1. PGY2-to-Be Retreat *Due to a lack of available conference room space, the 2016 retreat will not be at the Four Seasons Bora Bora, it will instead be in the Tinkham Veale Center Senior Classroom. We will return to Bora Bora in 2017.*

2. Overview 4:00-4:30PMSnacks and informal discussion 4:30-6:00PMDidactics Giving feedback Milestones Student teaching - clerkship directors 6:00-7:00PMDinner & Small Groups How to be a ward resident Q&A 7:00-9:00PMAdministrative issues/changes for next year/chief residents New for next year: CICU/MICU moonlighting, VA Cards nightfloat, VA “Swing“ resident Electives Jeopardy Transition dates Team caps/duty hours Staffing/new roles Coverage/schedules Moonlighting Professionalism/conferences In-training exam Night float Codes

3. Changes for Next Year CICU/MICU nights meets moonlighting VA Cards night float VA “swing” resident during ambulatory blocks Discuss intern nightfloat at UH arriving at 6PM

4. (Same as last year) Interns will take Q4 overnight call with their paired senior resident – Last day of rotation their call day will end at 11PM 2 attendings 2 teams UH MICU

5. Overnight Call – Post Call – Helper Day – Pre Call Senior residents get pre-call day off if between Friday through Monday (interns get helper day off if between Friday through Monday) 5 senior residents in the MICU (plus rotators) Each senior will be paired with an intern. Senior “supervises” their intern, but intern “staffs” new patients with the MICU fellow. Interns will take Q4 30 hour call with their residents (iCOMPARE study). Last day of rotation they will leave by 11PM Helper day = supervise the post call intern (their senior will leave by 11AM) and help out the on-call resident until at least 7PM Note: Our program is responsible for the care of a very sick MICU. Things are always happening. Other than post-call residents/interns, no person should sign out before 4PM. Signing out early adds another thing to the on- call team’s plate. UH MICU

6. UH MICU Nights May have 2 weeks as MICU night resident, you will be responsible for 6 nights a week (Saturday*-Thursday) MICU night resident responsibilities – Arrive at 9PM – Cross-covers unit at night – Alternates admissions with resident on call until 2AM then does all admissions after 2AM Patients admitted by MICU nights resident will be distributed to teams (assisted by the MICU fellow in the AM) MICU night residents sometimes stay to present on rounds (for complex patients) Post-call resident will present their patients and sign out to the helper resident

7. UH CICU Nights May have 2 weeks as CICU night resident, you will be responsible for 6 nights a week (Sunday-Friday*) CICU night resident responsibilities – Arrive at 9PM – Cross-covers unit at night – Alternates admissions with resident on call until 2AM then does all admissions after 2AM – CICU night resident may need to stay and present if a sick patient was admitted overnight Any senior can get a night float admission. Use your judgment to determine which senior should get the night floats based on how many patients they are already carrying/covering for the day, acuity/expected length of stay of the patient.

8. Moonlighting opportunities still remain Friday and Saturday night in the MICU/CICU Shifts available for moonlighting – Friday evening MICU – Saturday evening CICU – Friday (CICU) and Saturday (MICU) will only be opened once: Friday (MICU) and Saturday (CICU) shifts have been filled AND The night resident is OK with allowing a moonlighter to take their paid scheduled shift MICU/CICU night residents are expected to work on Saturday in the MICU and Friday in the CICU if no moonlighters are available (You get paid for it!) New! MICU/CICU Night Moonlighting

9. UH CICU Follows the UH MICU model for senior residents Interns are on either q2 or q3 day call depending on if there are 2 or 3 interns. Intern "call" means they can admit new patients until 7pm. Max # of new admissions for interns on any day is 2. Max intern cap is 3 (rolling cap). – Interns in the CICU will alternate taking admissions with their paired on call senior resident during the day – Interns should take less complicated patients (e.g. post-cath, post-TAVI)

10. A senior should always be on heart failure rounds if the teams split, even if the patient is an intern's. – If the senior who admitted the patient with the intern is unavailable (off day, post call, rounding on their own patient on the general cardiology team), the helper resident should be present in their place. All interns should stay for evening rounds. Helper residents should stay at least through evening rounds UH CICU - Rounds

11. New! VA Cards Nights Aim is to help offload excessive admissions for the on- call VA Cards resident and improve duty hours Nights resident arrives at 9PM and leaves at 7AM Responsibilities – Alternates admissions with on-call resident until 2AM and admits all afterwards, allowing on-call resident to have protected sleep time – Helps cross-cover patients Will be responsible for assigning overnight patients VA Cards nights resident will have Sat/Sun off

12. Aim is to help offload excessive admissions for on-call VA senior  reducing stress/anxiety Assigned ~1 day every 1-2 ambulatory blocks Expectations… – Arrive at 5PM – Admit all patients assigned to NF (1st priority) until 8PM when NF arrives – If there are no NF admissions, begin staffing orphan team patients – If admissions are minimal, help cross-cover New! VA “Swing” Resident

13. Ambulatory Model 3.0 Friday Morning Educational Half Day – 8AM-Noon: Didactics, Journal Club, Workshops organized by system – Systems chosen by gaps in other parts of the program – No clinic or UCC requirements during Friday mornings No 8AM Conference rest of the week, though VA clinics, DMC, and UCC start at 8 Tues and Wed AM DMC Clinic. Decreasing wasted travel time between VA and UH. Challenges – Ambulatory blocks are fixed (cannot trade) – Clinic days are fixed throughout the year, allows improved scheduling continuity

14. Ambulatory Flights

15. Example Schedules

16. DMC clinics Tuesday and Wed AM Clinics. Ongoing efforts to improve continuity New Attendings: Dr. Cassie Kovach

17. Changes at the VA Clinic names changing, talk with your preceptor if you need to change your list Alerts- important to go through all alerts for ambulatory patients before leaving every day. If you ordered it- it is your responsibility to follow it up!

18. Electives PGY II: 8 weeks PGY III: 12 weeks Quality Chief will now be assisting Barb in keeping a running list of what you are doing for elective For ACGME requirements each resident must have a specified activity and supervisor for each elective

19. Example Elective Tracking

20. Electives Research Electives: Must have a mentor/PI for project If doing two weeks (or more) of research elective, you are required to present a poster at Medicine Research Day If you present at a national meeting…travel money! Reading Electives: Requires approval, KBA is designated supervisor Required attendance at all UH noon conferences, UH M+Ms, UH Grand Rounds, VA Grand Rounds

21. Elective Reminder Elective Professionalism & Jeopardy Elective is not vacation You are expected to be in town and available - if you need to leave town, please let the Ambulatory chief know Everyone on elective is back-up jep any given day, but we will assign people on specific days to be the first called so you know when to have your pager with you. Look for the doodle poll email so you can choose your days. If you are on backup jep and do not answer your pager in 15 minutes, you will be assigned extra weekend coverage!

22. Jeopardy Please carry your pager 24/7 Monday thru Friday Failure to respond to pages within 15 minutes will result in extra weekend coverage. Use of jeopardy is tracked for training/support purposes Those getting jepped from electives will be tracked as well – Those jepped off elective multiple times will move down the list on future electives – Makes the system more fair KEY Points – Jeopardy still remains for emergencies and significant illness – Unless there is excessive use of jeopardy (decided on a case by case basis), you are not expected to pay back – When on the jep rotation, covering sick colleagues is the job. There is no pay-back for this coverage.

23. Transition Dates PGY1 end date: 6/23 – Enjoy the well-earned week off! Block Zero: 6/24 – 6/30 Block One: 7/1 – start of your PGY2 year!

24. Block 1a Block 1 starts July 1 st for Senior residents and interns Block 1a- 7/1-7/19. Longer block due to 7/1 starting on a Friday Most noon conferences will be intern boot camps Senior residents hold the interns’ pagers during boot camps

25. Team Caps UH Wards: 10 patients per intern for all services except Ratnoff & Weisman which cap at 8 (with rolling cap for Long & Med call) 2 Senior teams (Intern+AI or Intern/Intern): 12 patients; 10 patients for Ratnoff & Weisman. 1 Senior teams (Intern+AI or Intern/Intern): Same rules as per individual intern caps; 10 patients for all wards except Ratnoff & Weisman (where cap is 8) Short call day caps at 8 (based on the number of patients you start the day with, not a rolling cap). Exceptions- intern/intern pair or intern/AI pair have short call cap of 10 if on 1 senior team, 12 if on 2 senior team. VA Wards: 8 patients per intern Intern+AI or Intern/Intern: 10 patients

26. Team Caps Special circumstances: 1.Hellerstein Short gets only 1 short admission. 2.No Eckel short admissions. 3.No weekend short admissions. 4.AIs can get new admissions on short call. 5.No short call admits for residents with clinic that afternoon (Med/Peds, Family Practice)

27. Admissions Long Call: – 3 patients (4 if paired with AI) until 7 PM – Max of 2 patients if after 5 PM – Max of 1 patient if after 6 PM (unless paired with an AI) – Anesthesia interns should leave by 9PM, work up admissions accordingly Medium Call: – 2 patients until 4 PM – Can sign out at 7 PM Short Call: – 2 patients until 12 PM at UH (NF or ICU transfers) – 2 patients until 1 PM at VA (NF or ICU transfers) Senior Resident: – Residents on call MUST stay until 8 PM when the NACR and NFs arrive. – Weekdays: ward seniors staff any patient assigned before 4 PM. – Weekend coverage seniors must stay and staff at least until 1 PM or longer depending on how busy the other seniors are – Paired resident teams- one resident assigned to that team must be present each day during the weekend. PLEASE CONTACT THE CHIEFS IF ANY QUESTIONS ARISE.

28. Staffing UH wards will have double coverage the first 3 blocks, longer for some services. There will be minimal orphan coverage in the first few blocks See and examine EVERY patient – No staffing note required for ICU transfers or inter-service 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

29. Acting Interns New Admissions: – Need a FULL H&P from the senior resident (includes ICU transfers) Daily Progress Notes: – Need a short progress note for you that must incorporate vitals, physical exam, independent assessment/plan – Unless attending is writing a full note (Naff/Wearn) – Unless attending agrees to “as scribed for…” Take the time to teach and to mentor!

30. Your New Role – The Manager Print out daily patient list for attending at UH Enter team attending into the EMR Lead rounds Review active medications and orders EVERY DAY! Direct intern work flow Help with discharge summaries! Have teaching topics Maintain a white board and saved list of patients Review discharge profiles

31. Your New Role – The Teacher Great teachers are motivators, respectful, and treat their students as colleagues/equals Take time to critically evaluate presentation skills Find your own method of teaching

32. Your New Role – Steward of Sign-out! Help your interns! What changes management? What is not important? Observe signouts early- For first three blocks, please observe each intern’s signout to NF at least once, and each AI until they feel comfortable

33. Moonlighting FLEX – when your team is capped and a patient is in need of your specific team. Senior residents should be open to flexing. It’s paid, it helps the nightfloat, and it keeps patients on the team that will provide the best care. A win-win-win. PRN SHD – admit 3 patients Early and Late SHD – admit 3 patients Admitting LHD – admit 6 patients from 6 PM – 6 AM Cross Cover LHD – cross covers hospitalist, NPs, and admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM MICU/CICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for alternating admissions with resident until 2am, then all admissions No moonlighting during wards or ICU

34. Coverage and Schedule Switches All coverage arrangements and schedule switches must be approved by the Ambulatory chief! This is to ensure Amion is updated and there are no holes in coverage – A major patient care issue! Switches must be arranged 2 weeks before rotation start date, ideally sooner

35. Professionalism: Weekday Swaps Where weekday absences would be needed for events such as weddings, reunions, conferences, or interviews, residents should swap full blocks rather than weekday coverage when possible. Exceptions may be granted when only full block swaps cannot reasonably arranged. Exceptions will need pre-approval by the ambulatory chief resident and will be on a case-by-case basis.

36. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean – department pays for dry cleaning Scrubs: long call, weekends, nights, and ICUs No denim Closed toe shoes No fleeces to morning report or on rounds (unless under a white coat)

37. Professionalism: Absences 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 31529 the Ambulatory Chief DO NOT EMAIL DO NOT TEXT PAGE DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

38. Professionalism: Reading Electives Residents on reading elective are expected to attend morning reports and journal clubs at the VA Must attend Grand Rounds and M&M 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 will be assigned specific days of back up jeopardy – you must have your pager on these days. Failure to answer a page within 15 minutes when you are on jeopardy will result in extra weekend coverage.

39. Professionalism: Discharge Summaries If you put in the discharge order, you do the discharge summary Do them the day of discharge This is a great way to lead your team by example and show your intern that you (1) care and (2) are not above helping with the scut work. Once the AI rotates off service, all remaining summaries fall on the resident

40. Professionalism: Conferences/Clinics Be on time. Walking in late is often taken as a sign of disrespect by the attending/presenter. If a pattern of lateness to ambulatory clinics/ambulatory conferences develops, a letter of professional misconduct will be added to your academic record on file

41. In-service Training Exam In-service Exam Dates are in September – exam is completely computerized this year Includes all PGY1/2/3/4 (Med peds) ITE during 2 nd year is an important predictor of passing boards ITE remediation by percentile rank >50% - no remediation, continue to study 31-49% - turn in in 60 multiple choice questions every 4 weeks to assigned APD for review; continue studying and attend board review sessions 16-30% - high risk for ABIM failure multiple choice questions as above with directed notes If you are not already doing this PLEASE talk with us or your APD, ABIM failure is no joke 1-16% - more intense remediation, urgent intervention required (we are here to help!)

42. VA Nightfloat Resident Works from 8 PM to 8AM Cover the VACR pager (medicine consults) Run codes Evaluate CARES Tower 6 patients – If patient needs more evaluation then direct admission (DO NOT GO TO THE ED) Use ‘Night Float Admission Note’ and assign the VA chief as the co- signer VA chief will page you in the morning to distribute patients Discuss Code status of patients Change team assignment in CPRS (admission order: team)

43. The NIGHTFLOAT TEAM NACR Nightfloat Resident Rotating MSIII Nightfloat Resident Nightfloat Intern Rotating MSIII Nightfloat Intern

44. UH Nightfloat Resident Works from 8 PM to 8AM Meets the NACR in the KACR Admit patients overnight, works with the nightfloat intern to help answer questions/manage ill patients. NACR is always available if you need help Two nightfloat residents, each resident either gets Saturday or Sunday off (must have 1 nightfloat resident each night) Must go to all Code Whites during the first 6 months with intern Go to all Code Blues

45. Running Codes

46. 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!

47. Code Blues “Too many chefs spoil the soup” One person leads the code Make sure interns are involved: Never kick an intern out of the room during a code, they will be running it next year! Maintain a calm quiet atmosphere Keep the ACLS cards in your pocket CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; always notify attending John Hornick has a.code note dot phrase

48. Running Codes Rule #1: You are in charge If uncomfortable, defer to more senior resident Assign Roles (Delegate!) – assign crowd control, chest compressions, airway, etc. Use the DACR/NACR if you need help Call the nurses/interns/RT by their name, closed-loop! communication Assign someone to call the family During a crisis, people want to feel like soldiers, not victims. Given them a job “please draw up 1mg of epinephrine” and things will fall into place. After the code, regardless of the outcome, gather for post code debriefing to discuss how the code went. Reflection will help hone code running skills!

49. Running Codes Notify attendings at night of any Code Blue Page the attending let them know the outcome (either of transfer to ICU or death)