Intro to inpatient services Neuro Boot Camp 2017

ward General Neurology, most common diseases include: Neuro-oncology Dementia GBS ALS Myasthenia Gravis Encephalitis “Neurology – Merritt Service” on Eclipsys

Team structure Two teams (A&B) that each consist of a(n): Attending PGY3 or 4 senior neuro resident PGY2 junior neuro resident Psych or Medicine Rotator Medical Students Occasional Sub-Is, external rotators

Team structure On weekends: There is often a new weekend attending for both teams Senior neuro residents each cover one weekend day Junior neuro resident from one team does a 24 hr call, serving as ward long call during the day and JNF/ANF at night Other junior resident is off all weekend On Sunday, the psych rotator and a separate PGY2 (usually on clinic block) will help out.

Daily structure – long call 6:30am – Report to 8HN nurse’s station for signout from JNF. Then, sign over the JNF pager (82576) to your pager. Log into Mobile Heartbeat and put yourself as the resident on the CareTeam Widget. 6:45am – Pre-round on patients: Check DataVis tab for vitals, labs, check documents for consult notes or any overnight tests, eg, MRI. Evaluate patients with overnight events and focused neuro exam. Also, see any new admissions pending from 5:30am onward. 7:30am – Work Rounds 8:00am – Conferences and/or report to 8HS conference room to hear overnight admissions going to short call team

Daily structure – long call 9:00am – Touch base with attending briefly regarding any anticipated discharges and brief plan for any morning admissions. 9:15am – Floor work/new admissions 12:00pm – Noon conference in 8HS conference room 1:00pm – Table rounds in 8HS conference room then bedside rounds 3:00pm – Floor work/new admissions 5:00pm – Take signout from short call team, continue floor work/admissions and teaching if able. Change CareTeam widget for short call’s patients to you. 5:30pm – Prepare signout 6:00pm – Signout to JNF in 8HN nurse’s station. Sign out pager to JNF pager 82576

Daily structure – short call 6:30am – Report to 8HN nurse’s station for signout from JNF. Log into Mobile Heartbeat and put yourself as the resident on the CareTeam Widget. 6:45am – Pre-round on patients: Check DataVis tab for vitals, labs, check documents for consult notes or any overnight tests, eg, MRI. Evaluate patients with overnight events and focused neuro exam. 7:30am – Work Rounds 8:00am – Conferences and/or report to 8HS conference room to hear overnight admissions to be distributed to your team. 9:00am* – Table rounds in 8HS conference room then bedside rounds *Variable depending on conference schedule

Daily structure – short call 12:00pm – Noon conference 8HS conference room 1:00pm – Floor work, teaching, family meetings, etc. 5:00pm – Signout to long-call team, sign over pager to long call resident’s pager.

stroke Most common diseases: Ischemic stroke Carotid stenosis Hemorrhagic stroke Subarachnoid Hemorrhage Subdural Hemorrhage Vasculitis “Neurology – Putnam Service” on Eclipsys (NOT NeuroStrokeSvc)

Team structure One attending One fellow (most of the time) One senior PGY3 or 4 neurology resident One junior PGY2 neurology resident Two anesthesia interns One medicine rotator

Team structure On weekends: On Saturday, patients are split between the stroke senior and anesthesia intern A, the rest having the day off On Sunday, patients are split between the stroke junior and anesthesia intern B, the rest having the day off. The stroke fellow is typically on on Sunday

Daily structure 6:00-6:30am – Accept signout from JNF in 8HN nurse’s station. Log into Mobile Heartbeat and put yourself as the resident on the CareTeam Widget. 6:30am - Pre-round on patients: Check DataVis tab for vitals, labs, check documents for consult notes or any overnight tests, eg, MRI. Evaluate patients with overnight events and focused neuro exam. 7:00am – Work rounds in stroke conference room 8HN 7:30am – Table Rounds with attending in stroke conference room, first overnights then follow-ups

Daily structure 12:00pm – Noon conference 1:00pm – Admissions, floor work, family meetings, teaching, etc. 6:00pm – Signout to JNF. Sign over pager to 82576.

Work rounds One-liner Relevant clinical data To-Do List Dispo Plan E.g., 76 year old with HTN, HLD who came in with a cardioembolic L MCA stroke now with aphasia and R hemiparesis. Course complicated by tachycardia. Relevant clinical data Has been tachy and agitated overnight, now not responding to fluid boluses To-Do List Needs CTA of chest stat, needs TTE later today and MRI if stable Dispo Plan PT recommends acute, OT recommends subacute, rehab consult pending

Work rounds Dos Identify only relevant details of patient’s history for one-liner Discuss clinical changes overnight Stay informative but succinct Donts Give the whole history Give the whole exam Leave out relevant clinical information Leave out tests needed that day

Conference schedule Noon conference daily, 8HS conference room Tuesday: 8:00-9:00am Neuroradiology Rounds, 8HS conference room Wednesday: 8:30-9:30am Chief of Service, 8HS conference room Thursday: 8:00-9:00am Morning Report, NI14 Library Friday: 1:15-2:15pm Grand Rounds, NI1 Auditorium

admissions Perform H&P If Neuro consultation note written in full, can be addended with any additional history, your updated exam and impression/plan. If not, write Neuro Admission Note and assign attending as co-signer. NYP Admit Order Set Consider DVT ppx at this tie (not for post-tPA patients) Neuro Floor Admissions Set or Neuro Ischemic Stroke Order Set Med Rec

discharges Discharge Planning Ensure no meds require prior authorization NYP Discharge Summary Note In Handoff, keep updated Hospital Course (Recommend not by date, just update as needed every day) MUST include discharge neurological exam Discharge med rec Can be saved as incomplete prior to discharge If anticipate discharge the following day, place Conditional Discharge Order if pending test/treatment unlikely to affect disposition. Have senior review DC summ Discharge Order

Signout IPASS Format Print front page of report from Handoff/Snapshot tab in Eclipsys Hand-write things to-do overnight and pertinent contingency planning

Junior night float Overnight Coverage Service for all non-ICU inpatient services (ward, stroke, grad, EMU) Manage mostly medical complications Responsible for reviewing EEGs and checking imaging Can assist with bed management as needed

Night structure 6:00pm (5:00pm Sunday) – Report to 8HN nurse’s station for signout (Grad first). Put name as coverage for all patients in CareTeam Widget. Login to Mobile Heartbeat. Sign pager 82576 to your personal pager. 6:30pm – Coverage, follow-up tests, labs, etc. 6:00am – Report to 8HN nurse’s station for signout.

admissions Occur when on JNF/ANF, only admit once patient arrives on floor as you cannot leave the floor Also occur for grad patients. Perform H&P, admit as you typically would, then sign patient out to grad NP in the morning (does not need to be staffed or presented to attending).

Trigger protocol Attendings expect to be called for events mentioned in the trigger protocol. See Niresidents.org, password milstein for protocols