10; AI+AI paired together =12

(if 2 seniors, 10 when one senior) Intern + AI @ UH = 12 when 2 seniors; 10 when 1

senior

Team Caps

Long: 3 patients until 7:00 stay until 9:00 Medium: 2 patients until 4:00 stay until 7:00 Short: 2 patients until 12:00 UH and 1:00 VA

MICU transfer/NF only at UH, can be new patients at the VA No short patients on clinic days or if intern already has 8

patients

ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!

Senior Resident: On call residents stays until 9:00 Staff patients available to be seen anywhere in the hospital

until 4:00 (Monday-Sunday) Weekend team covering resident staffs until at least

1:00PM

Duty Hours

On call senior resident must stay till 9:00 PM must leave by 11:00 PM

Starting Block 4-5 you will be staffing orphan interns on other teams as well when on call

See and examine EVERY patient No staffing note required for ICU transfers Focused notes by the senior resident with

detailed plan See PGY1 note for full H&P. Briefly, pt is a …

Helpful to new interns: Antibiotic doses Description of imaging- With contrast? Without? Medications to continue, medications to discontinue CODE STATUS and Allergies

Staffing

On call resident should notify the nightfloat resident of tenuous patients

Be proactive about staffing patients

***Please note, even if you are not on call, you must staff all patients who are available to be seen if they are assigned to your team before 4 pm (even on the weekend)

Weekend coverage resident should staff all patients until 1pm

Staffing

Patient Safety and Quality Improvement

* Introduction to quality improvement during DACR rotation

-Hand-washing audits-CLIPPS -Quality Assurance meetings-Write-up cases for Medicine QA-Attend ED/IM QA-Attend Quality Patient Safety Committee meetings-Mortality review, PASS reports, and Risk Management meetings

Each PGY3 resident identifies and completes a quality improvement project as one of the requirements by ACGME

Work in groups of ideally 3 (no less than 2, no more than 4) Work with one of the chief medical residents and quality

center to develop project ideas and aid with data collection Start by identifying a quality issue, collect background data,

design an intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources)

Present quality poster at Research Day

Guidelines for Resident Quality Improvement Project

General Timeline: Mid-August to early October: define objectives,

collect background information, plan an intervention Mid-October: schedule a meeting with project

chief to review objectives and plan Late October through January: implement your

intervention January through February : collect and analyze

post-intervention data and schedule meeting with project chief to discuss results

March through April: write-up project and finalize poster; submit poster for printing to be presented at Research Day

Timeline for QI Project

All low risk chest pain, sickle cell pain crisis, gastroenteritis in a young patient, syncope is an observation patient

Please follow ER description on blue sheet Instead of admission order, click the “Place in

Observation” box Please keep your UH care team lists up-to date! Quality center is tracking admissions by

diagnosis

Obs vs admit is related to clinical criteria and not expected LOS!

To Admit vs. Observe

Professionalism

Professionalism: Attire

Men Shirts and ties

Women Professional

Keep white coats clean No denim Do not show up to Morning Report

looking sloppy

Referral to RECC If you have to call in sick > 1 day, you will need a

doctor’s note from the Bolwell Family Practice clinic You will be able to get a same-day appointment

If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy

Call-offs: You must PAGE 31529 the Ambulatory Chief DO NOT EMAIL DO NOT TEXT PAGE DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

Professionalism: Absences

Professionalism: Electives

While on elective, you are expected to attend all Grand Rounds and M&M’s

Please note that when you are on elective, you are back up jeopardy!!

You are expected to have your pager turned-on throughout your elective rotation

If you are going out of town for the weekend, please notify the ambulatory chief prior to leaving

Elective should not be treated as vacation Please email Barb 2 weeks prior to starting your

electives

Professionalism: Reading Electives

Residents on reading elective are expected to attend morning reports and journal clubs at the VA

Must attend Grand Rounds at UH Your pager is expected to be turned on and on you

during the entire two weeks of elective All reading electives must be approved by KBA For PGY2s it can only be used to study/take step 3 Please note that when you are on elective, you are

back up jeopardy!!!

Professionalism: Conference Attendance

Be on time! Noon conference:

UH: Mon-Wed-Thurs VA: Mon-Thurs-Fri

Grand Rounds on Tuesday: UH & VAM&M Fridays @UH, Wednesdays @VA

Professionalism: Ambulatory Conference Attendance

• Ambulatory conference attendance is mandatory and tardiness and absences are extremely disrespectful to our educators

• Late Policy will be strictly enforced: • Sign-in sheet will be available until 8:05AM• At your 2nd instance of being late, extra

weekend coverage will be assigned• Any MISSED conferences without prior approval

by the ambulatory chief will result in weekend coverage

Professionalism: Discharge Professionalism: Discharge SummariesSummaries

Do them the day of dischargeDo them for your internDo them for your friendsDo them for your patientsWeekend coverage is responsible

for discharge summary

All coverage arrangements and schedule switches must be approved by the Ambulatory chief

Switches must be arranged before 1 week of rotation starting

Weekend Coverage switches before 48 hours of day

NO SWITCHING AMBULATORY OR ELECTIVE BLOCKS!!!

Coverage and Schedule Switches

Senior Grand Rounds-Start in late August-Dr. Mourad is the APD in charge. -Email learning objectives to assigned

faculty mentor and ambulatory chief resident two weeks prior to talk

-Evaluation process will be in place-Should be evidence-based

Research-All residents doing away and research

electives must present at Research Day

TalksTalks

Register by December Plan ahead…costs about $1,365 (more if you

sign up late) Noon Conferences to include more board prep

sessions Intense June weeklong session for board review Can use ITE exam results to help guide studying In-service Exam Dates are Oct 4 – 19th

Remember: no Moonlighting if ITE < 30% of your peers

BOARDS!!!

Remember to keep your BLS/ACLS updated Must have Step 3 results prior to license

application Start FCVS by December ($430) State licensing ($335) can often take 5-6

months. DEA license is much quicker but more

expensive ($551) Plan ahead!!!

Medical License

Perform medicine consults Be available to help out ward teams as

needed Prepare EBM lecture on a topic of choice for

morning report Attend all morning reports One Saturday 24 hour VA MICU coverage

VACR

DACR / NACR:DACR / NACR:Your education in systems-based Your education in systems-based

practicepractice

The NACR as The NACR as OmbudsmanOmbudsman

Distribute admissions to teams on call in AM Enforce geographic localization Run codes See medicine consults at night (Ortho co-management) Cover emergencies in CF patients on RBC 7/Lakeside and

Hanna House Cover flex patients at night Find out intern census from nightfloat interns for each

team Admit BMT and Transplant Medicine patients along with

NF (must inform BMT fellow and Transplant attending) Transplants within the past year should be admitted to

surgery *ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization

““The BookThe Book” ” as it should as it should be…be…

Medicine

Fam Med

Neuro

Surgery

Ortho

Transplant

ENT

RealityReality

““The BookThe Book” ” according to according to the ED…the ED…

Medicine

Surgery

Fam Med

Neuro

Ortho

Transplant

ENT

How the ER views the worldHow the ER views the world

Appropriate Service?Appropriate Service?

Is the patient

stable for the floor?

PCP an FP?

NoMICU/CICU/NSU/SICU

Yes

Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission.

No

Appropriate for

medicine?

No Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient”Yes

FM capped!?&*#@!

Stroke, SBO, femur fracture, etc

YesAppropriate

for FP?

Appropriate Service?Appropriate Service? Look up the patient in Portal and EMR before

assigning Patient’s PCP – Family practice patient? Private

patient (list of attendings available)? Physician Portal (summary page, physicians) Previous discharge summaries EMR patient info clinical summary (visit history) Ask the patient!

Hints as NACRHints as NACR

Be proactive – keep an eye on the ED board Admissions require bed assignment Figure out PCP (verify with patient if possible) Quick visit history/portal search for past visits Assign patient to NF or house doc (consider

team in the morning for geographic localization)

Call admitting with location and ER with pager (or place it in EMR)

Types of PatientsTypes of Patients Private (PCP will attend) – Coviello, Schnall, D. Brown,

DeJoseph, Junglas, King, Tomm, Locke ER must call private attendings; but if the patient is

on the floor and the ER did not call, it is the DACR/NACR responsibility

Assign to med NPs (private spots) during the day! If no spots, then flex versus team (Eckel, Carpenter, or Gen Med; not Ratnoff/Weisman/Hellerstein)

D. Brown must be flex (not NP)

Staff – NPs (no procedures), hospitalists (few social issues low complexity), general medicine teams

*Non-cardiology patients needing telemetry can go to Hellerstein and hospitalists (not med NP)

Specialty services:• Eckel: ESRD, hypertensive

urgency/emergency. ESRD transfers need to be accepted by Nephrologist.

• Ratnoff/Weisman: SCC with active issues

• Hellerstein: active cardiology issues (regardless of PCP)

• Dworkin: GI patients. Can take liver to a cap of 3 (but flexible) if Post/Gholam patients

• Fang service: newly renamed HVI.

• Patients with no right answer (HIV patient with ESRD and chest pain followed in HF clinic) - most active issue prevails

Types of PatientsTypes of Patients

Types of PatientsTypes of Patients

HIV patients go to Carpenter-When Carpenter is not admitting, give them one a day early or have resident flex

Pulmonary cases go to general medicine-Pulmonary HTN and flolan patients need to be on T5

MICU transfers followed by renal consult team-If chronic Eckel-If acute gen med with renal consult

Non-Teaching Non-Teaching ServicesServices

Reaffirm census/open spots in the morning and afternoon

Medical NPs will call in evening with open spots for the next day

Berger NPs will email the night before with spots Hospitalist A (NPs), B, C, and D will call the Admissions

Coordinator with next day’s open spots (make sure they are written in the book)

Fang Service - Just call them

NPsNPs

Medical Nurse Practitioners Patients who do not need procedures Patients who are not being ruled out for ACS CAN take syncope patients on tele They will take most private patients (not D.

Brown)

Berger Nurse Practitioners Stable patients who do not need procedures: sickle

cell, pain management, hospice, routine chemo admissions

Hospitalist B, C, & DHospitalist B, C, & D

Have a cap of 12 patients each Straightforward medicine patients without complicated social

issues Try to give them patients whom you anticipate will have short

stays Unfilled spots rollover to the next day Cannot take ICU transfers that were in unit >48h Take bouncebacks, but count against cap

Fang ServiceFang Service

Two NPs with Hellerstein fellow

During the week, admit cardiology patients to team cap

Will take NF admits and CICU transfers up to their cap

All Effron/Heart Failure patients

MoonlightingMoonlighting Cross-Cover long house doc: 8pm to 8am

Cover the nurse practitioner, BMT, hospitalist services, and Hanna House overnight

Admits one patient per night (or three if NP on with them) Holds transfer pager (remember, don’t accept ESRD –

Nephrology must!) Early and late Short House Doc

Each admits three patients Admitting Long House Doc: 6pm to 6am

Admits six patients Bomb the long house doc! Give them private patients that go to the NPs Must cap them! No admissions after 0400 Appropriate patient selection for the house doc is key; in

most cases these patient should not come back to the housestaff the next day

The NIGHTFLOAT TEAM

The NIGHTFLOAT TEAM

NACR

Nightfloat ResidentRotating MSIII

Nightfloat Resident

Nightfloat InternRotating MSIII Nightfloat Intern

NIGHTFLOAT TEAM

Nightfloat Intern

NACR specificsNACR specifics 8pm – midnight:

Meet Admissions Coordinator in KACR to get sign out Start NACR sheet, Admissions Coordinator will be holding the book and

pagers til midnight on most days so this is prime admitting time Midnight and after

Stay on top of the ED board Master the art of the NACR

5-6am Get organized, make copies of NACR sheet, print out new board (on

medicine.case.edu; UH resources ), get intern census Talk to NFs regarding admits and appropriateness for teams vs. NPs vs. flex

6:30-8am Review admits with KBA and V-BLSS 8am hospitalists call for assignment Fax assignment sheets from day prior and overnight to admitting and

hospitalist offices Call non-teaching services to assign patients

Chief Resident may call you to check in on your first NACR night

ED IssuesED Issues

Neurology Strokes go to neurology Seizures – try neuro first

General Surgery: insist (politely) that they take SBO’s, etc Make the resident call their attending (or do it for them)

VA: far better to transfer BEFORE admission

Ortho: perhaps worth arguing, but Medicine co-manages most ortho patients (NACR/DACR consult)

Other Duties: Medicine Other Duties: Medicine ConsultsConsults

See the patient in a timely fashion Write a note

Leave at least a preliminary note in the chart Call the Gen Med consult attending if needed Co-management with orthopedics

We follow along with ortho patients; they don’t need a “question”

You can put in orders dealing with medical issue

Transfers to MedicineTransfers to Medicine

All transfers to medicine must be approved by medicine consult attending (not Dr. Whelan), chiefs, or KBA

Consults for transfer to medicine: If clear subspecialty issue, refer to appropriate

attending If clear gen med transfer, no consult necessary If unclear, offer to do a consult and staff with

attending Don’t accept transfers overnight

Outside Hospital Outside Hospital TransfersTransfers

Transfer Center 41111 Attendings are supposed to call 67121 or page

30512 when they accept a patient

8 am – 8 pm – Rotating attendings M-W: Chief Resident and KBA Th-F: Dr. Chandra et al

8 pm – 8 am – Cross-Cover Long House Doc

DACR/NACR HoursDACR/NACR Hours

DACR = 0800 – 2000 NACR = 2000 – 0800 MAN = 0800 - midnight DACRs come to morning report, Grand Rounds,

and M&Ms NACRs have a staff attending on call

Running Codes

Code Whites (UH)Code Whites (UH)

** 1ST six months – an upper level must go to all Code Whites with an intern**

Sick or decompensating patients on the floor or Hanna House

Initial response from ICU nurse, intern, and PGY2

DACR/NACR for level 2 code white If you want to transfer to MICU, call

MICU fellowAlways write a Clinical Event Note!

Check your own pulse first

“Too many chefs spoil the soup” One person leads the code Make sure interns are involved Maintain a calm quiet atmosphere

Keep the ACLS cards in your pocket until you are comfortable with the protocols

Make sure your BLS and ACLS are up to date

CODE BLUE NOTE and notify family

Code Blues

Rule #1: You are in charge

If uncomfortable, defer to more senior resident

Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc.

Use the DACR/NACR if you need help

Don’t be afraid to ask people to leave the room

Call the ICU nurses by their name, closed-ended communication

Call the family

Use the Code Note EMR, all Code nurses have it and should be available in the ICUs

Running CodesRunning Codes

Notifying Attendings at night Most attendings want to be paged and notified

(either of transfer to ICU or death) Can clarify with your attending on first day of service

what their preferences are Don’t get burned by not calling your attending- you

may hear about it the next day

Running Codes

Questions?Questions?

We are looking forward to a great year together!!!

-VBLSS