Junior Resident Medical Teaching Unit Orientation Document Foothills Medical Centre Peter Lougheed Centre Rockyview General Hospital South Health Campus

Welcome to the Medical Teaching Unit (MTU) at the University of Calgary! You will receive a brief orientation on your first day depending on which site you are assigned to, but this is a detailed overview of the locations, schedules and expectations of the MTU. MTU is first and foremost a teaching unit. You will be part of a multidisciplinary team with various levels and areas of training. Formal teaching is scheduled at each site as per the schedule below. MTU patients are typically academically interesting, complex or too unstable for other services. Sometimes they are all three! Remember that your two priorities on the MTU are patient care and your education. Have fun! Last updated September 2016

A TYPICAL DAY ON THE MTU: Morning

• Handover: Meet at 8 am sharp in the designated team rooms (see site specific section). Here you will meet your team, receive patient handover.

• Print out a single spaced patient list and write the clerk / resident assigned for the day next to the patient name. Provide this list to the Unit Clerk (FMC Unit 36/PLC Unit 38/RGH Unit 93/SHC Unit 66).

• Morning Report: site dependant • Review Admissions: Meet with your staff to review overnight admissions • See your patients: See patients in order from sickest >> those needing discharge >> least

sick. Afternoon

• Lunchtime Rounds: (site specific) • “Run the List” - Meet with your team in the afternoon to discuss the patient list (depending

on the senior resident/staff, generally 2-3pm) • Follow up on any outstanding issues from the morning • Update Signout Tool: Update the electronic Sign-Out in SCM • Evening Handover: Meet the evening / overnight team at 5 pm for patient handover

Teaching (Site Specific)

• Educational Rounds are a strong tradition within the culture of MTU. In addition to informal teaching, there are a number of scheduled teaching rounds – please refer to the department website for the up to date calendar

o Morning Report - The senior resident assigned (see call schedule emailed to you) will lead a case-based presentation. Staff are encouraged to attend.

o Subspecialty Rounds o Simulation Rounds (RGH Site-Specific) o CPC Rounds - Joint rounds between the departments of Internal Medicine and

Pathology. A case is co-presented by a resident from each department. TEAM STRUCTURE Pre-Clerks – 2nd year medical students doing an elective as part of their 440 course. No SCM access, can not order any investigations or medications. Clerks – 3rd or 4th year medical students. Have completed all lectures/course work. Have SCM access and can order medications, but these must be “verified” by an MD before they are active. Junior Residents – First year residents. Able to order medications and investigations independently. Senior Resident – R2 or R3 Internal Medicine residents. Act in one of two roles:

• Ward Senior – manages their respective team. Oversee all patient management and rounds and reports directly to the staff physician.

• Emergency Liaison (EL) – responsible for daytime consults from ED and transfer-of-care requests, supervising juniors and clerks perform any available procedures, confirm all teaching sessions

• Night Float Senior – responsible for triaging overnight ED consults/admissions Attending – The staff physician ultimately responsible for all patients on the team. All admissions must be reviewed directly with staff.

FOOTHILLS MEDICAL CENTER MTU – Unit 36 Team Room: Blue/Yellow/Silver teams meet on Unit 36 in the conference room (turn left off

elevator/stairs, walk straight past nursing station. First door on the left past the big whiteboard). Swipecard access

Blue team: back room Yellow team: main conference room Silver team: main conference room, far side Call Rooms: Junior / Clerk Call Room – Main Building EG19 (ground floor, directly under the ED). Swipe Card Entry initially; the code to the individual call rooms is 1500*. Senior Call Room – McCaig Tower Room 6476.

• Take the public elevators to the 6th floor and turn left towards unit 64 • Go through the recessed door on the right immediately before the main double doors to Unit

64 (swipe card required). • Follow the hallway. Swipe card access into call room on the right.

Doc’s Lounge: Found in the hallway between SSB and the main building (art work is on the walls of this hallway) – unlabelled white double doors. Swipe card entry. Resident Lounge: Main Tower 2nd floor at the far west end of the hallway (past nephro offices) Scrub Room: In the basement accessible via main elevators (0700-1500h, door usually left open after hours). FMC WEEKLY SCHEDULE:

Monday Tuesday Wednesday Thursday Friday 0800 – 0815 Handover Handover

Handover Handover Handover

0815 – 0900 Morning Report

Week 1/3 – Pharmacy Week 2/4 -

Clinical Pharmacology

Morning Report Jr/clerks/Sr Bedside Teaching

0900 – 1200

1200 - 1300

Subspecialty Teaching Week 1 – MTU Intro Week 2 – Endocrine Week 3 – Hematology Week 4 – Blank (U36 Team Rooms)

CPC Rounds (Coombs) IM Resident

Half Day

Nephrology Rounds (Unit 36)

Subspecialty Teaching Week 1 – Geriatrics Week 2 – Rheum Week 3 – Resp Week 4 – Med Onc (U36 Team Rooms)

1300 – 1700 1700 – 1715 Evening Sign-out, Blue team room, Unit 36 Bullet Rounds (1100, U36 Conference Room) – attended by the Ward Seniors Staff Led Bedside Teaching - Junior Medicine Teaching occurs Fridays from 0815 to 0900 on Unit 36– the Thursday overnight house staff is expected to attend

PETER LOUGHEED CENTER MTU – Units 38 / 39 / 49 Team Rooms: Green Team Meet in Room 3841 on Unit 38 Gold Team Meet in Room 3952 on Unit 39 Orange Team Meeting in Room 3051, East Wing Call Rooms: Junior/Clerk and Senior Call Rooms are in the basement of the old building/west wing.

• Go down the hallway between Second Cup and the West Entrance Info Desk. • Take the elevators (on the right) to the basement. • Turn right and go up the short staircase. • The door to your right is the entry to the call rooms (swipe card entry). • Look for the labeled call rooms for Junior / Senior Medicine.

Doc’s Lounge: On main floor of old building near the South Entrance. Take a left when you see the Emergency sign/Admitting. The doctor’s lounge will be the first door on your right after you pass health records. Code: 6978* Resident Lounge: See Call Room directions. These rooms are rarely used, but contain and assortment of free instant coffee/toast/peanut butter/jam and juice containers. Scrubs: The scrub room is in the basement (0730-1700h). Otherwise, try the ORs on the second floor of the main building. The OR nurses can be a stingy with their scrubs, so try to be stealth. PLC WEEKLY SCHEDULE:

Monday Tuesday Wednesday Thursday Friday 0800 – 0815 Handover Handover Handover Handover Handover

0815 – 0900 Morning Report

Morning Report

0900 – 1130

1130 – 1200 IM Teaching Clerks/Jr/Sr

1200 - 1300 CPC Rounds

(usually in Auditorium)

IM Resident’s Half Day

“Professor Rounds” (Rm 3841) Week 1 – allied health Week 2 – various Week 3 – none Week 4 – no rounds; pizza lunch

1300 – 1400 Respirology

CXR Rounds (Unit 39)

ID Rounds (Room 3841) Every second

Thursday

1400 – 1700

1700 – 1715 Evening Sign-out, Green Team Room, Unit 38 Rm 3841

Bullet Rounds – attended by the Ward Seniors Unit 39: Tuesdays @ 1000h (Rm 3841 – Green Team Room) Unit 49: Tuesdays @ 1030 h (Rm 4931 – across from nursing station) Unit 38: Wednesdays @ 1000h (Rm 3952 – Gold Team Room)

Staff Led Bedside Teaching – Junior Medicine Bedside Teaching occurs Tuesdays BEFORE CPC.

ROCKYVIEW GENERAL HOSPITAL MTU – Units 93 / 94 LOCATIONS: Team Room: Meet in the conference immediately to the right as you enter Unit 93 (Rm 9333)

Amber Team Meet in Room 9333 on Unit 93/94

Purple Team Meet in Room 9333 on Unit 93/94

Please avoid storing your personal items (jackets, bags) in the Unit 93 conference room. This is not a secure location. There are a number of lockers designated for use by residents and clerks that are located on Unit 93 for day use only, and require the user to bring a lock. Please ask at the nursing station for the location of these lockers. Call Rooms: Call rooms are located in the Education Annex (Follow the signs for Conference Room

4577 – Go up the stairs once in the portable)…. The code is 1234*. Senior Call Room – Rm 4N129 – (next to the new gift shop and across from the Chapel) Junior Call Room – Rm 4586 and 4594

Resident Lounge: In the Education Annex (aka portables). Code for entry is 1234* (follow signs to conference room 4577). Doc’s Lounge: From the main entrance (by the Good Earth Coffee) follow a long hallway towards health records. The lounge is at the very end. Code is the four numbers from bottom up on the left side of the keypad, then *. Scrubs: Some scrubs are found in the Residents’ Lounge. The main scrub room is in the basement. RGH WEEKLY SCHEDULE:

Monday Tuesday Wednesday Thursday Friday 0800 – 0815 Handover

Handover Handover Handover

0815 – 0900 Morning Report Morning Report

Morning Report

1000 – 1200

1200 - 1300

High Fidelity Simulation

(Simulation Center – Basement)

CPC Rounds (Rm 10331 – RGH

10th Floor)

Harvey (Simulation Center

– Basement)

Harvey for IM residents

(Simulation Center – Basement)

JAMA Rational Clinical Exam Series (U93 Conference Room)

1300 – 1700 IM Resident’s

Half Day

1700 – 1715 Evening Sign-out, Unit 93 Conference Room (Rm 9333)

SOUTH HEALTH CAMPUS MTU – Unit 66 LOCATIONS: Team Room: Meet in Room 670109B on Unit 66 Call Rooms: Call rooms are located on the 6th Floor beside Unit 66 (See Appendix A: Maps)

Junior / Clerk Call Room – Rm 60117 Senior Call Room – Unassigned spare call rooms in On-Call Suite Rm C-260142

Doc’s Lounge: Located between the cafeteria and the YMCA Wellness Center. Swipe card access into the “Business Lounge” room. Resident Lounge: Take the Inpatient Elevators to the 4th Floor. Go past the direction of the administrative offices to Rm 480100. Swipe card access. There’s a Keurig Machine in there! (No Keurig cartridges though). Scrub Room: Scrubs can be obtained from Linen Services on the basement floor. Follow the signs toward Facilities Engineering and Maintenance, and eventually there will be a sign that says Linen Services. It closes before 5 pm. SHC WEEKLY SCHEDULE:

Monday Tuesday Wednesday Thursday Friday 0800 – 0815 Handover Handover Handover Handover Handover

0815 – 0900 Morning Report CXR Rounds (Rm 670109B)

Morning Report

1200 - 1300 CPC Rounds (Rm 410015)

IM Journal Club or Subspecialty

Rounds (alternate weeks)

(Rm 670109B)

1300-1400 Nephro/ID Rounds (alternate weeks)

(Rm 670109B)

1300 – 1700 Resident’s

Half Day

1700 – 1715 Evening Sign-out, Rm 670109B

Common Questions: Where is Rm 410015? Take the Outpatient Elevators (the set of elevators closer to the GoodEarth Coffee) to the 4th floor and make a left. The conference room is at the end of the hall. What is the code to the staff washrooms? Type in the last 4 digits of the “room number” then *

JUNIOR RESIDENTS UNIVERSAL EXPECTATIONS

1. Attend all work rounds, the times of which are set by the ward senior and staff physician. 2. Attend all educational rounds. 3. Discharging Patients

a. A Written Discharge Summary is to be done on all discharges, at the time of discharge, such that the patient may have a copy. Make sure to copy your staff, the patient’s family physician, and any physicians the patient will see in follow-up.

4. Ask for help whenever needed – there is a senior resident or staff in house 24/7 EXPECTATIONS OF CLERKS and JUNIORS:

1. Examine your patients daily - basic exam includes review: a. Vitals (including overnight) - all vitals are recorded in SCM b. Physical exam: CV/Resp, Abdo and any additional pertinent exams c. Review “ins/outs” - drains, foley, lines, chest tubes etc.

2. Communicate with bedside nurse daily.

3. Review lab work – address critical values immediately. Order tomorrow’s labs rationally. Note:

patients with central lines or PICC lines are ordered as “unit to collect”.

4. Review medications – justify EVERY ORDER on SCM a. Know what is ordered and why. b. Cancel old PRNs that aren’t needed. c. Ensure medications such as antibiotics and fluids have appropriate stop dates. d. Mark medications as “reviewed” and renew appropriately. e. Consider DVT and GI Prophylaxis when appropriate.

5. Discharge Planning

a. Thorough, yet succinct, discharge summaries that indicated the (1) Admission and discharge diagnoses, (2) Important events and treatments in hospital, (3) discharge medications, and (4) follow-up for the patient.

b. Preventative Health - vaccinations c. Patient Education d. Follow-up Appointments – whenever possible, ask the Unit Clerk to book BEFORE the

patient is discharged. Record appointment dates, locations, and contact numbers in the chart AND in the written discharge summary provided to the patient.

i. MTU coordinators Jennifer Cowles (FMC) and Mary WIdas (PLC) are excellent resources for facilitating outpatient resources for your patients at time of discharge

6. Write a note – date and time always! Every patient gets a daily note. Use SOAP format.

Clerks must review their patients/notes with a Junior or Senior Resident on a Daily Basis. • ID – one or two line summary of patient (ie: 73M admitted 5 days ago with

AECOPD) • Subjective – descriptive summary of clinical status, overnight issues (ie: O2

requirements decreasing. Afebrile overnight. Feels “Well.) • Objective –record vitals, physical exam and relevant lab work • Assessment/Plan –issues based, numbered based on priority

I.Hypoxia a. Likely secondary to AECOPD but consider PE if not better

b. Day 4/5 prednisone 50mg (then stop), 4/5 Levofloxacin c. Chest physiotherapy

II.DM2 a. Stable – no changes to insulin regimen b. diabetic diet (tolerating), Metformin restarted

III.Disposition – OT/PT to assess safety to discharge home

7. Attend all teaching sessions. They are mandatory unless your patient is unstable. 8. Call for help right away! Assess all patients personally with any change in status and

document. If your patient is unstable or you are worried, call/page your team right away. Seniors and staff are there to help you, don’t risk patient safety because you are unsure or don’t want to appear “dumb”.

9. Handover a. Each day, update the “Health Issues” section of SCM so that they may be integrated

into the Handover Document b. Take ownership of your patients at 1700h Handover. Present your patients succinctly,

giving an Identification, relevant Past Medical Issues, Present Active Issues, and Anticipated Overnight Problems.

EXPECTATIONS OF THE ON CALL CLERK/JUNIOR

1. Check in with the Senior Resident a. At FMC/PLC – handover at 1700h and 2000h b. At RGH/SHC – handover at 2000h

2. Take charge of your ward/team. a. Check in with the Charge Nurses for each of your patients and ensure that overnight

issues are dealt with. b. Manage urgent/emergent issues at night and document patient encounters. c. Ask for help as needed. Keep your senior resident aware of major occurrences. d. “Sign” any phone orders on SCM.

3. Admit new patients as directed by your senior. 4. Clerks must review all activities with a junior or senior resident 5. MTU On Call residents must stay in the hospital for the entire duration of their call shift.

WEEKEND/STATUTORY HOLIDAYS CALL

1. During the day, the juniors/clerks round on their own team’s patients, reviewing directly with staff.

2. After rounding, the rest of the call proceeds as per night call.

Things to Remember When Admitting Patients: ED Length of Stay The intent of this process is to enhance patient care and shorten the ED admission process.

The senior resident taking emergency department consultations will conduct an initial triage of a patient and make a decision around admission prior to assigning the consult to the junior trainee to complete. The admission order should be entered in Sunrise Clinical Manager WITHIN 2 HOURS of the initial request for consultation, if appropriate.

A decision to admit may be delayed until it is clear that the patient is appropriate for the MTU service (i.e. awaiting assessment via another consulting service). Refer to Appendix B for official policy. Medication Reconciliation Implemented in 2013 by Alberta Health Services as part of their accreditation standards. Complete the entire Med Rec forms scattered throughout the emergency or already in the Emergency patient chart. Anticipated Date of Discharge Implemented in 2013 by AHS. An order in SCM to document your “best guess” at a patient’s anticipated length of stay in hospital. This can be found in the SCM under “ADOD”. You can indicate “unknown” if it is truly the case.

Program Contacts

Dr. Marcy Mintz Program Director Tana McPhee MTU Program Administrator Jennifer Glow Jenna Young Erin Layton Lisa Voluntad

IM Program Administrators

Dr. David Sam FMC MTU Director Dr. Ben Wilson PLC MTU Director Dr. Oliver Haw For Chin RGH MTU Director Dr. Paul Davis SHC MTU Director Jennifer Cowles FMC MTU Patient Care Coordinator Mary Widas PLC MTU Patient Care Coordinator John Lam Caley Shukalek Sarah Perry Mike Bosch

Chief Medical Residents (2016-2017)

Fareed Kamar, PGY 3 Yael Shrom, PGY 2 TBA, PGY 1

MTU Committee Representatives

APPENDIX A: MAP FOOTHILLS MEDICAL CENTER

PETER LOUGHEED CENTER

ROCKYVIEW GENERAL HOSPITAL

SOUTH HEALTH CAMPUS

SOUTH HEALTH CAMPUS