1. WELCOME Orientation to Harper University Hospital
Courtney M. Moore-Luibrand
Chief Medical Resident

2. Changes at HUH Q12 overnight call for Interns/Sub-I’s/Students
Full schedule on wsumed.com
Advance Management Resident (ER/IM)
Team Caps
Intern Caps
NEW Morning Report Formats

3. Specific to this block….
Interviews
Seniors may need extra coverage.
Please be sure that other seniors have had their required days off before covering for an interview.
Required days off take precedence and there are other options for interview coverage so please keep me in the loop.

4. TEAM STRUCTURE

5. In General: A Day on Harper Floors
On-Call (Q2)
7 am
AMR carries admission pager
Floor residents get signout from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report
1 pm
Admission pager is carried by short-call senior
Work on your patients’ cases
Short call senior and intern admit patients
3 pm
Check on your patients again before signing out
Other team signs out to long call = cross coverage (pagers!)
Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients
Long call team begins admitting patients
8 pm
Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!)
If it is the night float intern day off on call floor intern and students stays overnight
7 am next day
Return to get sign-out about your patients (pagers!)
If Night float team is here they stay to round with the team and present the patients they admitted overnight
If on-call intern stayed overnight they remain in house to round with attending but does no admit patients (the new on-call team does)
Non-Call (Q2)
7 am
AMR carries admission pager and admits to other team
Floor residents get sign out from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report
1 pm
Work on your patients’ cases
3 pm
Check on your patients before signing out
If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!)
7 am next day
Return to get sign-out about your patients (pagers!)
You’re now on-call!!
--Refer to that side of the slide 
**YOU MAY ADMIT PATIENTS TO YOU TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

6. In General: A Day on Harper Floors
On-Call (Q2)
7 am
AMR (ER/IM) carries admission pager
Floor residents get signout from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report

7. In General: A Day on Harper Floors
On-Call (Q2)
1 pm
Admission pager is carried by short-call senior
Work on your patients’ cases
Short call senior and intern admit patients

8. In General: A Day on Harper Floors
On-Call (Q2)
3 pm
Check on your patients again before signing out
Other team signs out to long call = cross coverage (pagers!)
Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients
Long call team begins admitting patients
If your intern is on 24-hour call they should not cap with 5 new patients before night float senior arrives
They should be given every-other patient between 3 and 8 pm (no more than three patients) so that they may help admit patients overnight

9. In General: A Day on Harper Floors
On-Call (Q2)
8 pm
Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!)
If it is the night float intern day off on call floor intern and students stays overnight

10. In General: A Day on Harper Floors
Non-Call (Q2)
7 am
AMR carries admission pager and admits to other team
Floor residents get sign out from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report
1 pm
Work on your patients’ cases
3 pm
Check on your patients before signing out
If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!)
7 am next day
Return to get sign-out about your patients (pagers!)
You’re now on-call!!
--Refer to the previous slides 
**YOU MAY ADMIT PATIENTS TO YOUR TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

11. In General: A Day on Harper Floors
On-Call (Q2)
7 am
AMR carries admission pager
Floor residents get signout from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report
1 pm
Admission pager is carried by short-call senior
Work on your patients’ cases
Short call senior and intern admit patients
3 pm
Check on your patients again before signing out
Other team signs out to long call = cross coverage (pagers!)
Short call team can sign out to long call as well if they are done admitting/working up their patients, patients are stable and you are ready to sign-out their patients
Long call team begins admitting patients
8 pm
Night float team arrives to take sign-out (cross coverage) and begins admitting patient (pagers!)
If it is the night float intern day off on call floor intern and students stays overnight
7 am next day
Return to get sign-out about your patients (pagers!)
If Night float team is here they stay to round with the team and present the patients they admitted overnight
If on-call intern stayed overnight they remain in house to round with attending but does no admit patients (the new on-call team does)
Non-Call (Q2)
7 am
AMR carries admission pager and admits to other team
Floor residents get sign out from night float/intern overnight (pager!)
Evaluate your patients
Pre-round with your senior
Pre-round with students
Round with your attending
Attend morning report
1 pm
Work on your patients’ cases
3 pm
Check on your patients before signing out
If your work is completed and your patients are stable you can sign out your patients to the long call team (pagers!)
7 am next day
Return to get sign-out about your patients (pagers!)
You’re now on-call!!
--Refer to that side of the slide 
**YOU MAY ADMIT PATIENTS TO YOU TEAM ON NON-CALL DAYS IF THE OTHER TEAM IS CAPPED!!**

12. WHEN TO ARRIVE…WHEN TO LEAVE…
Arrive 7 am
ONLY THE OVERNIGHT POST-CALL FLOOR INTERN/NIGHT FLOAT INTERN/SENIOR CAN LEAVE AFTER ROUNDS (and they must sign out their patients)
NO OTHER RESIDENTS SHOULD LEAVE BEFORE 3 PM
Work on patients management, discharges, morning reports, etc.

13. AMR aka. ER/IM AMR (ER/IM) carries admission pager from 7 am – 1 pm
While you’re rounding and in Morning Report
Arrive at 7AM in 7 Brush lounge
Assign the admission pager (0092) to themselves
Admit patients to the on-call team
They will place the following orders:
Covering physician order
Basic orders until the primary team evaluates the patient (which should be after morning report)
Short-call team should begin carrying the admission pager from 1 (until 3 pm at which time the long-call team carries the admission pager)
When senior is off: AMR round and staff with the team
Won’t leave until after team signs-out

14. Long Call Team Notes
Cross-Coverage Long call team will cross cover the other teams’ patients from 3pm until 8 pm
Stay and provide sign out to the night float team at 8 pm Don’t forget to forward your pager to the covering resident
Long Call team accepts admissions and writes full H & P’s until 6:30 pm (unless capped)
Admissions between 6:30 pm and 8:00 pm will evaluated by on call senior who will admit the patient, add the patient to the list, place a covering physician order and place basic orders
Seniors must sign these patients out to night float!!!
Full admission note to be done by the night float team
Admissions from 6:00 am to 7:00 am will be evaluated by the night float senior who will admit the patient, add the patient to the list, place a covering physician order and place basic orders
Patient sign out to AMR but Full note to be done by the on call team

15. Night Float and Intern 24 +4
Night call 8 pm - 7 am
Patient cap to admit overnight is currently 10 patients
Cross-coverage of patient continues; sign-out occurs at 7 am next morning
4 nights: Night Float intern + Night Float Senior
2 nights: Floor interns stay overnight (in-house from 7 am that morning until after round the next day) with Night Float Senior
hours
24 hours = accept new patients (but remember; short call will be helping until 3 pm
4 hours = post-call wrap up (rounding, notes, etc)
Night float senior rounds with you too

16. Team Cap EFFECTIVE IMMEDIATELY TEAM CAP IS 23 patients per team
If the on-call team caps…
Before 6:30 pm  page Dr. Saker, Safwan who will take over the admission pager until 8 pm
YOU CANNOT LEAVE THE HOSPITAL! YOU MUST CONTINUE TO CROSS COVER PATIENTS, SIGN THEM OUT TO NIGHT FLOAT AND TELL NIGHT FLOAT TO TRANSFER THE PAGER AND ADMIT TO THE OTHER TEAM
At 8 pm the night float team arrives, transfers the admission pager to themselves and will admit patients to the other team
After 6:30 pm  on-call senior admits patients to the other team, places covering physician orders, evaluates the patient, places basic orders, signs the patient out to night float who will continue the workup and do the full H & P
THE ON-CALL SENIOR MUST PLACE BASIC ORDERS ON THESE PATIENTS AND SIGN THEM OUT TO NIGHT FLOAT, LET THEM KNOW WHAT YOU’VE ALREADY DONE SO THEY CAN PICK UP WHERE YOU LEFT OFF
If both teams cap > admissions go to Dr. Saker, Safwan

17. Intern Cap EFFECTIVE IMMEDIATELY INTERN CAP IS 10 patients TOTAL
- 10 patients = (new and follow-ups)
Interns should not admit more than 5 new patients on any call day
If your intern is on 24-hour call they should not cap with 5 new patients before night float senior arrives
They should be given every-other patient between 3 and 8 pm (no more than three patients) so that they may help admit patients overnight

18. A Few General Floor Notes
Rounds should begin by 8:30 so that there is time to discharge patients before morning report 

You should be identifying patients for potential discharge at least the day before and completing paperwork early so that on rounds you can just place the discharge order
Participate in the TEMPO boards on a daily basis and notify nurse daily and directly of patient plans/dispo plans .

19. Days Off Each resident must take 1 day off in each 7 days
All team members must be here on call days
INCLUDES SHORT AND LONG CALL DAYS
Seniors should avoid taking post-long call days off as much as possible and can only take days off when AMR is in-house….so please check the master schedule
AMR is off on Sunday

20. ADMISSIONS

21. Admissions ED
MICU
Transfers
DRH

22. Admission Etiquette Please provide your name Return pages promptly
Please do not review patient chart to decide if the patient needs to go to different attending before accepting new admission.
First you accept the admission and staff with you attending the next day who will decide if the patient needs to be transferred to different team (the attending has to sign the transfer order)

23. Admissions (pager 0092) AMR-1 PM Short Call- 1 pm until 3 pm
On-Call Senior – 3 pm until 8 pm and on AMR days off
When you’re called take sign-out, briefly review the chart, ask the physician any questions you might have, provide the attendings name and go evaluate the patient immediately or at least within 15 minutes
Place the following orders:
Covering physician order
Basic orders until the primary team evaluates the patient (which should be after morning report)
Always evaluate the acuity of your patient’s illness; determine if they are stable for the floor or need evaluation by the ICU
Admissions can not be refused. If you believe the patient does not need admission, staff with your attending and your attending will decide whether to discuss this with the ED.

24. Admissions From the ED (HUH or DRH)
Please do not have to wait for the patient to receive a bed on the floor to work them up.
Evaluation and orders should begin in the ED.

25. Non-ICU transfer to Medicine
In House Transfers
Floor to ICU
The floor resident is responsible for calling the MICU/CCU fellow on call for any transfers to the critical care
ICU to Floor
Transfer order will be entered by MICU team
Cannot place orders on the patient until they physically have left the unit
Communicate with MICU team if you’d like something done/cancelled
Non-ICU transfer to Medicine
Patients transferred to your team from another service if you have not taken care of that patient before.
The Medicine Consult service must FIRST to approve this transfer, pager 5501.

26. Direct Admission and Facility Transfer
Admissions from the clinic/outside are direct admissions.
If you accept an admission from the clinics, it is your responsibility to check which floor the patient is going to be admitted to.
- Your attending physician must accept transfers from outside hospitals first. If you are called to accept a transfer, talk to the transferring physician and obtain the following information
provisional diagnosis
history
vital signs
pertinent physical examination
pertinent work-up
reason for transfer
phone number of transferring physician
Make sure the patient is stable for transfer and management on the floor. Discuss this with your attending physician before accepting the transfer.
Bed assignment number: 51387

27. Bounce Backs
Bounce backs are admitted by the on call team (regardless of who the bounced pt belongs to).
The next morning, the team staffs the pt with the attending, writes a progress note, and signs out the pt to the team that the pt belongs to originally
If the patient is being discharged on the next day, the discharge will be done by the team that admitted the pt.
Courtney with FIN of EVERY bounce back and reason of bounce back
No bounce backs on the first and last days of the rotation

28. Rule of 6 Covering physician CODE STATUS!! IV fluid Tomorrow’s AM labs
Diet order
SQ heparin
Tomorrow’s AM labs
CODE STATUS!!

29. Who Does Count as a Hit?
Patients seen, staffed and directly discharged from the ED
BUT MUST BE STAFFED WITH ATTENDING FIRST
Completed H&P but patient ends up going to a different service
Patients admitted to your team who you will be following on a daily basis
Patients transferred to your team from another service if you have not taken care of that patient before  Medicine Consult service must FIRST to approve this transfer, pager 5501.

30. Medicine Consults
After 4 pm on the weekdays and 2 pm on the weekends the medicine consult pager will be forwarded to you and you may need to see a HUH/RIM patient
SENIORS, after that time you must:
Evaluate STAT medicine consults
Conduct pre-op assessment on a patient
Staff over the phone with the DRH UPG Medicine Hospitalist (pager 5755)
Write a brief incident note (SOAP format)
Add patient to Medicine Consult list and page the team the next morning, give them a brief signout and they will do the full consult note
These DO NOT count as hits

31. Discharges Discharge before 11am
If it is not possible, you may still discharge in the afternoon.
Be pro-active, get discharge paperwork/process started early
Complete the discharge summary on the DAY of the discharge.
Remember that dc summaries count as progress notes
Must include Subjective, PE and vitals!
New discharge template includes these

32. Discharges By Covering Teams/Night Float
The covering/night float teams should confirm with the respective attending on the team before discharging any patients if asked to do so by the primary team
Also, the primary team should complete the departure process/discharge plan before leaving including:
Completing depart in computer
Making all discharge appointments
placing scripts in the chart
arranging for transportation
answering all patient/family/caregiver questions

33. Documentation Always document lines
PIV
Central Line, Midline, PICC, ect
Foley
Date inserted and indication for ALL LINES
Code status, date discussed and any details
Family member/contact and RELATIONSHIP
Diet
Disposition (update DAILY!!)
Avoid copying and pasting
MUST update information!!!!!

34. Codes
On-call team responds to codes and actively participates (Senior, intern, students)
Other people/resources should be there too
If they are not, ASK FOR THEM

36. Important Issues
All emergencies or change in clinical condition must be discussed with the attending physician
All procedures need to be supervised. If uncomfortable or not trained to do the procedure call your attending or Pulmonary team
Fill out death certificates (tips on wsumed.com)
No curb-side consultations (but advice ok)
Jeopardy: A CMR must be notified if jeopardy is activated, NO EXCEPTIONS

37. Important Issues Continued
When possible, place a midline rather than a PICC line
PICC lines should never be placed if anticipated use is <5 days unless there is a clear indication
If the patient already has central access, care should be taken not to order another central access

38. Important Issues Continued
Every cystic fibrosis patient needs a Pulmonary consult
Notify Drs Kissner and Saydain when their pts are admitted.
I&O’s and Daily weights when needed!!
Tempo board
Isolation orders: order with labs directly (e.g.: c diff pcr + contact isolation, influenza pcr + droplet isolation). DO NOT DELAY.
Daily SW/CM will be ed by CMR.

40. Telemetry Renew after 48 hrs.
If not needed --> discontinue the order
If pt can travel w/o tele, pt doesn’t need tele (order can be discontinued)
If patient needs telemetry they cannot travel without it

41. E-Prescribing

42. Sepsis ADDRESS sepsis alerts (accept or reject)
Utilize Sepsis PowerPlan

43. Education Morning Report- combined at DRH
Morning report will start promptly at 11:00 am.
All residents are expected to attend MR except the senior who is on short call
1 case per day
case presentation and teaching slides to be covered by the intern
Clinical quesiton, literature search and appraisal by the senior
Senior is responsible for case oversight and assisting intern
Review the MR schedule and guidelines on MR schedule

44. Morning Report Deadlines (can also be found on MR schedule)

45. **USE YOUR POCKETPOINT CARDS**
Students/Sub-I
Third Year Medical Students/Sub-I’s will take 24 hour call
Sub-I’s
Admit 1-2 patients each call
They should carry between 2-3/4 patients at all times
Student Teaching:
**USE YOUR POCKETPOINT CARDS**
Give students their patients early and go over the cases in more detail
You must co-sign the student orders
Make sure they get a good variety of cases (PP cards)
Seniors are responsible for Sub-I teaching

46. Don’t hesitate to contact me with any questions
Finally…
WELCOME TO HUH FLOORS!
Don’t hesitate to contact me with any questions
Questions?