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Night Float / Sign Outs / Patient List Management Nightfloat Ben Szpila Cell: 501-733-8047 Pager: 352-413-2270 Intern Conference.

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Presentation on theme: "Night Float / Sign Outs / Patient List Management Nightfloat Ben Szpila Cell: 501-733-8047 Pager: 352-413-2270 Intern Conference."— Presentation transcript:

1 Night Float / Sign Outs / Patient List Management Nightfloat Ben Szpila Cell: Pager: Intern Conference June 26, 2012

2 Night Float / Sign Outs / Patient List Management The Concept 24/7 in house coverage –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!

3 Night Float / Sign Outs / Patient List Management 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 (dont accept NTD) -Its all in the details…. (dont 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

4 Night Float / Sign Outs / Patient List Management 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, nutrn, renal-UOP)

5 Night Float / Sign Outs / Patient List Management Sign out –Heme (bleeding issues, plt/inr/ptt, anticoagd) –ID (active infex, recent cxs, 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

6 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management 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

8 Night Float / Sign Outs / Patient List Management 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/cs

9 Night Float / Sign Outs / Patient List Management Other tips Think for yourself…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 Night Float / Sign Outs / Patient List Management Other tips New admissions:New admissions: –Hospital to hospital transfers 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 its one of ours, then youll 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 patients arrival. –Dictate or write the H&P in Epic. –Add the patient to the list.

11 Night Float / Sign Outs / Patient List Management Other tips You might feel like the only person awake in Shands but you are not alone. CALL YOUR CHIEF.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 Night Float / Sign Outs / Patient List Management Other tips TRAUMA.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 requestBed request CT formCT form OrdersOrders H&PH&P Tertiary (if youre feeling really generous)

13 Night Float / Sign Outs / Patient List Management 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

14 Night Float / Sign Outs / Patient List Management Patient Census Management Tad Kim, Vince Mortellaro UF Surgery (c) (p)

15 Night Float / Sign Outs / Patient List Management Overview Diagnosis List Notes (history) 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 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management Diagnoses – Commonly Missed Acute blood loss anemia Hyper/Hypo-NaUrinary tract infection Atelectasis (IS)IleusBacteremia Acid-/AlkalosisIntestin obstrux – SBO or LBO DVT/PE Atrial flutterMalnutritionARF or AKI CHF(D or Sys)Pleural effusionSeptic shock Decubitus ulcer – specify site Cellulitis,seroma abscess,wd infx Aspiration GI bleed (site)Urinary retention

18 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management 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/polys, 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 Night Float / Sign Outs / Patient List Management Examples of initial presentation 56yo M PMH NIDDM/CHF w EF 35%/CRI, prior choly 76, Crohns 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 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management Initial Information, contd 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 Night Float / Sign Outs / Patient List Management Trauma specific information Mechanism (mentioned above) LOC, GCS, FAST, Hct, SBP EtOH & UDS results Which CT scans or XRs 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 Night Float / Sign Outs / Patient List Management Additional Information Antibiotics with start (& stop) date –Abx: Cpime/Vanc(7/4- ) (include stop date) –Abbreviate so that its still recognizable –Include last vanc trough Cultures – include date –pos results (recent neg results) & usu. dont 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 Night Float / Sign Outs / Patient List Management Additional Information, contd 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 weeks 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 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management Using the Name section For TRE, Trauma goes under last name –Trauma name itself goes after 1 st 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 Night Float / Sign Outs / Patient List Management 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 Night Float / Sign Outs / Patient List Management 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 youre signing out to should be able to look at the list and know the patient fully

31 Night Float / Sign Outs / Patient List Management 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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