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Nightfloat Ben Szpila Cell: Pager:

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1 Nightfloat Ben Szpila Cell: 501-733-8047 Pager: 352-413-2270
Intern Conference June 26, 2012

2 The Concept 24/7 in house coverage Night team:
South: PBS, MIS/GI, BMSE, CRS, GSA, Transplant North: Burn, Peds, Vascular Night 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.

3 The 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 signout It’s all in the details…. (don’t accept “NTD”) Face-to-face signout, senior resident present Help your co-interns with end of day chores Bedside rounding for sick/dynamic patients Get feedback from seniors re: management Document everything on both chart & your list Don’t leave a ton of work on the night float either

4 Sign out Brief history/presentation
Age, comorbidities, presentation, dx, operation Notable, relevant changes past 24hrs Foley, NGT removed, diet, pain meds changed Active issues (by systems, esp. in ICU) Neuro (bleed, stroke, neuro deficit, delirium/AMS) Pulm (lung dz, pna, PE, secretions) CV (pressors, rhythm issues, BP, baseline CAD) GI (bowel fn status, baseline abd exam) FEN (acid-base, lyte, fluid, nutr’n, renal-UOP)

5 Sign 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/infected Conditional statements (if/then) Foreseeable issues and plan if they come up Plan Special meds (anticoag, abx, atyp pain meds) Meds to avoid (over-benzo/narcs in elderly) Allergies -on the list Of course, once the night float is familiar with a patient, can abbreviate this to just active issues/changes/if-then/plan

6 Workflow – what to do after signout
Postop checks Time/date note, read the op note Dx, 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 issues Get check-boxes done (your ‘to-do’ list) Respond to calls If any question of urgency, have nurse repeat new vitals, and go see pt

7 Workflow – patient assessment
Nurse calls – ask for repeat vitals, go see the patient, examine, check wounds, tubes/lines Types of routine calls Pain, nausea, insomnia Fever, AMS Tachycardia, hypoTN Low UOP Critical labs Assess, make a plan (or call if unsure) & document, document, document Transfer to higher level of care if needed If 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

8 Workflow Update the list (be brief / informative)
Update room numbers (Navicare/portal) After midnight, print list & get it ready Vitals (trends), I&O, to-do check boxes For ICU/IMC pts 4-4:30am, update labs Updates/events to flag for the day team Bonuses (clean-up the list) Clean up the list: DVT/GI prophylaxis, Abx, Cx Help Trauma (if caught-up): alerts, terts, d/c’s TRE pts: labs come out before 6am as well The 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.

9 Other tips Think 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 Tylenol Notify chief before major decisions: Transfers, antibiotics, transfusions, vasoactive agents, CT scans

10 Other 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 admits Each 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.

11 Other tips You might feel like the only person awake in Shands but you are not alone. CALL YOUR CHIEF. They want to help They are always available They want to protect you Call with questions but also be thinking of plans

12 Other tips TRAUMA. The NF pager is on the trauma list for a reason. If you are not busy, you must be there. Experience and procedures Have the junior resident start teaching you how to FAST or put in the A-Line. Just plain “Helping out the team” Paperwork: Bed request CT form Orders H&P Tertiary (if you’re feeling really generous)

13 Take home points You are not alone
Document everything on chart & list both Transfer to IMC/ICU, get CCM involved Workflow – 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 issues Be friendly/responsive to nurses The nurses can be a great asset – do not burn bridges or make enemies.

14 Patient Census Management
Tad Kim, Vince Mortellaro UF Surgery (c) (p)

15 Overview Diagnosis List Notes (history) section Surgery section
Initial presentation Essential information (Abx, Cx, PAB, etc) Hospital Course Surgery section How to use the Name section to your advantage Take Home Points

16 Diagnosis 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 purposes List 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

17 Diagnoses – Commonly Missed
Acute blood loss anemia Hyper/Hypo-Na Urinary tract infection Atelectasis (IS) Ileus Bacteremia Acid-/Alkalosis Intestin obstrux – SBO or LBO DVT/PE Atrial flutter Malnutrition ARF or AKI CHF(D or Sys) Pleural effusion Septic shock Decubitus ulcer – specify site Cellulitis,seroma abscess,wd infx Aspiration GI bleed (site) Urinary retention

18 Coding 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 debridement Type of instrument- scissors, scalpel Type of tissue- necrotic, skin, fascia, muscle, bone Approximate depth, size, or weight removed Septic shock is a much higher DRG compared to “sepsis”. The key is shock Wound infection

19 Notes section: Initial Presentation
First line Age, gender, relevant past medical/prior surgeries & presentation For trauma (TRE): presentation = mechanism, LOC, GCS, FAST, Hct, SBP, (add EtOH/UDS) Relevant labs & studies on presentation WBC +/- 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”

20 Examples 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)

21 Examples 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

22 Initial Information, cont’d
Special allergies, i.e. contrast dye & type of reaction especially if the reaction was anaphylaxis Special meds (especially anticoagulants) “PMH Afib on Coum” Next of kin information when applicable

23 Trauma specific information
Mechanism (mentioned above) LOC, GCS, FAST, Hct, SBP EtOH & UDS results Which CT scans or XR’s were done DVT scans/date (Radiology section) IVC Filter placement/date (Surg section) List of consults following patient Only injuries (not mechanism) go in the diagnosis slot

24 Additional Information
Antibiotics with start (& stop) date “Abx: Cpime/Vanc(7/4- )” (include stop date) Abbreviate so that it’s still recognizable Include last vanc trough Cultures – include date pos results (recent neg results) & usu. don’t include sputum For 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)

25 Additional 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 afternoons include current one w last week’s in ( ) “PAB 8(10)” Put right before the plan: section Before PAB, write TF formula/goal rate This helps when writing transfer orders A section for “Plan“ at the end after Abx “Plan: OR w Ortho 7/12, Dispo: Rehab” Must update constantly to be useful

26 Hospital Course Create 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

27 Surgery section Reverse chronological order with the surgery type and date in parentheses Separate 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

28 Using 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, nexium VAC dressing changes on MWF or TThSat “iHD (Hemodialysis) on MWF” or “CVVHD” “Coum”, “Hep gtt”, “Loven” for anticoagulation This helps you stop these when “pre-opping” the pt TPN (to remember to write for TPN before 12) i.e. “Smith, John (VAC MWF) (iHD) (COUM)”

29 Other minor pointers Use Navicare to:
Find out room assignments fastest See if there are any unexpected transfers Status of an OR patient under OR SuiteVue For consults, list the actual “Date of admission” not the date of the consult Update resident & student info on the list Designate a spot on the paper list to be for elements needing computer-list updating

30 Take Home Points Remember to include:
Prophylaxis, Abx, Cx, PAB, Vanc trough (if pt is on Vanc), Goal tubefeeds Past medical history, special allergies / meds Use the first name section as an alert for the need to write TPN, anticoag status, or perform a VAC change Ideally, 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

31 Other Professional Duties
Duty Hours – complete once a week (Tue) HIPAA Training – yearly Compliance (Billing) – yearly Complete delinquent charts on portal Be 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 case For the future, each operation, think of: Op note, orders, dictate, list, case log

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