1. Night Float Survival Guide Overnight Orientation 2016-2017

2. Objectives 1.Understand relationship between Pediatric Surgery and our Pediatric Resident Team. 2.Identify situations when you NEED to notify the hospitalist or PICU attending of critical situations. 3.Take an interactive tour of Santa Clara Valley Medical Center’s most essential overnight places (the ED/Trauma Bay and the Burn Unit)

3. Management of Pediatric Surgery Patients The Pediatrics Team is the PRIMARY team for Pediatric Surgery patients. That means, we write orders on all Pediatric Surgery patients (in addition to the Pediatric Surgery team). Overnight – if there is a NEW pediatric surgery patient admitted to the floor, the night team MUST CONSULT the on call pediatric surgery resident, regardless of the time. DO NOT WAIT until the morning to consult pediatric surgery. THIS MAY RESULT IN A DELAY IN GETTING OR TIME. Refer to Amion to see who is on call for pediatric surgery. For Appendicitis Patients: *Pediatric surgery covers up to age 12 yo. *General surgery covers 13 yo and older (teens) For all other general surgery needs in patients under 18 yo, Pediatric Surgery is the primary service (ex - lap chole, solid mass/tumor, etc) along with the Pediatrics Team. The Pediatrics team writes orders and the discharge summary.

4. Peds Surgery Management cont. Overnight – if there is a question on a pediatric surgery patient who is already on the ward or the PICU, the night team MUST CALL the on call Pediatric Surgery ATTENDING. Do not expect the pediatric surgery resident on call to know anything about the ward/PICU patients. Do NOT worry about the time of night – if there is a question, the Pediatric Surgery ATTENDING must be called. Do NOT wait until the morning for an active patient issue. Also, if there is a major change in medical status of a pediatric surgery patient overnight, the Pediatric Surgery ATTENDING MUST BE NOTIFIED, regardless of the time of night. Any new pediatric surgery patient that arrives to the ward/PICU, even if it is after the OR, must have an H&P; not a consult note.

5. Pediatrics is the Primary Team for: Pediatric Surgery patients Orthopedic Surgery patients ages 0-23 months Neurosurgery patients Rehab patients Any patient that a surgical team wants Pediatrics to be primary on. As the primary team, you are responsible for writing orders and the discharge summary.

6. Pediatric Trauma Patients Any pediatric trauma patient should be admitted to the Trauma service with a pediatric consult. Admission orders should be written by the trauma service. Trauma team responsibilities: Admission orders Orders for fluids/ tranfusions Initial pain management orders Specialty consultations – writes orders and calls consultants Determines timing of feedings, timing for all operations and procedures Manages tubes, drains, and wounds The trauma team may sign off after the tertiary survey if the patient has isolated neurologic or orthopedic injuries. If this occurs, the patient will be transferred to the PICU team with subspecialty service consulting.

7. Pediatric Trauma Patients Pediatrics Team responsibilities: Ventilator management orders Consult regarding fluid management and provide recommendations to trauma team May write fluid management orders in an emergency but should notify trauma team simultaneously Monitor pain management, may change meds as needed May change doses of any other meds as needed Evaluates for abuse/ neglect, coordinates meetings with family and social services The trauma team must be contacting regarding: Any hemodynamic instability or emergent change in course Any decision to transfuse Any feeding decisions Any major elective decisions (extubation, surgeries, etc)

8. When do you need to call the NICU hospitalist overnight? 1.Transferring a patient from ward to PICU for worsening status. 2.Any new PICU admission. 3.Overnight ED consults. 4.When a patient in the PICU worsens despite initial treatment. 5.Whenever you are worried about any patient.

9. When do you need to call the PICU attending overnight? 1.Whenever a patient in the PICU is worsening despite medical interventions. 2.When there is a Code White. 3.Newly intubated patients and patients requiring intubation. Best to call before the intubation occurs. 4.Patients who are sick enough to require BiPAP or mechanical ventilation. 5.Head Trauma patients who are unconscious. 6.Patients who may require vasoactive drugs. 7.Patients with refractory status epilepticus (seizures persist despite treatment with two or more anticonvulsants). 8.Medically complex new patients coming to the PICU. 9.Any patient that you are worried about.

10. Documentation Overnight If there is a 5th Floor Hospitalist in house: Send all Ward/ED Notes for entire shift and all PICU admit notes before Midnight If a NICU hospitalist is covering: Send all Ward and PICU notes before Midnight Send all ED consult notes done overnight Ward admission H&Ps after midnight should be sent to DAY Ward attending If it is a Burn Consult Note: Send to DAY PICU attending If there is a change in patient’s status, document it in a significant event note. Please make your best effort to complete all notes in a timely manner. Don’t wait until the end of your shift.

11. Let’s Take a Tour Now (before things get too busy!)

12. The Trauma Bay (go visit it now!) Pediatric Major Trauma: Peds team MUST be present Junior and Senior to go Announce your presence! Pediatric Minor Trauma: Peds team not required to be present Attend if time permits

13. The Burn Unit (go visit it now!) Located on 4th floor above ED The Peds Resident Team co-follows all pediatric burn patients Examine/consult note day of admission Progress note at least every 3 days Pay attention to: Pain management and dosing Medical history and outpatient medications Immunization status Possibility of abuse Discuss all NEW burn patients with the DAY PICU attending, not overnight (unless there are questions regarding management or patient is critically ill and/or intubated)

14. Lastly…. Don’t drive home if you are overly exhausted or too sleepy! Consider - *taking a nap in the call room first *call a taxi or Uber *call your chief resident