Download Handover Orientation Exercise Care Transitions – Intern Orientation

Handover Orientation Exercise
Care Transitions – Intern Orientation
Part 1: 15 minutes
Directions:
For this exercise, you will read through three cases below. Imagine that each of these patients are on
your team and you will need to sign them out to the cross-covering intern.
1. Read each case, taking note of active issues and problems that may occur overnight. Refer to
the overnight handover sheet (handovertemplate_intern.doc) to make sure this is filled
appropriately for the first two patients.
2. For the 3rd patient, YOU will fill in the active issues and overnight tasks/anticipated events.
3. You will have 10 minutes to complete this exercise. At the end of the 10 minutes, we wlll
discuss as a group how you filled in the information for Case 3.
Case 1:
History of Present Illness
Ms. Josephine Smith is an 82 y woman who was brought in by her family two weeks ago with acute on
chronic systolic heart failure (EF 15%). She was extremely volume overloaded and required aggressive
diuresis and a brief course of ultrafiltration to become euvolemic. In the past few days, she has been
gradually transitioned over to all oral medications and is euvolemic. She did experience a brief episode
of worsening of her renal failure but her creatinine and BUN are back to baseline.
Her course of treatment was complicated by atrial fibrillation with ventricular rate to the 160s.
Metoprolol has been used for rate control for the past two days. Her family has declined warfarin
therapy because she falls often.
Her course has also been complicated by a flare of her gout, for which she is on a slow prednisone taper.
Currently, she is not complaining of any pain.
She had a urinary tract infection present on admission that was treated with levofloxacin.
Throughout her admission, delirium has been a problem. She has now been on quetiapine at night
which helps to decrease her symptoms.
She had previously been living at home with her daughter who can no longer manage her care, so she is
currently awaiting a decision on a site of discharge. There have been some family issues so the only
person to be given information is her daughter who is her healthcare power-of-attorney. She is “full
code”.
Past Medical History
Vascular dementia
Chronic Kidney Disease, Stage IV
COPD, on 2L oxygen at home (stable)
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CHF, EF 15%
Diabetes Mellitus on insulin
Atrial fibrillation
Hypertension
History of bladder cancer
Medications
Furosemide 80 mg po bid
ASA 325 mg po qday
Metoprolol 50 mg po bid
Lantus 40 units SQ QHS
Aspart insulin 10 units SQ with meall
Captopril 6.25 mg p.o. t.i.d
BiDil 1 tab po q8 hrs
Prednisone 10 mg p.o. b.i.d
Lexapro 10 mg p.o. qday
Donepezil 10 mg p.o. qday
Calcium with Vitamin D, one tab daily
Case 2:
History of Present Illness
Mr. Harold Jackson is a 57-year-old male who was admitted 3 days ago with a COPD exacerbation. He
was started on scheduled albuterol and ipratroprium inhalers as well as daily prednisone and antibiotics.
He has been very slow to improve. He is on 2 liters of oxygen at home; he is currently 92% on 3 liters of
oxygen and feels dyspneic on minimal exertion. His respiratory rate was 24 on admission, now it is 20
with 3 liters of oxygen. He has a few scattered wheezes on exam but in general his exam is improved
from admission.
He is usually seen at the VA where is also seen for his anxiety disorder and chronic pain. He has had a
few episodes of anxiety while in the hospital.
Past Medical History
COPD, on 2 liters of oxygen at home
Chronic Hepatitis C infection
Chronic back and leg pain, secondary to prior motor vehicle accident
Anxiety disorder
Depression
Tobacco abuse
Current medications
Prednisone 60 mg po qday
Levofloxacin 750 mg po q 24 hrs
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Albuterol/ipratroprium, inhaled q4 hrs scheduled
Albuterol, inhaled q2 hrs prn shortness of breath
Citalopram 60 mg p.o. q.day
Quetiapine 150 mg po qhs
Lorazepam 1 mg p.o. q 6 hrs prn
Nicotine patch
Morphine ER 30 mg p.o. q 12 hrs
Morphine 4 mg IV q 4 hrs p.r.n. pain
Case #3:
History of Present Illness
Mr. Randall Thomas is a 65 year-old male who was admitted today. He has had 2-3 days of worsening
respiratory distress, fevers, and cough productive of purulent sputum. In the ER, he was found to have
multilobar pneumonia on chest X-ray. His vital signs upon presentation to the ER were a temperature of
38.7C, heart rate 136/minute, respiratory rate 36/minute, BP 84/56, and 86% on room air. In the ER, he
received 2 liters of normal saline as well as antibiotics. Blood culture results are pending. He was
admitted last month for severe hyperglycemia, so he was started on vancomycin and levofloxacin to
cover a potential healthcare-acquired pneumonia (HCAP).
His laboratory tests on admission to the ER were notable for a BUN of 45, a creatinine of 2.4
(BUN/creatinine were 24 and 1.5 at last admission), a glucose level of 84, and a troponin I of 0.08. His
CBC showed a WC of 24,000, hemoglobin/hematocrit of 10.8/31.2.
His vital signs upon reaching the step-down unit were Temperature of 37.6, heart rate of 96, respiratory
rate of 26, and blood pressure of 108/72. His O2 saturation is 92-94% on 4 liters of oxygen by nasal
cannula.
Past medical history
Chronic systolic heart failure, EF 25%, secondary to ischemic cardiomyopathy, AICD has been placed
Coronary artery disease with stent 5 years ago to the LAD
Diabetes mellitus, type 2, on Glargine, metformin, glipizide at home
Chronic kidney disease stage III
GERD
Penicillin allergy
Current medications
Vancomycin 1.25 g iv X 1 (awaiting repeat creatinine)
Levofloxacin 750 mg iv q 48 hrs
Sliding scale / corrective insulin
ASA 81 mg po qday
Lansoprazole 40 mg po qday
Metoprolol XL 25mg daily
Lisinopril 40mg PO daily (currently being withheld because of low blood pressure)
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Part II: 20 minutes
1. In groups of 2, you will practice signing out to your cross covering intern.
a. TIPS:
i. Think Health Hierarchy
ii. Remember that not every patient will need full details included in the sign-out.
iii. Don’t forget to ANTICIPATE what your cross-covering intern may be called about
overnight.
iv. Ask your cross-covering intern if he/she has questions.
v. Active listening may involve taking notes or asking questions to provide clarity
on a situation.
2. In the last 10 minutes we will come together as a group to watch 2 volunteers practice sign-out.
We will review the key components of the 2-HANDOVER approach.
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