Hospitalist Program Inpatient Orientation

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Hospitalist ProgramInpatient Orientation

• Daniel Robitshek, MD
• UC Irvine Medical Center

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Attending Information (example)

• Daniel Robitshek, MD
• Pager 506-2267
• Cell 658-0440
• Office 456-5726 (Christal Wright)
• Email drobitsh_at_uci.edu

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Daily AM Activities

• Weekday Morning Rounds
• 700-900 Team pre-rounding without attending
• or Short Call rounds w/attending
• 900-1100 Attending work/teaching rounds
• 900-910 Morning debriefing
• Urgent/overnight issues
• Discharge planning
• 910-1100 Patient/Bedside Rounds, includes
  radiology rounds
• 1100-1120 Didactic Teaching rounds
• 1120-1155 Team Work rounds
• Noon conference
• 1200-130 Daily
• Mandatory on-time attendance for all house-staff

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Daily PM Activities

• Afternoon
• House-staff/student Work Rounds
• Afternoon specific
• Admissions
• House-staff PC Clinic
• Post-Hospital F/u clinic
• Family meetings
• F/U on Lab/diagnostic test/consultation
• Afternoon attending debriefing
• Clinical Vignettes (students)
• Course didactics (students)
• End of day (time varies)
• Senior Resident (or designate)
• Check-out rounds with attending either at end of
  routine day or at end of call
• In person, over the phone, at bedside/conference
  room

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Team goals

• All team members will provide the highest quality
  patient care
• All team members will provide patient-centered
  empathic care
• All team members will foster an atmosphere of
  teaching and learning that is patient-based and
  team oriented
• House staff and students will develop confidence
  and progressive autonomy in the care of patients
• All team members will implement a cost and
  time-efficient model of care, while ensuring the
  highest quality with minimal risk
• All team members will foster a positive inclusive
  approach with nursing staff, case-management,
  social service and chaplains/spiritual care team

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Responsibilities

• Attending responsibility
• Assume final responsibility for overall patient
  care
• Ensure the highest quality of evidence-based
  medical care
• Ensure optimal risk, time, and cost management
• Conduct formal daily teaching rounds
• Ensure optimal educational experience of students
  and house-staff in an open and non-threatening
  environment
• Be available 24-hours daily as consultant and
  mentor to team, nursing staff, case manager,
  patients and families
• Role model the practice of an Internal Medicine
  hospitalist
• Role model the practice of patient-centered
  compassionate care
• Role model excellent communication skills with
  patients, families, colleagues, house-staff,
  students, nursing, case-management and other
  ancillary staff-members

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Responsibilities

• Senior resident responsibilities
• Responsible for overall team management,
  organization and supervision of patient care
• Provide leadership for and supervision of interns
  and students
• Leads teaching activities during pre-rounds, pm
  work-rounds and on-call
• Actively participate in attending teaching rounds
  and work rounds discussions
• Discusses and or assigns pertinent evidence-based
  topics and articles to team
• Provides positive role-modeling to interns and
  students
• Ensures orders, tests and consultations are
  carried out expeditiously and results are
  addressed in a timely fashion
• Recognized by the patients and families as the
  leader of the house-staff/student team

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Responsibilities

• Senior resident responsibilities (contd)
• Ensure that medical records are accurate, timed,
  dated and signed by Interns and/or Students
• Ensure attending is made aware of any significant
  results or changes in clinical status of patients
  in a timely fashion
• Dictates all admission HPs at time of admission
  (excluding short-call admissions)
• Dictates all D/C summaries for all patients
  ideally on day of but certainly within 24 hours
  of discharge
• Perform 1 CEX with each MS3
• Ensure 1 observed CEX is performed by the
  attending
• Be available during reasonable working hours
  (7am-7pm) daily or later if necessary except
  designated days off and other arranged times for
  any patient or team-related issues
• Inform Primary Care Provider of admission and
  updates as appropriate

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Responsibilities

• Intern and Sub-Interns
• Responsible for day-to-day assessment and care of
  patients
• Responsible for timely implementation of
  care-plans, orders, diagnostic tests,
  consultations
• Develop rapport with and trust of patients and
  families
• Demonstrate/develop history taking skills and
  physical examination techniques
• Develop focused and organized case presentation
  skills
• Develop broad understanding of DDx and care plans
• Develop technical/procedural skills
• Dictation of death summaries within 24 hours of
  death

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Responsibilities

• Intern and sub-intern (cont.)
• Understand and demonstrate proficiency at
  evidence-based, cost-effective ordering of labs
  and diagnostic tests
• Be available to attending, resident, nursing
  staff and case managers during reasonable working
  hours(7AM- 7PM) daily or later if necessary
  except designated days off and other arranged
  times.

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Responsibilities

• Medical Students (MS-3)
• Responsible for day-to-day assessment of
  designated patients
• Develop rapport with patients and families as
  care-giver and advocate
• Demonstrate compassionate whole-person care of
  patient and family
• Ensure that patient assessment and test results
  are discussed with intern/senior resident and/or
  attending in a timely manner on rounds and
  throughout the day.
• Refine and demonstrate proficient history taking
  and physical examination skills.
• Develop an understanding of the recognition,
  patho-physiology, differential diagnosis and
  practical management of common disease states and
  syndromes.
• Develop focused and organized case presentation
  skills

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Responsibilities

• Medical Students (MS-3)
• Full written HP given to attending for
  evaluation and feedback 2/block
• 1 observed CEX by senior resident per block
• 1 observed CEX by Attending per block
• Case-based literature search/presentations gt1
  per week.
• Attend all designated conferences, lectures,
  clerkship meetings.

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Documentation

• Senior Resident
• Dictated HP for all new admissions (excluding
  short-call admissions)
• Responsible for reviewing and co-signing all
  Medical Student HP and progress notes
• Responsible for ensuring medical record and
  medication reconciliation documentation is
  accurate, dated, timed, signed and without any
  unapproved abbreviations
• Intern/Sub-Intern
• Responsible for medication reconciliation on all
  patients
• Comprehensive History and Physical must be
  written for all admissions.
• Documentation must be dated, timed, signed and
  without any unapproved abbreviations

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Initial Presentation

• PCP name (If applicable)
• CC, HPI, PMHx, PSHx, Allergies, Meds, Social Hx,
  ROS
• Physical Exam, Labs, Diagnostic tests
• EKGs/rhythm strips should be available at time of
  presentation
• Radiographic studies reviewed at time of
  presentation
• Assessment and Plan with DDx

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Follow-up SOAP Presentation

• S events from overnight and/or need for
  continued hospital stay new sxs, f/u on old sxs
• O focused including all vitals and pertinent
  diagnostic data
• A/P problem based
• Include in addition
• Lines, catheter necessity
• DVT/PUD Prophylaxis
• Antibiotic day/anticipated treatment length
• Skin/integument evaluation
• Nutritional assessment and plan
• Disposition/Prognosis and outcome planning

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Medication Reconciliation

• Purpose Patients are most at risk during
  transitions in care (hand-offs) across settings,
  services, providers, or levels of care.
• It should be done at every transition of care in
  which new medications are ordered or existing
  orders are rewritten. Transitions in care include
  changes in setting, service, practitioner, or
  level of care.
• Ambulatory care
• Outpatient procedural areas
• Emergency and urgent care
• Inpatient services
• Post-hospital care

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Discharge Med Reconciliation

• This process is required for ALL discharges.
• This includes discharges from the acute inpatient
  setting to ARU (acute rehabilitation unit),
  inpatient Psychiatry, SNF (skilled nursing
  facility), or hospice.
• This includes discharges from ARU or inpatient
  Psychiatry to the acute hospital.
• Shortcuts such as continue previous home
  medications or no change in home medications
  are not acceptable.
• This process will be audited for compliance.

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Do Not Use Abbreviations

• "U" mistaken as 0
• write Unit
• "iu" mistaken as iv
• write international unit
• "Qd, qod" mistaken for each other
• write every day, every other day
• "MS, MSO4, MgSO4" confused for one another
• write morphine sulfate or magnesium sulfate
• "tiw" mistaken for three times a day or twice
  weekly
• write 3 times weekly
• "as, ad, au" confused with os, od, ou
• write left ear, right ear or both ears
• "Trailing zero (3.0)" decimal point is missed
• never use a trailing zero
• "Lack of leading zero (.3)" decimal point is
  missed
• always use a leading zero
• "ug" for microgram mistaken for mg
• write mcg

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Heart Failure

• A
• ACEi or ARB must be prescribed at the time of D/C
  
• If not, reason for NOT prescribing the ACEi/ARB
  must be clearly documented in chart
• Aldosterone blockers should be prescribed in the
  appropriate HF patients.
• B
• Beta-blocker must be prescribed at the time of
  D/C
• If not, reason for NOT prescribing the
  Beta-Blocker must be clearly documented in chart
• C
• If on Coumadin f/u INR and Coumadin
  clinic/physician appt required
• D3
• Discharge instructions
• Diuretics
• Digoxin
• E
• Ejection fraction must be documented in chart
• study type, date, EF if no evaluation within
  last 1 year must provide f/u EF evaluation
  (appointment or phone number)

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Heart Failure

• Discharge instructions All 6 items listed below
  are mandatory for HF Patients.
• All 6 items must be entered on all D/C
  instructions in TDS
• Can begin D/C instruction entry at any point
  during hospitalization.
• D Diet as appropriate
• i.e. Sodium restriction 2 gm daily, low fat, low
  Cholesterol, Fluid restriction 2L daily
• A Activity instructions
• W Weigh self daily
• M Medications
• name, dose, freq of all new and old meds that
  will be continued
• list all prescription and non-prescription meds
• list all discontinued meds
• S2 Symptom management smoking cessation
• i.e. call doctor if you gain gt 3lbs/day or
  gt5lbs/week
• F/U f/u appt for HF mgmt provided on D/C
  instructions
• Heart Failure clinic 456-6699

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Heart Failure

• Please notify any of the following of all Heart
  Failure admissions
• Cardiology consult fellow (consults)
• Nathalie De Michelis (CV Program mgr) p9088
• Molly Nunez (HF NP) out of office until 3/08
• Beth Westberg (Cards Research RN) x7945
• Dawn Lombardo (HF Cardiologist) p4150

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Pneumonia

• Smoking Cessation counseling should be offered to
  all patients who have a smoking history in the
  last 12 months
• All patients admitted to the hospital should be
  evaluated for the need for Pneumovax and
  Influenza Vaccine
• All patients admitted to the hospital with a
  diagnosis of pneumonia or who subsequently are
  diagnosed with pneumonia
• MUST be evaluated for the need for a PNUEMOVAX
  and this clearly documented in the chart

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Forms

• Consult request forms must be signed by
  attendings prior to requests if possible
• DNR forms must filled out on the day it is
  discussed with patient/family and signed by the
  attending within 24 hours.
• Attending should be present at all DNR
  discussions or be notified immediately of any
  such discussion.
• Nursing Home transfer form must be filled out and
  reviewed with the attending prior to patients
  discharge

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Discharging a Patient

• All discharge meds, instructions and follow-up
  plans should be reviewed with the attending PRIOR
  to discharge
• Case managers can help with authorization for
  post-hospital specialty follow-ups
• Discharging a patient in TDS requires three
  steps
• Entering a Physician Discharge Summary note
• Entering Discharge Instructions for the patient
• Entering an order to discharge patient today,
  tomorrow, etc.

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Discharge InstructionsWhat Should be Included?

• The screens will guide you through the
  instructions that need to be entered on your
  patient, such as
• Condition
• Diet
• Self-care
• Activity
• Follow up/clinic appointments
• Specialty Instructions
• Medications needed (this includes the medication
  reconciliation process!)

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Post-Hospital Follow-up

• Patients should be scheduled for post-hospital
  f/u with their/a Primary Care Provider
  preferentially
• The date and time of the follow-up appointment
  should be given to the patient/family PRIOR to
  discharge
• The PCP should be contacted at the time of
  discharge and de-briefed about the hospital
  course and f/u plans
• A copy of the d/c dictation should be forwarded
  to the PCP
• If the patient has no PCP, the inpatient
  resident/intern caring for the patient will
  become the PCP (if appropriate insurance and
  agreed to by the patient)

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Post-Hospital Follow-up

• Only if no appointment is available in a timely
  fashion with a PCP
• The patient should be scheduled into PHFU clinic
  by contacting Jessica Ellis-Mills
  456-3962/506-0599 or Primary Care clinic
  456-7542
• If no f/u appointment is necessary urgently and
  the patient has no insurance
• A list of community clinics MUST be provided to
  the patient and follow-up instructions clearly
  given and documented

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Post-Hospital Follow-up

• Where to send the patients for labs or imaging
  studies
• Patients with Cal-Optima Direct , Medicare or
  Medi-cal can come to UCI for primary care, lab
  tests and imaging studies
• Others
• Quest Labs
• Radnet (714-288-5400, fax [phone]) or West
  Coast Radiology Santa Ana/Tustin Center
  (714-835-2323) or Irvine Center (949-753-0900)
• MSI Patients have to go to Quest for outpatient
  lab tests

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Other issues

• Transfers
• For any patients requiring transfer from floor to
  intensive care unit, this must always be
  communicated to the attending prior to transfer
• Procedures
• Consent must be obtained prior to any procedure
  and the procedure discussed with and approved by
  the attending

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Other issues

• Co-management
• All ONCOLOGY patients are admitted to the
  Internal Medicine service, including
  NEURO-ONCOLOGY patients
• the oncology fellow should be notified
  immediately of all admissions AND communicated
  with daily
• All GI patients (including post-procedure
  patients) should be admitted to the Internal
  Medicine service
• communication with the GI fellow/attending daily
• Most PULMONARY (USUALLY POST-PROCEDURE) patients
  are managed privately by Dr. Colt and his fellow
  in partnership with the Internal Medicine
  resident/student team BUT NOT the Medicine
  attending

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Evaluations and Feedback

• Informal evaluations are conducted at any time
  during the month and include two-way
  communication of any observations, commendations
  or concerns between attending, house-staff and
  students
• Formal two-way feedback sessions are conducted at
  mid-block and at the end of the block
• Written evaluations are completed by
  attending/house-staff at the end of each block