QMC WARDS Upper Level Orientation

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QMC WARDSUpper Level Orientation

• April 7, 2004
• DME Bruce Soll, M.D.
• CMR Sandra Loo, M.D.

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Two-Way Street

• You will be working hard
• We will work hard to ensure an enjoyable,
  educational, comfortable, and supportive
  experience

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PHILOSOPHY

• EXCELLENT PATIENT CARE
• COLLEGIALITY AND CAMARADERIE
• Team Work is the KEY!
• Please take time on the 1st day to tell your R1
  MS about your goals expectations of them for
  the month
• Ask your intern/subI/ms about their
  goals/expectations
• Be of assistance to other interns residents
• EBM
• LEARNING / TEACHING (While having FUN!!)

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Recent Changes

• MTC Changes/Modifications
• New Work Rule Sheet
• UL is responsible to learn work caps, admission
  system, work hours
• UL is responsible to work comprehensively but
  efficiently to help the intern achieve the same
• UL is responsible to let CMR know if going over
  80hrs/week on avg over 4 weeks
• To be signed after reading and going over any
  questions with CMR on orientation day
• Minimizing Transfers between MTC teams
• For MTC residents on call, they keep their pts
  the next day
• During short call, will get pts according to team
  and/or census to help even out teams
• Transferring from MTC to UHS vice versa is
  inevitable
• Will have a mix of pts at any one time

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MTC Changes Contd

• Start Call day at 730am for UL (no earlier)
• As UL must stay til after conference on post call
  day to preserve attendance at our noon
  conferences
• Interns can still preround on their call day from
  6am ? thus, if they did, they can miss post call
  noon conference as cannot work more than 30hrs
  continuously
• Xray rounds are optional on call day for UL as
  start at 730am
• If interns preround on call day, they should
  attend the Xray rounds to preserve attendance
• If interns do not attend post call noon
  conference, the UL is responsible for presenting
  the teams case for that conference
• No Post Call Clinic
• Can move post call attg rounds to another day
  (remind attg!)
• No day off when intern has clinic
• Pls have checked on results in CLIQ/chart on an
  xray/CT/MRI if requesting to go over in radiology
  rounds (as much as possible)

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UHS Changes Contd

• UHS
• New UHS Work Rule Sheet
• UL is responsible to learn work caps, work hours,
  and admission system
• UL responsible to work comprehensively but
  efficiently and to help intern do the same
• UL responsible at letting CMR know if going over
  80hrs/week on average
• Must sign sheet after reviewing admission
  system/work caps/hours with CMR on orientation
  day
• See UHS Condensed Schedule in back of Work Rules
  Sheet
• Maximal Staffing
• Weekend days off as much as feasible
• No same clinic days for all 4 UHS residents (with
  rare exception)
• Change of Call System to On Call every 8th night
• Longer non call/non post call day shifts 6am
  6pm
• No day off for upper when other UHS upper is in
  clinic or is post call

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Recent Changes

• UHS Contd
• Mon Fri 6am to 6pm (except on call day, UL
  start at 730am)
• Sat-Sun 7am to 1pm
• Post Call Day
• Leave by 130pm (6hrs after 24hr continuous call
  shift)
• No short call on weekends/holidays (no admitting
  pts)
• Accepting Transfers 7 days a week
• M-Friday 1) general hospitalist to UHS and/or
  joint MTC/general hospitalist admission
• Sat Sun, Holidays ONLY joint MTC/general
  Hospitalist admissions are transferred (Important
  note!!!)
• When intern without upper
• If below 12, can still accept transfers
  however, can only accept transfers from joint
  MTC/hospitalist admissions
• If intern already at 12, on call upper can still
  admit for that team with the hospitalist at
  night, but attg accepts the transfer in the
  morning (as intern cannot round on gt 12pts/day)
• For pts taken care of by UL over the interns 12
  pts, these pts are rounded on by the attg when
  upper off and signed out by attg to long call
  intern

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Recent Changes

• When UHS team is on call, they can admit pts to
  be transferred to other UHS team in morning up to
  other UHS teams cap - In past, pretty strict
  about not transferring between 2 UHS teams
• Hospitalists are now being contacted through
  Physicians Exchange for pt care issues
  (524-2575) or Hospitalist admission pager for
  triage hospitalist 5-8751 - s are no longer
  available on call schedule or via console
• Every morning, the division of joint
  MTC/Hospitalist admissions that came in overnight
  is made before our MR Please look at your
  attgs list on CLIQ in Iol-5 to see which teams
  have which pt
• UHS not being closed via bed control anymore bed
  control (4398) will close MTC only hospitalist
  to find out if long call team can take admissions
  by calling On Call Upper!!!
• On Weekdays, UL will be given Admission guide to
  help you with seeing how many you can admit, each
  teams census, etc
• Interns do not have to do d/c template summary in
  Logician anymore they just have to dictate d/c
  summary on day of discharge

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Recent General Changes

• QET 5 Neuroscience Floor
• QET 6 Cardiovascular Floor
• CCU pts (if turns into MICU status, has to go
  down to 4M to be taken care of by
  Intensivist/MICU team if no room in 4M, then
  they will come up to take over care on T6
  (spillover into T6))
• If there is room for pt in MICU and pt turns into
  MICU status, but cannot be physically moved due
  to constraints i.e. 3 pressors, too unstable,
  then MICU attg has agreed to take over in that
  location
• Telemetry cardiac pts
• Post Op CABG pts
• Floor cardiac pts
• MICU now called 4M (17 beds)
• Work station on T6 T5 in front of each pts
  room chart, computer
• ID and Pulm Case Conferences have moved back to
  Iolani 5 (majority of noon conferences at Iol 5)

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Remember

• Pt admission Caps
• Interns
• 5 admissions 2 transfers per call
• 8 admissions over 48 hours
• Residents
• 10 admissions per call with 2 intern team (if NF
  is on), 8 admissions per call with 1 intern team
  (if NF off)
• 16 admissions over 48 hours
• Pt Census Caps
• Intern 12 patients at any one time
• Residents
• 1 intern team 16 patients at any one time
• 2 intern team 24 patients at any one time

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Important to Learn!!!

• For interns, limited by either
• 12 body cap
• 2 transfers, 5 admits per call
• For uppers, limit depends on 1 or 2 intern team
• For upper with night float on (2 intern team),
  then limited by either
• 10 admits or
• 24 body cap
• For uppers without night float on (1 intern
  team), then limited by either
• 8 admits or
• 16 body cap
• Above rule applies to time when night float has
  not arrived yet

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Important to Learn!!!

• Only type of patients uppers can admit by
  themselves (once their intern is capped) before
  night float comes on are CCU pts and Hospitalist
  pts up to their 8 admit cap or body cap of 16!!!
• Once night float arrives, then UL functions as if
  has 2 intern team (10 admit cap or body cap of
  24)
• Fill your long call intern first (mix of MTC or
  UHS) then, use night float if have to up to your
  caps
• Learn resident admit and census caps if dont
  understand, ask!!! Prevents admitting more than
  you are supposed to!
• Always call me promptly during weekdays before
  10pm to close team care appropriately!!! If
  dont, then team care remains open!

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Important!!!

• Residents/Interns should not be working over
  80hrs/week on average over a 4 week period (ACGME
  Rule)
• I.E. If work 85hrs/week for one week, then should
  work 75 hrs or less for 2nd week
• Please keep Work Hr Tally up to date
• Stay within hours on Work Rule Sheet as much as
  possible
• Let me know immediately if not able to make hours
  your responsibility

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TEAM STRUCTURE

• QMC Resident Teams
• Ward teams 3 MTC, 2 UHS teams (5 total each
  with upper level intern)
• MICU Team separate, closed unit
• 5 WARD TEAMS Upper, Intern, MS3, Sub-I
• MTC Cardiology Drs Schatz Hong
• MTC Pulmonary Dr. Soll
• MTC Infectious Disease Dr. Brown
• UHS 1 and 2 Monthly Assigned Hospitalist for
  each team (please refer to back of green sheet
  for names of UHS attgs, dates they are on no MS
  on UHS)

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WORK HOURS ACGME guideline 80hr/week!

• WEEKDAYS
• MTC arrive no later than 715am (unless on call
  for UL)
• UHS arrive no later than 600am (unless on call
  for UL)
• On Call day arrive no later than 730am for
  MTC/UHS
• Non-call / Non-post call days Must finish work
  and leave latest around 4pm (by 6pm for UHS)
• Sign-outs 4pm
• If your work is not completely done, sign out
  small issues to on-call team
• Post-call day leave at 130pm (for both UHS and
  MTC)
• Which is based on ACGME guideline where no one
  should stay beyond 6hrs after their 24 hr
  continuous call
• Post-call day Clinic CANCELLED as of block 5!
• Means less flexibility in schedule and makes your
  requests due atleast 6-8wks in advance of your
  block as schedules are now made 1 month in
  advance

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WORK HOURS ACGME guideline 80hr/week!

• WEEKENDS AND HOLIDAYS
• Arrive by 7am
• Must finish your work by 1pm
• If your work is done before 1pm, sign out to the
  on call team and go home
• UL on call must be present during the sign out
  for week ends and holidays
• Saturday Upper Level Morning Report (8am)
• If you are off, R1 must be present to represent
  team

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Upper Level ResponsibilitiesGeneral Duties

• Be a Team Leader/Support/Guide/Teach
• Ensure your team is PREPARED and ON TIME for
  conferences and rounds
• If you have an admission/sick patient, you take
  care of the pt and make the R1 and MS to go to
  conferences and rounds ON TIME!!
• Practice with your intern presentation before
  conferences
• Ensure your team is on time for Xray rounds as
  well

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Upper Level ResponsibilitiesGeneral Duties

• Upper level on-call must be present at sign out
  during weekends and holidays
• Be a good role model for intern/students
• Make sure patient care is complete
• Be main communicator with attending
• Make sure intern completes all dictations
  (otherwise will go to your name)
• Let CMR know of any good cases for specialty
  conferences
• Make sure team is on track with work hours let
  me know if intern having problems or if team
  unable to keep hours

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Responsibilitiesfor Medical Students

• Be a Role model Teacher
• Write addendum (A/P) to MS III and IV notes (your
  responsibility)
• Assist with their presentations (encourage to
  present at conferences), written HPs
• Give Constructive Feedback i.e. their daily notes
• Get them involved with the team i.e pt care,
  procedures, codes
• Allow them to present in SOAP format in Team
  Rounds
• CMR will give MS lectures on Mondays/Thursdays at
  130pm in I-5 on topics (1-2hrs each)
• Reading CXRs
• Reading EKGs
• Acid-Base Evaluation
• Mechanical Ventilation
• Fluids/Electrolytes i.e. hyponatremia
• ACS
• Atrial Fibrillation

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Responsibilitiesfor Medical Students

• For MS III
• Provide 2 new pts/week
• Start with one new patient / call, can increase
  as ability allows
• Average load 3 pts once they become accustomed
  to pt care
• For MS IV Open for 3 new admissions / call
• Bread Butter patients no ICU transfers,
  etc...
• Dictate H/P, D/C summary, Interim summary for Sub
  I
• Average load of Sub-I 3-4

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ResponsibilitiesMedical Students Contd

• Teach bread butter medicine topics as well as
  case related topics (PEARLS are great!!)
  ultimately your responsibility
• Review their progress notes, give them
  constructive feedback
• MS should have their SO part of SOAP note
  written before team rounds but not A/P portion
  until after discuss with team
• SOAP note in chart after team talks about daily
  plan to ensure MS note reflects the patients
  care
• Serve as a resource of information
• Allow them to read in afternoons if their work is
  done they need reading time to balance books
  with clinical stuff

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ResponsibilitiesTo Your Intern

• Be a supportive, accessible Upper Level
• Tell them to give you a call anytime while on
  call for assistance or to run their ideas by you
• Give constructive feedback
• Allow them to make decisions first
• Make your expectations clear from day 1
• Be a good role model
• Obtain articles as pertinent to case topics may
  look in CMR collection (currently being built)
• Teach / Teach / Teach when able
• Practice with them presentations before the
  conferences
• Give them tips on interacting with certain
  attendings, on being more efficient, feedback on
  notes if note problems, ask me to round with
  you sometime!!! Very imp to catch problems early!

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PAPERWORK

• Brief written Admit notes on chart after
  evaluation
• for SUB - I they write HP in chart, you write
  addendum to their written HP dictate the HP
• Post-call YOUR TEAM may have to write a brief
  note for an admitted pt who will be transferred
  if there are significant changes since their
  admission
• Brief written Transfer /Accept notes to/from MICU
• Ultimately responsible for discharge summaries
• Dictate death summaries, transfer summaries to
  other institutions ready for transfer (e.g.
  Tripler)
• Addendum (A/P) to MS/SUB-I Notes
• MS notes are NOT complete until YOU write the
  addendum.
• Dictate HP and D/C summaries for Sub-I patients
• MS can not dictate at QMC they write Admit HP

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Paperwork Cont

• Note on UHS Interns Responsibility
• FOR UHS, a new standard has been implemented due
  to a new hospitalist standard
• All discharge summaries should be done on day of
  discharge esp important as doctors following up
  on these pts will need this (for community
  doctors, less urgent as they followed pt in
  house)
• For all interns, All Interim summaries should be
  done on day they leave the service
• For UHS interns, when downgrade to SNF, dont
  have to do interim as still will be following
  (just do d/c when discharged)
• Only way interns should be leaving at 430pm is
  if no admissions at that time and they have done
  the d/c summaries for all their discharges for
  that day
• If they get an admission at 430, then d/c
  summary can be done next am to keep within work
  shift 6am to 6pm

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ON CALL

• LONG CALL 0730 to 0730
• MTC Q4 days
• UHS Q8 days
• SHORT CALL (730-200pm for MTC, 6-430pm for
  UHS)
• MTC short call triaged by CMR according to team
  attg physician is on or census, team
  circumstances i.e. sick pts, short staffing
• Hospitalists triage their own short call admits
• Everyday except post call weekends/holidays
  (even for UHS service)
• CMR hands off Admit pager to On Call UL Resident
• Call me to close team care before 10 pm on
  weekdays!!!(Weekends, holidays can be closed by
  upper level if appropriate always call Bed
  Control only to close MTC or CCU not using Bed
  Control to close UHS)

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ON CALL

• Night Float Hours 6pm 6am
• Still does cross coverage for non call team pts
• Now, admits up to 5 new patients if upper level
  can admit that many
• If NF is admitting a patient with you, then your
  intern does cross coverage for that time
• NF leaves at 600am and signs out any significant
  issues to respective interns/teams before
  leaving if interns not in yet, then night float
  will sign out significant event to long call
  intern

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CODE 500

• Hand off pagers at 730am
• Pls do not lose pagers (replacement fee if lost
  is 100) code pager for upper, intern, night
  float, sub I
• Remember to always document change in code status
  in chart and computer
• MICU On Call Resident is designated code leader!
• Must still attend all codes to assist MICU
  team!!! If want to run code, tell MICU upper
  (dont fight)
• Delegate duties among team
• i.e. chart review, lines, CPR, ABG, etc
• STC to place lines!!!
• Notify Attending of events decide amongst
  yourselves who will do this
• Write Code Note/Sign Code Flowsheet if lead the
  code
• Determine together with MICU resident whether pt
  should be CCU or MICU

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CALL MaximumsOther considerations

• For Intern/Sub-I Team
• Sub I adds makes that specific MTC team to close
  at 15 total bodies instead of 12
• CCU stays open
• Cap of 4 CCU admits / call
• If above intern limit, pt is solely for UL
  management
• R1 to pick up after post call day if total
  census is lt12
• CCU pts can be on ventilator however, they
  should have mainly cardiac problem (ACS,
  recalcitrant Vtach, cardiogenic shock)
• Once getting into other organ systems, GI bleed,
  ARF with HD/CVVHD, Hepatic failure, should be an
  MICU pt
• If having to stay in CCU all day or too much for
  night float to handle, pls let me know so that we
  may transfer to MICU

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Basic Admission Rules Subject to change w/o
notice

• No transferring done between MTC teams (unless
  special circumstances i.e. excellent case)
  necessary transfers done daily at MR in am
  between MTC and UHS
• Please meet in Iol 5 on Sundays/holidays to sign
  out new pts to be transferred enter admissions
  into computer!!! (should be in computer by Monday
  MR)
• Admission limited by own cap other teams
  ability to accept transfers
• If medical team is on call but hospitalist teams
  are full capacity (16 each), then cant admit any
  more for them
• If hospitalist team is on call, they should be
  careful not to admit MTC pts if all MTC full (at
  12 each)
• This makes knowing the other teams current census
  important!
• Please keep updated census on board in Iol-5 am
• Please place total and open for on sign out
  sheets this is the most up to date at the end
  of the day!!!! Go by this census!!! Will also
  fill out Resident Admission Guide at end of each
  weekday at Sign Outs for you to use, intern will
  give u)

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Counting the s Subject to change w/o notice

• Each admitted patient counts as 1 for the
  admitting upper level intern
• When pt is transferred to respective team, that
  patient counts as 1 also for that accepting upper
  intern
• Transfer of patients from MICU to the ward team
  is considered as 1
• If intern is capped at 12 pts on long call
• Intern cannot admit more patients to be
  transferred the following am to other teams
• Upper Level can admit for UHS teams CCU before
  night float arrives if their intern is capped
• hospitalists wanted help in high admitting time

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ONCOLOGY ADMISSIONS?NEUROLOGY ADMISSIONS?Please
Call

• Oncology Resident
• with Dr. Higuchi

Neurology Resident with Dr. Watters
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CLINIC DAYS

• Upper levels in clinic are covered for team
  issues admissions
• On Call UL/CMR can be of assistance to your
  intern if you are in clinic for an afternoon
  tell them this so they know they are not alone
• Assigned upper level will admit pts for you on
  call clinic days (Coverage) see board for
  dates!
• FYI regarding non-medicine interns
• Ob/Gyn Residents weekly continuity clinic (no
  post call for them)
• Transitional Residents night-time colloquium
  every other Thursday
• Psychiatry Residents conference Monday
  afternoons
• Med-Peds Interns have weekly clinic while on
  wards (Med-Peds Uppers have 1 CC/week while on
  ward months new!!!)

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DAYS OFF

• 1 day off per week on avg over 4 weeks (ie. 4
  days per block)
• MS3 should get a weekend day off
• Sub-I may take 2 off w/R1, 2 off w/UL
• Will not get a day off when your partner has
  clinic and vice versa to keep maximal staffing,
  even if it means taking day off on Mon or Wed
  now
• NO CHANGE OF DAY OFF unless you get prior OK from
  the DME or CMR, very stringent currently to
  prevent low staffing

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Welcoming UHSRequired Conferences

• Mandatory attendance at X-Ray Rounds, Morning
  Report (for UL)
• Encouraged to attend the noon conference, but not
  mandatory except MM, CPC
• Have to attend MM, CPC to review pathologic
  slides
• May ask UHS resident/intern to present a case at
  our noon conference if great case (will check
  with your attg first)
• UHS Team Conference cancelled now with CPC in
  that time slot!!!
• EKG Review with Dr. Schatz is optional
• No Sub-Is, MS 3 on these teams
• Will have own teaching lectures from University
  Attgs (own schedule)

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DAILY SCHEDULE

• After 6A, Before 715AM Pre-Rounds
• 0715 XRAY ROUNDS- Please have your interns
  present all cases! (Optional if on call)
• 0730 Morning Report (sign-in rounds only for
  UL) Iol 5
• 0830-1100 Team work rounds
• YOU ROUND AS A TEAM!!!
• 1100 ATTENDING ROUNDS (For MTC 3X/week For
  UHS daily at individual times)
• 1200 Lunch everyday but Tuesday
• 1230 NOON CONFERENCES see paper schedule, wipe
  board schedule
• 1600 SIGN-OUT ROUNDS in Iol 5 with CMR (only
  MTC interns UHS can now sign out when ready,
  usually 6pm)

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Morning ReportAKA Sign-In Rounds

• Every weekday morning, 0730-0830 (0800 on Sat) in
  I-5
• Upper levels only, but if you are off, R1 MUST be
  present!
• Transfer patients admitted o/n to appropriate
  teams
• Post Call UL should bring printed CLIQ updated
  patient list
• Mark pts admitted overnight
• Please write interns name next to pt you
  admitted with them
• Any Upper that had short call admits the day
  prior should also bring their printed CLIQ
  updated patient list
• Use of Transfer Ticket to keep track of newly
  accepted patient and their issues
• Update me of any biopsies, deaths, or
  autopsies!!!
• Run by Dr. Soll or Dr. Brown CMR

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Morning ReportAKA Sign-In Rounds

• Format
• -- Will present all pts admitted over previous
  day, with focus on transfers long call admits
  (short call admits will be briefer)
• -- Also follow ups on unsolved/interesting cases
  problems encountered while on call should be
  brought up
• --Presentations need to be complete, yet succinct
  (CONDENSED)
• Upper can choose which cases they want to spend
  more time on!!!
• Presentations need to be on the mark, organized
• --Chance to bounce ideas off colleagues, DME, CMR
• --If have question on management of short call
  pt, can bring up briefly i.e. I have a pt with
  PE, but I am not sure how to manage this pt
• --Chance to look up answers/abstracts to
  questions on Up To Date
• - will be directed to articles on board/in
  drawer
• - can obtain printed out UTD article on topic to
  share with group
• --Chance to obtain interesting cases for case
  conferences!!! Please volunteer your good
  cases!!!

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Schedule of Conferences
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Case Conferences

• Involves presentations of cases in 1 specialty
• Involves participation of all teams
• Select Consultants will be invited to attend -
  they may bring their own cases as well
• present 2-3 cases
• You will be told ahead of time regarding the case
  to present by Dr. Soll/Dr. Brown/CMR (look on
  board as well!) - please notify your intern that
  they have to present the case chosen
• If your R1 is off, you are responsible to present
  the case
• Focused and crisp presentation - not just a
  reading of the H P also know summary of
  course!!!
• Please invite the attending and any appropriate
  consultant on your patient to the conference!

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Case Conference Contd...

• Bring print of images to I5 (PACS is up in Iol
  5, but not as good as hard copy)
• Give me EKG day prior to make transparency for
  you
• If conference at QCC
• Give me the Films LATEST 700AM the morning of
  the conference to give to QCC to scan
• If you FAIL to give me the above materials, it is
  YOUR responsibility to go over to QCC PRIOR to
  the conference to have them scanned
• NO ONE LIKES THIS LAST MINUTE, SO LETs BE
  COURTEOUS!!
• Make sure you go over the above materials so that
  you know WHAT you are looking for!!
• Pls print out only exact films you want scanned
• Please return all films to Radiology!!! Thanks

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Team Conference (IOL - 5)

• Conference put on by each of the teams
• Bring 1-2 cases centered around 1 topic
• Please go over and discuss the cases with your
  team attending i.e. Dr. Brown, Dr. Soll, Dr.
  Schatz/Dr. Hong
• Invite the attending/consultants on the patients
  case
• Please make presentations focused, pertinent,
  organized R1 to present case Upper Level to
  present didactic
• Ask focused clinical questions apply EBM
  principles Avoid general reviews of basic topics
• Power point presentation preferred
• Plan Ahead / Be prepared (you may be post call)

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Pathology Support

• Available for any conference
• Great support and teaching!!!
• gt48 hr notification to pathology required
• Contact Dr Kirk Hirata
• They will direct you to the pathologist on your
  case who can then go over slides with you
• Please go over the specimen slides with them
  PRIOR to conference so that they know what you
  are looking to show
• Pathology brings all slides over for you on day
  of conference just give them name medical
  record

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Autopsy

• Encourage post-mortem exams, especially on
  patients with unknown or unexpected deaths
• Depending on your relationship with the family,
  you may want the attending to be present as well
• Have atleast one member of the team observe the
  autopsy good experience!!!
• Please sign in
• When attending autopsy, sign in log in sheet in
  morgue
• When reading a pts autopsy report in MR, sign in
  log in sheet in MR (prelim report available
  within 1wk)
• Rayette Kaneshiro (x 2896) Chief Path Assistant
  to co-ordinate viewing of post-mortem

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MEDICAL RECORDS

• Check WEEKLY for pending dictations or signatures
• Delinquent records posted weekly
• If charts not completed in timely manner,
  suspension (without pay) may be imposed if not
  completed by end of block, will not receive
  credit for rotation until done
• Access key (grey) application apply at Medical
  Records for 24 hr access/entry into hosp via POB1
• COPIES
• Ask med records staff to help with copying chart
  material in compliance with HIPAA 24hrs before
  want chart copy
• QMC Banned Abbreviations make note! Will
  receive notice if use banned abbreviations from
  Dr. Freidman

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CONFIDENTIALITY

• QMC Monitors Your Actions on CLIQ
• Do not attempt to access any pts record unless
  you are directly involved in the care of the
  patient
• If using PDA (e.g. Palm pilot) for patient
  information, it must be Password Protected in
  case it is misplaced
• Do not discuss specific patients in public places
  (i.e. elevators) and/or in front of 3rd parties
• Discard patient specific information in shredding
  bins on floors (grey bins)
• Do not email any patient related information

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HIPPA

• Need your own PACS Code
• Call Charles Kam 585-5436
• Now have to fill out access request form (obtain
  from me, return to me)
• He will give you an ID Password
• PACS available in I5, various ward computers,
  radiology department, MICU
• Conference preparation
• Eliminate names for public presentation
• MR and Account are OK

47
EVALUATIONS

• Faculty eval via computer throughout month
• WebCT website http//webct.hawaii.edu/
• All residents will meet on the last Thursday of
  the block at 1200pm in I-5 Mandatory for all
  residents/interns, including UHS
• To complete evals for your intern/subI/MS3/attendi
  ng/rotation
• To vote for the intern who dictates the best HPs
• To fill out Epsworth Sleep Study questionaire
• To turn in Work Hour sheet

48
A Minute on Communication

• Use Resident adhesive decals on charts
• This is important with the transfers!!!
• Please make this a new priority!
• Mandatory to Print your last name with pager
  under your signature at the end of each H/P or
  Progress Note we are striving for legibility
  and less confusion! or use your stamps after
  your signature!!!
• Please change pager messages appropriately
  always let people know when you will be returning
  to the hospital when you record a new message
• Pager on until 10pm on noncall days

49
CommunicationSome Tips

• Formulate your own thoughts before calling Attg
• Confirm the plans with the attending physician on
  a pt on a daily basis (either verbally if
  unstable, urgent issues or written in chart if
  course is as predicted)
• Call attending after you have admitted their pt
  to discuss assessment plan, even at night or
  early morning this applies for accepting a
  transfer as well to let them know you are now on
  board!
• Keep Attg or consultants abreast about major
  changes in status or plans (Be Courteous they
  appreciate it!)
• Make sure attendings understand that you dont
  follow SNF pts (for MTC pts) when you discuss
  with them about downgrading a patient
• If consultant says pt can go home, pls always
  confer with attg!!!
• Dont just sign off automatically when pts go to
  surgery - make sure attg knows you are thinking
  about signing off pre-surgery to get their
  opinion

50
Communication

• Getting hard-to-find consultants
• You and the attending should agree on 3
  consultants, whom you may then call
• If all 3 are unavailable, then call the attending
  back who then will obtain a consultant himself
• Document important big changes in pts status or
  plans
• Big Treatment Plans should be communicated with
  the RN after they are ordered (can look up their
  phone on board at each station)
• Return pages promptly

51
Tracking Program Changes

• Resident Admit s tally will be done weekly!
• Resident Work Hours
• Asking all to track hrs weekly and will ask if
  over qweek!!!
• Have to stay below 80hrs/week, no longer than 6
  hrs post call, and have 10hrs between working
  days
• Autopsy s/Reviews
• Important to sign in at morgue and at MR when
  reviewing autopsy report
• Please encourage autopsies on all patients
• Attending Bedside Visits with Resident Team
• Within 36hrs of admission residents
  responsibility to set up with attending (has to
  meet with atleast 1 member of the team)
• Will ask for of this occuring at end of
  rotation
• Fatigue/Sleepiness using Epsworth sleep study
• Attending s / Team want to limit from being
  excessive

52
New Pharmacy Regulations

• Based on National Regulations
• In pt Pharmacy is now limiting d/c medication amt
• Maximum of days is a 7 day supply on discharge
  from inpatient pharmacy
• If pt wants larger supply, then can write
  additional prescription to take to fill at
  outside pharmacy (get separate prescription pad
  at any nurses station)

53
Problems??

• QMC Blood/Body Fluid Exposure Policy
• 24-hour confidential hotline [phone]
• Dont wait! Based on the risk, you may need
  immediate care follow-up as well as the patient
• Alternative ER
• Please let CMR know ASAP within 24hrs (need to
  report to UHIMRP, HRP)
• Please clean up after your own procedures, esp
  regarding sharps!!!(See Infectious Waste Disposal
  Guidelines in your packet)
• Verbal abuse, sexual harassment, or other
  inappropriate behavior are NOT tolerated Please
  let me or Dr. Soll know about any occurrence
• Any problem notify CMR early what I do not
  know I cannot respond to

54
ACGME CompetenciesCurriculum Incorporated and
Evaluated

• 1) Medical Knowledge
• 2) Interpersonal Communication
• 3) Patient Care
• 4) Professionalism
• 5) Practice-based learning
• 6) Systems-based practice
• must know for site visit in april 2004!!!

55
Reminders

• Sympathy Cards in I-5
• Procedure cards in I-5
• QMC 9F copier ID, then 1103, then press
  password 6377, then ID (green button) ask for
  key at 9DH nurses station
• Batteries are available ask me!
• Articles in I-5
• Newest ones on board
• Others in file drawer Articles of Interest
• Please check your mailboxes periodically in I-5!
• Update the Procedure List on the board I send
  your names to ICU/ER/QEC so if have available
  procedures to give you, they may call you

56
Reminders

• If pagers go down
• Please let Sandra know as she is contact person
  with Island Page
• Please let ER (4311), bed control (4389), and
  console (4501) know to call you via the MTC
  admissions pager 578-8169 (serves as a back up
  as it is a hospital pager)
• Interns are told to let console know to page them
  through their Code pager (serves as back up pager)

57
EDUCATIONAL MATERIALSUp Coming

• Case-Based Articles are available on board in
  file drawer in I-5
• New Textbooks are available in I-5 and Call Rms
  pls keep them in good shape!
• Board Review Questions specialty run,
  consultants present
• Board Review ShowTell in MR
• UTD now on I5, MICU computer, HML Website (can
  only access from Queens)
• ICU Files (PDA, PDF) available on I5 Computer
• Antibiotic Corner read succinct summary on each
  class of abx for review
• MKSAP 13 can borrow a book for the month from
  CMR
• Focus on Curriculum inpatient curriculum in
  your folder!

58
Miscellaneous

• Jeopardy Call
• will be staffed by residents / interns from
  non-call months (Electives, VA, AS)
• Will be paid jeopardy
• Oncology Resident for block will do the last
  shift in MICU for those months with Q3 shifts
  (paid jeopardy)
• On Call Meal ticket is available in your packet
  (10/call)
• Scrubs can ask for pair to borrow for month,
  must return
• New Call Rm is on QET 7 (code is 4-3-5-1)
• Iolani-5 Conference Rm code is 4-3-1-2
• MAPs please always calculate if going to use
  for monitoring esp when going to based
  treatment upon MAPs if pt without a-line (looking
  into this currently)
• Death Leave 3 days leave with pay is allowed if
  death of an immediate family member (5 days if
  off island see handbook)

59
Miscellaneous

• Punctuality for all Rounds
• Please keep I-5, QCC, call room clean
• Ultimately, nonpost call and nononcall teams are
  responsible to clean I-5 after conference if
  Sandra is not at conference!
• PLEASE CLEAN UP AFTER YOUR OWN MESS!!!
• If you fail to keep I-5 clean, lunch will be
  cancelled until the end of the block!!!
• Please do not leave bagel/other in toaster oven
  unattended!!! (set off fire alarm recently after
  it burnt!)
• Please do not steal food at Mabel Smythe from
  other conferences
• Can call CMR for assistance with pts, supervision
  for procedures, Mini-CEX exams!!! Dont hesitate!
• Let me know if you are going over 80hrs/week on
  average over a 4 week period so that we can
  respond!!! If I dont know, I cant help you get
  out within the rules

60
Thank You!Recognition for Hard Work

• Are you over 35? Club
• Recognizes the upper levels interns who
  admit/accept atleast 35 patients total by end of
  the block
• At end of the year, 1 upper 1 intern will be
  randomly selected from the club to each win a
  100 gift certificate to Roys
• Look at weekly tally on board In I-5 to peek at
  your s
• Best Intern HP Award
• Each block, the residents/interns at Queens will
  vote on the intern who does the best HPs
  (complete, concise, timely)
• The awarded intern each block will receive a 25
  gift certificate to Kuuaina Burger