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GUIDELINES FOR WARD HOUSESTAFF

By Jeanne Armstrong,2014-03-29 03:16
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GUIDELINES FOR WARD HOUSESTAFF

    GUIDELINES FOR VA WARD HOUSESTAFF (Subject to Change)

    Revised 8/5/09

    Call Schedule stndrd- Six call teams rotating on-call, post call, 1 up, 2 up, 3 up, golden. stndrd- The 1, 2, and 3 teams up take admissions from 7am 3pm everyday. This is not

    necessarily the order you will take patients, however.

    - Admissions from within the VA facility CALLED by the deadline count to that team no matter

    what time the patient hits the floor. You can go to the Clinic or the ER to see the patient.

    - Weekend call is 7AM to 7AM with one single team admitting.

    - Check out post-call must be within 30 hours of your arrival the day before. stndrd- Weekday Holidays: 1, 2 & 3 teams admit from 7AM Noon, all of those teams will

    have 1 intern off & admissions will alternate in sequential fashion. Call Team admits starting

    at Noon.

    - The telemetry intern is responsible for cross cover of all patients on 4C and 3C (whether they

     are on the monitor or not) and the floor intern is responsible for cross cover of all patients on

     4D and 2C.

    How to access Rosters (with housestaff schedules for VAW and ICU/electives) - Go to Internet Explorer. The VA Intranet home page will come up.

    - On the blue bar on the left hand side, select ―Patient Care/Clinician Toolbox‖.

    - Then, under this heading, click on ―Medicine‖.

    - Next, select ―Housestaff schedules‖

    - From here, you can choose the VAW or ICU/electives rosters. These give you all the

    schedule details including members of the teams, pager numbers, days off, etc. It will also

    tell you who is on elective so you can page residents on subspecialty services with consult

    questions.

    Admission Caps stnd- 1, 2 interns each cap at 3 admissions each.

    ; If both 2nd & 3rd up team has intern off each will take 4 admissions. rdstnd; 3 up team caps at 3 admissions if 1 and 2 up teams have 2 interns in house.

    - Distribution of admissions is determined by the chief resident, with the goal of keeping the

    teams as even as possible. No team will receive more than 4 patients in a row. - On call interns cap at 4 each on weekdays (Mon-Fri) & 5 each on weekends (Sat/Sun).

    On Holidays, admitting day teams cap at 3 patients per team. Again, subject to change

    as the year advances.

    - Interns should not be responsible for ongoing care of >12 patients.

    - Residents should not be responsible for ongoing care of >24 patients.

    Holdovers

    - The ER physician WILL write holding orders for stable medical teaching patients when:

    a. The on-call team has filled.

    b. It is after 3AM and the on-call team has admitted at least 5 patients.

    (The theory behind (b) is to provide some sleep time for the on-call teams)

    c. It is after 6AM, regardless of the number of patients admitted. - The ER physician does not write H&Ps.

    - The on-call resident should be notified of each holdover. Please briefly

    assess the patient and write a BRIEF note: For example, ―Patient assessed. ER Physicians

    orders reviewed. Stable for holdover until morning team arrives.‖ OR ―Patient assessed.

    Moonlighter called in to stabilize patient and do history and physical.‖

    - When speaking with LSU physicians, please be courteous and professional we’re all

    here to help patients! If issues arise, please speak with Chief Resident or Attending the

    following morning.

    Bounce Policy

    - Patients readmitted while the senior resident is still on service will bounce to the resident. - A team is eligible to accept bounce patients every day except post-call days. You can get

    bounces on your Golden Day that will count as an admission the following day,

    regardless what day of the week your Golden. For example if you are Golden on Sunday

    and get a bounce Saturday night, that patient will count toward your admissions for your

    Monday call.

    - If accepting a bounce would be a major hardship for a team due to the number of other

    admissions already accepted for the day, the senior resident should speak to the attending

    and/or the chief resident about asking the on call team to accept the bounce for that day only. - WeekEND bounces from ICU: these do not count as an admission to the call team or the

    primary team. The call team is not to write an accept note, they are only to cross cover the

    patient. The on call team should make sure that the patient is stable & double check the

    orders. The patient may NOT be counted as an admit for the primary team on the Monday

    following that weekend unless the bounce was received on the Golden Day. For example, if

    the patient was transferred out on Saturday and the primary team picked up the patient on

    Sunday, it will not count as an admission on Monday.

    - WeekEND bounces from the ED, clinics, or hospital transfers: these count as an

    admission for the call team that does the admission since they have to write a new H&P, but

    not to the primary team that will receive the bounce the following weekend day they will

    simply write a daily progress note on the weekend day. If the patient was admitted on

    Sunday night, the primary team may count them as an admission on Monday, since Monday

    is an admitting day.

    - WeekDAY ICU bounces: patients will count as an admission ONLY to the primary team to

    whom the patient is bouncing. If the floor team is post-call, or not in house at the time of the

    transfer, the ICU team will check out the patient to the on call team so that all issues are

    covered but that team DOES NOT have to write an accept note. The on call team should

    make sure that the patient is stable & double check the orders. The original admitting team

    will count the patient as a full admit either on the day the patient comes to them or on the

    next day if they were post-cal/out of housel when the patient came out of the ICU.

    - WeekDAY bounces from the ED, clinics, or hospital transfers: these will count as an

    admission for both the call team and the primary team the following day.

    - Please be aware that even though the bounces that don’t count to the primary team on the

    weekend, they will add to their total census, and since the admission are distributed based

    on census, they will affect their counts indirectly.

    - If the resident has a day off when the team receives a bounce, the on-call resident will assist

    the intern. Please let your attending know that you have received a bounce. - If a patient bounces on the last day of service AND the senior resident has left for the day,

    the admission stays with the admitting team.

    - If a resident does two consecutive months, he/she is only responsible for bounces only

    during the current month.

    Overnight Calls by Other Services (Podiatry/Surgery/Ortho patients)

    If a pt not on the medicine service has medical issues the on-call resident from the respective service

    should be notified.

    - If a patient has urgent medical issues, the medicine resident should be called. - If significant, the medicine resident can transfer them to the medical or ICU team (depending

    on the level of care they need) and accept them as one of their admissions. - Non-urgent medical issues involving these patients can wait until the hospitalists are here in

    the am.

    - Issues related to pain, wound care, abx, etc should be taking care of by podiatry. - Always err on the side of patient safety.

    Lastly, there is always a hospitalist on call 24/7 if a resident ever needs help/guidance. We shouldn't be

    involving ER staff.

    Moonlighter

     - A moonlighter is available as a back up to the on-call team when:

    a. The on-call team has filled and there are additional admits too ill to be handled with

    holdover orders.

    b. The on-call team is overwhelmed by the acuity of in-house patients and needs help - The moonlighter should NOT be called in to see stable holdovers.

    - The moonlighter is to be called by the on call resident only, NOT the ER. - The moonlighter on call is listed in telephone directory under Geriatrics Physician and is also

    noted on the monthly calendar.

    ICU and Transfers:

    - In order to transfer a patient to the ICU the Nursing Supervisor (779-8408) should be

    called FIRST and then the algorithm followed.

    - The ICU team admits patients 24 hours a day.

    - There will only be one discharge summary for the patient.

    a. It will be done by the Floor Resident if the patient is discharged from the floor. The

    ICU Resident will make sure that the transfer note written on the patient’s last day in

    the ICU is sufficiently complete to permit the Floor Resident to easily dictate the ICU

    course in the discharge summary.

    b. If a patient expires in the ICU or within 24 hours of transfer to the floor, is transferred

    to another hospital from the ICU, or is discharged home from the ICU, the ICU

    Resident who admitted the patient to the ICU will do the discharge summary. If the

    discharge or death or the patient occurs after the resident switch day, the ICU

    Resident who either discharges or pronounces the death will be responsible for the

    discharge summary.

    - In the unlikely instance that the Floor Resident and ICU Resident disagree over the

    appropriateness of a transfer in or out of the ICU, these guidelines should be followed:

    a. If the patient is moving from the floor to the ICU, the Floor Resident has the final say,

    unless overruled by the Intensivist.

    b. If the patient is moving from the ICU to the floor, the ICU Resident will have final say

    unless overruled by the hospitalist.

    If in doubt, discuss with your attending.

    - Transfers into or out of the ICU will have a Transfer Summary written by the transferring

    service. The Transfer Summary MUST include:

    o List of Diagnoses

    o List of Procedures, including Lines, Intubations, Major Radiology studies

    o Consultations

    o Summary of ICU or Ward Course (Should be multiple paragraphs if patient has been

    hospitalized for more than a week).

    Emergent Transfers to Outside Facilities

    - Must be approved by the AOD, to obtain this number contact admitting at 2627 or 2621 - Place fee basis consult, under consults then click fee basis inpatient

    - Stat DC summary, most of the time this should be typed out

    - DC order cascade

    - If you have any questions contact the nursing supervisor, especially if you need copies of any

    Imaging studies

    CLC (Previously known as the NHCU) Transfers:

    - All transfers to the CLC must take place prior to 3 PM.

    - The extended cutoff time is to be helpful/flexible, not to increase their workload late in the day.

    Every attempt should be made to get patients to the CLC prior to noon.

    - Prior to transfer, verbal report must be given to the attending at the CLC. Patients should not

    just arrive at the CLC without having previously communicated with the accepting physician

    (Drs. Buckhout and Rousseau).