Resident Business MeetingJuly 2019

Dr. Nguyen

Scholarly ActivityScheduling Reminders

Med TeamsIMC

ICU/CCUMisc

Scholarly Activity

PGY1 Scholarly Activity Requirements

• Journal Club – 2 presentations per day scheduled throughout the year, will be posting sign-

up sheet in Chief’s office early next week.– First Journal Club: September 13th

– E-mail chief resident the article you have selected the week prior to when you’re scheduled to present

• Scholarly Activity– Be on the look out for cases or projects-- never too early to start!– Consider working on scholarly projects early if you are interested in

Fellowship

Transitional & Prelim Scholarly Requirements

• QI Project

– TY Group Presentation

– See email from Dr. George

PGY2 Scholarly Activity Requirements

• Case Presentation or Research/QI Project

– August/September/October

– Present an interesting case/research/QI project

– Sign-up sheet posted in Chief’s office – already getting filled

• Clinical Pathology Case Presentation

– March/April/May

PGY3 Scholarly Activity Requirements

• M&M/QI Presentation

Scholarly Activity

Requirements & PowerPoint Templates posted to website

IMC Reminders

• Look ahead to see when your clinic days are in Epic

– If unsure how to do that– ask any senior resident or me

– Refer to step-by-step in IMC Packet

• When you’re on electives– template open far in advance to improve continuity

ECW General Access

• Old IMC records prior to 2015

• Generic login to assist in reviewing past medical information on a patient

• Username: intern

• Password: medicine

• For viewing ONLY, no changes/documentation of any kind

CBT

• PGY2’s

• Mandatory on electives and IMC months

• Excused on ICU/CCU/NF/Med Team and when on call/post-call

• Resident’s responsibility to coordinate with assigned office

Scheduling Reminders

Step 3

• Schedule when on an elective

– NOT ICU, CCU, Med Team or Night Float

• Fill out an off call form (green form) indicating your dates so that I can schedule you off appropriately

• For categoricals

– Must be completed by the end of PGY2 year

MKSAP BOARD PREP

• Mandatory for categorical interns/residents

• Taken in the department of medicine during normal business hours

• Prior to taking– Let either Mike Oravec, Emily George, Mary Yanik, or Joel Rayl

know you’ll be taking the exam

• After taking– Show one of us your score – even if you do not “pass” so that we

can record that you are “caught up” and working the program

MKSAP board prep

• Subspecialty Quizzes– 30 questions– 1 hour – Take on or before scheduled date (listed on master call schedule)– Must get >80%

• 60 Question Random Quizzes– Required to do 2 each year– 2 hours

– PGY1: Complete 2nd Quiz by end of April• Goal Score >60%

– PGY2: Complete 2nd Quiz by end of March• Goal Score >70%

– High Risk PGY3: Complete 3rd Quiz by end of March• Goal Score >80%

Call Changes

• MUST be approved by me

• CANNOT violate duty hours

• FORMS available in my office

– Coordinate call and post call days out of IMC, LTC, CBT

Chest pain drills

• Part of SUMMA being an accredited chest pain center

• Do what you would normally do for chest pain

• Oftentimes STEMI situations

• PGY1s are always allowed/should call AR2 for supervision/guidance (drill or not)

Code Blues

• Night– ICU, CCU and Night Float teams– ICU resident & intern, CCU resident & intern, AR2, AI2, AI3

• Day– Unit codes:

• ICU and CCU senior WITHOUT the pager – Since senior with pager usually doing ER evals or floor transfers

• ICU and CCU intern WITH the pager

– Floor codes:• ICU and CCU senior WITHOUT the pager• ICU and CCU intern WITH the pager• AR2, AI2/3

– Outside hospital codes (Team 4’s):• ICU and CCU senior WITHOUT the pager • ICU and CCU intern WITH the pager

Evaluations

• Request 2 evaluations from attendings before end of each month (even night float)– Except on Med Team

• Done through New Innovations

• MUST DO BEFORE END OF THAT MONTH– If you forget until the following month:

• When clicking to request an evaluation by attending make sure to hit “change” to change date range for the month you rotated with that attending

Reviewing Personal Evaluations completed by attendings

Med Team & Night Float

bullpen

Med Teams

• Admission Orders – please enter as soon as decision to admit is made.

– If no “Consult to Internal Medicine,” place order when called by ED Provider.

– If slam dunk –enter immediately or after short 5-10 senior eval

– If not sure – wait until staffing

Med Teams

• If called by ED, go see patient unless they specifically are asking only for follow up appointment

• Do not ask if patient “really needs admitted” or if patient can go to CDU.

• If you feel they should not come to MT, go to ED and chat with attending and PA in person

Haiku

Needed to document photos of rashes, lesions, cellulitis in EPIC so care team can follow and staffing attending can view at home

• Summa @ Work -> search “Haiku”

• 2 Part Registration (must do both parts)

– 1: install on device and send Install ID code to mercy

– 2: accept user agreement

Med Teams

• Sticky Note

– Only way that nursing, pharmacists, social workers know who to call

Vancomycin Dosing

No consult needed for clear cut patients (normal body weight, normal renal function).

- If have question – quick phone call to pharmacy or floor/rounding pharmacist

For more difficult patients (over or underweight, advanced age, HD/PD/or CKD, etc.)

- a consult for pharmacy to dose is more than appropriate

Document All Calls

• ALWAYS leave a note – including ALL night calls– i.e- called for SOB overnight; Even if patient completely

stable, write something like “Called for shortness of breath. Pt received albuterol x 1 prior to my arrival. Breathing is non-labored w/no wheezes. Saturating 98% on Room Air. Likely secondary to pneumonia for which he/she is on antibiotics.”

– If patient has chronic low back pain and you want to give heating pad: “called by RN, patient with chronic unchanged back pain. Will trial heating pad”

Request from Nursing

Please do NOT change settings or cancel fluids on IV pumps.

- Requires proper documentation in EPIC that we are unable to complete.

- 2 nurse verifier is required for any IV dose changes

Initial H&P’s

• Issues with H&P’s not including family medical history or social history

• When evaluating/admitting a patient—make sure to click history tab and UPDATE/REVIEW the Home Med List, PMH, PSH, FMH, and SHx– Update it in EPIC and click “reviewed”

– Refresh your note and it will appear

Discharge Summaries

• Issues with Discharge Summaries being too detailed– No need for day to day events (i.e. don’t make

it a 10 page journal entry)

• Be concise, hit main points especially things to follow up as outpatient (i.e. labs, imaging, etc.)

Discharge Summaries

• 78 yo M PMH COPD on 2L chronically, tobacco abuse presented 7/1 for respiratory distress. Admitted to ICU for respiratory failure requiring intubation 7/1. CT chest w/ new lung nodule and concern for new infiltrates. Treated with antibiotics/steroids/duonebs. Strep pneumopositive. Extubated 7/3 and transferred to floors. Continued to require 4L O2 on floors but overall improved. Discharged to SNF 7/5 with 2 week steroid taper, increase in home O2, and 3 additional days of oral Omnicef. Seen by pulmonology and will follow with Dr. Niraula in Lung nodule clinic.

IMC Reminders

IMC Reminders

• MUST SIGN IN with rooming staff upon arrival

• If you’re scheduled to be in clinic at a certain time but don’t have patients scheduled until later:– You are still expected to be physically present in

clinic

Queries

• If you receive a message from….

– Wendy (Winifred Myers) about Billing & Documentation

– RN/MA about patient question

… send a reply back to close the loop of communication

LAB ORDERS AFTER PATIENT VISIT

If labs orders are added after patient leaves- the order must be printed and given to Jillian.

Jillian then writes “ADD ON ORDER” and sends to the lab. If this is not done, the lab can process the late order.

“Left without Being Seen”

• If patient roomed by MA but left the office before you could see them:

– Do NOT cancel the encounter | Not “erroneous encounter”

– Delete any pre-charting

– Type: “patient left without being seen” in a note

– Level of Service “E1”

– Visit Dx: “Left without being seen”

– The IMC will bill insurance for facility charge

Colorectal Cancer Screening Project

• Cologuard is an option now

• If you order Cologuard for your patients, please place .imccologuard in the “Patient Instructions” section of the AVS. It explains a little about the test, provides necessary phone numbers, and gives them a link to watch a video about how to collect the sample

• Give order to nursing staff

• New Talking Point cards are being printed

Closing IMC Encounters

• Notes should be completed by end of day and MUST be completed within 24 hours.

• Billing of notes occurs day following encounter.

• Resident and patient safety concerns

Result Notes

• Result notes should be placed on all results obtained from patients in the IMC.

IMC Box Coverage

• “Buddy” system– When on CCU

• Can cover your own box but NOT a 2nd person’s box

– When on an elective (including research, “off campus” electives such as rheum, derm, endo) or Night Float• Still expected to cover your own box & buddy if needed

– If you and your buddy are both unable to cover your box – YOU are responsible to finding different box coverage and informing Lisa Geerand Nuge

– Do not try to cover your own box when on ICU – it never works

Lidocaine Patches

• Never Covered….

• Try lidocaine cream 3% or 4% first if want to use lidocaine

LEP Patients (Limited English Proficiency)

• Call CJ to schedule as office process in place to ensure not too many scheduled at same time

IMC: Non-English speaking patients

• Remember to use dot phrase

– .interpreter (if interpreter used)

– .interpreter declined (if patient declined interpreter)

IMC Box Coverage

• Other than the instances where you need your box covered

– You should be going through your EPIC inbox DAILY

– If busy, prioritize tasks:

• Refill requests

• Patient calls

• Urgent issues/concerns from support staff

– This is a professional responsibility and extremely important for patient care

IMC Patient Calls & Refills

• Ask about refills when seeing patient in the office (even if you aren’t their PCP)

• Refill meds for 6 months to 1 year at a time depending on circumstances

• Issues with patients calling multiple time for med refills, etc

• Reminder– If you aren’t sure what to do with a certain refill request or

patient call PLEASE ask a senior resident or one of the faculty (we’d be happy to help!)

IMC Telephone Encounters

• Front staff now trained to review and address encounters routed to them– If scheduling/clerical issue

• route encounter to “front desk” pool

– If clinical issue or URGENT issue• route encounter to “clinical staff” pool

• Reminder:– If you reply to a telephone encounter and click “route

to sender” you also need to route back to the entire pool (in case sender is off for vacation, etc)

IMC: Sending Patients to ER

• Make sure to document in your note:

– Patient was transferred to the ER by IMC nurse via wheelchair

Rx Fund For Indigent IMC Patients

• Set up by Lisa Geer and Elizabeth Puckett in association with Akron Health Mart Pharmacy

• For patients who:– Need meds and have exhausted all possibilities for

coverage– Have an immediate need for an Rx and cannot pay

• If you have a patient that meets one of the criteria:– Notify Elizabeth so she can call the pharmacy– If e-prescribing, add a note to the Rx before sending

Parking Passes for IMC

• Elizabeth has parking passes for any patients who need them

• Obtained from the Schneider Fund

ICU & CCU

CCU and ICU Census

• CCU census– 1 PGY1: 5 patient maximum– 2 PGY1’s: 10 patient maximum– CCU teaching attending responsible for cutting list– New ACH CCUres in addition to ACH CCU list (similar to cutting lists in ICU)

• ICU census– 3 PGY1’s: senior reduces list to 15 patients– 2 PGY1s but 3 Seniors -> senior reduces list to 15 patients– 2 PGY1’s but 2 Seniors -> senior reduces list to 12 patients

CCU and ICU Transfer Notes

Transfer Notes need to be accurate

“see today’s progress note” is not acceptable

You do NOT need to put summary of patient course

Remember to Log Procedures

Transitioning When Fatigued

• Protocol in place– Posted on website at top of monthly conference

calendars

– Review Dr. Sweets Presentation from 1/2/19

• To summarize…– If you’re too tired to work or care for patients

• Call/notify chief +/- Dr. Sweet

• If overnight—– Notify the most senior resident on

– Still call the chief or Dr. Sweet

Miscellaneous

PGY3’s: Medical Licenses

• If you have not started the process start ASAP as it can take several months depending on which state

– Usually busier/longer delay after February

• See Nuge, Joel Rayl, or Kamal Dayal with any questions or estimates on cost

Patient Health Information

Please do not to leave any PHI in public areas – including patient lists left in Cafeteria sign out room

Need a Notary?

Val (Department of Medicine Secreatary) and Elizabeth (Social Work) are certified notaries!

Noon Conference

• Mandatory

• Monday through Friday

• Usually in PCS Basement Auditorium

• Starts at 12- please try to be on time

• Calendar posted on website

Find us Online!

www.summalearner.com

www.facebook.com/IMSumma

Summa Sports Group: Search #IMSummaSports on Facebook

QUESTIONS??

Michael Nguyen “Nuge”, MD

Cell: 937-418-6653

Office: 330-375-3735

Pager: 330-971-0147