1. PGY2-to-Be Retreat
*Due to a lack of available conference room space, the 2017 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 2018.*

2. 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

3. 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

4. Your New Role – Steward of Sign-out!
Help your interns!
What is important?
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

5. Step 3 and Money Should be taken by the end of your 2nd year
Book Money:
$200
but there are caveats, check with Deena before you make a purchse
Conference Money
$1000
Presenting is mandatory
MUST send Deena your acceptance letter and get a travel number

6. UH MICU (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

7. UH MICU 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 (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.

8. 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 8PM (NEW)
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

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)
Staffing notes for intern admissions

10. UH CICU - Rounds
IF there are HF patients in the CICU, 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

11. 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 8PM (NEW)
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.

12. MICU/CICU Night Moonlighting
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!)

13. 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 8PM 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
May be asked to admit medicine floor patients if the night is very busy
May be asked to help in the MICU (lines, etc)
Will be responsible for assigning overnight patients
VA Cards nights resident will have Sat/Sun off

14. VA “Swing” Resident
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

15. 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
VA/DMC clinics and UCC start at 8am
Challenges
Ambulatory blocks are fixed (cannot trade)
Clinic days are fixed throughout the year, allows improved scheduling continuity

16. Ambulatory Flights Flight 1 Flight 2 Flight 3 Flight 4 Myers Karb Lei
Wells
Chouhan
Saric
Stubbs
Guttikonda
Dawsey
Kobe
Tashtish
Kraninger
Washington
Tofovic
Alencherry
Welch
Al-Aghil
Church
Abou Saleh
Harding
Hernandez
Al-Omari
Mandviwala
Khalid
Deng
Wazzan
Satyavada
Nizialek
Al Sharani
Kuo
Pham
Patel, K.
Cruz
Reback
Husnain
Kortwabi
Dolan
Okereke
Dosani
Wright
Pandit Oh
Okapal
Alsamman
Eldemire
Siddiqui
Fadlalla
Van Aartsen
Tefera
Lopes
Mousley
Wooley
Michener
Khatib
German
Bond
Ladas
Al-Khatalan
Giradil
Meurer

17. 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
Is a requirement to Barb at the start of your elective what you will be doing and who your faculty member is!

18. Electives Research Electives: Reading 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

19. Elective Reminder Elective Professionalism & Jeopardy
Elective is not vacation
You are expected to be in town and available
If you have other obligations (conferences, family events, weddings) you MUST confirm with the Ambulatory chief BEFORE making travel arrangements
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 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!

20. Jeopardy Please carry your pager from Sunday 5pm thru Friday 5pm
Weekend Jep will cover from Friday 5pm to Sunday 5pm
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.

21. Transition Dates PGY1 end date: 6/23
Block Zero (aka vacay for you!): 6/24 – 6/30
Block One: 7/1 – start of your PGY2 year!

22. Block 1A Block 1 starts July 1st for Senior residents and interns
Longer block due to 7/1 starting on a Saturday
On the first weekend, July 1st and 2nd, both seniors of a 2 senior team are EXPECTED to be here
We tried to make sure this would not break duty hours for anyone, but if you think that this means you will be breaking duty hours, let us know ASAP
Most noon conferences will be intern boot camps
Senior residents hold the interns’ pagers during boot camps

23. Team Caps UH Wards: 10 patients per intern for all services
Except Ratnoff & Weisman which cap at 8
No more rolling caps
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

24. Team Caps UH Wards – Short Call:
Short call day caps at 8 (not a rolling cap). Exceptions:
intern/AI pair on 1 senior team- short cap call of 10
intern/intern pair on 1 senior team- short cap call of 10
Intern/AI pair OR intern/intern pair on 2 senior team- short cap call of 12

25. Team Caps VA Wards: 8 patients per intern
Intern+AI or Intern/Intern: 10 patients

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

27. Admissions Long Call: Medium Call: Short 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)
Medium Call:
2 patients until 4 PM
Short Call:
2 patients until 1 PM at UH (NF or intrahospital transfers)
2 patients until 1 PM at VA (NF or intrahospital transfers)
PLEASE CONTACT THE CHIEFS
IF ANY QUESTIONS ARISE.
Times subject to change….

28. Expectations
Residents on call MUST stay until 8 PM when the NACR and NFs arrive.
Intern sign out is 6pm at UH
Intern sign out is 7pm at VA
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.

29. 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

30. Acting Interns New Admissions:
Need a FULL H&P from the senior resident
Transfers
Needs a full transfer accept note
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!

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

32. 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

33. 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)
VA chief will page you in the morning to distribute patients
Discuss Code status of patients
Change team assignment in CPRS (admission order: team)

34. No moonlighting during wards or ICU
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
Admits six patients
Bomb the long house doc!
No admissions after 0400
Appropriate patient selection for the house doc is key
Cross Cover LHD – cross covers hospitalist, NPs, and admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM
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!)
No admissions after 0600
No moonlighting during wards or ICU

35. Professionalism: Attire
Men
Shirts and ties
Women
Professional
Keep white coats clean
department pays for dry cleaning
Your white coat MUST say Cleveland Medical Center (not Case)
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) 35

36. 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 the Ambulatory Chief
DO NOT
DO NOT TEXT PAGE
DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

37. 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 4 weeks before rotation start date, ideally sooner

38. 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.
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.

39. 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.
REMINDER for the millionth time!! 39

40. 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
As the senior, you often have the birds eye view of the admission anyway so you’re well positioned to do this. 40 40

41. 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
Your teams should be WALKING TO KULAS at 11:55 on Tuesdays and Fridays!
As senior people will follow your lead 41 41

42. Running Codes

43. Code Whites (UH)
** 1ST 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! 43

44. Running Codes 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
Call the ICU nurses by their name, use 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. 44

45. 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)