ADULT PGY-2 AND PEDS NEUROLOGY ORIENTATION June 21, 2013 Brian Cabaniss & Pouya Tahsili-Fahadan

Schedule Overview  weeks: Floor (Stroke & General)  7-9 weeks: Neurology Consults  4 weeks: NNICU  2 weeks: Night-float  3 weeks: Vacation  2-3 weeks: EEG/EMU (Peds 1 wk)  2-3 weeks: Specialty Clinics  4 weeks: Child Psychiatry (Peds only)  1 week: Pediatric Neuro consult (Peds only)

Conferences DayMonTueWedThuFri AM Morning Report* Morning Report Grand rounds & CPC Noon M&M/QI (1 st week) NeuroRadiology Translational Research Meeting EBM Stroke (Jul-Oct) CNS lectures (Nov-Jun) Stroke lectures (Jan-Jun 1 st and 3 rd week) Summer Stock* CNS lectures Summer stock Journal Club Lunch & Learn EEG (1 st week) EMG (2 nd week) L&L/CPC-R (3 rd week) Meeting of Brains 80% conference attendance required * Participation is mandatory for PGY-2’s

Neurology Floor : Overview  Inpatient Ward:  General Neurology team  Stroke Neurology team  Team Members:  the Attending  PGY-4 chief resident  4 Junior Residents  Outside rotators (psych & PMR)  NP*  Medical students

Neurology Floor: Schedule  Four day cycle: on-call, post-call, short-call, clinic/off  Clinic: Mon-Wed on Pre-call days (Peds: Pre-call Tue or Wed)  Off: Pre-call Thu-Sun DayMonTueWedThuFriSatSunMon Resident 1 CallPostShortOFFCallPostShortClinic Resident 2 ClinicCallPostShortOFFCallPostShort Resident 3 ShortClinicCallPostShortOFFCallPost Resident 4 PostShortClinicCallPostShortOffCal

Neurology Floor: Daily Work Flow * on-call person not before 6:30 † Put in orders and discharge order during rounds, if possible ◊ On call resident gets sign out from NP before 16:00. All residents have to sign-out to the on-call junior prior to leaving the hospital. TimeWork Flow 6:30-7:30Arrive at Hospital * Sign out from post-call resident Review O/N events, labs, imaging Update Census Board Pre-round and finish your progress notes 7:30- 12:00Rounds † Wed & Thu: Rounds start after morning report (7:30-8:15) Fri: Rounds start after Grand Rounds (8:00-9:00) 12:00-13:00Lunch and Noon Conference 13:00-17:00Finish your tasks Clinic (pre-call residents Mon-Wed) Sign out to On-call resident ◊

Neurology Floor: Admissions  The floor chief has the final say on who admits …  Where patients come from: ED, OSH, NNICU, Other services, Direct admissions, and Private patients (mostly NM)  All patients should be at least “eyeballed” upon arrival to the floor.  Admission orders should be done within an hour of a patient’s arrival on the floor. Use Stroke or General medicine order sets.  There are specific order sets in “Compass” for the following: MS Exacerbation, IVIg, vEEG, RPD, Hypercoagulable workup, Rituxan,and Cytoxan.  Dictate H&P the day of admission.  Procedures: LPs are generally done by the resident caring for the patient. For other procedures (ex: central lines), you can call the medicine procedure team on Monday through Friday, 8am to 5pm, at IV therapy places PICC lines (order in Compass).

Neurology Floor: Call Day  q4 call for juniors; q2 call for chiefs.  Admissions start at 15:00 or when the shorts (resident and intern) cap.  Patients admitted prior to 6:30 should go to the on- call resident.  For patients that arrive after 6:30, the on-call resident must eyeball the patient, then hand them out to the appropriate short call resident.  Post-call person must leave by 10:30. Sign out to the On-call resident before you leave.  Make sure your admission H&P’s and discharge summaries are done.

Neurology Floor: Shorts  Shorts are handed out by the on-call resident.  Junior residents/Interns admits until they cap or 15:00, whichever comes first.  Cap for new admissions: 4 for junior residents, 3 for interns.  Any patient that is in-house, and is accepted by the ward chief between 6:30 and 15:00 should be handed out as shorts.  If your chief tells you about a patient before 15:00 and they are in the hospital (ED, ICU, other service, etc), they are still your short- even if they arrive on the floor after 15:00.  When you get a short, go see them- even if you have to leave rounds briefly.  Do everything you can to be on rounds- you will cross-cover!

Neurology Floor: NNICU transfers Chiefs know who is transferring out of the unit by AM rounds. Distribute these as shorts- patients to be seen after rounds complete Unit transfers have orders- need to be checked and cosigned Write a brief accept note Unit transfers assigned as shorts, but that do not come out of unit until after 3 pm do NOT count as a “hit” for the on-call resident (already have transfer orders & accept note) Unit transfers occur at all times of day & night. Beware: If there is no sign-out/transfer note- talk to the chief about the plan

Neurology Floor: Discharges  Start discharge draft on the day of admission.  Follow PT/OT/ST recs everyday.  Run your patient list daily after rounds with SW (Tom 11400, Lisa 11500) to determine discharge plan  The chiefs will meet daily with SW, Case mgt, Nursing, ect. as well.  Talk to the SW and case manager as soon as you know a pt can go  Be aware of home health, home infusions, Rx.  Finish discharge summary the day before discharge.  Dictate STAT discharge summaries on the date of discharge.  If patients don’t have insurance, complete the Medicaid application that will be placed in the chart. Once Medicaid pending, they can go to TRISL and Barnes Clinic.

Neurology Floor: Follow ups  All patients must have a plan for follow-up appointment scheduled prior to discharge.  All stroke patients must have an appointment at Stroke Clinic. You must fax the Compass discharge order to the Stroke Clinic.  Insurance and Follow ups:  Private or Medicare. Any subspecialty clinic (Epilepsy, Movement, Neuromuscle, MS, Sleep, Stroke). Also can refer to private neurologists. Some insurance (ie, Tricare – military) needs PCP to fill out pre-certification.  Medicaid alone. Barnes COH or Connect Care  Illinois Public Aid (IPAC).Connect Care Only (No longer COH).  Patient Pay (no insurance) Connect Care only – Note that the patient will need PCP for referral.  If a patient calls with questions/concerns after discharged, but before their follow-up appointment, the clinic will page you.  Document all conversations in Touchworks under “BJ Call Note”

Sign-outs: June 30th  Please contact the residents whose team you are taking over:  Incoming General: Jonathan (on-call on 1 July) for Heather Joe for Lynn Jason for Jacquie Stephanie for Kristy (on-call on June 30 th )  Incoming Stroke: Peter (on-call on 1 July) for Neeta Shannon for Kristin Michael for Alex Fay Alex Dietz for Nathan (on-call on June 30 th )  ICU: Laura for Gus  Consults: Youngmin and Kyle for David and Kristin, respectively

NNICU  Two teams: A and B (you are always with A but will cover B team pts over the weekends):  Attending  NNICU fellows (2 first year and 2 second year fellows); sometimes stroke or fellows of other units  Neurology residents (PGY-2 and PGY-3)  ED PGY-2 residents  NSGY intern  NP (enter orders, perform procedure, very helpful and knowledgeable)  Most days Pharmacist (Theresa) is present at rounds  Get NNICU handbook prior to beginning rotation. You can get this from the ICU office (Liz Vansickle, )  No clinic when in ICU But check your tasks daily  You are supposed to attend noon conferences  Q3 or Q 5 call  PGY-2, PGY-3, and ED residents as well as NPs share calls  NSGY interns do not take overnight calls  Calls: Mon, Thu-Sun (NPs take calls on Tue and Wed)  Off: wed, Thu, or Fri

NNICU – Daily Work Flow  Overnight team sign out at 6:00 am  Pre-round on your pts; also try to pre-round with NSGY  Walking Rounds starts at 7:00; typically a quick neuro exam with updates of major overnight events.  Sit-down/computer rounds at 8:00 (Usually min breakfast break)  Resident provides the admission or interval history and exam  Nurses play a major role in presentation at rounds: almost all vitals, vent settings, labs  Fellow or attending are in charge  system-based discussions A few tips:  Try to be involved  Learn how to use compass to extract ICU data  You will get verbal sign-out and plans during rounds.  Finish your tasks in the afternoon  Attend PM rounds (checklist of tasks, update of major events, etc)  Sign out to on-call resident ~ 16:00

Continuity Clinics Adult residents have continuity clinic 1-2 afternoons per week:  M or F: St Louis ConnectCare (5535 Delmar Blvd- go west on Delmar, make a right on Belt, parking lot is immediately to your right)  T, W, or Th: 4 th Fl Center for Outpatient Health  Both clinics begin at 1:00 pm  BEWARE: The days in which you have clinic vary each week.  Peds residents have clinic 1-2 days a week (T or W).  You will not have clinic when on-call, post-call, Night Float (except the first Monday of NF), and in the NNICU.  Check your tasks for both ConnectCare and COH daily.  You have 24 hours to return the call.  Document the call in Touchworks as a “Call Note.”  Barnes Clinic will page you when your patients call for emergent issues.

Night Float  Very different from medicine NF: You are the only neurologist to cover the entire hospital, with the exception of the neuro floor and NNICU.  6 days a week from 7 pm to 7 am from Saturday to Thursday, including holidays  You may have clinic before night float your first Monday.  At 7 pm, meet in the lounge. You will be handed the consult pager and the tPA pager by the consult residents.  Make sure you know about patients that are still in ED.  0 to 14 per night (average ~6-8).

Night Float: Details  ER, inpatient floors, or ICUs will call consults.  tPA page is an emergency and IS A CODE. Respond immediately.  Don’t refuse consults.  See consults in the order they come, triage based upon severity  When you get a consult in the ER:  Call back the ED communications center (x19300 or ). Touch base with the ED resident or attending after you have talked with your chief/attending.  The ER likes to keep things moving, we try to oblige. It is counterproductive to argue with them.  All ER consult notes are to be entered into HMED. Make sure you have HMED access and it works before your first night float or consult day.  Call on-call chief for neurology or NNICU admissions or questions on floor consults.  Call on-call consults attending for patients being discharged home.  If patients get admitted to another service, sign them out to the PM rounding PGY-3 in the morning.

NF: more details and tips  Don’t give the attending name to ED before staffing with the chief.  Don’t hang out in ED after you are done seeing your pts.  All pts with a private service neurologist should be staffed with that neurologist or whoever is covering for him/her. If in doubt, contact Doctor’s Access Line.  You will also field phone calls from clinic patients. You do NOT cover for attending neurologists, either private or faculty, or for neuroradiology. For those calling with new symptoms or a seizure, have a low threshold to have them come into the ED. Most calls are for medication refills. Call in non- narcotic medications as a courtesy to the resident who is the primary neurologist. Narcotic meds do not need to be filled during off-hours. Document all calls in Allscripts as a “Call note,” and or “task” in Allscripts to the resident what happened.  ObGyn may call you to do a LP. We have a relationship with them to do these when the need arises. It’s often difficult to do these procedures when you’re carrying the tPA pager, but you should work together with your floor resident and the OB-GYN floor resident to help.

Consults  Two consult teams: AM (rounds in AM) and PM (rounds in PM); new patients are seen when not rounding.  The team: PGY-3 senior resident (runs the service), Junior neurology resident. Usually 1-3 residents from medicine, neurology and psychiatry intern, medical students, and an attending.  You will hold the tPA pager when not rounding (or if your colleague has clinic).  You split the weekend with the opposite team.  Holidays and weekends are staffed by consult PGY 2s and 3s only.

Jeopardy  Be advised that pull list is not limited to the people on jeopardy. All available residents may be pulled.  There are at least three of you on Jeopardy at all times (usually when you are on your specialty clinics, EEG and consults).  This means that you have to be available to come into the hospital to cover for your co-resident within 1 hour of getting paged.  Keep your pager on or provide the administrative chief with alternate contact info.  If you want to go out of town when you are on Jeopardy, you must arrange coverage – PGY3’s and PGY4’s can help with this – and offer the appropriate payback.  Carol Lane keeps track of all Jeopardy activity. Certain cases which could be viewed as potential abuse will be brought to the attention of Dr Snider and Dr Holtzman. Please treat others as you would like to be treated!

Clinics Overview Continuity Clinic (13:00-17:00 pm) CC: Connect Care; COH: Center for Outpatient Health Day MonTueWedThuFri PM Clinic CCCOH Peds Neuro COH Peds Neuro COHCC Specialty Clinics (PGY-2) AM EpilepsyMS-ParksSleepNMStroke PM -RehabMovementNMDementia

Neurophysiology: EEG  Arrive 8:00 in EEG suite on  Ask the fellow or one of the senior residents to show you how to use the software and create a report  Don’t make changes to the recording, Don’t open on-going non-continuous EEG recordings  Review H&Ps for the EMU admits  Read routine EEGs as they are done  Be on-time for epilepsy surgery conference on Thursdays  Rounds with Epilepsy attending 11:00-12:00  Review all routine EEGs with Epilepsy attending at 4pm  Can get the key to EMU from charge nurse of after hours; make sure to return the key

Suggestions  To make things run smoothly for you and others, remember to play fair.  Treat others as you would like to be treated.  Please provide us with feedback, good or bad. We all want to improve the program.  Never hesitate to call your chief for advice or backup. That is what we are there for!

Odds and Ends  Bags  Neurology tools -  Check current literature on the go  Handbooks  Textbooks