resident orientation to ctu and b6 - western university · paediatric subspecialties for inpatients...

Resident Orientation to CTU and B6

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Welcome to your CTU Rotation. We trust the following information will be useful in transitioning to a meaningful learning experience and providing patient care in this clinical service:

The B6 CTU – Who We Are The clinical teaching units consist of two teams: CTU Red and CTU Blue. Each is tasked to handle similar patient care cohorts – although there may be differences in patient populations. The paediatric CTU are interspersed with the rooms in LHSC Ward B6 in the 100 and 200 rooms, located on B or North tower, 6th floor at the Victoria campus. We see patients referred for admission from the LHSC Paediatric Emergency Department (1st floor, D tower), the Paediatric Critical Care Unit, the Neonatal Intensive Care Unit, and outside regional hospitals requiring primary, secondary and tertiary paediatric care. Our team also provides a consultation and follow-up service to other paediatric subspecialties for inpatients on the B6 ward. Our patient care rounds are visioned to be patient and family centred in context. This requires a discussion in the patient room with health partners, the family and patient to update status of care, share results, table care proposals and plan for short term and/or long term goals of care. The CTU Care Team is composed of:

Each team has 1 senior paediatric resident (PGY3), 1-2 junior paediatric residents (PGY 1) and 2-3 medical students (Schulich Medicine Clerkship, Elective and other medical school elective learners), along with a consultant paediatrician. This paediatrician may be an academic full time (Red) or community based (Blue) general paediatrician

A variety of health professionals who support patient care. Each team rounds with a paediatric pharmacist and we attempt to link at the bedside with the patient’s primary nurse. Other professionals include social work, nutrition, nursing and a large variety of health care partners.

Supports from subspecialty paediatric divisions in co-managing patients with complexity

Patients (infants, children and adolescents) and families from London-Middlesex and our regional partners in Southwestern Ontario with acute health care needs in common health care problems and others who are medically complex and need a collaborative care to address an acute health needs along the journey of chronic disease management.

A circle of care with internal and external partners in acute and chronic health care needs.

Scheduling: 1. Start times:

Teams meet every morning at 0730 hrs. in the CTU classroom (B6-362) for teaching, rounds with nursing, review and allocation of duties and assignment of patients (see below).

On weekends and holidays we meet at 0900 hrs. 2. Teaching The CTU is an opportunity in your residency curriculum to teach and deliver as an educator. Teaching takes many contexts – brief insight at handover, meaningful “in the moment” bedside teaching in rounds, afternoon case based sessions around topics from team patient care, formal CTU curriculum and teaching you receive from


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other faculty, staff. As well, a key competency of your CanMEDS 2015 role is scholar, and delivering education to other learners and professionals is an important objective of our rotation. Teaching occurs not only on rounds, but case-based resident /staff sessions for residents and students occur Friday mornings from 0730 – 0815 hrs. Formal CTU specific medical student education is delivered on Monday, Tuesday, and Thursday at 0730 hrs. by the Junior Resident. Topics include but are not exclusive to:

o Failure to thrive o Asthma o ALTE / BRUE o Neonatal jaundice o Febrile neutropenia

3. CTU Red and Blue Team Schedule

a. Monday - Friday

Time Activity

07:30 – 08:00 h B6-362

Clinical clerk teaching by residents Senior residents do bullet rounds with nursing staff

08:00 – 08:30 h B6-362

Joint morning handover from on-call team - overnight issues on existing patients and discussion/dispersion of new admissions NOTE: Due to Grand Rounds on Wednesday morning, all times are pushed back by one hour

08:30 ~ 09:30 h Independent patient rounding, contact with consult services, outside data retrieval, early discharge and plan for the day.

9:30h ~ 11:30 h Patient and Family Centred Rounds

12:00 – 13:00 h Academic Teaching Sessions

13:00 – 15:00 h Ward work / Teaching; Write daily progress note; meet with patients/families/other health professionals; Discharge patients.

16:00 – 1630 h Team reviews patient issues with their senior resident/staff

1630 – 1700 h Work to address gaps for handover

17:00 h Team handover to residents/students on call. NOTE: Please try to ensure clerks hand over first and are able to leave in timely manner

b. Weekend Rounds

Handover starts at 0900 h

Rounds commence immediately after handover

4. Communication

Please pick up the list of nursing IP phones and call nurses when you round on their patients

You will be carrying an on-call pager and a team specific pager as the Senior

The Senior will carry a team specific IP phone


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5. Progress Notes

Keep notes short and concise o For complicated patients, an issues list can be helpful o For uncomplicated patients, SOAP notes are adequate

Notes should be concise overviews of current issues and the plan

Please do not copy your note from the previous day, nor recap the entire patient admission

Please review the medical student notes on your team as the Senior Resident

A note should also be written when you reassess a patient due to a change in status, if PCCOT is activated or if a patient is transferred to the PCCU.

6. Overview of the day

a. Handover

Concise point based dialogue that is relevant to patient care

Background relevant to care for new patients

Plan for short term management

Disclosure of consultant involvement and suggestions

b. Rounding

Review documents from Powerchart outside the room

Arrange for patient nurse to be present at patient room

Speak on decisions of care and plans in the room with family, patient, caregiver, nurse

Examine patient in a focused manner relevant to the presentation and active problems

Review relevant chart fields: vitals/fluid balance/weight/ investigations/medication/discharge or disposition as appropriate

Create an approach to care for short and long term problems

Formulate a plan for investigation and management

c. Patient presentation

Brief greeting and Identification of patient and family/support person

Present significant information from past 24 hours (For new patients, present only relevant history)

Physical exam findings, investigations, medications, etc.

Problem list (if relevant) and plan for the day

Please ensure all investigation and therapy orders for the patient are written during rounds and clerk orders co-signed by resident/staff

Follow-up on patient care notes written later that day

d. Consulting other services

Many patients on CTU are involved with other divisions and departments

The resident / clerk looking after the patient are responsible for calling the consulting service between 0830 and 0930 hrs. daily and if there is a significant change in status of the patient

Give brief patient history, pose a suggested plan of care and discuss any relevant clinical questions

Ensure the consultation form is completed on the patient chart

Consult other divisions in the morning so they can be seen the same day


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e. Updating the patient list

Very important as this is used by all team members to follow the patients

The admitting resident/clerk is responsible for adding new admissions to the list in time for handover

Responsibility of the resident/clerk looking after the patient to update investigations, medications, problem list and plan on a DAILY basis

f. Afternoon Handover

Make sure you are on time for handover at 1700 h

Use iPASS method of handover to allow for consistency of handover between all residents/clerks Other Details: Evaluations

You will meet with Dr. Peebles at the beginning of your rotation to discuss your objectives. These objectives will be shared amongst the staff

You will receive a weekly evaluation from the CTU staff.

You will meet midway through the rotation and at the end of the rotation with Dr. Ojha

You are responsible for pushing to have support in meeting your objectives

Being coached every 2 days by your CTU staff is an effective way of understanding your progress and will help make your rotation a success

Objectives

See attached Appendix A

Simulation

There is a CTU simulated “mock emergency” that will happen during your rotation. Objectives are sent separately.

The senior resident (or admitting resident) will meet with Dr. Peebles at the beginning of the rotation to review how the session will run.

Clerk Experience with on call

We have introduced a paging system so that clerks and juniors to receive pages on their patients

Please ensure the paging list is given to the ward clerks on the 100 and 200 side each morning

As residents, you have the biggest impact on clerk learning during their CTU rotation – please ensure clerks stay involved with their patients throughout each day!

If you have any concerns during your rotation, please feel free to approach any of the staff. Our goal is for CTU to a fun learning experience in all seven competencies. We want to do everything to make sure it is!


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Paediatric Residency Training Program

Western University, Canada

Rotation Specific Objectives for Clinical Teaching Unit Junior Resident (PGY-1)

The CTU Red Junior is a rotation completed at minimum once during the PGY1 year in training. All residents are

expected to meet the objectives stated below. The degree of competency achieved within each objective will be

commensurate with the resident’s level of training. Effective team communication and collaboration, and development of the manager role are central to the

successful competition of this rotation. Additional objectives for those completing this rotation a second time in the PGY1 year are listed below (Italics).

CanMEDS Roles

CanMEDS Competencies Methods to Achieve Competencies

1. Medical Expert

a) Knowledge

1.1 The resident will be able to assess and manage the infant/ child hospitalized to inpatient wards with: a) Asthma b) Bronchiolitis c) Pneumonia d) Urinary tract infection e) Suspected sepsis/Meningitis f) Other common childhood infections (ie cellulitis, osteomyelitis) g) Fever under 3 months of age h) Possible seizure i) Altered level consciousness j) Suspected malignancy k) Febrile neutropenia l) Dehydration/Electrolyte abnormalities m) Nutritional Deficiencies n) Pain (acute or chronic) o) Diabetic Ketoacidosis p) Suspected Non-Accidental Injury

Patient care during rotation Daily family-centered rounds Teaching of medical students Independent reading around

cases

1.2 Demonstrate the ability to elicit a history that is relevant, concise, accurate and appropriate to the child’s problems

Performing history and physical exam for patient admissions

Daily patient assessments

Daily family-centered rounds Observed patient encounters

1.3 While collecting data, demonstrate cognitive and process skills toward solving the child’s problems.

1.4 Perform a physical examination that is relevant, sufficiently elaborate, appropriate and meets paediatric standards

1.5 Although not mandatory, the resident may attempt to successfully perform the following procedures:

Performance of skills under nursing or physician


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CanMEDS Roles


b) Skills

a) Lumbar puncture observation Video clips available on

residency app “Pedia-Tricks” b) Obtaining intravenous access

c) Bladder catheterization

d) Nasogastric tube placement

1.6 The resident will demonstrate skill in interviewing and physical exam tailored to the unique needs of the adolescent population

2. Communicator

2.1 Demonstrate the ability to communicate effectively and offer support to the patient and all members of the patient’s family.

Daily observation of senior resident and faculty communication with families

Daily communication with families during rounds and patient assessments

Timely completion of concise dictations and written notes

Daily handover of patients Communication with families

and allied health team members during

multidisciplinary team- and family meetings.

2.2 Demonstrate the ability to deliver information to the patient and the patient’s family in a humane manner and in such a way that it is understandable, encourages discussion and promotes their participation in decision-making.

2.3 Demonstrate effective patient management skills by writing admission, progress and transfer notes that are logical, concise and yet sufficiently detailed to demonstrate adequate patient care and allow for continuity of care.

2.4 Demonstrate the ability to write an effective discharge summary.

2.5 Demonstrate skills in working with other who present significant communication challenges such as anger, confusion, or an ethno-cultural background different from the physician’s own

2.6 Demonstrate the ability to gather information not only about the disease of the patient, but also about the family’s beliefs, concerns and expectations about the illness, while considering the influence of factors such as cultural and socio-economic background and spiritual values.

2.7 Demonstrate the ability to present patient information obtained to the team in a succinct summary, with appropriate level of detail.

2.8 Recognition of one’s limitation and communication in a timely and clear manner when more senior support is needed.

3. Collaborator


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CanMEDS Roles


3.1 Demonstrate the importance of cooperation and communication with the allied health professionals of the inpatient multidisciplinary team, such that the roles of these professionals are delineated and consistent messages are delivered to patients and their families.

interactions with nursing and allied health

Communication with community physicians as appropriate for patient care 3.2 Demonstrate the ability to form collaborations

with community care providers to optimize patient care. 4. Leader

4.1 Select medically appropriate investigative tools in a cost-effective, ethical and useful manner.

Daily discussion of patient management during rounds

Developing management plans for new admissions

Daily ward work and responding to multiple requests in a timely fashion

4.2 Demonstrate the ability to prioritize and manage one’s own activities as a member of the CTU team.

4.3 For those completing a second CTU Red Rotation 4.3.1 Demonstrate the ability to identify when

junior team members are in need of support, and provide this support independently

4.3.2 Balance ones priorities within the needs of the team, and independently prioritize the teams needs appropriately

4.3.3 With support, address issues affecting any patient on the team, regardless of patient assignments.

5. Health Advocate

5.1 Demonstrate the ability to arrange for investigations in a timely manner.

Leading discussion during family centered rounds

Discussion regarding appropriate outpatient follow up for patients.

Ensuring that community resources are in place prior to discharge

5.2 Demonstrate the encouragement of active family involvement in decision-making and continuing management of the child’s care.

5.3 Describe advocacy issues that arise from the care of patients.

5.4 Discuss the determinants of health for specific patients and provide anticipatory guidance to patients’ families. 6. Scholar

6.1 Demonstrate the ability to make clinical decisions and judgments based on sound clinical evidence for the benefit of the patient and the family.

Daily morning clerk teaching Teaching of clerks during

patient rounds Clinical questioning during

rounds

6.2 Demonstrate the ability to recognize gaps in knowledge, pose a clinical question, formulate a plan to fill the gap, critically evaluate the evidence found, propose and implement a solution to the clinical question, and evaluate the result. 7. Professional

7.1 Demonstrate a proficiency at self-assessment in regard to one’s personal and professional performance and establish a pattern of ongoing professional development.

Weekly feedback sessions with faculty


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CanMEDS Roles


7.2 Recognize the limitation of one’s competence and appropriately consult with others.

Daily feedback sessions with senior resident, as needed

Discussion of ethical issues surrounding patient care, when relevant

Self-directed learning regarding medical ethics

7.3 Demonstrate honesty and integrity (i.e. be fair, truthful and keep one’s word; meet commitments; be forthright in interactions with patients, peers and in all professional work through documentation, personal communication, presentations, research or other aspects of interaction; accept feedback graciously). 7.4 Demonstrate reliability, responsibility and conscientiousness (i.e. meet deadlines, be punctual, complete assigned duties and fulfill commitments; be accountable to patients and their families; be willing to accept responsibility for errors). 7.5 Be insightful as to the impact of one’s behaviour on others and cognizant of appropriate professional boundaries.

7.6 Demonstrate knowledge of Medical Ethics


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Rotation Specific Objectives for Clinical Teaching Unit Senior Resident (PGY-3)

The CTU Red Senior role is completed at minimum once during the PGY3 year in training. All residents are expected to meet the objectives stated below. The degree of competency achieved within each

objective will be commensurate with the resident’s level of training. Effective team communication and

collaboration, and development of the manager role are central to the successful competition of this rotation. Resident’s should expect to receive feedback in focusing on their proficiencies in all of the Can MEDS roles.

CanMEDS Roles


1. Medical Expert

a) Knowledge

1.1 The resident will be able to assess and manage with support the infant/ child hospitalized to inpatient wards with: a) Asthma b) Bronchiolitis c) Pneumonia d) Urinary tract infection e) Suspected sepsis/Meningitis f) Other common childhood infections (ie cellulitis, osteomyelitis) g) Fever under 3 months of age h) Possible seizure i) Altered level consciousness j) Suspected malignancy k) Febrile neutropenia l) Dehydration/Electrolyte abnormalities m) Nutritional Deficiencies n) Pain (acute or chronic) o) Diabetic Ketoacidosis p) Suspected Non-Accidental Injury

Overseeing patient care during rotation

Daily discussion around patient management plans

Teaching medical students and junior residents

Independent reading around cases

1.2 Demonstrate the ability to elicit a history that is relevant, concise, accurate and appropriate to the child’s problems.

Reviewing history and performing physical exam for patient admissions

Daily patient assessments Daily family-centered rounds Observed patient encounters

1.3 While collecting data, demonstrate cognitive and process skills toward solving the child’s problems.

1.4 Perform a physical examination that is relevant, sufficiently elaborate, appropriate and meets paediatric standards.

b) Skills

1.5 Although not mandatory, the resident may attempt to successfully perform or supervise the junior resident in performing the following procedures: a) Lumbar puncture b) Obtaining intravenous access c) Bladder catheterization

Supervising junior residents Perform the skill when necessary Video clips available on residency app “Pedia-Tricks”


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CanMEDS Roles


d) Nasogastric tube placement

1.6 The resident will demonstrate skill in interviewing and physical exam tailored to the unique needs of the adolescent population

2. Communicaton

2.1 Demonstrate the ability to communicate effectively and offer support to the patient and all members of the patient’s family, such that limited support is required by the attending physician.

Daily communication with families during rounds and patient assessments

Discussions with allied health team members

Timely completion of consultations

Supervise daily handover of patients to the on-call team

Provide learners feedback and contribute to formal learner evaluation

2.2 Demonstrate the ability to deliver information to the patient and the patient’s family in a humane manner and in such a way that it is understandable, encourages discussion and promotes their participation in decision-making.

2.3 Seek assessment from consultants in a manner that clearly identifies the concern being addressed, and initiates appropriate level of dialogue with the consultant service.

2.4 Demonstrate the ability to write an effective consultation note after performing a consultation to another hospital service 2.5 Demonstrate skills in working with other who present significant communication challenges such as anger, confusion, or an ethno-cultural background different from the physician’s own

2.6 Demonstrate the ability to give effective feedback to junior trainees and students.

3. Collaborator

3.1 Demonstrate the importance of cooperation and communication with the allied health professionals of the inpatient multidisciplinary team, such that the roles of these professionals are delineated and consistent messages are delivered to patients and their families.

Interactions with nursing and allied health

Communication with community physicians as appropriate for patient care


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CanMEDS Roles


3.2 Demonstrate the ability to lead a planning conference for a patient with complex needs, allowing the family and health care professionals to discuss issues and reach a mutual agreement on goals and plans.

Communication with families and allied health team members during multidisciplinary team- and family meetings.

4. Leader

4.1 Demonstrate the ability to manage the daily activities of a hospital based health care team, including the ability to assign workloads and supervise the work of more junior trainees.

Daily discussion of patient management during rounds

Overseeing junior residents and learners and providing support throughout the day

Daily ward work and responding to multiple requests in a timely fashion

Timely identification of patients ready for discharge, and facilitating pre-round discharges when appropriate

4.2 Demonstrate the ability to prioritize the daily work on the CTU.

4.3 Determine which patients should be admitted and discharged from the CTU.

4.4 Select medically appropriate investigative tools in a cost-effective, ethical and useful manner. 4.5 Demonstrate the ability to priorize and manage one’s own activities as a member of the CTU team. 5. Health Advocate

5.1 Demonstrate the encouragement of active family involvement in decision-making and continuing management of the child’s care.

Leading discussion during family centered rounds

Discussion regarding appropriate outpatient follow up for patients.

Ensuring that community resources are in place prior to discharge

5.2 Describe advocacy issues that arise from the care of patients.

5.3 Discuss the determinants of health for specific patients and provide anticipatory guidance to patients’ families.

6. Scholar

6.1 Demonstrate the ability to make clinical decisions and judgments based on sound clinical evidence for the benefit of the patient and the family.

Review admission and inpatient management plans with learners

Teaching around patients on rounds and during patient assessments

Self-assessment of knowledge and reading around areas of identified weakness

6.2 Demonstrate the ability to recognize gaps in knowledge, pose a clinical question, formulate a plan to fill the gap, critically evaluate the evidence found, propose and implement a solution to the clinical question, and evaluate the result. 6.3 Demonstrate an understanding of the principles of adult learning and the ability to teach, supervise and evaluate junior trainees and students.

7. Professional


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CanMEDS Roles


7.1 Demonstrate a proficiency at self-assessment in regard to one’s personal and professional performance and establish a pattern of ongoing professional development.

Weekly feedback sessions with faculty

Provide regular feedback to junior learners, ideally on a daily basis.

Discussion of ethical issues surrounding patient care, when relevant

Self-directed learning regarding medical ethics

Disclosure of medical errors, with attending support, should the need arise

7.2 Recognize the limitation of one’s competence and appropriately consult with others.

7.3 Demonstrate honesty and integrity (i.e. be fair, truthful and keep one’s word; meet commitments; be forthright in interactions with patients, peers and in all professional work through documentation, personal communication, presentations, research or other aspects of interaction; accept feedback graciously). 7.4 Demonstrate reliability, responsibility and conscientiousness (i.e. meet deadlines, be punctual, complete assigned duties and fulfill commitments; be accountable to patients and their families; be willing to accept responsibility for errors). 7.5 Be insightful as to the impact of one’s behaviour on others and cognizant of appropriate professional boundaries.

7.6 Demonstrate knowledge of Medical Ethics

resident orientation to ctu and b6 - western university · paediatric subspecialties for inpatients...

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