1. Pediatrics at MSKCC 2007-2008

2. Overview GME folders and beepers GME folders and beepers Organization of the clinical services Organization of the clinical services Expectations of residents, fellows, NPs Expectations of residents, fellows, NPs Daily schedules Daily schedules Administrative Procedures Administrative Procedures Computer information Computer information

3. First day at MSKCC On your first day, please go to M9 first at 7AM On your first day, please go to M9 first at 7AM No need to stop by the GME office anymore No need to stop by the GME office anymore Once on M9, you will first receive sign-out from the post-call resident, and then you will be given a brief orientation Once on M9, you will first receive sign-out from the post-call resident, and then you will be given a brief orientation

4. GME folder and beeper GME office = M2101 GME office = M2101 Please sign all paper work including: Please sign all paper work including: Confidentiality agreement Confidentiality agreement DEA acknowledgment DEA acknowledgment HIPAA security form HIPAA security form “White card” with general phone numbers, your institutional DEA number, and all computer passwords “White card” with general phone numbers, your institutional DEA number, and all computer passwords Blue prescription card Blue prescription card ID slip (security office, basement Memorial Hospital), scrubs/lab coat requisition (general stores, basement Memorial Hospital)  MUST obtain these after rounds on first day ID slip (security office, basement Memorial Hospital), scrubs/lab coat requisition (general stores, basement Memorial Hospital)  MUST obtain these after rounds on first day

5. Organization of clinical services M9 – Inpatient, Pediatric Observation Unit (POU), and Pediatric Day Hospital (PDH) M9 – Inpatient, Pediatric Observation Unit (POU), and Pediatric Day Hospital (PDH) Two teams on M9 Inpatient – two medical teams (“green”, “blue”) Two teams on M9 Inpatient – two medical teams (“green”, “blue”) POU – step-down unit for peds  PICU at NYPH POU – step-down unit for peds  PICU at NYPH PDH = outpatient clinic: PDH = outpatient clinic: Primary teams include attendings, NPs, social work: Primary teams include attendings, NPs, social work: leukemia (Drs. P. Steinherz, Yurasov) leukemia (Drs. P. Steinherz, Yurasov) lymphoma (Dr. Trippett) lymphoma (Dr. Trippett) sarcoma (Drs. Meyers, Wexler, Merola, Merchant, Chou) sarcoma (Drs. Meyers, Wexler, Merola, Merchant, Chou) neuro-oncology (Drs. Dunkel, Khakoo, Lyden) neuro-oncology (Drs. Dunkel, Khakoo, Lyden) neuroblastoma (Drs. Cheung, Kramer, Kushner, Modak) neuroblastoma (Drs. Cheung, Kramer, Kushner, Modak) surgery (Drs. LaQuaglia, Kayton) surgery (Drs. LaQuaglia, Kayton) long-term follow-up/endocrine (Drs. Sklar, Oeffinger) long-term follow-up/endocrine (Drs. Sklar, Oeffinger) Cardiology (Dr. L. Steinherz) Cardiology (Dr. L. Steinherz) BMT (Drs. O’Reilly, Boulad, Kernan, Small, Prockop, Scaradavou) BMT (Drs. O’Reilly, Boulad, Kernan, Small, Prockop, Scaradavou) Open M-F from 7:30am until 7:30pm Open M-F from 7:30am until 7:30pm Sees approximately 120 - 150 patients/day Sees approximately 120 - 150 patients/day

6. Primary teams include attendings, NPs, social work: Primary teams include attendings, NPs, social work: Leukemia (Drs. P. Steinherz, Yurasov) Leukemia (Drs. P. Steinherz, Yurasov) Lymphoma (Dr. Trippett) Lymphoma (Dr. Trippett) sarcoma (Drs. Meyers, Wexler, Merola, Merchant, Chou) sarcoma (Drs. Meyers, Wexler, Merola, Merchant, Chou) Neuro-oncology (Drs. Dunkel, Khakoo, Lyden, Gillheeney) Neuro-oncology (Drs. Dunkel, Khakoo, Lyden, Gillheeney) Neuroblastoma (Drs. Cheung, Kramer, Kushner, Modak) Neuroblastoma (Drs. Cheung, Kramer, Kushner, Modak) Surgery (Drs. LaQuaglia, Kayton) Surgery (Drs. LaQuaglia, Kayton) Long-term follow-up/endocrine (Drs. Sklar, Oeffinger) Long-term follow-up/endocrine (Drs. Sklar, Oeffinger) Cardiology (Dr. L. Steinherz) Cardiology (Dr. L. Steinherz) BMT (Drs. O’Reilly, Boulad, Kernan, Small, Prockop, Scaradavou) BMT (Drs. O’Reilly, Boulad, Kernan, Small, Prockop, Scaradavou) Meet the Staff

8. M9 Inpatient Service GREEN Team – general oncology Attending Fellow PGY-3 senior resident from Downstate 3-4 PGY1/PGY2 from Cornell, St. Barnabas, Harlem, Lincoln 2-3 NPs (Courtney, Rebecca, Angela) Case manager (Megan Behringer) BLUE Team – BMT Attending Fellow PGY-3 senior resident from Downstate 3-4 residents from Cornell, Downstate, Metropolitan NP (Heidi) Case manager (Megan Behringer)

9. The Nurses

10. Role of the Nurse Practitioners on M9 Provides continuity of care for patients Provides continuity of care for patients NPs fulfill several roles on the inpatient unit NPs fulfill several roles on the inpatient unit Patient care Patient care Work-flow facilitator Work-flow facilitator Education Education Administration Administration NPs do not work on weekends and thus their patients are covered by housestaff on weekends NPs do not work on weekends and thus their patients are covered by housestaff on weekends Surgical NPs (Carol, Courtney, and Rebecca) take primarily post-op surgical patients. If there are not many, they will then assume responsibility for general oncology patients Surgical NPs (Carol, Courtney, and Rebecca) take primarily post-op surgical patients. If there are not many, they will then assume responsibility for general oncology patients

11. Role of the Fellow Mentor, supervisor, educator There is ALWAYS a fellow available Fellows are notified about all admissions to the floor Fellows are responsible for writing all of the chemotherapy orders for all patients

12. Housestaff at MSKCC 6 residencies throughout NYC: Cornell, Downstate, Lincoln, Harlem, Metropolitan, St. Barnabas 6 residencies throughout NYC: Cornell, Downstate, Lincoln, Harlem, Metropolitan, St. Barnabas Without you, MSKCC cannot function!! Without you, MSKCC cannot function!! Primary caretaker when patients are admitted to M9 Primary caretaker when patients are admitted to M9 Typical census = 5-6 patients/resident Typical census = 5-6 patients/resident Responsible for all orders (medications, IVF, diagnostic tests [labs, radiology], admission orders, discharge orders) except chemotherapy Responsible for all orders (medications, IVF, diagnostic tests [labs, radiology], admission orders, discharge orders) except chemotherapy Prescriptions upon patient discharge Prescriptions upon patient discharge Admission notes, daily progress notes, acceptance notes, discharge notes, off-service notes Admission notes, daily progress notes, acceptance notes, discharge notes, off-service notes

13. Role of the PGY-3 Senior Resident Works closely with the Pediatric Chief Resident, Pediatric Fellow on-service, and the Pediatric Attending Works closely with the Pediatric Chief Resident, Pediatric Fellow on-service, and the Pediatric Attending Serves as a knowledgeable resource of general pediatrics to PGY- 1 / PGY-2 residents, nursing staff, and NPs Serves as a knowledgeable resource of general pediatrics to PGY- 1 / PGY-2 residents, nursing staff, and NPs Supervises PGY-1 and PGY-2 residents on the rotation Supervises PGY-1 and PGY-2 residents on the rotation Responsible for knowing all of the patients on their team Responsible for knowing all of the patients on their team Takes on patients and/ or does admissions/ discharges of their own when necessary Takes on patients and/ or does admissions/ discharges of their own when necessary Aids in the distribution of admissions Aids in the distribution of admissions Takes in-house, overnight call 4-5 times a month Takes in-house, overnight call 4-5 times a month Attends own continuity clinic at their home institution Attends own continuity clinic at their home institution Attends Tuesday and Friday Morning Report in addition to all resident conferences (core lectures, tumor boards, grand rounds) Attends Tuesday and Friday Morning Report in addition to all resident conferences (core lectures, tumor boards, grand rounds)

14. Role of the Chief Resident Assists with new resident orientation Assists with new resident orientation Maintains communication among the resident staff and pediatric hematology/oncology fellows. Maintains communication among the resident staff and pediatric hematology/oncology fellows. A liaison to the pediatric administration, nursing, and all ancillary services to improve work relationships on the inpatient unit A liaison to the pediatric administration, nursing, and all ancillary services to improve work relationships on the inpatient unit Identify issues and work on solutions to improve resident well being and patient care Identify issues and work on solutions to improve resident well being and patient care Make the schedule of rotating residents, provide residents with feed back on progress, complete resident evaluations, communicate with Outside Chief Residents Make the schedule of rotating residents, provide residents with feed back on progress, complete resident evaluations, communicate with Outside Chief Residents Organize daily noon conferences, give didactic lectures on topics of interest in general pediatrics and pediatric hematology/oncology Organize daily noon conferences, give didactic lectures on topics of interest in general pediatrics and pediatric hematology/oncology Be informed of all “sick” patients on M-9, provide advice to Attendings/ Fellows/ Residents regarding patient care Be informed of all “sick” patients on M-9, provide advice to Attendings/ Fellows/ Residents regarding patient care

15. Admissions Fellows are notified of all admissions to the floor Fellows are notified of all admissions to the floor Patients being admitted will be posted on the patient board on M9 Patients being admitted will be posted on the patient board on M9 Typically, admissions from 9am-5pm come from the PDH after being assessed by the primary team Typically, admissions from 9am-5pm come from the PDH after being assessed by the primary team Once a patient’s name has been posted on the admission board, you do not have to wait until the patient physically comes onto the floor before evaluating them. You can go to the PDH to start the admission process. Once a patient’s name has been posted on the admission board, you do not have to wait until the patient physically comes onto the floor before evaluating them. You can go to the PDH to start the admission process. After 5pm, they usually come from UCC after being assessed by the fellow on-call After 5pm, they usually come from UCC after being assessed by the fellow on-call Many patients come with typed admission notes BUT this does not mean you don’t take a full H & P on all admitted patients. Many patients come with typed admission notes BUT this does not mean you don’t take a full H & P on all admitted patients.

16. Discharges Anticipate discharges so you can get prescriptions filled and follow-up appointments set-up early on. Anticipate discharges so you can get prescriptions filled and follow-up appointments set-up early on. Communicate with the case manager, Megan (b. 4547, x2331) for setting up home-care, getting supplies, etc. requires advance planning Communicate with the case manager, Megan (b. 4547, x2331) for setting up home-care, getting supplies, etc. requires advance planning Discharge orders and instructions are computerized in HIS Discharge orders and instructions are computerized in HIS Please write a discharge note summarizing the hospital course/admission Please write a discharge note summarizing the hospital course/admission

17. Consults Main MSKCC page operator = 7900 or 2000 Contact main MSKCC page operator to obtain numbers to call (telephone and/or pager) for most consults

18. Medication Reconciliation Accurately and completely reconcile medications across the continuum of care. Accurately and completely reconcile medications across the continuum of care. Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization with the involvement of the patient. Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization with the involvement of the patient. This process includes a comparison of the medications the organization provides at admission, transfer, and discharge to the medications on the list. This process includes a comparison of the medications the organization provides at admission, transfer, and discharge to the medications on the list. Definition Definition A process for obtaining a complete and accurate list of the patients’ current home medications, including OTC’s and herbals, and comparing the practitioner’s admission, transfer, and/or discharge orders to that list. A process for obtaining a complete and accurate list of the patients’ current home medications, including OTC’s and herbals, and comparing the practitioner’s admission, transfer, and/or discharge orders to that list. Instructions found in Resident Manual Instructions found in Resident Manual

19. A “typical” day 7 am: sign-out/sign-in (weekdays/weekends) 7 am: sign-out/sign-in (weekdays/weekends) Pre-round on your patients, obtain vital signs, I/Os, PCA doses/ attempts Pre-round on your patients, obtain vital signs, I/Os, PCA doses/ attempts RENEW ORDERS for IVF and narcotics RENEW ORDERS for IVF and narcotics 9 am: Start of attending work rounds 9 am: Start of attending work rounds 11 am: Radiology rounds in PDH classroom (M-F) 11 am: Radiology rounds in PDH classroom (M-F) 1 pm: Core conference and lunch (M-F) 1 pm: Core conference and lunch (M-F) 2 pm – 5 pm: Admissions, Discharges, etc. 2 pm – 5 pm: Admissions, Discharges, etc. 5 pm: sign-out (weekdays/ weekends (buddy system)) 5 pm: sign-out (weekdays/ weekends (buddy system)) Enter AM lab orders for next day Enter AM lab orders for next day

20. Weekday call On weekdays, call starts at 5 pm On weekdays, call starts at 5 pm You will never be asked to cross-cover other team You will never be asked to cross-cover other team On-call resident is responsible for all admissions to the floor after 5 pm On-call resident is responsible for all admissions to the floor after 5 pm There is always one fellow supervising. On-call fellow is responsible for both teams on M9 as well as the Urgent Care Center There is always one fellow supervising. On-call fellow is responsible for both teams on M9 as well as the Urgent Care Center Responsible for making sure all AM labs are appropriate Responsible for making sure all AM labs are appropriate Midnight rounds with on-call fellow Midnight rounds with on-call fellow A call room on the floor is provided; meal cards for dinner are provided A call room on the floor is provided; meal cards for dinner are provided

21. Weekend calls Sign-out starts at 7 am Sign-out starts at 7 am Attending rounds start at 9 am Attending rounds start at 9 am On-call resident responsible for daily progress notes on all patients on the service (may be typed or written) On-call resident responsible for daily progress notes on all patients on the service (may be typed or written) On-call resident responsible for all admissions, discharges, and transfers from the POU On-call resident responsible for all admissions, discharges, and transfers from the POU Will be supervised by one fellow per team (unlike weekdays) Will be supervised by one fellow per team (unlike weekdays) Cafeteria closes at 7pm on weekends Cafeteria closes at 7pm on weekends Midnight rounds with on-call fellow Midnight rounds with on-call fellow Gets AM vitals and I/Os of all patients Gets AM vitals and I/Os of all patients A call room on the floor is provided; meal cards for dinner are provided A call room on the floor is provided; meal cards for dinner are provided

22. Call schedules Adheres to ACGME rules (<80 hours/ week) Call schedules are made monthly by the Pediatric Chief Resident Can be found on-line in Pediatrics shared drive Please let the Pediatric Chief Resident know if there are any conflicts, emergencies, illness as early as you can Tawana Winkfield-Royster: winkfiet@mskcc.orgwinkfiet@mskcc.org Long range pager 917-205-4091, In-house pager #2244, Office x 8398

23. HIPAA Training Currently MSKCC requires that all of its rotating residents complete its on-line HIPAA training course (takes at most 40 min) Currently MSKCC requires that all of its rotating residents complete its on-line HIPAA training course (takes at most 40 min) START  Reference Manuals & Tutorials  Computer Based Training  HIPAA CBT START  Reference Manuals & Tutorials  Computer Based Training  HIPAA CBT Sign in with your MSKCC employee ID# found on your ID tag Sign in with your MSKCC employee ID# found on your ID tag Choose “All Users” under ‘Job Function’ Choose “All Users” under ‘Job Function’ Choose the curriculum labeled “All Other MSKCC Users” Choose the curriculum labeled “All Other MSKCC Users” Then make sure to complete the required courses (HIPAA Awareness and HIPAA Security) Then make sure to complete the required courses (HIPAA Awareness and HIPAA Security) PLEASE complete this as soon as you can…and give me the certificates when you are done PLEASE complete this as soon as you can…and give me the certificates when you are done

24. Computer Information Passwords found on back of “white card” Passwords found on back of “white card” Healthcare Information System – central hub for all clinical information at MSKCC; integrates order entry, labs, medical records, radiology, pathology, on-line databases (UpToDate, Lexi-Comp), on-line calculators Healthcare Information System – central hub for all clinical information at MSKCC; integrates order entry, labs, medical records, radiology, pathology, on-line databases (UpToDate, Lexi-Comp), on-line calculators On-line tutorial = http://mskcbt.mskcc.org On-line tutorial = http://mskcbt.mskcc.org Username: “pedteam” / Password: “pedteam” sign-on for all computer workstations Username: “pedteam” / Password: “pedteam” sign-on for all computer workstations Start  Programs  Accessories  Windows Explorer Start  Programs  Accessories  Windows Explorer Peds Shared Drive = H:-drive Peds Shared Drive = H:-drive

25. On-line HIS Tutorial Can be accessed from within MSKCC or at home Can be accessed from within MSKCC or at home http://mskcbt.mskcc.org http://mskcbt.mskcc.org Log in using "New User“ Then take course called "Clinical Systems"

26. Peds Shared Drive (“H:-drive”) Must log-in to computer station using “pedteam/pedteam” Must log-in to computer station using “pedteam/pedteam” Contains notes, schedules, resident resources Contains notes, schedules, resident resources Start  Programs  Accessories  Windows Explorer Start  Programs  Accessories  Windows Explorer For inpatient admission/progress notes: For inpatient admission/progress notes: H:\notes_M9\M9_GREENTEAM_ONC\M9_GREENTEAM_ONC H:\notes_M9\M9_GREENTEAM_ONC\M9_GREENTEAM_ONC H:\notes_M9\M9_BLUE TEAM_BMT\Blue Team_Progress_Notes H:\notes_M9\M9_BLUE TEAM_BMT\Blue Team_Progress_Notes For monthly call schedule For monthly call schedule H:\Pediatric On-Call Schedules\Fellows Schedules\On Call Schedule H:\Pediatric On-Call Schedules\Fellows Schedules\On Call Schedule H:\Residents  you will find orientation materials, lecture slides, review articles, handy databases, etc. H:\Residents  you will find orientation materials, lecture slides, review articles, handy databases, etc.

27. Housekeeping Every morning, please renew all IVF and PCAs/narcotics after checking AM labs and obtaining vital signs Every morning, please renew all IVF and PCAs/narcotics after checking AM labs and obtaining vital signs Please also renew all medication orders promptly Please also renew all medication orders promptly Blue meal cards are provided for meals on-call only: $5.50/meal Blue meal cards are provided for meals on-call only: $5.50/meal Please return all beepers to “beeper drawer” at end of each day Please return all beepers to “beeper drawer” at end of each day M9 Hallway Bathroom code = 27368 M9 Hallway Bathroom code = 27368 Important phone numbers: Important phone numbers: Chief Resident: Tawana x2923 Chief Resident: Tawana x2923 Wendy Werner: x 5966 Wendy Werner: x 5966 Alexander Chou, MD: 6057, beeper 917-205-1757, e-mail: choua@mskcc.org Alexander Chou, MD: 6057, beeper 917-205-1757, e-mail: choua@mskcc.org When in doubt, please ask When in doubt, please ask

28. Don’t worry, you’ll be just fine!!