Intern WardIntern WardIndoctrinationIndoctrination

ACGME’s Core CompetenciesACGME’s Core Competencies

•Patient carePatient care

•Medical knowledgeMedical knowledge

• Interpersonal & communication skillsInterpersonal & communication skills

•ProfessionalismProfessionalism

•Practice-based learningPractice-based learning

•Systems-based practiceSystems-based practice

www.acgme.org

Hierarchy of ValuesHierarchy of Values

•Patient carePatient care

•Adherence to work hour rulesAdherence to work hour rules

• Formal educationFormal education

– Conferences & lecturesConferences & lectures

– Bedside teachingBedside teaching

– Individual studyIndividual study

Goals and Objectives:Goals and Objectives:Patient CarePatient Care

• Interview patients more skillfullyInterview patients more skillfully

• Define and prioritize patients' medical Define and prioritize patients' medical problemsproblems

• Generate and prioritize differential Generate and prioritize differential diagnosesdiagnoses

• Develop rational, evidence-based Develop rational, evidence-based management strategiesmanagement strategies

Goals and Objectives:Goals and Objectives:Medical KnowledgeMedical Knowledge

• Expand knowledge of the basic and clinical Expand knowledge of the basic and clinical sciences underlying the care of medical sciences underlying the care of medical inpatientsinpatients

• Access and critically evaluate current medical Access and critically evaluate current medical research that is relevant to the care of research that is relevant to the care of individual patientsindividual patients

Goals and Objectives:Goals and Objectives:CommunicationCommunication

• Communicate effectively withCommunicate effectively with– patients and familiespatients and families

– other physiciansother physicians

– all non-physician members of the health care teamall non-physician members of the health care team

• Present clinical data clearly and concisely, both verbally Present clinical data clearly and concisely, both verbally and in writingand in writing– H&P’s, progress notes, narrative summaries, etc.H&P’s, progress notes, narrative summaries, etc.

– Rounds, consults, morning report, etc.Rounds, consults, morning report, etc.

• Supervise and instruct medical students, PA students, Supervise and instruct medical students, PA students, nurses, corpsmen, etc.nurses, corpsmen, etc.

ProfessionalismProfessionalism

• Staff will look for…Staff will look for…– Evidence that you…Evidence that you…

• have reviewed the charthave reviewed the chart• are keeping up with the case & the cases of others on the are keeping up with the case & the cases of others on the

teamteam• know the labs, tests, plan, etc.know the labs, tests, plan, etc.• are reading independentlyare reading independently

– Proper attention to turnoverProper attention to turnover– EfficiencyEfficiency– CleanlinessCleanliness– Attitude Attitude – motivation, being respectful, carrying – motivation, being respectful, carrying

out all orders given by staff & residents, maturityout all orders given by staff & residents, maturity

Goals and Objectives:Goals and Objectives:Practice-Based LearningPractice-Based Learning

• Recognize gaps in personal knowledge and Recognize gaps in personal knowledge and clinical skills in the care of inpatientsclinical skills in the care of inpatients

• Develop and implement strategies for Develop and implement strategies for correcting gaps in knowledge and skillscorrecting gaps in knowledge and skills

• Improve documentation of medical careImprove documentation of medical care

Goals and Objectives:Goals and Objectives:Systems-Based PracticeSystems-Based Practice

• Understand and utilize multidisciplinary resources Understand and utilize multidisciplinary resources to optimize the care of inpatientsto optimize the care of inpatients

• Collaborate with other members of the health care Collaborate with other members of the health care team to ensure comprehensive patient careteam to ensure comprehensive patient care

• Use evidence-based, cost-conscious strategies in the Use evidence-based, cost-conscious strategies in the care of inpatientscare of inpatients

Work Hours: RulesWork Hours: RulesNO EXCEPTIONS!NO EXCEPTIONS!

• No more than 80 hours per week, averaged over 4 No more than 80 hours per week, averaged over 4 weeksweeks

• No more than 30 consecutive hours in the hospital No more than 30 consecutive hours in the hospital (24 + 6)(24 + 6)

• 1 day off in 7, averaged over 4 weeks1 day off in 7, averaged over 4 weeks– Establish days off todayEstablish days off today

• No day off earned while on leave or TADNo day off earned while on leave or TAD

• YOU ARE RESPONSIBLE FOR REPORTING ANY YOU ARE RESPONSIBLE FOR REPORTING ANY CONCERNS FOR GOING OVER YOUR HOURS CONCERNS FOR GOING OVER YOUR HOURS

– Notify your resident, your staff, and me.Notify your resident, your staff, and me.

Work Hours: RealityWork Hours: Reality

• ONCE AGAIN -Must adhere to RRC ONCE AGAIN -Must adhere to RRC rules!!!rules!!!– IM interns – Karen will send out monthly work IM interns – Karen will send out monthly work

hour reports – return these to herhour reports – return these to her– You will be very inefficient for the first 2-4 weeksYou will be very inefficient for the first 2-4 weeks

• Before going to sleepBefore going to sleep– ALL H&P’s must be doneALL H&P’s must be done– ALL patients must be added to sign outALL patients must be added to sign out– ALL Narrative Summaries must be startedALL Narrative Summaries must be started– ALL notes for the following day can be started / outlinedALL notes for the following day can be started / outlined

Caring for PatientsCaring for Patients

• See every patient EVERY DAYSee every patient EVERY DAY

• Check patients’ VS, labs, meds, & TELE EVERY DAYCheck patients’ VS, labs, meds, & TELE EVERY DAY

• Write a progress note every day, including the day of Write a progress note every day, including the day of dischargedischarge– D/C day can be a brief noteD/C day can be a brief note– Write any and all procedure notes – LPs, Blood Write any and all procedure notes – LPs, Blood

Transfusions, etc…Transfusions, etc…

• Write a concise narrative summaryWrite a concise narrative summary

• Read EVERY CONSULTANT NOTERead EVERY CONSULTANT NOTE

• Write event notesWrite event notes

• Complete notes before roundsComplete notes before rounds

Caring for Patients—Caring for Patients—Have some type of method to track patient vitals/meds/labs on Have some type of method to track patient vitals/meds/labs on daily basis– see examples:daily basis– see examples:

• Name:Name: Allergies:Allergies:

PROBLEM LIST:PROBLEM LIST:

INPT MEDS / Start:INPT MEDS / Start:1.1.

• SSN:SSN: 2.2.3.3.

• PCM:PCM: 4. 4. DVT Px:DVT Px:5. CIWA/Banana 5. CIWA/Banana

Bag:Bag:6. Stool 6. Stool

Softener:Softener:Age:Age:

HPI:HPI:

PMHx:PMHx:

OUTPT MEDS:OUTPT MEDS:

DATE

BP

Pulse

Pox

Temp

I/O

IVFS:

Diet

Glucose

Na/K

Teaching VenuesTeaching Venues

•Three conferences per day Three conferences per day •ARRIVE 5 MINUTES EARLY (no scrubs)ARRIVE 5 MINUTES EARLY (no scrubs)

– Morning Report at Morning Report at 08000800– Second Half at Second Half at 08300830– Noon Conference at Noon Conference at 12001200

•Work rounds with residentWork rounds with resident•Teaching rounds with attendingTeaching rounds with attending•One-to-one with resident & attendingOne-to-one with resident & attending

Event ReportsEvent Reports

•Report lapses or problems in careReport lapses or problems in care

•Report forms available on intranetReport forms available on intranet

– http://nmcsdintranet.med.navy.milhttp://nmcsdintranet.med.navy.mil

•Closely examined and investigatedClosely examined and investigated

– Root Cause Analysis (RCA)Root Cause Analysis (RCA)

CommunicationsCommunications

• Notify primary care physician (PCP) via e-Notify primary care physician (PCP) via e-mail that his/her patient has been mail that his/her patient has been admittedadmitted

– Ultimately the duty of the admitting residentUltimately the duty of the admitting resident

– DOES NOT INCLUDE NIGHTFLOATDOES NOT INCLUDE NIGHTFLOAT

• Notify nurses of pending dischargesNotify nurses of pending discharges

• Write an event note whenever you are Write an event note whenever you are asked to evaluate a patientasked to evaluate a patient

AppearanceAppearance

• No food, drink, or gum during roundsNo food, drink, or gum during rounds

• Clean lab coat at all timesClean lab coat at all times

• Scrubs only when on-callScrubs only when on-call– After 1600 on weekdaysAfter 1600 on weekdays– All day on Saturday & SundayAll day on Saturday & Sunday

• Men must shave dailyMen must shave daily

• Women must keep long hair Women must keep long hair controlledcontrolled

• Professional attire on weekendsProfessional attire on weekends– No jeans, shorts, sneakers, or flip-flopsNo jeans, shorts, sneakers, or flip-flops

ConsultsConsults

• Place Consults as EARLY as possiblePlace Consults as EARLY as possible• Form consult in a question format – always Form consult in a question format – always

discuss with resident / staff before consultingdiscuss with resident / staff before consulting• Different Consultants have different Different Consultants have different

procedures:procedures:– Call all consults via telephoneCall all consults via telephone– Speech, PT, Nutrition all require CHCS I entriesSpeech, PT, Nutrition all require CHCS I entries– Cardiology: Zeke (call fellow’s personal pager)Cardiology: Zeke (call fellow’s personal pager)– Derm, Endo, ID, H/O, Neuro, Nephro, Rheum, Surgery : Derm, Endo, ID, H/O, Neuro, Nephro, Rheum, Surgery :

call duty pagercall duty pager– GI, Pulm: Call fellow’s personal pagerGI, Pulm: Call fellow’s personal pager

Labs & RadsLabs & Rads

• EKGs: Must be evaluated & signed dailyEKGs: Must be evaluated & signed daily– TELEMETRY MUST BE REVIEWED EVERY AM FOR OVERNIGHT TELEMETRY MUST BE REVIEWED EVERY AM FOR OVERNIGHT

EVENTS EVENTS yes, every morning!!! yes, every morning!!!– Ok to use the telemetry phone to call the techOk to use the telemetry phone to call the tech

• Labs: Labs: – Always double check to make sure appropriate labs were Always double check to make sure appropriate labs were

drawndrawn– Stop all unnecessary qday labsStop all unnecessary qday labs– Verbally tell nurses when any stat lab is orderedVerbally tell nurses when any stat lab is ordered

• Rads:Rads:– U/S and CT’s - place Consult in CHCS I as STAT order and place U/S and CT’s - place Consult in CHCS I as STAT order and place

order “Please contact US/CT tech for pending study”order “Please contact US/CT tech for pending study”– Call MRI reading room for MRIs + order CHCS I ordersCall MRI reading room for MRIs + order CHCS I orders

Medication ReconcilliationMedication Reconcilliation

•New JACHO requirementNew JACHO requirement– Must compare patient’s home Must compare patient’s home

medication list with the current list in medication list with the current list in AHLTAAHLTA

– Discharge medication list must be Discharge medication list must be complete and up to date.complete and up to date.

– ““How do I do this?”, you ask.How do I do this?”, you ask.

Discharge SummaryDischarge Summary

• Likely the most important document Likely the most important document during hospitalizationduring hospitalization– ALL medications must be clearly ALL medications must be clearly

listedlisted

– Must have follow-up scheduled with Must have follow-up scheduled with PCMPCM

Additional Ward Key PointsAdditional Ward Key Points

• Take ownership of your patients – know your Take ownership of your patients – know your patients!patients!

• IM Wards are NOT shift workIM Wards are NOT shift work• Keep on top of your fellow intern’s patients as Keep on top of your fellow intern’s patients as

you are responsible for knowing those patients you are responsible for knowing those patients on call and while covering during days offon call and while covering during days off– ““I don’t’ know because he/she’s not my patient.” IS I don’t’ know because he/she’s not my patient.” IS

NEVER ACCEPTABLE!NEVER ACCEPTABLE!• Sign out is key to patient safetySign out is key to patient safety• NO sign out occurs without both residents NO sign out occurs without both residents

present!present!

SIGN OUT – see intern SIGN OUT – see intern handbookhandbook

Red Team Staff Pgr Resident Pgr / Cell / Home Phone Intern Pgr Intern Pgr

Patient Info5N

PMHx & Acute Illnesses

Current Meds Current / Pending Studies

To Do List

Smith, JohnSSN

55 y/o male admitted for fever and mental status changes – likely aseptic meningitis.

DOA:Code:Allergies:Intern:

PMHx:xxxxxxAcute Illnesses:xxxxxxx

XXX MRI Head Results - pendingCT Head noncon: neg for bleedBlood Cx 7/1, 7/4: negativeLP: cx neg 3 WBC Protein 50 Glucose 85

-F/U prelim CT contrast results (pt at CT ~1700)-PanCx (blood, urine) + CXR if spikes > 100.4-F/U Chem Panel (due at 1800) – replace K+ if not = 4.0-Give Percocet PRN pain ONLY (do NOT give Demerol)-EGD / COLO tomorrow b/c of xxxx

SIGN OUT – see pg 28 of SIGN OUT – see pg 28 of intern handbookintern handbook

• Inappropriate sign-outs:Inappropriate sign-outs:– My patient is getting a thoracentesis right My patient is getting a thoracentesis right

now.now.• Do we need to check post-procedure labs & CXR? Do we need to check post-procedure labs & CXR?

What do we do with those numbers?What do we do with those numbers?

– My patient is altered but don’t worry ‘cuz he’s My patient is altered but don’t worry ‘cuz he’s been that way for the last 4 daysbeen that way for the last 4 days• What’s the most recent A&O/MMSE/GCS, etc…? What’s the most recent A&O/MMSE/GCS, etc…?

• Why do you think he’s altered?Why do you think he’s altered?

• What do we do if he becomes more agitated?What do we do if he becomes more agitated?

SIGN OUT – see intern SIGN OUT – see intern handbookhandbook

• Inappropriate sign-outs:Inappropriate sign-outs:– The patient has Afib but rate is The patient has Afib but rate is

controlled… but she may go into RVR controlled… but she may go into RVR overnight?overnight?•What exact regimen do you want us to treat What exact regimen do you want us to treat

with – b blocker vs CCB vs digoxin, etc…with – b blocker vs CCB vs digoxin, etc…

•What usually works?What usually works?

•What max rate of tachycardia are you What max rate of tachycardia are you tolerating?tolerating?

SIGN OUT – see pg 28 of SIGN OUT – see pg 28 of intern handbookintern handbook

• Inappropriate sign-outs:Inappropriate sign-outs:– Code status is not on the turnover & Code status is not on the turnover &

your response… “DNI – I think she wants your response… “DNI – I think she wants everything else…” everything else…”

Additional Ward Key PointsAdditional Ward Key Points

•Each individual resident will have Each individual resident will have specific details to add specific details to add

•When in doubt – check your Intern When in doubt – check your Intern HandbookHandbook

• For Clinical Questions – read your For Clinical Questions – read your Clinical HandbookClinical Handbook

Questions or ConcernsQuestions or Concerns

•Call YOUR ResidentCall YOUR Resident

•Call YOUR ResidentCall YOUR Resident

•Call YOUR ResidentCall YOUR Resident

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