1. Welcome to DRH

2. DRH is >100 years old ! (It was founded in 1915)
Level 1 Trauma Center (first in MI)
Famous art collection (consists of major sculptures, 800 paintings, works on paper, textile, and crafts, pewabic pottery) which continues to grow and serves to lighten the burden of illness carried by patients and their families.

3. General Structure Team Structure A1 A2 A3 Senior Intern A Intern B
Sub-I MS
Q3 Calls
Day Structure
Call days
Post-call days
Non-call days

4. General Structure Teams Structure Q3 Calls Day Structure Call days
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
On Call
Post Call
Pre-Call
Day Structure
Call days
Post-call days
Non-call days

5. General Structure Teams Structure 7 am Preround 8 am 10 am Q3 Calls
12 pm
3 pm
8 pm
Preround
Q3 Calls
Teaching Round
D/C
Day Structure MR
Non-Call teams
Call days
On-Call team
Post-call days
Non-call days

6. General Structure Teams Structure Teams will be on call Q3 days.
Call starts at 3 pm.
Call team can get a total of 7 new admissions + 2 bounce-backs per 24 hours
Call team will admit upto 3 patients from 3 pm to 6:30 pm. If team gets 3 patients before 630, transfer pager to Med B and take back at 630 pm.
After 630 to 8PM senior resident on call is responsible for triaging any patients until NF comes.
Sign-out to the NF residents at 8 pm.
NF can admit total of 5 patients (but total cap remains at bounce-backs)
Q3 Calls
Day Structure
Call days
Post-call days
Non-call days

7. Admission Process The admission pager is 0997
7 AM – 1 PM: ER/IM resident covers the pager
1 PM – 8 PM : On call resident covers the pager
8 PM – 7 AM: night senior resident covers the pager

8. Total Team Cap is 20 patients (as per ACGME rules).
If the on call team hits their team cap of 20 during the night, patients admitted by NF will count as overflow and go to the pre-call team the next morning.
If a team is post-call or has met their 20 patient cap then they do not get any bounce-backs that day. However the patient will return to that team the next day (whether from Med A teams or Med B attending team) in the case where the team was post-call. In the case where the team was capped at 20 patients, they should get the bounceback back to their team once they have room on the list.

9. On-Call Resident Role
The admitting ER/IM resident covers the admission pager from 7 AM-1 PM.
He/She accepts new admissions from ER, does basic orders and calls consult teams as necessary. (ER/IM is responsible for the patient uptil 1 pm). At 1 pm, ER/IM will sign-out all admissions to pre-call team.
During this time, pre-call can wrap up post round work, plan discharges, and attend MR.

10. General Structure Teams Structure
Inherit patients from the night float (up to 5). NF team will round on their patients first during teaching rounds and then will leave.
Postcall teams do not get any new admissions, including bounce-backs to their team.
Sign out to the on-call team (not before 3 pm).
Q4 Calls
Non-call days
Call days
Post-call days
Non-call days

11. General Structure Teams Structure
The precall team can get upto 4 new admissions from 7 AM – 3 PM.
If the precall team caps early (i.e before 3 pm then the admission pager should be forwarded to Med B)
Sign out is 3 PM.
Q3 Calls
Non-call days
Call days
Post-Call days
Non-call days

12. Bounce Backs Bounce backs are re-admission within the same block
Are usually admitted to the same team who discharged the patient within that block.
The only exception is when the bounce back patient comes after 3 pm, then the on-call team will admit the patient, count him as a hit, and then give the patient back to the original team after rounding the following day.
If on-call team has a bounceback, they can get the patient at any time during the day (even before their call starts)
Postcall teams will no longer take bounce backs.
The night float will admit up to 2 bounce backs. They will staff with that’s team attending over the phone in the morning and sign out to the bounce back team senior (or intern when senior is off) who will then be responsible for the formal presentation during rounds.

13. Sign Out Interns A/B  on-call intern A/B  NF Intern/NF senior
Seniors  on-call senior (sick pts)  NF senior
Med consult  on-call senior (sick pts)  NF senior
Please give verbal + written sign out; ask questions when receiving sign out and if necessary go to the bedside and assess the patient with the other provider
Seniors are expected to observe their interns sign out in the first few months

14. Weekends
There is no difference in the flow between weekends and weekdays.
Cut off for taking new admissions, bounce backs, and sign out time is still 3 pm.
Caps are the same.

15. Admissions Introduction ER MICU Transfers Medicine Consults Misc
From 7 AM - 1 PM, the ER/IM resident will admit upto 4 new patients for the precall team.
Once 4 patients are admitted, the admission pager should be transferred to Medicine B (pager 5755) until 3 pm.
If precall is not capped at 4 patients, then at 1 PM the on-call senior resident will take the pager and continue to admit for the precall team until 3 PM.
At 3 pm, on call senior will start taking new admissions for call team.
Total cap for on call team is 7; they will admit 3 patients or until 6:30 (whichever comes first). If 3 patients are admitted before 630 pm, admission pager transferred to Med B and taken back at 630 PM!
Any patients admitted between 630-8PM will be seen by the senior resident and necessary orders will be placed by him/her until night float arrives. NF takes over pager at 8 PM.
Again, after NF caps, pager is transferred to medicine B and notify them.
Introduction ER
MICU Transfers
Medicine Consults
Misc

16. Introduction MICU transfers Medicine Consults Misc
Be Professional & Courteous. Never refuse a patient.
Please provide the attending name when contacted by ED without delay.
All patient must be assessed within minutes from the time of ER contact.
After assessing the patient, if you think that a higher level of care is needed, discuss with ER staff. Ask them to consult MICU if you feel it is necessary for patient care. If they disagree consult MICU yourself.
Introduction ER
MICU transfers
Medicine Consults
Misc

17. Introduction ER Medicine Consults Misc
MICU transfers count as new admission to the team.
MICU transfers have typically been rounded on by the ICU attending and deemed safe for transfer.
Please provide the attending name when contacted by MICU without delay.
The MICU team will continue to manage the patient as long as the patient physically remains in the ICU. You can’t place orders until the patient comes to the floor.
If by sign-out time the patient is still in the ICU, make sure you still sign out the patient to the on-call resident or NF resident and have them place a covering physician order.
Introduction ER
MICU Transfers
Medicine Consults
Misc

18. Introduction ER MICU transfers Misc
There is a medicine consult team during the day.
After hours (around 5 pm), they will sign out the consult pager to the on-call senior resident and leave.
Senior resident is responsible for cross coverage for medicine consult patients after hours.
If there is any new routine consult; place the patient on the consult list (HA-Collaborative Medicine Service) and patient will be seen the following day.
Stat consults need to be seen by the on-call resident and staffed with the medicine B attending (5755). They are not counted as hits and only a brief note is needed. Please add the patient to the consult team list as well.
Neuro ICU consults after 5pm – Consider them as STAT. If patient has active medical issues he can be admitted to MED A(Take as a hit). If no active medical issues can admit to MED B after discussing with MED B attending-5755 either ways ER
MICU transfers
Medicine Consult
Misc

19. Introduction ER MICU transfers Medicine Consults
NICU (or other services) transfers: Go through medicine consult (YOU after hours) to determine appropriateness
HUH ER Admissions: Patient will have a different FIN when admitted to DRH. You will need this to see the current location and place orders. Please contact Admission for the new FIN. Do not assign to teams until patients hits the floor.
Transfers from outside hospitals: Get sign out and call back number, then call CMR and your attending. Then call back with the attending name. Do not assign to teams until patients hits the floor.
Direct Admissions: (from UPG clinics); should go through CMR. If contacted for direct admission, get the call back number and contact your CMR.
Psych Unit: they might call you for medical emergencies, please assess patient and facilitate transfer to floor/ MICU.
Introduction ER
MICU transfers
Medicine Consults
Misc

20. Placing Orders/ Consults
Caring For Patients
Basic Orders
Basic Orders
All patients should have the following orders:
Covering physician order: assume responsibility and taking care of the patient, people need to know who to contact if something happen.
Code status: after proper discussion
Diet order: placed as soon as patient is admitted; imagine starving for 3 hours for no good reason
Medication Reconciliation: Please do a MedRec on all your patient’s. It’s the seniors responsibility to make sure this is done on all patients.
DVT prophylaxis: should be placed within 24 hours of admission, but preferably as soon as patient is admitted. If any contra-indication, please document that in your note.
Always check the clinic system (NextGen) for any records.
Placing Orders/ Consults
Lines/ Foley
Telemetry
Discharge Planning
Documentations

21. Placing Orders/ Consults Placing Orders/ Consults
Caring For Patients
Basic Orders
Orders/ consults can be placed as: stat (meaning within 20 minutes of placing the order), now (one hour) and routine.
This should be determined exclusively based on medical necessity and patient care. Just because you want something done before your attending asks or social worker goes home is not a good reason.
Stat orders/ consults: placing the order in the computer doesn’t mean it’s done. If you need a stat lab/ imaging/ or consult, please place the order and then communicate with nurses/ consult teams to make sure they are aware.
When placing orders for medications, place them as “now”. Otherwise, they will be scheduled for the following day if placed after 9-10 am.
Daily labs: please only order if necessary, there is no need to do daily labs unless you are monitoring something specific. Please don’t place them as “stat”
Placing Orders/ Consults
Placing Orders/ Consults
Lines/ Foley
Telemetry
Discharge Planning
Documentations

22. Placing Orders/ Consults
Caring For Patients
Basic Orders
CVC/ PICC/ midline require a provider order prior to placement.
Please assess the need for those lines/ catheters on a daily basis and remove as soon as possible.
Placing Orders/ Consults
Lines/ Foley
Lines/ Foley
Telemetry
Discharge Planning
Documentations

23. Placing Orders/ Consults
Caring For Patients
Basic Orders
Please evaluate the need for telemetry on a daily basis and d/c when no longer needed.
Indications include (but not limited to):
Class I (72 hours): ADHF, ACS, Arrhythmogenic drugs/toxins, At risk cardiac procedure, Cardiopulmonary arrest/Hypotension Risk, Conscious Sedation/Anesthesia/Recovery, Dysrhythmia/EP device malfunction, Myocarditis, Sepsis
Class II (48 Hours): Chest pain, DNR with symptomatic arrhythmia therapy, Electrolyte Imbalance, Non Acute Coronary Disease/CHF, Pericarditis, Presyncope, Routine Cardiac periprocedural, Stroke
Class III (24 hours): Asymptomatic Chronic stable AFIB/PVCs, DNR Without arrhythmia treatment, Recovery from low risk surgery
Placing Orders/ Consults
Lines/ Foley
Telemetry
Discharge Planning
Documentations

24. Placing Orders/ Consults
Caring For Patients
Basic Orders
D/C planning starts on the day of admission.
Talk to the SW/ CMS and involve PT/OT in a timely manner to avoid delaying the discharges.
Please update the nursing staff daily after the round of your d/c plan (including pending SW/CMS needs…) and ask them to update the “unit boards, AKA tempo boards” with the date and your initials. They will help you expedite the discharge process.
Place discharge orders before 11 am. This will require starting the process from day 1 and not on the day of discharge.
When your patient is medically stable, please place d/c order. Even if the patient is waiting for placement.
Placing Orders/ Consults
Lines/ Foley
Telemetry
Discharge Planning
Documentations

25. Placing Orders/ Consults
Caring For Patients
Basic Orders
Please avoid copy/pasting as much as possible. When copy/pasting, review and edit as appropriate
Complete your progress note early during the day to enable other providers to be aware of your plans.
Discharge summary should be done within 24 hours. It can be used as your progress note for the day if written during the same day and “objective/ physical exam” parts are included. Please don’t copy paste your progress note as your d/c summary. This is your communication to the PCP.
If you will delay the d/c summary until the next day, please write a progress note for that day. Use ‘DMC WSUPG IM Discharge summary’.
Placing Orders/ Consults
Lines/ Foley
Telemetry
Discharge Planning
Documentation

26. Work Rooms Main work-room 5N 14 Lounge 4S – 6 Charting Room 4V-23
Code: 4-2-5
6 desktop computers, 1 printer, 2 phones, small fridge
Lounge 4S – 6
5 desktop computers, 1 printer, 6 phones, television, full size fridge, microwave , couch and lounge chairs
Charting Room 4V-23
Code: 1-4-2
2 computers, large amount of desk space
WOWs
available for rounding in 5M-16 conference room

27. Medical students Each team will have 2-3 MS3 and 1-2 Sub I’s/MS4.
Take up to 1-2 new admission per day and carry 3-4 patients on the service.
CALL DAYS: Students will admit patients and stay until 8 pm on call days and attend all codes.
ADMISSIONS: You will be staffing all new patients with Senior/Intern. Discuss HPI, PE, Labs, Imaging and come up with an assessment and plan. Try to come up with differentials! The more you do the better you get.
FOLLOWUP: Please pre round on your patient with Senior/Intern everyday before rounds.

28. Medical students
ROUNDS: Starts around usually. Could be table discussion followed by bedside rounds or direct bedside rounds. Feel free to ask any question.
REMEMBER! The more you pre-round with your team the more polished your presentations get. Try to make this a habit!
CODE BLUE: Students are expected to attend all code blue’s while the team is on call. They are expected to stay in the room and witness all the events happening. You can perform CPR voluntarily.
EDUCATION: Please use the pocket card provided to you at the beginning of the rotation.
DAYS OFF: All MS3 and MS4 get one day a week off. Please discuss this with your team

29. VTE
Please select the correct relation to your patient ( responsible resident, covering resident, fellow, home physician etc) on opening the chart each time.
Note that VTE Risk Assessment/Screening and Prophylaxis / Management is a Core Measure which needs to be completed on all admitted patients within 24 hours.
The provider who is responsible for initial admission orders is also the first responsible person to order this.
Please be aware that you need to complete VTE Risk Assessment even if your patient is admitted with a DVT or PE or if they are receiving anticoagulation for another reason like A. Fib.
Develop a daily routine to check on your patients safety/quality measures.

30. VTE The correct Order for VTE assessment is “VTE Risk Screening”.
After evaluating the patient, review the alert, choose the appropriate prophylaxis/therapy/contraindication based on your assessment and click on “Submit” to capture the risk assessment. Then please sign the appropriate orders.
Please note that the EMR based tool is only to assist you and is solely based on the information entered in CIS. Always use the best judgment based on your complete patient assessment and document the reason in the chart.
Also note that some of the patient information pulled by the tool may be duplicate or no longer relevant.
If you need more information, please refer to DMC Perfect Care Widget on your Desktop or App.

31. E-prescribe
Please use the E-Prescribe option in the EMR for all your patients.
Exceptions include patients pharmacy not accepting E-prescriptions, weekend discharge when pharmacy might be closed.
This is a quality metric and results are being monitored for each resident.
Results will be reported at the end of the month.

32. Morning Report
Each MR is a1-hour-long presentation including discussion/teaching from PM.
Roles
Interns: Make the case presentation slides for initial discussion facilitated by the CMR
Senior: Makes the teaching slides and presents them
Medical Student: No role required. Students are allowed to help with part of presentation if interested, but CMR must be notified
Time Deadlines
72 hours prior: Case FIN or MRN# relayed to the CMR
48 hours prior: Slides should be prepared and sent to the CMR
Ex: For a Tuesday MR the chief must know the FIN/case by 11am on Saturday and the slides are DUE to the chief by 11 am on Sunday. 
CMR’s will help with suggestions, polishing, and teaching changes, however, sending the CMR a slide set with no teaching slides, or just a skeleton outline of the presentation is considered as not received.
If no case is selected by 72 hours the CMR will choose a case for the residents to present 
If slides are not received by 48 hours or are received incomplete, the senior resident will facilitate the discussion for the case instead of the CMR

33. Morning Report
This is not a copy and paste of your Admission H+P Note.
Chief Complaint: Why the patient came in their own words, such as “I can’t catch my breath doc!” (things like “Dyspnea” or “SOB” are not acceptable.
ROS
Anything relevant to the HPI does not have to be repeated here. Only include things that were also found on ROS not related to HPI
Physical exam
Do not copy and paste the exam from your note as is.
Remember: inspection, palpation, percussion, auscultation.
For further expectations and sample MR presentations, wisit WSUMED.COM -> Resources and Rotation Guides -> Morning Report Expectations/Examples

34. Days Off Please discuss days off ASAP.
Seniors cant take days off on the same days as their interns
Seniors shouldn’t take on-call days or post-call days off. Interns can be given post-call days off when necessary.
Please try to coordinate your day off with the other seniors and AVOID having >2 seniors off on any day. Also try not to take Sundays off as there is no ER/IM.
Students and Sub-Is get one day off per week as well.

35. Didactics Morning Report daily 11 AM- 12 PM
On Fridays, Grand Rounds 12 – 1 PM
Didactics on Thursdays
Ambulatory is PM

36. Pager Etiquette As before, double check covering physician orders
Sign out pagers to night float (or call team) when leaving, be sure to take back your pager in the morning when you arrive
Call (313) , then follow the prompts
On your off days, forward your pager to your senior, don’t make it unavailable
Return pages ASAP, 15 minutes at longest

37. Final Words Enjoy your rotation
Do not hesitate to call/ text/ me with any questions
Welcome aboard!

38. Thanks