1. PGY 3/4 to Be Retreat *Due to a lack of available conference room space, the 2015 retreat will not be at the Four Seasons Bora Bora, it will instead be on Tower 11. We will return to Bora Bora in 2016.*

2. Changes for Next Year Interns will take overnight call in the MICU Adoption of the MICU call structure in the CICU Implementation of intern ambulatory blocks (goodbye weekday resiterning!) Friday Ambulatory Academic Half Day

3. UH MICU new for next year Interns will take Q4 overnight call with their paired senior resident. Last day of rotation their call day will end at 11PM. Return to 2 attendings, 2 teams.

4. UH MICU Overnight Call – Post Call – Helper Day – Pre Call Senior residents get pre-call day off between Friday and Monday (interns get helper day off during same days) Five senior residents in the MICU (plus rotators) Senior will be paired with intern. Senior “supervises” their intern, but intern “staffs” new patients with the MICU fellow. New: interns will take Q4 30 hour call with their residents (iCOMPARE 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 on-call resident until at least 7 PM 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.

5. UH MICU Nights May have 2 weeks as MICU night resident (have Friday and Saturday nights off that are covered by MICU moonlighter) MICU night resident responsibilities – Comes at 9 PM – Cross-covers unit at night – Alternates admissions with resident on call until 2 AM, then does all admissions after 2 AM Patients admitted by NF will be distributed by the MICU fellow in AM NF residents sometimes stay to present patients on rounds (complex patients) Post-call resident will present and leave, sign out to the post call intern and helper resident

6. UH CICU new next year In response to feedback that: 1.There were too many handoffs in the CICU 2.There were too many cross-coverages in the CICU Brainstorm: ideas regarding cause; possible remedies. Intervention: trial run of the MICU call model in the CICU. The feedback from this pilot was that the residents preferred the new format (MICU call model) to the current CICU call model. We will therefore adopt this change for next year.

7. 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 No 8AM Conference, though VA clinics and UCC start at 8 (DMC start time TBD) Tues and Wed AM DMC Clinic. Decreasing wasted travel time between VA and UH. Challenges – Ambulatory blocks are fixed (cannot trade) – Clinic days are fixed throughout the year, allows improved scheduling continuity

8. Ambulatory blocks for interns All categorical interns will have one primary care block and 2 ambulatory blocks with the senior residents. No Clinic on Wards/ICU! Resident no longer will have to cover interns in the afternoon who are in clinic (exception for Med/Peds)

9. Ambulatory Model 3.0

10. Example Schedules

11. Changes at the DMC Tuesday and Wed AM Clinics. Ongoing efforts to improve continuity New Attendings: Dr. Crystal Lantz and Dr. Babak Moini. 2 resident favorites back as outpatient teaching attendings!

12. Changes at the VA Clinic names changing, talk with your preceptor if you need to change your list Alerts

13. 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

14. Example Elective Tracking

15. 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 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

16. Elective Reminder Elective Professionalism & Jeopardy Elective is not vacation You are expected to be in town and available - if you need to leave town, please let the Ambulatory chief know 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 email 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!

17. Jeopardy Please carry your pager 24/7 Monday thru Friday 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.

18. Transition Dates PGY1 end date: 6/23 Block Zero: 6/24 – 6/30 Block One: 7/1 – start of your PGY3 year!

19. Team Caps UH Wards: 10 patients per intern for all services except Ratnoff & Weisman which cap at 8 (with rolling cap for Long & Med call) 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; 10 patients for all wards except Ratnoff & Weisman (where cap is 8) Short call day caps at 8 (based on the number of patients you start the day with, not a rolling cap). VA Wards: 8 patients per intern Intern+AI or Intern/Intern: 10 patients

20. Team Caps Special circumstances: 1.Hellerstein Short gets only 1 short admission. 2.No Eckel short admissions. 3.No weekend short admissions. 4.AIs can get new admissions on short call.

21. Admissions Long 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 – Anesthesia interns should leave by 9PM, work up admissions accordingly 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 or ICU transfers) Senior Resident: – Residents on call MUST stay until 8 PM when the NACR and NFs arrive. – 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

22. 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 Daily AI notes: need a progress note for you, unless the attending is also writing a full daily progress note (Naff/Wearn)

23. Moonlighting 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 Cross Cover LHD – cross covers hospitalist, NPs, and admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM MICU/CICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for alternating admissions with resident until 2am, then all admissions No moonlighting during wards or ICU

24. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean – department pays for dry cleaning 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)

25. 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

26. Professionalism: weekday swaps Swapping weekday coverage of ward and ICU teams will not be routinely permitted. 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 for academic pursuits 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.

27. Professionalism: 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 2 weeks before rotation start date, ideally sooner

28. 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.

29. 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.

30. Professionalism: Conferences Be on time.

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

32. 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 2 weeks before rotation start date, ideally sooner

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

34. https://www.aamc.org/students/medstudents/eras/fellowship_a pplicants/ Please review this website! https://www.erasfellowshipdocuments.org/ Request ERAS token Ask for letters of recommendation…if you haven’t yet, this is your week! Personal statement July 15, 2015: first day to submit application AND programs begin downloading applications. Have everything in place. Special considerations (double check now): Sports Medicine Hospice and Palliative Care Fellowship Timeline

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

36. Fellowship Timeline

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

38. In-service Training exam In-service Exam Dates are in August and September – exam is completely computerized – Includes all PGY2/3, PGY1’s 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!)

39. Medical License Remember to keep your BLS/ACLS updated Must have Step 3 results prior to license application Start FCVS by later summer($430) State licensing ($335) can often take 5-6 months. DEA license is much quicker but more expensive ($740) Plan ahead, it takes 5 months at a minimum, and usually longer from start to finish.

40. DACR / NACR / VACR Your education in systems-based practice

41. VACR Many PGYIII’s will have this rotation, not all Perform medicine consults. VACR service often takes 2-3 straightfoward patients early to middle of the week. Be available to help out ward teams as needed VACR talk: prepare EBM lecture on a topic of choice 2 nd Tuesday morning report Attend all morning reports One Saturday 24 hour VA MICU coverage

42. DACR/NACR Hours DACR = 8am – 8pm – Come to morning report, Grand Rounds, and M&Ms NACR = 8pm – 8am Admission coordinator = 8am – 12am (8pm on Saturday and Sunday)

43. DACR Quality curriculum (EQUIPS) PRN SHDs Flex Service – D Brown patients – Pulmonary patients – Overflow of heme/onc patients Consults – Sometimes there is an anesthesia resident to help

44. 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

45. Guidelines for Resident Quality Improvement Project QI project for PGYIII required by ACGME You will now also get QI teaching during your ambulatory block You’ll learn about the QI project in your first ambulatory block Present quality poster at Research Day

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

47. 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!!!!******

48. “The Book” as it should be…

49. “The Book” according to the ED…

50. 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

51. 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?

52. 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; 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)

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 – 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) Dworken: GI patients (abdominal pain anyone?). Can take liver to a cap of 4 (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 ***If you are slammed with heme/onc patients, uncomplicated sickle cell patients should be admitted to Tower and go to the Hospitalist service HIV patients go to Carpenter -When Carpenter is not admitting, give them one a day early or have resident flex 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 Berger Hospitalist B, C, and D will call the NACR at 8am to get assignments Fang Service – Call with admissions in AM; NP on service will tell you if they can accept the patient 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 Straightforward medicine patients without complicated social issues Try to give them patients with likely short stays Cannot take ICU transfers that were in unit >48h

63. 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!) No admissions after 0600 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! No admissions after 0400 Appropriate patient selection for the house doc is key

64. ED Issues Neurology: Strokes go to neurology Seizures – try neuro first General Surgery: for patients with recent surgery, have the ED consult the service who performed the surgery – Make the resident call their attending to refuse all patients and document attending name in their note VA: far better to transfer BEFORE admission Ortho: Medicine co-manages ortho patients if desired (NACR/DACR consult)

65. Medicine Consults, Comanagement, Transfers to Medicine

66. Medicine Consults DACR and NACR 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 orthopedics – we 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 – On the bulletin board in the KACR room

68. Transfers to Medicine All transfers to medicine must be approved by medicine consult attending, 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. Running Codes

71. 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!

72. Code Blues “Too many chefs spoil the soup” One person leads the code Make sure interns are involved: Never kick an intern out of the room during a code, they will be running it next year! Maintain a calm quiet atmosphere Keep the ACLS cards in your pocket CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

73. 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, closed-ended 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.

74. HAVE A GREAT YEAR!!!