1. PGY2-to-Be Retreat June 9, 2014 Scott Denstaedt Marty Tam Angel Qin Khanjan Shah

2. “With great power comes great responsibility” -Spiderman

3. Overview 4-4:30 PMSnacks and informal discussion 4:30-6 PMIntroductions and classroom activities Giving feedback Milestones Changes in the ambulatory program Student teaching - clerkship directors 6-7:45 PMDinner How to be a ward resident - small groups Intern class group meetings 8-9 PMAdministrative issues/changes for next year/chief residents Ambulatory program Electives Jeopardy Transition dates Team caps/duty hours Staffing/new roles Coverage/schedules Reading list Moonlighting Professionalism/conferences In-training exam MICU/CICU schedule Night float Two midnight rule Codes

4. Changes for Next Year Ambulatory Model 2.0 Electives Jeopardy

5. Ambulatory Model 2.0 2013-2014: four ambulatory blocks and 2-4 clinics in elective 2014-2015: five ambulatory blocks and no clinic in elective (there is a panel management day) “6+2” model – 6 weeks of ICU/wards/elective – 2 weeks of dedicated ambulatory – 7 half days of clinic each block and 1 administrative half day Positive Effect – Continuity: you and three other seniors make up a team (with two interns) and see the same patients (great for you and the patients!) – Electives Preserved: you can make more of your elective now! – Curriculum: streamlined and less repetitive New Challenges – Ambulatory blocks are fixed (cannot trade) – Change is uncomfortable, but we do it to try and make things better

6. Ambulatory Model 2.0

7. TeamFlight 1 (1A,4B,8A,10A,12A)Flight 2 (1B,5A,8B,10B,12B)Flight 3 (2A,5B,9A,11A,13A)Flight 4 (2B,6A,9B,11B,13B) VA 1 RedPerihanJohn SAnodikaPrashanth VA 2 SilverAndresRachelAbdullah AlmPerica VA 3 PurpleAlinaKatiePhiliciaKhadejah VA 4 YellowAmhedWissamNupurLesley DMC 1 MBryanJacobRaniaNeetika DMC 2 TuStephanie KSadeerJohn GNate S DMC 3 WMayaCarinePatrickGabe DMC 4 ThAhmadDafinaAtallahVincent DMC 5 FStephanie MBrandonYosraChris DMC 6 MRoopaCassieWonDhruti DMC 7 TuJackMoAbdullah AljHussain DMC 8 WAniketAnthonyRishiShiv DMC 9 ThBouchraPriyamNingZiyad

8. Ambulatory Model 2.0 # ResidentsMonTuesWedThursFri 1Team 1 2 3 4 5 6 7 WEEK 1 8 BOX Admin Team 1 # ResidentsMonTuesWedThursFri 1Team 1 2 3 WEEK 2 4 5 6 7 8 BOX Team 1 BOX Admin # ResidentsMonTuesWedThursFri 1Team 1Team 2Team 1Team 2Team 1 2Team 3Team 4Team 3Team 4Team 3 3Team 4Team 5 Team 6Team 5 4Team 6Team 7Team 6Team 7 5 Team 8 Team 9Team 8 6Team 9 7*Intern 1*Intern 2*Intern 3*Intern 4*Intern 5WEEK 1 8*Intern 6*Intern 7*Intern 8*Intern 9 BOXTeam 2Team 3Team 4Team 5Team 6 BOXIntern AdminTeam 8Team 9 Team 1Team 2 # ResidentsMonTuesWedThursFri 1Team 1Team 2Team 1 Team 2 2 Team 3 Team 2Team 3 3Team 4Team 5Team 4 Team 5WEEK 2 4Team 6Team 7Team 6Team 5Team 6 5Team 8Team 9Team 8Team 7Team 8 6Team 9 7*Intern 1*Intern 2*Intern 3*Intern 4*Intern 5 8*Intern 6*Intern 7*Intern 8*Intern 9 BOXTeam 7Team 8Team 9 Team 1 BOXIntern AdminTeam 3Team 4Team 5Team 6Team 7

9. Ambulatory EMR - DMC Beginning July 1 st, DMC will transition to ambulatory EMR Experts will be available to assist with any day- to-day problems You need to complete the EMR training via Oracle prior to July 1 st (alternative was full day of in-house training!)

10. Electives PGY II: 8 weeks PGY III: 12 weeks Quality Chief will now be assisting Barb in keeping a running list of what you are doing for elective For ACGME requirements each resident must have a specified activity and supervisor for each elective

11. Example Elective Tracking

12. Electives Research Electives: Must have a mentor/PI for project If doing two weeks (or more) of research elective, you are required to present a poster at Medicine Research Day If you present at a national meeting…travel money! Reading Electives: Requires approval, KBA is designated supervisor Required attendance at all UH noon conferences, UH M+Ms, UH Grand Rounds, VA Grand Rounds

13. Elective Reminder Elective Professionalism Elective is not vacation You are back-up jep and expected to be in Cleveland If you are going out of town, please let the Ambulatory chief know “Don’t you remember when you were a resident?” Having your pager on 24/7 on elective is unreasonable Everyone on elective is back-up jep any given day, but we can assign people on specific days to be the first called so you know when to have your pager with you

14. Jeopardy Minor changes to the jeopardy system will be made Use of jeopardy will be tracked for training/support purposes – Make sure everyone is meeting minimum requirements – Make sure we provide help and resources to those that need it Those getting jepped from electives will be tracked as well – Ties into the “first call” back-up jep list, you move down the list after getting jepped – Makes the system more fair KEY Points – Jeopardy still remains for emergencies and significant illness – Unless there is excessive use of jeopardy (decided on a case by case basis), you are not expected to pay back – There is still a jep rotation, coverage here is not tracked and you do not get paid back

15. Transition Dates PGY1 end date: 6/23 Block Zero: 6/24 – 6/30 Block One: 7/1 – year of SMAK!

16. Team Caps UH Wards: 10 patients per intern 8 patients per intern on Ratnoff/Weisman Intern+AI: 12 patients if two seniors; 10 patients if one senior VA Wards: 8 patients per intern Intern+AI: 10 patients AI+AI pair: 10 patients Short Admissions: No shorts on weekends No shorts if intern has 8 patients Shorts for Intern+AI pair to cap of 10 patients

17. Duty Hours Long Call: – 3 patients (4 if paired with AI) until 7 PM – 2 patients if after 5 PM – 1 patient is after 6 PM Medium Call: – 2 patients until 4 PM – Can sign out at 7 PM Short Call: – 2 patients until 12 PM at UH (NF or ICU transfers) – 2 patients until 1 PM at VA (NF, ICU transfers, new admissions) – No short patients on clinic days ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!! Senior Resident: – Residents on call MUST stay until 9 PM – No matter what the call, ward seniors staff any patient the seen before 4 PM – Weekend coverage seniors must stay and staff at least until 1 PM or longer depending on how busy the other seniors are

18. Staffing UH wards will have double coverage Blocks 1-4a There will be minimal orphan coverage in the first few blocks See and examine EVERY patient No staffing note required for ICU transfers or interservice transfers Focused notes by the senior resident with detailed plan See PGY1 note for full H&P. Briefly, pt is a … Helpful to new interns: Antibiotic doses Description of imaging - With contrast? Without? Medications to continue, medications to discontinue CODE STATUS and Allergies

19. Staffing On call resident should notify the nightfloat resident of tenuous patients Be proactive about staffing patients

20. Your New Role Be a Manager : Print out daily patient list for attending at UH Enter team attendings in the EMR Lead rounds Review active medications and orders EVERY DAY! Direct intern work flow Help with discharge summaries! Have teaching topics Maintain a white board and saved list of patients Review discharge profiles

21. Your New Role Be a Teacher : Great teachers are motivators, respectful, and treat their students as colleagues/equals Take time to critically evaluate presentation skills Find your own method of teaching

22. Your New Role Be a Steward of Sign-outs: What is important? What changes management? What is not important? Observe signouts early

23. Coverage and Schedule Switches All coverage arrangements and schedule switches must be approved by the Ambulatory chief so it can be noted in amion Switches must be arranged before 1 week of rotation starting

24. Residency Reading List Residency Reading list: Landmark and review articles in all sub-specialties Last major update in 2011 Looking a 20-40 year old resident who enjoys long nights of Boolean searching to help update the site with new landmark trials…

25. Moonlighting FLEX – occasionally, when your team is capped and a patient is in need of your specific team, they can be admitted by you for money, usually go to intern the next day as admission PRN SHD – admit 3 patients Early and Late SHD – admit 3 patients Admitting LHD – admit 6 patients from 6 PM – 6 AM Cross Cover LHD – cross covers hospitalist, NPs, and can admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM MICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for alternating admissions with resident until 2am, then all admissions No moonlighting during wards or ICU

26. Professionalism

27. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean No denim Do not show up to Morning Report looking sloppy

28. Professionalism: Absences If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic You will be able to get a same-day appointment If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy Call-offs: You must PAGE 31529 the Ambulatory Chief DO NOT EMAIL DO NOT TEXT PAGE DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

29. Professionalism: Electives Attend all Grand Rounds and M&M’s You are back up jeopardy!! = pager on If you are going out of town for the weekend, as a courtesy please notify the ambulatory chief prior to leaving Elective is not vacation Please email Barb 2 weeks prior to starting your electives; Quality chief will be keeping track of electives Research for more than 2 weeks = present at Research Day

30. Professionalism: Reading Electives Residents on reading elective are expected to attend morning reports and journal clubs at the VA Must attend Grand Rounds at UH Your pager is expected to be turned on and on you during the entire two weeks of elective All reading electives must be approved by KBA For PGY2s it can only be used to study/take step 3 Please note that when you are on elective, you are back up jeopardy!!!

31. Professionalism: Conference Attendance Please be on time; our speakers usually have prepared a well thought out talk/powerpoint, so please be respectful of the time they spent Noon conference: UH: Mon-Wed-Thurs VA: Mon-Thurs-Fri Grand Rounds on Tuesday: UH & VA M&M Fridays @UH, Wednesdays @VA Conference attendance is part of your ACGME graduation requirements

32. Ambulatory Conference Attendance Ambulatory conference attendance is mandatory Late Policy will be strictly enforced: Sign-in sheet will be available until 8:05AM At your 2nd instance of being late = extra weekend coverage Any MISSED conferences without prior approval by the ambulatory chief will result in weekend coverage

33. Professionalism: Agre Society First Wednesday of each month beginning September Organized by Dr. Proweller Excellent opportunity to hear the career trajectories of influential clinicians/ researchers May be your solution to “I cannot find a mentor…”

34. Professionalism: Discharge Summaries If you put in the discharge order, you do the discharge summary Do them the day of discharge Do them for your intern Do them for your friends Do them for your patients Remember it is now easier than ever to do it in UH EMR

35. In-service Training Exam In-service Exam Dates are in September – exam is completely computerized this year Includes all PGY2/3, PGY1’s? ITE during 2 nd year is an important predictor of passing boards ITE remediation by percentile rank >50% - no remediation, continue to study 31-49% - turn in in 60 multiple choice questions every 4 weeks to assigned APD for review; continue studying and attend board review sessions 16-30% - high risk for ABIM failure multiple choice questions as above with directed notes If you are not already doing this PLEASE talk with us or your APD, ABIM failure is no joke 1-16% - more intense remediation, urgent intervention required (we are here to help!)

36. CICU Intern Two interns scheduled in the CICU – Day intern: works 7 AM - 7 PM, admits with supervision of senior – Night intern: works 7 PM - 7 AM, helps cross-cover and can admit Interns do one week of nights and one week of days Both interns have Sunday off (accommodate switch days and transition from nights to days)

37. CICU Resident 5 senior residents – Night call – Post-call – Day call – Helper day – Pre-call Pre-call day between Thursday and Monday is day off The Day Call senior, Helper Day senior, Night Call senior, and Day Shift intern should be present on evening fellow rounds (5 PM)

38. CICU Resident Night call = come in at 4 PM to admit; present patients first on rounds Day call = pre-round and admit patients until 4 PM Helper day = pre-round and carry most team cross coverage Pre-call = mostly days off New system with LOTS of hand-offs; remember all patients are “ours”

39. MICU Resident Overnight Call – Post Call – Helper Day – Pre Call Senior residents get pre-call day off between Friday and Monday (interns get helper day off during same days) Five senior residents in the MICU (plus rotators) If two MICU attendings, there are two teams (Blue and Gold) If one MICU attending, the entire unit team rounds together Senior will be paired with intern, your responsibility to supervise but who “staffs” directly with fellow Helper day = supervise the post call intern (their senior will leave by 11am) and help out on-call resident until at least 5 PM

40. MICU Resident May have 2 weeks as MICU night resident (have Friday and Saturday nights off that are covered by MICU moonlighter) MICU night resident responsibilities – Comes at 9 PM – Cross-covers unit at night – Alternates admissions with resident on call until 2 AM, then does all admissions after 2 AM Patients admitted by NF will be distributed by the MICU fellow in AM NF residents sometimes stay to present patients on rounds (complex patients) Post-call resident will present and leave, sign out to the post call intern

41. VA Nightfloat Resident Works from 8 PM to 8AM Cover the VACR pager (medicine consults) Run codes Evaluate CARES Tower 6 patients – If patient needs more evaluation then direct admission (DO NOT GO TO THE ED) VA chief will page you in the morning to distribute patients Discuss Code status of patients Change team assignment in CPRS (admission order: team)

42. The NIGHTFLOAT TEAM NACR Nightfloat Resident Rotating MSIII Nightfloat Resident Nightfloat Intern Rotating MSIII Nightfloat Intern

43. UH Nightfloat Resident Works from 8 PM to 8AM Meets the NACR in the KACR Admit patients overnight, works with the nightfloat intern to help answer questions/manage ill patients. NACR is always available if you need help Two nightfloat residents, each resident either gets Saturday or Sunday off (must have 1 nightfloat resident each night) Must go to all Code Whites during the first 6 months with intern

44. Two Midnight Rule Arose out of for profit hospital chain fraud Requires attending to sign and admission order that includes language that the attending expects the patients medical problems to require admission for two days Some logistical issues on getting attendings to sign/place order

45. Running Codes

46. Code Whites (UH) ** 1 ST six months – an upper level must go to all Code Whites with an intern** Sick or decompensating patients on the floor or Hanna House Initial response from ICU nurse, intern, and PGY2 DACR/NACR for Level 2 code white If you want to transfer to MICU, call MICU fellow Always write a Clinical Event Note!

47. Code Blues Check your own pulse first “Too many chefs spoil the soup” One person leads the code Make sure interns are involved Maintain a calm quiet atmosphere Keep the ACLS cards in your pocket until you are comfortable with the protocols Make sure your BLS and ACLS are up to date CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

48. Running Codes Rule #1: You are in charge If uncomfortable, defer to more senior resident Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc. Use the DACR/NACR if you need help Don’t be afraid to ask people to leave the room Call the ICU nurses by their name, closed-ended communication Assign someone to call the family Use the Code Note EMR, sign code sheet

49. Running Codes Notifying attendings at night Most attendings want to be paged and notified (either of transfer to ICU or death) Can clarify with your attending on first day of service what their preferences are Don’t get burned by not calling your attending- you may hear about it the next day

50. We are looking forward to a great year together!!! -SMAK

51. Questions?