Ward Inpatient Service

WARD INPATIENT SERVICE

INPATIENT EXPECTATIONS AND RESPONSIBILITIES

Senior Resident Goals & Objectives

Goal: Provide leadership and organization to the inpatient team.

Objectives:

1. Assign admission and consult patients to interns and students, promoting continuity of care
2. Provide clear expectations to learners
3. Lead time efficient, educational, family centered rounds
4. Coordinate communication between subspecialty attendings and team
5. Maintain patient sign-out list for call team and intern assignment list for HUC (including pm coverage for clinic/post-call interns)
6. Attend daily discharge planning rounds at 0730, meet with charge nurse daily regarding admissions and discharges

Goal: Supervise the clinical care provided by interns and students on the PACC.

Objectives:

1. Directly oversee all clinical care of the sub-intern, co-signing orders and notes
2. Provide oversight, leadership and support to interns
3. Review plan of care and orders on all new admissions and consults with interns and students; encourage intern interaction with attending/fellows for new admissions and consults
4. Assist and guide interns in developing time efficient strategies for organizing and completing clinical work (calling consults, reviewing labs and studies, writing orders, preparing discharges, and following up on results of labs/studies after discharge)
5. Utilize faculty as consultants, updating with important clinical information and asking for assistance in clinical management when needed
6. Respond to all pediatric Code 99s

Goal: Serve as the principal educator for the team, coordinating educational opportunities for learners.

Objectives:

1. Schedule teaching time for the team
2. Delegate educational topics to students, interns and faculty
3. Demonstrate physical exam findings and clinical pearls on bedside rounds
4. Provide students with direct, constructive feedback, a safe learning environment, input on write ups and presentations, and access to information about their patients

Junior Resident Goals & Objectives

Goal: Provide family-centered patient care for patients with common pediatric signs, symptoms, and diagnoses requiring hospitalization.

Objectives:

1.See and examine your patients daily prior to bedside rounds.

2.Review your patients’ notes, vitals, labs, studies, & MAR daily prior to bedside rounds.

3.Develop plan of care for the day.

4.Prioritize work-entering orders, calling consults, following up on studies, etc. efficiently

Goal: Understand the scope of medical knowledge needed to manage common inpatient diagnoses and demonstrate the ability to acquire, interpret and apply new knowledge to patient care.

1. Provide education and guidance for the medical students, giving them direct, constructive feedback, a safe learning environment, input on notes and presentations and access to information on their patient
2. Anticipate discharges by initiating discharge instructions and summary and providing prescriptions to parents as early as possible
3. Attend teaching conferences and rounds
4. Read about your patients and share learning with the team
5. Complete educational checklist of common inpatient diagnoses.

Goal: Demonstrate effective communication skills with patients, families and colleagues

1. Prepare patients and families for bedside rounds. Serve as primary communicator with family in room during rounds (unless followed by MS3). Keep family informed of changes in clinical status or in plan of care.
2. Write a history & physical and systems or problem based plan of therapy on each new admission
3. Write a concise daily note on each patient, emphasizing your medical decision making and plan of care.
4. Complete detailed off-service notes for complicated patients.
5. Complete discharge summaries at discharge and route to PCP
6. Communicate daily plans with the nurses
7. Document changes in clinical status whenever they occur
8. Communicate with senior resident with updated patient information
9. Communicate key medical information to the nighttime team during handoffs and provide thorough sign out to the incoming intern at the end of your rotation

Student Expectations:

Sub-interns

• Follow 4-6 patients at one time. Discuss with the senior resident which pts you should follow.
• Function as much as possible like an intern (see above intern expectations) but without MS3 involvement on your pts.
• Review daily exam and notes with senior resident (senior resident will examine your patients and cosign notes)
• Present your pts in rounds.
• Complete discharge summaries within 48 hours of discharge, ideally the same day. See dictation guidelines for details.

Third year Medical Students

• Follow 2-4 patients at one time, assigned by PL3. You will be the expert about your patients. Your patients should regard you as the primary caretaker.
• Write a history and physical on patients you admit and place in chart within 24 hours. Assessment should include a differential diagnosis with the most likely diagnosis first. Plan should be by systems or problem.
• See and examine the pts you are following everyday
• Review all orders, consults, treatments, labs and imaging results over the last 24 hours on your patients
• Present your pts in rounds according to presentation guidelines.
• For retrieval of urgent imaging results, coordinate with your team when requesting the results to avoid multiple phone calls to the same radiologist.
• Go with your pts to their procedures (imaging, operating room, etc) after approval of senior resident and radiology or surgery attending.
• Provide the parents with the team structure (attending, resident, student) and serve as the primary communicator to your patient’s families on rounds and throughout the day.
• Anticipate discharges by initiating and sharing EPIC Discharge Instructions, as well as writing prescriptions.

Attending Expectations
The attending is directly responsible for the care provided to all of the children on his/her service. She is also a teacher, a mentor, and a consultant. Attendings should:

• Review histories written by residents and students.
• Empower the PL3 to manage the team.
• Review or perform physical examination as necessary.
• Cosign resident notes.
• Contact private primary care providers regarding admission, updates and discharges.
• Attend bedside rounds
• Approve discharges of patients
• Provide feedback to team members

ADMISSIONS, CONSULTS, and DISCHARGES

Incoming Admissions:

• Transfers from outside ED/Hospital/Clinic come to the attending through the transfer center, 4-7000. The attending will contact the senior resident with the details. The HUC should call the senior when the pt arrives to the floor.
• Admits from OHSU ED will be called to the senior resident by the ED resident. For Gen Peds pts, the ED attending will also call your attending (true for OHSU and Kaiser).
  Maintain collegiality and professionalism (Don’t try to deflect admits). Simply ask if the ED has contacted your attending.

Admissions on weekdays will be "worked-up" by the ward team to which they are assigned until 5:30 p.m., and by the night call team thereafter. On Saturdays and Sundays all admissions are worked-up by the weekend call team.

Identifying and Contacting the Attending Physician
Discuss the preferred communication about admissions with your attending. Contact the attending with any questions or concerns that you have about a patient. If you are worried, we want to worry with you.

The name of the attending physician must be written in all admission and transfer orders (the latter includes service to service and place to place, e.g., PICU to floor). If the orders do not include the name of the attending, the orders cannot be activated until the name of an attending is provided. EPIC should reflect the proper attending for each patient.

Pediatric Consults
When a General Pediatrics consult is requested on the wards, the patient should be assessed, staffed, and followed just as a new admission would be. The attending should be notified promptly that there has been a consult requested. The PL-1 (or senior) should review the history, examine the child, review the consult with the senior resident and subsequently staff with the attending.After the case has been staffed with the attending, the service requesting the consult should be called and the recommendations should be communicated verbally and in an EPIC consult note.

A consult should ALWAYS be put on the list for the day team to know about them, and should be assigned to an intern to follow. The team can decide at a later time if they feel it is appropriate to sign off.

In the event of a non-acute consult called late at night, you should ask the requesting service if they think it’s appropriate for the consult to be staffed the following day by the attending. If they are ok with the attending staffing it the next day, you may complete your consult, add the patient to the list, and staff with the attending the following morning.

Discharges

Anticipate discharges by preparing necessary paperwork (instructions, discharge summary, prescriptions) in advance. Make an attempt to provide discharge prescriptions to parents the day prior to discharge to be filled at the DCH pharmacy as many pediatric formulations are difficult to obtain at local pharmacies. Notify the attending of any “pre-rounds” discharges that may be appropriate to see and discharge prior to bedside rounds.

Interns/sub-interns are expected to follow pending cultures/lab results on their discharged patients unless alternate arrangements are made with the PCP, subspecialist, etc.

WARD TEAM SCHEDULE

(subspecialty rounding time TBD at time of document completion)

Please note that on-call residents are not permitted to arrive prior to 0700 on their call day so as to be able to attend noon conference the following day without violating duty hours.

Weekends/Holidays on DCH Inpatient Service
Expectations of On-call/Post-call Residents:

• Friday Progress Notes need to indicate long range plans to assist cross-covering residents on the weekend. Paperwork should not be left to the weekend team. Complicated discharges should be neatly coordinated prior to the weekend if at all possible.
• On weekends and holidays, pre-round on all General Pediatric and Subspecialty patients by 0900. Facilitate discharges prior to rounds when appropriate.
• Senior resident assign weekend assignments to residents and students and will lead weekend rounds in conference room. Subspecialty, Kaiser attendings may join sit down rounds. OHSU hospitalist will run the list with the on call team after rounds.
• After 0900 rounds, residents will finish patient care.

DOCUMENTATION

• All admissions need an H&P documented by a resident
• All daily notes must have a physical exam and plan of care for the day documented by a resident
• Notes should reflect thoughtful clinical decision making, and should not be a 3page list of vitals, labs, studies, medications, followed by an outdated plan that has been copied and pasted from the day before.
• COPYING OTHERS WORK IS PLAGIARISM AND FRAUD AND WILL NOT BE TOLERATED—this includes, but is not limited to H&Ps, progress notes and consult notes
• Notes should be completed by noon
• In addition to daily notes, you will be expected to document:

• Event notes documenting changes in patient status or extensive interaction with pt/family. The note should contain pertinent vital signs and/or physical exam findings, and any new laboratory data as well as your assessment of the patient and your new plan.
• Transfer notes for any child transferred from the ward to an ICU or other service area or vice versa.

COMMUNICATION & ROUNDS

Bedside Rounds
Purpose:

• To create and enact plans to deliver high quality family-centered care for our patients
• To communicate the daily plan with the family and the nurse
• To provide PL1- directed informal teaching and physical exam findings
• To teach MS3’s how to present new and old patients.

Sign-Out Rounds
Communication failures are the leading cause of preventable medical errors. Effective handoff communication is crucial! Sign out rounds are intended to:

• Communicate key clinical issues regarding the current patients in order that the overnight team may adequately prepared to safely and effectively care for the patients on the service
• Discuss upcoming admissions