Mount Sinai Hospital Monthly In-Patient Orientation Update: November, 2003

Mount Sinai HospitalMonthly In-Patient OrientationUpdate: November, 2003

Minerva Galang MDJose-Luis Velazquez MDChief Medicine Residents

Ermias Tilahun, MD, FACPSite & Associate Program DirectorAssistant Professor of MedicineChicago Medical School

Last modified on 7/1/03; subject to change

Version 11/1/03, subject to change

Time punctuality

Pre-round for interns: 7:00AM- 7:30 AMSign-in for floor teams with CMR at OS 653- Monday, Tuesday, Thursday: 7:30- 7:45- Wednesday: 8:30 8:45- Friday: 7:00 7:15Teaching rounds: 8:00- 9:00 (except wednesdays)*Morning report at Noon (MRAN): 12:00- 1:00pmSign-out Rounds: 4:00 pm (fridays at 3:00 p.m.), OS653, except mondays held at 9th floor.

Bed side rounds with Dr.Gall: 4th Monday. 11:00- 12:00. Team assignment in call scheduleEthics Rounds: every Thursday from 11:00- 12:00 on 5N with Dr. SokolGrand Rounds: Wed. at 8:00 amTumour board in Conference Rm C- 3rd Thursday from 12:00- 1:00 PMContinuity clinic:1:00 pmCommunity free clinic: 2nd and 4th Thursday of every month at 6:00 pm- residents to be assigned from electives*varies in some teams according to attending clinics schedule



ConferencesAttendance required for > 80% of the conferences (M-F @ noon, Wednesday @ 7:30 a.m. and Friday at 7:00 a.m.). IMPORTANT PART OF YOUR MONTHLY EVALUATION!.Attendance has to be on time (5 min. tolerance) to be considered, late arrivals are marked as absent.ICU and CCU resident attendance is optional.Morning report(MRAN): Case to be discussed according to specialty of the day (check conference schedule at web site)Questions raised during the morning report are due in 2 days.



Schedule & webpagewww.amion.comPassword: chimed



Amion.com examplesFullMonthScheduleIncludesJeopardy,Sinai andVA schedules



Amion.com, monthly schedule



Amion.com whos on call?



Websitecms.velcec.comConference schedulesJeopardy, team structureBulletin boardDownload forms (sign-out)THIS PROCEDURES/ ORIENTATIONJournal club articles



Web site, conference schedules



NEW: Weekday Long Calls (1)Call starts at 11:00cross-coverage until 9:00 p.m.Admit until cap of 10 or midnightInterns: 1 intern stays in the hospital (gets early admissions), 1 goes home (usually the intern that has clinic next day, should go home at 9:00 p.m.). The H&Ps are to be filed in the chart before going home if possible or early next morning. BOTH INTERNS STAY IN THE HOSPITAL ON FRIDAY, SATURDAY AND SUNDAY. Seniors: Stay over-night in the hospital (1 Senior from MSI team). Leave next day at NOON. Clinic will be cancelled on post-call day(s) not morning clinics (yet!). If you have Clinic the same day On Call, Leave Satellite Clinic at 3:00 p.m. and 4 p.m. at Kling. Make sure to notify the attending when you are going to be on call (at least the day before, if you notice some reluctancy, please notify the CMR the day before).



NEW: Weekday Long Calls (2)The team admits until CAP (10 patients) or midnight

Night Float crosscover from 9:00 p.m. (regardless of cap status, early or late)

Consults will be done by the person carrying the pager at the time the consult is received. If patient is away for a procedure, consult should be done when the patient is back by the person who received the consult



NEW: Weekends Long calls SaturdayCall start at 11:00 a.m. until 11:00 a.m. of Sunday (long call team come to the hospital for sign-out).Regular Saturday work (writing notes, calling attendings, but starting from 11:00 a.m.)Cap of 10.Trigger point for calling the NF is 8 pt on the floor by 8:00 pm.NF (if called) will admit/do consults and will not cross cover.Overflow from NF or long call will be admitted by moonlighter.After the moonlighter admits 4 patients, SMR, NFR and the moonlighter will alternate.



NEW: Weekends Long calls SundayCall starts at 11:00 a.m. (no need to come to the hospital before this time)Admit until 7:30 a.m. Monday morningClinics will be cancelled in the post-call dayMonday is a normal working day for the team (sign-out at 4:00 p.m.)



NEW: Weekdays short callsWeek days: from 7:30 a.m. to 11:00 a.m.

Cap of 8 patients.

Over night cases admitted by NF and moonlighter will go to the short call team

Redistribution policies are flexible and the final decision will be made by the CMR depending on individual situation.



NEW: Weekends short callsSaturdays and holidays: admits overnight cases and until 11:00 a.m. with cap of 8 patients. Overflow go to the long call team temporarily, pending distributing them to the team on short call MondayNo short-call on SundaysOn Mondays you accept the overflow pt from Sat. and or Sun.Overflow of Sat night must be endorsed to Sunday long call for coverage



Cross CoverageIt is carried out by long call team from 4:00 pm until 9:00 PM

Floor cross coverage by the interns:Floors 5 & 6 and 2 & 3 floors

You should get good clear endorsements at sign out round and during the weekends

Any cross coverage even must be documented in the chart

Must be endorsed to the team in the sign in rounds



Week days night floatWeek days: 9:00 p.m.- 9:00 a.m.

Admit from 9:00 p.m. until 7:30 a.m., unless called early or SMT (long call) still admitting.

Cross-coverage of the non-teaching service from 8:00-9:00 AM. Also from 5:00 p.m. to 8:00 p.m.

Cap of 8 pt, 4 each, overflow admitted by moonlighter



Weekends night floatThey will be called by the long call team when there are 8 pt on the floor by 8 pm

One person should come in if the NF is to be called, and he will have a cap of 4 without doing any cross coverage

The 2nd person will be called in the following day if NF is to be called in again or as arranged between the NF

Overflow should be admitted by moonlighter.

After the moon lighter admits 4 patients, the senior resident, NF resident and the moon lighter will take alternate admissions in that order.



Community free clinicCommunity free clinic, on either the 2nd or 4th Thursday of every month.Residents in electives at Sinai (check your schedule!)

Address:2611 W Chicago AveTime: 6:00 PM



General Medicine ConsultsShould be done by whoever is carrying pager 1555, For short call 7:30 until 11:00 a.m. unless they cap earlyLong call 11:00 a.m. until pager given to Night Float (9:00 p.m.).Attending list on consultation (as per current policy- MOX)Username: MSHPassword: policy



Continue Consults:All consults for medicine should be seen by whoever is carrying pager 1555, regardless of the patient condition and this resident decides whether the patient needs ICU, CCU or floor and get in touch with appropriate person (ICU or CCU resident on call)The exception for the above rule is that Family Practice and Dialysis unit will call MICU directly.Also the person carrying pager 1555 will be responsible for D/Cing Tele beds.If you want to place a surgical consult (regardless of the specialty), you can do that by paging the surgery consult team on pager 1456.



General communicationCheck your MOX often!Check your e-mail every day!Make sure that the CMR has your UPDATED/CURRENT e-mail!Check your mail box often, if possible every day!Check the web site for schedules



Patient care communicationCommunicate with your nurse every stat order, any overnight events.Label your chart at any time you admit new patient or change the service of a patient, and put it back in its right place.Communicate with your senior any events for your patientsCommunicate with CMR any problem with your intern, senior, patients attending, nurses, teaching attending, or any house staff membersCommunicate with the primary care attending everyday especially on Sat. for any change in the status of your patient health (ICU, Death, Tests, Consults, Procedures, Admission, Discharge, Transfer)



Tips for better communication and conflict resolution:(By Dr Tilahun)Always communicate face to face whenever the opportunity arises.Be direct in communication, but respectful of differences.Learn to negotiate.Be agreeable and positive.Appeal to shared values.Delay a decision if consensus is not possible.Involve all stakeholders in the decision making process, if possible.Acknowledge that there legitimate firm differences in opinion Do not let the disagreement overwhelm the real goal of the discussion.



DictationClearance form: by the end of the rotation you must submit the clearance form from the medical records signed by the manager and cosigned by the chief residents and submitted to Trina.No pending dictations are to be left at the end of the rotation (strictly monitored).

MSI team must dictate their patients and the seniors should make sure they are doing so. If there is a transfer of patients care either from ICU or at the end of the rotation from the previous month intern, You will dictate all the patients who were under your care for at least 2 days and if less than 2 days will be done by the previous intern.



Sign off patientsSMR(Team decision)Relabel chartSign off orderReflect in note

DiscussWithCMREndorse patient to non-teaching serviceNotify the floorNurse ManagerDiscussWithAttendingagreedisagreedisagreeagree



Violent and abusive patientsIf you think your patient is abusive, or harassing you whether verbally or physically, get out of the room immediately , and call the security and activate code green and report to CMR, Nurse manager on that floor immediately Get a witness if you canSigning off that patient will be consideredThe hospital official policy regarding this matter is now in progress



Dealing with an Angry person(by Dr Tilahun)Never lose your cool.Keep your distance and do not touch.Do not comment on the other persons anger.If possible, speak first-you will set the tone for communication.Listen to the outburst without interrupting.Empathize by paraphrasing the others concerns.Control the dialog by asking thoughtful questions.Conclude with assurance that something will be done.



New admissionAll the orders must be written within the first 30 min of patient being on the floor.All the primary attendings should be informed as soon as possible by the interns at all times day or night. Follow attending preference of contact during night time (page Vs. phone)Full H&P must be written in the first 24hrs.If the patient was admitted within one month of the current admission, you might copy the previous H&P and add addendum and full dictation is required at the time of discharge.



24 hrs. observationIf you think a patient could be observation, ask the attending to change the admission status upon admission, ONLY the attending is authorized to make this decision.

Stable patients under Subspecialty services (could be admitted from ER, direct admission or for chemotherapy and after or before a procedure as Renal biopsy & Cardiac cath & Liver biopsy)

If during working hrs; All admission issues, follow up and discharge orders will be done by that subspecialty service.

After working hrs; 24hr observation patient needs a brief H&P only with no dictation at discharge, and does not count as an admission

Cross coverage after hrs for emergency situation will be carried out by floor coverage on call and should be communicated to the subspecialty next day.

Document any coverage in the chart, as this is very important.



Bounce backPatients transferred to the ICU will return to the original intern upon transfer back to the floor. Night float will sign out the patient the same morning.Short call will not take a patient if the team is in the hospital and it is before 2:30 p.m. Long call team will take any patients admitted after 2:30 p.m. and sign out to the original team the next day morning.Patients discharged home and getting re-admitted are bounce back if the PGY-1 is still in the rotation. MSI team= goes by senior.



Sign out to surgery serviceAll patients admitted by the team will be followed by the admitting team every day (except on Sundays and bounce backs). Patients transferred to SICU or surgical service may be signed out to surgical service/ attending after discussing with the CMR and the attending and with a sign out note and order.



JeopardyYou should be available 24 hrs via pager while you are in jeopardy.

It is a pay back call (exceptions as decided by SMR)

If you are in Jeopardy and CANNOT take call, be aware that you are also calling Jeopardy yourself, so you will also owe a call to the 2nd or third person called.

You may cover the CCU, ICU or the floor, as in case of the unit resident being pulled for CC-ER orientation or in case of in-service exam, or urgent leave.

If you are going to be absent for any reason you need to notify the CMR ASAP.

No exams are allowed to be scheduled while on inpatient rotations.



Patients admitted with fractures(conflicts)Simple fractures which need orthopedic surgery in a patient without other medical problems under medicine attending will not be admitted to medicine, but might need medicine consult Fractures which need surgery in a patient with multiple medical problems will be admitted by medicine if the patient is under medicine attending, and to be followed by orthopedicsPreoperative consults are to be done on the same day of admission



ER BoardingIf a pt is admitted from the ER and accepted to ICU or the floor, and there is no bed, he should be seen and followed by the moonlighter.

Medicine resident will not follow or write orders as long as they are in the ER



Days offRule of 4 days every rotation (1/week) usually Sundays.If a weekday: Should not be on short call or long call or any switch day either junior or senior and CMR should be informed.Only one senior from the floor is allowed to be off on any particular day.A MOX should be sent to MED.ALL about the day off.CHANGE YOUR VOICE MAIL MESSAGE (even if it is only for one day)Notify the CMR (seniors day off), only after approval by CMR you are allowed to take the day off.Should not be more than one member of the team on the same day.If you are on call on Sun, you will be off on Sat, your senior will cover you and he will take one week day off.Exams should not be scheduled when you are on a floor or MICU rotation.No more than 2 weekdays off in one particular floor rotation.YOU MUST notify the CMR if you are planning to leave town on your days off while you are on a floor or ICU rotation, except for emergencies.



Leave requestsFor leave requests, you should fill out the special form; get the appropriate approval; remember to cancel your continuity clinic before you go on leave (must be one month in advance or ASAP)



MSI team and studentsMust not call for any surgical consultNo week days off if they are on call on SaturdaysIf one MSI is missing their long call cap will be 10 as usual and their short call will be 8Be sure to fill their blue evaluation form for any MSI or any students on your service before the end of your rotationMSI must sign out their patients at 4:00 pm like any other intern as well as attend the sign in round at 7:30 am for any cross coverage issuesAny problem, please contact Dr. KumarAll orders, consent etc must be cosigned by a senior.Make sure that they dictate their patients at the time of dischargeDo not forget to feed them, remind them to move their cars at 4:00 pm to the regular parking lot when they are on call



ICU callsWeek days: Call starts at 4:00 pm till 7:00 AM.

Week ends: Call starts at 7:30am till 7:30am of the following day.

ICU/CCU team must be in the ICU no later than 7:00 AM and relieve the on call team for the residents sign in at 7:30 a.m.



ICU senior dutiesSenior: See all the consults promptly, and admit after the intern caps at 5 pt. Help presenting and writing notes during the weekends if the ICU intern has more than 8 pts to cover and to present during roundsLeads the code in the ICU, and provide help during codes on the floor.ER consult should be seen within 30 min of the consult placement, and if you are busy please communicate with the ED physician and explain the reason for the delay.Inform the ER staff about your decision and recommendations.To admit patient to ICU initiate contact with the charge nurse in the ICU so a bed can be made. Communicate with ER regarding lack of bed/staffing issuesPerform focused HPI and PE and call the fellow/attending with the information that would be useful in the decision to admit /not to admit to ICUAn ICU attending need to be called for all major events like death, unexpected worsening of patients condition or if there is a disagreement between the resident and the fellow.



ICU junior dutiesJunior admits up to 5 pt with the senior while on call

Call the primary attending for new admission, transfer in and out the unit, or any dramatic events for their patients

Present patients and write notes: up to 8 during the weekend coverage (if you x-cover your co-intern)

Will accompany the patients to xrays, procedures etc if the patient is critically ill, who is on 2 pressors, requires high peep and high fio2, or if the nurse requests it



ICU conferences and clinic attendanceICU intern must attend the intern morning report on (Wed, and Thu) ICU and CCU residents attend optionally as long as it does not interfere with their work in the unit ICU Interns will go to their clinic if it is at Sinai. Please inform the clinic about the days that youre not able to attend.There must be one intern in the ICU all the time.



Post-ICU callHome early by 1:00 pm after the noon conference, this also applies to the ICU & CCU teams after assuring appropriate coverage ( i.e. the ICU resident can cover the post-call CCU resident and vice versa.)

Let your attending and your fellow know that you will leave early at least one day in advance

Make sure you sign out your patients to your attending or to the fellow before you leave



CODE BLUELeadership is the keyAvoid fighting, crowd-controlTeam leader: on the floors by the senior medical residents or whoever is carrying the pager 1555.Cover both medicine and family practice patientsAny abnormal behavior should be reportedMedicine territories are everywhere but Surgery and Ob-Gyn floors which include Cafeteria, Psychiatry ward, elevators, lobby and parking lot.No coverage for Schwab



Writing ordersClear, precise orders avoiding duplicate onesCorrect dose, routeTime your order with date and hr:minAppropriate stat order, flag chart red, and communicate with the nurse.Check the results of your orderBefore you sign out to check the results make sure your order is already thereIf you do not know a dose or how to write an order; check your pharmacopeia ask your senior, your attending or the pharmacy.



NotesAll notes should be stamped, or signed with your full name(legible), pager and dated. You must mention the name of the Attending whom you discussed the case with. Please use the signature stamps that you are provided.

All notes written by 3rd year students should have addendum and a co- signature.



Safety and hospital policyIf you wear scrubs , adhere to the appropriate policiesWear only Mount Sinai scrubsKeep your lab coat fully buttoned over green scrubsDo not leave the hospital or come from home wearing scrubsRefrain from eating, drinking in patient care areasPay attention to fire alarms and follow the safety procedures, assist patients and visitorsKnow the closed exit stairwell, fire alarm, fire extinguisher, and where the what IF boxes are locatedRemember the emergency procedure: R A C E, RESCUE, ALARM, CONTAIN, EXTINGUISHFollow Hand washing policyFollow up the isolation proceduresDo not disclose the key code to anyone or write it down on the wall


last modified on 7/1/03; subject to changelast modified on 7/1/03; subject to change

Mount Sinai Hospital Monthly In-Patient Orientation Update: November, 2003

Documents

morning clinics

satellite clinic

free clinic

pmcontinuity clinic

morning reportmran

scheduleethics rounds

sokolgrand rounds

teaching rounds