Welcome to John D. Dingell Welcome to John D. Dingell VA Medical CenterVA Medical Center

Mashkur Husain, MDChief Medical Resident

BackgroundBackground

• 267 bed facility.• One of the largest VA hospitals.• Provide primary health support to Veterans. • Affiliated with WSUSOM/DMC. Provide

significant portion of residents’ salary.• In-patient: Medicine, Surgery, Psych and

ICU.• Also NH, extended care, hospice

Floor structure & Typical dayFloor structure & Typical day• Four (Blue, Green, Red and Yellow)

medical teams.• Each team consists of 1 resident, 2 interns,

1-2 medical student(s) and social worker.• 6:45 arrive and get sign out• 7-7:30 see your patients• 7:30-8 AM: Pre-round with your senior.• 8-11:00: Rounds with medicine attending.• 11:00-11:50: Discharge• 12 – 1:00 PM Morning report.

Floor structure & Typical dayFloor structure & Typical day• 12-1 PM: Medicine Grand Rounds on

Mondays • Morning Report will be held at 1:15pm-

2:15pm (On Mondays Only) • Didactics per WSU-IM program (Academic

half Day), on every Wednesday • 1-5 PM: Finish work (including new

admissions), exit rounds and sign outs.

Admissions FlowAdmissions Flow• On call resident gets code blue pager from night float senior.• On call resident assign one of the intern with the other code

pager, get from night float intern• NP’s on Weekdays will transfer/carry Medicine admission

pager # 9775 to him/herself from 8am – 1pm (similar to role of ER/IM in DRH)

• NP is responsible for triaging, assessing pts. and putting basic orders on weekdays from 8am-1pm

• From 7am to 8am the on call senior should transfer the pager to him/herself and triage patients.

• NP will sign out new admissions to senior resident of the respective accepting team after 1PM, this is to give the team time to finish up discharges.

Admissions FlowAdmissions Flow• On the Weekend on call senior will transfer the admission

pager #9775 to him/herself

• On call senior will get sign-out from the ER, then inform the accepting team senior about the admission ASAP

• Accepting senior will be responsible to evaluate the pt. ASAP in the ER (less than half an hour please)

• On the weekend, MOD is responsible for medicine consult (STAT)

• Routine consult is seen by on call attending• If your attending wants you to see the consult, you can count it

as a hit.

Admissions FlowAdmissions Flow• On weekdays please inform the consult attending till

4:30PM • after that any routine consult doesn’t need to be seen

– Primary team needs to call the attending for consults. You do NOT see routine medicine consults on Weekdays.

– Primary team needs to put a consult and inform the consult attending in the morning.

• STAT consult needs to be seen and staffed over the phone with your on call attending

• On STAT consult pt you round the following morning before signing out the pt to consult attending, count as a hit

Admissions FlowAdmissions Flow• Team on call Q4, every 4th day• On call team gets total of 9 new admissions • Non call team gets 3 new pts each per day • Post call team gets no new pts. • Each day on call senior will start admitting

patients to him/herself after 2 pm • Or whenever the other teams are capped meaning

6 admissions to medicine team whichever comes first.

Admissions FlowAdmissions Flow• On call team will start admitting at 2pm (changed

from 3pm) to allow the team adequate time to work up all the patients and leave on time

• Total number of patients for the team will be 9 patients

• On call team will admit 5 patients till 6pm (will be at senior resident discretion how the patients get distributed between the interns)

• On call team will stop admitting new patients at 6pm to prevent violating mandatory short break

Admissions FlowAdmissions Flow• From 6pm MOD for the day will start admitting till

night float team comes in at 8pm

• Night float will admit total of 5 patients, should have zero patients waiting on arrival at 8pm

• Once the night float team reaches the cap of 5 patients, MOD will again admit rest of the night

• As the total team cap is 9 patients, the on call team will receive 4 patients from night float the following day to meet the total number of 9 patients

Admissions FlowAdmissions Flow• The other patient admitted by night float and any

patients admitted by MOD will become overflow to be distributed to the non call teams

• In the event the on call team gets total of 9 patients before 5pm, the senior resident is expected to have admissions orders in for all 9 patients and call the MOD at 5pm to hand off the other 4 patients to be admitted by MOD.

Admissions FlowAdmissions Flow• Senior will hand over code blue pager to NF senior

resident. • Intern carrying the code pager hand over to NF intern• Night float senior + intern will admit up to 5 patient

overnight. • Any additional admission after both on call team/night

float reaches cap, will go to the MOD on call.• Total team cap is 20 pts.• Medicine Team cross cover other medicine team• Pt. admitted by MOD is cross covered by MOD till

6:30am the following day then signed out to night float senior

Admissions FlowAdmissions Flow• New admission typically comes from ER • Also can come from clinics, direct admissions,

physician will page #9775, will give you sign-out as well as put delayed orders, Admitting Physician is also responsible to call Bed Control and precert pt

• Can get transfers from other VA or other hospitals, Chief Resident or MOD will review transfer packet and provide sign-out to you

• Can also get pt. from CLC or NH located in 6th floor, again same process

• Responsibility:1. Cross coverage. (only medicine and step down beds). 2. You are responsible to flag the covering physician order (a must

Nurses and other staff use this to contact you)3. Urgent Labs4. Codes (blue and gray): Keep pagers with you. Let CMR know

asap if they’re malfunctioning. Respond to calls from other services and call THEIR attending. Code blue from CLC DO NOT go to ER, only falls do.

5. You are required to put code gray/blue note in CPRS and call attending.

• Please don’t lose code pager, you will be held responsible for it, $350 per pager.

• Please return test page, dial 0 to call the operator and inform them code pager is working

Responsibility:•Transfers: nursing home, other VAs, outside community. Accept but do not count until they reach the floor.

•Once capped inform ED and MOD (look online on intraweb).

•Once capped, MOD takes over admission. MOD will sign out to Night float senior at 6:30 am (must be face to face)

•If on-call team caps before MOD arrives (5 PM), let your attending and CMR know.

People You need to knowPeople You need to know• Chief Medical Resident(s):

– Mashkur Husain: 313-258-3665– Pierre Tannous (Q&S): 732-241-9422

• Housestaff coordinator:– Beverly Greene, Dial 576-1000 then ext. 63334

• Send your case at least 48 hours in advance. It will be responsibility of the senior to go through case and correct / add to it beforehand. All cases must be from the VA, please send Pt. last Initial and Last 4

• If case is not sent 48 hours in advance to CMR then senior on that team will have to conduct morning report!

• Zero tolerance for late comers to morning report. I keep track of your attendance.

• Seniors: Please attach 2 MKSAP questions and explanation to your intern presentation as well as 3 key points

Morning ReportMorning Report

HIPAA privacyHIPAA privacy• It is imperative to respect privacy of our patients in

public places, outside patient rooms and on phone. It is being monitored very closely every day.

• Duty hours should not be violated. If there is some concern, please approach your senior/attending/CMR.

Helpful InfoHelpful Info• 4 days off per block. Work ahead.

– Can not take on-call days off.– No day off on the first day or last day of

rotation as this is critical for effective handoff.

Unique to the VAUnique to the VA• Meals during call days (1-2 meals).• Very nice call rooms. (6th floor/semiprivate

bathroom).• Exceptional computer/EMR system (paperless

system) + connected to all other VAs.• Patients are mainly in A3 Med, A5 Surg and A4

S/D.• Paging system• Nursing home/hospice unit – considered outside

facility. If pt is already hospice, should be admitted as hospice.

• Bounce back: Pts who are readmitted within the same block.– If before 3 pm (weekday), 1 pm (weekend)

will go to original team NOT counted as a hit. Unless the team is post call and can’t take patients.

– Otherwise will still be given to the original team the very next day.

• Admitting team will round on bounce back patient next day, write progress note and then give back to original team.

• HIV verbal consent NEEDS documentation in CPRS.

• Core measures– Address vaccinations prior to discharge.– Document why patient with CHF is not on

ACE/ARB, Beta blocker.– Why pt with CAD is not on ASA or statin

ADMISSIONS FROM EMERGENCY ROOMADMISSIONS FROM EMERGENCY ROOM

• Once you accept patient, give the admission information to the ED physician and he/she will place “bridging orders”.

• Must go down to ED ASAP after getting called.

• Delayed orders should be written by the resident within 60 minutes of being called.

Resident supervision Resident supervision policy after hourspolicy after hours

Senior residents on call must call their supervising physician (Hospitalist on call for that 24 hour period) for update, review, and advice concerning any patient in the following situations:

• Admission to the Step Down Unit, or transfer (or possible need to transfer) of patient to SDU/ICU

• Code Blue or Gray called on a Medicine patient

Resident supervision Resident supervision policy after hourspolicy after hours

• Serious change in medical status on the Medical floor or SDU (including, but not limited to: blood pressure; respiratory, cardiac or neurological status)

• Concern that the ED is inappropriately admitting a patient to Medicine floor when he should go to ICU or to the SDU.

VA pt. infoVA pt. info• Don’t share VA protected health information

PHI outside of the VA system. Don’t share via:– @gmail, @yahoo.com etc, @med.wayne.edu (not

even by using {secure})– SMS, iMessage.– Non-secure voicemail, e.g iPhone.– Drop Box, Google Drive, icloud

• May use @va.gov e-mail by sending a secure message: To automatically set up – just open Microsoft Outlook.

1. Covering physician order + flag must be added on every admission and transfer.

The 3 essential EMR tasksThe 3 essential EMR tasks

2. Medication reconciliation:Use the H&P template when admitting a pt. and make sure to indicate whether or not there is a discrepancy between home meds and meds that are listed in our EMR.

Must use Medication Reconciliation tool

The 3 essential EMR tasksThe 3 essential EMR tasks

3. Change encounter location:• Make sure to select a new encounter

location BEFORE adding your note (DET INPT GEN MED).

Important measures• Place anticipated discharge date• Goal Discharge of 40% by 12am

The 3 essential EMR tasksThe 3 essential EMR tasks

Proper Discharge ProcessProper Discharge Process• Rounds must end by 11:00 AM.• Place your discharge order BEFORE

11:00 AM and make sure patient leaves the facility on time.

• Use the discharge menu.• Don’t place a text order “D/C IV and D/C

patient”• Afternoon rounds to discuss possible

discharges the next day.

Team names should be Team names should be standard: Red block 1 standard: Red block 1

20152015

Medication ReconciliationMedication Reconciliation• Please utilize medication reconciliation

tool in EMR

• Any Questions???

Mashur HusainChief Medical Resident

VA Medical Center