Orientation to the Wards

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Orientation to the Wards

• Teri Lynch, MD
• Meredith Mowitz, MD

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Welcome!

• Quick overview of the wards,
• You probably wont remember ANY of this
• But it will be good to look back over before you
  start on the wards

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Where am I supposed to be?
Resident Parking Lot
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Where am I supposed to be?

• 4th Floor
• 4400
• Orange Workroom (4437)
• Conference Room (4433)
• 4500
• Green Workroom (4507)
• Blue Workroom (4530)
• Chief Offices
• Dr. Novaks Office

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So I found my way, now what?

• Before 7am Sign-out
• Until 8am Pre-Round
• 8-830am Morning Report
• 830-12 Rounds
• Noon Conference
• 1-3pm Work, work, work
• 3pm Sign-out

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Morning Sign-Out

• In Workroom or Conference Room
• Sign out from night float about over night events
  and new admissions
• New admissions before midnight Tuesday-Friday and
  all new admission from weekend on Monday are the
  responsibility of the intern to see and write a
  note.
• After midnight admissions Tuesday-Friday will be
  seen by the Senior Resident

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Pre-Rounds

• Gather information about your patients, see your
  patients and write notes.
• Update the family and remind them about family
  centered rounds (general patients).
• Update your senior about any possible discharges
  for the day and prepare their discharge paperwork.

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How do you know that? Where to find the info you
need

• Paper chart (Blue Back)
• Daily progress notes
• Information from outside hospitals (in the back)
• Daily orders
• Written consults (consult section or progress
  note section)

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How do you know that? Where to find the info you
need

• Bedside Chart
• Printed MAR nurses record what time meds were
  given

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How do you know that? Where to find the info you
need

• Computer/ Net Access
• Electronic flow sheets for floor patients
• MAR Not always up to date
• Lab/ Study results
• Dictated HP, discharge summaries consults
• Radiologic studies Stentor

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Morning Report

• Daily from 8-830 am
• Interesting and educational case presentation
  given by a senior resident

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Grand Rounds

• Friday 8-9am in Communicore C1-4

Follow a Friend!!
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Rounds

• General Family Centered Rounds
• Sub-specialties Each has their own set aside
  time to round with the team, usually sit down
  rounds
• Green Team Attending dependent, mostly sit down
  rounds.
• Radiology Each team has a set time to meet in
  radiology to review studies
• List should be faxed to radiology every morning
  of studies to be reviewed (include study type,
  patient name and MRN) - usually the job of the
  medical students

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The Teams
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The Team Players
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Family Centered Rounds
Patient
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Family Centered Rounds(Responsibilities)

• Intern (Taking Care of Patient)
• Remind parents during pre-rounds that the entire
  team will be entering the room later in the
  morning.
• Every morning the team completes family centered
  rounds, we feel that you and your child are the
  center of the team therefore we would like to
  discuss our care in front of you. This is a
  chance to meet the entire team, discuss your
  childs care and answer questions. As a group we
  will come see your child this morning around ___
  am. Does this sound ok to you?
• During rounds, introduce all of the people
  present in the room.
• As we talked about earlier this is the team
  taking care of your child. (Introduce all members
  of the team and the family) We are going to give
  a short presentation about your child, please
  feel free to interrupt or correct the
  information. At the end we will be sure to
  summarize and translate the information so that
  you understand. We will only be here a short
  time but will try to answer all of your questions
  or Dr. _________ will come back at a later time.
• Supplement the medical students presentation and
  add to or reaffirm the plan
• Provide teaching points when applicable

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Family Centered Rounds(Responsibilities)

• Medical Student (Taking Care of Patient)
• Present the patient without interruption, if
  possible
• Other Medical Student(s)
• Write orders on the chart
• Intern (Not taking care of patient)
• Review bedside MAR
• Write discharge criteria on white board
• Sr. Resident
• Translate for the family (laymans terms) and
  summarize the plan
• Ask for questions from the patient and/or family
• Provide teaching points when applicable
• Attending
• Provide additional information and provide
  teaching points when applicable.

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Family Centered Rounds(Responsibilities)

• Family/Patient
• Provide clarification and supplemental
  information.
• Ask for clarifications of plan, if needed.
• Nurses/Social workers/Case Managers/Other
  healthcare professionals
• Provide clarifications and supplemental
  information.

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Lunch-time!

• Noon conference
• Subspecialty conference Mondays Fridays
• Core lecture- Tuesdays, Wednesdays Thursdays
• Journal Club
• Core Conference
• Primary Care
• Bench to Bedside
• QI Projects
• Jeopardy
• Mock Code Review
• Intern Lecture Series
• Given by 3rd year residents
• Monday and Friday 1230 to 1pm

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Afternoon/Nightfloat Checkout

• Usually occurs 3-4 pm and 6-7pm
• Transfer of information from one team to another
• Should include
• Brief description of patient and their current
  problems
• Pending labs/studies AND what to do with the
  results
• ie transfuse if Hctlt30 when results of CBC
  available
• Pertinent changes in pt status/disease course
  since the other resident has cared for the
  patient
• Plans for possible changes in patient status
• ie may be able to wean NC O2 if respiratory
  status improves

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Call

• Short call 3pm-6pm
• Check out from at 3pm to find out what needs to
  be done/ monitored during the evening overnight
• Will check out patients to the night float team
• Responsible for cross-cover admissions during
  this time

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Call

• Overnight call
• Only on Friday and Saturday on the wards
• Responsible for all admissions cross-cover

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Call

• Take a nap if you can, but remember you are there
  to take care of the patients

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Night Float

• Monday night to Friday morning
• 6pm to 8am
• Continuity clinic is moved to Friday mornings
  with less patients
• Saturday OFF!!!
• Sunday
• Sunday morning to Monday morning

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Cross-Cover Responsibilities

• Admissions-
• HP, Admission orders, Add to the list
• Trouble-shooting issues with current patients
• Change in patient status
• Abnormal test results
• Orders for pain, anti-pyretic, and/or other meds
• Make your senior resident aware of any major
  changes
• Always write a cross-cover note if you have been
  called to the bedside to see a patient or if
  there is a change in the patients status
• Remember that you always have back-up if you have
  questions about what to do

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The Paperwork
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Admissions and Discharge
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Tag Youre IT

• Who is responsible for admissions?
• 8am-4pm Day Team
• 4pm-6pm Short Call
• 6pm-8am Night Float
• Senior resident admits new patients between 6-8am
  to allow for interns to check out

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Admission Notification
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Discharges

• Goal Improve timely discharges
• Communication
• Discharge criteria presented as part of rounds
  daily and written on the daily progress note
• Interns should notify their Senior resident prior
  to rounds in the morning of potential discharges
• Review discharge criteria with family daily and
  inform them when discharge is imminent
• Notify case manager of any home supplies that may
  be needed ASAP and write order in chart that
  teaching be done with the family.
• Orders
• Write anticipate discharge on _____ by 10am on
  the day prior to discharge either during morning
  rounds or in the afternoon prior to check-out
• Paperwork
• Keep up with it and it will be much easier and
  quicker for you on the day of discharge
• Prescriptions
• Write prescriptions the day prior to discharge if
  possible and give to the family or put in the
  chart and alert the nurse so that they can be
  filled prior to discharge

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Discharge Notification
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Discharges
All charts should be with the team during rounds
to ensure orders can be written in a timely
fashion. Use these sheets when you take charts
off the floor.
When using this be sure to time orders for the
time you drop them off not when you write
them. For example an order that is written at
9am and placed in the rack at 10am should be
timed 10am.
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Transfers to and from the PICU

• Transfer orders
• Similar to admission orders ADC VAN DIMALS
• Medications can be printed and signed
• Transfer summary
• Brief but thorough description of HPI and
  hospital course
• Be sure to include why the patient needs an
  elevation in care/or stable for floor
• Abnormal labs or pending labs that impact patient
  care

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Medications and Dosing

• Harriet Lane
• Has pediatric dosing for most of the medications
  that you will use
• Also contains info on how the meds are supplied
• Clinical Pharmacology on the Shands portal
• Contains both adult and pediatric dosing
• Info on how to adjust for renal or liver
  impairment
• Wider selection of medications than Harriet Lane
• PICU Guide/Intern Survival Guide
• Your friendly pharmacist
• Assist in redosing medications when peaks/troughs
  are abnormal
• May be able to provide info on alternative drug
  regimens
• Remember to write weight-based dosing
  (mg/kg/dose) and patients weight on every
  medication you prescribe
• i.e. Wt 10kg Acetaminophen 150 mg PO Q 4
  hours PRN fever (15mg/kg/dose)

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Progress Notes

• Pre-printed progress note templates
• Should be completed in time for rounds
• Can be amended on rounds
• Plan for general patient should be problem based

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Progress Notes
You write here
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Progress Notes
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Progress Notes
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Progress Notes
Changes made on rounds go here
What needs to happen so they can go home
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General Expectations

• Know your patients, take responsibility
• Admit your patients write the orders, think of
  the differential, come up with a plan
• Update the list with changes, results, etc
• But Ask for help if you need it
• Be on time and be prepared
• Examine patient, check vitals, labs and MARs
  prior to rounds
• Timely orders and dictations
• Orders should be written as soon as possible so
  that care is not delayed
• Admission HP should be dictated at the time of
  admission
• Discharge summaries should be dictated within 48
  hours of discharge
• Leave on time
• Work efficiently, if everything is not done dont
  be afraid to sign things out, as long as you have
  tried your best its okay.
• Help teach the medical students