Arrive at 5PM and Check in with the On-Call Resident First

VA SWING RESIDENT ORIENTATION

Staffing

- Arrive at 5PM and check in with the on-call resident first

- Night float admissions are 1st priority (if applicable, see patients who have arrived on the floor first)

- If you admit a patient as a night float, please use the “Medicine Nightfloat Admission Note” template and designate the VA chief as the cosigner. Patients have fallen off the list and do not get assigned to teams in the morning if the VA chief is not added as a cosigner

- Additionally, make sure you sign out all of your admissions to the NF resident

- Orphan long admissions are 2nd priority. Please staff with the intern/AI (you must write a full “medicine admission note” for an AI, but can simply enter a “medicine inpatient progress note” titled PGY2/3 Staffing Note with a detailed assessment/plan when staffing with an intern)

- If the orphan team is capped, help cross-cover other teams and be available to help the on-call resident (e.g see VACR consults, address critical patient care issues, etc) – 3rd priority. However, you should not be staffing admissions to the on-call resident (it is important that the on-call senior be involved with admissions assigned to his/her team)

- Before you leave, check with the on-call resident to see how they are doing

- Once the night float senior arrives, sign all NFs out.

- If you are going to be late to your VA swing shift, notify the on-call resident (pager in amion) and the VA chief. (p31533)

Procedures
- Be sure that proper documentation is completed for procedures even if they are unsuccessful

- For any procedure that requires consent, please page either the VA chief or Dr. Lopresti for supervision if your attending is not able to supervise

- For after hours, there is an in-house hospitalist who can supervise procedures

General Tips

- Please notify NOK/MPOA any time a patient transfers to a higher level of care, has a marked clinical deterioration, or dies overnight. Document the discussion briefly in CPRS.

- Always admit a suicidal patient with the "Suicide Order Set." (Orders Tab  Add New Orders  Sucide/Hostile Behavior precautions). The order set includes a psych consult and this should ALWAYS be placed. You can write on the consult "can be seen tomorrow." Of note, if a patient is suicidal, you should never discontinue a 1:1 sitter order (which is part of the suicide order set - even if the patient’s suicidal ideation resolves AND/OR the on-call psychiatry resident recommends discontinuing the order) until the psychiatry team evaluates the patient.

- For patients being admitted for alcohol detox, please place the VARC consult overnight. Please use the CINA/CIWA order sets in CPRS. Go to Add New Orders  Detoxification Menu. These order sets automatically prompt you to order labs; many of these patients do not need the entire panel, so please be judicious about his.

IMPORTANT DNR ORDER INFORMATION:

1) Review the chart (if the patient is being transferred here) for a portable DNR sheet and CPRS (cover sheet -> postings on the upper right) to look for previous inpatient DNR progress notes and advanced directives

2) Do NOT place additional DNR orders once one is already in place. Once the patient has an inpatient DNR order, it does not and should not be re-ordered unless it is being changed to a comfort care order

3) The patient must have the capacity to understand the DNR conditions before proceeding through the ordering process

4) DNR orders placed by night float must be discussed with the chief resident in the morning

5) Code status should be mentioned on rounds and listed on every transfer note, H&P and handoff

6) Residents should NOT be using the attending order for DNR, extend the 24-hr timeframe for their order or order daily DNR orders

7) Rescinding DNR for procedures must only be completed by the attending for a procedure. There is a "Rescind DNR Note" used to change any DNR Order. Do not discontinue and replace a DNR order without activating the rescind note.

8) The attending on service must sign the DNR note and place the appropriate DNR order under the "Orders" tab in CPRS within 24 hours from the time in which the housestaff order was placed

9) If a patient wishes to have a DNR order placed without notification of family or MPOA/DPAHC, an ethics consult should be placed so third party documentation is attained in the event that the patient may not be able to make a decision in the near future.

--> Cares Tower DNR orders should transfer with the patient to an acute care setting (BUT they have to be ordered by an attending for this to work)

--> Ohio portable DNRs should be considered at discharge for patients who wish to continue their DNR code status. The DNR Out of Hospital Order Note is used to document outside DNR orders or the placement of a new portable DNR. The attending must sign the portable sheet.