VA GM WARDS ORIENTATION DEPARTMENT OF HOSPITAL & SPECIALTY MEDICINE

VA Portland Health Care System – updated Nov 2020 –

Orientation materials are also available online: VA DHSM Sharepoint IMResPDX OHSU MedHub GM ATTENDING ROTATION LEADERS Kyle Kent (site director) office 5-1061 pager (503) 237-0846 cell (503) 422-9466 Anne Smeraglio (director quality and safety education) office (650) 493-5000 x65490 pager (503) 202-0850 cell (503) 686-0683 Shona Hunsaker (section chief) office 5-7632 pager *41-3008 cell (503) 703-7997 RESIDENT COORDINATORS Smitha Rejoy 5-6245 e-mail: vhapor-dhsmresidentcoordinator@va.gov Adam Trabka (backup) 5-9822 CHIEF RESIDENTS AmIOn (login = vaportland or ohsu im) or OHSU operator (4-9000) to identify the Chief Resident On-Call Office: VA Building 101, Rm 102 Email: medchiefs@ohsu.edu Joel Burnett pager 25201 office 5-6095 Edward Maldonado pager 25591 office 5-5742 Kelsi Manley pager 25617 office 5-2115 Matthew O’Donnell pager 25770 office 5-2251

***ANY EXPECTED ABSENCES MUST BE REPORTED via a PAGE to ON CALL CHIEF RESIDENT. *** (Please include your name and a callback number)

IMPORTANT LOCATIONS IMPORTANT NUMBERS Morning and evening sign-out rounds: Bed control/AOD 5-5424 or 5-5425 By Phone/Teams ED 5-5438 Team rooms: Code: Triage/CHS On-Call *41-2810

GM1 8D-111 4125* GM2 6D-107 8641* (Temp 7C-109, door code i227*) GM3 5D-135 3525*

GM4 6D-125 1357* (Temp 7C-133B, door code 2733*) GM5 8D-112 4125*

NF 9C-123 no code Call rooms (key in 9C123): 7C-101 (resident), 5D-148c Call room linens – should be changed daily, if not please call x54300 and someone from housekeeping should be able to help you. PERSONAL PROTECTIVE EQUIPMENT (PPE)

o Please watch the latest video for VA ward specifics to make sure you are up to date o Please review the latest VA PPE document

TABLE OF CONTENTS: PAGE

Learning Objectives 3-4 Educational Resources 5 Evaluation and Feedback 5 Admitting Cycle and Daily Schedule 6-7 General “Hit the floor time” Admit Flow 8 Shift and Role Descriptions 8-11 Tips for Success on the Wards 12 Resident Documentation 13 Codes/RRTs 14 Bounce-Back Policy 14 Patient Distribution 14 Caps 14 Hip fracture admissions 14 Weekly Resident Huddle 15 Heart Failure Follow Up 15 Pulmonary Rehab 15 Sign-Out and Pager Status 15 Internal Medicine Conferences 15 Anesthesia Intern Conference 16 Holiday Schedule 16 Jeopardy 16

Learning Objectives Interns

• Evaluate chest pain • Initiate effective diuretic regimen to treat decompensated heart failure

• Evaluate respiratory distress

• Initiate appropriate therapy for a COPD exacerbation

• Evaluate AKI utilizing the prerenal, intrinsic, postrenal framework

• Titrate basal bolus insulin therapy

• Initiate appropriate antibiotics based on type of pneumonia

• Initiate appropriate antibiotics for cellulitis

• Initiate diagnostic evaluation for delirium

• Initiate and titrate multimodal pain control therapies

• Interpret ECG in a systematic fashion

• Interpret chest x-ray in a systematic fashion

• Obtain a hypothesis-driven patient history

• Perform a targeted, hypothesis-driven physical examination

• Develop prioritized differential diagnoses

• Deliver appropriate, succinct, hypothesis-driven oral presentations

• Perform an accurate medication reconciliation

• Provide accurate, complete, and timely documentation

• Utilize patient friendly language at the bedside

• Identify clinical questions and access medical information resources

• Seek assistance or guidance from resident or attending when appropriate

• Communicate effectively and professionally with interdisciplinary team members (RN, pharmacy, SW)

• Use feedback to improve performance

• Triage and execute daily tasks efficiently

Learning Objectives

Senior Residents

• Manage and escalate care in a patient with unstable vital signs • Manage withdrawal syndromes (alcohol or opioids)

• Recommend appropriate risk stratification for patients admitted with chest pain

• Manage atrial fibrillation/atrial flutter

• Manage decompensated heart failure

• Manage respiratory failure

• Manage decompensated cirrhosis

• Manage GI bleed

• Manage hyponatremia

• Initiate and tailor antibiotics appropriately based on clinical course and culture data

• Provide comfort care at the end of life

• Obtain subtle, sensitive, and complicated information that may not be volunteered by the patient including use of ancillary sources

• Modify differential diagnosis and care plan based on clinical course and data as appropriate

• Integrate evidence into clinical decision making

• Teach learners on rounds

• Communicate effectively and efficiently with patients (teach back, leading family meetings, etc.)

• Engage in collaborative communication with all members of the health care team including consultants and ED staff

• Author timely documentation that clearly and succinctly conveys medical decision making

• Seek assistance or guidance from attending when appropriate

• Anticipate and coordinate care transitions within the hospital and at discharge

• Minimize unnecessary care including tests

• Manage the team to ensure efficient completion of daily tasks

Educational Resources

• High yield landmark articles on IMRESPDX by specialty as well as Med Ed for teaching tips

• UpToDate – quick guidance for differential diagnosis and appropriate work up

• DynaMed Plus – quick evidence summary to round out your treatment plans, appraised for you

• Pocket Medicine – great “approach to” tables for things like respiratory failure, hyponatremia, etc

Evaluation and feedback Please give in person feedback during your time on service to your learners and your attendings, call it “feedback,” and emphasize at least one thing they are doing well and one specific thing they can do to improve. We expect your attendings to do the same. Please complete your MedHub evaluations on your last day on service or within 7 days of finishing to ensure timely feedback for colleagues and the program.

• Your evals have been updated to more specifically reflect what we want you to learn on this rotation and to direct specific feedback your way on how you are doing learning these things

• Review what is on the evaluations and utilize the 1-page handouts to take notes re what you see one another do each week as well as to guide your goals and feedback sessions.

• You can also track these as you go using the MedHub App, just download it on your phone and it auto-saves.

Admitting Cycle and Daily Schedule

Sa Su M T W Th F

GM1 RON/RS/RS IS/DW/LW L2 D1 D2 IS L1

admits 0 4 3 4 4 2 3

duties AM S/O

day off interns/MS3s resident/-/- resident

GM2 RS/RON/RS LW/IS/DW D1 D2 IS L1 L2

admits 0 4 4 4 2 3 3

duties AM S/O

day off interns/MS3s -/resident/- resident

GM3 RS/RS/RON DW/LW/IS D2 IS L1 L2 D1

admits 0 4 4 2 3 3 4

duties AM S/O

day off interns/MS3s -/-/resident resident

GM4 DW/LW RS L1 L2 D1 D2 IS

admits 4 0 3 3 4 4 2

duties AM S/O

day off interns/MS3s resident

GM5 LW/DW RS IS L1 L2 D1 D2

admits 4 0 2 3 3 4 4

duties AM S/O

day off interns/MS3s resident

Legend: (details below) D or DW Day Call or Day Weekend L or LW Late Call or Late Weekend RS Resident Solo (MS3s and interns off) IS Interns Solo (resident off) RON Resident Overnight (rotates every third week among GM1-3) NF Night Float AM S/O The attending who is present at the AM sign-out rounds

ORDER OF THE DAY: MONDAY – FRIDAY

Time Activity

7:15 am Day Call & Intern Solo teams arrive, receive signout from Night Float via phone/Teams; finish by 7:45 am Late Call teams arrive at 7:45 am – finish signout by 8 am

7:15 am Day Call admitting teams begin to take admissions

8:00 am TUES – Dept of Medicine Grand Rounds – ALL RESIDENTS/INTERNS/STUDENTS

9:15-9:30 am

Multidisciplinary Rounds w/ SW, nursing, pharmacy, UM, +/- nutrition, HF RN

• GM1-GM5 at same time via Teams

9:30-11:15 am Attending Rounds

• Goal to finish by 11:15 am, must finish by 11:30 am

12:00 pm

Noon Conference begins – attendance is MANDATORY o MON/WED – Noon Report (web-ex) o TUES/THURS/FRI – Noon Conference (web-ex)

1:15 pm FRI – Intern Report (web-ex) – INTERNS ONLY

3:00 pm Day Call ends and Late Call begins

3:00 pm If work is done, Day Call teams may sign out internally to one designated team member. Interns on Intern Solo day may also sign out to their counterparts on L2 call if all work is done (Mon: GM5→GM1, Tues: GM3→GM4, Wed: GM2→GM5, Thurs: GM1→GM3, Fri: GM4→GM2)

7:00 pm Night Float team arrives, all teams sign out by phone/Teams (NF prints their own sign out sheets)

9:15-9:45 pm ALL TEAMS (except night float) MUST BE OUT OF THE HOSPITAL

• If Day or Intern Solo the following day must be out by 9:15 to have 10 hours between shifts

• If Late the following day must be out by 9:45 to have 10 hours between shifts

ORDER OF THE DAY: SATURDAY – SUNDAY

Time Activity

7:15 am

Admitting teams arrive, receive signout from Night Float/RON via phone (no staff present) o SAT – Non-admitting teams (GM1/2/3) arrive by 7:45 o SUN – All teams, including non-admitting teams, must arrive by 7:15 to take signout from RON

7:15 am Day Call team open to admissions

7:30 – 8:30 am SUN – RON rounds on newly admitted patients with attending and interns RON departs after new patients are seen/discussed; attending/interns round on established pts

Morning, tbd Attending rounds timing at discretion of other teams

2:00 pm Day Call team stops taking admissions and Late Call team begins

3:00 pm SAT – RS/DW may sign out to RON if work is done and patients are stable. SUN – RS/Post-RON IS/DW may sign out to Late Call team if work is done and patients are stable.

7:00 pm SAT – RON starts taking new admits after 7 pm and gets signout from Late Call team when finished with their work. SUN – Night Float team arrives, Late Call team signs out via phone/Teams.

9:15-9:45 pm ALL TEAMS (except night float and RON resident ) MUST BE OUT OF THE HOSPITAL

• If Day or Intern Solo the following day must be out by 9:15 to have 10 hours between shifts

• If Late the following day must be out by 9:45 to have 10 hours between shifts

General “Hit-the-Floor Time” Admit Flow

Details:

o Resident teams CANNOT go to the ED. o Patient will not be assigned a team/signed out until they are coming to the floor within 15-

30 mins. o Day call:

▪ Patient must arrive on the floor by 15:00. If after 15:00, team will call AOD to re-assign to late call, and will give sign out to new accepting team. *Day Weekend is 14:00.

o Late call: ▪ Patient must arrive on the floor by 19:00. If after 19:00, team will call AOD to re-

assign to night float, and will give sign out to night float. o Night Float:

▪ No change to cap: 6 patients/night ▪ Patient must arrive on the floor by 05:30. All admits between 05:30-07:00 will get

holding orders and be signed out to day team(s) to complete the admission. o Per usual, you’ll be alerted to direct admits from clinic or outside transfers via a note in CPRS

with the details gathered by the doc who took the call. Verbal heads up is not required in these instances and will likely be rare.

o Precautions reminder - If ED wants to admit a patient to Enhanced Respiratory Precautions (Purple) they call and discuss with CHS. If both agree patient can be admitted to Enhanced Standard Precautions the patient is admitted to the next GM or CHS team up in the admitting cycle. If there is no consensus after the conversation and ED requests Enhanced Respiratory Precautions the patient will be admitted to CHS. If the ED is admitting a patient to you and thinks they might need to be on Enhanced Respiratory Precautions please direct them to discuss with CHS. If you have concerns about the level of precautions please call the relevant GM attending to discuss and have them call CHS if appropriate. Remember, Enhanced Standard Precautions are designed to keep providers low risk exposures even if exposed to a patient with COVID.

Shift and Role Descriptions D = Day Call Day Call teams arrive for sign-out at 07:25 (D1) and 07:35 (D2) and each admit up to 4 patients until 15:00, including patients from Night Float. NF patients will be distributed first two to the Intern Solo team (on Monday-Friday), then across the D1 and D2 teams. New admissions during the Day Call shift will then be distributed among the D1, D2 and CHS teams. Teams are responsible for admitting any patient who arrives on the floor (from the ED, ICU or OMU) by 15:00. When work is done teams may sign out internally, leaving one designated team member to cover their patients until 19:00 and sign out to Night Float. All teams are required to maintain a presence in the hospital until 19:00 except IS (see below). If there are extenuating circumstances that might warrant straying from the typical admissions distribution (absences, very busy service, other team difficulties, etc.) please discuss with Kyle Kent or Shona Hunsaker and we will work through these on a case-by-case basis.

L = Late Call Late Call teams arrive at 07:45 for cross-cover sign-out. Teams begin admitting when both Day Call teams have filled or at 15:00, whichever is first, and are open for up to 3 admissions. When on Late Call the team should arrange the day to allow most work regarding established patients to be done (e.g. progress notes completed, orders entered) well before 15:00 (preferably by 12:00) so that they can focus solely on new admissions after that time. Admissions will alternate among the L1, L2 and CHS teams. Teams are responsible for admitting any patient who arrives on the floor by 19:00. The admitting team should wait to see the patient until they hit the floor but start their notes and enter DELAYED – ADMIT TO GENERAL MEDICINE orders. Patients still “belong” to their current location until they are physically moved so for any urgent orders that need to be executed prior to transfer please discuss directly with the ED/ICU/OMU care team. Teams are expected to be ready to sign out established patients at 19:00 sign-out rounds, then to call NF to update them on new admissions before leaving for the night. It is vital that teams be done and out of the hospital BY 21:15-21:45 AT THE LATEST to allow for an ACGME-mandated 10-hour duty free period between shifts. If/when there are violations of the 10-hour rule, PLEASE keep Dr. Kent and the Chief Residents informed of the factors that led up to this in order to help us improve the system accordingly. RS = Resident Solo This will always fall on Saturday or Sunday. Both interns and the students will have the day off together. There will be no new patients on this day. Each team can decide how this day runs (i.e. timing of rounds etc). Residents must be available to nursing and to their patients and their families until 1500. In the event of downtime, there is plenty that can be done: finishing D/C summaries, calling families, keeping track of clinic patients, catching up on reading, etc. See "Order of the Day" for information about which team to sign out to. Residents may sign out at 1500 if all patients are clinically stable and all clinical care is wrapped up thoroughly. See the schedule above for information about which team to sign out to. Once per rotation, the resident from GM1-3 will stay after a Resident Solo shift and spend Saturday night in the hospital (see RON below). IS = Intern Solo This will fall on a different weekday for each team. The resident will have the day off but students will be present. Intern Solo interns come at 0715 for cross-cover and new patient sign-out. The first two patients admitted by Night Float will go to the Intern Solo team (one each per intern); if Night Float admits no patients or only one, the Intern Solo team will NOT be open to admit additional patients during the day. Interns may sign out at 1500 if all patients are clinically stable and all clinical care is wrapped up thoroughly. See the schedule above for information about which team to sign out to. Sign out should be to the corresponding intern (A or B) for that team. If there are tenuous patients, we recommend a phone call to the NF intern at 1900 to provide direct sign-out. For GM1-3, there will be a second Intern Solo day on Sunday following the RON shift (see below). On that day, the team resident will leave after rounding formally on the new overnight admissions, and the day will carry on like an Intern Solo day otherwise: attending and interns will write all notes and manage the patients for the day. Interns may sign out at 1500 if all patients are clinically stable and all clinical care is wrapped up thoroughly. See the schedule above for information about which team to sign out to. Sign out should be to corresponding intern (A or B). DW = Day Weekend Shift On Saturdays, GM4 and GM5 will alternate Day and Late Shifts every other week (see amion for the assignment). On Sunday, GM1-3 will rotate through this assignment once every 3 weeks (after the IS and

before the LW shift; again, check amion). The team on DW shift will arrive at 0715 for sign-out from Night Float (Saturday) or RON (Sunday) and will be open for admissions until 1400. There are some differences between Saturday and Sunday on DW shift:

• Saturday: DW team will take up to 4 overnight admissions from Night Float. If it fills all 4 admissions slots, there are no more admissions for the day. If not, the DW team will continue admitting until it has a total of 4 new patients or it is 1400. Any patient who arrives on the floor by 1400 is their responsibility.

• Sunday: DW team will not start the day with any overnight admissions, since these will stay on the RON’s team. The team will be open for up to 4 admissions until 1400. Any patient who arrives on the floor by 1400 is the DW team’s responsibility.

The DW team may sign out to the RON (Saturday) or LW team (Sunday) as early as 1500 (NO EARLIER) if all patients are clinically stable and all clinical care is wrapped up thoroughly for the day. LW = Late Weekend Shift On Saturdays, GM4 and GM5 will alternate Day and Late Shifts every other week (see amion for the assignment). On Sunday, GM1-3 will rotate through this assignment once every 3 weeks (after the DW and before the IS shift; again, check amion). The LW team will start taking admissions at 14:00 or after the DW team has taken 4 new admissions, whichever is first. They can receive up to 4 new admissions up until 19:00. Teams are responsible for admitting any patient who arrives on the floor (from the ED, ICU or OMU) by 19:00. The admitting team should wait until the patient hits the floor to see them but start writing the admit note and enter DELAYED – ADMIT TO GENERAL MEDICINE ORDERS. Patients still “belong” to their current location until they are physically moved so for any urgent orders that need to be executed prior to transfer please discuss directly with the ED/ICU/OMU care team. The LW team should finish work and leave BY 21:15-21:45 AT THE LATEST. There are some differences between Saturday and Sunday on LW shift:

• Saturday: LW team arrives at 07:45 for sign-out from Night Float. Be aware that the LW team is at risk for at least one overnight admission if NF has admitted 5 or more patients, and for immediate new admits if DW has already filled from NF admissions.

• Sunday: LW team arrives at 07:15 for sign-out of cross-cover RON. There will not be any admissions to hand off.

Non-admitting teams may sign out their patients to the LW team on Sunday at 15:00 BUT NO EARLIER. Sign-out on Saturday will be to the RON, not the LW team. See "Order of the Day" above for instructions about who signs out to whom. Attending rounds timing is at the discretion of each team. RON = Resident Overnight The Night Float team is off on Saturday night. Instead, the residents from GM1-3 will rotate to cover Saturday night every 3rd week (i.e., once each per rotation). On this weekend, the resident works on Saturday as usual (Resident Solo shift, with no new patients). However, at 1500 the other Resident Solo teams, and potentially the DW team, can sign out to the RON and leave. After 1900, the LW team will also sign out, and the RON will then be responsible for cross-cover on all GM patients as well as admission of up to 4 new patients between 1900-0530. Any patients who arrive on the floor between 0530 and 0715 should be eyeballed, receive holding orders, and be verbally signed out to the DW team to complete the admission. The RON will otherwise keep all patients admitted on their own team and sign out cross-cover at 0715. The RON will then round with the rest of their own team on Sunday morning on all new overnight admissions. The RON should then leave, and the attending and interns will stay for the rest of the day to manage the new patients and round on established patients. There will be no additional admissions to this team. The resident's own team attending will provide support for new admissions as needed for the night.

NF = Night Float Night Float arrives at 1900 and leaves by 0800. Please see separate Night Float orientation document. AM S/O Rounds The attending assigned this role will be present with the IS team at 0715 sign-out rounds Monday-Friday. The attending will provide any important feedback on sign-out and is also expected to dispense the occasional pearl of wisdom. NF will be tagged on the attending note for IS patients and may also receive an email with feedback.

Tips for Success on the Wards Microsoft Teams – Please make sure you are signed onto Teams when you start your rotation. Using the chat messaging feature is your key to better efficiency. Many people at the VA respond to direct messages faster than phone calls. Use it to schedule follow up appointments with nurse care managers and facilitators. Use it to follow up throughout the day with RNs, pharmacists, social workers, or your attendings. Computer/equipment/PIV card issues – Please contact our residency coordinator Smitha Rejoy at x56245 or email vhapor-dhsmresidentcoordinator@va.gov for help. Sometimes residents sit on things and perform complex workarounds for weeks at a time when there could be a quick fix. CPRS – If it takes you more than a few seconds to find what you want in CPRS please ask someone on your team, someone on another team, or ask your attending. There are also some screenshots of tips and tricks on IMRESPDX. Late admits – the goal of these admissions is to formulate an initial assessment and put a safe plan in place for them before handing off to the night float team. If you don’t have every detail figured out that’s ok, some things can wait until the next day. Prioritize the main issues, address urgent consults and interventions, direct their care in the right direction and avoid harms, and order what you need so you’ll have results and more answers by the next morning. Start writing your orders and your note as soon as you hear sign out and go see them right away when they hit the floor. Sign over Discharge Summaries – before a day off or before you hand off your service to a colleague please sign over (edit the author listed) any discharge summaries you have started to the person who will be working the next day. This allows the team to edit and finish DC Summaries and avoids the frequent issue where the note is only visible and editable by the person who is no longer around.

Additional Guidance Regarding Workflow and Sign-Out Resident documentation New patient:

• Interns will document a History and Physical, using the mandated H&P template that pops up when they open the note titled INPAT – MED – Hist&PHYS. They will document medication reconciliation by annotating the med list that populates into this note or by using the APHID tool.

• Residents write a brief admit note using the standard template that pops up when they open the note titled INPAT – MED – RES - ADMIT.

• If the resident is writing the team H&P they must use the INPAT – MED – Hist&Phys template.

• Life Sustaining Treatment (LST) Plan note: o LST plans have replaced “code status”. o LST notes/orders do not auto-expire or discontinue when a patient changes level of care

or goes from inpatient to outpatient. o This means that if a patient already has the LST note/orders and their wishes remain the

same, you don’t have to write a new note or place new orders (just document in your H&P that you reviewed it).

o For patients without the LST note/orders, the new note template is called the “Life Sustaining Treatment Plan”.

o The LST note/orders should be done for all patients who are DNR and those who are high risk (meaning you wouldn’t be surprised if they had a major medical event within the next year – for reference 1/5 veterans admitted to the hospital will die within 1 year so documenting/confirming LST on pretty much everyone is a good idea).

o The only mandatory questions are: ▪ Does the Veteran have decision-making capacity? (Question #1) ▪ What are the Veteran’s goals? (Question #5) ▪ What does the Veteran want done in emergencies where they DO NOT have a

pulse? (Question # 6—lower portion) ▪ Do they consent to this LST plan? (Question # 8)

o Once you finish the note, the LST orders will appear. o Attending co-signature is required within 24 hours.

• Daily progress notes will be completed using personal/shared soap note template. It is expected that, when present, these notes will be completed by the intern following that patient.

o If there is an assigned MS3, the note will be completed by the MS3 with an addendum/cosignature by the intern that includes an exam and a brief assessment and plan. A full intern note in addition is optional but encouraged.

o If there is an assigned sub-I, the note will be completed by the sub-I with an addendum/cosignature by the resident that includes an exam and brief assessment and plan.

o On resident solo days, it is expected that residents will complete the daily progress note.

• Discharge summaries may be completed by residents or interns, using the mandated discharge summary template that pops up when you open the note.

The note completion times, as defined by the hospital, ACGME and residency program, are outlined here: Patients discharging home: DC Summaries – within 48 hours of discharge Patients discharging to CLC or Community SNFs: DC Summaries – BY THE TIME OF DISCHARGE Daily Progress notes – by the end of each work day ICU Transfer – progress note by the end of the day Night Float admit – progress note by accepting team by the end of the day (post-rounds addendum not acceptable)

Codes and RRTs You’re no longer carrying pagers and running these during the day. We regret the decrease in learning

opportunities. We have been able to get Night Float responding again and if this goes well the daytime

residents would be added back next.

The codes and RRTs for all patients during the COVID pandemic are now being run by a small group of

people to limit exposure, optimize care, and reduce PPE usage (MICU fellow, MICU

attending/Anesthesia/ED for airway, etc – MICU resident/NF resident is team leader overnight)

• The presumption since codes are aerosolizing and RRTs may turn into something aerosolizing is

that all patients could have COVID

• If you are on the floor when an RRT/code is called please wait for the team to arrive rather than

entering the room

• Determining code status in a code scenario -

o If a code 99 happens and the bedside nurse is confident the patient is on comfort care

or is DNR, resuscitative efforts will NOT be initiated while CPRS is opened to confirm

the LST plan.

o If there is any doubt, or the patient is known to be full code, resuscitative efforts will be

initiated once staff/code team are in full PPE but a member of the team should still

open CPRS to confirm the LST plan for the patient.

o If no LST plan is documented, that means the patient is full code.

Bounce Back Policy The default is that there are NO BOUNCE BACKS. If a patient is discharged and readmitted or transferred to the ICU and comes back to the ward the patient will go to the admitting team who is up for an admission. Trying to get patients back onto the same team causes a lot of problems with our admission capacity and flow. If a team would like to take a patient back onto their service because it is in the best interest of the patient they can work with the site director Kyle Kent (cell 5034229466) and AOD (extension 5-5424) to make this happen. If the team is admitting that day the patient will count as an admit, if team is not admitting that day the patient will count as an admission for the GM team who is accepting the patient that day and then transfer to the desired team the following morning but not count as an admit that morning. Patient Distribution There is a set admission algorithm each day which alternates between the GM teams and CHS. This is only adjusted when needed for GM teams (need to give a team with a low census more patients, need to reduce census/admissions due to time of year/struggling learners/high acuity/hospital admitting needs for that team in the coming days). Again, if there are extenuating circumstances that may warrant changes to the typical admissions distribution please discuss with Kyle Kent or Shona Hunsaker. Caps Each team should have no more than 14 patients at end of day. The teams can flex above 14 patients during the day if there are pending discharges. Of course, it is more than team census that determines how busy each team is. Anytime a team is stretched to the point that patient care or mental health is at risk, they can/should close to admissions. If such a situation arises, the team attending should work with Kyle Kent or Shona Hunsaker to develop a plan for diverting admissions to other teams. Hip fracture admissions

These patients go to CHS by policy.

Weekly Resident Huddle You are essential to the work we do at the VA. Our systems are continuously improving and we want you to know what is going on so you can best care for patients and lead your teams. We also want to be able to hear about issues in real time so we can help troubleshoot them.

o When: Every Monday, 2-2:15/2:30 PM o Where: Via Microsoft Teams o Who: All Interns/Residents and GM5 Interns (Mon is GM5 Resident’s day off, updates

will be delivered to interns)

Heart Failure Follow Up Patients admitted with acute heart failure as the primary or secondary diagnosis they need follow up within 7 days in the heart failure clinic or with their PCP. Please utilize the heart failure team (info in team rooms). Pulmonary Rehab Please enter consult on discharge for anyone admitted with a COPD exacerbation or severe COPD who would benefit. This improves mortality. Sign-Out and Pager Status For the first 3 months of the academic year (until October 1), by residency program’s policy the senior resident must be present for sign out to the night shift. On Intern Solo days, it is expected that the attending will supervise sign-out in lieu of the resident. This early-year supervision is designed to promote learning through role-modeling and feedback for the sign-out process, and also patient safety through ensuring accurate and complete sign-out. Please see Shift and Role Descriptions above for specific sign-out instructions for each team, October 1 – June 30. To ensure nursing staff, ward secretaries, and consulting teams can always reach someone responsible for the care of each patient, it is important to have a uniform policy regarding sign-out and pager status. The VA policy is consistent with the one in use at OHSU. Always leave your pager on, status “In hospital, on page.” Whenever you leave for the day, use SmartWeb to forward all pages to the covering resident or intern. Most often this will be the night float intern, but there may be situations where there will be more than one hand-off before your return (e.g., handing off to your team co-intern at 17:00 on Day Call, then to Night Float at 19:00, then to your team resident the next morning if it is your day off). On those occasions, make certain you set coverage for all of those transitions. SmartWeb instructions:

• Click "Personal Profile"

• Login (use your usual computer login)

• Click "exception", then "Coverage" and hit "new"

• Type in the pager of whomever you signed out to and what time you want to stop coverage

• If you have a day off, forward to the night intern (RON resident on Saturday), and then set a second coverage to your resident/intern for the day off

If you need help call the OHSU Pager Operator for assistance. Internal Medicine Intern/Resident Conferences Conference attendance is expected of all residents and interns on VA wards. The only exception to this rule is an urgent patient care issue that requires immediate triage. Attending rounds are expected to finish no later than 11:30 every day in order to facilitate resident conference attendance. Nursing staff have been asked to limit non-urgent messages between 12-1 to allow residents to attend conference uninterrupted. The conference schedule can be found at http://www.imrespdx.com/.

Anesthesia Intern Conference

The Anesthesia intern on GM1 has required departmental conference on Monday mornings. GM1 will be LC on Mondays to help facilitate attendance. The Anesthesia intern will attend their morning conference and then join the team. At least half of the daily progress notes for established patients will be written by the GM1 resident. Anesthesia interns should return to the GM1 team immediately following conference to receive updates and review the plan for patient care before IM noon conference. For any questions or concerns please contact Christine Martin, Director of APOM Clinical Base Year, at martich@ohsu.edu. Holiday Schedule

We operate on a holiday schedule for all federal holidays except Columbus Day and Veterans Day: New Year's Day January 1 Martin Luther King, Jr. Day Third Monday in January George Washington’s Birthday Third Monday in February Memorial Day Last Monday in May Independence Day July 4 Labor Day First Monday in September Thanksgiving Day 4th Thursday in November Christmas Day December 25

When a federal holiday falls on a Saturday, it is usually observed on the preceding Friday. When the holiday falls on a Sunday, it is usually observed on the following Monday.

• Day Shift teams take a max of 3 patients who hit the floor by 13:00 and can leave at 15:00 if all work is done. D1 signs out to L1, and D2 signs out to L2.

• Intern Solo teams may leave at 15:00 if all work is done. They still take 2 patients in the morning from Night Float. IS interns sign out to L2.

• Late Shift teams have no change except to start taking admissions at 13:00 instead of 15:00. Thanks for taking one for the team, Late Call teams!

• Night Float is unchanged.

Jeopardy In the event of unexpected illness or a significant event where housestaff are unable to attend to their previously scheduled duties, there is a Jeopardy system in place. The primary purpose of the Jeopardy system is to ensure patient safety while allowing housestaff to attend to personal and family emergencies. Housestaff should report unplanned absences to the Chief Resident on Call so that Jeopardy can be mobilized. The Chief on Call is found at the top of the Internal Medicine Amion page. The Chief on Call should be paged with the name of the person and their contact information. Housestaff should expect to receive a phone call from the Chief on Call. Email is not an appropriate means to communicate an unexpected absence. Paging should be used for any communication that requires prompt reply (within less than 24 hours). Not every intern or resident absence will be covered by the Jeopardy system. The VA site director(s), working closely with program leadership, may elect to cover the patient care workload without a jeopardized learner.