Welcome to Orientation!
Wards Rounding Consults Pagers/ASCOM Labs/Phlebotomy Radiology Discharges Topics to be Covered
Inpatient Wards 5 Intern Ward Teams: Academic Team 1 Silver: Hospitalist + Kaiser Hospitalist (UMD Rotating Resident) Red: Hospitalist Academic Team 2 Orange: Hospitalist + Genetics/Metabolic (Walter Reed Resident) Purple: Hospitalist
General Inpatient Ward Schedule 6:00 AM: Arrive for sign out in team room 6:00 8:00 AM: Pre-round (see all patients and write notes) 7:30 8:00 AM (T/Th): Morning Report (MECC), Mock Code (3 rd Thursday) 8:00 8:30 AM: Teaching organized by senior resident and attending 8:00 9:00 AM (W): Grand Rounds (2 nd floor Auditorium) 8:30 10:00 AM: Family centered rounds 10:00 12:00 PM: Patient care (orders, consults, discharges) 12:00 1:00 PM: Noon conference (MECC) 1:00 5:00 PM: Patient care (if continuity clinic, sign out before conference) 5:00 PM: Sign out to night intern
Family Centered Rounds Inpatient Ward Rounds Led by senior resident (PL3) and attending Round with charge nurse, bedside nurse, family, patient, +/- dietician Nursing Summary (I-5): I know what is wrong, I know what to do, I know what to worry about, I know when to escalate, I see what you see Progress Notes Should be completed prior to rounds (includes editing medical student notes) Update notes on or immediately after rounds
Academic Team 1 (AT1) Silver: Hospitalist + Kaiser Hospitalist 1 Hospitalist Attending 1 Kaiser Attending 1 Senior Resident (PL 3) 1 Intern + 1 UMD Family Med Intern Patient Caps: Float: 10 if CNMC Intern only 14 if MS4 or Family Medicine Resident present QI Curriculum Shadow Admitting Hospitalist Red: Hospitalist 1 Hospitalist Attending 1 Senior Resident (PL 3) 1 Intern Patient Caps: 10 if CNMC Intern only 14 if MS4 present Float: QI Curriculum Shadow Admitting Hospitalist
Academic Team 2 (AT2) Orange: Hospitalist + Metabolic 1 Hospitalist Attending 1 Senior Resident (PL 3) 1 Intern + 1 WR Intern Patient Caps: 10 if CNMC Intern only 14 if MS4 present Float: Shadow Nursing Genetics Clinic Purple: Hospitalist 1 Hospitalist Attending 1 Senior Resident (PL 3) 1 Intern Patient Caps: 10 if CNMC Intern only 14 if MS4 present Float: Shadow Nursing Genetics Clinic
Patient Care Keep a to do list on paper or computer during rounds Help each other put in orders while rounding (except AT1 and AT2) After rounds: Enter all orders (especially STAT orders) Sign TPN in BAXA (deadline 1 PM) Call ALL consults prior to noon conference Prioritize discharges and expedite when possible!
Hospital Summaries: Discharges Start them early and never leave non-updated if patient may be discharged by another team member Summary should be clear and concise (intended for pediatrician) Read and edit all medical student hospital summaries Copy forward and re-name Discharge Summary when ready Follow Up: Create list with team senior after rounds and notify team scheduler Follow up plan may be different on subspecialty service Someone on team should notify pediatrician prior to discharge
High Risk Cognitive Work Tasks that may require additional help: Med Order: Morphine, Dilaudid, Clonazepam, Baclofen, Insulin, Anti-Epileptic Drug, Insulin Potassium IV bolus IVIG, Albumin, Blood Products TPN EKG Reading Ordering Metabolic Formulas Transitioning enteral meds to IV Ordering a Sedated MRI or LP
Consults Page all consults as early as possible (things get very busy after noon) If you don t know why you are calling a consult, ask your senior/attending! How should I page? Search for consultant on on-call list (located on Intranet) Leave a brief message: Good: Abreo,x7185, consult re: John Doe, room 724, likely Kawasaki Poor: x7185 Fail: p57185 What makes a good consult? To Access On Call Know your patient and your question Schedule Use them for education: why do they want a specific study or intervention? Find who you want to consult and click on hyperlink
ASCOM/CISCO/iPhone ASCOM = in house phone system (transitioning to iphone) CISCO = PICU, NICU, Code Team iphone = all nurses (dial 602-XXXX to speak with nurse) ASCOM s are role-specific, not individual specific like pagers GI Intern 2, Neuro Res 1, PICU Fellow
Paging CNMC Individual Pager: 202-259-XXXX (individual pager number) Role Based Pager: 5-XXXX (ASCOM extension) Page through: Intranet Amion Phone (as above) Batteries located in chief s office To Access Paging System
Role Based/Virtual To Login to Paging Pager Links an individual s pager to a specific role using a virtual pager number When you arrive to EVERY inpatient shift: User ID: virtual pager number (5+ASCOM number) Password: same as User ID Why do we do this? Prevents nursing from paging individual residents who may have signed out All admission orders should reflect correct ASCOM and virtual pager each day To Re-Assign Pager To Access Paging System Enter Individual To Re-Assign Pager Pager Then Click Change
Phlebotomy/Lab Lab Collect: Phlebotomy will draw at 0600, 1300, 1800 Orders must be entered by 0400 (0600), 1100 (1300), 1600 (1800) How to order? Clinician to collect NO, Collected NO Time Drug Monitoring (TDM) Collection (Vancomycin, FK level, Aminoglycoside) Order as TDM Lab Collect Monday through Friday 0800 to 2000 Saturday and Sunday 1000 to 1800 STAT Phlebotomy and IV Crisis available if needed (ask nurse to page) If no Phlebotomy available, make the attempt and use resources (seniors)!
STAT Orders If you place any STAT order: Please verbally notify the bedside nurse as soon as possible STAT orders must be acted on quickly Bedside nurse may not be near computer to verify orders
Radiology Plain Film (X-ray) May be done in Radiology Department or Portable (on the floor, limited view) If ordered STAT -> call Radiology, completed within 10 minutes If ordered Next Available -> completed within 30 minutes CT Faster/easier to obtain than MRI but more radiation MRI Limited availability and may require sedation (see Intranet protocol) Ultrasound Improved availability during weekday, weekends, and overnight
Opportunities for Hand Hygiene What We Measure? Before patient contact After patient contact After environmental contact
The Patient Zone: Sub-Area within a Patient Room/Bay Reference: World Health Organization Training Slides
The Patient Zone: Sub-Area within a Patient Room/Bay INCLUDED in Patient Zone: Patient Bed Linens Bed Rails TV Remote/Keyboard given to patient to use Call Buttons Equipment connected to the patient (eg. Dialysis, EEG, Monitors, Infusion pump) Over-the-Bed Table Nurse Server/Smart Cart EXCLUDED from Patient Zone: Staff Phone Desktop Computer Computer on Wheels Door Knobs of Entry Door Healthcare worker area (i.e. sink, counter, cabinets, etc) Bathroom in Patient Room
Hand Hygiene and Workflow You must wash your hands: When entering and exiting the patient zone From a contaminated body site to a clean body site while in the patient zone When re-entering the patient zone after touching an item outside of the zone (i.e. staff computer, phone, door knob, nurse server, computer on wheels, etc.) When leaving the patient room after touching anything inside or outside of the patient zone In Patient Zone: No need to wash your hands between included items and the patient once in the zone
Scenario 1 Physician opens the door to a patient room, enters the room and goes to the patient bed, a clinical assessment is conducted and then the physician leaves the patient room (the door is open). a. Wash before entering the patient room b. Wash after touching the door handle but before conducting the clinical assessment c. Wash after leaving the patient room April 21, 2016
Scenario 2 Environmental services staff member finishes up cleaning a patient room, leaves the room and moves to the next room and starts cleaning the new patient room a. They do not need to wash between patient rooms b. Wash between the two patient rooms *EVS can go between the patient room and their cart without washing hands. April 21, 2016