PGY 3/4 to Be Retreat

June 3, 2014

Scott DenstaedtMarty TamAngel Qin

Khanjan Shah

Hoping for the best, prepared for the worst, and unsurprised by anything in between.-Maya Angelou

Last year of residency…

Success!

Overview5:30-6 Dinner

6-7:30 Quality Center (Heidi et al.)Milestones discussion (Dr. Arfons)

Ambulatory ChangesMedicine Clerkship (Dr. Leizman)

Changes for next year

Logistics reminders

Issues unique to 3rd year

Fellowship

Boards/ITE

Medical License

Senior talks

Patient Safety/Quality Externship

7:30 - 8:00 DACR/NACR Orientation

Gen Med Consults

8-8:30 Questions

Changes for Next Year

•Ambulatory•Electives•Jeopardy

Ambulatory Model 2.0• 2013-2014: four ambulatory blocks and 2-4 clinics in elective• 2014-2015: five ambulatory blocks and no clinic in elective (there is a panel

management day)• “6+2” model

– 6 weeks of ICU/wards/elective– 2 weeks of dedicated ambulatory– 7 half days of clinic each block and 1 administrative half day

• Positive Effect– Continuity: you and three other seniors make up a team (with two interns) and see the

same patients (great for you and the patients!)– Electives Preserved: you can make more of your elective now!– Curriculum: streamlined and less repetitive

• New Challenges– Ambulatory blocks are fixed (cannot trade)– Change is uncomfortable, but we do it to try and make things better

Ambulatory Model 2.0

Ambulatory Model 2.0

Team Flight 1 (1A,4B,8A,10A,12A) Flight 2 (1B,5A,8B,10B,12B) Flight 3 (2A,5B,9A,11A,13A) Flight 4 (2B,6A,9B,11B,13B)

VA 1 Red Perihan John S Anodika Prashanth

VA 2 Silver Andres Rachel Abdullah Alm Perica

VA 3 Purple Alina Katie Philicia Khadejah

VA 4 Yellow Amhed Wissam Nupur Lesley

DMC 1 M Bryan Jacob Rania Neetika

DMC 2 Tu Stephanie K Sadeer John G Nate S

DMC 3 W Maya Carine Patrick Gabe

DMC 4 Th Ahmad Dafina Atallah Vincent

DMC 5 F Stephanie M Brandon Yosra Chris

DMC 6 M Roopa Cassie Won Dhruti

DMC 7 Tu Jack Mo Abdullah Alj Hussain

DMC 8 W Aniket Anthony Rishi Shiv

DMC 9 Th Bouchra Priyam Ning Ziyad

Ambulatory Model 2.0# Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 1 Team 12 3 4 5 6 7 WEEK 18

BOX BOX

Admin Team 1 # Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 1 Team 1 2 3 WEEK 24 5 6 7 8

BOX Team 1BOX

Admin

# Residents Mon Tues Wed Thurs Fri1 Team 1 Team 2 Team 1 Team 2 Team 12 Team 3 Team 4 Team 3 Team 4 Team 33 Team 4 Team 5 Team 5 Team 6 Team 54 Team 6 Team 7 Team 6 Team 7 Team 75 Team 7 Team 8 Team 8 Team 9 Team 86 Team 9 Team 9 7 *Intern 1 *Intern 2 *Intern 3 *Intern 4 *Intern 5 WEEK 1

8 *Intern 6 *Intern 7 *Intern 8 *Intern 9

BOX Team 2 Team 3 Team 4 Team 5 Team 6BOX Intern Intern Intern Intern Intern

Admin Team 8 Team 9 Team 1 Team 2# Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 2 Team 1 Team 1 Team 22 Team 2 Team 3 Team 3 Team 2 Team 3 3 Team 4 Team 5 Team 4 Team 4 Team 5 WEEK 24 Team 6 Team 7 Team 6 Team 5 Team 65 Team 8 Team 9 Team 8 Team 7 Team 86 Team 9 Team 9 7 *Intern 1 *Intern 2 *Intern 3 *Intern 4 *Intern 5

8 *Intern 6 *Intern 7 *Intern 8 *Intern 9

BOX Team 7 Team 8 Team 9 Team 1BOX Intern Intern Intern Intern Intern

Admin Team 3 Team 4 Team 5 Team 6 Team 7

Electives

• PGY II: 8 weeks • PGY III: 12 weeks• Quality Chief will now be assisting Barb in keeping a running

list of what you are doing for elective• For ACGME requirements each resident must have a specified

activity and supervisor for each elective

Example Elective Tracking

Electives

• Research Electives:• Must have a mentor/PI for project• If doing two weeks (or more) of research elective, you are

required to present a poster at Medicine Research Day

• Reading Electives:• Requires approval, KBA is designated supervisor• Required attendance at all UH noon conferences, UH

M+Ms, UH Grand Rounds, VA Grand Rounds

Elective Reminder

• Elective Professionalism• Elective is not vacation• You are back-up jep and expected to be in Cleveland• If you are going out of town, please let the Ambulatory

chief know

• “Don’t you remember when you were a resident?”• Having your pager on 24/7 on elective is unreasonable• Everyone on elective is back-up jep any given day, but we

can assign people on specific days to be the first called so you know when to have your pager with you

Jeopardy• Minor changes to the jeopardy system will be made• Use of jeopardy will be tracked for training/support purposes

– Make sure everyone is meeting minimum requirements– Make sure we provide help and resources to those that need it

• Those getting jepped from electives will be tracked as well– Ties into the “first call” back-up jep list, you move down the list after getting

jepped– Makes the system more fair

• KEY Points– Jeopardy still remains for emergencies and significant illness– Unless there is excessive use of jeopardy (decided on a case by case basis), you

are not expected to pay back– There is still a jep rotation, coverage here is not tracked and you do not get paid

back

Logistics Reminders

Transition Dates

•PGY1 end date: 6/23•Block Zero: 6/24 – 6/30•Block One: 7/1 – year of SMAK!

Team Caps

• UH Wards: • 10 patients per intern • 8 patients per intern on Ratnoff/Weisman• Intern+AI: 12 patients if two seniors; 10 patients if one senior

• VA Wards: • 8 patients per intern• Intern+AI: 10 patients• AI+AI pair: 10 patients

• Short Admissions:• No shorts on weekends• No shorts if intern has 8 patients• Shorts for Intern+AI pair to cap of 10 patients

Duty Hours• Long Call:

– 3 patients (4 if paired with AI) until 7 PM– 2 patients if after 5 PM– 1 patient is after 6 PM

• Medium Call:– 2 patients until 4 PM– Can sign out at 7 PM

• Short Call:– 2 patients until 12 PM at UH (NF or ICU transfers)– 2 patients until 1 PM at VA (NF, ICU transfers, new admissions)– No short patients on clinic days

ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!

• Senior Resident: – Residents on call MUST stay until 9 PM– No matter what the call, ward seniors staff any patient the seen before 4 PM– Weekend coverage seniors must stay and staff at least until 1 PM or longer

depending on how busy the other seniors are

Staffing• UH wards will have double coverage Blocks 1-3• There will be minimal orphan coverage in the first few blocks• See and examine EVERY patient• No staffing note required for ICU transfers or interservice

transfers• Focused notes by the senior resident with detailed plan• See PGY1 note for full H&P. Briefly, pt is a …

• Helpful to new interns: • Antibiotic doses• Description of imaging - With contrast? Without?• Medications to continue, medications to discontinue• CODE STATUS and Allergies

Staffing• On call resident should notify the nightfloat resident of

tenuous patients• Be proactive about staffing patients

Coverage and Schedule Switches

• All coverage arrangements and schedule switches must be approved by the Ambulatory chief so it can be noted in amion

• Switches must be arranged before 1 week of rotation starting

REMINDER: Residency Reading List

• Residency Reading list:• Landmark and review articles in all sub-specialties• Last major update in 2011• Looking a 20-40 year old resident who enjoys long nights

of Boolean searching to help update the site with new landmark trials…

Professionalism

Professionalism: Attire

•Men• Shirts and ties

•Women• Professional

•Keep white coats clean•No denim•Do not show up to Morning Report looking sloppy

Professionalism: Absences

• If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic • You will be able to get a same-day appointment

• If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy

• Call-offs: You must PAGE 31529 the Ambulatory Chief• DO NOT EMAIL• DO NOT TEXT PAGE• DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

Professionalism: Electives

• Attend all Grand Rounds and M&M’s• You are back up jeopardy!! = pager on• If you are going out of town for the weekend, as a courtesy

please notify the ambulatory chief prior to leaving• Elective is not vacation• Please email Barb 2 weeks prior to starting your electives;

Quality chief will be keeping track of electives• Research for more than 2 weeks = present at Research Day

Professionalism: Reading Electives

• Residents on reading elective are expected to attend morning reports and journal clubs at the VA

• Must attend Grand Rounds at UH• Your pager is expected to be turned on and on you during

the entire two weeks of elective• All reading electives must be approved by KBA• For PGY2s it can only be used to study/take step 3• Please note that when you are on elective, you are back up

jeopardy!!!

Professionalism: Conference Attendance

• Please be on time; our speakers usually have prepared a well thought out talk/powerpoint, so please be respectful of the time they spent

• Noon conference: • UH: Mon-Wed-Thurs • VA: Mon-Thurs-Fri

• Grand Rounds on Tuesday: UH & VA• M&M Fridays @UH, Wednesdays @VA• Conference attendance is part of your ACGME graduation

requirements

Conference attendance during ambulatory

• Ambulatory conference attendance is mandatory • Late Policy will be strictly enforced:

• Sign-in sheet will be available until 8:05AM• At your 2nd instance of being late = extra weekend coverage• Any MISSED conferences without prior approval by the ambulatory

chief will result in weekend coverage

Professionalism: Discharge Summaries

•If you put in the discharge order, you do the discharge summary

•Do them the day of discharge•Do them for your intern•Do them for your friends•Do them for your patients•Remember it is now easier than ever to do it in UH EMR

Issues Unique to 3rd year

• Fellowship• Boards/ITE• Medical License• PGYIII QI project• Senior Grand Rounds• VACR• NACR/DACR

https://www.aamc.org/students/medstudents/eras/fellowship_applicants/

• Please review this website! There are many new changes this year

• https://www.erasfellowshipdocuments.org/• Request ERAS token; June 11, 2014• Ask for letters of recommendation…now!• Start considering your future destinations for fellowship• Work on your personal statement• July 15, 2014: first day to submit application AND programs

begin downloading applications• Special considerations (double check now):

• Sports Medicine• Hospice and Palliative Care

Fellowship Timeline

Fellowship Timeline

• Deadline for completed application varies but is as early as July 31st; check with program and be prepared

• Interviews: August - November 2014 First • MATCH: first Wednesday in December 2014

*KBA will perform mock interviews upon request

BOARDS!!!

•Register starting in December•Plan ahead…costs about $1,365 (more if you sign up late)

•Noon Conferences to include more board prep sessions

•Can use ITE exam results to help guide studying

In-service Training exam• In-service Exam Dates are in October – exam is

completely computerized this year• Includes all PGY2/3, PGY1’s?

• ITE during 2nd year is an important predictor of passing boards

• ITE remediation by percentile rank• >50% - no remediation, continue to study• 31-49% - turn in in 60 multiple choice questions every 4 weeks

to assigned APD for review; continue studying and attend board review sessions

• 16-30% - high risk for ABIM failure multiple choice questions as above with directed notes• If you are not already doing this PLEASE talk with us or your APD, ABIM

failure is no joke• 1-16% - more intense remediation, urgent intervention

required (we are here to help!)

Medical License

• Remember to keep your BLS/ACLS updated• Must have Step 3 results prior to license application• Start FCVS by December ($430)• State licensing ($335) can often take 5-6 months. • DEA license is much quicker but more expensive ($551)• Plan ahead!!!

Senior Grand Rounds

• Noon conference lecture for each senior resident, late August (after intern boot camp has finished)

• Dr. Mourad is the APD in charge• Email learning objectives to assigned faculty mentor,

ambulatory chief and Dr. Mourad two weeks prior to lecture date

• Topic of your choice, should be evidence-based • MORE INFORMATION TO COME!

Patient Safety and Quality Improvement

• Introduction to quality improvement during DACR rotation• UH Care feedback • Quality Assurance meetings• Write-up cases for Medicine QA• Attend ED/IM QA• Attend Quality Patient Safety Committee meetings• Mortality review, PASS reports, and Risk

Management meetings

Guidelines for Resident Quality Improvement Project

• QI project for PGYIII required by ACGME• Form groups of 2-4 (ideally 3) people• Work with one of the chief medical residents and quality center to

develop project ideas and aid with data collection• Start by identifying a quality issue, collect background data, design an

intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources)

• Present quality poster at Research Day

• Select project/team in July, first meeting regarding the project occurs in August

Timeline for QI Project• General Timeline:

• July: select project/team• August : meeting with assigned chieg resident and QI RN

(complete FOCUS PDCA) define objectives, collect background information, plan an intervention

• September-November: collect baseline data (initial survey)• December: meet with chief resident and QI RN to discuss

baseline data and intervention implementation• January through February : implement plan• March through April: collect data post-implementation, write

abstract for research day, make research day poster• May: present at research day

VACR

•Many PGYIII’s will have this rotation, not all•Perform medicine consults •Be available to help out ward teams as

needed•Prepare EBM lecture on a topic of choice

for morning report•Attend all morning reports•One Saturday 24 hour VA MICU coverage

DACR / NACR:Your education in systems-based

practice

To Admit vs. Observe

•Arose out of for profit hospital chain fraud•Requires attending to sign and admission order that includes language that the attending expects the patients medical problems to require admission for two days

•Some logistical issues on getting attendings to sign/place order

The NIGHTFLOAT TEAM

NACR

Nightfloat ResidentRotating MSIII

Nightfloat Resident

Nightfloat InternRotating MSIII Nightfloat InternNightfloat Intern

The NACR as Ombudsman*• Distribute admissions to teams on call in AM • Enforce geographic localization• Run codes• See medicine consults at night (ophtho and ortho co-management if

requested)• Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House• Cover flex patients at night and ?additional PRN SHD patients• Find out intern census from nightfloat interns for each team• Admit BMT and Transplant Medicine patients along with NF (must inform

BMT fellow and Transplant attending)• Transplants within the past year should be admitted to transplant

surgery

*ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization

*****Transplant service is not the Transplant attending! MUST ASK OPERATOR FOR TRANSPLANT ATTENDING!!!!******

“The Book” as it should be…

Medicine

Fam Med

Neuro

Surgery

Ortho

Transplant

ENT

“The Book” according to the ED…

Medicine

Surgery

Fam Med

Neuro

Ortho

Transplant

ENT

Patient enters ED, decision to admit

ED enters admitting bed

request

ED pages NACR for signout

Medicine floor admission

appropriate?

No

Yes

Admitting pages NACR with bed

request

Ask ED attending to reconsider

triage of patient, work-up, or

admitting service

NACR calls admitting and

makes appropriate bed assignment

NACR assigns admission to NF

or her/himself

AdmittingED

NA

CR

NACR distributes patients in the AM with help of KBA

and chief

NACR OVERVIEW

Medicine

Appropriate Service?Is the

patient stable for the floor?

PCP in FP?

NoMICU/CICU/NSU/SICU

Yes

Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission.

No

Appropriate for

medicine?

No Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient”Yes

FM capped!?&*#@!

Stroke, SBO, femur fracture, etc

YesAppropriate

for FP?

Appropriate Service?• Look up the patient in Portal and EMR before assigning• Patient’s PCP – Family practice patient? Private patient

(list of attendings available)? • Fang Service does not have a cap per Dr. Oliviera; if they

have been seen in HF and are coming in w/ HF exacerbation, have ED call the overnight admissions person

• Physician Portal (summary page, physicians)• Previous discharge summaries• EMR patient info clinical summary (visit history)• Ask the patient!

NACR• The two most important things you can do as NACR:

• 1) Admit the patient to the appropriate service (never forget to look up PCP/patient info/dc summaries)

• 2) Plan ahead and assign patient to appropriate floor based on available spots/admitting diagnosis/co-morbidities ie. GEO LOC

• Be proactive – keep an eye on the ED board• If the patient is unstable or you do not feel comfortable, it is okay to ask

for ED to either re-triage patient (ie MICU/CICU) or to set a goal for admission to the floor (eg BP should be better than 240/120 for me to admit this HTN urgency to the floor)

Before your first NACR night, you will have a more detailed orientation with one of the chiefs at UH.

NACR specifics• 8pm – midnight:

• Meet Admissions Coordinator in KACR to get sign out• print out new board (on medicine.case.edu; UH resources)• start NACR sheet, Admissions Coordinator will be holding the book and pagers until midnight on

the weekdays, so this is your PRIME admitting time• Usually try to see most of your patients at this time; orders and notes can be done after the MAN is gone

• Midnight and after:• Stay on top of the ED board • Master the art of the NACR

• 5-6am • Get organized, make copies of NACR sheet, get intern census• Talk to NFs regarding admits and appropriateness for teams; biggest decisions are Hosp/NPs vs.

flex• 6:30-8am

• Review admits with KBA and SMAK• 8am hospitalists call for assignment• Fax assignment sheets from day prior and overnight to admitting and hospitalist offices• Call non-teaching services to assign patients (Fang/Transplant/BMT)

Chief Resident may call you to check in on your first NACR night

Types of Patients•Private (PCP will attend) – Coviello, Schnall, D.

Brown, DeJoseph, Junglas, King, Tomm, Locke• ER must call private attendings; but if the patient is on the floor

and the ER did not call, it is the DACR/NACR responsibility• Assign to med NPs (private spots) during the day! If no spots,

then flex versus team (Eckel, Carpenter, or Gen Med; not Ratnoff/Weisman/Hellerstein)

• D. Brown must be flex (not NP)

•Staff – NPs (no procedures), hospitalists (few social issues low complexity), general medicine teams

*Non-cardiology patients needing telemetry can go to Hellerstein and hospitalists (not med NP)

Specialty services:• Eckel: ESRD, hypertensive urgency/emergency. ESRD

transfers need to be accepted by Nephrologist.

• Ratnoff/Weisman: SCC with active issues

• Hellerstein: active cardiology issues (regardless of PCP)

• Dworkin: GI patients (abdominal pain anyone?). Can take liver to a cap of 3 (but flexible) if liver attending accepts

• Fang service: HF issue who is seen by a HF attending (Oliviera, El-Amm, Ginwalla, Effron)

• Patients with no right answer (HIV patient with ESRD and chest pain followed in HF clinic) - most active issue prevails

Types of patients

Types of PatientsHIV patients go to Carpenter

-When Carpenter is not admitting, give them one a day early or have resident flex

Pulmonary cases go to general medicine-Pulmonary HTN and flolan patients need to be on T5 and goes to Hellerstein/Gen Med

MICU transfers followed by renal consult team-If chronic Eckel-If acute gen med with renal consult

Non-Teaching Services

• You or DACR will get an e-mail stating the number of open spots for the next day for MNP, Berger

• Hospitalist A (NPs), B, C, and D will call the Admissions Coordinator at 8am (make sure they are written in the book)

• Fang Service – Call with admissions in AM; apparently they have no cap…

• Transplant/BMT – Overnight admissions should have been discussed with transplant attending or BMT fellow; it is good practice to call in AM to make sure the team is aware of the patient

NPs

• Medical Nurse Practitioners• Patients who do not need procedures • Patients who are not being ruled out for ACS • CAN take syncope patients on tele• They will take most private patients (not D. Brown)• Can take very complex patients!

•Berger Nurse Practitioners• Stable patients who do not need procedures: sickle

cell, pain management, hospice, routine chemo admissions

Hospitalist B, C, & D• Have a cap of 12 patients each• Straightforward medicine patients without complicated social issues• Try to give them patients whom you anticipate will have short stays• Unfilled spots rollover to the next day• Cannot take ICU transfers that were in unit >48h• Take bouncebacks, but count against cap

Fang Service

•Two NPs with Hellerstein fellow•During the week, admit cardiology patients to team cap

•Will take NF admits and CICU transfers•“No cap”, but chief/KBA may need to speak with attending in AM

•All Effron/Heart Failure patients

Moonlighting• Cross-Cover Long House Doc: 8pm to 8am

• Cover the nurse practitioner, BMT, hospitalist services, and Hanna House overnight

• Admits one patient per night (or three if NP on with them)• Holds transfer pager (remember, don’t accept ESRD – Nephrology

must!)• Early and Late Short House Doc

• Each admits three patients• Admitting Long House Doc: 6pm to 6am

• Admits six patients• Bomb the long house doc!• Give them private patients that go to the NPs • Must cap them!• No admissions after 0400• Appropriate patient selection for the house doc is key; in most

cases these patient should not come back to the housestaff the next day

ED Issues• Neurology:

• Strokes go to neurology• Seizures – try neuro first

• General Surgery: insist (politely) that they take SBOs, etc• Make the resident call their attending (or do it for them)

• VA: far better to transfer BEFORE admission• Ortho: perhaps worth arguing, but Medicine co-manages most ortho

patients (NACR/DACR consult)

Other Duties: Medicine Consults

•See the patient in a timely fashion •Write a note

• Leave at least a preliminary note in the chart •Call the Gen Med consult attending if needed•Co-management with orthopedicsWe follow along with ortho patients; they don’t need a “question”

• You can put in orders dealing with medical issues

Co-management Memos

• ENT and Ophtho have specific co-management pathways (in handout)

• It is a good idea to review these prior to your first NACR

Transfers to Medicine

• All transfers to medicine must be approved by medicine consult attending (not Dr. Whelan), chiefs, or KBA• Your medicine attending can ONLY accept to general

medicine (Naff/Wearn, MNP etc); if the other service wants to transfer to a subspecialty team (ie Dworkin), they MUST consult the attending on call for the day

• Consults for transfer to medicine:• If clear subspecialty issue, refer to appropriate attending• If clear gen med transfer, no consult necessary• If unclear, offer to do a consult and staff with attending• Don’t accept inter-service transfers overnight

Outside Hospital Transfers

•Transfer Center• 41111• Attendings are supposed to call 67121 or page 30512 when

they accept a patient

•8 am – 8 pm – Rotating attendings• M-W: Chief Resident and KBA• Th-F: Dr. Chandra et al

•8 pm – 8 am – Cross-Cover Long House Doc

DACR/NACR Hours

•DACR = 8am – 8pm•NACR = 8pm – 8am•MAN = 8am – 12am (8pm on weekends)•DACRs come to morning report, Grand Rounds, and M&Ms

•NACRs have a staff attending on call

Running Codes

Code Whites (UH)

** 1ST six months – an upper level must go to all Code Whites with an intern**

•Sick or decompensating patients on the floor or Hanna House

• Initial response from ICU nurse, intern, and PGY2

•DACR/NACR for level 2 code white• If you want to transfer to MICU, call MICU fellow

•Always write a Clinical Event Note!

Code Blues• Check your own pulse first

• “Too many chefs spoil the soup”• One person leads the code• Make sure interns are involved• Maintain a calm quiet atmosphere

• Keep the ACLS cards in your pocket until you are comfortable with the protocols

• Make sure your BLS and ACLS are up to date

• CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

Running Codes• Rule #1: You are in charge

• If uncomfortable, defer to more senior resident

• Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc.

• Use the DACR/NACR if you need help

• Don’t be afraid to ask people to leave the room

• Call the ICU nurses by their name, closed-ended communication

• Assign someone to call the family

• Use the Code Note EMR, sign code sheet

Running CodesNotifying attendings at night

• Most attendings want to be paged and notified (either of transfer to ICU or death)

• Can clarify with your attending on first day of service what their preferences are

• Don’t get burned by not calling your attending- you may hear about it the next day

We are looking forward to a great year together!!!

-SMAK

Questions?