Resident Business MeetingDecember 2019

Dr. Nguyen

Scholarly ActivityScheduling Reminders

Med TeamsIMC

ICU/CCUMisc

Scholarly Activity

PGY1 Scholarly Activity Requirements

• Journal Club – 2 presentations per day scheduled throughout the year, sign-up sheet

in Chief’s office.– E-mail chief resident the article you have selected the week prior to

when you’re scheduled to present

• Scholarly Activity– Be on the look out for cases or projects-- never too early to start!– Consider working on scholarly projects early if you are interested in

Fellowship

Transitional & Prelim Scholarly Requirements

• QI Project

– TY Group Presentation

– See email from Dr. George

PGY-2 Scholarly Activity Requirements

• Case Presentation or Research/QI Project

– August/September/October

– Present an interesting case/research/QI project

• Clinical Pathology Case Presentation

– March/April/May

PGY3 Scholarly Activity Requirements

• M&M/QI Presentation

Abstract Deadlines

**Remember- All PGY2’s must submit an abstract by the end of the PGY2 year. • SLEEP 2020: June 13-17, 2020 in

Philadelphia, PA• Accepts poster and oral basic/clinical/QI-

PS/innovations in clinical practice research• Abstracts due December 16, 2019• https://www.sleepmeeting.org/submit/call-for-

abstracts/•

• American Diabetes Association 80th

Scientific Session: June 12-16, 2020 in Chicago, IL

• Accepts oral and poster basic/clinical research• Abstracts due January 13, 2020• https://professional.diabetes.org/content-

page/abstracts-1•

• Microbe 2020: June 18-22, 2020 in Chicago, IL

• Accepts oral and poster basic/clinical/QI-PS research and case reports

• Abstracts due January 24, 2020• https://www.asm.org/Events/ASM-

Microbe/Abstracts

Scheduling Reminders

Step 3

• Schedule when on an elective

– NOT ICU, CCU, Med Team or Night Float

• Fill out an off call form (green form) indicating your dates so that I can schedule you off appropriately

• For categoricals

– Must be completed by the end of PGY2 year

MKSAP BOARD PREP

• Mandatory for categorical interns/residents

• Taken in the department of medicine during normal business hours

• Prior to taking– Let either Mike Oravec, Emily George, Mary Yanik, or Joel Rayl know

you’ll be taking the exam

• After taking– Show one of us your score – even if you do not “pass” so that we can

record that you are “caught up” and working the program.

• Email Etiquette– Emails from Joel or myself needs a reply ASAP

Call Changes

• MUST be approved by me

• CANNOT violate duty hours

• FORMS available in my office

– Coordinate call and post call days out of IMC, LTC, CBT

Perfect Serve

• Everybody should be using it by now

• Call schedules are also listed in Perfect Serve

– IMPORTANT!• IF you have a call change or you had a conversation with me about

switching shifts, double check Perfect Serve to make sure the change has happened so you don’t keep getting pages.

• Night Teams and Admitting Teams should be checking at the beginning of their shifts to ensure they are the correct person getting called.

• If not let me know ASAP so I can fix it so pages go to the correct person

• Patient Safety Issue so please keep on top of this!

Evaluations

• Request 2 evaluations from attendings before end of each month (even night float)– Except on Med Team

• Done through New Innovations

• MUST DO BEFORE END OF THAT MONTH– If you forget until the following month:

• When clicking to request an evaluation by attending make sure to hit “change” to change date range for the month you rotated with that attending

Reviewing Personal Evaluations completed by attendings

Evaluations

• New evaluations through Google Forms

• Rolling out to Med Teams, ICU/CCU, and Sub-specialty rotations

• All evaluations are active now – Request evals on a weekly basis

• Currently working on a reminder system for evaluations for attendings

Med Team & Night Float

Med Teams

• Admission Orders – please enter as soon as decision to admit is made.

– If no “Consult to Internal Medicine,” place order when called by ED Provider.

– If slam dunk – enter immediately or after short 5-10 senior eval

• OK to quick pre-staff with attending if on the fence.

– If not sure – wait until staffing

Med Teams

• If called by ED, go see patient unless they specifically are asking only for follow up appointment

• Do not ask if patient “really needs admitted” or if patient can go to CDU.

• If you feel they should not come to MT, go to ED and chat with attending and PA in person

Med Team CapsPatients counted towards Maximum Maximum Who takes over Evals / Admissions when reaching

Max

Day AR1 – Rule 1 Med Team census +Transfers from ICU/CCU +Admissions +Pending Evals

14 Day AR2

Day AR1 – Rule 2 Admissions + Pending Evals 10 Day AR2

Night AR1 Admissions + Pending Evals 10 Night AR2

Day ICUR (Res #1) ICU Admissions (including transfers) + Pending Evals

8 Second ICUR

Day ICUR (Res #2) ICU Admissions (including transfers) + Pending Evals

8 AR2

Night ICUR ICU Admissions (excluding transfers done by AR2) 8 AR2

*Exception

- if there is a second senior or intern on the admitting team during the day the cap goes to 20

Haiku

Needed to document photos of rashes, lesions, cellulitis in EPIC so care team can follow and staffing attending can view at home

• Summa @ Work -> search “Haiku”

• 2 Part Registration (must do both parts)

– 1: install on device and send Install ID code to mercy

– 2: accept user agreement

Med Teams

• Sticky Note

– Only way that nursing, pharmacists, social workers know who to call

Document All Calls

• ALWAYS leave a note – including ALL night calls– i.e- called for SOB overnight; Even if patient completely

stable, write something like “Called for shortness of breath. Pt received albuterol x 1 prior to my arrival. Breathing is non-labored w/no wheezes. Saturating 98% on Room Air. Likely secondary to pneumonia for which he/she is on antibiotics.”

– If patient has chronic low back pain and you want to give heating pad: “called by RN, patient with chronic unchanged back pain. Will trial heating pad”

Initial H&P’s

• Issues with H&P’s not including family medical history or social history

• When evaluating/admitting a patient—make sure to click history tab and UPDATE/REVIEW the Home Med List, PMH, PSH, FMH, and SHx– Update it in EPIC and click “reviewed”

– Refresh your note and it will appear

Discharge Summaries

• Issues with Discharge Summaries being too detailed– No need for day to day events (i.e. don’t make

it a 10 page journal entry)

• Be concise, hit main points especially things to follow up as outpatient (i.e. labs, imaging, etc.)

Discharge Summaries

• 78 yo M PMH COPD on 2L chronically, tobacco abuse presented for respiratory distress. Admitted to ICU for respiratory failure requiring intubation 7/1. CT chest w/ new lung nodule and concern for new infiltrates. Treated with antibiotics/steroids/duonebs. Strep pneumopositive. Extubated 7/3 and Continued to require 4L O2 on floors. Discharged to SNF with 2 week steroid taper, increase in home O2, and 3 additional days of oral Omnicef. Seen by pulmonology and will follow with Dr. Niraula in Lung nodule clinic.

IMC Reminders

IMC Reminders

• Look ahead to see when your clinic days are in Epic

– If unsure how to do that– ask any senior resident or me

– Refer to step-by-step in IMC Packet

• When you’re on electives– template open far in advance to improve continuity

IMC Changes

• Definitions: – True Clinic = Half day scheduled to see patients– Work-In Clinic

• Labeled as “Special” clinic slot • Only available for Nursing to schedule as it is for Work-In appointments• Up to 4 1-Hour long appointment slots• The actual number of Work-In Clinic half days will be variable – more dependent on the number of

staffing attendings available for that day. • This will also be changing as attending schedules are currently being updated to allow for more

available staffing starting in January.

– Medicine Back-up• Must be in IMC -> back-up for residents who need help• Work on Panel of patients, Healthy Planet, MKSAP, paperwork, etc.

– *** Medicine Back-up must sign-in to red binder and document interventions completed in the binder.

IMC Changes

• PGY-3: (Per Week)– IMC Month or IMC/NF

• At least 3 True Clinic half days• Combination of 3 Work-In Clinic/Medicine Back-Up/LTC• May change based on available staffing• Goal – get back to 6 True Clinic half days

– Elective/Research/Academic• 1 True Clinic half day• 1 Work-In Clinic/Medicine Back-Up/LTC

– Neuro• Work in progress• Condensed schedule • 4 True Clinic half days• 3 Medicine Back-Up half days + 1 LTC

IMC Changes

• PGY-2: (Per Week)– IMC Month or IMC/NF

• At least 3 True Clinic half days + 1 CBT if scheduled that month• At least 4 True Clinic half days if no CBT scheduled• Combination of 3 Work-In Clinic or Medicine Back-up half days• May change based on available staffing • Goal – get back to 6 True Clinic half days

– Elective/Research/Academic• 1 True Clinic half day + 1 CBT if scheduled that month • 2 True Clinic half days if no CBT scheduled

– Neuro• Work in progress• Condensed schedule • 3 True Clinic half days + 1 CBT if scheduled that month • 4 True Clinic half days if no CBT scheduled• 4 Medicine Back-Up half days

IMC Changes

• PGY-1: (Per Week)– IMC Month or IMC/NF

• At least 4 True Clinic half days• 2 Panel Management half days• May change based on available staffing• Goal – get back to 6 True Clinic half days

– Elective/Research/Academic• 1 True Clinic half day

– Neuro• Work in progress• Condensed schedule • 4 True Clinic half days• 4 Panel Management half days

IMC Reminders

• MUST SIGN IN with rooming staff upon arrival

• If you’re scheduled to be in clinic at a certain time but don’t have patients scheduled until later:– You are still expected to be physically present in

clinic

IMC Pre-Charting

• Pre-charting is critical for the current workflow of the IMC

• Residents should Pre-Chart on their patients and review issues they can anticipate going over with the patient.

• This allows for Pre-Staffing with the attending to make the whole visit smoother and streamlined.

Queries

• If you receive a message from….

– Wendy (Winifred Myers) about Billing & Documentation

– RN/MA about patient question

… send a reply back to close the loop of communication

LAB ORDERS AFTER PATIENT VISIT

If labs orders are added after patient leaves- the order must be printed and given to Jillian.

Jillian then writes “ADD ON ORDER” and sends to the lab. If this is not done, the lab can’t process the late order.

“Left without Being Seen”

• If patient roomed by MA but left the office before you could see them:

– Do NOT cancel the encounter | Not “erroneous encounter”

– Delete any pre-charting

– Type: “patient left without being seen” in a note

– Level of Service “E1”

– Visit Dx: “Left without being seen”

– The IMC will bill insurance for facility charge

Closing IMC Encounters

• Notes should be completed by end of day and MUST be completed within 24 hours.

• Billing of notes occurs day following encounter.

• Resident and patient safety concerns

Result Notes

• Result notes should be placed on all results obtained from patients in the IMC.

IMC Box Coverage

• “Buddy” system– When on CCU

• Can cover your own box but NOT a 2nd person’s box

– When on an elective (including research, “off campus” electives such as rheum, derm, endo) or Night Float• Still expected to cover your own box & buddy if needed

– If you and your buddy are both unable to cover your box – YOU are responsible to finding different box coverage and informing Lisa Geerand Nuge

– Do not try to cover your own box when on ICU – it never works

IMC Box Coverage

• Other than the instances where you need your box covered

– You should be going through your EPIC inbox DAILY

– If busy, prioritize tasks:

• Refill requests

• Patient calls

• Urgent issues/concerns from support staff

– This is a professional responsibility and extremely important for patient care

LEP Patients (Limited English Proficiency)

• Call CJ to schedule as office process in place to ensure not too many scheduled at same time

IMC: Non-English speaking patients

• Remember to use dot phrase

– .interpreter (if interpreter used)

– .interpreter declined (if patient declined interpreter)

IMC Patient Calls & Refills

• Ask about refills when seeing patient in the office (even if you aren’t their PCP)

• Refill meds for 6 months to 1 year at a time depending on circumstances

• Issues with patients calling multiple time for med refills, etc

• Reminder– If you aren’t sure what to do with a certain refill request or

patient call PLEASE ask a senior resident or one of the faculty (we’d be happy to help!)

IMC Telephone Encounters

• Front staff now trained to review and address encounters routed to them– If scheduling/clerical issue

• route encounter to “front desk” pool

– If clinical issue or URGENT issue• route encounter to “clinical staff” pool

• Reminder:– If you reply to a telephone encounter and click “route

to sender” you also need to route back to the entire pool (in case sender is off for vacation, etc)

IMC: Sending Patients to ER

• Make sure to document in your note:

– Patient was transferred to the ER by IMC nurse via wheelchair

Parking Passes for IMC

• Elizabeth has parking passes for any patients who need them

• Obtained from the Schneider Fund

Short Term Brief Intervention Counseling

• Short, problem focused session with BHC

• Assistance for anyone experiencing mental health, substance abuse, or behavioral change issues.

• Scheduled Monday PM, Tuesday and Thursday AM

• Talk to Stephanie (BHC) for more info

ICU & CCU

CCU and ICU Census

• CCU census– 1 PGY1: 5 patient maximum– 2 PGY1’s: 10 patient maximum– CCU teaching attending responsible for cutting list– New ACH CCUres in addition to ACH CCU list (similar to cutting lists in ICU)

• ICU census– 3 PGY1’s: senior reduces list to 15 patients– 2 PGY1s but 3 Seniors -> senior reduces list to 15 patients– 2 PGY1’s but 2 Seniors -> senior reduces list to 12 patients

CCU and ICU Transfer Notes

Transfer Notes need to be accurate

“see today’s progress note” is not acceptable

You do NOT need to put summary of patient course

Procedure Notes

- ICU Procedure Notes all start with .IM followed by the procedure.

- Charts are being audited for correct use of the notes as they have all necessary requirements for coding/billing/charting.

- Example: .IMARTERIALLINE

Remember to Log Procedures

Transitioning When Fatigued

• Protocol in place– Posted on website at top of monthly conference

calendars

– Review Dr. Sweets Presentation from 1/2/19

• To summarize…– If you’re too tired to work or care for patients

• Call/notify chief +/- Dr. Sweet

• If overnight—– Notify the most senior resident on

– Still call the chief or Dr. Sweet

Post-Arrest Protocol

• Protocol in place for those who arrest and obtain ROSC

– .impostarrest – within in 24 hours of ROSC (within H&P or Consult)

– .impostarrestcerebralperformancecategory – at time of transfer to floors or SELECT (within Transition Note or DC Summary)

Urinalysis and Urine Cultures

• ID and ICU are working to decrease unnecessary urine cultures

• Don’t obtain urine studies unless they have symptoms

• Always obtain UA prior to Urine culture

• Don’t fall for the “Pan-culture”

– Check a UA prior to getting the culture (blood culture/UA/Sputum culture)

ICU Transfers from Med Team

• If Med Team patient requires transfer to ICU

• During the day -> Med Team Residents should staff with an ICU attending

– Quicker response, patients get better care

– *Early 2nd year seniors may need additional ICU help so let ICU know and be available to help.

• If Admitting w/ evals in ER -> Call ICU for help

• At Night or not on campus -> AR2

Stroke Teams

• AR2/AI2/3 Responsibilities:

– Respond to ER Stroke Teams from 5pm – 6:30pm (AR2 Day) and 6:30pm – 7am (AR2 Night)

– Same protocols in place

– Responsible for Floor Stroke Teams and ICU/CCU Stroke Teams 24/7

Miscellaneous

Inpatient Queries

• Residents/Interns to start receiving inpatient queries

• MUST BE ADDRESSED w/in 3 days

• If NOT addressed, query will be forwarded to attending

– MUST meet with attending to get query addressed.

Patient Introductions

• Request for residents to introduce themselves as members of the team and what role they play.

• Improves patient care and improves patient physician dynamic.

PGY3’s: Medical Licenses

• If you have not started the process start ASAP as it can take several months depending on which state

– Usually busier/longer delay after February

• See Nuge or Kamal Dayal with any questions or estimates on cost

PGY3’s: Emails

• If you are planning to sign up for Boards or send emails to potential jobs use a personal email

• Summa will end access to your email accounts within a week of the end of your residency.

Patient Health Information

Please do not to leave any PHI in public areas – including patient lists left in Cafeteria sign out room

Need a Notary?

Val (Department of Medicine Secreatary) and Elizabeth (Social Work) are certified notaries!

Duty Hours

Required for ICU, CCU rotations and months of July and February.

- Answer page from Mary regarding completing these

Noon Conference

• Mandatory

• Monday through Friday

• Usually in PCS Basement Auditorium

• Starts at 12pm please try to be on time

• Calendar posted on website

ER

Find us Online!www.summalearner.com

www.facebook.com/IMSumma

Summa Sports Group: Search #IMSummaSports on Facebook

QUESTIONS??

Michael Nguyen “Nuge”, MD

Cell: 937-418-6653

Office: 330-375-3735

Pager: 330-971-0147