Welcome to John D. Dingell VA Medical Center Sachin Goyal, MD Chief Medical Resident

Background 267 bed facility. One of the largest VA hospitals. Provide primary health support to Veterans. Affiliated with WSUSOM/DMC. Provide significant portion of residents’ salary. In-patient: Medicine, Surgery, Psych and ICU. Also NH, extended care, hospice

Floor structure Four (Blue, Green, Red and Yellow) medical teams. Each team consists of 1 resident, 2 interns, 1-2 medical student(s), and social worker.

Typical Day Arrive before 7 to get sign-out from Night float 6:45 arrive and get sign out 7-7:30 see your patients 7:30-8 AM: Pre-round with your senior. 8-11:00: Rounds with medicine attending. 11:00-11:50: Discharge Arrive before 7 to get sign-out from Night float

Floor structure & Typical day 12-1 PM: Noon Report(Morning Report) Noon Report at 1:15pm-2:15pm on Monday (after grand rounds) Wednesday- No Morning report, academic half day Didactics per WSU-IM program 1-5 PM: Finish work (including new admissions), exit rounds and sign outs.

Admissions Flow NP’s on Weekdays will transfer/carry Medicine admission pager # 9775 to him/herself from 8am – 1pm (similar to role of ER/IM in DRH) NP is responsible for triaging, assessing pts. and putting basic orders on weekdays from 8am-1pm

Admissions Flow From 7am to 8am the on call senior(not the team senior) should transfer the pager to him/herself and triage patients. NP will mark on the board outside the room when they get admission. Resident comfort- when to get sign out.

Admissions Flow On the Weekend on call senior will transfer the admission pager #9775 to him/herself On call senior will get sign-out from the ER, then inform the accepting team senior about the admission ASAP Accepting senior will be responsible to evaluate the pt. ASAP in the ER (less than half an hour please)

Consults Weekday: please inform the consult attending till 4:30PM After 4.30 PM>>Stat consult seen by team and counted as hit(flow similar to new patient) Consult attending needs to be notified

Consult Weekend: MOD is responsible for medicine consult Routine consult is seen by on call attending If your attending wants you to see the consult, you can count it as a hit. All consults seen staffed over the phone with your on call attending same day

Call System Team on call Q4, every 4th day On call team gets total of 9 new admissions Non call team gets 3 new pts each per day Post call team gets no new pts. Each day on call senior will start admitting patients to him/herself after 2 pm Or whenever the other teams are capped meaning 6 admissions to medicine team whichever comes first.

Call System On call team will start admitting at 2pm (changed from 3pm) to allow the team adequate time to work up all the patients and leave on time Total number of patients for the team will be 9 patients On call team will admit 5 patients till 6pm (will be at senior resident discretion how the patients get distributed between the interns) On call team will stop admitting new patients at 6pm to prevent violating mandatory short break

Night float From 6pm MOD for the day will start admitting till night float team comes in at 8pm Night float will admit total of 5 patients, should have zero patients waiting on arrival at 8pm ideally(but MOD discretion depending on type/load) Once the night float team reaches the cap of 5 patients, MOD will again admit rest of the night Night float cut off-6.15 PM

Admissions Flow As the total team cap is 9 patients, the on call team will receive 4 patients from night float the following day to meet the total number of 9 patients The other patient admitted by night float and any patients admitted by MOD will become overflow to be distributed to the non call teams

Admissions Flow In the event the on call team gets total of 9 patients before 5pm, the senior resident is expected to have admissions orders in for all 9 patients and call the MOD at 5pm to hand off the other 4 patients to be admitted by MOD.

Admissions Flow Senior will hand over code blue pager to NF senior resident. Intern carrying the code pager hand over to NF intern Night float senior + intern will admit up to 5 patient overnight. Any additional admission after both on call team/night float reaches cap, will go to the MOD on call. Total team cap is 20 pts.

Cross Coverage Medicine Team cross cover other medicine team(NP is part of team) Pt. admitted by MOD is cross covered by MOD till 6:30am the following day then signed out to night float senior

Admissions Flow New admission typically comes from ER Also can come from clinics, direct admissions, physician will page #9775, will give you sign-out as well as put delayed orders, Admitting Physician is also responsible to call Bed Control and precert pt except in CLC transfers Outside transfers- CMR/MOD Can also get pt. from CLC or NH located in 6th floor, again same process. We are responsible to call Bed control in this case, and put the transfer order

Codes Codes (blue and gray): Keep pagers with you. Let CMR know asap if they’re malfunctioning. Respond to calls from other services and call THEIR attending. Code blue from CLC DO NOT go to ER, only falls do. Code White: only afterhours and all day weekend You are required to put code gray/blue/white note in CPRS and call attending, in the case of code white it’s the neurology attending on call. Please don’t lose code pager, you will be held responsible for it, $350 per pager. Please return test page, dial 0 to call the operator and inform them code pager is working

Responsibility: Transfers: nursing home, other VAs, outside community. Accept but do not count until they reach the floor. Once capped  inform ED and MOD (look online on intraweb). Once capped, MOD takes over admission. MOD will sign out to Night float senior at 6:30 am (must be face to face. Let CMR know if this does not happen) If on-call team caps before MOD arrives (5 PM), let your attending and CMR know.

People You need to know Associate Program Director- Dr. Kareem Bazzy Chief Medical Residents: Dr. Sachin Goyal(Clinical) Dr. Allison Zhang(Q&S)

Housestaff coordinator: Beverly Greene, Dial 576-1000 then ext. 63334 Responsible for all medicine divisions

Morning Report Purpose: Educational, scholarly activity Bedrock of Inpatient Academic Medicine around the world Responsibility: Everyone

Morning Report Long Case by 1 intern. Each intern presents atleast once. No separate senior report. Do not have to be 'Zebra'. Plenty of great teaching points on common cases too. Send your presentation at least 48 hours in advance. No exceptions. No rough draft on 48th hour( 2 PM) It will be responsibility of the senior to go through case and correct / add to it before 48 hours. All cases must be from the VA, please send Pt. last Initial and Last 4

Morning Report 25-30 slides total. 5-7 lines per slide. No cut and paste/ screen shots of up-to-date tables. Focused teaching points Should get something out of every teaching slide Should have a reference slide in the end

Morning Report

Morning Report Vancomycin should be changed to a penicillinase-resistant semisynthetic penicillin antibiotic (oxacillin or nafcillin). The patient's blood cultures indicate infection with a methicillin-sensitive Staphylococcus aureus (MSSA) isolate. The β-lactam antibiotics are more rapidly bactericidal than vancomycin and are therefore the preferred class of antibiotics for treating serious S. aureus infections. Because this patient is not allergic to penicillin, oxacillin or nafcillin are the best choices. Vancomycin is associated with worse outcomes when used to treat MSSA infections. Empiric therapy with vancomycin is appropriate for patients in whom infection with methicillin-resistant S. aureus is a consideration. However, therapy should be modified as appropriate as soon as culture and antimicrobial susceptibility results are available. Combination antimicrobial therapy (such as vancomycin and rifampin) for the treatment of S. aureus bacteremia does not improve clinical outcomes. Therefore, it would not be the most appropriate management choice for this patient. Vancomycin therapy is monitored by serum trough levels, not serum peak levels. When vancomycin is used in the appropriate setting, the usual goal for the serum trough level is 15 to 20 µg/mL. Definite or probable thrombosis occurs in approximately 70% of patients who have central venous catheter–associated S. aureus bacteremia. Imaging of the previous intravenous site is not necessary unless suspicion exists for suppurative thrombophlebitis (pain, swelling, palpable cord) or a fluid collection that would require drainage.

Morning Report If final presentation is not received before 48 hours or only a very rough draft is sent > senior resident will facilitate the discussion and expected to be excellent!! Late comers, no show, left to answer a page, never came back and no satisfactory explanation is found. Will be reported for lack of professionalism in all above scenarios and included in evaluations as well. In addition, team may be asked to present a third morning report as well.

Resident Recognition Discharge Efficiency Award

Nurses Quiet time 2-3 PM Minimize communication Pro-active Wait if not urgent

HIPAA privacy It is imperative to respect privacy of our patients in public places, outside patient rooms and on phone. It is being monitored very closely every day. Duty hours should not be violated. If there is some concern, please approach your senior/attending/CMR.

Helpful Info 4 days off per block. Work ahead. Can not take on-call days off. No day off on the first day or last day of rotation as this is critical for effective handoff.

Unique to the VA Meals during call days (1-2 meals). Very nice call rooms. (6th floor/semiprivate bathroom).1-9-2-1 Exceptional computer/EMR system (paperless system) + connected to all other VAs. Patients are mainly in A3 Med, A5 Surg and A4 S/D. Paging system Nursing home/hospice unit – considered outside facility. If pt is already hospice, should be admitted as hospice.

Code White Medicine is responsible for covering Code White (Stroke) Weekdays afterhours starting 5pm till 8am the following, all day on the weekend and holidays Code White pages will come through on the Code Blue pager. Please respond during the above mentioned time.

Bounce back: Pts who are readmitted within the same block. If before 3 pm (weekday), 1 pm (weekend) will go to original team NOT counted as a hit. Unless the team is post call and can’t take patients. Otherwise will still be given to the original team the very next day. Admitting team will round on bounce back patient next day, write progress note and then give back to original team.

HIV verbal consent NEEDS documentation in CPRS. Core measures Address vaccinations prior to discharge. Document why patient with CHF is not on ACE/ARB, Beta blocker. Why pt with CAD is not on ASA or statin

ADMISSIONS FROM EMERGENCY ROOM Once you accept patient, give the admission information to the ED physician and he/she will place “bridging orders”. Must go down to ED ASAP after getting called. Delayed orders should be written by the resident within 60 minutes of being called.

Resident supervision policy after hours Senior residents on call must call their supervising physician (Hospitalist on call for that 24 hour period) for update, review, and advice concerning any patient in the following situations: Admission to the Step Down Unit, or transfer (or possible need to transfer) of patient to SDU/ICU Code Blue or Gray called on a Medicine patient

Resident supervision policy after hours Serious change in medical status on the Medical floor or SDU (including, but not limited to: blood pressure; respiratory, cardiac or neurological status) Concern that the ED is inappropriately admitting a patient to Medicine floor when he should go to ICU or to the SDU.

VA pt. info Don’t share VA protected health information PHI outside of the VA system. Don’t share via: @gmail, @yahoo.com etc, @med.wayne.edu (not even by using {secure}) SMS, iMessage. Non-secure voicemail, e.g iPhone. Drop Box, Google Drive, icloud May use @va.gov e-mail by sending a secure message: To automatically set up – just open Microsoft Outlook.

The 3 essential EMR tasks Covering physician order + flag must be added on every admission and transfer.

The 3 essential EMR tasks 2. Medication reconciliation: Use the H&P template when admitting a pt. and make sure to indicate whether or not there is a discrepancy between home meds and meds that are listed in our EMR. Must use Medication Reconciliation tool

The 3 essential EMR tasks 3. Change encounter location: Make sure to select a new encounter location BEFORE adding your note (DET INPT GEN MED). Important measures Place anticipated discharge date Goal Discharge of 40% by 12am

Proper Discharge Process Rounds must end by 11:00 AM. Place your discharge order BEFORE 11:00 AM and make sure patient leaves the facility on time. Use the discharge menu. Don’t place a text order “D/C IV and D/C patient” Afternoon rounds to discuss possible discharges the next day.

Team names should be standard: Red block 6 2016

Medication Reconciliation Please utilize medication reconciliation tool in EMR Morning report tomorrow by Dr. Zhang on this

Infection Control

Infection Control

Professionalism Please remember to be professional and respectful to all staff Bad mouthing other staff(RN/MD/PCA…) the night-time hospitalists/MODs and ED staff. Remember you cannot refuse an admission if you would like additional workup you need to ask respectfully to the ER staff. Otherwise, you will need to call your attending.

Occupational Health In case of a blood or body fluid exposure, or any injury while caring for a patient at the JDDVA Medical Center please report immediately. Employee Health (located C1783) : Monday-Friday  8:00 am-4:30 pm Emergency Department : after hours, weekends, and holiday.  In addition to the care you will receive at the VA, please report the incident as soon as possible to Employee health at DMC/ your home institution

Any Questions???