2The Concept 24/7 in house coverage Night team: South: PBS, MIS/GI, BMSE, CRS, GSA, TransplantNorth: Burn, Peds, VascularNight team:Trauma chief ( )Trauma junior ( )Trauma intern ( )Night float ( )CCM ( )YOU ARE NOT ALONE!2nd call = senior resident on each service. If in a bind or emergent situation, TRE junior/chief, CCM are options.
3The Basics Active response 6p – 6a Flexibility in the 6a to 7a hour is essential for transfer of care.Signout 6pm or else page service & get signoutIt’s all in the details…. (don’t accept “NTD”)Face-to-face signout, senior resident presentHelp your co-interns with end of day choresBedside rounding for sick/dynamic patientsGet feedback from seniors re: managementDocument everything on both chart & your listDon’t leave a ton of work on the night float either
5Sign out Conditional statements (if/then) Plan Heme (bleeding issues, plt/inr/ptt, anticoag’d)ID (active infex, recent cx’s, abx – on the list)Drains/tubes/lines: where are those drains?Wound status: open/closed, clean/infectedConditional statements (if/then)Foreseeable issues and plan if they come upPlanSpecial meds (anticoag, abx, atyp pain meds)Meds to avoid (over-benzo/narcs in elderly)Allergies -on the listOf course, once the night float is familiar with a patient, can abbreviate this to just active issues/changes/if-then/plan
6Workflow – what to do after signout Postop checksTime/date note, read the op noteDx, procedure, SOAP (pain, CP/SOB/N/V UOP, vitals, exam, wound, drains, labs, CXR)Walk by & check on rest of pts“eyeball test” (look good, okay, not so good)Talk to / examine any w potential issuesGet check-boxes done (your ‘to-do’ list)Respond to callsIf any question of urgency, have nurse repeat new vitals, and go see pt
7Workflow – patient assessment Nurse calls – ask for repeat vitals, go see the patient, examine, check wounds, tubes/linesTypes of routine callsPain, nausea, insomniaFever, AMSTachycardia, hypoTNLow UOPCritical labsAssess, make a plan (or call if unsure) & document, document, documentTransfer to higher level of care if neededIf you don’t leave a note, you weren’t there.Know your limitations. If you’re in over your head, worried about a patient, call and/or transfer to higher level of care
8Workflow Update the list (be brief / informative) Update room numbers (Navicare/portal)After midnight, print list & get it readyVitals (trends), I&O, to-do check boxesFor ICU/IMC pts 4-4:30am, update labsUpdates/events to flag for the day teamBonuses (clean-up the list)Clean up the list: DVT/GI prophylaxis, Abx, CxHelp Trauma (if caught-up): alerts, terts, d/c’sTRE pts: labs come out before 6am as wellThe flags will remind you about the events on the 50 pts you’re covering, when you’re signing out. Do not rely on your brain/memory anymore.
9Other tipsThink for yourself… Nurses will make requests all night long for pain meds, nausea meds, sleep meds…. See every patient and only give those out as necessary.Do not dismiss a fever or try to mask it w TylenolNotify chief before major decisions:Transfers, antibiotics, transfusions, vasoactive agents, CT scans
10Other tips New admissions: Hospital to hospital transfers Preop admits Use Navicare, go to 5E (for Gen Surg) or 6E (for Txplt) and look at beds with pending transfers: click on all of them to see which are coming from outside, then look at the attending who accepted (if it’s one of ours, then you’ll be getting called for “orders on your new patient”)Preop admitsEach patient needs Full H/P and orders on arrival to the ward.Look thru the OSH paperwork carefully. Take extra care to find and secure Imaging CDs/films.Call the Service Chief on Call or Trauma Junior with questions, to notify them of the patient’s arrival.Dictate or write the H&P in Epic.Add the patient to the list.
11Other tipsYou might feel like the only person awake in Shands but you are not alone.CALL YOUR CHIEF.They want to helpThey are always availableThey want to protect youCall with questions but also be thinking of plans
12Other tipsTRAUMA.The NF pager is on the trauma list for a reason. If you are not busy, you must be there.Experience and proceduresHave the junior resident start teaching you how to FAST or put in the A-Line.Just plain “Helping out the team”Paperwork:Bed requestCT formOrdersH&PTertiary (if you’re feeling really generous)
13Take home points You are not alone Document everything on chart & list bothTransfer to IMC/ICU, get CCM involvedWorkflow – get postops & check-boxes done so you are ready: for calls, help trauma w alerts, new admits, etc.Be proactive – check actively on new ops, concerning patients, active/dynamic issuesBe friendly/responsive to nursesThe nurses can be a great asset – do not burn bridges or make enemies.
14Patient Census Management Tad Kim, Vince MortellaroUF Surgery(c)(p)
15Overview Diagnosis List Notes (history) section Surgery section Initial presentationEssential information (Abx, Cx, PAB, etc)Hospital CourseSurgery sectionHow to use the Name section to your advantageTake Home Points
16Diagnosis For trauma, “Fall” or “MVC” is not a dx If no injuries & patient had confusion, AMS, GCS, you can use “CHI (Closed head injury)”Also is a valid code for coding/billing purposesList all secondary (not PMH) diagnoses and complications (examples on next page). This helps in a number of ways:Dictations are easier (Prim/2ndary dx are done)Helps chiefs for M&M
17Diagnoses – Commonly Missed Acute blood loss anemiaHyper/Hypo-NaUrinary tract infectionAtelectasis (IS)IleusBacteremiaAcid-/AlkalosisIntestin obstrux – SBO or LBODVT/PEAtrial flutterMalnutritionARF or AKICHF(D or Sys)Pleural effusionSeptic shockDecubitus ulcer – specify siteCellulitis,seroma abscess,wd infxAspirationGI bleed (site)Urinary retention
18Coding Tidbits Commonly omitted by residents Atelectasis (if we treat this with incentive spirometry, the hospital can bill for it)Blood loss anemia (Anemia from blood loss)Excisional debridementType of instrument- scissors, scalpelType of tissue- necrotic, skin, fascia, muscle, boneApproximate depth, size, or weight removedSeptic shock is a much higher DRG compared to “sepsis”. The key is shockWound infection
19Notes section: Initial Presentation First lineAge, gender, relevant past medical/prior surgeries & presentationFor trauma (TRE): presentation = mechanism, LOC, GCS, FAST, Hct, SBP, (add EtOH/UDS)Relevant labs & studies on presentationWBC +/- bands/poly’s, EtOH/UDS (for TRE)“CT A/P- ..” or “CT hd/Csp/C/A/P/T&L spine”Interventions or consults (esp for TRE)i.e. “L CT placed”, “GI Cs (consult) pending”
20Examples of initial presentation 56yo M PMH NIDDM/CHF w EF 35%/CRI, prior chol’y ’76, Crohn’s s/p SBR x3 last in ’03 now p/w N/V/abd pn x2d. WBC 14. KUB- AF lvls, dilated SB. CT- SBO. Plan: NPO/NGT/Resus IVF, GI Cs p. (pending)
21Examples of initial presentation (TRE) 26yo F PMH ADHD rest driver in MVC RO (rollover) w ejection, +LoC, GCS 14 (-1V), FAST neg, Hct 33, SBP 120, EtOH 200, UDS +cocaine. Pt c/o abd and pelvic pain. CT hd/Csp/C/A/P as above. IR- angio/embolization of pelvic bleeder
22Initial Information, cont’d Special allergies, i.e. contrast dye & type of reactionespecially if the reaction was anaphylaxisSpecial meds (especially anticoagulants)“PMH Afib on Coum”Next of kin information when applicable
23Trauma specific information Mechanism (mentioned above)LOC, GCS, FAST, Hct, SBPEtOH & UDS resultsWhich CT scans or XR’s were doneDVT scans/date (Radiology section)IVC Filter placement/date (Surg section)List of consults following patientOnly injuries (not mechanism) go in the diagnosis slot
24Additional Information Antibiotics with start (& stop) date“Abx: Cpime/Vanc(7/4- )” (include stop date)Abbreviate so that it’s still recognizableInclude last vanc troughCultures – include datepos results (recent neg results) & usu. don’t include sputumFor Blood, include how many bottles of total“Cx: 7/2 UCx Ecoli, 7/4 BCx 2of4 MRSA”Abbreviations: CNS (Coag neg staph), MSSA, MRSA, Cdif, PSA (Pseudomonas Aeruginosa)
25Additional Information, cont’d Vancomycin trough w date of last result“7/3 Vtr 30.5” (put this in Abx section)Pre-albumin – update on Mon afternoonsinclude current one w last week’s in ( )“PAB 8(10)” Put right before the plan: sectionBefore PAB, write TF formula/goal rateThis helps when writing transfer ordersA section for “Plan“ at the end after Abx“Plan: OR w Ortho 7/12, Dispo: Rehab”Must update constantly to be useful
26Hospital CourseCreate a block in the notes section for the hospital course in chronological fashion between PAB & initial presentation“7/2 OR. 7/3 txfr to 64, DC NGT/OOB. 7/4 Clears/POM (PO meds). 7/5 Wound opened, W-D BID. 7/6 Fevers -> CT scan- IAA (intra-abd abscess), CT-perc drain. 7/8 Reg diet, DC Drain, D/C home.”If the list is done right, you could perform dictations without flipping thru the chart
27Surgery sectionReverse chronological order with the surgery type and date in parenthesesSeparate different days with semi-colon“Trach/PEG(7/10); ORIF R femur(7/7); ex-lap, splenect, NJT(7/4)If the full procedure is listed in the surgery section, no need to repeat in the notes section. Just write “7/7 Ortho OR” in notes
28Using the Name section For TRE, “Trauma” goes under last name Trauma name itself goes after 1st name in ( )Use the First name section as a way to alert yourself not to forget certain things:Prophylaxis (H,N) = heparin, nexiumVAC dressing changes on MWF or TThSat“iHD (Hemodialysis) on MWF” or “CVVHD”“Coum”, “Hep gtt”, “Loven” for anticoagulationThis helps you stop these when “pre-opping” the ptTPN (to remember to write for TPN before 12)i.e. “Smith, John (VAC MWF) (iHD) (COUM)”
29Other minor pointers Use Navicare to: Find out room assignments fastestSee if there are any unexpected transfersStatus of an OR patient under OR SuiteVueFor consults, list the actual “Date of admission” not the date of the consultUpdate resident & student info on the listDesignate a spot on the paper list to be for elements needing computer-list updating
30Take Home Points Remember to include: Prophylaxis, Abx, Cx, PAB, Vanc trough (if pt is on Vanc), Goal tubefeedsPast medical history, special allergies / medsUse the first name section as an alert for the need to write TPN, anticoag status, or perform a VAC changeIdeally, any new resident or the night float you’re signing out to should be able to look at the list and know the patient fully
31Other Professional Duties Duty Hours – complete once a week (Tue)HIPAA Training – yearlyCompliance (Billing) – yearlyComplete delinquent charts on portalBe on time to conferences, M&M, etc.Case log entry – do these at least at the end of the day, if not right after the caseFor the future, each operation, think of:Op note, orders, dictate, list, case log