Pediatric Ward Orientation For Clinical Clerks Welcome to MacPeds!

CTU Structure Team 1 & 2: General Pediatric Inpatient Teams Patients located on 3C +/- ER Team 3 Chronic complex care team 4C consults As of January 2017, team 1 and 2 patients will be on 3C +/- ER Team 3 patients will be on 3Y

A Day in the Life… 7:15 or 7:35 Morning Handover 8:00 Morning Teaching 9:00 Patient Care 10:15-12:30 Rounds – Walk around Afternoon – Complete notes, Consults, Update List 15:00 – (Depends on day) Subspecialty or Bedside Teaching 16:40 or 17:00 Evening Handover Teaching schedule currently in the process of being looked at – keep in touch with residents about monthly teaching schedule

Morning Teaching Morning (8 – 9am) Monday: Gen Peds Grand Rounds (4E20) Tuesday: Resident teaching (1A3) or RRT (3A14) Wednesday: Heart-to-Heart Cardiology Rounds (1J7) - 1/month Thursday: Pediatric Grand Rounds (MDCL 3020) Friday: Case Based Learning (3E26)

Protected Time Please let your attending and senior resident know at the start of your rotation when you have protected teaching time. Please write these times beside your name at the top of the handover list. Attendance at all teaching sessions is mandatory! If you are attending to a sick child, please notify the staff or senior resident that you have protected teaching time so they are able to take over their care. Update the list and touch base with your team before leaving!

Multidisciplinary Rounds Team 1: Tuesday 13:00-13:30 Team 2: Tuesday 13:30-14:00 (Team 3: Thursday 13:00-13:30)

Team 1 admits on ODD days, Team 2 admits on EVEN days AM Handover AM handover starts promptly at 7:15 or 7:35am AM handover on weekends start at 8:30 Team on take that day has the later AM & PM handover times Ensure you print a list and bring it to handover The on call residents/clerks will briefly review new admission and any overnight issues Team 1 admits on ODD days, Team 2 admits on EVEN days

Guide to presenting new consults Spend 2-3 minutes on each new patient and discuss Name, age, main presenting complaint Brief HPI focusing on pertinent positives/negatives Brief summary of objective findings (physical exam, investigations) Admitting diagnosis and plan

PM Handover PM handover occurs at 16:40 or 17:00 Remember that JPRs may cross cover CTU and may not know the patients from the ward Day team is in charge for printing 2 updated patient lists for the night time team IPASS format for handover!

PM Handover – iPASS

Handover - Sample

Team Lists Team lists are located on the Citrix handover site Please update the lists everyday and include any overnight / weekend instructions Don’t wait to the last minute to update a list as there can only be one checked out list at a time Be sure to check your lists back in so that others can edit them Remember: The patient lists contain confidential information! Do not leave printed copies in the handover rooms or on wards! Dispose in confidential waste bins at the end of the day!

How to access the Handover List

Appscriber- Search for ‘service Handover’

Open the Clinical folder

Open Service Handover

Choose your team list

Check out to Edit

**Save and Check in before you exit **

Press OK

Documentation Every patient requires a daily progress note Exact details (ie labs and vital signs) are part of the electronic chart. It is important to capture these by documenting trends and providing interpretations. The most important part of your note is the impression and plan: Make sure you detail the rationale for pursuing one treatment versus another or reasons for changes in mgmt. Include working diagnosis or differential diagnosis. Important to include a disposition plan

Documentation On Fridays, each patient should have a more detailed note outlining the treatment plan for the weekend, especially if the patient is a predicted discharge Please try to have planned weekend discharges organized (prescriptions written, appointments arranged, CCAC arranged etc.) You are responsible for the discharge dictation if the patient has been admitted for longer than 48hrs

CTU Scut Sheet

ROUNDING Efficiency is KEY! How can you help? Make sure the charts are on the cart by 10:15am If you are not presenting a patient, someone should have the chart and write down orders/fill scripts/DI req’s etc as the plan is being decided for the patient Use the rounding checklist to help guide you when presenting your patients. Feel free to ask JPRs/SPRs for feedback.

Rounding Presenting on rounds: Step 1: Patient ID – Age, gender, reason for admission with pertinent past medical history (if relevant) and POST if any? Step 2: Prioritized issues list Step 3: Overnight issues Step 4: Present Issues/updates according to issue list Ex. Bronchiolitis – any O2 requirements, last fever, last puffer use? Ex. Gastro – Any IVF requirements, ?po intake, last emesis or diarrhea, last anti emetic Step 5: Comments on feeding is not previously mentioned Step 6: Physical Exam – fever? O2? Changes in PE? Ins/Outs? Step 7: Monitoring – CRM, BW, PRN meds etc. Step 8: Assessment – 1 line summary of current patient status and diagnosis Step 9: Plan for Day

Rounding Resource Can be found on the MacPeds Website  Subspecialities  General Pediatrics

Dictations Every Consult and Discharge requires a dictation within 24-48hrs Exception – PICU transfers do not need a dictated consult note When dictating, ensure you indicate the relevant staff (the one who reviews the consult with the senior/fellow or you) and please SPELL their name Dictations should be done AFTER review with staff to incorporate all information and decisions The Pediatric Survival Guide can be used for templates for dictations Make sure you write down the dictation number on your consult note, or on the discharge face sheet Note: exception is admission of PICU transfer – no dictation

Discharges Face sheet must be filled out for every patient at the time of discharge Please put the dictation job ID on the face sheet once the dictation is completed Chronic patients will have a “chronic patient checklist” that must be completed before discharge Ask your SPR if you think your patient might qualify as chronic

Who to call if you need help Senior Resident (or any other resident on the team) The SPR is available for any questions or to be support if you are concerned about a patient NEVER feel worried to get a more senior member of the team if you are feeling uncomfortable about a patient REMEMBER – there is always either a SPR or staff carrying pager 1645

PACE Paediatric Assessment of Critical Events Team includes: Call paging or page 75030 Team includes: PICU resident and fellow PICU nurses RT PICU staff Activation criteria available on PACE cards ANYONE who is concerned about a patient based on these criteria can call PACE

On-Call Arrive to handover at 4:30pm to introduce yourself to the team You do not need to print team lists You may be dismissed from handover to start seeing consults Throughout the evening, the SPR will page the clerk/JPRs as they receive consults The SPR will see the patient briefly to ensure they are stable If you are concerned about your patient at any time, page the SPR, get the ER MD or activate PACE All consults need a written and dictated note While waiting to review, write your note, and start an admission order set

Admission Order Writing Please use the Pediatric Admission Order Set when admitting patients Look for the “order set” icon on your citrix, and search under the pediatric tab on the right Be aware or ask your fellow residents if there are specific order sets that you should be using ie. bronchiolitis, asthma, DKA, UTI etc. We encourage you to try to start the order set on your own if you are waiting to review

Meditech access

Select “Live Applications”

Remember HAH!!

Enter your username and password

Choose Patient Care Inquiry

More than one way to find your patient Search by Name, Number Search by Location – scroll down to MI-3C

Recent Investigations

Meditech Patient Flowsheet for Vitals, Ins/Outs

Patient Flowsheet Hit ‘F12’ *If it asks you for a facility – type in ‘M’ If asks you for facility – always put in ‘M’

Flowsheet Key tabs – Vital signs (Pain Mgmt), Vital Signs graph, Intake/Output, Cumulative I/O

Vital signs – Pain Mgt Helpful if looking for o2 requirements and amount of O2

VS – Graph

Intake and output -Daily charted weight -Fluids, Feeds, PO intake charted per hour -Voids (volume or frequency), BM, Emesis, Drains

Cumulative I/O Helpful to look at fluid balance Note – In babies, can be misleading to calculate u/o from the total output as some might be urine mixed with stool. Better to use the Intake & Output flow sheet

Useful Resources Website, CTU handbook, Scut sheet, rounding and handover guide and articles: http://www.macpeds.com/general_pediatrics.html

Have a great rotation! We want to create a positive learning environment for you so please give us feedback on how we can make things better!