PGY-3 to Be Retreat June 11, 2013 Sumit Bose Crystal Lantz Kamal Shemisa Claire Sullivan Navin Vij

“ Don ’ t count the days, make the days count ” -Muhammad Ali Congrats!!! You are entering your last year of Internal Medicine residency !

5:30-6 Dinner 6-7:30 Changes for next year -CICU schedule -New Ambulatory Model Patient Safety/Quality Externship Clerkship issues Miscellaneous administrative issues Boards Noon conferences Board review series License, jobs/procedures Senior talks Dictations Professionalism/RECC In-training exam Weekend coverage/handoffs Reading elective 7:30 - 8:00 DACR/NACR Orientation Gen Med Consults 8-8:30 Questions Overview

New ambulatory model New CICU schedule Changes for Next Year

* Rounds with CICU attending start at 8 AM. Heart failure rounds (separate attending) usually start at 10 AM.  Attendings rotate in one week blocks  4 residents do overnight call every fourth night  May have rotators from Emergency Dept. as well  No nightfloat system  Sometimes admit MICU overflow patients  Cardiology fellow not in-house at night (though staff admissions with fellow on the phone and if patients sick, fellow comes in)  Drawbacks to this system: only one resident at night, can be challenging to leave post-call by 11 AM if busy night Current Structure of the CICU Team

*2 interns scheduled in the CICU: -Day intern: works 7 AM-7 PM. May follow/admit one to two patients under supervision of senior resident. -Night intern: works 7 PM-7 AM. Helps with cross-cover, gains valuable night ICU experience including procedures, and possibly allows for on-call resident to take a quick nap. *Interns will do one week of nights and one week of days during two week rotation *Both interns have Sunday off (accommodate switch days and transition from nights to days) The New CICU for Interns

 5 senior residents  On-call  Post-call  Regular day  Day call  Pre-call  Days off will be Pre-call day between Thursday and Monday  Signout should occur after evening fellow rounds (4-5 PM) to overnight resident The New CICU for Senior Residents

 Every fifth night is overnight call, but resident does not come in until 4 PM that day. Resident then presents the following morning on rounds and leaves hopefully by noon (20 hour call), with wiggle room to prevent duty hour violations.  After post-call day, resident has regular day (til 5 PM). No admissions this day.  After regular day is day call where resident is responsible for admissions from 7 AM- 4 PM (when overnight resident arrives). Day call resident works until 7 PM.  After day call is pre-call day without admissions. The New CICU for Senior Residents

 Weekly continuity clinic during inpatient wards, electives, and ambulatory blocks  Two 1-month Ambulatory Blocks comprised of didactics, medicine subspecialty clinics, VA UCC, Psych CL, and continuity clinic The Current State of Continuity Clinic & Ambulatory Blocks

 Four 2-week Ambulatory Blocks  Morning VA subspecialty clinics  For 1 week you will have 5 consecutive afternoons of Clinic *Green Road 5 clinic sessions over 2 weeks including morning sessions *Residents must turn in sessions to Amb Chief  For the other week you will have 5 afternoons of VA UCC and subspecialty clinics  2 Clinics during Electives  PGY2 = 8 weeks  PGY3 = 14 weeks New Ambulatory Model

 No continuity clinic during Wards!!!  Precept with different attendings each day of week to get different clinical perspectives  Improving the outpatient experience of our program and limiting extended periods of time on wards  Continuity with patient panel: guaranteed clinic q8weeks for chronic disease management (CDM) and preventative health Pros of New Ambulatory Model

 The ambulatory schedule is fixed  Ambulatory blocks cannot be swapped  Elective rotations cannot be switched New Ambulatory Model

 The new ambulatory model is proposed to decrease stress of balancing inpatient and continuity clinic responsibilities  Opportunity to improve continuity with panel of patients and develop QI projects  Greater autonomy  Increased engagement in the clinic environment  Resident feedback throughout the year is strongly encouraged and leads to continued improvements in your ambulatory rotation! Summary…

Applications should be in by July 1; ERAS token can be requested June 18th Have faculty working on your letters of recommendation Another meeting with KBA June 18 th at 6 PM July 15, 2013: programs begin downloading applications Deadline for completed application varies but is as early as July 31 st ; check with program and be prepared August - November 2013: interviews conducted First Wednesday in December 2013: Match results available *KBA will perform mock interviews upon request Fellowship Timeline

*Primary care and subspecialty specific *Both landmark and review articles *Case Medicine website  Residents  Education  Residency Reading list REMINDER: Residency Reading List

 Research poster is a requirement for those who take two or more weeks as a research elective  Can present subspecialty research done during electives  Establish connections with a mentor  Chief residents are available to help find mentors and research opportunities  Research Day is usually in May Research Day

New intern orientation 6/13/2013 Last day of work for current PGY-1’s 6/23/13 Transition week (Block 0) starts 6/24/13 First day as PGY3 is 7/1/13 Transition Dates

 UH ward teams cap at 10 patients per intern except for the Seidman teams which cap at 8  VA ward teams cap at 8 patients per intern  No short call on weekends  No shorts if intern has 8 patients (but AI/intern pair with 2 seniors can go to 10 patients on short day)  Intern + VA = 10; AI+AI paired together =12 (if 2 seniors, 10 when one senior)  Intern + UH = 12 when 2 seniors; 10 when 1 senior Team Caps

 Long: 3 patients until 7:00 stay until 9:00  Medium:2 patients until 4:00 stay until 7:00  Short:2 patients until 12:00 UH and 1:00 VA  MICU transfer/NF only at UH, can be new patients at the VA  No short patients on clinic days or if intern already has 8 patients ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!  Senior Resident:  On call residents stays until 9:00  Staff patients available to be seen anywhere in the hospital until 4:00 (Monday-Sunday)  Weekend team covering resident staffs until at least 1:00PM Duty Hours

 On call senior resident must stay till 9:00 PM must leave by 11:00 PM  Starting Block 4-5 you will be staffing orphan interns on other teams as well when on call  See and examine EVERY patient  No staffing note required for ICU transfers  Focused notes by the senior resident with detailed plan  See PGY1 note for full H&P. Briefly, pt is a …  Helpful to new interns:  Antibiotic doses  Description of imaging- With contrast? Without?  Medications to continue, medications to discontinue  CODE STATUS and Allergies Staffing

 On call resident should notify the nightfloat resident of tenuous patients  Be proactive about staffing patients  ***Please note, even if you are not on call, you must staff all patients who are available to be seen if they are assigned to your team before 4 pm (even on the weekend)  Weekend coverage resident should staff all patients until 1pm Staffing

Patient Safety and Quality Improvement * Introduction to quality improvement during DACR rotation -Hand-washing audits -CLIPPS -Quality Assurance meetings -Write-up cases for Medicine QA -Attend ED/IM QA -Attend Quality Patient Safety Committee meetings -Mortality review, PASS reports, and Risk Management meetings

 Each PGY3 resident identifies and completes a quality improvement project as one of the requirements by ACGME  Work in groups of ideally 3 (no less than 2, no more than 4)  Work with one of the chief medical residents and quality center to develop project ideas and aid with data collection  Start by identifying a quality issue, collect background data, design an intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources)  Present quality poster at Research Day Guidelines for Resident Quality Improvement Project

 General Timeline:  Mid-August to early October: define objectives, collect background information, plan an intervention  Mid-October: schedule a meeting with project chief to review objectives and plan  Late October through January: implement your intervention  January through February : collect and analyze post- intervention data and schedule meeting with project chief to discuss results  March through April: write-up project and finalize poster; submit poster for printing to be presented at Research Day Timeline for QI Project

 All low risk chest pain, sickle cell pain crisis, gastroenteritis in a young patient, syncope is an observation patient  Please follow ER description on blue sheet  Instead of admission order, click the “Place in Observation” box  Please keep your UH care team lists up-to date!  Quality center is tracking admissions by diagnosis  Obs vs admit is related to clinical criteria and not expected LOS! To Admit vs. Observe

Professionalism

Professionalism: Attire  Men  Shirts and ties  Women  Professional  Keep white coats clean  No denim  Do not show up to Morning Report looking sloppy

 Referral to RECC  If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic  You will be able to get a same-day appointment  If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy  Call-offs: You must PAGE the Ambulatory Chief  DO NOT  DO NOT TEXT PAGE  DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW Professionalism: Absences

Professionalism: Electives  While on elective, you are expected to attend all Grand Rounds and M&M’s  Please note that when you are on elective, you are back up jeopardy!!  You are expected to have your pager turned-on throughout your elective rotation  If you are going out of town for the weekend, please notify the ambulatory chief prior to leaving  Elective should not be treated as vacation  Please Barb 2 weeks prior to starting your electives

Professionalism: Reading Electives  Residents on reading elective are expected to attend morning reports and journal clubs at the VA  Must attend Grand Rounds at UH  Your pager is expected to be turned on and on you during the entire two weeks of elective  All reading electives must be approved by KBA  For PGY2s it can only be used to study/take step 3  Please note that when you are on elective, you are back up jeopardy!!!

Professionalism: Conference Attendance  Be on time!  Noon conference:  UH: Mon-Wed-Thurs  VA: Mon-Thurs-Fri  Grand Rounds on Tuesday: UH & VA  M&M

Professionalism: Ambulatory Conference Attendance Ambulatory conference attendance is mandatory and tardiness and absences are extremely disrespectful to our educators Late Policy will be strictly enforced: Sign-in sheet will be available until 8:05AM At your 2 nd instance of being late, extra weekend coverage will be assigned Any MISSED conferences without prior approval by the ambulatory chief will result in weekend coverage

Professionalism: Discharge Summaries  Do them the day of discharge  Do them for your intern  Do them for your friends  Do them for your patients  Weekend coverage is responsible for discharge summary

 All coverage arrangements and schedule switches must be approved by the Ambulatory chief  Switches must be arranged before 1 week of rotation starting  Weekend Coverage switches before 48 hours of day  NO SWITCHING AMBULATORY OR ELECTIVE BLOCKS!!! Coverage and Schedule Switches

Senior Grand Rounds -Start in late August -Dr. Mourad is the APD in charge. - learning objectives to assigned faculty mentor and ambulatory chief resident two weeks prior to talk -Evaluation process will be in place -Should be evidence-based Research -All residents doing away and research electives must present at Research Day Talks

 Register by December  Plan ahead…costs about $ 1,365 (more if you sign up late)  Noon Conferences to include more board prep sessions  Intense June weeklong session for board review  Can use ITE exam results to help guide studying  In-service Exam Dates are Oct 4 – 19 th  Remember: no Moonlighting if ITE < 30% of your peers BOARDS!!!

 Remember to keep your BLS/ACLS updated  Must have Step 3 results prior to license application  Start FCVS by December ($430)  State licensing ($335) can often take 5-6 months.  DEA license is much quicker but more expensive ($551)  Plan ahead!!! Medical License

 Perform medicine consults  Be available to help out ward teams as needed  Prepare EBM lecture on a topic of choice for morning report  Attend all morning reports  One Saturday 24 hour VA MICU coverage VACR

DACR / NACR: Your education in systems-based practice

The NACR as Ombudsman The NACR as Ombudsman  Distribute admissions to teams on call in AM  Enforce geographic localization  Run codes  See medicine consults at night (Ortho co-management)  Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House  Cover flex patients at night  Find out intern census from nightfloat interns for each team  Admit BMT and Transplant Medicine patients along with NF (must inform BMT fellow and Transplant attending)  Transplants within the past year should be admitted to surgery *ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization

“The Book” as it should be… Reality

“The Book” according to the ED… How the ER views the world

Appropriate Service? Is the patient stable for the floor? PCP an FP? No MICU/CICU/NSU/SICU Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission. No Appropriate for medicine? No Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient” Yes FM capped Stroke, SBO, femur fracture, etc Yes Appropriate for FP?

Appropriate Service?  Look up the patient in Portal and EMR before assigning  Patient’s PCP – Family practice patient? Private patient (list of attendings available)?  Physician Portal (summary page, physicians)  Previous discharge summaries  EMR patient info clinical summary (visit history)  Ask the patient!

Hints as NACR  Be proactive – keep an eye on the ED board  Admissions require bed assignment  Figure out PCP (verify with patient if possible)  Quick visit history/portal search for past visits  Assign patient to NF or house doc (consider team in the morning for geographic localization)  Call admitting with location and ER with pager (or place it in EMR)

Types of Patients  Private (PCP will attend) – Coviello, Schnall, D. Brown, DeJoseph, Junglas, King, Tomm, Locke  ER must call private attendings; but if the patient is on the floor and the ER did not call, it is the DACR/NACR responsibility  Assign to med NPs (private spots) during the day! If no spots, then flex versus team (Eckel, Carpenter, or Gen Med; not Ratnoff/Weisman/Hellerstein)  D. Brown must be flex (not NP)  Staff – NPs (no procedures), hospitalists (few social issues low complexity), general medicine teams *Non-cardiology patients needing telemetry can go to Hellerstein and hospitalists (not med NP)

Specialty services: Eckel: ESRD, hypertensive urgency/emergency. ESRD transfers need to be accepted by Nephrologist. Ratnoff/Weisman: SCC with active issues Hellerstein: active cardiology issues (regardless of PCP) Dworkin: GI patients. Can take liver to a cap of 3 (but flexible) if Post/Gholam patients Fang service: newly renamed HVI. Patients with no right answer (HIV patient with ESRD and chest pain followed in HF clinic) - most active issue prevails Types of Patients

HIV patients go to Carpenter -When Carpenter is not admitting, give them one a day early or have resident flex Pulmonary cases go to general medicine -Pulmonary HTN and flolan patients need to be on T5 MICU transfers followed by renal consult team -If chronic  Eckel -If acute  gen med with renal consult

Non-Teaching Services  Reaffirm census/open spots in the morning and afternoon  Medical NPs will call in evening with open spots for the next day  Berger NPs will the night before with spots  Hospitalist A (NPs), B, C, and D will call the Admissions Coordinator with next day’s open spots (make sure they are written in the book)  Fang Service - Just call them

NPs  Medical Nurse Practitioners  Patients who do not need procedures  Patients who are not being ruled out for ACS  CAN take syncope patients on tele  They will take most private patients (not D. Brown)  Berger Nurse Practitioners  Stable patients who do not need procedures: sickle cell, pain management, hospice, routine chemo admissions

Hospitalist B, C, & D  Have a cap of 12 patients each  Straightforward medicine patients without complicated social issues  Try to give them patients whom you anticipate will have short stays  Unfilled spots rollover to the next day  Cannot take ICU transfers that were in unit >48h  Take bouncebacks, but count against cap

Fang Service Two NPs with Hellerstein fellow During the week, admit cardiology patients to team cap Will take NF admits and CICU transfers up to their cap All Effron/Heart Failure patients

Moonlighting  Cross-Cover long house doc: 8pm to 8am  Cover the nurse practitioner, BMT, hospitalist services, and Hanna House overnight  Admits one patient per night (or three if NP on with them)  Holds transfer pager (remember, don’t accept ESRD – Nephrology must!)  Early and late Short House Doc  Each admits three patients  Admitting Long House Doc: 6pm to 6am  Admits six patients  Bomb the long house doc!  Give them private patients that go to the NPs  Must cap them!  No admissions after 0400  Appropriate patient selection for the house doc is key; in most cases these patient should not come back to the housestaff the next day

The NIGHTFLOAT TEAM

NACR Nightfloat Resident Rotating MSIII Nightfloat Resident Nightfloat Intern Rotating MSIII Nightfloat Intern NIGHTFLOAT TEAM Nightfloat Intern

NACR specifics  8pm – midnight:  Meet Admissions Coordinator in KACR to get sign out  Start NACR sheet, Admissions Coordinator will be holding the book and pagers til midnight on most days so this is prime admitting time  Midnight and after  Stay on top of the ED board  Master the art of the NACR  5-6am  Get organized, make copies of NACR sheet, print out new board (on medicine.case.edu; UH resources ), get intern census  Talk to NFs regarding admits and appropriateness for teams vs. NPs vs. flex  6:30-8am  Review admits with KBA and V-BLSS  8am hospitalists call for assignment  Fax assignment sheets from day prior and overnight to admitting and hospitalist offices  Call non-teaching services to assign patients Chief Resident may call you to check in on your first NACR night

ED Issues  Neurology  Strokes go to neurology  Seizures – try neuro first  General Surgery: insist (politely) that they take SBO’s, etc  Make the resident call their attending (or do it for them)  VA: far better to transfer BEFORE admission  Ortho: perhaps worth arguing, but Medicine co-manages most ortho patients (NACR/DACR consult)

Other Duties: Medicine Consults  See the patient in a timely fashion  Write a note  Leave at least a preliminary note in the chart  Call the Gen Med consult attending if needed  Co-management with orthopedics  We follow along with ortho patients; they don’t need a “question”  You can put in orders dealing with medical issue

Transfers to Medicine  All transfers to medicine must be approved by medicine consult attending (not Dr. Whelan), chiefs, or KBA  Consults for transfer to medicine:  If clear subspecialty issue, refer to appropriate attending  If clear gen med transfer, no consult necessary  If unclear, offer to do a consult and staff with attending  Don’t accept transfers overnight

Outside Hospital Transfers  Transfer Center   Attendings are supposed to call or page when they accept a patient  8 am – 8 pm – Rotating attendings  M-W: Chief Resident and KBA  Th-F: Dr. Chandra et al  8 pm – 8 am – Cross-Cover Long House Doc

DACR/NACR Hours  DACR = 0800 – 2000  NACR = 2000 – 0800  MAN = midnight  DACRs come to morning report, Grand Rounds, and M&Ms  NACRs have a staff attending on call

Running Codes

Code Whites (UH) ** 1 ST six months – an upper level must go to all Code Whites with an intern**  Sick or decompensating patients on the floor or Hanna House  Initial response from ICU nurse, intern, and PGY2  DACR/NACR for level 2 code white  If you want to transfer to MICU, call MICU fellow  Always write a Clinical Event Note!

 Check your own pulse first  “Too many chefs spoil the soup”  One person leads the code  Make sure interns are involved  Maintain a calm quiet atmosphere  Keep the ACLS cards in your pocket until you are comfortable with the protocols  Make sure your BLS and ACLS are up to date  CODE BLUE NOTE and notify family Code Blues

 Rule #1: You are in charge  If uncomfortable, defer to more senior resident  Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc.  Use the DACR/NACR if you need help  Don’t be afraid to ask people to leave the room  Call the ICU nurses by their name, closed-ended communication  Call the family  Use the Code Note EMR, all Code nurses have it and should be available in the ICUs Running Codes

 Notifying Attendings at night  Most attendings want to be paged and notified (either of transfer to ICU or death)  Can clarify with your attending on first day of service what their preferences are  Don’t get burned by not calling your attending- you may hear about it the next day Running Codes

Questions? We are looking forward to a great year together!!! -VBLSS