Med Wards Rotations

Schedule

Priority rounds

1–3 patients (house or specialty): discharges, high acuity, or new/interesting

Cluster rounding

Walk rounds with Team Coordinator, RN, Care Coordinator, Residents and Attending, on all patients (including specialty). TC will print list of all patients and map out cluster rounds, calling RNs ahead of time. They can also help to get films from radiology, schedule appointments, and many other things. We are now trying to invite all families to rounds as well. Co-round on high acuity, split team PRN

Weekends / Holidays

Sit–down, sign–out rounds occur at 8 a.m. in the Sound Café. Your House attending may join you as you sign out the house patients, but it should not turn into rounds. Subspecialty attendings are expected to touch base with the SR prior to leaving the building.

Signout

OWLs (Overnight Ward Leaders = senior night coverage. Day seniors do not take q4 call) arrive at 6:30 p.m. for signout. This takes place in the staff dining area of the cafeteria. The small dining rooms can be used if not occupied for more confidentiality.

Meals

When on–call, dinner and breakfast the following day are provided in hospital cafeteria; sign your name at check-out. On weekends, lunch is also provided.

Conferences/Teaching

• Morning Report 8 to 8:30: Everyone is expected – we would like interns to come.
• Teaching Conferences: Mondays, Wednesdays, and Fridays. Tuesdays – either mock code or administrative ward discussion
• Grand Rounds: Thursdays 8 to  9 a.m., Wright Auditorium
• Noon Conference: Everyday except Thursdays, lunch served.

Documentation

It is important to document procedures and cross cover issues.

A good guideline is that if you feel compelled to go see the patient on cross cover, the SR or R1 should write a short note to document the patient's assessment. This note can be very brief and subjective, but it should include an assessment and plan.

Please emphasize documentation with your team. Procedures such as LPs deserve a note.

Please remember to have orders written for "change attending to" on switch days. If an attending has not written a note in MORE THAN one day, it needs to be investigated.

Senior Admission Notes

Every admission must have a brief admission note by the senior resident on call.

It must document:

• History has been reviewed
• Patient has been examined
• R1 admission note has been read
• Brief description of the assessment and plan

If you cosign a med student note to use it in place of a resident H&P, make SURE it is of good quality.

Visiting Residents

UW family practice interns come as a pair; they each have two afternoon clinics per week. If possible, have each member of the pair sign out to the on-call intern.

One of the UW FP residents is to attend didactics Wednesday afternoon starting at 12:30 p.m.

Psych. interns have required Thursday afternoon didactics. The official policy is that they do not go if they are on call or post call. Otherwise, they should sign out around noon on Thursdays.

Communication Issues

Bi–directional feedback at the midpoint of your interactions with interns/students/attendings is crucial, with follow-up at the end of the interactions.

If a new admission is a patient who has recently (in the past month) been on one of the surgical services, please make a courtesy call to that service.

PMDs deserve adequate communication; below are guidelines:

Formal PCP Communication Policy

On admission: The ER resident will contact the PCP at the time of admission. Direct admissions will already have been discussed, but the admitting resident will contact the PCP (who is usually the attending) with any questions on the day of admission.

On transfer to the ICU: The ward senior resident will contact the PCP at the time of transfer.

On transfer from the ICU: The ICU resident will contact the PCP at the time of transfer. Remember to ask the transferring resident to make sure this gets done.

The ward senior resident will also contact the PCP promptly for the following patient situations: Deaths, surgeries, significant changes in status, significant changes in diagnosis

On discharge: The resident (usually the intern) will contact the PCP before discharge to briefly relate a summary of the inpatient course and make outpatient plans.

Documentation: All contacts with the PCP should be documented in the hospital chart including contacting resident, time and date of contact.

Pharmacy Taste Test

If you are interested in arranging a Pharmacy Taste Test for your team, contact a pharmacist. If procedures are done on the floor, please consider utilizing Child Life: Kari Nelson and/or Jen Hartman.

Observation Status

As of November 1, 2004, state law requires all hospitals to use a standard set of criteria to classify patients as either "inpatient" or "observation". The status is based on reviewing the severity of the illness and intensity of services required by the patient's condition.

Using these criteria, Children’s will conduct utilization review (UR) of every admission within 24 hours, every day, to validate the appropriateness of the admission status. UR staff will communicate the appropriate level of service to the care teams.

Please do not change the status of a patient without checking with UR and/or your team coordinator. When in doubt, default observation.

Telemetry Service

The patients admitted for video EEG monitoring will be staffed by the Telemetry Neurology Attending and the inpatient neurology residents/fellow. Patients with surgically placed intracranial electrodes (grids and strips) are admitted to the Neurological Surgery service, and the Neurology Telemetry attending and PNPs provide consultative care (co–management).

At night, 5 p.m. to 8 a.m., in–house coverage for emergencies requiring immediate intervention will be provided by the Neuology/neurosurgical teams with the help of the residents on Med Team 1. If you are called directly by a nurse on a telemetry patient, make sure that the neurology fellow/resident has been called. If the fellow/resident cannot be reached, the back–up is the neurology attending, NOT the Med 1 senior!

The nurses covering these patients at night will page the out–of–house neurology resident on call with any questions, and the neurology resident will give a verbal order if necessary for anti–convulsant medication.

If it is necessary for the patient to be examined and evaluated in an acute situation, the neurology resident will then page the Med 1 senior resident on call for the medicine ward team. The senior will evaluate the patient and then formulate a plan with the medicine senior resident and/or the out–of–house neurology resident if necessary.

At 5 p.m. on weekdays and possibly sooner on weekends/holidays, the neurology resident responsible for the telemetry patients will sign out to the Team 1 intern or senior responsible for in–house nighttime coverage.

Medical Students – R1 Responsibilities

Teaching

The senior resident is responsible for medical student teaching during the month. Interns will teach students the "nuts and bolts" of being on the wards. Anything else is a bonus. The intern's most important job is to make sure that the student feels included in the team.

Feedback

You should give ongoing daily feedback about SOAP notes, order writing and basic clinical skills. At the end of each week, summarize this feedback and give it to your resident on one of the 1/2 page Feedback Forms.

DO NOT indicate what grade you think the student deserves. The senior resident is responsible for the formal feedback to the student, but you should share your observations with the SR.

Review of SOAP notes

Interns review, revise and cosign student daily progress notes (SOAP notes).

Students are expected to write notes on ALL patients they are following (even on their post call day). Be clear when you need the note on the chart: DO NOT re–write the student note.

If the student is having problems getting the note on to the chart in a timely manner, discuss this with the student and give this feedback to the SR.

Oral case presentations

Be available to go over the student's oral presentation before rounds so that the student can optimize the presentation.

History and physical

The senior resident is responsible for reviewing the initial H&P. The student note "counts" and SHOULD NOT be repeated. It is supposed to be on the chart before the student goes home when they are on call.

Review of write-ups

The Day SR should review the student's H&Ps with the student the day they do them or the following day

Students should write their patient H&Ps on regular progress note paper (not the blue-bordered forms Part B&C). These should be in the chart by the end of their shift before they go home. R1s and SRs CAN co–sign these H&Ps and they DO COUNT. You do not need to have Parts B&C filled, but you SHOULD add any information to the student H&P that will complete a 10 item review of systems and appropriate PMH. Students will also turn in write–ups to the attending physicians on three patients over the three–week period.

General information

Patients: Students should follow two to four patients at all times depending on census and individual ability.

Preferably, students should follow House patients to get more consistent feedback. Patient mix should reflect both team census and what types of patients pediatricians would care for:

• Two to three chronic patients in three weeks
• Two to three 'zebras' or complicated unknowns
• Six to eight 'bread and butter' cases

Optimal practice is from working up patients from the initial admission, but transfers are ok especially if an attending is available and willing to guide student through complex issues.

Call: Students should be paired with pediatric interns. On the first day of the student rotation, residents will assign students to the intern. Students will stay on call until 10 to 11 p.m. or until they admit one to two patients and finish their H&Ps.

On "post–call" days, students should round on, write notes and present their patients. This means that if a student is on call Friday night, they are expected to come in Saturday morning and care for their patient. If they are on call Saturday, they will come in on Sunday.

Daily SOAP notes

Students write notes on all their patients and these are reviewed and co–signed by the INTERN.

Oral case presentations

Remember that they will get the most of this experience if they really feel like part of the team! They should be doing brief (<5 min.) presentations of their patients during morning rounds even if the service is busy. Try to involve medical students in the team teaching responsibilities.

Conferences

Patient care is the students' first priority. Remind them that unless they are involved in direct patient care or another teaching conference, they should go to conferences (i.e. noon conference, 3 p.m. conferences, Thursday morning lectures, etc.).

What to do if there is a problem

Talk to your senior resident. You can also talk to the Chief Residents, Curt or Sherilyn. They will help problem solve. Don't wait until the end of the student's rotation to ask for help!