Download Chairman`s Welcome - Department of Medicine, Case Western

Chairman’s Welcome
To our interns: Our residency training program is the keystone for the
educational mission of the Department of Medicine. It is top priority. Here,
medical students, specialty fellows and faculty interact with housestaff in a
stimulating learning environment that centers on high-quality compassionate
patient care. Tailored programs prepare our residents for careers that include
leadership roles in academic medicine, physician scientists, practicing
generalists or specialists. The balanced and diverse admixture of career goals
among our housestaff catalyzes an intellectual atmosphere which is second to
none. Defined inpatient workloads and innovative ambulatory programs exist
against a backdrop of a medical school and department which are in the top
10 for biomedical research in NIH funding in a world-class hospital system.
We believe that the physical resources of our University Hospitals Case
Medical Center and the adjacent Veterans Affairs Medical Center are
unparalleled. Our faculty is justifiably proud of their initiatives in medical
education in general and housestaff training in particular. These ingredients
make our program one of the best. It gives me pleasure, on behalf of our
faculty, to welcome you to our program and to participate in your professional
development.
Richard A. Walsh, M.D.
John H. Hord Professor
Chairman of Medicine
Case Western Reserve University
Director, Department of Medicine
University Hospitals Case Medical
Center
1
Program Director’s Foreword
The Faculty in the Department of Medicine wishes to make your internship
year a productive, stimulating, and rich in educational experiences. In an
effort to focus your learning, our faculty has identified major learning
objectives for many of our rotations. They are enclosed in this booklet. We
recognize that this year will be busy and that you will have limited time to
study. It is my hope that these objectives will help you use your study-time
efficiently.
There are other important items in the booklet pertaining to the evaluation
and feedback. We hope that you find this material useful. Do not hesitate to
ask, if you have questions or concerns.
Keith B. Armitage, MD
Vice Chair for Education
Residency Program Director
Professor of Medicine
2
TABLE OF CONTENTS
Housestaff Information
Block Schedules ...................................................................................................... 4
Residency Calendar ................................................................................................ 5
Miscellaeous Information ...................................................................................... 6
Department of Medicine Conferences ................................................................ 7
Elective Time
Report Form ........................................................................................................... 10
Policies
Uncovered Patients .............................................................................................. 12
Duty Hours / Workload......................................................................................... 13
Order Writing......................................................................................................... 15
Patient Care Responsibilities ............................................................................. 16
Moonlighting .......................................................................................................... 19
Attending – Housestaff Interactions ................................................................. 19
Dress Code .............................................................................................................. 21
Conference Attendance ....................................................................................... 26
Definition of Internal Medicine and Goals of Training Program ............... 27
Tips for the VA ............................................................................................ 29
Tips for UHCMC ......................................................................................... 50
Service Excellence Standards .................................................................. 88
Library Access Issues ................................................................................. 91
ACGME and Competencies ........................................................................ 92
3
Academic Calendar 2013 – 2014
Block 0
6/24-6/30
Block 1
7/1 – 7/30
Block 1A
Block 1B
Block 2
7/31 – 8/27
Block 2A
Block 2B
7/31 – 8/13
8/14 – 8/27
Block 3
8/28 – 9/24
Block 3A
Block 3B
8/28 – 9/10
9/11- 9/24
Block 4
9/25 – 10/22
Block 4A
Block 4B
9/25 – 10/8
10/9 – 10/22
Block 5
10/23 – 11/19
Block 5A
Block 5B
10/23 – 11/5
11/6 – 11/19
Block 6
11/20 – 12/17
Block 6A
Block 6B
11/20 – 12/3
12/4 – 12/17
Block 7
12/18 – 1/14/14
Block 7A
Block 7B
12/18 – 12/28
12/39-1/14/2014
Block 8
1/15 -2/11
Block 8A
Block 8B
1/15 – 1/28
1/29 – 2/11
Block 9
2/12 – 3/11
Block 9A
Block 9B
2/12 – 2/25
2/26 – 3/11
Block 10
3/12 – 4/8
Block 10A
Block 10B
3/12 – 3/25
3/26 – 4/8
Block 11
4/9 – 5/6
Block 11A
Block 11B
4/9 – 4/22
4/23– 5/6
Block 12
5/7 – 6/3
Block 12A
Block 12B
5/7 – 5/20
5/21– 6/3
Block 13
6/4 – 6/30
Block 13A
Block 13B
6/4 – 6/17
6/18 – 6/30
4
7/1-7/16
7/17-7/31
Annual Residency Calendar
July
USMLE Step III (generally advised to take before end of PGY2 year)
August
Fellowship interviews (Aug-Oct)
September
Grand Rounds begins weekly
Agre Society begins monthly
October
Holiday Schedule Planning
Intraining Exam
Senior Grand Rounds begin
November
Holiday Days off
Recruitment Begins- Noon Lunches@ UHCMC and Dinners
December
Recruitment continues- Noon Lunches@ UHCMC and Dinners
Fellowship Match Occurs
January
Recruitment continues- Noon Lunches@ UHCMC and Dinners
February
Morale Week
March
IM Match Results
April
Future Chief Resident Conference
May
Housestaff Dinner Spring Dinner
Department of Medicine Research Day
Bronson Day
June
Future PGY 3 and PGY 2 Retreat
Spring Picnic
New Intern Orientation
ERAS Fellowship Application process opens
1 week vacation before beginning PGY 2 for outgoing Interns (last week of June)
5
Miscellaneous Information
Xerox machine available at UHCMC across from the Carpenter roomLakeside 3108
Instructions for the pager system:
Get dial tone
Dial “222”
Wait for long beep, enter 5 digit pager numbers
Wait for a series of beeps, then enter your number, followed by the # sign
(most residents and faculty “tag” their pagers by then entering the “*” key
which adds a space, then enter their own pager number
Wait for short beeps, and then hang up.
If you make a mistake in the number you enter you can hit “*” three times
and start over (this is a little known pearl!)
From outside the hospital including the VA: 216-207-7244; then follow the
above directions.
Swipe cards are given to each house officer annually to be used for meals at
UHCMC. It is given in a lump sum according to the number of call nights for
the academic year. It is refilled January 1st of each year and funds on the
card will be lost if not used by December 31st of each year. At the VA, food
will be available when on call.
Resident mailboxes are located at UHCMC outside the Carpenter Room,
Lakeside 3108.
Please check regularly and keep them uncluttered
6
Conferences
Department of Medicine Conferences
All of the conferences listed below offer Continuing Medical Education (CME)
credit unless otherwise noted. CME credit is available without charge to
physicians who attend any of our conferences.
Morbidity and Mortality ( M & M) Conference
The M & M conference is held weekly at noon on Fridays in the Kulas
Auditorium on the 5th floor of Lakeside. The Chief Medical Resident selects
one or two cases for the presentation. Following the case presentation by the
housestaff, the Chairman moderates the discussion around the issues of
disease prevention, differential diagnosis, and management. This conference
is often lively and interactive; comments and discussion from physician
participants are welcome and encouraged.
Grand Rounds
Grand Rounds are held weekly at 12-1pm on Tuesday in the Kulas
Auditorium on the 5th floor of Lakeside from practitioners of Internal
Medicine. Generally one topic is presented during the hour, with a 45minute
presentation and 10-15 minutes for questions. We simulcast to UHHS
affiliated hospitals
Infectious Disease Case Conference
Tuesday afternoon from 4-5:30pm in Lerner Tower Room 2060
Infectious Disease Fellows Didactic Lecture
Foley 306
Monday Noon -1pm.
Infectious Disease Fellows Journal Club
Foley 306
Thursday, Noon-1pm
Rheumatology Grand Rounds
Thursday morning 8-9am on the second floor of the Foley Building room 216
(excluding July and August)
Pulmonary/Critical Care Grand Rounds
Friday morning 8-9am in the RB&C Amphitheater.
Pulmonary Case Conference
Thursday at 7:30-8:30 am VA Medical Center, Rockefeller Gardens
Conference Room
7
CARES Towers, Room 1F 160
Multi professional Critical Care Lecture Series
Wednesday, Wearn 6th floor Conference Room 618
Sleep Medicine Grand Rounds
Tuesday 8-9am Wearn 6th floor Conference Room 618
Pulmonary Research Conference
Monday, Noon-1pm Cardiovascular Institute, Mather 1735
Topic in Nephrology
Tuesday afternoons May-September 5-6pm in Humphrey Conference room
2628
Endocrine Grand Rounds
Wednesday afternoons October-May 4-5pm in The Carpenter Room, Lakeside
3108
Cardiovascular Medicine Grand Rounds
Thursday 12 noon-1:00pm September-June in The Wolstein Reasearch
Building, Room 1413. September-June
Cardiovascular Clinical Case Conference
Wednesday morning 7:30-8:30am Lakeside 3108. August - June
Cardiovascular Medicine- Cath Conference
Tuesday 5:30pm Lakeside 3108. August-June
Cardiovascular Medicine Fellows Core Lectures
Tuesday and Thursday 7-8am Lakeside 3068. August-June
Cardiovascular Medicine EP Conference
Monday and Friday 8-9am Lakeside 3068. August-June
Cardiovascular Medicine Echo Conference
Monday, 12:30-1:30pm Lerner Tower 2060. August-June
Topics in Geriatrics
Friday mornings 8-9am in Room K119 at the VAMC
GI Division Med-Surg Conference
Tuesday 4:40-5:30pm September-June in the RB&C Amphitheater
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Frontiers in Gastroenterology
1st and 3rd Thursday 4:40-5:30pm in the Frohring Auditorium (BRB 105)
Hematology Conference
Monday 1-2pm in the Wolstein Research Building Room 2136
Hematology/Oncology Division Research Conference
Wednesday 8-9am in the Radiology Oncology Conference Room (Lerner
Tower B-151)
Hematology/Oncology Fellows Conference
Friday 8-9am July-June in the Wearn Conference Room 137
Hematology/Oncology Morphology Conference- (alternates every other
week)
Friday 2-3pm Pathology Building Room B-20 and
Friday 1-2pm Wolstein Research Building Room 2136
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MEMORANDUM
TO:
Medicine Interns and Residents
FROM:
Keith B. Armitage, M.D.
SUBJECT:
Elective Time
DATE:
In order to receive credit by the ABIM, we must be able to verify where/how you
spend your elective time. You are asked to submit your written intentions via email
to Barbara Bonfiglio for elective by the Monday of the ½ block prior to
commencement of the elective. Failure to do so will result in an individual meeting
with your designated Program Director.
We need to receive this sheet completed PRIOR TO YOUR ELECTIVE.
If you would like to do an elective at another institution, you need to discuss this
with me initially, and upon my approval Deena Segal needs to be notified BEFORE
committing to the elective. Additional paperwork needs to be completed besides this
form, and the elective needs to be approved by both institutions BEFORE the
elective begins.
Please complete the information below and return it either in electronic form or hard
copy to Barbara Bonfiglio.
Name _________________________________________________________________
Month _________________________________________
Elective/Site _________________________________________________________
Attending _____________________________________________________________
What you would like to achieve during this time:
________________________________________________________________________
10
RESIDENT ELECTIVE MONTH ROTATION: GOALS AND
EXPECTATIONS
DEPARTMENT OF MEDICINE
UNIVERSITY HOSPITALS CASE MEDICAL CENTER
VETERANS AFFAIRS MEDICAL CENTER
GOALS:
Throughout your residency, you may take electives to acquire and enhance
the knowledge and skills necessary to become a competent scientist and or
practitioner of internal medicine.
EXPECTATIONS:
In order to meet this goal, you are expected to attend and actively participate
in all scheduled conference, lectures, specialty, urgent care, and grand rounds
during your rotation. In addition, you are to identify a preceptor/mentor with
whom you will work during the month and who will be required to evaluate
the extent to which you achieved your educational objectives for the month.
The program director, associate program director and chief residents can help
you to identify a mentor.
ATTENDANCE:
Attendance at electives is mandatory. Residents on electives should have
their pagers on from 8:00am to 5:00pm. Residents on jeopardy must have
their pagers on 24 hours/day. Residents on elective are allowed to use this
time for job or fellowship interviews but must notify a Chief Resident in
advance when they will be out of town.
EVALUATIONS:
Your evaluation will be sent to you and your preceptor/mentor by
MyEvaluations.com at the end of your elective month.
There are no reading elective for Interns.
11
Case Western Reserve University
Internal Medicine Residency Program
Policy on Uncovered Patients
Revised 5/27/09
1. The on call senior resident ("NACR/DACR") is responsible for
responding to emergency calls (ie Code Blue/Code White) on all
uncovered medical patients, including Bone Marrow Transplant,
Hanna House 4, RBC 7/CF patients. All non-urgent calls should go to
the primary physician or service.
2. No resident should do routine work (such as drawing blood, filling out
requisitions) on any uncovered patients.
3. The Chief Medical Resident will decide which patients will be
transferred from the uncovered to the covered medical service should
the primary physician request it.
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Case Western Reserve University
Internal Medicine Residency Program
Policy on Duty Hours and Work Load for Interns and Residents
Revised 6/06/11
1. Interns on all services are limited to 3 admissions per long call day, 2
per medium call and 2 for short call day.
2. Residents on all services are limited to ten new patients and two
transfers per long call day.
3. Interns on all services may not have more than 10 patients under their
care at one time.
4. Short and medium call admissions will be limited based on the number
of patients carried by an intern. There will be no short call admissions
on the intern’s clinic day.
5. Interns with an excessive number of complex patients may have their
patient load reduced at the discretion of the Chief Medical Resident.
Residents are encouraged to notify the Chief Resident if the patient
load on a team is suboptimal for education or patient care.
6. Residents must not be responsible for the ongoing care of more than 22
patients.
7. Admissions will be limited if the intern or resident feel that the work
load might compromise the 80-hour rule.
8. All residents must comply with the ACGME duty hour rules including
working a maximum of 80 hours a week, 24 + 4 hours for residents, 810 hours between duty periods and 1 day off in 7 averaged over a 4
week period. The maximum consecutive duty hours for interns are 16
hrs.
9. Any duty hour violation must be reported to the IM program director.
10. A detailed duty hours audit will be completed the 2nd week of each
bock, and all residents on ward and ICU rotations must complete the
audit. All residents must be aware of the ACGME duty hour
requirements.
11. ACGME Requirement: Duty hours are limited to 80 hours per week,
averaged over a 4-week period, inclusive of all in-house call activities,
including moonlighting.
If a resident suspects or anticipates they are in danger of exceeding
those limits for any reason, those concerns must be brought to the
attention of the Program Director.
12. ACGME Requirement: Residents are provided with 1 day in 7 free
from all educational and clinical responsibilities, averaged over a 4week period.
13
Residents’ schedules are designed such that all services allow for one
full weekend and at least 2 other weekend days off per month.
Residents must report to the Chief Residents if the schedule calls for
less than 1 in 7 days off on average. All schedules are created for 1 in 7,
and the potential for less than 1 in 7 would only occur when there are ½
blocks back to back with different days off schedules.
13. ACGME Requirement: Adequate time for rest and personal activities
is provided by an 8-10-hour time period provided between all daily
duty periods.
Daily schedules are created such that work hours regularly end at between 5
and 6 PM and start at 7:00 AM. In the instance of q4 call when the PGY2 or 3
resident hands off to night float; residents are allowed an 8-hour period as
long as it is not routine and the schedule is created for 10 hours, and time
between duty periods of less then 10 hours must be monitored by the program
director.
14
Case Western Reserve University
Internal Medicine Residency Program
Order Writing Policy
Department of Medicine Teaching Service
Revised 6/02/09
In accordance with ACGME policy, all orders on patients on the
teaching medical service should be written only by the house officers
(intern or resident) assigned to that patient or on night float or cross
coverage duty. Attending physicians may write orders on patients on the
teaching medical service under circumstances where the order will
significantly expedite patient care (e.g.; the intern and resident are at a
conference, the attending is seeing the patient and an order needs to be
written.) In these circumstances the intern or resident must be notified
that the attending is going to write an order or has just written an order.
The Chief Medical Resident will notify attendings that violate this policy
and Program Director and consistent violation will lead to termination of
admitting privileges to the Teaching service.
Orders may be written by medical clerks (third year medical
students) or acting interns (fourth year medical students) who are
assigned to a patient, but at all times must be co-signed by the intern or
resident assigned to that patient before they can be taken off.
15
Case Western Reserve University
Internal Medicine Residency Program
Patient Care Responsibilities on the Teaching Medical Service
University Hospital and Cleveland VA Medical Center
Revised 6/06/12
1. Interns
Interns have primary care responsibility for all patients assigned.
These responsibilities include performing a complete admission
history and physical and formulating a diagnostic and therapeutic
plan in conjunction with the senior resident and attending. The
admission history and physical must be in the patient’s chart
within 24 hours of admission. The intern is responsible for all dayto day management issues, which must be reflected in a daily
intern progress note [the note may be written by the resident or
the attending for post call and day off interns]. Copy and paste of a
patient note without daily editing is discouraged. All patients
assigned to the intern are to be examined by the intern every day.
Interns are responsible for discharge summaries on all nonprivate patients on the Teaching Service. Discharge summaries
on days off are to be done by the Resident. When working with 3rd
year medical students, all H&P’s by intern must be completed as
well as daily progress notes by interns.
2. Residents
Residents are responsible for all patients assigned to their service
and are responsible for supervising all patient care activities of the
interns. They are to perform a history and physical on all
admissions which take place while they are on duty and write a
brief resident admit note within 24 hours of the patient being
admitted. With the assistance of the attending physician, they are
responsible for aiding the intern in formulating a diagnostic and
therapeutic plan on all patients admitted. They are to make rounds
on all the patients assigned to them every day. When working
with AI’s, Residents should complete initial H&P with physical
exam; can sign daily progress notes with small addendums
3. Attendings
Attendings have ultimate responsibility for all patients assigned to
their service. All new admissions must be seen within 24 hours of
admission. The attending is responsible for co-signing the
admission note and the daily progress note of the intern. The
attending is to aid the resident and intern in developing a
diagnostic and therapeutic plan for patients assigned to their
16
service. The discharge summary of private patients assigned to the
teaching service will be dictated by the attending.
4. Procedures
An attending or resident who is credentialed in that specific
procedure must supervise procedures. Residents are considered
credentialed (and available to supervise) after documentation that
they have successfully completed the prescribed number of
supervised procedures (see procedure card or website for specific
number needed for each procedure.)
5. Acting Interns
For all acting interns, a resident must complete an initial H&P, in
addition to that completed by the acting intern. For daily progress
notes, residents may sign the acting intern’s progress note and
write a small addendum.
6. Third Year Medical Students
For all third year medical students, both H&Ps, as well as daily
progress notes, must be written by the ward intern in addition to
those notes written by the 3rd year medical student.
17
Moonlighting Policy
Revised 6/06/11
1. Moonlighting during Ward, ICU rotations is not allowed.
2. Moonlighting during other rotations at approved sites is allowed with
prior approval provided the moonlighting does not interfere with the
activity of the assigned elective. Current approved moonlighting sites
include Lakeside Housedoc and Flex at University Hospitals, and VA
Urgent Care.
3. The Program Director should be notified in advance about
moonlighting at non-approved sites.
4. Total duty hours of combined moonlighting and residency-training
activities must not exceed 80 hours per week.
5. Residents should report total weekly moonlighting hours to the
program director if the total moonlighting and resident duty time
exceeds 80 hours.
6. Residents who do not attend at least 60% of required conferences or
who score <30% on the in-training exam are not allowed to moonlight.
18
Guidelines for Attending/Housestaff Interactions
Admissions of patients to housestaff covered services at University Hospitals carries with
it important responsibilities for our Attending staff. In exchange for around the clock in
house care of their patients, Attendings should follow these guidelines:
1. Attending physicians should conduct themselves in compliance with the rules
of the Residency Review Committee (RRC) for Internal Medicine. The
written RRC Requirements for training states that:
“On inpatient rotations resident’s responsibilities must include development of diagnostic
strategies, planning and decision-making commensurate with resident’s abilities and with
appropriate supervision by the attending physician.”
2. The RRC requires that all orders on patients under the care of housestaff be
written by the housestaff; the RRC states that:
“Residents must write all orders for patients under their care, with appropriate
supervision by the attending physician. In those unusual circumstances when an
attending physician or subspecialty resident writes an order on a resident’s patient, the
attending or subspecialty resident should communicate his or her action to the resident in
a timely manner.”
With the rapid pace of patient care in the hospital it may not be possible to contact
the housestaff before an urgent order is written, communication about the order
should take place when possible.
3. Attending physicians should treat the housestaff as junior colleague. While all
final decisions on patient care rest with attending physicians, Attendings
should engage in discussions of patient care issues with housestaff, allowing
housestaff to voice their input. Attending physicians should engage and
interact with the housestaff in a teaching capacity.
4. Contentious interactions on the part of the housestaff or faculty should be
avoided and conflicts handled professionally.
5. Attending physicians and housestaff should mutually readily be available to
discuss patient care issues.
6. Attending physicians are expected to call housestaff at the time a patient is
admitted. The Senior admitting Resident (pager 30512 24 hrs a day, 365 days
a year) can be called to clarify housestaff assignmentsif needed. The
housestaff is expected to call Attendings after evaluating a new patient, and
whenever there is a significant change in patient’s status
7. Attending physicians who are unable to comply with the guidelines will be
referred to the Faculty-Housestaff Liaison Committee. Repeat non compliance
may result in the loss of housestaff teaching service admission privileges. All
decisions are subject to the approval of the Chairman of the Department of Medicine.
19
8. Nonteaching services that offer an equivalent level of coverage will be maintained.
These services will offer nurse practitioners to aide in the management of patients
during normal working hours and a house doctor to cover patients during evening and
nighttime house. Patients may be admitted to the non-teaching service when the
admission quotas of the housestaff teams (as defined by the RCC) have been met.
Under these circumstances specific requests for housestaff coverage should be
referred to the Senior Admitting resident or Chief Resident (pager 31250)
20
Case Western Reserve University
Internal Medicine Residency Program
Revised 6/6/11
Dress Code for Department of Medicine Residents
Patients have a right to feel comfortable with their health care providers. A
sensitive and compassionate doctor will recognize that appearance affects
how patients feel about him/her and the experience the patient has in the
hospital. We have avoided elaborate specific guidelines and expect common
sense to prevail. Our litmus test is the following: if you grandmother was in
the hospital, would she be comfortable with your appearance?
Simple guidelines:
1. Blue jeans and sweatpants should not be worn during patient care.
2. Scrubs are OK on long call days, in ICUs and on nightfloat rotations
only, but a white coat should be worn over scrubs when doing patient
care.
3. Appropriate professional attire should be worn on non-call
days.
All health care providers should have a name tag visible to patients.
21
CLINICAL RESEARCH STUDY
What to wear today? Effect of doctor’s
attire
on the trust and confidence of patients
Shakaib U. Rehman, MD,a,b Paul J. Nietert, PhD,b,c Dennis
W. Cope, MD,d,e
Anne Osborne Kilpatrick, DPAf
aRalph
H. Johnson Veterans Affairs Medical Center, Charleston, SC; bDepartment of
Medicine and cDepartment of
Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina,
Charleston, SC; dUniversity of
California at Los Angeles (UCLA) San Fernando Valley Program and eOlive View-UCLA
Medical Center, Sylmar, Calif;
fDepartment of Health Administration and Policy, Medical University of South Carolina,
Charleston, SC.
ABSTRACT
PURPOSE: There are very few studies about the impact of physicians’ attire on patients’ confidence
and
trust. The objective of this study was to determine whether the way a doctor dresses is an important
factor in the degree of trust and confidence among respondents.
METHODS: A cross-sectional descriptive study using survey methodology was conducted of patients
and
visitors in the waiting room of an internal medicine outpatient clinic. Respondents completed a written
survey after reviewing pictures of physicians in four different dress styles. Respondents were asked
questions
related to their preference for physician dress as well as their trust and willingness to discuss sensitive
issues.
RESULTS: Four hundred respondents with a mean age of 52.4 years were enrolled; 54% were men,
58%
were white, 38% were African-American, and 43% had greater than a high school diploma. On all
questions regarding physician dress style preferences, respondents significantly favored the
professional
attire with white coat (76.3%, P _.0001), followed by surgical scrubs (10.2%), business dress (8.8%),
and casual dress (4.7%). Their trust and confidence was significantly associated with their preference
for professional dress (P _.0001). Respondents also reported that they were significantly more willing
to share their social, sexual, and psychological problems with the physician who is professionally
dressed (P _.0001). The importance of physician’s appearance was ranked similarly between male and
female respondents (P _ .54); however, female physicians’ dress appeared to be significantly more
important to respondents than male physicians’ dress (P _.001).
CONCLUSION: Respondents overwhelmingly favor physicians in professional attire with a white coat.
Wearing professional dress (ie, a white coat with more formal attire) while providing patient care by
physicians may favorably influence trust and confidence-building in the medical encounter.
© 2005 Elsevier Inc. All rights reserved.
KEYWORDS:
Physician attire;
Physician dress;
Patient trust
The patient-physician relationship is the foundation for all
patient care. Research has demonstrated that a patient’s
initial consultation plays a vital role in the development of
this relationship.1 During this consultation, a patient will
develop a first impression of his or her physician2 based
22
upon the physician’s verbal and nonverbal communication,
as well as personal attributes like clothing, grooming, and
cleanliness. This article examines respondents’ preferences
to their physician’s attire, one component of this first impression.
Sociologists and psychologists have long recognized
the effect of one’s appearance on important life exThis work was supported in part by Department of Veterans Affairs
Research Services.
Requests for reprints should be addressed to Shakaib U. Rehman, MD,
Ralph H. Johnson Veterans Affairs Medical Center, Medical University of
South Carolina, 214 Historic Drive, Mount Pleasant, SC 29464.
E-mail address: [email protected].
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2005.04.026
The American Journal of Medicine (2005) 118, 1279-1286
periences such as interpersonal relationships and job-related
successes.3-6 In fact, the importance of physician dress on
the patient-physician relationship can be traced back to
Hippocrates, who stated that the physician “must be clean in
person, well dressed, and anointed with sweet-smelling unguents.
. .”7
Even in ancient societies, the way healers dressed played
an important part in rituals of healing.8 More recently, one
can find a variety of personal opinions about the dress and
appearance appropriate for physicians as reflected in editorials
and letters.9-27 Review of the existing literature about
physicians’ dress style revealed conflicting findings. Many
studies found that patients favored a more traditional dress
style for physicians, yet there are studies showing that
patients preferred physicians in a more casual outfit. In a
pioneer study in 1987, Dunn et al reported that 65% of 200
patients wanted their physicians to wear a white coat during
a consultation, and the majority believed that physicians
should wear formal dress.28 Many studies reported similar
outcomes and the traditional items of attire such as formal
dress, a name tag, and a white coat were suggested by
respondents as appropriate attire for physicians.6,29-35 In one
study, a majority preferred their doctor to wear a white coat,
be free of political badges, and for men to have conventional
length hair; however, most patients did not mind a male
doctor with an earring, a woman in trousers, or a man
without a tie.35 A study performed among teenage patients
actually measured patient attitudes after encounters with
physicians whose dress varied from “very informal” to
formal; the results were that dress style made no statistical
difference in patient attitudes toward their physician.36 In
other studies, most of the patients claimed that the attire of
the physician had no influence on their choice of family
physician37 or satisfaction.38 The two studies that assessed
the impact of dress in actual patient encounters found it to
be an insignificant factor overall.36,38 However, very few
studies have examined the impact of physician attire and
appearance on the confidence and trust in physicians by
patients. No studies have assessed the effect of physician
attire on patient adherence to prescribed regimens. In addition,
no studies have assessed patient preferences for physician
23
attire in an internal medicine outpatient setting. The
purpose of this study was to determine whether the way a
doctor dresses is significantly associated with patient selfreport
of their trust and confidence in physicians.
Methods
Subjects were administered a survey to assess the selfexpressed
degree of patient trust, confidence in physicians,
and adherence to prescribed regimens. The study used a
randomized cross-sectional design, which made use of survey
methodology. Before the administration of the surveys
to the study subjects, the survey’s reliability and validity
were tested. Two researchers familiar with instrument development
and clinical research assessed the questionnaire’s
content validity. After a slight revision, the questionnaire
was then administered to the clinical staff and nurses to
assess clarity and ease of use. Ten volunteers took the
survey and expressed that they did not have any trouble
understanding the survey questions and would not hesitate
to take the survey again if needed. The questionnaire was
administered to the same group again after a month to test
the reliability and consistency of answers. This pilot testing
produced a reliability of 90%. The study was approved by
the institutional review boards of the participating Veterans
Administration (VA) and the University.
After determining that the instrument was valid and
reliable, a convenience sample of patients and visitors in the
waiting room of internal medicine outpatient clinics at the
Ralph H. Johnson VA Medical Center participated during a
6-month period in 2003, from January through June. If a
patient was accompanied by one or more persons, only one
of them was selected to participate. We did not record
whether the subject was a patient of that clinic or an accompanying
visitor. However, because we wanted to ensure
that approximately half of the subjects were female, and
because most of the VA clinic patients are male, it is highly
conceivable that the majority (but not all) of the female
subjects were not clinic patients and that the majority (but
not all) of the male subjects were clinic patients. Subjects
who were demented, noncommunicative, or blind were excluded
from the study. Demographic information was collected
on each participant. Subjects completed the questionnaire
after reviewing pictures of physicians attired in a
variety of styles (Figure 1). Questions were asked about
their preference for physician attire within the context of
several scenarios as well as their trust and willingness to
discuss sensitive issues with their physician.
The prespecified sample size chosen for the study was
400 respondents to ensure high (_90%) statistical power to
detect significant differences across groups. Respondents
were randomized into 1 of the following 4 groups:
● Respondents who were shown the photographs of a
“white male doctor” dressed in 4 different styles as described
below (Figure 1a).
● Respondents who were shown the photographs of a
24
“white female doctor” dressed in 4 different styles as
described below (Figure 1b).
● Respondents who were shown the photographs of an
“African-American male doctor” dressed in 4 different
styles as described below (Figure 1c).
● Respondents who were shown the photographs of an
“African-American female doctor” dressed in 4 different
styles as described below (Figure 1d).
Each patient saw only one set of photographs, comprising
4 photographs of one of the above doctors (ie, the same
doctor) in each of following styles of dress:
● Business attire (suit with neck tie for male physician,
either tailored trouser or skirt for female physician)
1280 The American Journal of Medicine, Vol 118, No 11, November 2005
25
Case Western Reserve University
Internal Medicine Residency Program
Policy on Conference Attendance
Revised 5/27/09
1. Attendance at 60% of required conference is necessary for
successful completion of the training program.
2. Required conferences include Grand Rounds, M & Ms, Noon
Conference and Morning Report.
3. Attendance at Grand Rounds, M & M, Noon Conference and
Morning Report is expected during “Reading” Elective.
4. Failure to comply with the conference attendance policy may lead
to loss of elective time, moonlighting privileges or annual
Educational Allowance.
26
Definition of Internal Medicine and Goals of the Training Program
Definition of Internal Medicine:
“Internal medicine is the discipline encompassing the study and
practice of health promotion, disease prevention, diagnosis, and treatment
of men and women from adolescence to old age, during times of health and
through all stages of acute and chronic illness. Intrinsic to the discipline
are the application of the scientific methods of problem solving, decision
making, and an attitude of caring driven by humanistic and professional
values. The practice of internal medicine requires comprehensive
knowledge of human biology, behavior, and spirit; an understanding of the
epidemiology and pathophysiology of disease; and the mechanisms of
treatment. Internal medicine requires a mastery of clinical skills in
interviewing, physical examination, differential diagnosis, diagnostic
testing strategies, therapeutic techniques, counseling, and disease
prevention.”
Goals of the IM residency- at the end of 3 years of training:
1.
Residents demonstrate a broad understanding of medical problems in
adults and learn a rational approach to medical problems in adults.
2.
Residents understand the science behind the etiology and therapy of
common medical conditions that affect adults.
3.
Residents comprehend principles of efficient and cost-effective
practice, and system based practice.
4.
Residents demonstrate competence in the history and physical exam
of adults, and receive additional training as needed.
5.
Residents demonstrate professionalism and comprehend common
ethical and legal issues and the psychosocial aspects of the practice of
medicine.
6.
Residents recognize how to apply the evidence in the medical
literature to medial problems in adults.
7.
Residents learn to critically evaluate the medical literature.
27
8.
Residents formulate a research question and produce a plan for
carrying out research.
9.
Residents demonstrate the fundamentals of teaching internal
medicine.
10.
Residents will develop a basic understanding of patient safety and
quality and how it relates to core competencies.
28
Your First Day on VA wards
Here is some info to help you throughout this month:
1. Rounds. Rounds will be at 8:00AM in your work room. The Green and
Blue work rooms are on Ward 4B and the Orange and White work rooms
are on Ward 4A. Your patients will be located on Ward 4A, Ward 4B,
PCU (telemetry) or occasionally the 5th floor. Blue and Green are
considered 'sister services' because these teams are on call on alternate
days, and they cover each others patients when you are on call. Similarly,
Orange and White are sister services as well.
2. Call. There will be two interns on each ward team. Call will be as
follows: Long call, medium call, short call and then no call on 4
consecutive days. The cycle will then repeat. One intern will take long
call with the senior resident, while the other intern will be the ‘orphan’
and will be covered by a senior from the other on-call team.
Short call consists of two (2) admissions before noon with the following
exceptions:
a. If you have clinic on your short call day, you do not get
admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm
c. As a general rule, you cannot carry more than 8 patients at a
time at the VA. There are certain circumstances where an intern may
be asked to accept an additional patient or two however these
situations are rare.
d.Days Off: Days off will be your SHORT AND/OR HAPPY days
that fall on Saturday and Sunday. In one month, this will result in one
black weekend, one golden weekend, one Saturday and one Sunday off.
3. Signouts: The signout at the VA is still done by making a table on
Microsoft Word/Excel with Patient ID and info, summary statement and
active issues, allergies, medication list, code status, and to do list.
Signouts can be accessed on the “S” drive and then clicking on the folder
corresponding to your team. However, the VA CPRS system also contains
the “Shift Handoff Tool” which you can use to generate signouts. When
you signout at the end of the day, if your co-intern is on call, you should sign
out to him or her. Someone from each team should be present at the hospital
until at least 4:00pm.
4. An important rule of thumb at the VA is that nothing happens unless you
talk to someone about it. What this means is that if you order an imaging
study, you should call down to radiology (x4301) and confirm that they got
the order. If you order a urine sample for the floor to collect, you should
talk to the patient's nurse and make sure they know to collect it.
5. Phlebotomy and IVs. There are phlebotomy rounds 8 times a day and
daily IV therapy rounds. There is a physician supply room on each floor
29
that contains supplies for phlebotomy and IVs. After midnight, IV
therapy/Labs on Demand may be asked to draw urgent labs. Phlebotomy
and nurses occasionally will draw stat labs if they are asked nicely during
the day. As a rule, use “Labs on Demand” for labs that you need outside of
the normal phlebotomy rounding times. After you place a “Labs on
Demand” order you should call down to the lab to verify they can perform
the lab draw.
6. Consults. If you need to call a consult, page the consulting fellow. Some
services (ie Psychiatry) may ask that you enter a consult in the computer
as well. You should try to call all consults before noon, if possible. The
consulting service will then see the patient that day and give final
recommendations within 24 hours. You can get a list of the consulting
services for each month from the Chief Resident office.
7. On-call Meals. There is a refrigerator and cabinets in the 2nd floor lounge
(by the VA Cardiology team room in the PCU) stocked weekly with food
for the on-call residents. There is also a second refrigerator there to store
food if you want to bring meals from home.
8. Social Work.
Blue/Green: Social worker is Stephanie (pager 440-562-0589) and
discharge planner is Sue (x6714, pager 440-562-0702).
Orange/White: Social Worker is Sarah (x4238, pager 440-562-0631)
and the Discharge Planner is Lucie (x6713 pager 440-562-0678).
Please include them in your discharge planning as they can be of a lot of
assistance in SNF placements. The discharge planners will often round
with the post call teams each morning. If you have a renal (dialysis)
patient, then you need to work with Denise Green (phone x4248,pager
440-562-0315). If you have a oncology patient, your social worker will be
Miranda Payton (x4258, pager 440-562-1491.) If you have a patient being
placed on hospice, you need to contact Beth McIver (x3277, pager 440-5621749)
10. Discharge Planning. Before a patient can be discharged the following five
items need to be addressed:
1. Discharge medications need to be put in the computer
(preferably 24 hours in advance). After you correct the outpatient
meds (or inpatient meds if patient is going to SNF), you complete
an “Anticipated Discharge Note” that is reviewed by the ward
pharmacist for completeness and accuracy. They will addend you
note (and tag you as a cosigner so that it pops up in your alerts)
with any discrepancies. This way, you can correct the meds before
writing the discharge instructions. An effort should be made to
complete the Anticipated Discharge note 24 hours prior to
discharge.
2. Travel arrangements need to be made. If requesting
transportation through Travel services you need to enter a Travel
Consult. Talk to your social worker about whether a patient will
qualify for travel. Currently, even if the patient was brought to the
VA by an ambulance they may not necessarily qualify for
30
transportation home. .
3. Complete “Discharge instructions” in computer. Be sure you
make any necessary follow-up appointments. You can do this through the
discharge instructions template.
4. Discharge summary done and in the computer on day of
discharge
5. Discharge Order (under Admissions/Discharge/Transfer order
set, as well as included in the discharge isntructions)
11. Radiology After Hours (evenings and weekends).
a. If you need a stat portable X-ray, you should enter it in the
computer and then call x4301. If no one answers, have the operator page
'X-ray' overhead to call your extension.
b. If you need a CT scan done after hours you have to call the
operator. They will page the radiology technician who will call back to
your extension. Explain to the technician the urgency of the test and they
will then come in to perform the test. The films will then be sent over to
UH and you can page 32494 to speak to the radiology resident on-call at
UH to read the CT scan.
c. If you need an MRI or other specialized radiological test after
hours, you must transfer the patient to UH. You must call UH transfer
center to arrange this. Then, you must place a Non-VA Special procedure
in CPRS.
12. Expiring Orders. Certain medication orders will expire on a timed basis.
You must renew them periodically otherwise they will not be given.
These medications are:
a. IV fluids, IV drips, TPN - 1 day
b. Nebulizer solutions, IV ranitidine, class II narcotics - 3 days
c. Coumadin, lovenox, inhalers, antibiotics - 7 days
d. Class III through Class V narcotic drugs - 14 days
13. Consents. All consents for procedures and blood transfusions are to be
completed electronically on CPRS. Each team has a portable laptop that is
equipped with an electronic signature pad. You can access the consent
program in CPRS under “tools”, then IMED consent. You can enter in
“phone consent” into IMED as well.
14. DNR orders. You can enter a DNR order that is good for the first 24
hours. After that, a new order must be written by the attending. There
are two types of DNR orders:
a. DNR comfort care (DNRCC): this order is active as soon as it is
written and the focus of this is order is to ease pain and suffering. There
are no resuscitative efforts taken to initiate or sustain life
b. DNR comfort care –arrest (DNRCCA): this order is not activated
until patient experiences an arrest. The goal is to provide all indicated
treatment until the patient experiences an arrest.
Note: You have to fill out both a DNR order set from the order menu AND
a DNR progress note. The DNR progress note must be cosigned by the
attending in the morning.
c. It is good practice to clarify with patients who want to be
31
DNRCCA if they would want elective intubation. If not, you should add
“DNI (do not intubate”) in the comment section of the DNRCCA order.
15. Phones: To reach an outside local line, just dial ‘9’ and then the number.
To call UH, dial ‘86’ and then the extension.
16. Pagers: VA pagers generally are 440-562-xxxx. Simply dial this number,
when you hear a beep, enter your callback number and press ‘#” when
done. To page a UH pager, dial 9-207-7244
17. Codes: Codes at the VA are called ‘Dr. Heart.’ They are announced
overhead as well as sent to the code pagers. It is expected that all on-call
interns should go to codes and help out in whatever way they can.
18. ICU Transfer: ICU Transfers are coordinated between the ward
intern/resident and the ICU resident/fellow. Transfer notes must be
written on all patient transfers to and from the ICU
19. Conferences: There are conferences every weekday at the VA, the
schedule is:
Day
Monday
Conference Noon
Conf.
Tuesday
Grand
Rounds
Wednesday
Morbidity
& Mortality
Conf
K119
Location
Thursday
Noon
Conference
Friday
Noon
Conference
K119/4th K119
K119/4th
K119/4th
Med
floor med
floor med
conf
conf room
conf. room.
room
K119 Auditorium is on the first floor, past the cafeteria, the rec hall and
the library.
In addition, on Thursday there is also intern morning report at 10:00AM in
the Department of Medicine conference room
Your seniors are always available to help. The only stupid question is
the one you did not ask.
WARD 4A & 4B HELPFUL HINTS: TIPS FOR THE VA
 DISCHARGE PLANNING: An anticipated discharge note should be
completed by the intern 24 hours prior to discharge and includes
medication reconciliation. This note will be reviewed by the ward
pharmacist for completeness and accuracy and will be forwarded back
to the discharging intern.
o Discharge orders MUST be written in CPRS before the
discharge process can begin.
o Check to see if the patient needs a Pneumovax or Flu Vaccine
prior to discharge.
32
o Communicate with the discharge planner as soon as a decision
has been made concerning a patient’s discharge.
o Discharge planners can assist with travel, supplies, follow- up
appointments, home care and IV antibiotics. Order prescriptions
on the computer with pharmacy at least ONE DAY BEFORE
discharge.
 A Medicine anticipated discharge note should be included
in the chart for review by a discharge pharmacist.
 Make sure that the Medical Record Discharge
Instructions agree with ordered Rxs.
o Once it is known that the patient will need travel at discharge
complete TRAVEL REQUEST in CPRS. Travel restricted to
patients who qualify and/or transfer to CARES. If in questions,
call the Travel office.
 Note if the patient has special needs, ie wheelchair or
oxygen.
 Travel is generally restricted to non-ambulatory,
wheelchair bound, and ambulance patients
o Allow 3-5 days for delivery of necessary prosthetic (durable
medical supplies). You may order as an electronic consult to W
Prosthetics.
o IV antibiotics/hyperalimentation must be ordered thru
consultation to HBPC/Community Primary Care. Allow a
minimum of 48hrs to obtain from pharmacy. An ID consult must
accompany home IV antibiotics.
o Notify the VNA coordinator 24 hours in advance for needed
VNA, HBPC, or Hospice Care. Fill-out appropriate referral
form, ie Nursing Care Referral Form
o Must complete the discharge summary and discharge
instructions in lay terms prior to the patient’s discharge.
o CARES TOWER TRANSFERS
 Charts must be coded prior to the patient’s transfer so
please notify the Discharge Planner and CARES Intake
about CARES transfers one-day prior to discharge.
 Physician to Physician report must be called to the
provider at CARES on the morning of the transfer
 Notify the patient’s nurse about the transfer as soon as
possible so that she can make arrangements for transfer.
 PPD status must be determined prior to transfer to
CARES or any community nursing home.
 STANDARD ORDER RENEWALS
o
o
o
o
IVFs - 24hrs
Narcotics - 72hrs
Respiratory treatments - 72hrs
Oxygen – 72hrs
33
o
o
o
o
o
o
o
IV zantac - 72hrs
Oral anticoagulants - 7 days
Restraints (soft wrist and posey) - 24 hours, and this must be done on the special
order form.
Fluid orders with potassium – 3 days
IV heparin – 24hrs
SQ heparin – 7 days
TPN & PPN – 24hrs, before noon
 MANDATORY LINE CHANGES
o
o
o
o
o
Peripheral – 4 days
Femoral (central venous catheter) – 4 days or change to another site sooner (highest
infection rate with this site so avoid continuous infusion)
Arterial Line – 3 days
Central Lines – No time limitation but site must be inspected daily and may be
changed over a wire if no infection is present. (Generally, changed every 5-7 days)
If a line is left in longer that the above policy then a note must be written daily. (ie
line site clean, no other evidence of infection; will leave line in place and monitor.)
Remove all lines that are not needed
 BLOOD DRAWS AND COLLECTION TIMES
o
o
o
o
o
o
o
o
0600 collection with cutoff time of 0500
0900 collection with cutoff time of 0830
1100 collection with cutoff time of 1030
1300 collection with cutoff time of 1230
1430 collection with cutoff time of 1400
1700 collection with cutoff time of 1600
1900 collection with cutoff time of 1830
2100 collection with cutoff time of 2030
INFORMED CONSENT

Patients must sign informed consent forms prior to receiving:

Blood products

Or undergoing thoracentesis, paracentesis, lumbar punctures,
central venous catheter placement, and arterial line placement.
* As a general rule, anytime skin barrier is compromised.

The witness may be anyone not on the team. Nursing staff may co-sign as a witness on a
permit; however, they must be present for your discussion with the patient.

All consent form must be completed via I-MED consent. Include a procedure note in CPRS.

Include the name of the procedure and its indication, as well as the patient’s attending and the
name of the residents performing the procedure.

Consent remains viable for thirty days.

The patient must initial and sign the consent as well.. If you can’t obtain a signature due to an
emergency then a comprehensive progress note must be written.

The order of surrogates: durable power of attorney for health care, legal guardian, next of kin
(wife, adult child, sibling, close friend  contact social worker)

Consent in emergency cases may be obtained from the chief of staff if no surrogate is
available. The administration or social services will assist in locating the patient’s surrogate.
34

A procedure note should accompany all situations requiring informed consent, and it should
include comments related to the patient’s competency and discussion with the
patient/surrogate about indication, risks, benefits, and alternatives to the procedure.

BLOOD PRODUCTS: Consent should be signed prior to the administration of blood products
except in emergencies. One consent form is good for all blood products needed in a 30-day
period.
SOCIAL WORK
 The firm’s social worker will attend morning rounds with the ward
team that is post-call.
 Nursing Home Care Unit (NHCU) @ CARES TOWERS
o
o
o
Place a consult to B NHCU
Administrative coordinator for the NHCU is Helen Ferrer, B# 388-1284
Requirements for transfer: PPD placement required; discharge summary
completed; discharge order placed with time specified; travel request sent; doctor-todoctor report and RN-to-RN report called.

CLERK and patient’s RN must be notified of discharge in advance.
 COMMUNITY
NURSING
HOME
PLACEMENT
REQUIREMENTS: private pay, medicare, and Medicaid forms per
social work instructions.
 Transfer back to the same facility:
o
o
NHCU  contact Ms Ferrer, and complete doctor-to-doctor verbal report, discharge
summary, discharge orders, and travel request
COMMUNITY NH and OHIO VETERANS HOME  NH form, discharge order, and
travel request complete. NH transfers must occur within 14 days or the patient’s bed
will be lost.
DOCUMENTATION
 HISTORY & PHYSICAL
o Use the Admission Boiler Plate (admission BP)
 Must complete each field in order to sign the admission
BP. If the patient presents with Chest pain, use the Chest
pain BP.
 Medical student H&P may not be used or cosigned as the
official H&P
 Advance Directives must be addressed in the admission
H&P. See DNR.
 Reference to discharge planning must occur in the plan of
the admission note (DISCHARGE PLANNING SHOULD
BEGIN ON ADMISSION)
o A complete physical exam should include documentation of
breast, pelvic, genitourinary, skin and lymph node exam.
o Addressing social issues, ie living situation, nursing home
resident, drives or takes a van, guardian, etc, will assist with
discharge planning.
 PROGRESS NOTE
35
o
o
o
o
o
o
Avoid the CUT & PASTE phenomenon, or in other words update your notes
Co-sign and/or place an addendum to all medical student notes. There is no need to
write a separate note.
Acknowledge consultants, abnormal labs, radiology, and therapeutic responses
Daily, unless the patient is on intermediate care then it can be every other day.
Document anything that is taught to the patient and/or their caregiver, and their
responses.
Refer to discussions with attendings (Seen and discussed with Dr …)
 ORDERS
o Co-sign all medical student/AI orders and verbal orders ASAP.
OTHER IMPORTANT TIPS










Notify the nurse caring for the patient immediately after writing a “NOW” or “STAT” order.
DNR orders must be co-signed by the patient’s primary attending in order for them to be valid.
Paper Charts that are not being used should be returned to the nursing station.
Nurses do not perform guaiac tests or electrocardiograms and they do not titrate oxygen.
Non-PCU nurses will only perform ECG’s in emergent situations (e.g. pt with active chest
pain)
Verbal orders cannot be accepted except in emergency situations.
Allergy assessments need to be entered on all patients.
Labs on Demand: any lab that is STAT; peak and trough levels; blood cultures; ABGs
CONSULTS: Place requests in CPRS except for those consults you personally phone to a
provider to have a patient seen on the ward, ie general surgery, cardiology, etc
IV Therapy to assist with IV placement from overnight 7 days a week; you can make
requests by paging B# 388-0599, however the nursing staff and ward clerks generally do the
paging. If the IV nurse is unavailable other options include nursing supervisor, ICU nurse, or
a resident.
Escort Services: to assist with lab specimen, blood bank requisition, and stat lab specimen
pick-up 24hrs a day, 7 days a week; also, to assist with patient transport; for assistance call
ext 5095 from 0800-1630 or page 388-0647 // 388-1018 from 1630-0800
AFTER HOURS EMERGENCY RADIOLOGY
 CT scan, Angiography, and MRI
o
o
o
o
o
Call the VA operator for the number of the radiologist on call
It the patient is to be transferred outside the VA, then complete the “request for non-VA
services,” and the Chief of Radiology, Dr Naheedy, must sign this on the next working day.

Patients with IVs will need a minimum of a paramedic attendant and
unstable patients may require ground ICU transport.
The radiologist on-at UH will read the film if the team does not feel comfortable
interpreting the film.
If consent is needed for a procedure and the patient is unable to consent then discuss the
procedure with the surrogate and have that individual stay near the phone to provide
consent.
If considering an MRI then determine if the patient has any metallic prosthesis or
internal shrapnel prior to scheduling the procedure.
 Nuclear Medicine attendings should be called if a nuclear procedure is
required after hours. The attending comes into the hospital to
interpret the study after it is completed.
36
INFECTION CONTROL
 BLOOD/BODY FLUID EXPOSURE (needle stick, splash, etc)
 Wash affected area and notify supervisor
 Report to personnel Health during administrative hours
and at all other times report to the Acute Treatment
Room
 Prophylaxis for high-risk needle stick injury should begin
ASAP (within fifteen minutes). Patient HIV counseling is
done by an AIDS team member
 Avoid bending, breaking, and recapping needles. If
recapping is required use the one-hand technique
 Follow Infection Waste Management guidelines. Use red
bags, sharp containers, etc, appropriately.
 The following are available through Personnel Health: Hepatitis B
vaccine and antibody testing, PPD testing, Flu vaccine, Varicella titers,
and Varicella vaccine
 BLOOD CULTURES: Draw two sets of peripheral blood cultures or
one set from a central line and one set peripherally when obtaining the
initial set of blood cultures from a patient. Place 7-10cc of blood in
each bottle and do not cover bar code with label.
 INFECTION CONTROL NURSE: Liza Eckstein, RN
B# 648-2139
ext 4791
 PERSONNEL HEALTH: Dan Tinman, MD ext 4445
ADVANCE DIRECTIVES/DNR
 DNR orders must be co-signed by the attending physician in order to
be valid.
o Use pre-printed order form and progress note to document DNR.
o These orders must be reviewed when a patient has a change in
their medical status, on admission or discharge from an ICU and
every 30 days. In addition, they must be rewritten on transfer.
o Limitations must be specified in the orders.
o In order to preserve the right of the patient to choose among
treatment options, DNR orders will not automatically be
cancelled when a patient goes to the OR.
o The attending physician or resident must document the
discussion, as it relates to DNR, with the patient and/or
surrogate in the chart.
37
o Ohio portable DNR should be on the chart during transfers
 Use advance directives to clarify end of life care, except DNR.
o They must be reviewed at every hospital admission, per patient
request, change in mental status, admission to ICU, and
annually in long term care patients and outpatients.
o These discussions should be documented in the admission note
or progress note, acknowledging the Advanced Directives and
clarifying any care limitations.
o If a patient desires to make an Advanced Directive or designate
a durable power of attorney for health care (DPAHC) then call
social services or a chaplain.
o A member of the medical team cannot witness the form.
 END OF LIFE DISCUSSION
o Include the following in the discussion with the patient:
diagnosis, prognosis, treatment options, comfort care, and
hospice care.
o PALLIATIVE CARE
 Write specific comfort care orders, ie oxygen, suctioning,
analgesia, and sedation
 May refer to the palliative care team (Beth McGyver) for:
terminal illness comfort care and patient/family emotional
distress.
o ORGAN DONATION can be discussed/addressed when asking
about advanced directives
 Contacts: Coroner  721-5610 & LifeBanc  752-5433
DICTATION FORMATS
USE THE DISCHARGE SUMMARY BP WHEN TYPING DISCHARGE
SUMMARIES ON CPRS.
DICATATE EVERY ADMISSION REGARDLESS OF THE PATIENT’S
LENGTH OF STAY
OXYGEN THERAPY
 Obtain a pulse oximetry or ABG prior to and within 6hrs of initiating
oxygen
 Reason for oxygen must be documented either in progress notes or
with the order
38
 Order to be renewed every 3 days
 Consult Wendy Dukes for home oxygen therapy
o Patient must have pulse oximetry < 88% or PaO2 < 55 on room
air and this must be documented in the patient’s record.
o Values must be obtained within one-week of discharge
SHORT STAY UNIT (extension 5714)






Located on Ward 52
Nurse manager  Marion Yowler (B# 388-0699)
Social Work coordinator is by service, ie medicine, renal, palliative care, HIV, etc
Patients may only be admitted to ward 52 and stay for 23 hours. If the patient’s length of stay
increases then he or she must be admitted to the medical service on ward 42 or 44.
All charting to be completed on the short stay tri-fold, including the discharge summary.
Barbara Adams (ATR and ward 3A) and Margaret Harris (ward 3B), from quality
management and utilization review, can assist with questions regarding patients that may be
appropriate for the short stay unit.

Examples of appropriate admissions include: pain control, blood transfusion, periprocedure (thoracentesis, paracentesis, PEG tube placement, lung or liver biopsy),
and other diagnosis or symptoms requiring a brief observation period.
HOPTEL
This is a service rendered to Veterans and families of hospitalized veterans who live greater than 60
miles from Wade Park so that they have a place to stay in Cleveland while undergoing treatment. The
VA currently contracts with a local hotel until such time that the hoptel facilities at Wade Park are
renovated. Arrangements can be made for Family members by contacting Carla Reed at ex 5700.
There is a 2 business day turn around time for hoptel requests. If an urgent request is required, please
call Carla Reed at ex 5714
ICU TRANSFERS
Resident- Resident report is critical and performed between the PGY2/3 ICU
resident and floor resident at the time of transfer.
Unless the ICU is full and a bed needs to be made available. Urgent floor to
ICU transfers are always available.
39
Your First Day on VA Nightfloat
Here are a few tips to help you out:
There will be one nightfloat intern and one nightfloat resident comprising
this service.
Your nightfloat coverage begins at 7:00 p.m. when you take signout from
the medium call interns in the Blue team room in Ward 4B.
The signout session between the medium call/long call intern and the
nightfloat intern will be facilitated by the upper level night float resident
or NACR at the beginning of the year.
Between 9-11PM, the on-call interns will be signing out their own
patients to the NF interns. By 11:00 pm, all patients should be signed out
to the nightfloat interns.
For at least the first 6 months of the year, you must page the senior
nightfloat to assess any patients you are covering on whom a M&R is
called.
When called about a significant event, it is important to make a brief note
about the event and what was done in the patient’s chart so that the
primary team and consultants are aware. Additionally, make a note of it
on the signout to facilitate communication.
Rule: If you go see a patient for ANY reason, you must document this in
the chart!
40
Your First Day on VA MICU
Here are a few tips to help you out.
There will be 3 interns on this rotation and 2 seniors. There is a day senior
(8am-8pm) and a night senior (8pm-8am) and they switch roles after one
week. On Saturdays, both seniors are off and there is a covering senior for
24h (8am Saturday to 8pm Sunday).
The interns are q3h call. On you call day you can admit until 7pm and should
leave by 9pm and must leave by 11pm.
Admissions that come between 7pm-7am are admitted by the night senior
and will be distributed to the on-call intern who comes in the next morning at
7am.
Days off for interns are the pre-call day when it falls on a Friday, Saturday or
Sunday. The senior will distribute the off day intern’s patients to the other
interns to cover for that day.
Rounds start at 8am in the team room with radiology rounds.
On your non-call days you can sign out to the on-call intern in the afternoon
when your work is done.
The VA MICU is a great place for learning. There is generally a lot of time for
teaching and reading. Have fun!
41
Ten Ways to Make Your Life Easier as an
Intern at the VA:
1. Be Organized.
a.
Develop a system to keep track of your patients’ admission info,
daily vitals, labs, studies and “to do” list. You need to have this
information at your fingertips at all times and don’t want to be
fumbling through scraps of paper for 20 minutes. One system that
most people use is to photocopy your admission H&P and fold it in
half and write your daily vitals, labs, studies and “to do” list on the
back. Another system is included on the website and consists of an
admission template that serves as the basis of your H&P and a
daily patient tracking sheet that has spaces for your vitals, labs,
studies and “to do” list. There is also patient tracking software for
use on a PDA. Find a system that works for you and stick with it.
2. Show up and get your notes started before rounds.
a. Once rounds are done, you will have a list of things to do that is a
mile long. It is often difficult to get your notes done between calling
consults, putting in orders, talking to families, etc…If you get to
work a little early, you can preround AND get a large chunk of your
note done before rounds. You can print this out from CPRS and use
this to present with on rounds. This has the following benefits:
i. After rounds all you have to do is enter the labs, [olish up your
plan and sign the note.
ii. You will have a chance to assimilate the data and put down a
plan. You
should try to come up with your own plan each
day. It does not matter if the plan is wrong! You can always
change this after rounds. The important part is that you are
learning and growing as an intern and your attending will be
impressed that you are coming up with your own plan.
iii. Your presentation will be more smooth and organized because
you will have all your data handy and you have thought through
the plan already.
iv. You will be less stressed during the day and you will save time
at the end of the day. After rounds you can concentrate on doing
your work and then when you are done, all you have to do is
signout. Since your notes are done before rounds, all you have
to do is make an addendum if anything changes. There is
nothing worse than writing notes when you are tired at the end
of the day. There is an old saying among interns: “The longer
your stay, the longer you stay.” What this means is that when
you have to stick around to do stuff at the end of the day (e.g.
writing notes) it is inevitable that something will come up that
will require you to stay longer.
42
3. Ask for help when you need it and work together as a team.
a. On a given day there is an inequitable distribution of work among
interns – one intern has a lot of patients while the others have less.
One intern is on long call or medium call and has a lot of work to
do, while the other may have less to do. This inequitable
distribution is not only an inefficient way to accomplish work, it is
bad for resident morale. If everyone chips in to help each other out
and redistribute work, it has the following advantages:
i. The long and medium call interns can leave by 9:00 PM and
7:00 PM respectively.
ii. The total amount of work on the team can be completed more
efficiently.
iii. The other interns on the team will learn more about each
other’s patients, which make rounds more interesting and make
it easier to cross-cover these patients while on medium call.
4. Try to see your new admissions while they are still in Urgent
Care.
a. If you have the chance to see new patients in the Urgent Care
Center (UCC), you can save a lot of time and get a lot done. By
talking to the UCC resident/attending you can get a lot of
information that you can put into your H&P before you even see the
patient: information on allergies, medications (especially if they
came from a nursing home/CARES), past medical history, PCP,
admission vitals, admission labs, radiology results, new and old
ECGs, and UCC course (medications given, progression of vitals).
In the UCC, it is reasonable to take your time going through old
discharge summaries to collect information before you actually see
the patient since the UCC attending is technically responsible for
managing the patient while they are still in the UCC. Once the
patient arrives on the floor, you are responsible for “eyeballing” the
patient and ensuring that they are stable and any immediate needs
are addressed before proceeding with collecting admission
information for your history and physical.
b. While the patient is still in the UCC, you can get additional labs
drawn and medication delivered that will take substantially more
time once the patient is on the floor. For example, there will be
many occasion when you will want additional blood cultures, urine
cultures, urinalysis, ABG, AMI, ECG, or coagulation panels done
that the UCC nurses/staff can do if you ask nicely. In addition, id
you think an investigation is warranted, talk to the UCC attending
– if you ask nicely and make a cogent argument for your study, they
will often order it in UCC. The advantage of this is that nay study
ordered in the UCC is first priority, while any study ordered from
the floor is last priority, even if it is ordered STAT.
43
c. Once you have seen and examined your patient in the UCC, you
can also enter admission orders in CPRS under suspended order
management. MAKE SURE YOU DO NOT ENTER YOUR
ADMISSION ORDERS UNDER THE REGULAR ORDER SET,
OTHERWISE THIS WILL ALL DISAPPEAR ONCE THE
PATIENT IS MOVED TO THE FLOOR. Once you have entered the
orders in suspend mode and written your note, you have done 95%
of your work before the patient has left the UCC. When the floor
pages you to let you know that your patient has arrived, simply tell
the secretary to tell the nurse to activate your orders from suspend
mode. The only thing you have left to do is to put your note in the
chart and staff the admission with your senior. When you can do
this consistently for your admissions, you really feel like you are
ahead of the game and your call-night stress is significantly
reduced.
5. Try to get old records on the night of admission.
a. When patients come from outside hospitals or they have had
previous admission at outside hospitals, it is very helpful to get
those records as soon as possible. For patients who have had
previous admissions at the VA, you can get records directly from
CPRS. If the patient was at another VA hospital, you can access
their information remotely by clicking on “REMOTE DATA” on the
top menu bar and then selecting which location you want to get
information from. Next, you click on the “REPORTS” tab and then
click on the “Health Summary” on the left hand menu and then you
can select if you want to look at Progress Notes, Laboratory,
Medications, etc… Once you make a selection, it take some time to
load up the data, so be patient. In general, the most relevant
document to read is the discharge summary from previous
admissions. In addition, there are also usually laboratory studies,
diagnostic investigations or procedures done on prior admissions
that are relevant to the current presentations. If you can get these
records on the night of admission, it has the following benefits
i. The information you obtain may change your management on
the night of admission. If a patient had a similar presentation
in the recent past, it is helpful to see how it was handled at that
time.
ii. It may prevent unnecessary duplication of studies and labs (i.e.
– if a CT scan, echo, or endoscopy was done recently, it is often
unnecessary to repeat these).
iii. Patients will often omit or misunderstand the course of events
at an outside hospital, so it is helpful to verify their history with
actual records.
b. Every hospital has someone who has access to medical records 24
hours a day. Do not be discouraged if the hospital tells you that
44
their medical records department is closed. You simply insist that
you need these records tonight and they can call in a supervisor to
get the records. Obviously, do not abuse this and only ask for
records that will be pertinent to your management that night or the
following day.
6. Do your discharge summaries on the day the patient is
discharged.
a. It is infinitely easier to do a discharge summary on the day of
discharge while the patient’s hospital course is fresh in your mind
and the information is in front of you.
7. Start to plan your discharge on the day of the admission
a. There is a motto among senior residents: ‘the day of admission is
the day you start discharge planning.” The reason for this is that
the process of discharge planning takes time and if you do not start
this process early it is inevitable that a patient’s hospitalization will
be delayed. This frustrates everyone and allows your services to
swell unnecessarily.
b. You need to do 5 things before a patient can be discharged from the
VA:
i. Discharge medications entered in CPRS – it takes
pharmacy several house at least to get medications together and
bring them up and go over them with the patient. You should
enter these first because this is often what holds up a patient
the longest and it frustrates the patient and the nurses. If it has
been a while since you entered the medications and the
pharmacist has not arrived, and you may want to call to the
pharmacist and encourage them to expedite the request and
inquire how much longer it will be before they can bring up the
medications.
ii. Travel request or travel arrangements – if you are sending
someone via VA travel, try to get your request in early because
it can take some time before arrangements can be made. If the
patient’s family is going to pick up the patient, try to set a time
when this will happen. It is not recommended that you arrange
a morning pickup by either family or travel, unless you plan on
getting the patient their medication the night before. In
general, you should arrange to have travel come after you know
that the patient’s medications will have arrived.
iii. Discharge Instructions entered in CPRS – You should do
this next, so that the nurses can go over these with the patient
once the medications arrive. The nurses will start to give you a
hard time if they do not see instructions in the computer after a
few hours. On the discharge instructions, you need to specify
any follow-up care, appointments and special instructions in the
45
appropriate sections as well as ensure that the list of
medications is correct. This is also the time to ensure that you
have adequate follow-up for your patient: if the patient is seeing
their PCP you need to try to arrange a date and time; if they are
going to follow up in the Firm clinics or a specialty clinic you
need to make sure the consult has been entered.
iv. Discharge orders in CPRS – Next you should enter a text
order that states “Discharge patient to _______ (place) today at
______ (time).” This is the one thing that interns most often
forget to do.
v. Discharge Summary – If you are sending a patient to CARES
(see below), you need to have this done before the patient leaves
the ward. They are also starting to require that even patients
going home should have this done on the day of discharge as
well. To be honest, it is probably better for you in the long term
because it is much less painful to do the discharge instructions
at the time discharge while the information is all fresh in your
mind.
c. A patient can be discharged to home, home with home care, nursing
home, SNF, hospice or another service (i.e. surgery). Each of these
destinations requires different preparations.
i. Home:
1. Make sure patient has a ride who can take them home or a
travel request in CPRS 24 hours ahead of time. The patient
also needs a way to get into their home. Many patients have
had to stay an extra day in the hospital because no one could
pick them up or they did not have a key to their home.
2. Make sure the patient has a follow up appointment that is
listed in their discharge instructions and prescriptions/refills
for all their medications.
ii. Home with home care:
1. Patients need a Community Home Care form completed in
CPRS at least the day prior to the day of discharge so that
home are can be in place when the patient is ready to be
discharged. You need to notify home care by phone. The form
must state that the patient is homebound and requires RN.
2. The patient or family member must be reachable and
physically able to assist with the home care. Home care will
only come out once a day and only for a limited number of
visits. The objective is to transfer care to the patient or
patient’s caretaker. Therefore, the patient or their caretaker
must be able to learn how to handle basic wound care or IV
antibiotics.
iii. Nursing home/SNF(Brecksvills):
46
1. The vast majority of VA patients that require placement in a
nursing home or SNF will be placed at the CARES VA.
Helen Ferrer is the coordinator of the nursing home care unit
at CARES. Basically, she determines if your patient meets
criteria for placement at CARES and if so, when a bed will be
available. You need to be as nice to Helen as you can,
because she can determine if you have a large service full of
patients awaiting placement or a small service of only acute
care patients. If your patient will require placement in
another facility (e.g. – Ohio Veteran’s Home) you will need to
involve social work. When you know someone will need
placement, the earlier you contact the social worker or Helen
Ferrer, the better your chance of finding a place. Also, if
your patient came from a facility and you plan on sending the
patient back to the same facility, make sure the
patient/family is agreeable to returning to the same facility;
some people hate their nursing home and refuse to go back,
however they neglect to tell you this until the day of
discharge.
2. If the patient came from home and you have the slightest
suspicion that the patient may need placement, then you
should order a PT and/or OT consult as early as possible
(preferably on the night of admission). This evaluation will
determine if the patient goes to a nursing home, SNF or the
patient is safe to return home.
iv. Hospice
1. If you are going to make a patient DNR-comfort care only,
they need to have hospice involved. Once this decision is
make it is imperative that you contact hospice as soon as
possible to set up a meeting with the family. The hospice
worker can explain the details of home hospice or hospice
care in a facility and can help the family decide between
these options. The hospice workers frequently cannot come
out the same day, so the earlier you call, the better. A
patient going home with hospice will need a Ohio DNR form
completed prior to their discharge. You must also
discontinue any medications on the gold form that the
patient does not need (typically hospice patients only have
oral pain medications and other ‘comfort medications such as
ativan, haldol and sleeping aids).
v. Another service (i.e., surgery) – for a patient going to surgery
you have to at least consider the following well in advance of the
date of surgery:
47
1. Do they need a type and screen? If so, how many units of
blood do the surgeons want the patient to be crossmatched
for?
2. Is there any coagulopathy present and has this been
sufficiently reversed? Do they need Vitamin K, fresh frozen
plasma, etc…?
3. Is there an order in CPRS to make the patient NPO after
midnight for the day of the procedure?
4. Are there medications that should be held in advance of the
surgery? For example, if the patient is on aspirin, coumadin,
or lovenox, how long prior to surgery do these need to be
held?
8. Identify the main family contact person early and have them help
you keep the rest of the family informed.
a. Talking to families is one of the most rewarding things that we do
as physicians, however, it can also be the most time consuming.
For patients with large families, you cannot spend every day
repeating the patient’s progress to several individuals. Instead,
have the family appoint a spokesperson who will be accessible to
you as well s the other family members who can help you to
disseminate information. If the family cannot agree upon a
spokesperson, at least have them agree on a time to meet so that
you can talk to everyone at once.
b. Some patients are not competent to make decisions about their own
care and different family members have different options about
what should be done regarding a patient’s care. You need to
determine who has durable power of attorney for healthcare as
early as possible. If no one has been made legally responsible, then
you need to determine who the next of kin is. If this is not clear,
then you need to have a family elect someone to make decisions. If
there is any question as to whether or not a patient is competent to
make their own decisions, you will need to call a psychiatry consult
for competency assessment
9. Be nice to the nurses, secretaries, and phlebotomists and they
will be nice to you and can make your life easier.
a. The ancillary staff in the hospital exists to assist with patient care
land can really make your life much easier. Remembering people’s
names and treating them with respect will to a long way toward
making friends and getting assistance down the line. Here are the
kinds of things you can get help with.
b. Labs – The nurses at the VA typically do not draw labs, unless it is
in the ICU. However sometimes people are nice and will draw an
occasional lab for you.
48
c. Blood cultures – Similarly, if someone spikes a fever at night, you
usually have to draw the blood cultures yourself, but occasionally a
nurse may help you our if you ask nicely.
d. Contacting people or other ancillary services – It is not
inappropriate to have a secretary page another physician or page
another services for you while you are rounding or busy with
patient care. This can save you from waiting by the phone. In
addition, the secretary can page respiratory care, social work or
physical therapy for you as well.
e. Conveying information to and from family members – Sometimes it
is impossible to be in two places at once and the nurses can often
help you convey information to a family member as well as obtain
information for you as well.
10. Put in orders for each other on rounds.
a. You should make it a habit to round with one of the laptop
computers that has CPRS access. You and your co-intern can both
log-on to CPRS under separate windows of the application. While
one intern is presenting, the other intern should be on the computer
looking up labs, radiology or consult notes to help answer that come
up on rounds. As a plan is discussed on rounds, you should enter
the orders on your co-intern’s patients. In this manner, when
rounds are over both of you have all of your orders done and
nothing gets missed. Don’t forget to double-check each others
orders after rounds. The additional advantage of this method is
that you learn the plan on each other’s patients.
49
Ten Ways to Make Your Life Easier as an
Intern at UH:
2. Be Organized.
a.
Develop a system to keep track of your patients’ admission info,
daily vitals, labs, studies and “to do” list. You need to have this
information at your fingertips at all times and don’t want to be
fumbling through scraps of paper for 20 minutes. One system that
most people use is to print an extra copy of your admission H&P
and fold it in half and write your daily vitals, labs, studies and “to
do” list on the back. Another system is included on the website and
consists of an admission template that serves as the basis of your
H&P and a daily patient tracking sheet that has spaces for your
vitals, labs, studies and “to do” list. Find a system that works for
you and stick with it.
3. Show up and get your notes started before rounds.
a. Once rounds are done, you will have a list of things to do that is a
mile long. It is often difficult to get your notes done between calling
consults, putting in orders, talking to families, etc…If you get to
work a little early, you can preround AND get a large chunk of your
note done before rounds. This has the following benefits:
i. After rounds all you have to do is enter the labs and polish up
your plan, then sign your note as ready to be co-signed by the
attending.
ii. You will have a chance to assimilate the data and put down a
plan. You
should try to come up with your own plan each
day. It does not matter if the plan is wrong! You can always
change this after rounds. The important part is that you are
learning and growing as an intern and your attending will be
impressed that you are coming up with your own plan.
iv. Your presentation will be more smooth and organized because
you will have all your data handy and you have thought through
the plan already.
v. You will be less stressed during the day and you will save time
at the end of the day. After rounds you can concentrate on doing
your work and then when you are done, all you have to do is
signout. Since your notes are done before rounds, all you have
to do is make an addendum if anything changes and then put
your note in the chart. There is nothing worse than writing
notes when you are tired at the end of the day. There is an old
saying among interns: “The longer your stay, the longer you
stay.” What this means is that when you have to stick around to
50
do stuff at the end of the day (e.g. writing notes) it is inevitable
that something will come up that will require you to stay longer.
vi.
4. Ask for help when you need it and work together as a team.
a. On a given day there is an inequitable distribution of work among
interns – one intern has a lot of patients while the others have less.
One intern is on long call and has a lot of work to do, while the
others have less to do. This inequitable distribution is not only an
inefficient way to accomplish work, it is bad for resident morale. If
everyone chips in to help each other out and redistribute work, it
has the following advantages:
i. The long-call and medium-call interns feel less stressed and can
leave by 9:00 PM and 7:00 PM respectively.
ii. The total amount of work on the team can be completed more
efficiently.
iii. The other interns on the team will learn more about each
other’s patients, which make rounds more interesting and make
it easier to cross-cover these patients on medium call day.
4. Try to see your new admissions while they are still in the
Emergency Department.
a. If you have the chance to see new patients in the ED, you can save
a lot of time and get a lot done. The ED chart has a lot of
information that you can put into your H&P before you even see the
patient : information on allergies, medications (especially if they
came from a nursing home), past medical history, PCP, admission
vitals, admission labs, radiology results, new and old ECGs, and ED
course (medications given, progression of vitals). Between the ED
chart and the discharge summaries on in Portal, you can collect a
substantial amount of useful information before you even see the
patient. In the ED, it is reasonable to collect this info before you
see the patient since the ED attending is technically responsible for
managing the patient while they are still in the ED. Once the
patient arrives on the floor, you are responsible for “eyeballing” the
patient and ensuring that they are stable and any immediate needs
are addressed before proceeding with collecting admission
information for your history and physical.
b. While the patient is still in the ED, you can get additional labs
drawn and medication delivered that will take substantially more
time once the patient is on the floor. For example, there will be
many occasion when you will want additional blood cultures, urine
cultures, urinalysis, ABG, AMI, ECG, or coagulation panels done
that the ED staff can do if you ask nicely. In addition, if you think
an investigation is warranted, talk to the ED attending – if you ask
nicely and make a cogent argument for your study, they will often
51
order it in ED. The advantage of this is that any study ordered in
the ED is first priority, while any study ordered from the floor is
last priority, even if it is ordered STAT.
c. Once you have seen and examined your patient in the ED, you can
also enter admission orders in the EMR under “pre admission on
hold.” MAKE SURE YOU DO NOT ENTER YOUR ADMISSION
ORDERS UNDER THE REGULAR ORDER SET, OTHERWISE
THIS WILL ALL DISAPPEAR ONCE THE PATIENT IS MOVED
TO THE FLOOR. You must also check the box for “RN to release
orders  On arrival to floor” in the order set. Once you have
entered the orders in suspend mode and written your note, you
have done 95% of your work before the patient has left the ED.
When the floor pages you to let you know that your patient has
arrived, simply tell the secretary to tell the nurse to activate your
orders from suspend mode. The only thing you have left to do is to
put your note in the chart and staff the admission with your senior.
When you can do this consistently for your admissions, you really
feel like you are ahead of the game and your long and medium call
night stress is significantly reduced.
5. Try to get old records on the night of admission.
a. When patients come from outside hospitals or they have had
previous admission at outside hospitals, it is very helpful to get
those records as soon as possible. For patients who have had
previous admissions at UH, check out the discharge summaries in
portal and more admission details through the EMR. There are
usually laboratory studies, diagnostic investigations or procedures
done that are relevant to the current presentation. For patients
with outside hospitalizations, call medical records to get these
records ASAP. If you can get these records on the day of admission,
it has the following benefits:
i. The information you obtain may change your management on
the night of admission. If a patient had a similar presentation
in the recent past, it is helpful to see how it was handled at that
time.
ii. It may prevent unnecessary duplication of studies and labs (i.e.
– if a CT scan, echo, or endoscopy was done recently, it is often
unnecessary to repeat these).
iii. Patients will often omit or misunderstand the course of events
at an outside hospital, so it is helpful to verify their history with
actual records.
b. Every hospital has someone who has access to medical records 24
hours a day. Do not be discouraged if the hospital tells you that
their medical records department is closed. You simply insist that
you need these records tonight and they can call in a supervisor to
52
get the records. Obviously, do not abuse this and only ask for
records that will be pertinent to your management that night or the
following day.
6. Think about discharge planning every day.
a. There is a motto among senior residents: ‘the day of admission is
the day you start discharge planning.” The reason for this is that
the process of discharge planning takes time and if you do not start
this process early it is inevitable that a patient’s hospitalization will
be delayed. This frustrates everyone and allows your services to
swell unnecessarily.
b. A patient can be discharged to home, home with home care,
nursing home, SNF, hospice or another service (i.e. surgery). Each
discharge, regardless of disposition, requires the discharge profile
in the EMR.
i. Home:
1. Make sure patient has a ride who can take them home and a
way to get into their home. Many patients have had to stay
an extra day in the hospital because no one could pick them
up or they did not have a key to their home.
2. Make sure the patient has a follow up appointment that is
listed in their discharge instructions and prescriptions/refills
for all their medications.
ii.
Home with home care:
1. Patients need a gold form done and faxed to home prior to
the day of discharge so that home care can be in place when
the patient is ready to be discharged. The gold form must
state that the patient is homebound and requires RN. The
social worker will often fax this form if you complete, sign
and place it in the chart.
2. The patient or family member must be reachable and
physically able to assist with the home care. Home care will
only come out once a day and only for a limited number of
visits. The objective is to transfer care to the patient or
patient’s caretaker. Therefore, the patient or their caretaker
must be able to learn how to handle basic wound care or IV
antibiotics.
iii. Nursing home/SNF:
1. If someone comes from a nursing home/SNF and you intend
on sending them back to a nursing home/SNF, then that
patient will need a gold form. The earlier you get it done, the
earlier the social worker can get it sent out and the earlier
the patient will leave. Also, make sure that the
53
patient/family is agreeable to returning to the same facility –
some people hate their nursing home and refuse to go back,
however, they neglect to tell you this until the day of
discharge.
2. If the patient came from home and you have the slightest
suspicion that the patient may need placement, then you
should order a PT and/or OT consult as early as possible
(preferably on the night of admission). This evaluation will
determine if the patient goes to a nursing home, SNF or the
patient is safe to return home.
iv. Hospice
1. If you are going to make a patient DNR-comfort care only,
they need to have hospice involved. Once this decision is
make it is imperative that you contact hospice as soon as
possible to set up a meeting with the family. The hospice
worker can explain the details of home hospice or hospice
care in a facility and can help the family decide between
these options. The hospice workers frequently cannot come
out the same day, so the earlier you call, the better. A
patient going home with hospice will need a gold form and
the gold form must state that the patient is DNR and that a
hospice worker is required (under the home care section).
You must also discontinue any medications on the gold form
that the patient does not need (typically hospice patients only
have oral pain medications and other ‘comfort medications
such as ativan, haldol and sleeping aids).
v. Another service (i.e., surgery) – for a patient going to surgery
you have to at least consider the following well in advance of the
date of surgery:
1. Do they need a type and screen? If so, how many units of
blood do the surgeons want the patient to be crossmatched
for?
2. Is there any coagulopathy present and has this been
sufficiently reversed? Do they need Vitamin K, fresh frozen
plasma, etc…?
3. Is there an order in EMR to make the patient NPO after
midnight for the day of the procedure?
4. Are there medications that should be held in advance of the
surgery? For example, if the patient is on aspirin, coumadin,
or lovenox, how long prior to surgery do these need to be
held?
7. Identify the main family contact person early and have them help
you keep the
rest of the family informed.
54
a. Talking to families is one of the most rewarding things that we do
as physicians, however, it can also be the most time consuming.
For patients with large families, you cannot spend every day
repeating the patient’s progress to several individuals. Instead,
have the family appoint a spokesperson who will be accessible to
you as well s the other family members who can help you to
disseminate information. If the family cannot agree upon a
spokesperson, at least have them agree on a time to meet so that
you can talk to everyone at once.
b. Some patients are not competent to make decisions about their own
care and different family members have different options about
what should be done regarding a patient’s care. You need to
determine who has durable power of attorney for healthcare as
early as possible. If no one has been made legally responsible, then
you need to determine who the next of kin is. If this is not clear,
then you need to have a family elect someone to make decisions. If
there is any question as to whether or not a patient is competent to
make their own decisions, you will need to call a psychiatry consult
for competency assessment
8. Do your discharge summaries on the day the patient is
discharged
a. The average discharge summary should take you no more than 510 minutes to dictate. Even if you are covering another interns
patients on their day off you MUST dictate the patient. Remember
the motto, “the hand that writes the discharge order does the
dictation”. If you get behind, you will be on a weekly list emailed
from Dr. Armitage.
9. Be nice to the nurses, secretaries, CTAs and phlebotomists and
they will be nice to you and can make your life easier.
a. The ancillary staff in the hospital exists to assist with patient care
land can really make your life much easier. Remembering people’s
names and treating them with respect will to a long way toward
making friends and getting assistance down the line. Here are the
kinds of things you can get help with.
b. Labs – All nursing staff will draw admissions labs on a patient..
Nurses on all floors should draw coagulation panels for patients on
heparin protocol, too. Tower 3 and 5 nurses will draw AMI panels,
however sometimes they will also draw other labs if you put them
in at the same time as AMI panels land. Similarly, Seidman nurses
will draw labs on staff Heme/Onc patients as well, particularly if
they have a mediport and you let them know what labs you want
before the port is accessed. The other floors typically do not draw
55
labs, however, sometimes people are nice and will draw an
occasional lab for you.
c. Blood cultures –All nurses will draw blood cultures but please ask
them nicely.
d. Contacting people or other ancillary services – It is not
inappropriate to have a secretary page another physician or page
another services for you while you are rounding or busy with
patient care. This can save you from waiting by the phone. In
addition, the secretary can page respiratory care, social work or
physical therapy for you as well.
e. Conveying information to and from family members – Sometimes it
is impossible to be in two places at once and the nurses can often
help you convey information to a family member as well as obtain
information for you as well.
10. Do you discharge prescriptions on EMR.
56
Your First Day in the UH MICU
The UH MICU is a very busy month and can be very intimidating to start. Just
remember that there is a very steep learning curve and that there are always upper
level residents and the MICU fellow around to help you. Here is some more info to
help you throughout this month:
1. You will be paired with an upper level for your MICU call. On your “medium” call
day, your senior will go home by 11:00 AM and you will be responsible for
covering their patients. You will be supervised by the “helper day” resident who
you can ask for any questions you may have when your senior is gone. Your
“short” call day is listed in Amion as “helper” day and will be your day off when it
falls on a Friday, Saturday, Sunday or Monday. Your senior will cover your
patients that day. Your senior will have their pre-call (aka “happy”) day off on
Friday, Saturday, Sunday or Monday and you will cover their patients on this
day. For this reason it is very important to know each other’s patients well.
2. Never be heard saying, “That’s not my patient.” Remember, while you may not be
the primary care giver for a particular patient, you should know about every
patient in the 20 bed MICU. If it is something simple like a nurse asking you to
replete potassium, then you should place the order and tell the resident who is
responsible for that patient. If it is something more complicated like a family
meeting, help the nurse find the resident who is responsible for that patient.
3. Rounds will start at 8:00AM in the back of the MICU. Radiology will be
reviewed on all the patients in the MICU. Try to review all the films taken in
the past 24 hours on your patients prior to rounds. Especially note where the
central lines are located and whether the ET tube is in proper position. You will
be asked to interpret the films in front of the team on rounds so take the time to
review the films so that you are prepared for rounds.
4. For call, you will be paired with an upper level resident. Interns will admit until
7:00 PM and may leave by 9:00 PM and must leave by 11:00 PM. It is up to the
discretion of the resident to determine how the patients will be distributed while
on call. Even if you are not writing the admission note, you should be aware of all
the patients that are admitted, as you will have to cover these patients when the
resident is off.
5. The MICU team on-call is responsible for attending all Code Blues in the entire
hospital. As the MICU intern, you should make your way into the room and be
an active part in the code (ie doing chest compressions, getting ABGs, etc). Keep
the ACLS algorithm cards in your pockets at all times while in the MICU.
6. Trust the opinions of the senior nurses and respiratory therapists. They have
been doing this much longer than you have and know what to do when a patient
is sick.
7. You should be involved in as many procedures that are done in the MICU as
possible. Have the resident or fellow walk you through how to do a procedure and
review the items in the pre-packaged procedure kits. After you have seen a few
lines placed, you should have the resident or fellow help you place a line. Be sure
to have a signed consent form in the front of the chart and write a procedure note
in EMR after every attempted procedure. Log your procedures on
myevaluations.com (especially until you have the required 5 procedures to be
considered ‘signed off’ – meaning safe to do the procedure unsupervised).
57
8. Remember to address code status with every patient admitted to the MICU.
9. There are two nurse practitioners in the MICU. They are very helpful for
everything from helping with lines and procedures to taking patients. Any
patient that is chronically vented or from a LTAC should be picked up by the NP
in the morning. The NPs will also help covering the patients of the intern or
resident who are off.
10. Please call the DACR to notify them of any patients that you are sending out of
the MICU to the floor. IT is helpful to know the patient’s primary care provider
and if they have any medical problems (ie HIV, ESRD, cancer) that necessitate a
particular team assignment. The DACR will then assign the team and give you
an intern to call report.
11. There is plenty to learn about mechanical ventilation, pressor support, ARDS,
CVVH, etc. Do not feel like you need to know everything before you start, but if
you want to get a headstart, the reading list can be found on casemedicine.com if
you click on the link called “UH MICU” or Resident Reading list under
Pulmonary.
**REMEMBER: There is a MICU fellow who is available 24-hours per day. The
only stupid question is the one you did not ask!
58
Your First Day on CICU
Schedule:

Rounds start at 8 am daily except Wednesday (8:30 am—because of
Cardiology Clinical Conference from 7:30-8:30 in Carpenter Room) in
the CICU.

Heart Failure Service joins rounds at 10:00 am to see patients who are
on the Heart Failure Service (generally those with LVADs or posttransplant).

Evening sign-out rounds generally occur at 5:00 pm. The focus is sign
out from CICU fellow to night float cardiology fellow. All residents
should be present for evening rounds. These rounds generally take 3045 minutes.

Fellows generally are in the CICU for 4 weeks (occasionally 2), starting
on a Thursday.

Attendings rotate in 1 week blocks, starting on Monday.

Attending and fellow lead rounds Monday-Friday. Saturday is staffed
by the CICU attending and a cross-covering fellow (the CICU fellow is
off). Sunday is staffed by the CICU fellow, and the CICU attending
generally comes in late morning or early afternoon (sleeps late).

CICU fellow generally has one brief morning clinic one day per week
(10 am-noon)

Emergency Medicine Residents are at EM conferences Thursday 8 amnoon.
Cardiology conferences (residents are welcome) include:
Echo (Monday at 12:30-1:30, lunch is served)
Clinical Case Conference (Wednesday at 7:30-8:30 am)
Cath Conference (Tuesday at 5:30-6:30 pm)
Grand Rounds (Thursday 12:00-1:00, lunch is served)
59
Team Work:

A team approach to patient care is essential. There are 168 hours in a
week, and an individual resident should be in hospital for (at most) 80
hours/week. Given the acuity, intensity, and velocity of CICU patient
care the notion of “my patient” and “not my patient, I’m covering” is
inappropriate and does not work. An essential skill for each resident
to master is efficient and effective sign-outs. The ability to effectively
transfer patient care is truly important, and should not be neglected
nor minimized.
Educational Resources:

There are many guidelines in cardiology, including ones for the most
common diagnoses seen in the CICU: STEMI, Unstable Angina and
non-STEMI, Heart Failure, and Atrial Fibrillation. Familiarity with
these guidelines will not only enhance patient care, but likely augment
individual in-service and board exam scores.

Cardiosource is an invaluable resource available to all UH physicians
via the Physician Portal (Library links). It is sponsored by the
American College of Cardiology and provides easy access to journal
articles, national guidelines, and self -teaching/assessment modules
(e.g. ECG interpretation).

There are two didactic sessions scheduled each week (Tuesday and
Thursday afternoons) that are designed for CICU and Hellerstein
house staff teams. Each month two sessions will be lead by Robert
Barcelona, PharmD, two by the Heart Failure fellow, and 4 by the
CICU and Hellerstein cardiology fellows.
Roles of Interns

There will be 2 interns in the CICU for each 2 week half block. One
will start as the day intern (7AM-7PM) and one the night intern (7PM7AM). Both interns will be off Sunday and will switch over from nights
to days and vice versa on the following Monday in the middle of the
rotation.

A primary job of the day intern will be to focus on quality of discharges
in the CICU. The quality chief resident will provide a brief orientation
to cardiology Core Measures, documentation, etc on the first day of
each rotation.
60

Interns should also attend interdisciplinary rounds which occur in the
CICU at 10:30 AM on Tuesdays and Thursdays. These rounds are held
with nursing and social workers. The intern should take notes on what
is said during rounds regarding disposition plans and report back
pertinent data to the team. They should also be prepared to offer any
insights from a physician perspective that were brought up during
rounds.

The night intern will focus on cross-cover along with the overnight
resident. Ideally, the overnight resident would be able to go to the call
room for a couple hours (which is located right outside the CICU).
However, the resident must be available to the intern in an instant,
and the intern should not feel guilty about getting them up if they
have any questions at all.

Both day and night interns will likely be responsible for handling
admissions and carrying patients per the discretion of the senior
residents.

The best thing about this new rotation is that interns will experience
the nature of working in the CICU prior to doing the rotation as PGY2
residents.
EMR:
 The EMR is integral to our work, and it should be used as efficiently as
possible. Some suggestions:

Use order sets whenever possible, particularly for MI and Heart
Failure. More than one order set can and should be used if there is
more than one important diagnosis. The order sets should make
things easier and minimize errors of omission (e.g. no beta blocker in a
patient with MI).

Medication reconciliation must be done at both admission and
discharge. Resident and nurse should review discharge instructions
together to insure accuracy and completeness.

Document if a particular Core Measure (e.g. beta blocker for MI or
Heart Failure) is NOT prescribed and the reason.

Do not waste time entering information in the Hand Off Tool that can
and should be in the admission or daily note.

A daily note can be started by one resident and finished by another
(particularly post call).
61

Patients should have admission notes on the day of admission when
feasible (i.e. a patient admitted at 2 pm on Monday, should have an
admission note for Monday and a daily progress note for Tuesday).

Patients should generally have a (brief) daily progress note on the day
of discharge.

Clinical event notes should be done when there is an important clinical
change or instability (e.g. recurrent angina, intubation).

Perform as many pre-discharge tasks as feasible on the day PRIOR to
discharge (schedule f/u appointments, begin to complete d/c forms).

Discharge dictations should be done stat (#8) when patient is
transferred to another institution or will be seen shortly after
discharge (most patients).
62
Your First Day on Carpenter
Here is some info to help you throughout this month:
Rounds will be at 8:00AM in the Tower 8 team room. Ideally, the majority of your
patients will be located on Tower 8.
There will be two interns on this ward team. Call will be as follows: Long call,
medium call, short call and then “happy day” (no admits) on 4 consecutive days. The
cycle will then repeat. . One intern will take long call with the senior resident,
while the other intern will be the ‘orphan’ and will be covered by a senior from the
other on-call team.
Short call consists of two (2) nightfloats or ICU transfers before 1:00 PM with
the following exceptions:
a. If you have clinic on your short call day, you do not get admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm
As a general rule, you cannot carry more than 10 patients at a time on UH wards.
Also, if you have 8 patients on short call day you generally will not get any new
short call admissions.
Your days off, like all 2 intern/1 senior wards at UH and VA are your short AND/OR
happy days that fall on Saturday and Sunday. This leads to having 1 Saturday, 1
Sunday, one “golden weekend” (both days off) and one “black weekend” for a total of
4 days off per month.
On the weekend, there is no short call, only medium and long call. You will
occasionally have a 3rd year medical student working with you on this service. They
can carry a maximum of three patients and they should pick up a patient on each
call. They will write an admission note and you should co-sign their note and write
a full admission note of your own. Try to pick patients that are interesting and
present a good learning experience. The third year medical students also do not
take overnight call so try to get them a patient early in the day, if possible.
When the team is on Long/Short call, the intern on short call should sign out to the
intern on long call at the end of the day. The long call intern will then sign out the
entire team to the nightfloat intern at 7:00 PM. They will carry their own pager and
patients until 9:00 PM at which point they can sign out. As the long call intern it is
helpful to write your patients on the back of one of the signouts you give away at
7:00 PM so if the team pager gets called with issues on those patients the nightfloat
intern can redirect the staff to you. When the team is on medium call, the medium
call intern will stay until 7:00 pm and sign the entire team out directly to the intern
nightfloat. In the morning, you should pick up your signout from the night float
intern on tower 5 promptly by 7:00am.
63
The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor
conference room (also known as the KACR [Keith Armitage Conference Room]) to
distribute the nightfloat admissions from the previous night. You should pop your
head in to see if you have any nightfloat admissions although if the night team isn’t
finished assigning patients they may say they will call you when they know. You do
not have to write a full admission note if the nightfloat has already written a note.
You simply have to write an acceptance note that contains a paragraph briefly
summarizing the nightfloat’s note and then the remainder of the note is the same as
a daily progress note. Try to see the patients before rounds but if time does not
allow it’s crucial to go back to them after rounds to clarify the history, examine them
yourselves and most importantly to introduce yourself to them as their primary
physician.
Some months on Carpenter, there is an ID fellow on service. They are there to assist
you in the management of your staff patients and can help supervise procedures as
well.
While performing your history for an HIV patient, you must find out the
following:
a. Where do they get their HIV care and who is their HIV doctor?
b. What is their last CD4 count and HIV viral load?
c. What HIV medications are they on and have they missed any doses?
d. Have they ever had an opportunistic infection (PCP, MAC,
toxoplasmosis, Cryptococcal meningitis)?
Note: the easiest way to get this initial info for HIV patients
who see physicians at UH is to call the Special Immunology
Unit (SIU) at x41585 and have them fax over this info from
their chart at the SIU.
e. Perform a thorough pulmonary, skin and lymph node exam. In
addition, you should perform a Mini-Mental Status Exam if there is
any question of mental status changes.
When performing a physical exam on an HIV patient, you should always
examine the skin for open blisters or sores, look for thrush or ulcers in their
mouth, and perform a thorough neurological exam.
HIV patients are on prophylactic antibiotics for opportunistic infections and you
need to determine if they have been compliant with this medication. Here is a
list of common prophylactic regimens:
64
As you may know, the war on HIV/AIDS is being won by early introduction of
highly active anti-retroviral therapy (HAART). Typically the three components
of HAART triple therapy are three drugs from at least two different classes.
Typically, this translates into two nucleoside reverse transcriptase inhibitors
(NRTI), plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or
a protease inhibitor (PI). A few points about HAART therapy:
 Patients should definitely be on HAART if their CD4+ count is
<200, and it should be considered if the CD4+ count is 200-350. In
addition, if their HIV RNA level is >100,00 copies/ml, they should
be on HAART.
 It is ESSENTIAL that patients are compliant with their
medication regimen and adhere to the dosing schedule. This is the
only way provide durable viral suppression and to prolong the time
to development of resistance.
 The HAART medications have some unique toxicities including
nephrolithiasis, hyperbilirubinemia, vivid dreams/nightmares, and
hypersensitivity syndrome. In addition, these drugs can also cause
more typical side effects, such as nausea, vomiting, malaise and
diarrhea. Furthermore, many of these medications are
metabolized by the cytochrome P450 enzyme and can lead to drugdrug interactions with other medications.
 If side effects or drug interactions become a problem and it
becomes necessary to change medications, it is ESSENTIAL that
you do not simply stop one or two HAART medications. This is
due to the fact that viral resistance can develop quickly to a one or
65
two drug regimen. It is better to stop all three medications than to
have the patient taking just one or two medications.
Amphotericin and other ‘big gun’ antibiotics are often restricted and you must
obtain approval from the Pharmacy Antibiotic Approval person on-call. You
must page 30316 and explain your rationale for prescribing this restricted
antibiotic.
The team pager for the Carpenter team is pager 32661. The nurses can use it to
contact you from 2:00 PM until 8:00AM the following morning. It is also a text
pager and you should encourage the nurses to use this function if they just want
to send you a piece of information (i.e. – your patient’s family has arrived, the
evening blood pressure, etc…). The team pager is also a code pager. You should
carry it with you at all times when you are on call and hand it off at rounds the
following morning. It also needs to be handed off to cross cover when signing out
to them.
Your seniors are always available to help. You can also check the ID
reading list on the website. The only stupid question is the one you did not
ask.
66
Your First Day on Dworkin
Here is some info to help you throughout this month:
Rounds will be at 8:00AM in the Lakeside 55 team room. Ideally, the majority of
your patients will be located on Lakeside 55 however they can be located anywhere
in the hospital.
There will be two interns on this ward team. Call will be as follows: Long call,
medium call, short call and then no call (“happy day”) on 4 consecutive days. The
cycle will then repeat. . One intern will take long call with the senior resident,
while the other intern will be the ‘orphan’ and will be covered by a senior from the
other on-call team.
Short call consists of two (2) nightfloats or ICU transfers before 1:00 PM with
the following exceptions:
a. If you have clinic on your short call day, you do not get admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm
As a general rule, you cannot carry more than 10 patients at a time on UH wards.
There are certain circumstances where an intern may be asked to accept an
additional patient or two however these situations are rare.
Your days off, like all 2 intern/1 senior wards at UH and VA are your short AND/OR
happy days that fall on Saturday and Sunday. This leads to having 1 Saturday, 1
Sunday, one “golden weekend” (both days off) and one “black weekend” for a total of
4 days off per month.
On the weekend, there is no short call, only medium and long call. You will
occasionally have a 3rd year medical student working with you on this service. They
can carry a maximum of three patients and they should pick up a patient on each
call. They will write an admission note and you should co-sign their note and write
a full admission note of your own. Try to pick patients that are interesting and
present a good learning experience. The third year medical students also do not
take overnight call so try to get them a patient early in the day, if possible.
When the team is on Long/Short call, the intern on short call should sign out to the
intern on long call at the end of the day. The long call intern will then sign out the
entire team to the nightfloat intern at 7:00 PM. They will carry their own pager and
patients until 9:00 PM at which point they can sign out. As the long call intern it is
helpful to write your patients on the back of one of the signouts you give away at
7:00 PM so if the team pager gets called with issues on those patients the nightfloat
intern can redirect the staff to you. When the team is on medium call, the medium
call intern will stay until 7:00 pm and sign the entire team out directly to the intern
nightfloat. In the morning, you should pick up your signout from the night float
intern on tower 5 promptly by 7:00am.
67
The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor
conference room (also known as the KACR [Keith Armitage Conference Room]) to
distribute the nightfloat admissions from the previous night. You should pop your
head in to see if you have any nightfloat admissions although if the night team isn’t
finished assigning patients they may say they will call you when they know. You do
not have to write a full admission note if the nightfloat has already written a note.
You simply have to write an acceptance note that contains a paragraph briefly
summarizing the nightfloat’s note and then the remainder of the note is the same as
a daily progress note. Try to see the patients before rounds but if time does not
allow it’s crucial to go back to them after rounds to clarify the history, examine them
yourselves and most importantly to introduce yourself to them as their primary
physician.
The team pager for the Dworkin team is pager 32299. The nurses can use it to
contact you from 2:00 PM until 8:00AM the following morning. It is also a text
pager and you should encourage the nurses to use this function if they just want to
send you a piece of information The team pager is also a code pager. You should
carry it with you at all times when you are on call and hand it off at rounds the
following morning.
The admission diagnoses accepted to the Dworkin team are as follows:
1) GI bleeding: must include either:
melena
hematochezia, and/or
hematemesis
Anemia with guiac + stool is NOT acceptable
2)
Established diagnosis of IBD with GI symptoms
3) Acute pancreatitis: Diagnosis established by 2 of 3 criteria: amylase/lipase
levels 3x normal, upper abdominal pain with nausea and vomiting or CT scan
showing pancreatic inflammation
4)
Established diagnosis of chronic pancreatitis with GI symptoms
5)
Primary diagnosis of acute or chronic diarrhea (including malabsorption)
6)
Established diagnosis of acute diverticulitis (CT confirmed)
7) Obstructive jaundice or cholangitis or choledocholithiasis (including dilated
bile ducts on imaging)
8)
Primary diagnosis of dysphagia
9) Esophageal/gastric/pancreatic/colon mass (if malignancy established pt
should go to Heme/Onc)
10) Foreign body or food impaction
68
Many of the patients you will admit to the Dworkin team will have gastrointestinal
bleeding. Here are some tips to help you with the initial management of these
patients.
 History and physical exam: The history obtained from a patient with a
suspected GI bleed should include: The age of the patient, any history of
previous GI bleeding, any previous surgeries (esp. AAA repair), medical
comorbidities especially any history of liver disease, any history of previous
endoscopies (MUST obtain these reports), what specific symptoms the patient
is suffering from and a complete medication list (NSAIDs). The physical
exam should be focused on identifying stigmata of liver disease, evoking any
abdominal tenderness and a rectal exam. ALL patients with suspected GI
bleeding should have a rectal exam done by the admitting intern (even in one
was already done in the ED).
 Venous access and Resuscitation: All patients with GI bleeding must have
adequate IV access. This includes 2 large bore peripheral IVs, a triple lumen
catheter (ICU) or a “Cordis” (ICU). Orthostatic vital signs should be checked
on all patients. Resuscitation can be done using crystalloid (IVF) or colloid
(blood products) and coagulopathies should be reversed. Remember a patient
has to have an adequate blood pressure to undergo sedation for endoscopy.
 NG lavage: An NG lavage should be completed on any patient with as
suspected upper GI bleed and should at least be considered on patient’s with
suspected lower GI bleeding unless the source of lower GI bleeding has
already been determined. Your senior resident can help you with this
procedure.
 Laboratory evaluation: Laboratory evaluation for a patient with a suspected
GI bleed should include: CBC, renal function panel and a coagulation panel.
Additional labs may be indicated depending on the individual patient
situation.
 Medications and definitive treatment: The medications given to a patient
with a suspected GI bleed will vary depending on what the suspected source
of blood loss is. Please work with your senior resident and the GI fellow to
determine the best medication regimen for your patient. Always make these
patient’s NPO overnight unless you are sure there will not be an endoscopy
the following day. You will work with your senior resident/GI fellow to
determine which patients need to receive bowel prep on admission.
Your seniors are always available to help. The only stupid question is the
one you did not ask.
69
Your First Day on Eckel
Here is some info to help you throughout this month:
Rounds will begin at 8:00 AM in the Lakeside 50 team room. Your hemodialysis and
private patients can be located anywhere in the hospital. However, most of your
peritoneal dialysis patients will be located on Lakeside 50 because the nurses are
trained in how to use the equipment. You are expected to pre-round on your patients
even if they are already in the hemodialysis center (across from Lakeside 20).
There will be 4 interns and 2 senior residents on this ward team. Call will be as
follows: Long call and medium call on 2 consecuative days, followed by 2 days of no
call. The cycle will then repeat. Two intern will take long call with a senior
resident, while the other two interns will be the ‘orphan’ and will be covered by a
senior from the other on-call team.
Short call: There is no short call on Eckel
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm
As a general rule, you cannot carry more than 10 patients at a time on UH wards.
There are certain circumstances where an intern may be asked to accept an
additional patient or two however these situations are rare.
Days off on Eckel are your pre-call (“happy”) day when it falls on a Friday, Saturday,
Sunday or Monday. In a 4 week block you will get one of each of these days off. On
the 2 senior/4 intern teams (Eckel and Hellerstein) there are no “golden” weekends
and no “black” weekends. On your day off the senior will redistribute your patients
to the other interns to cover.
You will occasionally have a 3rd year medical student working with you on this
service. They can carry a maximum of three patients and they should pick up a
patient on each call. They will write an admission note and you should co-sign their
note and write a full admission note of your own. Try to pick patients that are
interesting and present a good learning experience. The third year medical students
also do not take overnight call so try to get them a patient early in the day, if
possible.
When the team is on Long/Short call, the intern on short call should sign out to the
intern on long call at the end of the day. The long call intern will then sign out the
entire team to the nightfloat intern at 7:00 PM. They will carry their own pager and
patients until 9:00 PM at which point they can sign out. As the long call intern it is
helpful to write your patients on the back of one of the signouts you give away at
7:00 PM so if the team pager gets called with issues on those patients the nightfloat
intern can redirect the staff to you. When the team is on medium call, the medium
call intern will stay until 7:00 pm and sign the entire team out directly to the intern
nightfloat. In the morning, you should pick up your signout from the night float
intern on tower 5 promptly by 7:00am.
70
The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor
conference room (also known as the KACR [Keith Armitage Conference Room]) to
distribute the nightfloat admissions from the previous night. You should pop your
head in to see if you have any nightfloat admissions although if the night team isn’t
finished assigning patients they may say they will call you when they know. You do
not have to write a full admission note if the nightfloat has already written a note.
You simply have to write an acceptance note that contains a paragraph briefly
summarizing the nightfloat’s note and then the remainder of the note is the same as
a daily progress note. Try to see the patients before rounds but if time does not
allow it’s crucial to go back to them after rounds to clarify the history, examine them
yourselves and most importantly to introduce yourself to them as their primary
physician.
Eckel is a very data-oriented service and daily labs are very important.
Unfortunately, dialysis patients are often difficult for phlebotomy to draw labs from.
Make sure that you have ordered labs every day and call to make sure they were
drawn. If the labs could not be obtained, you will need to draw labs yourself. On the
days that your patient is in dialysis, it is easiest and most reliable to have labs
drawn in dialysis. This can be done through the dialysis order set in the EMR. In a
crunch, you can call the HD unit and ask one of the nurses/techs yourself.
Keep in mind the indications for acute (emergent) dialysis:
o Severe volume overload causing pulmonary edema
o Severe metabolic acidosis
o Refractory hyperkalemia
o Acute uremia causing mental status changes, pericardial effusion
with tamponade
o Toxin removal
Emergent dialysis during regular hours is done by calling the dialysis nurse
practitioner. After hours, the renal fellow on-call must be called.
While taking your history for a dialysis patient, find out the following:
o Who are their nephrologists?
o Where do they get their dialysis (i.e. CDC East, VA, UH, etc…)?
o What days do they get their dialysis? (Mon, Wed, Fri –OR- Tues,
Thurs, Sat)
o Have they missed a dialysis appointment recently? When was
his/her last dialysis?
o What is their access (fistula, graft, temporary catheter) and when
was it placed?
o What is their “dry weight?”
Once you have admitted your patient, you should call their dialysis center (if you are
unsure of the phone number, the HD unit at UH has most of them on file) and ask to
have the following faxed to UH, preferably directly to the dialysis unit (x48975) if it
is still open:
o The patient’s last three run sheets – from these you can find out
useful information, e.g., whether a run was terminated early, if a
71
o
o
patient became hypotensive or febrile on dialysis, how much fluid
was removed
The “monthly packet”, which includes routine dialysis labs (among
other things)
You should also call the patient’s dialysis center to follow up on
blood cultures drawn prior to admission.
Dosing of medications in renal patients must be adjusted for creatinine clearance. A
rough estimation of creatinine clearance can be obtained by using the CrockroftGault equation or it can be calculated accurately by a 24 hour creatinine collection.
For a dialysis patient that is anuric, their creatinine clearance is 0. ALWAYS check
every medication for dosage adjustments (calling the pharmacy x 42016 is
sometimes the best way to find out).
o Crockroft – Gault:
CrCl = (140-age) x (lean body weight in kg) x (0.85 in women)
(serum Cr in mg/dl) x 72
o 24 hour urine collection:
CrCl = (urine Cr in mg/dl) x (volume of urine in ml)
(serum Cr in mg/dl) x (minutes)
The dialysis techs are your friends! If you ask nicely and put in the orders the
following things can be done while patients are on dialysis :
o Labs can be drawn
o Blood cultures can be drawn from lines (phlebotomy can draw
peripheral blood cultures during regular hours)
o Blood products can be administered – this is particularly useful in
these fluid-restricted patients, since extra fluid can be removed to
compensate
o Antibiotics are often best given at dialysis and should be dosed q
dialysis.
Pain control in dialysis patients is a tricky issue. It is preferable to use small doses
of Dilaudid (hydromorphone) over morphine because Dilaudid is metabolized by the
liver. Morphine is a poor choice because it can accumulate causing respiratory
depression and mental status change. Similarly, for anxiety, Ativan can also
accumulate. Haldol may be a better choice.
Potassium is another tricky issue. Hemodialysis patient have a tendency to get
hyperkalemic (especially if they miss a dialysis session). Peritoneal dialysis patients
tend to be hypokalemic. Be careful about aggressively repleting potassium in your
hemodialysis patients – it is ok if it is a little low. You should also avoid repleting
potassium based on labs that were drawn immediately post-dialysis: the value will
be falsely low for a few hours while the patient’s body re-equilibrates. At discharge,
make sure your hemodialysis patients understand that they must follow a renal diet
and avoid foods with high potassium.
Be careful with your fluid management on your dialysis patients. Too much fluid can
send a patient into pulmonary edema. Too little and they can be hypotensive. You
will not be able to use your BUN/Cr to determine if a patient is volume depleted.
72
Therefore, you must rely upon your physical exam, checking orthostatics and a CXR
to determine if someone if hypo-, hyper-, or euvolemic. Comparing a patient’s
current weight to their “dry weight” can also be helpful in this assessment.
There are very helpful dialysis nurse practitioners who can arrange emergent
dialysis during regular business hours and act as the liaison between our service
and the Transplant Surgery service that is responsible for placing, maintaining, and
repairing dialysis access (i.e. – fistula or graft) in our patients.
Patients requiring temporary access will need this placed in Angiography. You will
need to have coagulation profile in the computer with an INR of 1.2 or below and the
patient must be able to consent for the procedure or have a power of attorney that
can consent for them. Also, if they have a contrast dye allergy they need to be
prepped accordingly.
The team pager for Eckel is 33559. It is also a text pager and you should encourage
the nurses to use this function if they just want to send you a piece of information.
The team pager is also a code pager. You should carry it with you at all times when
you are on call and hand it off at rounds the following morning.
Always ask questions, the only stupid question is the one you did
not ask!!!!
73
Your First Day on Hellerstein
Here is some info to help you throughout this month:

Rounds will begin at 8:00AM in the Tower 5 conference room. Most of your
cardiology patients will be located on the telemetry floors, Tower 3, Tower 5,
and Tower 7. You may have some patients on the observation unit on
Lakeside 50. Your cardiac patients that no longer require telemetry and
private patients can be anywhere in the hospital.

There will be 4 interns and 2 senior residents on this ward team. Call will be
as follows: Long call, medium call, short call and then no call on 4
consecutive days. The cycle will then repeat. Two interns will take long call
with their senior residents, while the other interns will be the ‘orphan’ and
will be covered by a senior from the other on-call team.
Short call consists of one (1) nightfloats or ICU transfers before 2:00
PM with the following exceptions:
a. If you have clinic on your short call day, you do not get admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm

Days off on Hellerstein are your pre-call (“happy”) day when it falls on a
Friday, Saturday, Sunday or Monday. In a 4 week block you will get one of
each of these days off. On the 2 senior/4 intern teams (Hellerstein and Eckel)
there are no “golden” weekends and no “black” weekends. On your day off the
senior will redistribute your patients to the other interns to cover.

As a general rule, you cannot carry more than 10 patients at a time on UH
wards. There are certain circumstances where an intern may be asked to
accept an additional patient or two however these situations are rare.

On the weekend, there is no short call, only medium and long call. You will
occasionally have a 3rd year medical student working with you on this service.
They can carry a maximum of three patients and they should pick up a
patient on each call. They will write an admission note and you should cosign their note and write a full admission note of your own. Try to pick
patients that are interesting and present a good learning experience. The
third year medical students also do not take overnight call so try to get them
a patient early in the day, if possible.

When the team is on Long/Short call, the intern on short call should sign out
to the intern on long call at the end of the day. The long call intern will then
sign out the entire team by 10:30 to the nightfloat intern. When the team is
on medium call, the medium call intern will stay until 7:00 pm and sign the
team out directly to the intern nightfloat. In the morning, you should pick
up your signout from the night float intern on tower 5 promptly by 7:00am.
74





The telemetry nurses are great and are very experienced in dealing with
cardiac patients. They will draw AMI panels on cardiac patients located on
telemetry and coagulation panels on patients on heparin protocol. They are
not required to draw any other routine labs, but occasionally they will do so if
you ask nicely.
You can get echocardiogram and cardiac catheterization reports online via
the Physician Portal. (On the Portal homepage, select “HeartLab” from the
“Cardiology Systems” menu on the left and enter your UHHS system signon
and password.) You should obtain the most current echo and catheterization
reports for all of your patients. You can also access these through the EMR.
Telemetry is a precious resource and beds are always limited. If your patient
no longer requires telemetry, do the honorable thing and discontinue it. The
nurse manager may approach you and ask if tele is necessary on all your
patients. The most common indications for telemetry are:
o Patient being admitted to rule out MI who has NOT had three
negative AMI panels
o Patients with significant bradyarrythmias or tachyarrythmias that
are not rate controlled
o Patients with significant hyperkalemia and concerning ECG changes
o Patients with a recent STEMI or NSTEMI who require monitoring for
ventricular arrhythmias
o Patients with documented ventricular arrhythmias or history
concerning for ventricular arrhythmias
o Patients with newly placed pacemakers or admitted for evaluation of
pacemaker firing or possible pacemaker malfunction
o Patients admitted for syncope workup
o Heart failure patients undergoing significant diuresis and/or initiating
ionotropic therapy
On your first day of Hellerstein, become familiar with the monitors on the
telemetry floors. Learn how to review your patient’s last 24 hours of
telemetry monitoring and ask the nurses at the monitoring stations if any
events happened overnight. Most of the time, abnormal telemetry strips will
be in bedside vitals chart. If any events happened, ask the nurse to print a
copy of the tracing and bring this to morning rounds. Checking with
telemetry is a mandatory part of your pre-rounds on this service and you
should include this info in your presentation each morning.
There are two classic types of admissions you get as a Hellerstein intern: 1)
chest pain-rule out MI and 2) heart failure exacerbation. There are certain
things you should determine for each type of these admissions.
When taking a history for a patient admitted with chest pain:
i. When did the chest pain start and how long did it last? What
was the patient doing at the time when the pain started?
ii. Where is the chest pain located? Does it radiate anywhere?
iii. Are there any exacerbating or relieving factors? Is it
associated with exertion and relieved with rest or
nitroglycerin?
iv. Have they had any associated symptoms such as dyspnea,
diaphoresis, or nausea?
75


v. Have they had an MI in the past? If so, did they have a heart
catheterization? If so, what was the result and where was the
procedure performed? Did they have a stent placed?
vi. Have they had a CABG in the past? If so, how many vessels
were bypassed? Where and when was the surgery done?
vii. Have they had their cholesterol checked? Were they placed on
cholesterol lowering medications?
viii. Have they ever had an abnormal ECG or stress test? Have
they had an echocardiogram?
ix. Do they have a family history of heart disease? Anyone ever
died suddenly without explanation?
x. Do they have social history or smoking, alcohol abuse, drug use
or sedentary lifestyle?
While taking your history for a patient admitted with heart failure
exacerbation, you must find out the following:
xi. Have they had any chest pain? (see above)
xii. Have they had any prolonged immobility, recent surgery or a
history of a DVT? Did they have an acute onset of dyspnea?
xiii. Have they had a cough, fever, worsening dyspnea, or sick
contacts?
xiv. Have they had any palpitations or has their defibrillator fired?
xv. Have they been compliant with their medications and/or diet?
xvi. Are they anemic or have they had a recent GI blood loss?
These questions pertain to the 6 most common causes of heart
failure exacerbations: MI, PE, pneumonia, arrhythmia,
medication/dietary noncompliance and anemia.
The ACC/AHA has a published guideline entitled ‘The Management of
Patients with Acute Myocardial Infarction.’ According to this guideline,
for each patient being evaluated for possible MI, the following should be
given (unless a contraindication exists):
o Aspirin 325 mg PO daily
(main contraindication: allergy, GI bleed, bleeding diathesis)
o Metoprolol 25 mg PO q6 hours
(main contraindication: reactive airway disease, significant
bradycardia or hypotension)
o Lisinopril 5 mg PO daily or Captopril 3.125 mg PO q8 hours
(main contraindication: allergy, angioedema history, renal
insufficiency)
o Statin: Atorvastatin 80 mg PO daily
(main contraindication: allergy, pregnancy, severe liver disease)
o Lovenox 1 mg/kg SC bid for creatinine clearance >30 or 1
mg/kg SC daily if the patient has a creatinine clearance <30.
Unfractionated Heparin for patients whose weight exceeds
150kg or with a creatinine clearance <10.
(main contraindication: allergy, active bleeding, thrombocytopenia)
****Remember these few things while putting in orders on patients:
o Echocardiogram (if indicated)
o Daily ECG’s.
o NPO after midnight for cardiac catheterization (if indicated)
76
o
Empiric pharmacotherapy: see above #8
*****For patients admitted for heart failure exacerbation,
o Echocardiogram
o Admission BNP
o Follow-up chest x-rays
o Daily diuretic regimen
If a patient has had a cardiac catheterization, abnormal stress test, or CABG
surgery in the past, you MUST obtain the report as soon as possible, preferably on
the night of admission. If you are planning on sending someone who has had a
CABG surgery for a cardiac catheterization, it is IMPERATIVE that you get either
the operative report or a post-surgery catheterization report that details the
patient’s anatomy, PRIOR to sending the patient for cardiac catheterization. In
addition, if a patient has had any sort of vascular bypass procedure it is essential to
know exactly what was done PRIOR to sending that patient for a heart
catheterization.
It is also essential to determine if a patient has an allergy to IV contrast dye and if
so, the patient needs to be properly prepped with the steroid prep. If a patient has
acute or chronic renal insufficiency, they must also be properly prepped with fluids
and Mucomyst prior to the procedure. For a patient with ESRD, arrangements must
be made to dialyze the patient after the procedure. In each of these situations, the
risk of the procedure must be weighed against the potential benefits before the
catheterization is scheduled.
The team pager for the Hellerstein team is pager 32605. It is also a text pager and
you should encourage the nurses to use this function if they just want to send you a
piece of information The team pager is also a code pager. You should carry it with
you at all times when you are on call and hand it off at rounds the following
morning.
Your seniors are always available to help. The only stupid question is the
one you did not ask.
77
Your First Day on Naff/Wearn
Here is some info to help you throughout this month:


Rounds will begin at 8:00 AM in the Lakeside 20 conference rooms (located at
the end of the hall to your right from the nurses station). Naff and Wearn are
the general medicine “sister teams.”
There will be two interns on this ward team. Call will be as follows: Long
call, medium call, short call and then no call on 4 consecutive days. The cycle
will then repeat. One intern will take long call with the senior resident,
while the other intern will be the ‘orphan’ and will be covered by a senior
from the other on-call team.
Short call consists of two (2) nightfloats or ICU transfers before 2:00
PM with the following exceptions:
a. If you have clinic on your short call day, you do not get admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm

As a general rule, you cannot carry more than 10 patients at a time on UH
wards. Also, if you have 8 patients on short call day you generally will not
get any new short call admissions.

Your days off, like all 2 intern/1 senior wards at UH and VA are your short
AND/OR happy days that fall on Saturday and Sunday. This leads to having
1 Saturday, 1 Sunday, one “golden weekend” (both days off) and one “black
weekend” for a total of 4 days off per month.

On the weekend, there is no short call, only medium and long call. You will
occasionally have a 3rd year medical student working with you on this service.
They can carry a maximum of three patients and they should pick up a
patient on each call. They will write an admission note and you should cosign their note and write a full admission note of your own. Try to pick
patients that are interesting and present a good learning experience. The
third year medical students also do not take overnight call so try to get them
a patient early in the day, if possible.

When the team is on Long/Short call, the intern on short call should sign out
to the intern on long call at the end of the day. The long call intern will then
sign out the entire team to the nightfloat intern at 7:00 PM. They will carry
their own pager and patients until 9:00 PM at which point they can sign out.
As the long call intern it is helpful to write your patients on the back of one of
the signouts you give away at 7:00 PM so if the team pager gets called with
issues on those patients the nightfloat intern can redirect the staff to you.
When the team is on medium call, the medium call intern will stay until 7:00
pm and sign the entire team out directly to the intern nightfloat. In the
morning, you should pick up your signout from the night float intern on tower
5 promptly by 7:00am.
78

The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor
conference room (also known as the KACR [Keith Armitage Conference
Room]) to distribute the nightfloat admissions from the previous night. You
should pop your head in to see if you have any nightfloat admissions although
if the night team isn’t finished assigning patients they may say they will call
you when they know. You do not have to write a full admission note if the
nightfloat has already written a note. You simply have to write an
acceptance note that contains a paragraph briefly summarizing the
nightfloat’s note and then the remainder of the note is the same as a daily
progress note. Try to see the patients before rounds but if time does not
allow it’s crucial to go back to them after rounds to clarify the history,
examine them yourselves and most importantly to introduce yourself to them
as their primary physician.

The Naff/Wearn teams were established as hospitalist teams to provide
inpatient general medicine care for patients who have their own PCP. The
idea is that these PCPs will turn over the care of their patients to the
hospitalist while the patient requires hospitalization and then the hospitalist
will help transition care back to the PCP when the patient is ready to go
home. Therefore, you should arrange for every patient to have follow-up with
their PCP upon discharge and either you or your attending should call the
PCP at discharge to summarize the patient’s hospital course and let them
know if any medication changes were made while the patient was
hospitalized. You should also send the PCP a copy of the discharge summary;
if the PCP is not in the UH online directory, include the physician’s fax
number or office address in your dictation to ensure that a copy gets to them.

These services can be busy but our senior residents often tell us they learned
the most on Naff and Wearn.

Since these are both general medicine services, you may be calling consults
more frequently on this service. It is recommended that you try to call the
consults early in the day (before noon), so that the fellow has a chance to see
the patient and staff it with their attending that day. If you call the consult
late in the afternoon, the fellow may be upset and they may not have a
chance to see the patient until the following day.

The team pager for the Naff team is pager 33726, for Wearn pager 32654.
The nurses can use it to contact you from 2:00 PM until 8:00AM the following
morning. It is also a text pager and you should encourage the nurses to use
this function if they just want to send you a piece of information. The team
pager is also a code pager. You should carry it with you at all times when
you are on call and hand it off at rounds the following morning.
Your seniors are always available to help. The only stupid question is the
one you did not ask.
79
Your First Day on Ratnoff/Weisman
Here is some info to help you throughout this month:
Rounds will begin at 8:00AM. Ratnoff will begin rounds on Seidman 3 and
Weisman will begin rounds on Seidman 4. Your patients will primarily be located
on floors 3 and 4 of the Seidman Cancer Center however, you may have some
patients on Seidman 6 or at Case Medical Center.
Call. There will be two interns on each ward team. Call will be as follows: Long
call, medium call, short call and no call on 4 consecutive days. The cycle will then
repeat. One intern will take long call with the senior resident, while the other
intern will be the ‘orphan’ and will be covered by a senior from another on-call team.
Short call consists of two (2) nightfloats or ICU transfers before 1:00 PM with
the following exceptions:
a. If you have clinic on your short call day, you do not get admissions.
b. There is no short call over the weekend.
Medium call consists of two (2) admissions before 4:00pm
Long Call consists of three (3) admissions before 7pm.
When you are on call, you will primarily be admitting patients who established with
the Seidman Cancer Center. Often, these patients will be direct admissions from
home or a clinic that have been seen as an outpatient that day.
When you hear that a patient is being admitted, you can find a great deal of
information about that patient by looking in the Physician Portal under the
outpatient Heme/Onc notes. It is always helpful to review several of the most recent
discharge summaries.
Most sickle cell patients have “Coordinated Care Notes” which are viewable only
through the Physician Portal. Please be sure to ALWAYS check for these notes for
any sickle cell patient being admitted as they contain important information from
the outpatient care team.
There is a nurse practitioner service that runs in conjunction with the Ratnoff and
Weisman services (called the Berger Service) and handles many routine chemo
admissions, admissions for complications of chemotherapy, and some sickle cell
admissions. There are times that you will be responsible for the cross cover of these
patients.
The Seidman nurses are excellent and are very experienced at dealing with
Heme/Onc patients. For the most part, they tend to have good instincts and are
used to handling sick patients. They will draw labs on patients and are trained in
providing chemotherapy.
As a general rule, you cannot carry more than8 patients at a time on UH heme-onc
ward teams. .
80
Your days off, like all 2 intern/1 senior wards at UH and VA are your short AND/OR
happy days that fall on Saturday and Sunday. This leads to having 1 Saturday, 1
Sunday, one “golden weekend” (both days off) and one “black weekend” for a total of
4 days off per month.
On the weekend, there is no short call, only medium and long call. You will
occasionally have a 3rd year medical student working with you on this service. They
can carry a maximum of three patients and they should pick up a patient on each
call. They will write an admission note and you should co-sign their note and write
a full admission note of your own. Try to pick patients that are interesting and
present a good learning experience. The third year medical students also do not
take overnight call so try to get them a patient early in the day, if possible.
When the team is on Long/Short call, the intern on short call should sign out to the
intern on long call at the end of the day. The long call intern will then sign out the
entire team to the nightfloat intern at 7:00 PM. They will carry their own pager and
patients until 9:00 PM at which point they can sign out. As the long call intern it is
helpful to write your patients on the back of one of the signouts you give away at
7:00 PM so if the team pager gets called with issues on those patients the nightfloat
intern can redirect the staff to you. When the team is on medium call, the medium
call intern will stay until 7:00 pm and sign the entire team out directly to the intern
nightfloat. In the morning, you should pick up your signout from the night float
intern on tower 5 promptly by 7:00am.
The NACR and nightfloat residents meet at 7:00 am in the Tower 5th floor
conference room (also known as the KACR [Keith Armitage Conference Room]) to
distribute the nightfloat admissions from the previous night. You should pop your
head in to see if you have any nightfloat admissions although if the night team isn’t
finished assigning patients they may say they will call you when they know. You do
not have to write a full admission note if the nightfloat has already written a note.
You simply have to write an acceptance note that contains a paragraph briefly
summarizing the nightfloat’s note and then the remainder of the note is the same as
a daily progress note. Try to see the patients before rounds but if time does not
allow it’s crucial to go back to them after rounds to clarify the history, examine them
yourselves and most importantly to introduce yourself to them as their primary
physician.
Chemotherapy orders are written by the attending physician ONLY. Only
attendings can stop, change or delay a chemotherapy order. The nursing staff
knows to contact the attending directly about chemotherapy questions or concerns.
When taking a history from an oncology patient, find out the following:
 Who is their oncologist and their primary care provider?
 Where do they get their chemotherapy, what chemotherapy do they receive
and when was their last cycle?
 Have they ever had a fever or sick contacts since their last oncology
appointment.
 Have they been compliant with their home medications?
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When taking a history from a sickle cell patient, find out the following:
 Where is their hematologist and their primary care provider?
 Have they had fever, cough, UTI symptoms, GI symptoms or sick contacts in
the past week?
 When was their last blood transfusion and how often are they transfused?
 Are they on iron chelation therapy?
 Have they been compliant with their home medications?
 What pain medications do they use at home?
 What is the character of their pain and is it typical for their “crisis pain?”
 For women, are they pregnant?
 Did the ED to a type and screen?
There are 4 must know admissions for the Ratnoff/Weisman intern: Sickle
cell crisis, neutropenic fever, rule-out spinal cord compression and
hypercalcemia of malignancy.
Sickle Cell Crisis: There is a care protocol for sickle cell patients posted in each
team room. There is also a sickle cell admission template in the EMR which should
be used.
 Fluids: If the patient is hypovolemic, hydrate with NS at 300-500ml/hr until
they are euvolemic. If the patient is euvolemic, hydrate with D5W1/2NS at
75-125ml/hr
 Lab/Radiology: CBC with diff, reticulocyte count, renal function panel and
hepatic function panel. All women should have a B-HCG. Blood cultures, UA
and urine cultures can be drawn if needed. CXR if not done in the ED.
 Transfusion: Transfuse PRBC if the Hgb is < 3g below baseline. Transfuse
PRBC for any symptomatic anemia (dyspnea at rest or on exertion,
orthostasis, etc.). Sickle cell crisis is NOT a symptom of anemia.
 Pain Medications: All narcotics should be give as IVPB. If the patient does
not have IV access, analgesics may be given IM or SQ. If the patient is on
long acting narcotics at home, continue that medication for the
hospitalization.
 For initial pain relief, give morphone 5-10mg IVPB and repeat Q1H
PRN until pain improves or give hydromorphone 1-2mg IVPB Q2H
PRN until the pain improves.
 Once adequate pain relief is achieved with bolus narcotics (should be
in the first 2 hours of admission), begin a PCA pump with morphine or
hydromorphone 0.2-0.4mg demand with a 6 minute lockout.
 If the patient is not on chronic long acting narcotics, consider adding a
basal rate per hour of 4 times the demand dose.
 Breakthrough pain medications should be equivalent to the 1 hour
demand dose if needed. Give a breakthrough medications in 1 time
doses. If frequent breakthrough doses are needed, consider increasing
the PCA demand dose.
 If there are no contraindications to NSAIDs (renal dysfunction, GI
bleeding, PUD, GERD etc.) you can add ketorolac 30mg IV Q6H.
 Reassess the patient frequently. Increase PCA doses by 25% if
needed.
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Respiratory: Incentive spriometry is very important. Routine use of
supplemental oxygen is not recommended unless Sa02 is <90%.
Ancillary medications: Tylenol for fever >38, diphenhydramine 25-50mg PO
Q4-6 hours or hydroxyzine 25-50mg PO Q6H PRN itching. Add antibiotics
and other home medications as appropriate.
Special Situations: Acute Chest Syndrome presents as new pulmonary
infiltrates on CXR, hypoxia and chest pain and may require exchange
transfusions. If exchange transfusions are required, a transfusion medicine
consult is required. PRBC can be given for mild symptoms.
Neutropenic Fever: In an oncology patient, the main concern is for a bacterial
infection (e.g. line infection, PNA, UTI, bacteremia etc.).
 Pan culture the patient: Obtain 2 peripheral blood cultures and cultures
from any lines, urine culture and sputum culture
 Daily CBC with differential and calculate the ANC.
ANC = (Wbc count x 1000) (% neutrophils + % bands)
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An ANC of ,1000 is considered neutropenia and, in the setting of fever,
requires antibiotics. IV antibiotics are required for a fever with an ANC of
<500.
The patient must be covered for gram negative organisms. Multiple agents
are acceptable including Zosyn, ceftazidime, cefazolin, imipenem etc.
Vancomycin is not necessary initially unless the patient has a suspicious
indwelling port or line or has severe mucositis.
Rectal exams are CONTRAINDICATED in neutropenic patients.
Consider starting G-CSF (Neupogen) at 5mcg/kg/day SC daily
Suspected Spinal Cord Compression Secondary to Metastasis:
 Start decadron 6mg Q6H along with a PPI and an insulin sliding scale
 STAT MRI for the appropriate spinal level (s) based on your neuro exam.
This is one study that MUST happen stat and often you may have to call the
radiology resident to make this happen. You also MUST get a “wet” read
(prelim read) that night.
 If the imaging shows cord compression, you must call the radiation oncology
team to initiate XRT.
Hypercalcemia of Malignancy:
 On admission, order PTH, PTHrp, 25-OH vitamin D, 1,25 di-OH vitamin D,
ECG, CMP, urine calcium and daily ionized calcium
 Initial therapy for severe hypercalcemia includes simultaneous
administration of saline, calcitonin, and a bisphosphonate.
 IV hydration, usually at an initial rate of 200-300 ml/hr is needed (depending
on the patient) and then can be readjusted to 100-150ml/hr
 Calcitonin 4 units/kg IM Q12H. This can be increased to 6-8 units/kg Q6H
 Zoldronic acid 4mg IV over 15 minutes. Be sure to discuss the rare but
possible side effect of jaw osteonecrosis.
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Pain control in Heme/Onc patients is of paramount importance. There is a
conversion chart for narcotics that can help you when switching from one narcotic to
another or from IV to PO formulations and vice-versa. People with intractable
cancer pain or sickle cell crisis pain have a very high tolerance for narcotics and will
require more frequent dosing of these medications. If you cannot adequately control
a patient’s pain with PRN morphine or hydromorphone, consider placing them on a
PCA pump. You can use this to titrate a patient’s pain medications to a dose that
allows them to be comfortable with less danger of overdose. As the patient
improves, you can gradually reduce the amount of pain medication and calculate the
total daily narcotic requirement before converting the patient to an oral regimen.
This can be done using the narcotic conversion chart and will likely consist of a long
acting pain medication and a shorter acting breakthrough medication. Remember
that every patient who is on a narcotic regimen should also be placed on a bowel
regimen. The Palliative Care team is a great resource for helping optimize a
patient’s pain regime. Their pager number is 35614.
Often patients are admitted who may be in need of hospice and/or palliative care
services. If the patient is appropriate for hospice services, please contact the
Heme/Onc social worker to facilitate a family meeting and hospice discussion with
you. The social worker can place the actual hospice referral. Please note that we do
not have a hospice agency or hospice floor located within University Hospitals or the
Seidman Cancer Center.
CODE STATUS must be addressed with EVERY oncology patient on
admission. If you get in the habit of having this discussion early in your training,
it will serve you well. If DNR or durable power of attorney paperwork has been
completed, this needs to be copied and placed in the chart.
Any DNR and/or hospice discussions need to be communicated to the
outpatient oncologist/PCP upon discharge.
The Ratnoff team pager is 33306 and the Weisman team pager is 33970. Nurses
utilize these pagers throughout the day in order to contact the team. For reference,
the Hematology consult fellow pager is 31251 and the Oncology (solid tumor) consult
fellow pager is 31600.
Lastly, these can be very emotionally draining services. Please take care of yourself
and be aware of the toll that the service is taking on you. There is nothing wrong
with taking “time-out” for a few moments or finding a corner to have a good cry. As
always, please let you senior resident know if you are feeling overwhelmed.
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Your First Day on Elective
Here is some info to help you throughout this month:
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Elective is your opportunity to explore career interests, pursue research
projects or gain additional knowledge in a specialized area of medicine.
There are a variety of clinical electives you can choose from. The most
common clinical electives are consult services. You can arrange these by
finding out which fellow is on the consult service for the month and asking
them if you can do an elective with them. The easiest way to do this is to
simply page them the morning your elective starts around 8 or 9 am. You
will work with the on-service fellow and any medical students doing elective
on the service as well. Other clinical electives are also available and as long
you can arrange a preceptor to supervise you, it is possible to do almost any
type of rotation. Examples of other types of clinical electives people have done
include rotating though the CICU or MICU, working in a community
physician’s office, anesthesia, dermatology, radiology, echocardiography and
ophthalmology.
Our program prides itself on the flexibility it allows housestaff to pursue
whatever interest they have while on elective. For this reason there is no
“list” of electives to choose from – you simply decide what you would like to do
and arrange it independently. If you need advice or assistance, the chief
residents are available to help you set up your elective.
All electives need to be approved by your program director and reported to
Barb Bonfiglio. This should be done via an email to Barb (name of elective,
who you are working with and if you are going to be based at UH or VA is allt
hat is required) 2 weeks before the start of the elective.
During your non-service months (elective, primary care block, CSB,
geriatrics, etc) you will have 1-2 Saturday VA Nightfloat shifts for the year.
These will be listed on Amion. If you don’t have this coverage, your weekends
are free.
Electives are also a great time to do research. If you have an area of interest,
talk to attendings in that department to see who is doing research in your
area. In addition, the chief residents and senior residents can also
recommend good research mentors. If you do research at any time during the
year, you will be required to present your work during the spring research
talks. This is a great opportunity to gain experience in presenting your work
as well as a chance to get some feedback on your project.
Residents have also done away electives in other cities or even other
countries. In the past, residents have done projects such as working at the
NIH, volunteering in Africa and rotating at another hospital. You need to set
this up several months in advance and identify a preceptor who will
supervise you. All away electives must be approved by the Program Director.
If you are planning an away elective the Ambulatory chief must be informed
at least 30 days in advance to arrange clinic coverage. If you inform the chief
less then 30 days prior to leaving for your elective you must arrange your
own clinic coverage.
You are expected to attend Grand Rounds, Morbidity and Mortality
Conference, Noon Conference and clinic, unless you are doing an elective
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outside of the Cleveland area. You are also required to attend morning report
at the VA daily.
When you are on elective, you may be on jeopardy call (this will be indicated
on your schedule as consult/jeopardy), which means you can be called to cover
an intern on the floor who is sick or has a family emergency. Interns on
elective may be pulled to cover for VA Saturday Nightfloat coverage. As a
result, you must keep your pager on you at all times and stay in the
Cleveland area. If you must leave the area, you must notify the chief
resident right away.
Again, the most important thing about elective is that you email Barb your
elective information 2 weeks prior to the start of the elective when possible
(or at least before the start of the elective).
Elective is also a time to get caught up on your sleep and take care of the
smaller details in your life. Enjoy yourself!
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Your First Day on UH Nightfloat
Here are a few tips to help you out:
There will be 3 interns on a two-week nightfloat rotation. There will be 2
interns per night, 7 days/week. Between the 3 of you, work out your day
off schedule and email it to the UH chief for approval prior to the start of
the rotation.
Your nightfloat coverage begins at 7:00 p.m. when you take signout from
the medium call interns in the Tower 5 medicine room.
The signout session between the medium call/long call intern and the
nightfloat intern will be facilitated by the upper level night float resident
or NACR at the beginning of the year.
Between 9-11PM, the on-call interns will be signing out their own
patients to the NF interns. By 11:00 pm, all patients should be signed out
to the nightfloat interns.
Each nightfloat intern MAY be responsible for admitting up to 2 patients
between 10:00pm and 5:30am at the discretion of the NACR. This occurs
infrequently, but may happen. These admissions are staffed with the
NACR usually, or the nightfloat residents.
At 7:00 a.m., formal signout rounds of all the medical teams will occur in
the Tower 5 medicine room.
During your time of coverage, you will be working as a team with the 2
PGY-2 nightfloats as well as the NACR. Any questions or concerns
regarding patient care should be addressed with them. The senior
resident should always be involved in the case of any patient who needs
an upgrade of care to an ICU-setting.
For at least the first 6 months of the year, you must page the PGY2
nightfloats or PGY3 NACR to assess any patients you are covering on
whom a Code White is called.
When called about a significant event, it is important to make a brief note
about the event and what was done in the patient’s chart so that the
primary team and consultants are aware. Additionally, make a note of it
on the signout to facilitate communication.
Rule: If you go see a patient for ANY reason, you must document this in
the chart!
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SERVICE EXCELLENCE STANDARDS
University Hospitals Cleveland Case Medical Center (UHCMC) physicians,
employees and volunteers follow four service standards that demonstrate
UHCMC’s commitment to ensuring the best possible outcomes and
experience for our patients and their families. UHC MC employees are
committed to our core mission; To heal, To teach, To discover.
Our Service excellence standards are based on the following key concepts:
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Patient Centered
Accountability
Communication
Teamwork
Patient Centered
We value the unique qualities and needs of individuals and are committed to
understanding and respecting the diversity of cultures, opinions and
experiences that patients, families and hospital staff bring to our
environment.
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Respect the customer’s knowledge of their medical condition. We ask,
“Is there anything I need to know about your child’s/your medical
condition?”
Show concern for the customer’s privacy by closing the door before
asking personal questions.
Demonstrate awareness of cultural differences and respect for other
people’s opinions and experiences.
Keep our voices down and refrain from personal conversations in
patient areas.
Do not ignore patients or speak about them as if they were not there.
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SERVICE EXCELLENCE STANDARDS
Accountability
We take responsibility to know, understand and perform in a professional
and competent manner and we extend ourselves, asking, “What more can I
do?” to ensure a positive outcome. We:
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Provide explanations in clear and understandable language to
customers of the services/treatments they are going to receive.
Inform patients about any schedule changes that may impact the
patient.
Take ownership of complaints or requests and follow through to
resolution.
Take care of equipment and facilities and report all problems
immediately.
Maintain a professional appearance and demonstrate pride in our
work and our jobs.
Communication
The purpose of communication is to provide clear, accurate information and
to achieve mutual understanding by active listening and open, respectful
dialogue.
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Always knock and ask permission before entering a patient’s room
All employees introduce themselves upon entering a patient’s room
including name, title and role.
Acknowledge patients and families by smiling, making eye contact and
offering assistance.
Address families with a formal greeting (Mr. /Ms.) unless asked to do
otherwise.
Ask patients and families for permission by saying, “Are you ready?”
or, “Shall we go ahead...?”
Always ask permission to discuss patient’s medical condition in front of
others in the room.
Do not discuss the patient’s condition as if they are not present.
Use language and terms the customer can understand and offer an
interpreter when needed.
Listen attentively to the customer and check for understanding. We
ask, “Have I answered your questions?"
Always keep the patient informed about what can be expected.
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Ask, “Is there anything else I can do for you” before leaving the
patient’s room.
SERVICE EXCELLENCE STANDARDS
Teamwork
We work collaboratively, valuing the specific and necessary contributions of
each member of the team. We work together with a shared goal of achieving
excellence in addressing patient needs, one patient at a time by:
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Encouraging participation from all team members (patients, families,
physicians and other caregivers and co-workers).
Daily patient rounds as a team including all caregivers.
Communicate daily goals to all team members.
Offering to help co-workers before being asked and asking for support
when we need it.
Working with others collaboratively in problem solving and decision
making.
Giving positive feedback publicly; give constructive criticism
thoughtfully and in private.
Initiating, promoting and adapting to change and the process of
continuous improvement.
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LIBRARY ACCESS ISSUES:
There are several ways you can increase your home access to journals. The easiest, as
mentioned, is getting VPN installed on your computer. The VPN (virtual private network) is
a piece of software (Cisco) that you install and set up to provide a network link of your
choosing. In this case, either Case Western Reserve or UH, if desired. Essentially the
program gives your computer network access, which also gives you seamless access to most
library resources as if you were either on campus or on-network.
To get the vpn you can do two things, call the Case help desk at 216-368-HELP to get
information on downloading the program and importing the correct profile to connect you via
Case (you will need to give them your Case information - usually a username and/or pin), or
you can call the UH help desk and ask for the VPN software / UH profile. While the UH
profile will only get you access to the UH network, you can use the same Cisco program to
import a Case profile and connect to either at your choosing. More information for getting
your Case information (pins, etc.) Is available from our website at:
http://intranet.uhhs.com/corelibrary/OHIOLINK.asp.
Aside from the VPN, you can also access a number of Case resources through ohiolink (more
information is available through that link). As for UH resources, there is the VPN, as well as
links from the physician portal and an ejournals page. The VPN for either institution,
though, is definitely the easiest to use once set up and running. Our webpage here:
http://intranet.uhhs.com/corelibrary/REMOTEACCESS.asp has more information on offcampus access.
Please feel free to contact us anytime if you are having trouble with this or any other issue. I
hope this helps.
-- Jennifer Staley, Librarian, Core Library
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ACGME Core Competencies
In 2002, the ACGME launched a competency initiative called the Outcome Project. As a result
of this project, ACGME identified six ACGME Core Competencies to be used by GME
programs to evaluate their residents in training
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Patient Care
Residents must be able to provide patient care that is compassionate,
appropriate, and effective for the treatment of health problems and the
promotion of health.
Medical Knowledge
Residents must be able to demonstrate knowledge about established and
evolving biomedical, clinical, and cognate (e.g. epidemiological and socialbehavioral) sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement
Residents must be able to investigate and evaluate their patient care
practices, appraise and assimilate scientific evidence, and improve their
patient care practices.
Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication
skills that result in effective information exchange and teaming with
patients, patients’ families, and professional associates.
Professionalism
Residents must be able to demonstrate a commitment to carrying out
professional responsibilities, adherence to ethical principles, and sensitivity
to a diverse patient population.
Systems-Based Practice
Residents must be able to demonstrate an awareness of and responsiveness
to the larger context and system of health care and the ability to effectively
call on system resources to provide care that is of optimal value.
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