1. PGY 3/4 to Be Retreat June 3, 2014 Scott Denstaedt Marty Tam Angel Qin Khanjan Shah

2. Hoping for the best, prepared for the worst, and unsurprised by anything in between. -Maya Angelou

3. Overview 5:30-6Dinner 6-7:30Quality Center (Heidi et al.) Milestones discussion (Dr. Arfons) Ambulatory Changes Medicine Clerkship (Dr. Leizman) Changes for next year Logistics reminders Issues unique to 3 rd year Fellowship Boards/ITE Medical License Senior talks Patient Safety/Quality Externship 7:30 - 8:00DACR/NACR Orientation Gen Med Consults 8-8:30Questions

4. Changes for Next Year Ambulatory Electives Jeopardy

5. Ambulatory Model 2.0 2013-2014: four ambulatory blocks and 2-4 clinics in elective 2014-2015: five ambulatory blocks and no clinic in elective (there is a panel management day) “6+2” model – 6 weeks of ICU/wards/elective – 2 weeks of dedicated ambulatory – 7 half days of clinic each block and 1 administrative half day Positive Effect – Continuity: you and three other seniors make up a team (with two interns) and see the same patients (great for you and the patients!) – Electives Preserved: you can make more of your elective now! – Curriculum: streamlined and less repetitive New Challenges – Ambulatory blocks are fixed (cannot trade) – Change is uncomfortable, but we do it to try and make things better

6. Ambulatory Model 2.0

7. TeamFlight 1 (1A,4B,8A,10A,12A)Flight 2 (1B,5A,8B,10B,12B)Flight 3 (2A,5B,9A,11A,13A)Flight 4 (2B,6A,9B,11B,13B) VA 1 RedPerihanJohn SAnodikaPrashanth VA 2 SilverAndresRachelAbdullah AlmPerica VA 3 PurpleAlinaKatiePhiliciaKhadejah VA 4 YellowAmhedWissamNupurLesley DMC 1 MBryanJacobRaniaNeetika DMC 2 TuStephanie KSadeerJohn GNate S DMC 3 WMayaCarinePatrickGabe DMC 4 ThAhmadDafinaAtallahVincent DMC 5 FStephanie MBrandonYosraChris DMC 6 MRoopaCassieWonDhruti DMC 7 TuJackMoAbdullah AljHussain DMC 8 WAniketAnthonyRishiShiv DMC 9 ThBouchraPriyamNingZiyad

8. Ambulatory Model 2.0 # ResidentsMonTuesWedThursFri 1Team 1 2 3 4 5 6 7 WEEK 1 8 BOX Admin Team 1 # ResidentsMonTuesWedThursFri 1Team 1 2 3 WEEK 2 4 5 6 7 8 BOX Team 1 BOX Admin # ResidentsMonTuesWedThursFri 1Team 1Team 2Team 1Team 2Team 1 2Team 3Team 4Team 3Team 4Team 3 3Team 4Team 5 Team 6Team 5 4Team 6Team 7Team 6Team 7 5 Team 8 Team 9Team 8 6Team 9 7*Intern 1*Intern 2*Intern 3*Intern 4*Intern 5WEEK 1 8*Intern 6*Intern 7*Intern 8*Intern 9 BOXTeam 2Team 3Team 4Team 5Team 6 BOXIntern AdminTeam 8Team 9 Team 1Team 2 # ResidentsMonTuesWedThursFri 1Team 1Team 2Team 1 Team 2 2 Team 3 Team 2Team 3 3Team 4Team 5Team 4 Team 5WEEK 2 4Team 6Team 7Team 6Team 5Team 6 5Team 8Team 9Team 8Team 7Team 8 6Team 9 7*Intern 1*Intern 2*Intern 3*Intern 4*Intern 5 8*Intern 6*Intern 7*Intern 8*Intern 9 BOXTeam 7Team 8Team 9 Team 1 BOXIntern AdminTeam 3Team 4Team 5Team 6Team 7

9. 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

10. Example Elective Tracking

11. 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 Reading Electives: Requires approval, KBA is designated supervisor Required attendance at all UH noon conferences, UH M+Ms, UH Grand Rounds, VA Grand Rounds

12. Elective Reminder Elective Professionalism Elective is not vacation You are back-up jep and expected to be in Cleveland If you are going out of town, please let the Ambulatory chief know “Don’t you remember when you were a resident?” Having your pager on 24/7 on elective is unreasonable Everyone on elective is back-up jep any given day, but we can assign people on specific days to be the first called so you know when to have your pager with you

13. Jeopardy Minor changes to the jeopardy system will be made Use of jeopardy will be tracked for training/support purposes – Make sure everyone is meeting minimum requirements – Make sure we provide help and resources to those that need it Those getting jepped from electives will be tracked as well – Ties into the “first call” back-up jep list, you move down the list after getting jepped – 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 – There is still a jep rotation, coverage here is not tracked and you do not get paid back

14. Logistics Reminders

15. Transition Dates PGY1 end date: 6/23 Block Zero: 6/24 – 6/30 Block One: 7/1 – year of SMAK!

16. Team Caps UH Wards: 10 patients per intern 8 patients per intern on Ratnoff/Weisman Intern+AI: 12 patients if two seniors; 10 patients if one senior VA Wards: 8 patients per intern Intern+AI: 10 patients AI+AI pair: 10 patients Short Admissions: No shorts on weekends No shorts if intern has 8 patients Shorts for Intern+AI pair to cap of 10 patients

17. Duty Hours Long Call: – 3 patients (4 if paired with AI) until 7 PM – 2 patients if after 5 PM – 1 patient is after 6 PM 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, ICU transfers, new admissions) – No short patients on clinic days ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!! Senior Resident: – Residents on call MUST stay until 9 PM – No matter what the call, ward seniors staff any patient the seen 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

18. Staffing UH wards will have double coverage Blocks 1-3 There will be minimal orphan coverage in the first few blocks See and examine EVERY patient No staffing note required for ICU transfers or interservice 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 CODE STATUS and Allergies

19. Staffing On call resident should notify the nightfloat resident of tenuous patients Be proactive about staffing patients

20. Coverage and Schedule Switches All coverage arrangements and schedule switches must be approved by the Ambulatory chief so it can be noted in amion Switches must be arranged before 1 week of rotation starting

21. REMINDER: Residency Reading List Residency Reading list: Landmark and review articles in all sub-specialties Last major update in 2011 Looking a 20-40 year old resident who enjoys long nights of Boolean searching to help update the site with new landmark trials…

22. Professionalism

23. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean No denim Do not show up to Morning Report looking sloppy

24. 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

25. Professionalism: Electives Attend all Grand Rounds and M&M’s You are back up jeopardy!! = pager on If you are going out of town for the weekend, as a courtesy please notify the ambulatory chief prior to leaving Elective is not vacation Please email Barb 2 weeks prior to starting your electives; Quality chief will be keeping track of electives Research for more than 2 weeks = present at Research Day

26. Professionalism: Reading Electives Residents on reading elective are expected to attend morning reports and journal clubs at the VA Must attend Grand Rounds 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 are back up jeopardy!!!

27. Professionalism: Conference Attendance Please be on time; our speakers usually have prepared a well thought out talk/powerpoint, so please be respectful of the time they spent Noon conference: UH: Mon-Wed-Thurs VA: Mon-Thurs-Fri Grand Rounds on Tuesday: UH & VA M&M Fridays @UH, Wednesdays @VA Conference attendance is part of your ACGME graduation requirements

28. Conference attendance during ambulatory Ambulatory conference attendance is mandatory Late Policy will be strictly enforced: Sign-in sheet will be available until 8:05AM At your 2nd instance of being late = extra weekend coverage Any MISSED conferences without prior approval by the ambulatory chief will result in weekend coverage

29. Professionalism: Discharge Summaries If you put in the discharge order, you do the discharge summary Do them the day of discharge Do them for your intern Do them for your friends Do them for your patients Remember it is now easier than ever to do it in UH EMR

30. Issues Unique to 3 rd year Fellowship Boards/ITE Medical License PGYIII QI project Senior Grand Rounds VACR NACR/DACR

31. https://www.aamc.org/students/medstudents/eras/fellowship_a pplicants/ Please review this website! There are many new changes this year https://www.erasfellowshipdocuments.org/ Request ERAS token; June 11, 2014 Ask for letters of recommendation…now! Start considering your future destinations for fellowship Work on your personal statement July 15, 2014: first day to submit application AND programs begin downloading applications Special considerations (double check now): Sports Medicine Hospice and Palliative Care Fellowship Timeline

32. Deadline for completed application varies but is as early as July 31 st ; check with program and be prepared Interviews: August - November 2014 First MATCH: first Wednesday in December 2014 *KBA will perform mock interviews upon request

33. BOARDS!!! Register starting in December Plan ahead…costs about $1,365 (more if you sign up late) Noon Conferences to include more board prep sessions Can use ITE exam results to help guide studying

34. In-service Training exam In-service Exam Dates are in October – exam is completely computerized this year Includes all PGY2/3, PGY1’s? 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!)

35. Medical License Remember to keep your BLS/ACLS updated Must have Step 3 results prior to license application Start FCVS by December ($430) State licensing ($335) can often take 5-6 months. DEA license is much quicker but more expensive ($551) Plan ahead!!!

36. Senior Grand Rounds Noon conference lecture for each senior resident, late August (after intern boot camp has finished) Dr. Mourad is the APD in charge Email learning objectives to assigned faculty mentor, ambulatory chief and Dr. Mourad two weeks prior to lecture date Topic of your choice, should be evidence-based MORE INFORMATION TO COME!

37. Patient Safety and Quality Improvement Introduction to quality improvement during DACR rotation UH Care feedback Quality Assurance meetings Write-up cases for Medicine QA Attend ED/IM QA Attend Quality Patient Safety Committee meetings Mortality review, PASS reports, and Risk Management meetings

38. Guidelines for Resident Quality Improvement Project QI project for PGYIII required by ACGME Form groups of 2-4 (ideally 3) people Work with one of the chief medical residents and quality center to develop project ideas and aid with data collection Start by identifying a quality issue, collect background data, design an intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources) Present quality poster at Research Day Select project/team in July, first meeting regarding the project occurs in August

39. Timeline for QI Project General Timeline: July: select project/team August : meeting with assigned chieg resident and QI RN (complete FOCUS PDCA) define objectives, collect background information, plan an intervention September-November: collect baseline data (initial survey) December: meet with chief resident and QI RN to discuss baseline data and intervention implementation January through February : implement plan March through April: collect data post-implementation, write abstract for research day, make research day poster May: present at research day

40. VACR Many PGYIII’s will have this rotation, not all Perform medicine consults Be available to help out ward teams as needed Prepare EBM lecture on a topic of choice for morning report Attend all morning reports One Saturday 24 hour VA MICU coverage

41. DACR / NACR: Your education in systems-based practice

42. To Admit vs. Observe Arose out of for profit hospital chain fraud Requires attending to sign and admission order that includes language that the attending expects the patients medical problems to require admission for two days Some logistical issues on getting attendings to sign/place order

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

44. The NACR as Ombudsman* Distribute admissions to teams on call in AM Enforce geographic localization Run codes See medicine consults at night (ophtho and ortho co-management if requested) Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House Cover flex patients at night and ?additional PRN SHD patients Find out intern census from nightfloat interns for each team Admit BMT and Transplant Medicine patients along with NF (must inform BMT fellow and Transplant attending) Transplants within the past year should be admitted to transplant surgery *ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization *****Transplant service is not the Transplant attending! MUST ASK OPERATOR FOR TRANSPLANT ATTENDING!!!!******

45. “The Book” as it should be…

46. “The Book” according to the ED…

47. Patient enters ED, decision to admit ED enters admitting bed request ED pages NACR for signout Medicine floor admission appropriate? No Yes Admitting pages NACR with bed request Ask ED attending to reconsider triage of patient, work-up, or admitting service NACR calls admitting and makes appropriate bed assignment NACR assigns admission to NF or her/himself Admitting ED NACR NACR distributes patients in the AM with help of KBA and chief NACR OVERVIEW Medicine

48. Appropriate Service? Is the patient stable for the floor? PCP in FP? No MICU/CICU/NSU/SICU Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission. No Appropriate for medicine? No Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient” Yes FM capped !?&*#@! Stroke, SBO, femur fracture, etc Yes Appropriate for FP?

49. Appropriate Service? Look up the patient in Portal and EMR before assigning Patient’s PCP – Family practice patient? Private patient (list of attendings available)? Fang Service does not have a cap per Dr. Oliviera; if they have been seen in HF and are coming in w/ HF exacerbation, have ED call the overnight admissions person Physician Portal (summary page, physicians) Previous discharge summaries EMR patient info clinical summary (visit history) Ask the patient!

53. NACR The two most important things you can do as NACR: 1) Admit the patient to the appropriate service (never forget to look up PCP/patient info/dc summaries) 2) Plan ahead and assign patient to appropriate floor based on available spots/admitting diagnosis/co-morbidities ie. GEO LOC Be proactive – keep an eye on the ED board If the patient is unstable or you do not feel comfortable, it is okay to ask for ED to either re-triage patient (ie MICU/CICU) or to set a goal for admission to the floor (eg BP should be better than 240/120 for me to admit this HTN urgency to the floor) Before your first NACR night, you will have a more detailed orientation with one of the chiefs at UH.

54. NACR specifics 8pm – midnight: Meet Admissions Coordinator in KACR to get sign out print out new board (on medicine.case.edu; UH resources) start NACR sheet, Admissions Coordinator will be holding the book and pagers until midnight on the weekdays, so this is your PRIME admitting time Usually try to see most of your patients at this time; orders and notes can be done after the MAN is gone Midnight and after: Stay on top of the ED board Master the art of the NACR 5-6am Get organized, make copies of NACR sheet, get intern census Talk to NFs regarding admits and appropriateness for teams; biggest decisions are Hosp/NPs vs. flex 6:30-8am Review admits with KBA and SMAK 8am hospitalists call for assignment Fax assignment sheets from day prior and overnight to admitting and hospitalist offices Call non-teaching services to assign patients (Fang/Transplant/BMT) Chief Resident may call you to check in on your first NACR night

57. Types of Patients Private (PCP will attend) – Coviello, Schnall, D. Brown, DeJoseph, Junglas, King, Tomm, Locke ER must call private attendings; but if the patient is on the floor and the ER did not call, it is the DACR/NACR responsibility Assign to med NPs (private spots) during the day! If no spots, then flex versus team (Eckel, Carpenter, or Gen Med; not Ratnoff/Weisman/Hellerstein) D. Brown must be flex (not NP) Staff – NPs (no procedures), hospitalists (few social issues low complexity), general medicine teams *Non-cardiology patients needing telemetry can go to Hellerstein and hospitalists (not med NP)

58. Specialty services: Eckel: ESRD, hypertensive urgency/emergency. ESRD transfers need to be accepted by Nephrologist. Ratnoff/Weisman: SCC with active issues Hellerstein: active cardiology issues (regardless of PCP) Dworkin: GI patients (abdominal pain anyone?). Can take liver to a cap of 3 (but flexible) if liver attending accepts Fang service: HF issue who is seen by a HF attending (Oliviera, El-Amm, Ginwalla, Effron) Patients with no right answer (HIV patient with ESRD and chest pain followed in HF clinic) - most active issue prevails Types of patients

59. Types of Patients HIV patients go to Carpenter -When Carpenter is not admitting, give them one a day early or have resident flex Pulmonary cases go to general medicine -Pulmonary HTN and flolan patients need to be on T5 and goes to Hellerstein/Gen Med MICU transfers followed by renal consult team -If chronic  Eckel -If acute  gen med with renal consult

60. Non-Teaching Services You or DACR will get an e-mail stating the number of open spots for the next day for MNP, Berger Hospitalist A (NPs), B, C, and D will call the Admissions Coordinator at 8am (make sure they are written in the book) Fang Service – Call with admissions in AM; apparently they have no cap… Transplant/BMT – Overnight admissions should have been discussed with transplant attending or BMT fellow; it is good practice to call in AM to make sure the team is aware of the patient

61. NPs Medical Nurse Practitioners Patients who do not need procedures Patients who are not being ruled out for ACS CAN take syncope patients on tele They will take most private patients (not D. Brown) Can take very complex patients! Berger Nurse Practitioners Stable patients who do not need procedures: sickle cell, pain management, hospice, routine chemo admissions

62. Hospitalist B, C, & D Have a cap of 12 patients each Straightforward medicine patients without complicated social issues Try to give them patients whom you anticipate will have short stays Unfilled spots rollover to the next day Cannot take ICU transfers that were in unit >48h Take bouncebacks, but count against cap

63. Fang Service Two NPs with Hellerstein fellow During the week, admit cardiology patients to team cap Will take NF admits and CICU transfers “No cap”, but chief/KBA may need to speak with attending in AM All Effron/Heart Failure patients

64. Moonlighting Cross-Cover Long House Doc: 8pm to 8am 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!) Early and Late Short House Doc Each admits three patients Admitting Long House Doc: 6pm to 6am Admits six patients Bomb the long house doc! Give them private patients that go to the NPs Must cap them! No admissions after 0400 Appropriate patient selection for the house doc is key; in most cases these patient should not come back to the housestaff the next day

65. ED Issues Neurology: Strokes go to neurology Seizures – try neuro first General Surgery: insist (politely) that they take SBOs, etc Make the resident call their attending (or do it for them) VA: far better to transfer BEFORE admission Ortho: perhaps worth arguing, but Medicine co-manages most ortho patients (NACR/DACR consult)

66. Other Duties: Medicine Consults See the patient in a timely fashion Write a note Leave at least a preliminary note in the chart Call the Gen Med consult attending if needed Co-management with orthopedicsWe follow along with ortho patients; they don’t need a “question” You can put in orders dealing with medical issues

67. Co-management Memos ENT and Ophtho have specific co- management pathways (in handout) It is a good idea to review these prior to your first NACR

68. Transfers to Medicine All transfers to medicine must be approved by medicine consult attending (not Dr. Whelan), chiefs, or KBA Your medicine attending can ONLY accept to general medicine (Naff/Wearn, MNP etc); if the other service wants to transfer to a subspecialty team (ie Dworkin), they MUST consult the attending on call for the day Consults for transfer to medicine: If clear subspecialty issue, refer to appropriate attending If clear gen med transfer, no consult necessary If unclear, offer to do a consult and staff with attending Don’t accept inter-service transfers overnight

69. Outside Hospital Transfers Transfer Center 41111 Attendings are supposed to call 67121 or page 30512 when they accept a patient 8 am – 8 pm – Rotating attendings M-W: Chief Resident and KBA Th-F: Dr. Chandra et al 8 pm – 8 am – Cross-Cover Long House Doc

70. DACR/NACR Hours DACR = 8am – 8pm NACR = 8pm – 8am MAN = 8am – 12am (8pm on weekends) DACRs come to morning report, Grand Rounds, and M&Ms NACRs have a staff attending on call

71. Running Codes

72. 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!

73. Code Blues Check your own pulse first “Too many chefs spoil the soup” One person leads the code Make sure interns are involved Maintain a calm quiet atmosphere Keep the ACLS cards in your pocket until you are comfortable with the protocols Make sure your BLS and ACLS are up to date CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

74. 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 Don’t be afraid to ask people to leave the room Call the ICU nurses by their name, closed-ended communication Assign someone to call the family Use the Code Note EMR, sign code sheet

75. Running Codes Notifying attendings at night Most attendings want to be paged and notified (either of transfer to ICU or death) Can clarify with your attending on first day of service what their preferences are Don’t get burned by not calling your attending- you may hear about it the next day

76. We are looking forward to a great year together!!! -SMAK

77. Questions?