Page 1 of 15

LAC+USC Medical Center Hematology Wards Orientation 2018-2019

First Day of Rotation: Report to 7A Med Consult room for sign-out at 7:00 AM, then to 7B work room to meet the fellow. Please make sure to watch the Orientation Video prior to starting this rotation. Videos can be accessed through MyEvaluations or on the Chief’s website (uscmedicine.blog / Resources / Rotation Orientation & Objectives / Hematology Wards).

GOALS The discipline of hematology relates to the care of patients with disorders of the blood, bone marrow, and lymphatic systems. It includes anemias, hematologic malignancies, other clonal processes, and congenital and acquired disorders of hemostasis, coagulation, and thrombosis. The general internist should be competent in 1) the detection of abnormal physical, laboratory, and radiologic findings relating to the lymphohematopoietic system; 2) determining the need for bone marrow aspirate and biopsy and lymph node biopsy; 3) the initial diagnostic evaluation and management of the hemostatic and clotting system; 4) the assessment of the indications and procedure for transfusion of blood and its separate components; 5) the management of therapeutic and prophylactic anticoagulation; 6) the diagnosis and management of common anemias; 7) the pharmacology and use of common chemotherapies; and 8) the management of neutropenia/immunosuppression. The range of competencies expected for a general internist will vary depending on the availability of a hematologist in the primary care setting. For example, in some communities a general internist may be responsible for bone marrow examination and administration of chemotherapy for certain disorders in conjunction with consultative assistance from appropriate hematologist and pathologist colleagues. (N.B. Leukemias and lymphomas are found in the Oncology section.) In addition to fostering competence in the areas of patient care and medical knowledge, the service provides critical experience in collaborating with other members of the healthcare team, including care coordinators, social workers, and pharmacists, as well as students and fellow residents, which builds skill in interpersonal communication and professionalism. Exposure to the intricacies of daily hospital care, including discharge planning and triage to higher or lower levels of care, builds competency in systems-based practice, provides opportunities to learn from mistakes, and builds patterns of practice-based learning.

Page 2 of 15

OVERALL OBJECTIVES

USC/LAC+USC Internal Medicine Residency Hematology Ward Rotation

OVERALL COMPETENCY PROGRESSION BY CORE COMPETENCY AND PGY LEVEL (Adapted from ABIM Developmental Milestones)

CORE COMPETENCY: PATIENT CARE

PGY LEVEL GOAL – Gathers and synthesizes essential and accurate information to define each patient’s clinical problem OBJECTIVES

1 a. Acquires accurate histories from patient in an efficient prioritized, and hypothesis driven fashion b. Seeks and obtains data from secondary sources when needed

PGY LEVEL GOAL – Develops and achieves comprehensive management plan for each patient OBJECTIVES

1 a. Consistently develops appropriate care plan b. Recognizes situations requiring urgent or emergent care c. Seeks additional guidance and/or consultation as appropriate

PGY LEVEL GOAL – Manages patients with progressive responsibility and independence OBJECTIVES

1 a. Requires direct supervision to ensure patient safety and quality care b. Seeks additional guidance and/or consultation as appropriate

PGY LEVEL GOAL – Skill in performing procedures OBJECTIVES

1 a. Awareness of indications, contraindications, risks and benefits of common invasive procedures

PGY LEVEL GOAL – Requests and provides consultative care OBJECTIVES

1 a. Provides consultative services for patients with clinical problems requiring basic risk assessment b. Asks meaningful clinical questions that guide the input of consultants

Evaluation Methods Faculty evaluation, Direct observation

CORE COMPETENCY: MEDICAL KNOWLEDGE PGY LEVEL GOAL – Clinical Knowledge

OBJECTIVES 1 a. Possesses the scientific, socioeconomic and behavioral knowledge required to provide care for

common medical conditions and basic preventive care PGY LEVEL GOAL – Knowledge of diagnostic testing and procedures.

OBJECTIVES 1 a. Consistently interprets basic diagnostic tests accurately

b. Needs assistance to understand the concepts of pre-test probability and test performance characteristics

Evaluation Methods Faculty evaluation, Direct observation, Conference Attendance

CORE COMPETENCY: SYSTEMS BASED PRACTICE PGY LEVEL GOAL – Works effectively within an interprofessional team

OBJECTIVES 1 a. Identifies roles of other team members but does not recognize how/when to utilize them as

resources b. Frequently requires reminders from team to complete physician responsibilities.

Page 3 of 15

PGY LEVEL GOAL – Recognizes system error and advocates for system improvement OBJECTIVES

1 a. Does not recognize the potential for system error

PGY LEVEL GOAL – Identifies forces that impact that cost of health care, and advocates for, and practices cost-effective care OBJECTIVES

1 a. Does not consider limited health care resources when ordering diagnostic or therapeutic interventions

PGY LEVEL GOAL – Transitions patients effectively within and across health delivery systems OBJECTIVES

1 a. Written and verbal care plans during times of transition are incomplete or absent

Evaluation Methods Faculty Evaluation

CORE COMPETENCY: PRACTICE BASED LEARNING AND IMPROVEMENT PGY LEVEL GOAL – Monitors practice with a goal for improvement

OBJECTIVES 1 a. Unable to self-reflect upon one’s practice or performance

b. Misses opportunities for learning and self-improvement PGY LEVEL GOAL – Learns and improves via feedback

OBJECTIVES 1 a. Rarely seeks feedback

b. Responds to unsolicited feedback in a defensive fashion c. Temporarily or superficially adjusts performance based on feedback

PGY LEVEL GOAL – Learns and improves at the point of care OBJECTIVES

1 a. Has limited awareness of or ability to use information technology b. Rarely “slows down” to reconsider an approach to a problem, ask for help, or seek new

information c. Can translate medical information needs into well-formed clinical questions with assistance

Evaluation Methods Faculty Evaluation, Direct Observation

CORE COMPETENCY: PROFESSIONALISM PGY LEVEL GOAL – Has professional and respectful interactions with patients, caregivers, and members of the

interprofessional team OBJECTIVES

1 a. Inconsistently demonstrates empathy, compassion and respect for patients and caregivers b. Inconsistently considers patient privacy and autonomy c. Inconsistently demonstrates responsiveness to patients’ and caregivers’ needs in an

appropriate fashion PGY LEVEL GOAL – Accepts responsibility and follows through on tasks

OBJECTIVES 1 a. Completes most assigned tasks in a timely manner but may need multiple reminders or other

support b. Accepts professional responsibility only when assigned or mandatory

PGY LEVEL GOAL – Responds to each patient’s unique characteristics and needs OBJECTIVES

1 a. Sensitive to and has basic awareness of differences related to culture, ethnicity, gender, race, age and religion in the patient/caregiver encounter

b. Requires assistance to modify care plan to account for a patient’s unique characteristics and needs

Page 4 of 15

PGY LEVEL GOAL – Exhibits integrity and ethical behavior in professional conduct OBJECTIVES

1 a. Honest in clinical interactions and documentation. Requires oversight for professional actions b. Has a basic understanding of ethical principles, formal policies and procedures and does not

intentionally disregard them

Evaluation Methods Faculty Evaluation, Peer Evaluation, Direct Observation

CORE COMPETENCY: INTERPERSONAL AND COMMUNICATION SKILLS PGY LEVEL GOAL – Communicates effectively with patients and caregivers

OBJECTIVES 1 a. Engages patients in discussion of care plans and respects patient preferences when offered by the

patient, but does not actively solicit preferences b. Defers difficult or ambiguous conversations to others c. Attempts to develop therapeutic relationships with patients and caregivers but is often

unsuccessful PGY LEVEL GOAL – Communicates effectively in interprofessional teams

OBJECTIVES 1 a. Uses unidirectional communication that fails to utilize the wisdom of the team

b. Resists offers of collaborative input PGY LEVEL GOAL – Appropriate utilization and completion of health records

OBJECTIVES 1 a. Health records are disorganized and inaccurate

Evaluation Methods Faculty Evaluation

Page 5 of 15

ROTATION STRUCTURE STARTING THE ROTATION Before the first day on service, sign-out should occur from the outgoing member to the oncoming team member. Please make sure to watch the Orientation Video prior to starting this rotation. Videos can be accessed through MyEvaluations or on the Chief’s website (uscmedicine.blog / Resources / Rotation Orientation & Objectives / Hematology Wards). WEEKLY SCHEDULE

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 8:30AM – 9:30AM Resident Didactics Resident Didactics Case Conference 11AM – 12PM Grand Rounds

DAILY SCHEDULE 7:00 AM – 7:30 AM Sign-out 7:30 AM – 9:30 AM Work Rounds 9:30 AM – 12:00 AM Attending Bedside Rounds 12:00 PM – 1:00 PM Lunch/Conference (Grand Rounds, M&M, CPC) 1:00 PM – 5:30 PM Patient Care and Management / Afternoon Didactics Fellow Work Rounds The Fellow Work Rounds are an opportunity for the consult team to discuss and evaluate the consults from the night before and the difficult management cases with the fellow prior to rounding with the attending. A preliminary plan on each patient should be made at this time. Attending Bedside Rounds Attending Bedside Rounds are performed from 10:00 AM – 12:00 PM every Monday through Friday. The attending should review all of the team's new consults from the previous twenty-four hours and discuss all of the team's established patients with new, significant developments. Any new patient must be seen by and discussed with the attending with the team at the bedside. Faculty are expected to perform bedside teaching, discussion of pathophysiology, and should use current available studies to aid in diagnostic and therapeutic decisions. Faculty must evaluate all of their team's patients each day and must co-sign all necessary notes. All documentation, including the initial history and physical must be signed within 24 hours. Each faculty attending is available for their team at all times when they are on service. Hematology Clinic Residents on Hematology Wards are not expected to attend Hematology Clinic unless otherwise indicated by the Chief Residents. TEAM STRUCTURE There will be 3 interns at any given time on the Hematology Wards team. The team will be overseen and managed by a Hematology fellow. An attending will be available to the house officers at all times of the day. The housestaff are expected to use this attending as the primary resource for

Page 6 of 15

issues regarding patient care. Overnight care of the patients on this service will be managed by the Medicine Consult Night Float resident. ADMISSION SCHEDULE The team is available to admit patients daily. All admissions during the day and the night will have been approved by the fellow or attending on service. The intern must see and evaluate all admissions. The team’s attending is always responsible for all activities no matter the time of day. SIGN-OUT The Hematology Ward night float resident is responsible for cross-covering and admitting for Heme Wards, two other medicine teams, and serve as medicine consult. The team signing out to the night float should provide a written handoff (“Physician Handoff”) in addition to preparing for a verbal sign-out. Sign-out should take place in a protected, quiet space, and follow the I-PASS format. It is the responsibility of the team member signing out patients to update the Physician Handoff. The Heme Wards intern should arrive promptly to receive sign-out on their patients at 7:00 AM and the night float should be ready to receive sign-out at 8:00 PM. CALL Interns are on long call every 3rd night. On their long call, interns will arrive to receive sign-out at 7:00 AM and stay until 8:00 PM that same evening. The intern will return the following day (unless scheduled for a day off) for a normal work day. DAYS OFF All house officers on Hematology Wards will get an average of one day off per week across the duration of the rotation. Days off will be designated by the Chief Residents and is available on AMION. Predetermining everyone's days off will ensure that days off are distributed fairly and that the appropriate complement of residents and interns are in the hospital at all times.

Page 7 of 15

CURRICULUM EDUCATIONAL GOALS The purpose of this rotation is to train residents to competently care for patients with a broad range of acute and chronic hematologic diseases. The rotation is designed to increase diagnostic skills, reasoning ability, therapeutic acumen, objective knowledge, overall patient care skills and team management skills. The curriculum is organized into three components: 1. inpatient hematology wards services 2. didactic lectures and conferences LEARNING OBJECTIVES Residents will be able to evaluate and treat the below clinical problems:

Hemosiderosis and hemochromatosis Hemostasis and thrombosis

o Abnormal coagulation (abnormal prothrombin and partial thromboplastin times) o Antiphospholipid antibody syndrome o Anticoagulation, fibrinolysis (therapeutic) o Disseminated intravascular coagulation o Hypercoagulable state o Hyperviscosity syndrome

Leukocyte disorders o Immunosuppression o Neutropenia o Leukemoid reaction

Myeloproliferative disorders o Chronic myelogenous leukemia o Polycythemia vera o ET and MF

Platelet disorders o Thrombocytopenia o Platelet dysfunction o Thrombocytosis

Polycythemia, secondary Red cell disorders

o Anemia o Hemoglobinopathy (e.g., thal sickle cell disease)

Transfusion therapy Hematologic Malignancies

o Non-Hodgkin’s lymphoma o Hodgkin’s disease o Acute lymphoblastic leukemia (ALL) o Chronic lymphocytic leukemia (CLL) o Acute myeloblastic leukemia (AML) o Chronic myelogenous leukemia (CML) o Multiple myeloma

Page 8 of 15

o Myelodysplastic syndromes CONFERENCES Resident Didactics Starting in October of the academic year, resident didactics are held every Monday and Tuesday mornings from 8:30 AM to 9:30 AM in IPT C8A136 conference room. Topics will be presented by fellows and attendings at a resident level. Attendance at this conference is mandatory. Hematology Case Conference Case Conference is held every Wednesday morning from 8:30 AM to 9:30 AM at Norris in the Norman Topping Tower 4444. Attendance at this conference is mandatory. Grand Rounds A formal presentation every Friday at 11:00 AM in IPT Conference Room A. Speakers are drawn from the USC Medical Campus or from other cancer centers. Attendance at this conference is mandatory. TEACHING METHODS Direct observation of patient care and bedside teaching occur in the setting of daily inpatient rounds with the attending. Residents evaluate and treat patients both in the capacity of follow-up as well as initial evaluation. The supervising attending reviews and critiques the resident’s interpretation of diagnostic studies and formulation of assessments and plans. Residents additionally attend didactic conferences as indicated above. FEEDBACK & EVALUATIONS The attending physician is responsible for providing verbal feedback and must submit evaluations of the resident physicians in MyEvaluations. The attending must meet face-to-face to provide mid-point and end-of-rotation feedback with all of the house officers they evaluate and indicate that discussion on the evaluation form. Evaluations must be completed within one week of completing a rotation. Peer evaluations for other trainees on the team should be completed in a timely manner.

Page 9 of 15

PATIENT CARE LOCATION & PATIENT CHARACTERISTICS The Hematology Wards Service is entirely at the LAC-USC hospital and comprises of floor patients only on 7B. Of note, the ICU and CCU are separate services and closed units. The patient population at LAC+USC Medical Center is very diverse, with multiple ethnic and socioeconomic groups represented. The spectrum of these encounters will be from primary presentation of new disease processes to the tertiary care for the patient who is referred for subspecialty care. We also receive transfers from outside hospitals needing acute hospitalization for higher levels of care. The care for these patients will occur on either general medicine floors or telemetry floors. Any patient requiring ICU or CCU level care will be transferred to the respective team who will assume care of the patient. Once the patient is stabilized and can be transitioned out of the ICU or CCU, the care for this patient can be reassumed by the general medicine ward service. ADMISSIONS All patient admissions are approved by the fellow and attending on service. Patients may be admitted for scheduled chemotherapy or if they have a complication from their hematologic disease. Residents will be made aware of any admissions by either the Hematology fellow on service or the attending physician. Once the patient arrives to an inpatient bed, the resident will be notified for admission orders. Day Team Admissions: 6:30 AM – 7:30 PM Night Team Admissions: 7:30 PM – 6:30 AM TRANSFERS If a patient is sick or unstable, the patient can be moved from 7B to the Telemetry Unit (8A), to a PCU (4M or 5F), or to the ICU. Transfers to the ICU Patients that the hematology service deems to require a transfer to a higher level are transferred to the MICU. While in the MICU, MICU is the primary service and the Hematology Ward team continues to follow the patient and continues to write daily notes. To initiate an ICU transfer, first notify Med Consult that there is a patient who necessitates transfer. Med Consult will then evaluate the patient and discuss the case with the ICU Fellow. If determined to be an appropriate ICU transfer, Med Consult will notify the team to place orders and to give sign-out to the ICU team. All transfers to the ICU must be accompanied by a Transfer Summary from the ward team. The ICU team is expected to write transfer orders and reconcile all prior active orders. Transfers from the ICU When the ICU team deems the Hematology patient stable for transfer to a lower level of care, the Hematology Wards team will be notified by Bed Control that a patient has been assigned to the medicine team. The team should call the ICU team to receive sign-out. A Transfer Summary will accompany all patients being transferred out of the ICU. The medicine team should addend the Transfer Summary upon transfer of care.

Page 10 of 15

Transfers from medicine teams If a consulted patient is deemed to be better served on the Hematology Inpatient Wards team, the patient may be transferred to 7B Heme Wards. This determination is made by the Heme consult team fellow and should be relayed to the Heme Wards fellow prior to transfer. DISCHARGES The decision to discharge a patient and the discharge plan must be discussed with the attending each day. This discharge plan should also be discussed with the patients. All hospital discharges require Discharge Instructions and educational material for the patient, appropriate medication reconciliation and prescriptions, appropriate follow-up referrals or appointments, an electronic discharge order, and a Discharge Summary (please see below). Transfers to other healthcare facilities (another hospital, long-term acute care (LTAC), skilled nursing facility (SNF), rehab, etc.) require a Discharge Summary (please see below). Additionally, a triplicate form, which can be obtained at each nursing station, will need to be filled out and signed by a licensed physician prior to transfer. LEAVING AGAINST MEDICAL ADVICE (AMA) & ABSENT WITHOUT LEAVE (AWOL) & ELOPING Patients have the right to leave AMA if they have the capacity to make their own medical decisions. This means that they know their diagnosis, prognosis, the risks of leaving the hospital, the benefits to staying in the hospital, and alternatives to hospitalization. If your patient can verbalize all of the above, is deemed to have capacity to make medical decisions, and still insists on leaving, the patient should sign the AMA form and the incident should be documented thoroughly in the chart. Patients who leave the hospital for more than 2 hours are considered to have left AWOL from the hospital. Patients are considered to have eloped only if they are on a psychiatric hold. This is different from leaving AMA. Patients who AWOL, elope, and who leave AMA still require discharge orders and a discharge summary. RAPID RESPONSE & CODE BLUES If a patient appears acutely unstable, do not hesitate to call the Rapid Response Team. If your patient is decompensating rapidly and requires intubation or resuscitation, call a Code Blue. Always document goals of care discussions, even if the decision is to remain full code. Keep in mind that the code status obtained during the hospitalization is dynamic and only relevant to the current hospitalization. It does not necessarily hold true for the next hospitalization unless the patient has a signed a POLST or on discussion with your patient, he/she reiterates his/her desired code status. Upon discharge, a POLST form should be completed in an effort document goals of care. The pink original goes with the patient and a copy should be placed in the chart for scanning into ORCHID. PLACING CONSULTS Decisions to consult a different service should always be discussed with the attending of the team. The consultant can be reached either through the operator (dial “0” from any hospital phone) or through AMION. Remember to be courteous when calling the consult and have a well-defined

Page 11 of 15

question for your consultants. Please give your consults enough time to see your patients, so try placing consults as early in the day as possible. PROCEDURES Interns will have the opportunity to observe Hematologic procedures such as therapeutic phlebotomy, intrathecal chemotherapy, and bone marrow biopsies. DEATH Deaths must be pronounced by a licensed provider on the primary team. All in-hospital deaths require a Death Summary to be written by the primary team. If a death is pronounced by the overnight cross-covering resident, he/she may write a brief Death Note to document the circumstances and death exam; however, a Death Summary still needs to be completed by the primary team. Deaths in the hospital are not uncommon, but may be an emotionally challenging experience. Housestaff are encouraged to discuss the experience of caring for a patient who has died with the team and/or chief residents. DOCUMENTATION All documentation must be completed electronically in ORCHID. Each note needs to end with “Discussed with Attending Dr. [Name]” and be forwarded to the attending on service for the day for review. History & Physical H&Ps must be written and signed by the attending within 24 hours of admission. In ORCHID, the note type, “History and Physical” should be used. Daily Progress Note A daily progress note must be completed for each patient unless an H&P or Discharge Summary will be written for the day of admission or day of discharge. Daily progress notes must be forwarded for evaluation to the attending of the team. In ORCHID, the note type, “Hematology Inpatient Progress Note” should be used. Discharge Summary Discharge Summaries are required for any discharge from the hospital and should be completed within 24-48 hours of discharge. This includes discharges against medical advice or elopements. In ORCHID, the note type, “Discharge summary” should be used. Discharge summaries should include the following:

Admission date Discharge date Procedures or surgeries Consulting services Summary of hospital course Discharge diagnoses and medication Follow-up plan

Page 12 of 15

Transfer Summary A Transfer Summary is required when the patient is being transferred to another service (ICU, surgical service) or to another facility. The transfer summary should follow the format of the Discharge Summary above. In ORCHID, the note type, “Transfer Summary” should be used. Death Summary A Death Summary is required when a patient expires in the hospital. The Death Summary should follow the format of the Discharge Summary above. In ORCHID, the note type, “Death Summary” should be used. MEDICAL RECORD DOCUMENTATION QUERIES You may receive a message in your ORCHID inbox from Medical Records inquiring about specific diagnoses. Please make sure to respond to all messages in a timely fashion as it affects hospital funding.

Page 13 of 15

ROTATION-SPECIFIC DETAILS

Almost all hematological problems are life threatening and a patient’s main/major medical issue. We are therefore responsible for the primary care of our patients as in-patients and as out-patients, usually for as long as they live. Patient education is critical to our ability to care for these individuals properly. Patients who receive chemotherapy are at risk for neutropenic sepsis, which is a major cause of death, even in otherwise curable individuals. Although each chemotherapeutic agent is different, in general, the nadir of blood counts occurs

approximately 7 to 10 days after drug administration; it is at these times that the patient is at highest risk for neutropenic sepsis. Note that for some chemotherapy agents (azacitidine, decitabine, imatinib mesylate) the myelosupression and nadir can be delayed.

The intern is ALWAYS expected to call the Fellow or Attending regarding issues or problems that arise regarding patient care. We will never be upset at being called. We WILL be upset if we are NOT informed as to issues or problems on the ward.

NEUTROPENIC PRECAUTIONS You MUST wash your hands before going into any patient room, and between patient exams. No fresh flowers are allowed on the floor or in patient rooms No fresh fruit or vegetables are allowed, as they carry large numbers of organisms which may

cause serious infection in individuals who are neutropenic Neupogen (G-CSF) is used frequently on the ward; the Fellow will provide guidelines for use of

the drug. Avoid in-dwelling lines or tubes whenever possible. Enemas, rectal temperatures are contraindicated in neutropenia Fever is an emergency, and is NOT to be covered by calling in an order for acetaminophen. The

patient MUST be seen and evaluated. Infected patients with neutropenia may not have the “usual” signs of infection, such as an actual

abcess, or infiltrate on chest x-ray in the setting of pneumonia. Therefore, physical exam is critical to making an appropriate diagnosis. The intern is expected to KNOW the physical findings of his/her patients each day, especially in terms of:

o Mouth: Look for mucositis, herpetic or other infections o Peri-rectal area: By inspection, NOT by rectal exam, which can shoot organisms into

the blood stream. Peri-rectal tenderness with erythema is seen in the setting of peri-rectal abcess in such patients

o Lungs: MUST know the PE of lungs each day. A new finding of rales/rhonchi may be enough to dx pneumonia, even though CXR is normal

THROMBOCYTOPENIA No IM injections are permitted with a platelet count < 50,000/dL Avoid use of aspirin, ibuprofen or other drugs that interfere with platelet function. We empirically transfuse a unit of platelets when the count is < 10,000/dL. Platelets are also transfused at higher platelet counts, in individual circumstances, or when a

patient is bleeding. Valsalva manuevers are to be avoided in patients with thrombocytopenia. Avoid cough (ie

suppress cough). Avoid constipation, and straining at stool. Development of headache or neurologic signs/symptoms constitute a potential emergency in

patients with low platelet counts. Consider rapid CT scans of brain, or other such studies to evaluate neurologic symptoms or signs in such patients.

Page 14 of 15

HLA specific platelets can be ordered from the Blood Bank when the patient has become refractory to platelet transfusions from random donors. In this circumstance, be VERY careful that these specially ordered HLA specific platelets are USED within the appropriate time frame. If platelets are no longer necessary, inform the Blood Bank immediately, so that they can release the platelets for use by another patient. These HLA specific platelets CANNOT be wasted and thrown away.

Blood products, including platelets, must be leukoreduced in patients with immuno-compromise. This is accomplished by filtration and by radiation of the product in question. Leukoreduced blood products MUST be requested for patients.

PAIN Each patient should be assessed for pain on a daily basis, and the degree of pain must be

recorded on the daily progress notes. Pain MUST be relieved, and documentation of pain relief must also be provided on the progress

notes. Algorithm for pain medications

Fentanyl patch=ugm/h dose. Takes 12 hours to “kick in” and then to dissipate Fentanyl 100 ug/h patch q 3 days=100 mg MS Contin po q 12 h MS-2 mg IVP q 5 minutes until comfortable. 4 mg/cc or 10 mg/cc concentration PCA pump Morphine after above loading dose: 1.0 to 1.5 mg q 10 minutes lockout. 1 mg/cc

concentration. Use of combination therapy, with medications from several classes of agents (eg: MS contin and

ibuprofen) are often more effective than single agents alone. Ibuprofen is particularly useful for bone pain.

Studies ordered on Hematology Wards:

Performed in “core” laboratory o Prothrombin time by the Quick method o Partial thromboplastin time o Fibrinogen o Peripheral blood smear

To obtain the peripheral smear, call the Clinical Hematology Laboratory at 409-7072 and request that the smear be pulled from the file.

You must include the patient’s name, MRN number and the date of the study. You can then pickup the smear from the Core Laboratory.

Allow a one hour turn-around time. For multiple slides, the turn-around time is 24 hours.

Done in special hematology lab o Thrombin time

Other Tests

ORAL DOSE ANALGESIC IV DOSE 15 mg Morphine (any) 5 mg 4 mg Dilaudid (hydromorphone) 1.5 mg 10 mg Oxycodone (2 Percocet) NA 30 mg Codeine (TC #3) NA 15 mg Hydrocodone (3 vicodin) NA 150 mg Merperidine-Demoral 50 mg 10 mg Methadone 5 mg

Page 15 of 15

o D-dimer o Specific coagulation assays, i.e. factor VIII, IX o Natural inhibitors, i.e. antithrombin III, alpha 2 plasmin inhibitor, etc. o Protein C or S (patient must not be on oral anticoagulants) o PCR for Factor V Leiden or G20210A prothrombin mutation. o Test for a lupus anticoagulant (patient must not be on heparin) o Test for resistance to activated protein C o Relative serum viscosity for patients with suspected hyper-viscosity syndromes. 2-

3 red top tubes are required and should be maintained at room temperature. o Dilute whole blood clot lysis time (a test for increased fibrinolytic activator). This is

performed on whole blood collected into an iced blue stoppered tube. The blood must be delivered to the laboratory within 10 minutes after it is obtained. Since the blood must be observed for at least 4 hours, it cannot be performed after 12 pm.

o Platelet aggregation tests must be scheduled with the supervising technologist. Patients need to be free of aspirin and/or plavix for one week, overnight fasting and a normal fasting control must be present.

o CD55 and/or CD59 as a screening test for PNH. NOTES FROM THE 7B NURSES The majority of nurses on 7B have been working on this Ward for many years. They are highly experienced and knowledgeable, know our patients very well, over the entire course of their illnesses, and are available to help you. The ability of nursing and medical staff to communicate and work well together is integral to the optimal care of our patients. We will ask you to help out in the following ways:

The nurses are available to draw blood tests and start IV’s. However, YOU will be asked to draw extra or “stat” blood tests when the nursing staff is overwhelmed and do not have the time to do so.

When ordering stat tests, please TELL the nursing staff what you need. Please fill out the forms required for various tests being ordered. Please obtain patient consent for administration of blood products. These consent forms

are placed at the front of the chart, and should be routinely signed by patient and physician, since the use of blood products is almost universal on the ward.

Please TELL the nursing staff if the patient is to be NPO