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UH Ward Orientation
Team Structure
• Attending
• Senior Resident
• Intern x 2
• Possibly a Sub-I
• Two 3rd Year Students
Duty Hours
• Residents/Interns:
– Must have 4 days off during their 4 week block. Give them one day off per week, including the first week!
– Cannot work more than 80 hours a week, averaged over a four-week period.
– Cannot work more than 24 hours (+ 4 hr transition) consecutively.
– Must have 8 hours off between each shift.
• It’s your responsibility to ensure duty hours are met.
• Also applies to Sub-I’s.
Duty Hours
• Time spent on notes and documentation counts towards your duty hours.
• Time spent covering the pager at home, does not count towards your duty hours unless you come in to the hospital to see a patient.
• You must log your hours for the preceding week by Monday at 5PM in New Innovations.
Work Load
• Interns can see up to 8 old patients.
• Interns can admit/transfer up to 5 additional patients.
• Team cap is 16 patients. Bounce backs can take you over cap, but the attending is responsible for extra patients.
• Touch cap is 18 patients. It resets at 7 pm.
• There should be some degree of pager sharing between interns and residents
The Flexible Drip
Makes sure no one team is seeing a significant number more than another team. Protects you from extreme variability. Equity of work.
• Q4 "Long Call" Admitting from 3pm – 6pm• Q4 "Pre-call" No admitting, only patients from night float if your team
went in with <12• Q28 "Short call" on Thursdays admitting from 11am – 3pm• Weekends/holidays are not different• No designated MICU accept, or Night Accept• New "Touch Cap" of 18
The Flexible Drip
• MICU transfers– Flow through just like admissions, all intake is equal.
• Other non-MICU transfers– Non-MICU transfers (FM-Card-Neuro-Surgical specialties) are transferred by the
consult service (Green Medicine).
• Night float admissions:– Will be signed out in the mornings to the teams.– A member of the teams is expected to be there.
Weekly Schedule
4 Day Call Cycle
Long Call Drip Drip Protected
Daily Schedule
Long Call
• Applies to both weekdays and weekends
• Start day with new patients from night only if you went in with <12 OR if all other teams capped you may get two more -> 14
• 7am – 3pm: Round and finish tasks and discharges
• 3pm – 6pm: New admissions performed by your team (to your team or other teams)
• 6pm – 7pm: Staff new patients with attending, finish H&P
• Touch Cap of 18
Pre-Long Call (kind of protected)
• Applies to both weekdays and weekends
• Only patients from night if you go in with < 12 patients (max 2)
• 4 of these days a month will be upper level days off.
• You DO NOT admit or transfer any of your own patients.
• You may have additional patients admitted to you by the triage team (Gray) up to team cap or touch cap.
Non-Long Call (The 2 other days)
• Applies to both weekdays and weekends
• Up to two patients in the morning from nightfloat (up to 4 if you went in with 10).
• 11am – 3pm: Responsible to perform a maximum of 2 admissions/transfers (to your team ONLY).
• You may have additional patients admitted to you by the triage team (Gray) up to team cap or touch cap.
Short call
• Q28 or once a month
• Only on Thursdays
• Similar to a normal non-long call day
• Up to two patients in the morning from nightfloat (up to 4 if you went in with 10).
• Admit patients from 11am – 3pm to allow other two teams to go to Thursday school
• You may have additional patients admitted to you by the triage team (Gray) up to team cap or touch cap.
Admission/Transfer
Admitting Patients• Appropriate Service:
– The ED triaging and the Gray (triage/admission) attending should have done it
– Good to double check
– “Who is their PCP?”
• A patient is FP if they identify their PCP as someone on the FP list (located on the UNM Hospitalist wiki).
• When in doubt, send a Tiger message to “FM Admit Resident”
• Prior admissions DO NOT MATTER.
• Where to locate PCP:
– Prior Clinic Notes
– Top of Powerchart (Sometimes)
– Rx Prescribers
Admitting Patients• All of the triaging should have been done by the Gray (triage/admission) attending, but the
info. is provided below
• Service Agreements:
– Available for FP, CF, Neuro, Cards, MICU, Psych, Heme/Onc, Peds, Ortho, Surgery.
– When in doubt, check the UNM Hospitalist wiki.
• ED Obs:
– In general, applies to cards, placement, COPD, pyelonephritis, and cellulitis.
• Caution with pregnant patients (get your attending involved if you have to admit).
Transfer Patients1) PALS
– The Gray (triage/admission) attending will assign you.
– Should be seen ASAP, at least within 1 hour of them arriving.
• Have not been evaluated by a physician thoroughly except by the triage attending
– If you think they need a higher level of care, call the appropriate ICU.
2) MICU
– The Gray (triage/admission) attending will assign you.
– Ask the MICU residents/interns for a warm hand-off
3) ED:
– The Gray (triage/admission) attending will assign you.
Admitting PatientsBounce-backs:
• Teaching Teams:– Within 14 days after discharge.
• Follows Residents, Interns, Externs, and Sub-I’s, regardless if that person was following patient previously.
• Gold/Silver/Copper/Nickle Medicine:– Within 14 days after discharge.
• Follows APP and attending, regardless if that person was following patient previously.
• Triage attending will assign a team to admit, regardless of bounce-back team.
• The Bounce Back rules apply to both MICU transfers and admissions from the ER
Admission/Transfer Flow
- The Gray (triage/admission) attending will assign the patients according to the algorithm.
- You don’t need to worry about this.
Admissions• Requirements on ALL patients:
– Bed Request
– Admission Order set
– Medication Reconciliation
– Code Status Note
– History and Physical
– Cache
• It’s your responsibility to ensure these are completed.
Documentation• History and Physical
– NEED TO INCLUDE:
• PCP
• Code Status
• Contact Person with Phone Number
• Code Status
– NEED TO INCLUDE
• Your discussion with the patient
• Surrogate Decision Maker with Phone Number
– If “Presumed Full Code,” update as soon as patient has improved mentation or family can be reached.
Documentation
Progress notes:
• Every patient every day.
• YOUR attending’s addendum on the Night Float H&P counts as daily note for following day.
• If the swing shift attending made the addendum for the H&P before midnight. You NEED a progress note on the following day.
• Discharge summaries dictated on the day of discharge counts as the daily note. NO NEED to include the physical exam. (Attending must include that they have made face to face contact with the patient).
24
Where to Find Sepsis Order Sets
1. Ensure Search Setting is
“Contains”
2. Search Term “Sepsis”
3. Select this First Choice
4. Select the Appropriate Power
Plan
Documentation• Discharge summaries:
– Must be dictated within 24 hours.
– CC the patient’s PCP.
Discharge Summary• Essential Elements of a Discharge Summary
• Date of admission and discharge• Final diagnoses • Brief description of reason for admission• Brief hospital course• Condition of patient on discharge• List of operations and procedures• Other significant findings and test results• Medication list on discharge• Follow-up appointments• Anticipated problems and suggested interventions• Pending laboratory work and test
• NO NEED to include the physical exam
MS3 (Phase II) Documentation
• Procedure note is not billable
• H&P in “Student Note” is not billable
• Progress note
– 1 note in “inpt progress note” is billable -> resident to addend (=resident+MS) -> attending to addend (=attending_MSandResident)
– 1 note in “student note” for education ONLY
• NO Discharge/Transfer Summaries
Sub-I (Phase III) Documentation
• H&P– in “H&P” is billable -> UL resident to addend (=resident+MS) -> attending to addend
(=attending_MSandResident)– MUST BE DONE SAME DAY
• Progress note– in “inpt progress note” is billable -> UL resident to addend (=resident+MS) -> attending to
addend (=attending_MSandResident)
• Discharge/Transfer summaries– billable -> UL resident to addend (=resident+MS) -> attending to edit and addend
(=attending_MSandResident)– Transfer summaries should be edited and addended prior to patient transfer
Crosscover
• OCD (CC1 and CC2) covers 1900 – 0700.
• Intern or Senior Resident signs out at 1900 (7:00pm).
– We all use IPASS.
• Cache determines the information that OCD first has to care for a potentially crashing patient, so make sure it’s UPDATED DAILY.
• OCD will use TigerConnect to send a team message for sign-out– It is OPTIONAL for OCD to be at the 4 West workroom between 6:45 and 7:15 every
morning for an in-person sign-out.
Education• Afternoon Report at 2:00 pm every Monday, Wednesday and Friday.
– NO Team is Excused
– Attendings should hold/answer the pager.
– Push the TigerConnect roles to the attending
• M&M once a month on second Friday at 1200.
• Grand Rounds/Thursday school activities start at 1230 every Thursday.
– Long call/Short call are excused.
Afternoon Report
• Resident (R2/R3) will present on post-call days.
– Present a case for each afternoon report
• …..unless resident wants to try something else?
– Residents should have gotten an email with their assigned dates
– Residents will email me and/or the UH QI chief the presentation 48 hr prior to his/her assigned date
– Chief resident will prepare the teaching after resident’s presentation
StudentsMSIII
• Follow 2-4 patients, but START with 1-2
• Only write 2 notes a day in the chart (see documentation section)
• One progress note is billable with addendum from resident & attending
• Should have all of their patients seen by another member of the team prior to rounds every day.
• One day off per week (usually non-call day).
– 5 days off on “switch weekend” (usually Wed-Sun)
• They will remind you when they have other commitments and needed to be off
Students• Passport:
– You can sign their passport (except H&Ps).
– Need to have attending sign off on required H&Ps
• Didactics:
– Tuesday afternoons.
• Not expected to return to the team afterwards – even when on call.
– Chief Rounds on Mondays 11:00 – 12:00 pm
– Thursday after 1330 is protected study time if not on short call or long call.
StudentsSub-Interns:
• Should be performing the duties of an intern (but still not actually a physician)
• Interns should not follow their patients
• The resident is the primary contact for the sub-intern
– Make sure they get an opportunity to carry the team pager AFTER 1st week
• Make sure either an intern or a resident has the other pager
– Give them feedback on documentation
– Opportunity to put in orders for resident co-signature
• DO NOT ask sub-I to carry the pager during pre-round
• Can perform billable H&P, progress note, discharge/transfer summaries (see documentation)
Days Off• Residents are in charge of team schedules.
• Everybody gets 4 days off each month except for MSIII.
• Interns should take at least one day off the first week.
• Resident:
– ONLY pre-call (protected) day off.
• Intern:
– NO pre-call (protected) day off unless resident is working.
– NO call day off
– Okay to have day off on post-call, post-post-call
• Try to avoid Thursdays (TS, GR).
TigerConnect on Apple
TigerConnect on Android
IMPROVE-IT Quality/Safety Dashboard
• Utilize during rounds
• Available on Cache view
• Fill out survey weekly if possible
• https://ctsctrials.health.unm.edu/redcap/surveys/?s=7YX89AWYFF
Questions?
Call or Email me:
808-675-8892
Come visit?
Office across from Dr. Jernigan’s
