Welcome toPediatrics at MSKCC!New Resident OrientationTina Desai, M.D.Pediatric Chief Resident 2016-2017

What Should You Learn At MSK?Pediatric Oncology Basics of ChemotherapyPain managementNausea and vomitingElectrolyte imbalancesConstipationAntibiotic managementInfections from A-ZDermatologic findings Fever and neutropenia

In addition, you will gain experience working with end-of-life issues and difficult family situations

Organization of Clinical Services

Organization of clinical servicesThe entire 9th floor is devoted to Pediatrics9th floor is divided into:Inpatient M9PICUPediatric Day Hospital (the PDH)

Pediatric Day Hospital (PDH)The PDH is the outpatient side of Pediatrics at MSKPatients come to see their primary team for everything from check-ups to chemo to transfusions to proceduresThe PDH sees >150 pts per dayMost of the floor admissions come directly from PDH

MSK Primary TeamsPatients are assigned a Primary Team (i.e., leukemia, neuroblastoma, sarcoma) based on their primary disease at diagnosisFollowed by Primary team throughout their disease courseWhile inpatient, primary team will give input on their care; the fellow is the liaison for this communication

Bone Marrow Transplant (BMT, Blue Team) is its own Primary Team

PICUThe PICU is a 5-bed unit, opened June 2014Manages all unstable patients except patients requiring CVVH/Dialysis or OscillatorThese patients will go to NYP/Cornell PICUPICU Consult (Call x6443)PICU NP within 30 minutesRapid Response (Call x5000)PICU NP + Charge RN + Resp Therapy within 5 minutesPediatric Code (Call x6000)

Inpatient Team StructureTwo Clinical Teams

Green General Oncology/SurgeryBlue Bone Marrow Transplant

M9 Inpatient ServiceGREEN Team General Oncology/SurgeryAttending and 1st Year Fellow2 PGY-3 Senior Residents from Downstate3-5 PGY1/PGY2 residents from Cornell, St. Barnabas, Harlem, Lincoln

3 Nurse Practitioners Each NP works 3 days/week (M-F)Most days: 1-2 NP on the teamSchedule is posted in the workroom

M9 Inpatient ServiceBLUE Team Bone Marrow Transplant (BMT)

One attending, one 1st year fellow3-4 residents from Cornell, Downstate, Metropolitan

People and Roles At MSK

Green Team NPsInclude: Liz Barry, Taylor Pecora-Saipe, Nadia WilsonIncredible resource: whom to call, how to get things done, great understanding of patient pathologyWill help senior resident with admission assignments/distribution of patients in the morningHours are 7am-7pm, Mon-FriThey cap at 6 patientsDont be shy!- Ask them questions, their office number is # 6403

NursesRNs at MSK know the kids and know the oncologyMany of the kids are well-known by the nursesIf they think something is wrong, it is wrong!If they ask you to speak to the parents or the patient, GO!

BMT Nurse CliniciansAdrienne & Katie 1 of them is here every weekdayHelp coordinate care of BMT patientsHelp communicate plan of care with staff RNsShare office w/ Green Team NPs & chief residentX5198Ask them lots of questions!!

Nurse Case ManagerThe Nurse Case Manager is a wizard with discharge and insurance issuesDevin PriceESSENTIAL TO COMMUNICATE DISCHARGES/HOME CARE NEEDS TO HER EARLY!

Clinical PharmacistsA clinical pharmacist rounds with each team on weekdaysExtremely knowledgeable about medication dosing, side effects, & oncology/BMT in generalWill help you with prescriptions, ordering meds, etc.Green Team: Jen, Shirley, DazhiBMT: Melissa, Michelle, Krisoula, Bryan

Green Team Senior ResidentSupervises PGY-1 and PGY-2 residents on GreenSupervises AM and PM sign-outWorks with the fellow/attending to make sure plans are being carried out by junior residents Facilitates rounds by checking labs, entering orders, updating hand off tabPerforms admissions with PGY-1 and PGY-2 residentsAttends daily 12pm discharge huddleCommunicates problems/concerns about residents to chief resident, fellow and attending

Daily Schedule and Expectations

MorningsAM Signout 7am for both teamsGreen Team signs out in workroom, supervised by senior residentsBlue Team - more individualized, get sign out from on-call resident

Get your pager from the drawer

Pre-round before 9am attending roundsReview vital signs, I/Os, PCA doses/ attemptsReview lab results and discuss problems or questions with the senior

HOSPITAL POLICY: Orders for PCAs and IV fluids must be renewed every single day

RoundsAttending Rounds - 9amYou MUST facilitate rounds by: Being prepared to present on your patientsHelping to look up labs, move computers when your patients are not being presentedWho goes into the patients room?Green team: all housestaff can, unless patient is on special isolation precautions or family preferenceBlue team: primary resident & blue resident on call for that night

Presentations on RoundsPresenting: New AdmissionsHPI, then summary of their Onc History (which you should have read carefully before presenting)

Presenting: Patients known to the teamOne liner, then the rest of your presentation by systems/problemsRelevant lab results only

Radiology RoundsMondays, Wednesdays and Fridays at 11am in the PDH ClassroomReview all radiology for the team for the past 24 hours with the pediatric attending radiologistFellow gives one-liner about patient & why study performedEx: Maggie is a 2 year old girl with Stage IV neuroblastoma who was having increased vomiting and abdominal distention and thats why we got the CT.

Lectures/ConferencesAbout 3-4 times per week at 1:30pm in workroomLectures given by attendings, fellows, pharmacists, chief residentGreen Team residents also give short interactive case presentations prior to the end of the blockLecture schedule posted in workroom Grand Rounds on Thursday mornings at 8:30am (except during the summer)Tumor Board (C-569) on Tues 2pm, Thurs 3pmNeuro-Onc Tumor Board on Wed @ 2:30pm

NotesDaily notesYou may copy/forward from previous notes BUT, you must UPDATE EVERY LINE, EVERY DAY!Yes, the Attendings DO read your notes!DO NOT hit resident complete or forward your note to the attending until you are absolutely 100% finished Everything in your note should be clear and correctYour assessment should be up-to-date and specificYour plan should be listed by systems OR problems

Labs/PhlebotomyMost labs will be back by the time you arrive in the morningYou must order routine morning labs before signing out in the evening (use order set!)AM Labs are drawn by the night nursesAll labs are drawn off of central lines, including blood culturesWhen labs are needed at other times, ask the patients RN and enter the order in the computerIf a patient does not have central access the RNs will draw the labsYou will rarely have to attempt venipuncture at MSK

PM SignoutEvening Sign OutGreen: Hospitalist & night float resident arrive at 6pmBlue: Sign out to on-call resident or moonlighting fellow at 5pmSign out should be clear & conciseInclude brief summary of days events only relevant issuesVery important to include contingency plans for overnightElectronic handoff tab must be updated before signout!

Admissions & Discharges

AdmissionsCheck white board in RN station for planned admissionsGreen Team: Admissions very common, several per dayChief resident gets initial sign-out on admissions Admissions are assigned to juniors/interns by the senior residentsBlue Team: Admissions are less commonIn general, you will decide among yourselves who will do which admissionBe kind and fair to each otherOn-call resident should take admissions that come after 4:30pm

AdmissionsAdmissions from 8am-6pm come from the PDH after being assessed by the Primary teamDo not wait for the patient to arrive on the floor go to the PDH to begin the admission process with your HPI, ROS and PE

Post-op admissions come from PACUNeed to get both surgical team and PACU signoutOnce patient is cleared by Anesthesia, floor team is responsible for patient including orders (even if patient must remain in PACU due to lack of available beds on M9)

At night, admissions come from UCC after being assessed by fellowUCC is the MSK Emergency Room only for MSK patientsThe fellow will discuss the patient and plan with you (and the hospitalist for Green admissions)

AdmissionsUse the M9 Admissions Sheet as a GuideReview the most recent outpatient notesPerform a careful HPI, ROS, review meds & allergiesBridge any gaps in their history since the last noteDo NOT do a full PMHx with the pt/family (although make sure it is in your note)Your plan will be discussed with the senior/fellowOrdersUse the Admission Order set in the computer for admissions!There are order sets for Blue and Green teamsIf patient not yet on M9, must use either Pre-admit chart or Peds UCC Inpatient chart (do not put orders in an outpatient chart you will have to re-do them!)You must print 3 copies of the Code Sheet at admission & give to unit assistants (Google cornell emergency medications)

Medication ReconciliationPerform Med Rec on both Admission and Discharge

ADMISSION MED REC:First, update the home med list by clicking Outpatient Medication Review on CIS toolbarPrint the medication list and review with familyClick green check mark for meds that are accurate/patient still takingDiscontinue any meds that the patient is no longer takingWhen finished, click Save CompleteNext, click Order Reconciliation on CIS toolbarMust be completed with 24 hours of admissionClick Admission (New) active home meds from home med list will appear on left; active inpatient orders appear on the rightReconcile all meds that will continue as inpatient ordersMark all remaining meds (that wont be continued) as held on admissionClick Save as Complete when finished

DischargesAnticipate discharges in advance Important Elements of DischargePrescriptions (using E-Prescribe)Must be sent to pharmacy 1-2 days in advanceCommunicate w/ Case ManagersHome care, supplies, IV antibiotics at home, etc.Follow-up appointmentsMed Rec (via Order Reconciliation)Discharge Order SetDischarge Note/Summary (saved on S drive)Start on HD #1 or #2, update twice per week, ESPECIALLY FRIDAYS

Discharge Med RecClick Order Reconciliation on CIS toolbarClick Discharge (New)All current inpatient orders & outpatient meds will appear on the leftNeed to reconcile all meds and continue the ones that patient will go home on (these will appear on the right)Need to write prescriptions from within Order Reconciliation module will link to prescription writerCannot submit prescriptions from within the module unless saving as complete must exit module (after saving as incomplete) and then click on Prescription Writer to submit prescriptionsClick Save as Complete when finishedCannot enter discharge orders until Discharge Med Rec is complete

Resident Email AccountEach resident has their own MSK email accountStart Menu OutlookPlease check your email!

CallTips and Expectations

BLUE TEAM PM SignoutBlue Team PM Sign-Out: 5pmMay start as early as 4:30pm only if the person on-call is done with their workDo not be bullied into allowing early sign-out if you are still completing notes/other work!Give good signout make sure electronic Hand-Off is updatedIndicate clearly what might happen, and what the resident on-call should doIf labs are expected, tell the on-call resident the time they will be drawn

Weekday Call: BLUE TEAMStarts at 5pmCall room & meal cards availableFellow on call with you, but is also supervising Urgent CareAlways available, page if neededResponsible for admissions that come after 4:30pmDuring morning rounds, very important to see all patients w/ team and take notes on the plan print a list of ALL the patients

Weekday Call: BLUE TEAMResponsibilities:Check to make sure AM labs for ALL patients are appropriateReview plans with on-call fellowNotes & orders on all admissionsMonitor vitals, I/Os, labs as they come backPrint sign-out sheets from electronic hand-off tabs on all patients (labs and meds auto-populate) Remember, on-call fellow & PICU are always available to you

Weekend Call: BLUE TEAM 24 hour call (7am-7am)Sign-out at 7 am; rounds at 9 amOn-call resident responsible for:Daily progress notes for all patients on the serviceAll admissions, discharges, and transfers with notes AM vitals & I/Os of all patientsFellow on call with youCafeteria closes early on weekends

Weekend Call: GREEN TEAMThere are always two residents on call7am-6pmDivide patients equallySeniors on short call: this is not a supervisory role; split the patients w/ the other residentFellow on call with you

Night Float: GREEN TEAMMonday night through Friday night6pm-7:30am (leave after signout)On call with hospitalist attendingResponsibilitiesAdmissions that come through UCC or late post-opsAssign admission notes to hospitalist attending not daytime attendingFollow up on AM labs overnightMonitor VS, I/Os

Call SchedulesShould adhere to ACGME rules (