WELCOME TO NEUROLOGY CONSULT SERVICE! There are two inpatient neurology consult teams at BJH. Two teams allow the attending to round with the entire team, improving both patient management and teaching. Two teams allow attendings to see and staff more of the patients seen in the ED. You will be assigned to either the AM rounding or PM rounding team. When your team is not rounding, they will be seeing new consults. Please refer to the Attending and resident tabs on the Employee only part of the website for the most up-to-date versions of this document and of the attending and resident schedules, including the call schedule. ATTENDING AVAILABLILITY/CALL: The AM consult attending is expected to be available to round on patients in person from 7 am until 1 PM; the PM consult attending is expected to be available to round on patients in person from 1 to 7 PM. Please make sure that your preferred contact information and at least one alternate contact method is available on the He-She list and on the laminated cards. Email Carol Lane (lanec@neuro.wustl.edu) if you need to make changes in your contact information. CHANGE EFFECTIVE OCTOBER 2013: The AM attending should plan to meet with the PM senior resident in the morning to round on any urgent consults seen overnight. The best practice would be to meet with the PM senior resident and the night float resident at 7:00 AM so that the attending can hear about the overnight consults from the resident who saw them. Since the night float resident must leave the hospital by about 7:30 AM, if attendings find it necessary to meet with the PM senior resident later (preferably by 7:30 AM), they will round on the patients with the PM senior resident only. The PM senior resident will not have seen the patient or had a chance to review the consult. The PM consult resident will begin getting new consults by 8:30 or 9:00 am so staffing of urgent consults must be completed as quickly as possible. If desired, the night float resident can send a text or email to the attending before 7:00 am to let them know how many (if any) consults need to be urgently staffed. BOTTOM LINE FOR ATTENDINGS: AM consult attending: 7:00 am rounds with PM resident and night float resident on urgent consults seen overnight. 9-10:00 am- rounds with AM consult resident and team on patients seen the prior afternoon. May get calls in the PM on patients seen by your team. Alternates overnight call with PM consult attending. This is usually the lighter service from the attending perspective. PM consult attending: Rounds in the afternoon (usually starting 1:30 or 2:00 pm at discretion of chief resident, rounds start once all consults from AM are seen). May get calls in the AM on urgent questions/patients seen by your team. Alternates overnight call with AM consult attending. This is usually the busier service from the attending perspective. 1
ATTENDING AVAILABILITY: Consult attendings are expected to be available by phone/pager for questions and to staff patients who will be discharged at night or before rounds; these are usually patients seen in the ED who will be discharged home. All patients who will be discharged must either be seen by an attending in person or, when an attending is not on-site (e.g. at night), staffed with an attending by phone. Attendings typically take call every other night, with the AM attending taking call the first night of the rotation. For your reference, the call schedule for attendings is posted online in the Adult Neuro Schedules section of the Neurology residents area on the employee only portion of the departmental website. If you want to make changes in the call schedule, email Carol Lane (lanec@neuro.wustl.edu) and cc snider@neuro.wustl.edu so the changes can be made in the online schedule. Even though you are scheduled to round in the morning or afternoon (AM or PM consult attending), you may be called to staff ED patients throughout the day, for example when the other consult attending is busy rounding. It is always preferable for these patients to be staffed in person by the attending, but when your other responsibilities preclude seeing the patient in person staffing by telephone is an acceptable option. HOW THE CONSULT SERVICES WORK: Each of the two neurology consult service teams is led by a PGY3 neurology resident. They will carry the consult pager, triage new consults and assign a member of the consult team to see each consult and present the case to the attending and the rest of the team. The consult team includes one PGY2 neurology resident, and may include PGY1 neurology residents, PGY2-3 medicine residents, medical students (M3 and M4) or rotators from other services (e.g. neurosurgery and psychiatry). You will be assigned as either the am or pm consult attending on the attending schedule. The time designation denotes when you should block out your time so that you are available for staffing patients and for teaching rounds. You and the senior resident on your service can decide exactly when to start rounds each weekday. The am consult attending is expected to be available for rounds from 7 am to noon and the pm consult attending should be available for rounds from 1-7 pm. The am consult attending will round in the morning with the team called AM Rounds Consults on the residents schedule. If consults seen overnight require urgent staffing, the AM consult attending will staff these consults with the PM consult senior resident between 0700-0900. Flow of the day for the AM consults attending: 1. The night float resident can email (or call or text page if you prefer) the AM consult attending and the PM senior resident each morning at 5 or 530 am to let them know how many urgent consults there are that need to be staffed in the AM. 2. 0700-0900: If there are urgent consults to be staffed, you can either come in person (or call in) at 0700 to hear about the urgent consults directly from the night float or, if you cannot come in 2
at 0700, you will see urgent consults from overnight along with the PM senior resident starting at 730 or 0800; the PM resident will not be familiar with the patients so will only be able to provide a second hand presentation. The NF resident must be done by 0730 or 0800 latest in order to comply with ACGME duty hours. The PM senior resident will be getting tpa pages and urgent consults, so rounding on urgent patients should be completed as early as possible, best before 0900. The number of urgent consults will vary, usually between 0-3 or at most 4. 3. 0900 or later: AM rounding attending meets with AM team to round on patients seen the day before between 1 pm and 7 pm. All patients need to be staffed by noon. While you are rounding with your designated team, the team will not be receiving any new consults and will not be responsible for the tpa pager. The other team will be seeing new patients while you are rounding. You may be called by the other team to see urgent consults or consults that are likely to be sent home from the ED. 4. 1300-1900: You may be called to staff urgent consults in-person until 1 PM. You may be called to staff consults in the afternoon if the other attending is busy rounding; you can staff these on the phone if you are unable to staff them in person. The PM consult attending will round with the team called PM Rounds Consults on the residents schedule. Flow of the day for the PM consults attending: 1. 0700-1300: PM consult attending will only be called about consults if there is an urgent consult that the AM rounding attending is unable to see (e.g., busy rounding). 2. 1300-1900: The PM senior resident will let you know when to start rounds, usually 1-2 PM. Along with the residents and students on your team, you will see consults seen in the morning and nonurgent consults seen by the night float overnight. Urgent consults from overnight that were staffed by the AM rounding attending do not need to be staffed again that day with the PM rounding attending; the PM rounding team and attending will follow these patients if needed. While you are rounding, the consult team will not be receiving any new consults and will not be responsible for the tpa pager. 3. The other team will be seeing new patients while you are rounding. You may be called by the other team to see urgent consults or consults that are likely to be sent home from the ED. WEEKENDS: Each attending is expected to round on one day each weekend; attendings will usually round the same day as the PGY3 resident assigned to their team (ask the PGY3 or check the on-call schedule on the departmental website under neurology residents schedules). If attendings want to trade weekend days, they must notify both senior consult residents. Weekend rounds start at 0700 so that the night float resident can briefly present the patients to the attending. This provides muchneeded feedback/teaching for the night float. The night float resident may participate in bedside rounds on Saturday am as they are on duty until noon. The night float is off duty starting at 7 am Sunday am so on Sunday will only briefly present new patients. 3
ED CONSULTS: You may be seeing more patients in the ED rather than after they have been admitted and moved to an inpatient room. There are two issues you should be aware of: 1. CHARTING IN THE ED: The ED uses an EMR system, HMED, for charting. When you see patients in the ED, you will need to login to HMED yourself, make any edits, and sign the note under your login in HMED. You will get an email with your login information or you can contact the BJH help desk for this information (email is_csc@bjc.org (note underscore between is_csc, or call 362-4700). The residents can show you how to use HMED. If the patient has already been transferred the floor and HMED is no longer available, you should write a note on a separate piece of progress note paper, making sure to reference the ED consult note. DO NOT print the resident s HMED note and sign the hard copy; this WILL NOT BE SCANNED into the record so no signed note will exist. 2. Staffing ED patients who may be sent home. The NF resident and consult teams sometimes see patients in the ED who may be sent home before they can be seen by an attending. The residents may call you to see or phone staff such patients. Please see these patients in person if possible. If you are the am attending and are available in the afternoon, your team may ask you to see these patients. The am team residents may ask the pm attending to staff some of these patients at some time during the afternoon. As noted above, you may be called to staff these patients by telephone throughout the day as well as overnight. Your flexibility here is appreciated. Brain death consults. The neurology consultation service is often asked to assess prognosis after cardiac arrest or other significant brain injuries; some of these consults are called in as brain death consults. These consults should be seen by the consult service residents. The vast majority of these cases will be staffed by you as the consult attending. In those cases where the senior consult resident determines that the patient is likely to meet criteria for brain death, they will ask the NNICU consultation team attending to perform the brain death examination. If they have questions as to whether a specific consult meets brain death criteria, they will first discuss with you, the consult attending. Prior to contacting the NNICU team, the consult residents should confirm that confounding conditions are excluded (see brain death policy on the website- link below, most common ones include hypothermia <36 degrees C, systolic BP < 100, severe metabolic disturbance, presence of sedating drugs) and that brainstem reflexes are absent. The NNICU consultation team will perform the brain death examination, including apnea test if indicated. Residents are encouraged to join the NNICU team for the brain death examination if their other duties permit. This change will insure that staffing for brain death examinations is done by faculty who have experience in brain death determination and are familiar with BJH brain death policies. FYI, you can find the brain death policy on the resident s part of the website under the Policies and Procedures link. http://neuro.wustl.edu/employee-info/neurologyresidents/policiesandprocedures/ EVALUATIONS: The residents and medical students appreciate feedback throughout the rotation on how they are doing and how they can be better physicians. If you have concerns about a resident s 4
performance or abilities, please let them know immediately so they can work to improve. Please let Dr. Snider or Van Stavern know as well. Please let Dr. Naismith know if you have concerns about a medical student. At the end of your attending block, you will be asked to complete a written evaluation of the neurology residents on your team, as well as the medical students and medicine residents. You may be asked to evaluate the night float resident as well. You should provide oral feedback to the residents and students individually at the end of the rotation. Written evaluations for neurology residents are done in New Innovations, an online tool. Carol Lane can provide more information on that system. As of July 1, 2013, we have changed to a Milestones based evaluation tool. Your feedback on the evaluation tool is much appreciated. Comments are greatly appreciated, especially ones that provide constructive suggestions for improvement. You will get email notification of evaluations for Medicine residents and links to their online evaluation tool-see below for more on evaluations of medicine rotators. You will receive medical student evaluation forms from Lorraine Edrington. MEDICINE ROTATORS: Medicine rotators will spend 3 weeks on the consult service and one week on in outpatient neurology clinics. You and the senior resident on the service will evaluate them. Toward the end of their time with you, please make sure to observe them doing a brief neurology history and exam. They should be able to do a basic neurological history and exam on patients with complaints of weakness, tremor, paresis, syncope, dizziness or vertigo, changes in sensation, stupor and coma, headaches or changes in vision. This can take the form of a presentation and demonstration of exam findings during rounds. Please remind the residents to take the exam online toward the end of the rotation. We will ask them to email their exam score to the medicine residency coordinator. A final note on medicine residents- they should let the attending and senior consult resident know in advance if they will be absent from the consult service in order to do fellowship interviews or have clinics. They should not be taking time off to trade coverage with other residents or to moonlight. They should not take more than 3 days off during a 4 week rotation (policy per Medicine Program Director). If you have concerns about this, please let me know and I will communicate these concerns to the Medicine PD. How do I figure out what residents I am working with? The He-She list is mailed out monthly and has information on what residents are on each service, as well as pager numbers for all residents. Alternatively, you can check the resident schedules on the secure part of the Neurology website. Go the Neurology residents section of the secure site, click on resident schedules, then check the PGY3 schedule for which resident is assigned to your consult team. Or, you can check the Consults PM rounds calendar and/or Consults AM Rounds calendars to see which residents are on each service, and what weekend day the PGY3 is on call. 5