Académique Documents
Professionnel Documents
Culture Documents
Handbook
- Inpatient First Edition
2013-2014
Editors:
Alejandro Moreno M.D.
Celina G. Mankey M.D.
Authors:
Payas Vasanth M.D.
Gayathri Nanja M.D.
Benjamin Salgado M.D.
Karthik Mekala M.D.
Table of Contents
14
Admission ............................................................................. 3
15
16
17
18
2.1
2.2
Amion ..................................................................................... 5
2.3
Geo-Loco ............................................................................... 5
2.4
2.5
Discharge .............................................................................. 8
4.1
4.2
X-Cover .............................................................................. 11
6.1
X-cover Responsibilities................................................ 11
6.2
6.3
8.2
ICU Rotation..................................................................... 15
10
11
12
13
Admission
Admit Orders:
When you are called to see a patient, head down to
locate them in the ED (Crash, Treatment or Chest
Pain). Add them to the list by MRN if not already
done.
Note the admit to location entered by the ED
physician. If you agree with that location, all is well.
If you do not on assessment of the patient, please
contact the ED charge nurse and alert him/ her to the
change of location.
Be aware that the ED fills up fast, and you will need
to enter your orders in a timely fashion, otherwise
the patient cannot move upstairs.
Look at the upper right hand corner to ascertain
whether the patient has been placed in a virtual bed,
only then the orders may be entered. You can plan
your orders and wait to initiate in the interim.
Powerplans:
When you are on a medicine service, whether you
are admitting to ICU, IMC, Telemetry II, use the
Hospitalist Admit powerplan. Under your admit to
orders, make sure you mention the appropriate level
of care, floor based on geo-loco, and reason for care
(admission diagnosis).
There are powerplans for different diagnoses, E. g.
DKA/HHS, A. Fib, UGI bleed, that are at your
disposal. Use these plans as you see fit but make
sure you use your clinical judgment as well.
You must state appropriate reasons for using or not
using VTE or GI prophylaxis.
If you do need to initiate a patient on a heparin drip,
insulin infusion or cardizem drip these orders can be
found in the power plans for heparin infusion plan,
DKA/HHS plan, and atrial fibrillation power plan
respectively.
Admission Medication Reconciliation:
Make sure you always enter physician team
assignment.
Once you have seen the patient enter pertinent
orders, and verify med reconciliation with the
patient.
As soon as you have completed your admission
orders, always complete the Admission Med Rec.
We are penalized every time we do not reconcile
medications.
Consults:
Calling consults: Call early. Start with the reason for
consult. Provide important information on the
patients past medical history, and current medical
problems. Be concise. Include the patients location,
2 Call Schedule
2.1 Q6 Call Schedule
Long Call:
Rounds start at 9.00 A.M.
Mandatory morning report /noon-conference 11.40-1
P.M.
Admit 4 patients from 4-7 P.M.
Resident, interns and medical student have to be
present.
Resident may get one handoff.
Mandatory checkout to cross-cover before leaving
the hospital.
Day 1:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9.00 A.M.
Mandatory morning report/noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Resident, interns and medical student have to be
present.
Day 2:
Resident picks up 1-2 handoffs from nigh float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9.00 A.M.
Mandatory morning report /noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Only one intern can take the day off.
Day 3:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning report/noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
4
Day 4:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8:45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning/noon-conference 11:40 A.M-1
P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Only one intern can take the day off.
2.3 Geo-Loco
Floor
4thFloor :Tele, Cardiac Step
Down Unit
7th Floor: Tele, Non tele
8th Floor: Non tele
9th Floor: Non Tele, EMU,
Hem/Onc, NeuroSurgery
ICU 1st and 6th , IMC 6th
Teams
Silver, Blue
Gold, Green, Red,
Orange
Gold, Silver, Ortho,
Surgery, Plastics
Tan, Surgery, Neuro,
EMU, Neurosurgery
All medicine teams and
ICU service
Day 5:
Interns pick 1-2 handoffs and get checkout from
cross-cover team at 7 A.M. in the doctors lounge
Finish pre-rounding at 8:45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning/noon-conference 11:40 A.M-1
P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Resident and medical student can take the day off.
Weekends:
No morning report and noon conference will be held on
weekends. Rounds usually finish earlier.
Cap/Team: 16 patients
Cap/Intern: 8 patients
Cap/Medical Student: 4patients
2.2 Amion
Amion is used to text/page residents and faculty www.amion.com
Groups
Internal Medicine
On call consult services
Neuro
Family
Surgery
UserName
austinim
Seton 3tak
utmbneuro
Amepfp
Traumall
Abx Day#
R1 Team Name
Subjective:
Events in the last 24 hours (include BMs, sleep, mental well being)
Objective:
1. Vitals:
Tm/Tc BP
2. Physical Exam:
General
HEENT
Neck
CVS
PR
RR
OSat I/O
Resp.
Abdomen.
Ext.
CNS
3. Labs
Alb|TP|AlkP|ALT|AST|TB
PRNs
4. Micro:
5. Imaging:
EKG:
A. Pain Meds
B. BZs
IVF
FOLEY
LINES
6. Assessment:
Dr. Moreno
Dr. Corak
Dr. Salib
Dr. Maxwell
Dr. Miller
Just relax.
Expand your differentials.
Dr. Huth
8. Recommended readings.
Pocket Medicine.
Washington Manuel Dr. Millers favorite.
ICU Book Dr. Perrets favorite.
Marinis Critical Care Dr. Morrisons favorite.
Felsons Principles of Chest Roentgenology.
Learningradiology.org.
Harrisons and Cecil textbooks of medicine.
MKSAP 16.
MedStudy.
9. Dress Code
Clothes must be clean, neat and in good
condition with no obvious stains or tears. This
includes your WHITE LAB COAT.
Physicians must maintain clean personal
hygiene.
Physicians are NOT allowed to wear scrubs
unless they are on call for ICU or are on night
float rotation.
All physicians on consult services, wards,
hospitalist, elective and clinics are expected to
be in formal clothing.
Formal clothing DOES NOT include BLUE
JEANS.
Formal clothing DOES NOT mean fancy or
revealing clothes (just normal/daily wear
clothing is considered appropriate). Please
consider that you are acting as a healer and
health mentor in the eyes of your patients and
therefore you should try to dress accordingly.
No sandals or open toe shoes.
Discharge
Initiate discharge.
Printing prescriptions:
Print scripts for all the new or changed medications
you are prescribing and ask the patient if they need
any new prescriptions for their chronic medications.
Click Medication History and Right click on
the medication you want to print.
Click Resend
A list of printers will appear, select the printer of
the floor you want the prescription get printed.
Prescriptions are printed in a special prescription
paper; most of the nursing stations have a printer
for that paper. Your prescription will come out
from one of them.
Review your prescription, sign it and leave in
the chart. RN of the patient will give the
prescription on discharge.
If the patient requires a controlled substance,
such as MS Contin, Dilaudid, etc. on discharge,
you will require a triplicate, which only certain
attendings carry. When you have patient on
Transfer Med Rec (in compass and paper):
In order to discharge a patient to a health care facility,
you must decide what medications you would like them
to continue.
Complete the on screen discharge med rec, as you
would for a patient being discharged home, as this
will be important for documentation.
- Health care facilities require a physical
medication reconciliation on paper and do not
require prescriptions.
- Click Task and select Med Rec to Outside
Care Venue and select Print.
- Once printed you must fill the boxes of which
medicines you want to continue, discontinue or
modify. If you have antibiotics, or steroids that
need to be tapered, include stop dates and taper
instructions. Initial each page, and sign the last
sheet.
Core Measures
SCIP
Order prophylactic antibiotics to be administered
within one hr of surgery start time, complete w/in 24
hrs of surgery end time.
Control 6am blood glucose on POD 1 and POD 2
(blood glucose < 200 mg/dL) for cardiac surgery
patients
Remove urinary catheter by POD 2 or document
reason not removed.
For patients on BB, order BB during perioperative
period or document reason not ordered.
Order VTE/DVT prophylaxis w/in 24 hrs prior to,
through 24 hrs after surgery.
Stroke
Order VTE/DVT prophylaxis on admission see our
guidelines. TEDS alone does not count as VTE
prophy for stroke patients neither does ambulation.
If antithrombotic therapy not started by hospital day
2, a reason must be documented.
Patients that arrive within6 hours of symptoms
should be considered candidates for acute stroke
interventions (IV-tPA, IA-tPA, or thrombectomy). If
patient is not a candidate an exclusion statement
should be documented.
Nursing bedside swallow screen should be
performed before anything PO including
medications. Patients with a failed swallow screen
should have a ST swallow eval.
Order fasting LDL and prescribe statin on discharge
or document reason not prescribed.
Order PT/OT evaluation for rehabilitation potential,
or reason must be documented why PT/OT eval not
done-if patient at baseline, document patient at
baseline does not need rehab eval.
Patients with Afib discharged home on
anticoagulation or reason must be documented
why patient was not discharged home on
anticoagulation.
VTE
All patients - Order VTE prophylaxis on admission or if
no risk document No VTE prophylaxis needed
Patients with DVT/PE - Overlap therapy for AT LEAST
5 days and with an INR >2 prior to discontinuation of
overlap therapy. Note: If discharged sooner than 5
days, either discharge on overlap therapy or document
reason otherwise.
Pneumonia
10
X-Cover
11
5. Urine Output:
< 50 cc in 8 hrs is ok i.e., 20-30 cc/hr is ok but if
<20 intervene.
Oliguria: <400 in 24 hrs, anuria <100/24 hrs.
Vitals, urine output, I/O, volume status: check
lytes, K+, Hco3, BUN/CR, UA
For RN to check: Foley-volume status a.
Hypovolemia, give fluids b. hypervolemia, i.e.,
CHF, Cirrhosis, renal failure-try lasix. If none of
the above get bladder scan > 2000-2500 ml do in
and out cath.
Causes of Oliguria:
a. Pre renal: volume depletion, CHF, cirrhosis,
nephrotic, hepatorenal.
b. Renal: glomerulonephritis, ATN (Drugs,
Toxins).
c. Post renal: obstruction (BPH), stones,
clogged foley.
Check FeNa: <1% prerenal. >1% renal
FeUrea: In case of diuretic use if <35% then pre
renal.
6. Alcohol Withdrawal: Watch for hyperautonomic
dysfunction (Confusion, HTN, Tachycardia, dilated
pupils, diaphoresis. Try IV Ativan PRN if not
controlled then DT protocol with antipsychotics
such Zyprexa (check QT interval). Make patients
NPO.
7. Constipation:
Try Miralax, Colace, Senokot, Dulcolax, Fleet or tap
water enema, if patient on opiates, can try Relistor.
NEVER GIVE MAGNESIUM CITRATE IN
ESRD/AKI/OLIGURIA.
8. Diarrhea: HYDRATE, Check stool for WBC, ova
and parasites. If on antibiotics get c diff stool toxin.
DONT MISS ISCHEMIC COLITIS.
9. Arrhythmias: Is it too fast, too slow, irregular
A. fib: EKG stat, No p waves, irregular, RVR, check
vitals, cardiac enzymes.
STABLE: If RVR, cardizem 10-15 mg IV X 1, start
the cardizem drip if rate not controlled at 5-15 mg
and titrate to keep HR<110. If the HR is consistently
less then start titrating to PO cardizem 30, 60, q 6
hrs.
- Get ECHO, TSH, CXR, cardiac enzymes
- Calculate CHADs score, if 0-1 start aspirin or if
2 then warfarin.
UNSTABLE: Cardiovert
12
HYPERTENSION:
a. HTN emergency: BP>180/110 with signs of
end organ damage (encephalopathy, ICH, CVA,
MI, angina, pulm edema, aortic dissection, renal
insufficiency.
b. HTN Urgency: BP>180/110.
LABS: CBC, BMP, EKG, troponin. Look for
precipitants cocaine, amphetamines, MAOI.
Treatment:
HTN emergency: Goal MAP<25% in 2 hours with
IV agents.
- IV Labetol (SE: Hypotension, especially
elderly).
- IV Hydralazine (SE: reflex tachycardia, long
life 10 hr, proteinuria).
- IV Nitroprusside (Cyanide toxicity, AMS< lactic
acidosis, death).
- IV Nitroglycerin (MI, pulm edema).
11. SOB: Get CXR, ABG, O2 sat, RT STAT
H&P: Causes include PULM (COPD, asthma, PE,
pneumothorax, pneumonia, mucus plugging), CVS
(CHF, MI, tamponade), RS depression (opiate
induced, try naloxone)
Oxygen Deliver: O2 via NC flow 1-6 L/min FiO2:
24-44% next try Simple mask with Flow 5-8 L min
with FiO2 40-60%.
If SaO2 still low with tachypnea try high flow
Venturi mask with flow 4-12 L/min and FiO2 2440%, or escalate to NRB with reservoir 6-10 L/min
FiO2 70%.
If still SOB try BiPAP titrate to keep SaO2 >88%.
Try CPAP for OSA/OHS EPAP 5.
12. GI Bleed: Check hemodynamics, hypotension,
tachycardia.
STAT H&H, BUN, Coags, type and screen.
Upper GI bleed (hemetemesis, coffee ground
emesis, melena).
Lower GI Bleed (hematochezia, BRBPR).
- Hgb/Hct>8/25, if not transfuse, give IVF.
Protonix bolus and drip with 8 mg/hr and
octeotride bolus and drip with 50 mcg/hr
Consult GI.
13
SCHEDULE:
You will have 4 weeks of emergency medicine, during
which you will have 17 9-hour shifts. Dr. Berger will ask
for your preferred 4 days off in the month 6 weeks in
advance, which he will try to accommodate. Your final
schedule will be posted on New Innovations. There is
usually also a schedule hung up in the ER Physicians
section of treatment. The schedule will specify whether
you are working in Crash or Treatment, and also
morning, afternoon or night shift.
SHIFTS:
You may be assigned to work the 7 am to 4 pm, 3 pm to
12 am, or 11 pm to 8 am shifts in ER. You are expected
to show up promptly and be present for teaching rounds,
which may occur in Treatment or Crash. The rounds
occur when there is overlap between the oncoming shift
and the outgoing shift. Usually the residents who are
outgoing will present mini discussions on interesting
cases or teaching points.
RESPONSIBILITIES:
Access the tracking list through FirstNet. Pick up
patients according to your interest, or the time of arrival.
When you pick up a chart you may fill out all the
documentation in terms of history and physical. ER
charts are designed as templates according to the chief
complaint, and pertinent negatives and positives can be
filled in with check marks and circles.
14
Specialty Rotations
ICU Rotation
10 Psychiatry Rotation
The attendings for this rotation are Dr. McRoberts and
Dr. Garapedian.
The schedule during your psychiatry rotation will be
from Monday to Friday, and usually form 8 am to 5 pm,
depending in how many patients you have assigned.
Rounds are twice a day; at 9 am and 2 pm. You will be
working with a second year resident of family medicine,
psychiatry residents, medical students and psychiatry
social worker.
As an intern you will be responsible for admissions and
progress notes of patients. Admission notes have to be
dictated and you must put emphasis in psychiatric
symptoms, mental examination and nuerological
examination. Assessment should include DSM-IV five
dimension diagnosis.
The DSM-IV organizes each psychiatric diagnosis into
five dimensions (axes) relating to different aspects of
disorder or disability:
Axis I: All diagnostic categories except mental
retardation and personality disorder
Axis II: Personality disorders and mental retardation
Axis III: General medical condition; acute medical
conditions and physical disorders
Axis IV: Psychosocial and environmental factors
contributing to the disorder
Axis V: Global Assessment of Functioning or
Children's Global Assessment Scale for children and
teens under the age of 18
15
11 Emergency Coverage
In order to have coverage of interns/residents that may
have unexpected leaves, 2 interns will be assigned for a
certain period of days to be emergency coverage 1 or 2.
There is no preference in which one can be called first.
Chiefs do reserve the right to call either one in order to
cover for interns/residents that may have an unexpected
leave.
If you are in emergency coverage it is recommended to
stay within 1 hour UMCB just in case you get called in.
12 Access to Pathways
Log on to Seton Intranet, go under Clinical resources,
Clinical Practices, You may access Antimicrobial
Management and Anticoagulation Guidelines.
13 Death Records
Once a patient passes away, you are expected to right a
brief death note with course in the hospital, and cause of
death, dictate a Death Summary, and record the patient
on the CTMF Census Deceased Patients Log on the G
drive. You will eventually be forwarded the Death
Certificate for signature, just follow the given steps.
14 Quality Improvement
International Dc Planner
(Oscar)
77825,77824
47047 (W), 47041 (E)
47003
47110
47022
49731 (ER), 78957 (Floor)
49810
47007
49838
73021
78962
78847
49757
78964
78970(W),
78844(E)
589-8802 (Cell)
17 Contact Information
Emergency Room
ER resident room
Crash
Treatment
Chest Pain Unit
Step Unit
Spanish Interpreter
Charge RN
Charge RN
Case Manager (Monica)
Social Workers (Jessicas)
795-5100
77750 or 324-7111
73947
73943
73771
47758
47759
88018
47797
48589 - press option
number 2
78921
Payas
Vasanth
Cell-phone: 803-295-0155
Email: amrew84@yahoo.com,
aalahmad@seton.org
Cell-phone: 703-577-8706
Email: payas.vasanth@gmail.com,
pvasanth@seton.org
18