1. Welcome to John D. Dingell VA Medical Center
Mashkur Husain, MD
Chief Medical Resident

2. 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

3. Floor structure & Typical day
Four (Blue, Green, Red and Yellow) medical teams.
Each team consists of 1 resident, 2 interns, 1-2 medical student(s) and social worker.
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
12 – 1:00 PM Morning report.

4. Floor structure & Typical day
12-1 PM: Medicine Grand Rounds on Mondays
Morning Report will be held at 1:15pm-2:15pm (On Mondays Only)
Didactics per WSU-IM program (Academic half Day), on every Wednesday
1-5 PM: Finish work (including new admissions), exit rounds and sign outs.

5. Admissions Flow
On call resident gets code blue pager from night float senior.
On call resident assign one of the intern with the other code pager, get from night float intern
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
From 7am to 8am the on call senior should transfer the pager to him/herself and triage patients.
NP will sign out new admissions to senior resident of the respective accepting team after 1PM, this is to give the team time to finish up discharges.

6. 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)
On the weekend, MOD is responsible for medicine consult (STAT)
Routine consult is seen by on call attending
If your attending wants you to see the consult, you can count it as a hit.

7. Admissions Flow
On weekdays please inform the consult attending till 4:30PM
after that any routine consult doesn’t need to be seen
Primary team needs to call the attending for consults. You do NOT see routine medicine consults on Weekdays.
Primary team needs to put a consult and inform the consult attending in the morning.
STAT consult needs to be seen and staffed over the phone with your on call attending
On STAT consult pt you round the following morning before signing out the pt to consult attending, count as a hit

8. Admissions Flow 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.

9. Admissions Flow
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

10. Admissions Flow
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
Once the night float team reaches the cap of 5 patients, MOD will again admit rest of the night
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

11. Admissions Flow
The other patient admitted by night float and any patients admitted by MOD will become overflow to be distributed to the non call teams
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.

12. 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.
Medicine Team cross cover other medicine team
Pt. admitted by MOD is cross covered by MOD till 6:30am the following day then signed out to night float senior

13. 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
Can get transfers from other VA or other hospitals, Chief Resident or MOD will review transfer packet and provide sign-out to you
Can also get pt. from CLC or NH located in 6th floor, again same process

14. Responsibility:
Cross coverage. (only medicine and step down beds).
You are responsible to flag the covering physician order (a must Nurses and other staff use this to contact you)
Urgent Labs
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.
You are required to put code gray/blue note in CPRS and call attending.
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

15. 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)
If on-call team caps before MOD arrives (5 PM), let your attending and CMR know.

16. People You need to know Chief Medical Resident(s):
Mashkur Husain:
Pierre Tannous (Q&S):
Housestaff coordinator:
Beverly Greene, Dial then
ext

17. Morning Report
Send your case at least 48 hours in advance. It will be responsibility of the senior to go through case and correct / add to it beforehand. All cases must be from the VA, please send Pt. last Initial and Last 4
If case is not sent 48 hours in advance to CMR then senior on that team will have to conduct morning report!
Zero tolerance for late comers to morning report. I keep track of your attendance.
Seniors: Please attach 2 MKSAP questions and explanation to your intern presentation as well as 3 key points

18. 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.

19. 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.

20. Unique to the VA Meals during call days (1-2 meals).
Very nice call rooms. (6th floor/semiprivate bathroom).
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.

21. 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.

22. 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

23. 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.

24. 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

25. 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.

26. VA pt. info
Don’t share VA protected health information PHI outside of the VA system. Don’t share via:
(not even by using {secure})
SMS, iMessage.
Non-secure voic , e.g iPhone.
Drop Box, Google Drive, icloud
May by sending a secure message: To automatically set up – just open Microsoft Outlook.

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

28. 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

29. 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

30. 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.

32. Team names should be standard: Red block 1 2015

33. Medication Reconciliation
Please utilize medication reconciliation tool in EMR

34. Infection Control

35. Infection Control

36. Professionalism
Please remember to be professional and respectful to all staff
in particular 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.

37. Taking the learners perception survey:
Learner Survery
Taking the learners perception survey: 

38. Chief Medical Resident
Any Questions???
Mashur Husain
Chief Medical Resident
VA Medical Center