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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).

    Days Off

     - 4 days off per month for each intern and resident, no more, no less. rd - Interns may have weekends, golden, 3 up days off.

     - No Mondays off unless Golden or by prior approval of the Chief Resident. stnd - No 1 or 2 up days off unless previously approved by Chief Resident.

     - Residents may have weekends and golden days off; No admitting days.

     - No days off on Intern or Resident Switch days.

     - No days off on clinic days (and try to avoid days off when your resident/intern is in clinic).

    Work hours and time between shifts

    - RRC mandates a maximum of 80 duty hours per week for all residents, averaged over 4

    weeks. Duty hours are defined as all patient care activities and conferences. Duty hours do

    not include reading and preparation, time spent away from duty site.

    - On Golden Days, pagers are to stay on until 5:00 PM.

    - A call shift should not exceed 30 consecutive hours in the hospital, i.e. 7am-1pm. - A resident should have a 10-hour duty-free period between shifts.

    - The residents and interns should log in on their computer when they first arrive and log off

    at the end of the day; this is how work hours can be tracked.

    - Day starts at 7 am, this is tracked by the computer log-in time.

    - Notify the Chief Resident if there is an issue with work hours during the month.

    Rounds

    - 8am Brief (10 minutes) session with Housestaff/CM/SW/Pharmacy to confirm discharges

    planned for the day.

    - Rounds with Attending/Housestaff/CM/SW/Pharmacy from 10am-11pm Monday-Thursday,

    9am-10am on Fridays.

    - 11am there is interdisciplinary walking rounds with nurses.

    - 2pm Brief (10 minutes) session with Attending/Housestaff/CM/SW/Pharmacy to identify

    who can be discharged the following day. Discharge orders are to be completed the PM

    before discharge. Residents will take primary responsibility for discharge orders.

    Med reconciliation should be performed with pharmacy prior to writing d/c orders.

    Conferences

    - Attendance is mandatory as the number of conferences is significantly reduced as compared

    to GS.

    - Morning Report is at 9AM SHARP on Tuesday-Thursday. Morning Report is held in room

    435C, on 4C.

    - On-call resident will present case unless otherwise noted by Chief Resident. - Noon Conference is two to three times weekly in room 4115.

    - Noon Conference is mandatory for those who are Golden.

    - Grand Rounds is at 11 AM Friday in the ACC basement conference room.

    Consults/Death Pronouncements

    - The on-call team is responsible for the after hours URGENT consults in the CLC and

    remainder of the medical center. The call resident has full authority to transfer a patient to

    the Medical Teaching Service.

    - If you are called to consult in Psych or another area and you do not transfer the patient to

    your service, write a consult note and let the hospitalist know in the AM. - The on-call team is responsible for pronouncing deaths on the medical wards and in the

    NHCU and writing a death note.

    - Per VA policy, an autopsy MUST be requested on all deaths in the Medical Center and this

    request documented in the death note. The on-call team will notify the family members of the

    death when it occurs, but will not request an autopsy. The primary team will make a

    follow-up call to the family the next day and will request the autopsy at this time. This

    will give the family some time to adjust, and it is better for the primary team to make the

    request since they know the family better.

    Attending Coverage

    - Attending staff in general medicine and all medical and surgical subspecialties are available

    by pager every night. If an attending does not answer your page, ask the operator to call

    them at home.

    - Call Schedule is in CPRS and with the operator.

    - On weekends and holidays the attending hospitalist will meet with the post-call resident to

    review the previous night’s admissions.

    - If your attending is off for the day, make sure you touch base with the ―on-call‖ attending if

    you get a new patient, i.e. bounce back/ICU transfer to your team on a Golden Day or

    weekend day. An attending note needs to be on the chart within 24 hours of a patient

    being admitted or transferred to the floor.

    Charting

    - 100% electronic

    - History and physicals should be typed by intern or resident (medical students H&Ps are not

    sufficient)

    - Student’s notes need to be reviewed and co-signed by the intern or resident. - If the intern writes a history and physical, the resident should write a separate admission

    note and not just an addendum to the H&P.

    - DO NOT cut and paste large reports of labs, imaging studies, procedures…this creates

    clutter and this type of information can be easily referred to in the computer and doesn’t need

    to be detailed in the notes.

    - DO NOT cut and paste from other physician’s notes or from your own note day in and day

    out.

    - DO NOT cut and paste another doctor’s signature into your note, even if it is part of a report.

    - Process your ―Alerts‖ daily.

    Discharge summaries

    - Discharge summaries MUST be dictated by the time call starts. This means that

    resident has from the time that they are post call until the beginning of their next call

    to complete all of their discharge summaries (6 days).

    - Any d/c summary that is overdue by 10 days will affect attending performance measures. If

    any d/c summary is overdue, the resident will be subject to a downgrading of their

    performance in the area of professionalism which is part of the core competencies

    required for successful completion of residency.

    - Additional sick call will be provided for those with discharge summaries that are more

    than 14 days overdue.

    - Discharge summaries may be typed, but no abbreviations can be used if this is done (i.e. you

    must type chronic obstructive pulmonary disease, NOT COPD).

    - Transfers to another service other than the MICU, such as surgery, podiatry, vascular, ortho,

    etc, require a dictated interim summarya typed transfer summary is not adequate.

    - Patients on service for seven or more days must have interim discharge summaries

    dictated by the resident leaving that service.

    - Patients discharged on resident switch day are to be dictated by the previous resident. - Those delinquent in discharge summaries will be pulled out of their next rotation to complete

    their discharge summaries, contingency coverage and repayment will be the responsibility of

    the resident.

    Staff Service

    - When services are busy, appropriate patients may be transferred to the Staff Service.

    Appropriate patients are medically stable and require ongoing hospitalization for rehab, IV

    antibiotics, awaiting therapeutic INR, etc.

    - The Chief Resident and Program Directors will give priority to the busiest teams. - The resident dictates a transfer summary from the time of admission through time of transfer. - A resident may not transfer a patient if the transfer would leave the intern with fewer than 6

    remaining patients.

    Security

    - Federal regulations prohibit you from visiting pornographic or gambling sites. - Log off all computers when you are done so that some person doesn’t come

    after you and search prohibited sites on your password. This has occurred and residents

    have been fined for this in the past.

    - All papers with patient information on them must be secured in a drawer or in the burn box

    when you are not in the team room.

    - Personally identifiable health information, i.e., names and last 4s or DOBs, CANNOT be

    placed on unencrypted thumb drives, PDAs, written logbooks or any other electronic medium

    that can be lost

    - No unauthorized thumb drives

    Codes/RRT

    - Code team comprised of ICU resident and floor intern

    - Rapid response team comprised of ward resident and telemetry intern

    - All of above have pagers to be handed off daily from post-call to on-call counterpart. The

    Operators will check each pager about 9:30 AM; please respond so the operator knows the

    pager is working. Dead batteries can be replaced through the Chief Resident. - During code arrests:

    a. The RTs will manage the airway/supervise at night/weekends once they are certified.

    During regular work hours, call the fellow or attending for all airway issues STAT.

    b. The surgical resident/intern can place lines during a code if needed.

    c. The ICU fellow handles airway by day and if necessary, procedures, during a code.

    Although the floor team can help if needed as well.

    d. The resident who runs the code is responsible for writing a code note.

    e. ICU resident runs the code with back up from the fellow if present during the day. On

    nights and weekends, the floor resident should be present if able.

    Additional Info

    - Restraint orders:

    o If restrained for patient safety (ie. pulling lines), order ―initiate restraint protocol‖, also

    may be initiated by nursing. Must be signed within 24 hours by the team.

    o If restrained for behavioral problem, order ―seclusion and restraint‖, patient must be

    checked on and order rewritten q4 hrs.

    - When an Ortho, Podiatry, or Urology patient moves to any of the ICUs, the patient is

    automatically assigned to Medicine for the duration of the ICU stay because Ortho and GU

    do not have ICU privileges and it is likely in the patient’s best interest.

    Teleradiology Reports for CT Scans Done at Night

    - A copy of each Teleradiology report is Faxed directly by the Teleradiology service to the

     nursing station of the patient, and/or to the LSU/Emergency Department if an ED physician

     also is listed on the order.

    - VA Radiologists do a formal ―over read‖ the next morning.

    - The original Teleradiology report is scanned by Medical Records into the electronic record,

     CPRS---but this last step may take more than 24 hours.

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