Welcome to John D. Dingell VA Medical Center

1. Welcome to John D. Dingell VA Medical Center Mashkur Husain, MD Chief Medical Resident

2. Background • 267 bed facility. • One of the largest VA hospitals. • Provide primary health support to Veterans. • Affiliated with WSUSOM/DMC. Provide significant portion of residents’ salary. • In-patient: Medicine, Surgery, Psych and ICU. • Also NH, extended care, hospice

3. Floor structure & Typical day • Four (Blue, Green, Red and Yellow) medical teams. • Each team consists of 1 resident, 2 interns, 1-2 medical student(s) and social worker. • 6:45 arrive and get sign out • 7-7:30 see your patients • 7:30-8 AM: Pre-round with your senior. • 8-11:00: Rounds with medicine attending. • 11:00-11:50: Discharge • 12 – 1:00 PM Morning report.

4. Floor structure & Typical day • 12-1 PM: Medicine Grand Rounds on Mondays • Morning Report will be held at 1:15pm-2:15pm (On Mondays Only) • Didactics per WSU-IM program (Academic half Day), on every Wednesday • 1-5 PM: Finish work (including new admissions), exit rounds and sign outs.

5. Admissions Flow • On call resident gets code blue pager from night float senior. • On call resident assign one of the intern with the other code pager, get from night float intern • NP’s on Weekdays will transfer/carry Medicine admission pager # 9775 to him/herself from 8am – 1pm (similar to role of ER/IM in DRH) • NP is responsible for triaging, assessing pts. and putting basic orders on weekdays from 8am-1pm • From 7am to 8am the on call senior should transfer the pager to him/herself and triage patients. • NP will sign out new admissions to senior resident of the respective accepting team after 1PM, this is to give the team time to finish up discharges.

6. Admissions Flow • On the Weekend on call senior will transfer the admission pager #9775 to him/herself • On call senior will get sign-out from the ER, then inform the accepting team senior about the admission ASAP • Accepting senior will be responsible to evaluate the pt. ASAP in the ER (less than half an hour please) • On the weekend, MOD is responsible for medicine consult (STAT) • Routine consult is seen by on call attending • If your attending wants you to see the consult, you can count it as a hit.

7. Admissions Flow • On weekdays please inform the consult attending till 4:30PM • after that any routine consult doesn’t need to be seen • Primary team needs to call the attending for consults. You do NOT see routine medicine consults on Weekdays. • Primary team needs to put a consult and inform the consult attending in the morning. • STAT consult needs to be seen and staffed over the phone with your on call attending • On STAT consult pt you round the following morning before signing out the pt to consult attending, count as a hit

8. Admissions Flow • Team on call Q4, every 4th day • On call team gets total of 9 new admissions • Non call team gets 3 new pts each per day • Post call team gets no new pts. • Each day on call senior will start admitting patients to him/herself after 2 pm • Or whenever the other teams are capped meaning 6 admissions to medicine team whichever comes first.

9. Admissions Flow • On call team will start admitting at 2pm (changed from 3pm) to allow the team adequate time to work up all the patients and leave on time • Total number of patients for the team will be 9 patients • On call team will admit 5 patients till 6pm (will be at senior resident discretion how the patients get distributed between the interns) • On call team will stop admitting new patients at 6pm to prevent violating mandatory short break

10. Admissions Flow • From 6pm MOD for the day will start admitting till night float team comes in at 8pm • Night float will admit total of 5 patients, should have zero patients waiting on arrival at 8pm • Once the night float team reaches the cap of 5 patients, MOD will again admit rest of the night • As the total team cap is 9 patients, the on call team will receive 4 patients from night float the following day to meet the total number of 9 patients

11. Admissions Flow • The other patient admitted by night float and any patients admitted by MOD will become overflow to be distributed to the non call teams • In the event the on call team gets total of 9 patients before 5pm, the senior resident is expected to have admissions orders in for all 9 patients and call the MOD at 5pm to hand off the other 4 patients to be admitted by MOD.

12. Admissions Flow • Senior will hand over code blue pager to NF senior resident. • Intern carrying the code pager hand over to NF intern • Night float senior + intern will admit up to 5 patient overnight. • Any additional admission after both on call team/night float reaches cap, will go to the MOD on call. • Total team cap is 20 pts. • Medicine Team cross cover other medicine team • Pt. admitted by MOD is cross covered by MOD till 6:30am the following day then signed out to night float senior

13. Admissions Flow • New admission typically comes from ER • Also can come from clinics, direct admissions, physician will page #9775, will give you sign-out as well as put delayed orders, Admitting Physician is also responsible to call Bed Control and precert pt • Can get transfers from other VA or other hospitals, Chief Resident or MOD will review transfer packet and provide sign-out to you • Can also get pt. from CLC or NH located in 6th floor, again same process

14. Responsibility: • Cross coverage. (only medicine and step down beds). • You are responsible to flag the covering physician order (a must Nurses and other staff use this to contact you) • Urgent Labs • Codes (blue and gray): Keep pagers with you. Let CMR know asap if they’re malfunctioning. Respond to calls from other services and call THEIR attending. Code blue from CLC DO NOT go to ER, only falls do. • Code White: only afterhours and all day weekend • You are required to put code gray/blue/white note in CPRS and call attending, in the case of code white it’s the neurology attending on call. • Please don’t lose code pager, you will be held responsible for it, $350 per pager. • Please return test page, dial 0 to call the operator and inform them code pager is working

15. Responsibility: • Transfers: nursing home, other VAs, outside community. Accept but do not count until they reach the floor. • Once capped  inform ED and MOD (look online on intraweb). • Once capped, MOD takes over admission. MOD will sign out to Night float senior at 6:30 am (must be face to face) • If on-call team caps before MOD arrives (5 PM), let your attending and CMR know.

16. People You need to know • Chief Medical Resident(s): • Mashkur Husain: 313-258-3665 • Pierre Tannous(Q&S): 732-241-9422 • Housestaff coordinator: • Beverly Greene, Dial 576-1000 then ext. 63334

17. Morning Report • Send your case at least 48 hours in advance. It will be responsibility of the senior to go through case and correct / add to it beforehand.All cases must be from the VA, please send Pt. last Initial and Last 4 • If case is not sent 48 hours in advance to CMR then senior on that team will have to conduct morning report! • Zero tolerance for late comers to morning report. I keep track of your attendance. • Seniors: Please attach 2 MKSAP questions and explanation to your intern presentation as well as 3 key points

18. HIPAA privacy • It is imperative to respect privacy of our patients in public places, outside patient rooms and on phone. It is being monitored very closely every day. • Duty hours should not be violated. If there is some concern, please approach your senior/attending/CMR.

19. Helpful Info • 4 days off per block. Work ahead. • Can not take on-call days off. • No day off on the first day or last day of rotation as this is critical for effective handoff.

20. Unique to the VA • Meals during call days (1-2 meals). • Very nice call rooms. (6th floor/semiprivate bathroom). • Exceptional computer/EMR system (paperless system) + connected to all other VAs. • Patients are mainly in A3 Med, A5 Surg and A4 S/D. • Paging system • Nursing home/hospice unit – considered outside facility. If pt is already hospice, should be admitted as hospice.

21. Code White • Medicine is responsible for covering Code White (Stroke) Weekdays afterhours starting 5pm till 8am the following, all day on the weekend and holidays • Code White pages will come through on the Code Blue pager. • Please respond during the above mentioned time.

22. Bounce back: Pts who are readmitted within the same block. • If before 3 pm (weekday), 1 pm (weekend) will go to original team NOT counted as a hit. Unless the team is post call and can’t take patients. • Otherwise will still be given to the original team the very next day. • Admitting team will round on bounce back patient next day, write progress note and then give back to original team.

23. HIV verbal consent NEEDS documentation in CPRS. • Core measures • Address vaccinations prior to discharge. • Document why patient with CHF is not on ACE/ARB, Beta blocker. • Why pt with CAD is not on ASA or statin

24. ADMISSIONS FROM EMERGENCY ROOM • Once you accept patient, give the admission information to the ED physician and he/she will place “bridging orders”. • Must go down to ED ASAP after getting called. • Delayed orders should be written by the resident within 60 minutes of being called.

25. Resident supervision policy after hours Senior residents on call must call their supervising physician (Hospitalist on call for that 24 hour period) for update, review, and advice concerning any patient in the following situations: • Admission to the Step Down Unit, or transfer (or possible need to transfer) of patient to SDU/ICU • Code Blue or Gray called on a Medicine patient

26. Resident supervision policy after hours • Serious change in medical status on the Medical floor or SDU (including, but not limited to: blood pressure; respiratory, cardiac or neurological status) • Concern that the ED is inappropriately admitting a patient to Medicine floor when he should go to ICU or to the SDU.

27. VA pt. info • Don’t share VA protected health information PHI outside of the VA system. Don’t share via: • @gmail, @yahoo.com etc, @med.wayne.edu (not even by using {secure}) • SMS, iMessage. • Non-secure voicemail, e.g iPhone. • Drop Box, Google Drive, icloud • May use @va.gov e-mail by sending a secure message: To automatically set up – just open Microsoft Outlook.

28. The 3 essential EMR tasks • Covering physician order + flag must be added on every admission and transfer.

29. The 3 essential EMR tasks 2. Medication reconciliation: Use the H&P template when admitting a pt. and make sure to indicate whether or not there is a discrepancy between home meds and meds that are listed in our EMR. Must use Medication Reconciliation tool

30. The 3 essential EMR tasks 3. Change encounter location: • Make sure to select a new encounter location BEFORE adding your note (DET INPT GEN MED). Important measures • Place anticipated discharge date • Goal Discharge of 40% by 12am

31. Proper Discharge Process • Rounds must end by 11:00 AM. • Place your discharge order BEFORE 11:00 AM and make sure patient leaves the facility on time. • Use the discharge menu. • Don’t place a text order “D/C IV and D/C patient” • Afternoon rounds to discuss possible discharges the next day.

33. Team names should be standard: Red block 1 2015

34. Medication Reconciliation • Please utilize medication reconciliation tool in EMR • Morning report tomorrow by Dr. Tannous on this

35. Infection Control

36. Infection Control

37. Professionalism Please remember to be professional and respectful to all staff • in particular the night-time hospitalists/MODs and ED staff. • Remember you cannot refuse an admission • if you would like additional workup you need to ask respectfully to the ER staff. • Otherwise, you will need to call your attending.

38. Housekeeping • Code status needs to be entered in the admission order • Frequent admission note need to be at the time of discharge, discuss with medicine attending • 1F treating specialty more on this soon

39. Learner Survery • Taking the learners perception survey: http://www.va.gov/oaa/surveys

40. Any Questions??? Mashur Husain Chief Medical Resident VA Medical Center