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The Basics

(warning) Summary of Ward Rotation Expectations (warning)

Everyone working on the wards should know this information before starting on wards. Look here for details of team member roles, responsibilities, and expectations.


Inpatient Wards Organization 

Team A:

Attending

Ward Senior (WS)

Ward Junior (WJ)

Psych Intern

Medical Students

Day Float (3rd priority)

Team B:

Neurohospitalist

Medical Students

Day Float (1st priority)


Summary of Wards Responsibilities/Workflow (full details below)


SaturdaySunday Weekdays
Week 1

TEAM B IS ON CALL

8AM-12PM:

CS2: consult pager, stroke pager, phone calls

(so that Team A can round)

CS1: acting WS, Team A rounds, then consult follow-ups

WJ: Team A rounds

Psych Intern: Team A rounds

12PM-later: Team A can signout to DF

Dayfloat: cross cover, new consults, phone calls, stroke pager until 8p

CS1: after completion of follow-ups, assists with new consults until 6p

8PM: Dayfloat signout to NF


TEAM A IS ON CALL

8AM-12PM:

WJ: Team A rounds, stroke pager, consult pager, phone calls

WS: Team A rounds, consult follow-ups

Psych Intern: Team A rounds

12PM-8PM:

WJ: complete inpatient work; hold consult pager, stroke pager, phone calls, hold cross-cover

WS: backup WJ, shares new consults until 6p, after completing consult follow ups

Psych Intern: can signout to WJ at 12

Team B: can signout to WJ at 12

8PM: Team A signout to NF


7AM-8AM: Team A pre-rounds

8AM: Team A rounds

12PM: Noon lectures (DeJong)

1PM: Stroke Rounds/Multidisciplinary Rounds

5PM: Team A signout to DF/mid-level

Week 2

TEAM A IS ON CALL

8AM-12PM:

CS2: consult pager, stroke pager, phone calls

(so that Team A can round)

WJ: Team A rounds

WS: Team A rounds, consult follow-ups

Psych Intern: Team A rounds

12PM-8PM:

WJ: complete inpatient work; hold consult pager, stroke pager, answer phone calls, hold cross-cover

WS: backup WJ; after consult follow ups completed, shares new consults until 6p

Psych Intern: can signout to WJ at 12

Team B: can signout to WJ at 12

8PM: Team A signout to NF



TEAM B IS ON CALL

8AM-12PM:

WJ: Team A rounds

CS1: acting WS, consult pager, stroke pager, phone calls, Team A rounds then consult follow-ups

Psych Intern: Team A rounds

12PM-later: Team A can signout to DF

Dayfloat: cross cover, new consults, phone calls, stroke pager

CS1: after completion of follow-ups, assists with new consults until 6p

8PM: Dayfloat signout to NF



General:

  • Rotation begins on Saturday, Team A is OFF call
    • WJ, CS1, CS2, and psych intern are ON, WS is OFF (see Weekends section below)
  • Call alternates between Team A and Team B every other day
  • The team on call is responsible for all admissions within their 8am-8am call cycle (see Admissions below)
  • The psych intern has required morning conferences every other Thursday


Admissions:

  • scheduled admissions
  • direct admissions from neurology clinics
  • admissions from Team C (usually from the ED)
  • OSH transfers
  • If WS (or coverage of Team A dummy pager 34742) receives the following:

    • OSH transfers for admission to Team A: defer to AOD
    • OSH transfers for admission to NICU: defer to NICU on-call attending
    • OSH stroke transfers: defer to on-call B.I.G. attending
    • MLINE calls re: UofM neurology patients at OSH: address question of OSH physician if able; if further expertise needed, can discuss with on-call attending; if OSH physician requesting transfer, defer to AOD

Caps:

  • The Team A cap is 16 patientsnot counting NICU patients
  • If Team A is capped, new admissions will go to Team B regardless of call day until Team A becomes under cap
  • While Team A is capped and while all subsequent admissions are going to Team B, if deemed necessary by the Neurohospitalist (typically a census greater than 13) then the jeopardy resident may be asked to help Team B until the census lightens


Continuity Clinic: during Ward rotations there will be no continuity clinic, this is new as of the 2019-2020 academic year


Weekdays:

  • 7:00-8:00AM: 
    • show up, pre-round as appropriate; pre-round earlier if needed/higher census
    • page Nightfloat to get signout 
  • 8:00AM-5:00PM:
    • Team A rounds; Nightfloat presents admits they admitted, goal to be out by 9:00AM
    • After rounds, Team A completes all inpatient work (consults, orders, medical student teaching, notes, signout)
  • 12:00-1:00PM: Noon lectures (DeJong Library)
  • 1:00-1:45PM: Stroke Rounds (Mon/Wed/Fri) or Multidisciplinary Rounds (Tue/Thu)
  • 5:00PM:
    • Team A can start signout to Dayfloat
    • WS to verbally FYI Dayfloat (Nightfloat by email) if any known pending admits or in-coming transfers

Weekends: Team A on call

  • 7:00-8:00AM: 
    • show up, pre-round as appropriate; pre-round earlier if needed/higher census
    • page Nightfloat to get signout 
  • 8:00AM-8:00PM
    • Team A rounds
    • WS then sees consult follow-ups with attending
    • Consult junior assists on Saturday mornings (8-noon) by holding stroke pager, consult pager, and answering phone calls; otherwise:
    • WJ holds stroke pager (1st responder to ALL ED/inpatient strokes) with WS as backup. Consult junior does this on Saturday morning (8-noon).
    • WJ holds consult pager for NEW consults. Consult junior does this on Saturday morning (8-noon).
    • WJ answers weekend phone calls. Consult junior does this on Saturday morning (8-noon).
    • 12:00PM: Psych Intern and Team B may signout to WJ, who holds cross-cover until 8:00PM
    • After rounds, Team A completes all inpatient work (consults, orders, medical student teaching, notes, signout)
      • After rounds, WS and WJ can split new consults 50:50 until 6:00PM
  • 8:00PM:
    • WJ signout to Nightfloat
    • WJ hands off stroke and consult pager to Nightfloat
    • WS/WJ send email signout with consult and Team A updates to CS1 (who will be acting WS on other weekend day), cc:Dayfloat/Nightfloat

Weekends: Team B on call

  • 7:00-8:00AM: 
    • show up, pre-round as appropriate; pre-round earlier if needed/higher census
    • page Nightfloat to get signout 
  • 8:00AM-12:00PM:
    • Team A rounds; CS1 is acting WS
    • Consult junior assists on Saturday mornings (8-noon) by holding stroke pager, consult pager, and answering phone calls. 
    • CS1 will carry the stroke pager, consult pager, and answer phone calls during team A rounds (when CS2 is off) until dayfloat arrives
    • After rounds, CS1 then sees consult follow ups with attending
    • After rounds, Team A completes all inpatient work (consults, orders, medical student teaching, notes, signout)
  • 12:00PM:
    • Team A can signout to Dayfloat once all inpatient work complete
    • CS1 hands over stroke pager, consult pager, phone calls to Dayfloat
    • CS1/WJ send email signout with Team A updates to WS, and consult updates to Dayfloat/Nightfloat/CS2

Days off: WJ and Psych Intern can be have days off on either call or non-call days

  • WJ: by default, both Fridays during the rotation block; can request alternative days in advance for approval by WS
    • this is up for review, with the new NICU/stroke policy as NICU resident has clinic Friday afternoons.
  • WS: day off is weekend non-call day; thus:
    • Week 1 of block: Saturday off
    • Week 2 of block: Sunday off
  • Psych Intern: by default, both Wednesdays during the rotation block; can request alternative days in advance for approval by WS


Summary of WJ responsibilities:

  1. First contact for assigned neurology inpatients (split with Psych Intern)
  2. All ED and inpatient strokes, new consults, and phone calls 8:00AM-8:00PM on-call weekend day
  3. Noon didactics
  4. Wednesday conferences
  5. Medical student teaching

Summary of WS responsibilities:

  1. Supervisory role for Team A: double check orders, notes, signout/handoffs to DF/NF
  2. Supervise NICU/WJ for ED stroke activations until NICU Jr is independent
  3. Backup WJ for stroke activations (weekdays and weekends), weekend consults, weekend phone calls
    1. for CS1: All ED and inpatient strokes on Sunday when Team B is on call, until dayfloat arrives
  4. Coverage of WJ's patients and stroke pager during WJ clinic and days off
  5. Coverage of Psych Intern's patients during days off and didactics
  6. Receive handoff for admits from Team C, neurology clinics, and scheduled admits, then triage to WJ or Psych Intern
  7. Medical student teaching
  8. Noon didactics
  9. Wednesday conferences

Summary of Psych Intern responsibilities:

  1. First contact for assigned neurology inpatients (split with WJ)
  2. Thursday didactics
  3. May see new consults or answer weekend phone calls at discretion of, and if also seen by, WS
  4. Noon didactics
  5. Medical student teaching


Summary of Weekday and Weekend Coverage

Multidisciplinary / Stroke Rounds: Template of what should be presented can be found here . Goal is to have a succinct discussion of patient medical problem + treatment, therapy needs, social work issues and disposition.

Additional Information: 

Holidays

Holidays include: Memorial Day, Labor Day, Thanksgiving Day, the day after Thanksgiving, Christmas Day, and New Year's Day. When holidays occur during the week, those days are treated as normal work days. This is re-visited every year and determined by majority vote.

ACT Monitor as outpatient

FYI-to avoid phone calls about a-fib monitoring  When ordering long-term monitoring for atrial fibrillation, use the diagnosis: atrial fibrillation (427.31). You only need a suspicion that the patient has a-fib to use this diagnosis code. If you write on your order "A-fib monitoring;  if covered by insurance-ACT monitor, if not, use A-Fib Express"  you will avoid follow-up phone calls if your patient's insurance doesn't cover the ACT monitor. (A-fib express is less expensive, but requires patient to download any recording over the phone,  with ACT monitor patients are sent a cell phone and recordings are sent automatically).

Methotrexate Patients

  • Target methotrexate level for discharge at 0.15.
  • Extrapolation may be taken into account. 
    • If < 0.2 may be discharged after an additional 6 hours of bicarbonate hydration.
    • If < 0.25, discharge after an additional 9 hours of hydration.
  • Discharge on sodium bicarbonate 650 mg 4 tablets 4 times daily x24 hours and leucovorin 25 mg 1 tablet 4 times daily x24 hours.
  • Ensure they have a supply at home since it can be a problem getting Leucovorin from some pharmacies.

MICHART INPATIENT CHEATSHEET

Inpatient Service Document

Other resources


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