August 19, 2014SYSTEMS

Geriatrics/Neurology rotation for interns Contacts:

Melanie Reeves, Geriatrics Program coordinator Aline Herlopian, Neurology Chief Resident

Rotation Switch: On the 17 th for months with 31 days On the 16 th for months with 30 days On the 15 th in February

UAMS

ECHO reports in EPIC Should be posted by 8am the day after ECHO completion

under “Cardiac Procedures” tab Make sure test was completed Page ECHO lab for verbal report

UAMS

Transferring overflow patients to Gen Med Teams Applies to “staffed” patients Must have accepting attending’s approval Must have hand-off between teams Must document on team lists for Ward Resident Shouldn’t be moved again!

UAMS

JOINT COMMISSION Will be visiting in the next few weeks Wear your name badges, be professional, etc.

Telemetry Unstable arrythmia or chest pain rule-out Re-assess every 24 hrs—order will discontinue!

Portatble CXR Starting Sep 3, you will have to justify reason pt cannot go to

radiology

TIME OUTs Need a NOTE for Time Out BEFORE the procedure is started Needs to be a SEPARATE NOTE from the procedure note

UAMS

Fellows should be called for EVERY admission

Both VA and UAMS

HEME-ONC ADMISSIONS

Step 3 Schedule during elective preferably Email dates to HEATHER AND SHEILA as soon as you book it If you require jeopardy, you have to pay it back IN KIND

(Ward for Ward, MICU for MICU, etc.).

Ward Team/ VA MICU Calendars Complete at the beginning of the month Complete for the entire month Forward completed copy to Heather Clinic days DO NOT count as days off

SCHEDULE

Fellowship Interviews during Ambulatory Week Try to reschedule if possible

For VA, discuss with your clinic attending Email Nick, Heather, and Sheila with the dates

For UAMS, find your own coverage Email Dr. Alexander in addition to Nick, Heather, and Sheila

SCHEDULE

Consults Call Fellow/Resident AND place consult order promptly INTERNS: Discuss with Resident/Attending prior to placing

consult

Project RED Involves ordering specific education for Veterans with CHF

on admission How-to posted in all VA workrooms

VA Email Open Outlook on any VA computer You are responsible for the information in that account as

well as in your UAMS account

VA

Nick still hasn’t eaten any Chief candy.

Dr. Vyas joined the competition... And lasted only 2 weeks, one of which he was on vacation.

CHIEF CANDY

Only IM PGY-3, MP-4

Only when on an elective or ambulatory week

May not violate ACGME work-hours—including 24-hr-rule, days off , and short break

Moonlighting is a privilege, not a right.

MOONLIGHTING

ADMITTING A PATIENT IN EPIC

Order is like always:1. Become aware that there is an admission2. Review chart3. Go see the patient4. Place the orders (easier if you have a problem list first)5. Do history and physical documentation

“I think the best advice with this pertains to the problem list for both outpatient and inpatient encounters. If the problem list is reviewed and updated at the onset of an encounter/admission, then the rest of the documentation and orders is a much more effi cient process.” Tobias Vancil, MD, FACP

H&P ORDER OF EVENTS

BEFORE starting the H and P:

Then click problem listClick history

Fill out PMH, PSH, FH, SHThen start your H and P

HISTORY TAB

REFORMING THE SYSTEM

Need to keep people alive by getting rid of double handoff s

Would prefer to keep duty hours neutral

NEW SYSTEM

6a-6P On call6p-6a night floatThe not-on-call team resident and intern will alternate

staying until checkout on all non-holiday week daysSo in every set of four days:

You stay 1 hour shorter on both call days You stay 2 hours longer on one of your non-call days You also stay 1 hour shorter on weekend call days

Duty Hour negative—better patient care!

Improving Discharge Effi ciency at the VA

PRE-DISCHARGE ORDERS:

Patients with fi rm discharge plans for the next day Post-procedure Observation (e.g. Chest pain r/o) Resolved Alcohol Withdrawal Placement-pending

Improved patients with high likelihood of discharge the next day

WHO NEEDS THEM?

To alert nursing that a patient will be discharged in next 24 hours

To more effi ciently coordinate transportation and other discharge needs (HHA, Home O2, Home IV abx, medications, etc.)

To identify potential barriers before the day of discharge

WHY PLACE THEM?

From Discharge Menu, Click “Pre-Discharge LR patient”

HOW?

HOW?

Scroll down to fill out all pertinent information for your patient’s discharge.

HOW?

Fill in time of expected discharge and transportation needs.

HOW?

Alert nursing to any education or supply needs.

HOW?

When completed with entire order, Click “OK” then “Accept Order” in next box.

HOW?

Order PICC or Port care if needed.

HOW?

Order Flu Vaccine if appropriate.

HOW?

Order outpatient labs, imaging, and consults. Include expected date of completion.

HOW?

Click “Done” to exit order set.

HOW?

Review order for accuracy then sign order.

HOW?

1) Highlight signed orders then go to “Action” on toolbar at the top.

2) Select “Flag.”

HOW?

1) Place date of discharge in “Reason” text box.

2) Click “OK.”

This will be repeated for each order.

HOW?

If done correctly, the order should look like this.

DELAYED DISCHARGE

If your patient’s discharge is delayed either after Pre-discharge orders or a Proceed order are placed:

1) Select “Hold Discharge” from the Discharge Menu.

DELAYED DISCHARGE

2) Enter the reason for the delay and new date for expected discharge (if known).

3) Click “OK.”

4) If indicated, discontinue your “Proceed” order.

DELAYED DISCHARGE

NEXT, change the pre-discharge order.

1) Right click the pre-discharge order.

2) Change the information in the free text box.

3) Click “Accept Order” when completed.

4) Keep the order flagged.

Keep pre-discharge orders fl agged until the “Proceed” order is placed on the day of discharge.

If discharge planning is held, use the “Hold Discharge” order to indicate reason for delay.

If the patient’s discharge will be signifi cantly delayed, discontinue the pre-discharge orders.

Update pre-discharge orders as indicated prior to discharge and communicate with appropriate services.

Follow previously established guidelines for Transitions of Care/Discharges on the day of discharge.

CLOSING THOUGHTS