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VA NIGHT FLOAT ORIENTATION DEPARTMENT OF HOSPITAL & SPECIALTY VA Portland Health Care System – updated Nov 2020 –

Orientation materials are also available online: VA DHSM Sharepoint IMResPDX OHSU MedHub

GM ATTENDING ROTATION LEADERS Kyle Kent (site director) office 5-1061 pager (503) 237-0846 cell (503) 422-9466 Anne Smeraglio (director quality and safety education) office (650) 493-5000 x65490 pager (503) 202-0850 cell (503) 686-0683 Shona Hunsaker (section chief) office 5-7632 pager *41-3008 cell (503) 703-7997

RESIDENT COORDINATORS Smitha Rejoy 5-6245 e-mail: [email protected] Adam Trabka (backup) 5-9822

CHIEF RESIDENTS AmIOn (login = vaportland or ohsu im) or OHSU operator (4-9000) to identify the Chief Resident On-Call Office: VA Building 101, Rm 102 Email: [email protected] Joel Burnett pager 25201 office 5-6095 Edward Maldonado pager 25591 office 5-5742 Kelsi Manley pager 25617 office 5-2115 Matthew O’Donnell pager 25770 office 5-2251 ***ANY EXPECTED ABSENCES MUST BE REPORTED via a PAGE to ON CALL CHIEF RESIDENT. *** (Please include your name and a callback number)

IMPORTANT LOCATIONS IMPORTANT NUMBERS Morning and evening sign-out rounds: Bed control/AOD 5-5424 or 5-5425 By Phone/Teams ED 5-5438 Team rooms: Code: Triage/CHS On-Call *41-2810 GM1 8D-111 4125* GM2 6D-107 8641* (Temp 7C-109, door code i227*) GM3 5D-135 3525* GM4 6D-125 1357* (Temp 7C-133B, door code 2733*) GM5 8D-112 4125* NF 9C-123 no code Call rooms (key in 9C123): 7C-101 (resident), 5D-148c Call room linens – should be changed daily, if not please call x54300 and someone from housekeeping should be able to help you.

PERSONAL PROTECTIVE EQUIPMENT (PPE) o Please watch the latest video for VA ward specifics to make sure you are up to date o Please review the latest VA PPE document TABLE OF CONTENTS: PAGE Learning Objectives 3-4 Educational Resources 5 Evaluation and Feedback 5 Roles Intern and Resident 6 Supervision 6 Admissions 6-7 Schedule 7 Bounce-Back Policy 8 admission 8 Caps 8 In the wee hours of the morning 8 Morning Sign Out Rounds 9 Documentation requirements 10 COVID testing 11 Code/RRT coverage 11-12 Tips for Night Float Success 13 Jeopardy 13 Executive Summary – Format for Giving Morning Sign Out 14

Learning Objectives

Interns • Evaluate chest pain • Initiate effective diuretic regimen to treat decompensated • Evaluate respiratory distress • Initiate appropriate therapy for a COPD exacerbation • Evaluate AKI utilizing the prerenal, intrinsic, postrenal framework • Titrate basal bolus insulin therapy • Initiate appropriate antibiotics based on type of • Initiate appropriate antibiotics for • Initiate diagnostic evaluation for • Initiate and titrate multimodal pain control therapies • Interpret ECG in a systematic fashion • Interpret chest x-ray in a systematic fashion

• Obtain a hypothesis-driven history • Perform a targeted, hypothesis-driven • Develop prioritized differential diagnoses • Deliver appropriate, succinct, hypothesis-driven oral presentations • Perform an accurate reconciliation • Provide accurate, complete, and timely documentation • Utilize patient friendly language at the bedside • Identify clinical questions and access medical information resources • Seek assistance or guidance from resident or attending when appropriate • Communicate effectively and professionally with interdisciplinary team members (RN, pharmacy, SW) • Use feedback to improve performance • Triage and execute daily tasks efficiently

Learning Objectives

Senior Residents

• Manage and escalate care in a patient with unstable • Manage withdrawal (alcohol or opioids) • Recommend appropriate risk stratification for admitted with chest pain • Manage /atrial flutter • Manage decompensated heart failure • Manage respiratory failure • Manage decompensated cirrhosis • Manage GI bleed • Manage • Initiate and tailor antibiotics appropriately based on clinical course and culture data • Provide comfort care at the end of life

• Obtain subtle, sensitive, and complicated information that may not be volunteered by the patient including use of ancillary sources • Modify differential diagnosis and care plan based on clinical course and data as appropriate • Integrate evidence into clinical decision making • Teach learners on rounds • Communicate effectively and efficiently with patients (teach back, leading family meetings, etc.) • Engage in collaborative communication with all members of the health care team including consultants and ED staff • Author timely documentation that clearly and succinctly conveys medical decision making • Seek assistance or guidance from attending when appropriate • Anticipate and coordinate care transitions within the hospital and at discharge • Minimize unnecessary care including tests • Manage the team to ensure efficient completion of daily tasks

Educational Resources

• High yield landmark articles on IMRESPDX by specialty as well as Med Ed for teaching tips • UpToDate – quick guidance for differential diagnosis and appropriate work up • DynaMed Plus – quick evidence summary to round out your treatment plans, appraisal is done for you • Pocket Medicine – great “approach to” tables for thinks like respiratory failure, hyponatremia, etc

Evaluation and feedback You will receive feedback on your admissions and cross cover via attendings adding you as an additional signer to their notes. Please read their notes to see what they continued and what they changed.

You will receive some on the fly feedback during morning sign out rounds about your management and presentations.

You will receive evaluations in MedHub.

You will fill out evaluations in MedHub on one another.

The goal is to provide information on what a learner is doing well and what they can focus on to continue to improve. You will learn more than the conditions and skills listed on your evaluation, but these are the things we have chosen to sample to get a sense of your progress.

Roles: • Intern: o Priority is to provide excellent cross cover, including leaving notes where appropriate. Hint: If you saw the patient or made a significant clinical maneuver (such as starting antibiotics) write an INPAT – CROSS COVERAGE NOTE. ▪ Set your default list to “teamgmall” so you can see all patients in one place (safest when you are entering orders if there is more than one patient with the same last name) o Admit new patients with the guidance of the resident. Note template that pops up when you open the note titled INPAT – MED – Hist&Phys. o Enter Life Sustaining Treatment Plan (LST) note on relevant patients (see documentation requirements below for further details) o Either intern or resident may present new patients, provided they are done in a succinct fashion. The focus is to explain what you think is going on and why, major diagnostic considerations, what actions you took, and what results may be pending vs what actions you considered but did not actually take. Practice this with your resident. • Resident: o Direct the admission of new patients. o Write brief resident admit note using the template that pops up when you open the note titled INPAT – MED – RES – ADMIT. If resident writes the admit note for a patient, you MUST use the note template INPAT – MED – Hist&Phys per hospital policy. o Assist the intern with cross cover issues. o Role model succinct “executive summary” patient presentations. o Teach!

Supervision: • The team attending for each patient is always available when you are on service. Indications to contact the attending: any ICU transfers, AMA discharges, unexpected deaths, procedures, and significant changes in clinical status. If the thought occurs to you to call the attending, you should probably call the attending. (Attending cell phone numbers are usually written on the white boards in team rooms or listed on amion.) • For questions regarding new admissions call or page the attending on the team who will be receiving that patient. • The CHS nocturnist is also available on-site during night hours to answer any questions at *41-2810.

Admissions: • The night float team is open for 6 admissions alternating with the CHS nocturnist. • The intern can admit up to 5 patients and the resident will complete the 6th admission. • If it is a busy cross cover night, the resident may elect to do more admissions solo without the intern writing an H&P. • The AOD will alert the accepting resident of the team assignment for each patient. If extenuating circumstances make you believe assignments should be changed please discuss with the CHS nocturnist and the AOD. • There may be occasional patients who have been signed out to a late team but hit the floor after 7 PM, in these cases the Late Call resident will notify the AOD that the patient will be admitted by Night Float and they will give you verbal sign out on what they know about the patient. • “Hit-the-Floor Time” Admit Flow (No Going to the ED) o Details: ▪ Resident teams CANNOT go to the ED. ▪ Patient will not be assigned a team/signed out until they are coming to the floor within 15-30 mins. ▪ Day call: • Patient must arrive on the floor by 15:00. If after 15:00, team will call AOD to re-assign to late call, and will give sign out to new accepting team. *Day Weekend is 14:00. ▪ Late call: • Patient must arrive on the floor by 19:00. If after 19:00, team will call AOD to re-assign to night float, and will give sign out to night float. ▪ Night Float: • No change to cap: 6 patients/night • Patient must arrive on the floor by 05:30. All admits between 05:30-07:00 will get holding orders and be signed out to day team(s) to complete the admission. ▪ Per usual, you’ll be alerted to direct admits from clinic or outside transfers via a note in CPRS with the details gathered by the doc who took the call. Verbal heads up is not required in these instances and will likely be rare. ▪ Precautions reminder - If ED wants to admit a patient to Enhanced Respiratory Precautions (Purple) they call and discuss with CHS. If both agree patient can be admitted to Enhanced Standard Precautions the patient is admitted to the next GM or CHS team up in the admitting cycle. If there is no consensus after the conversation and ED requests Enhanced Respiratory Precautions the patient will be admitted to CHS. If the ED is admitting a patient to you and thinks they might need to be on Enhanced Respiratory Precautions please direct them to discuss with CHS. If you have concerns about the level of precautions please call the relevant GM attending to discuss and have them call CHS if appropriate. Remember, Enhanced Standard Precautions are designed to keep providers low risk exposures even if exposed to a patient with COVID.

Schedule: • Arrival Time: 19:00 • Departure Time: 08:00 • When you first arrive: Go to 9C123 (your workroom) where you’ll print hard copies of the sign out for GM1-5 using the Shift Handoff Tool in CPRS and receive verbal sign-out from the day teams by phone or Teams (you all have webcams). There are late teams who may sign-out to you after this time, as they may be still admitting. If you do not hear from them by 21:00, FIND THEM. Please notify the chief residents if any house-staff are not leaving on time. • Please use 2 workstations so daytime CHS/GM attendings can use the other 2 workstations. • Printer in the room is - FPC7/MED-6C100vista/LP6C100PRT. • Follow steps per “Printers” flyer on the wall. If for some reason it doesn’t work you can also print at the 9C Nurses Station - PT1009CMAR.

Bounce Back Policy: The default is that there are NO BOUNCE BACKS. If a patient is discharged and readmitted or transferred to the ICU and comes back to the ward the patient will go to the admitting team who is up for an admission. Trying to get patients back onto the same team causes a lot of problems with our admission capacity and flow. If a team would like to take a patient back onto their service because it is in the best interest of the patient they can work with Kyle Kent or Shona Hunsaker and AOD (extension 5-5424) to make this happen. If the team is admitting that day the patient will count as an admit, if team is not admitting that day the patient will count as an admission for the GM team who is accepting the patient that day and then transfer to the desired team the following morning but not count as an admit that morning.

Hip fracture admissions: These patients go to CHS by policy.

Caps: Each team should have no more than 14 patients at end of day. The team can flex above 14 during the day if there are pending discharges. Of course, it is more than team census that determines how busy each team is. Anytime a team is stretched to the point that patient care or mental health is at risk, they can/should close to admissions. If such a situation arises, the team attending should work with Kyle Kent and Shona Hunsaker to develop a plan for diverting admissions to other teams (this is not your job).

In the wee hours of the morning: • Residents should review with the intern any interventions the intern has made on cross cover patients or other concerns that they have. You will be providing feedback to the day teams (see below) so please review any problems/concerns/congratulations the intern has regarding day care. • Take a moment to reflect on the shift and provide brief, specific feedback to one another. If either party feels things should go differently the next night, discuss. • New admissions that hit the floor after 05:30 will be “tuck-in” only. This means: o Eyeball the patient to ensure stability. o Place a set of basic holding orders to include admitting team, call parameters, diet (if appropriate), morning meds, vitals/activity, AM labs you think should be drawn. o If a patient is admitted after 05:30 and is quite sick, spend more time with them and stabilize as much as possible. Alter your AM sign-out rounds such that the receiving team hears about them promptly. • Conduct morning sign-out rounds (see below)

Morning Sign-out Rounds: • Time: 07:15-08:00 • Location: By phone vs Teams using webcam if you prefer • You will call teams in a staggered fashion for sign-out: o 07:15 Intern Solo o 07:25 Day 1 o 07:35 Day 2 o 07:45 Late 1 o 07:50 Late 2 • Keep in mind the main goal of sign-out rounds: Primarily to provide structured sign-out—data show that patient care is improved when sign-out is formalized (e.g. sign-out new patients from night float to day teams, then day teams to night teams). Secondarily, provide education to night float team. • Sign-out to each team should take no more than ~10 minutes for discussion of cross-cover issues and up to 2 new patients • Sign-out to each team should start with cross-cover o NF intern should write down everything that they are called about on cross-cover patients overnight and tell the relevant teams. o Attending and residents should ask questions about the major cross-cover issues, highlight learning points. • Then move on to new admissions: resident or intern can do this, but prefer the intern. o Start with the sickest patient. o New patients are presented quickly – in style of the shorter resident note or “executive summary” style. i.e.,: Reason for admission, sick/not sick, few sentences of HPI, most pertinent PMH/meds/vitals/exam/labs only, assessment/plan. Highlight outstanding labs, other already ordered but pending tests, decisions that need to be made o Attending and residents will ask question about management, and attending may highlight a learning point • Late teams arrive at 07:45 – cross-cover sign out should take no more than 5 minutes • You leave by 08:00. • Attending may provide verbal feedback during/after sign out rounds and will add both NF resident and intern as additional signers to the attending admit note.

Documentation requirements: • For the first 5 admissions, interns will write the H+P, residents will write a brief resident admit note. • For the 6th admission, the resident will complete a single H+P. • Med Rec needs to be done using the APHID tool or by annotating the H&P. You can annotate your H&P with (taking & not taking). Please DO NOT delete any section of the med/rec they are required for coding. • Life Sustaining Treatment (LST) Plan note: o LST plans have replaced “code status”. o LST notes/orders do not auto-expire or discontinue when a patient changes level of care or goes from inpatient to outpatient. o This means that if a patient already has the LST note/orders and their wishes remain the same, you don’t have to write a new note or place new orders (just document in your H&P that you reviewed it). o For patients without the LST note/orders, the new note template is called the “Life Sustaining Treatment Plan”. o The LST note/orders should be done for all patients who are DNR and those who are high risk (meaning you wouldn’t be surprised if they had a major medical event within the next year – for reference 1/5 veterans admitted to the hospital will die within 1 year so documenting/confirming LST on pretty much everyone is a good idea). o The only mandatory questions are: ▪ Does the Veteran have decision-making capacity? (Question #1) ▪ What are the Veteran’s goals? (Question #5) ▪ What does the Veteran want done in emergencies where they DO NOT have a ? (Question # 6—lower portion) ▪ Do they consent to this LST plan? (Question # 8) o Once you finish the note, the LST orders will appear. o Attending co-signature is required within 24 hours. • iMed Consent needs to be completed prior to any transfusion or procedure (e.g. LP, paracentesis). • A procedure note must be on the chart before leaving the hospital; please use the procedure template. • Leave cross cover notes on any patient who requires in-person evaluation. The note should include a f/u plan, even if that plan is to wait for the AM team to f/u on issues.

COVID Testing: *DO NOT order rapid COVID (cepheid) tests without talking to the attending of record* If a patient develops symptoms after admission concerning for COVID please call the attending of record to discuss whether to test them. Otherwise you should never order a rapid COVID (cepheid) test on any patient. All tests for procedures/surgeries/ongoing AGPs/SNF discharges should be ordered by the day teams. If you are pushed to order a rapid test at night by the nursing staff please say no and if they have questions they can call Shona Hunsaker.

COVID Testing Order Menu Update – Cepheid Shortage – Help Preserve Our Supply- • Rapid (cepheid) testing is only approved for 1) Unscheduled admissions (ED, transfers or clinics) 2) Inpatients with acute symptoms consistent with COVID-19, After discussing with your attending 3) Inpatients undergoing an approved aerosol-generating procedure (AGP) scheduled with <48 hours’ notice and without a negative test in the prior 3 days • A test within the last 3 days is acceptable for all scheduled admissions, AGPs, and discharge to CLC:

Day of admission, Monday Tuesday Wednesday Thursday Friday Saturday Sunday AGP, discharge to CLC Earliest acceptable Prior Prior Prior Prior Prior Prior Prior COVID test result Friday Saturday Sunday Monday Tuesday Wednesday Thursday

• After 14 days inpatient and 2 negative tests, no further testing is indicated for inpatients • All other indications for testing (discharge, second test for PUI, AGP that is anticipated at least 2 days in advance) will be run at OHSU with results available the following day at 1400. Please plan accordingly.

Code/RRT coverage: • Senior Resident and Intern on Night Float are now carrying code/RRT pagers • Pagers – in black bin labeled “code pagers” in 9C-123, turn on if needed, wear these during your shifts and leave them in the bin when you leave each morning • Both senior resident and intern respond to codes/RRTs o Senior resident - can run them and enter the room once donned in PPE as below o Intern - must help from outside the room (limits exposure and PPE use) • Code/RRT leader – ICU is the designated leader but if you have started things and they’re going well they will try to back you up rather than always take over • PPE o Senior Resident must keep N95 or PAPR shroud on them all shift and bring it with them to codes/RRTs o Senior resident – please review the excel spreadsheet to see which mask you are approved for, please know this, list posted in 9C123 and in the ICU charge nurse’s office for reference o If you already have this mask bring it with you when you start your week o If you do not have your mask get one in the ICU Charge Nurse’s office 3D-186 before you start your shift (wear your surgical mask and eye protection - the office is in the back corner of the ICU through the door where you need to wear both) ▪ Write your vhapor name, unit (9C), and date on it ▪ If you need a PAPR you will be given a shroud to pack around with you (it’s bulky but this is the only way to ensure providers can respond) ▪ If you need a PAPR tell the ICU charge nurse in person or by phone 58556, (alternative, ICU front desk 55056) at the start of your week Sunday night to keep an extra PAPR set up on the code cart for the week ▪ All VA employees are asked to shave facial hair to enable the use of N-95s, PAPRs are only for people who have failed N-95 fit testing or who are not fit tested o Upon arrival to code/RRT – senior resident must be donned in appropriate PPE before entering the room ▪ If PAPR – you must wait for the code team to arrive to help you don, you can direct care from outside the room while waiting ▪ If N-95 • Take surgical mask off and put N-95 on • Keep goggles on • Add faceshield • Gown • Gloves ▪ If code/RRT is off the ward (radiology, lobby, etc), wait until code team arrives, don PPE, then provide direct care ▪ Procedures for codes/RRTs attached if you’d like to review, the code committee has approved your participation, the documents will soon be updated to include you as part of the team o Doffing – this is the highest risk time for contaminating yourself ▪ Please review steps in PPE video, starts 9 mins in ▪ Code team gatekeeper will also help guide you through these steps so listen to what they say o Decontaminating – N95s and PAPRs (PLEASE DON’T THROW AWAY) ▪ Code team/charge nurses will help you with this ▪ PAPR decontaminating steps per attachment ▪ N-95 we put these into brown paper bags with your vhaporname, unit (9C), and date so they can go through UV decontamination and be re-used in the future if needed o Need a new N-95 ▪ Go back to ICU Charge Nurse’s office 3D-186, sign out another N-95, label as above, keep it on you o Give your PAPR shroud back to the ICU Charge Nurse at the end of your week o If you don’t use an N-95 mask you MUST keep it in a safe place (at work or at home) so you can use it the next time you are on a VA rotation where you’ll need it (help us save PPE)

Tips for Night Float Success: • An outstanding doctor has a sense of their limits and is not hesitant to call for help. • Attendings consistently want to know about any patient that will be “leaving the list”, such as deaths, ICU transfers, AMA discharges, or transfers to a different service. • Feel free to call for help with decision making (“should I make the MRI tech come in?”) or difficulty getting through red tape (a consultant will not see your patient). Your attending will be gracious and at least try to help. • Anticipate. • Identify patients as “sick” or “not sick”. Always alert team members at the time of sign out if a patient is “sick.” • Get to know the names of the nursing staff. Remember to use closed-loop communication when effecting plans that require action from multiple members of the patient care team.

Jeopardy: In the event of unexpected illness or a significant event where housestaff are unable to attend to their previously scheduled duties, there is a Jeopardy system in place. The primary purpose of the Jeopardy system is to ensure patient safety while allowing housestaff to attend to personal and family emergencies. Housestaff should report unplanned absences to the Chief Resident on Call so that Jeopardy can be mobilized. The Chief on Call is found at the top of the Internal Medicine Amion page. The Chief on Call should be paged with the name of the person and their contact information. Housestaff should expect to receive a phone call from the Chief on Call. Email is not an appropriate means to communicate an unexpected absence. Paging should be used for any communication that requires prompt reply (within less than 24 hours).

Night Float Sign Out – Executive Summary Style

Please use this template to deliver your new patient sign outs in an “executive summary” format. Your presentations should be thorough, yet concise, and focus on the key features of the patient’s presentation and diagnostic workup that influenced your decision making. You should identify your areas of uncertainty and action items for the accepting team. Goal presentation time is less than 4 minutes.

Orienting statement (Permission to spoil the surprise!) • Mr. Jones is a 65 yo M admitted for heart failure and AKI Presenting symptoms/story • 3-5 sentences, <1 minute Pertinent ED course • usually only abnormal vitals and major interventions, otherwise skip PMH/FH/SH/Meds • only if relevant to HPI and impacting management Vital signs/Physical exam • pertinent positives and negatives only Labs/EKG/Imaging • key results that impacted your decision making Summary statement • 1 sentence summary to frame case • use words like “acute” “subacute” “progressive” • get here in 2 minutes • only for main problems • what do you think is going on and why? • what else did you consider and why are these diagnoses less likely? • where does your uncertainty exist? • (be direct about elements of the case that don’t fit or give you angst) What did you do for the patient? • furosemide 80mg IV, 1L UOP since What needs to be followed up? • TTE ordered, troponin pending, ID needs to be called Other pertinent issues • HTN – lisinopril held in the setting of • DM2 – home glargine dose decreased What questions does the accepting team have? • get here by 4 minutes