Ward (Merritt) Junior

MERRITT/WARD SERVICE JUNIOR

Welcome to the Inpatient Neurology Merritt Service Rotation! The reputation of the Neurological Institute as a world class medical facility derives in large part from its Neurology Ward Attendings, clinician-teachers who have established and maintained a tradition of excellence in patient care and medical education.  This rotation will help to develop your diagnostic and examination techniques as you begin your training as a neurologist.

 

General Logistics

  • Theward service is divided into two teams (A&B) with two different attendings (unless one attending is covering both teams).  Each team has a senior resident (PGY3 or 4), a junior resident, a psych or medicine rotator and variably, sub-interns and medical students.
  • Use the “_Neurology Merritt Service” list on Eclypsis

 

Schedule:

  • Every day, one team is on short call and the other is on long call.
  • The short call team admits overnight patients and any late admissions from the day prior.
  • The long call team admits during the day, for admissions that occur from 5:30am through 5pm(please note any very early morning admissions will be covered by ANF until you come in).

**One new feature of the two-team system is that both teams will be present for overnight admission presentations from 8-9am on Mondays and Fridays.

 

6-6:30 AM – Get signout from JNF.  Sign-in your pager, and sign over CARETEAM TAB.  Make sure you are signed into Mobile Heartbeat.

6:30-7:30 AM – Preround on patients­ (check vital signs, examine the patients, give them updates from overnight events, review results of studies from overnight)

7:30 am – work rounds with the residents and NPs in the 8HS Conference room

8-10:30/11 AM – rounds starting in 8HS conference room (or otherwise specified meeting place).  Start time will depend on if there are conferences that morning

  • Monday/Friday – start at 8 AM
  • Tuesday – start 9 AM after Neuroradiology rounds
  • Wednesday – start 8:30 AM, then resume after COS at 10 AM
  • Thursday – may start 8 or 9 AM depending on attending preference to attend Morning Report

10:30am – the time by which rounds should end to allow residents to start their work before morning conference

11 am – Senior resident goes to Interdisciplinary rounds

12 – 1 pm– Noon Conference *mandatory* Give your pager/MHB to your senior.

Afternoon – Floor Work and admissions (long call team)

5 pm – If long team is not too busy, short call team can signout to long call team.

6 pm – Long call team signs out to JNF (pager 82576)

 

Weekend Schedule:

  • You will either work a 24-hour shift on Saturday with a senior, or will have a “golden” weekend.
  • Signout is still 6-6:30 AM on Saturday. You will be responsible for pre-rounding on all patients on the list (unless the list is very long, and then your senior should help you).
  • Attending rounds start at 8 AM in 8HS conference room (there are no work rounds).
  • You will perform all admissions and procedures during the day.
  • At 5 PM, you will either become Admitting Night Float (if a PA is on, meaning you will admit to all neuro floor services), or Junior Night Float (if the ANF resident is on).
  • In the morning, you will give signout to the day teams if you are JNF.
  • You will present your admissions and leave by 9 AM.
  • Notes: Patients need Resident Progress Notes 6 days a week but attending progress notes 7 days a week.  Tell the attending which patients will not have resident notes that day so he/she knows to write a separate note on those patients. Exceptions include patients in the step down unit (notes 7 days a week) and patients who are new admissions (should have a progress note the next day)
  • “Sunday Ward Jr” is a role that you will usually not fill while on Ward. It will serve to pull an off-service PGY2 to help cover Ward on Sunday ONLY if the Saturday census is >15 people.

 

Overnight coverage:

  • Please remember to write event notes for any major event or clinical change.
  • You can talk to the NICU fellow or the service attending for concerns overnight.
  • If there are any questions about graduate service patients, you can always reach out to Dr. Lennihan (or the covering grad attending if she is on vacation).
  • Overnight, you should “check-in” with the Charge nurses of 8HN, 8HS, and the NICU to see what bed availability is and if there are any patients expected to arrive on the floor.  Be in touch with the consult resident on the weekend to know how many patients are waiting for beds.

 

Admissions

  • To put in admission orders, start with “Admit NYP Order Set”, then diagnosis-specific order sets – Ischemic stroke, SAH, ICH, post-thrombectomy, etc. This is important to maintain Comprehensive Stroke Center guidelines.
  • Remember to always include the following in your admit orders:
  • Resident name and pager
  • Activity order (i.e. OOB ad lib, OOB with assistance, bedrest, etc)
  • PT/OT/speech and swallow orders when appropriate
  • DVT Prophylaxis unless contraindicated
  • When admitting patients from the NICU, go to the ICU for face-to-face signout and examine the patient prior to them leaving the unit (this will help identify inappropriate transfers and address concerning exam findings prior to transfer to the floor)
  • If you are waiting on patients to arrive to the floor that you have admitted during the day or that you heard are coming in to be admitted, inform the JNF.  Make sure any patient you already admitted has pending orders.  The JNF should work to try to get these patients (especially tPA patients) up to the floor as soon as possible.
  • Outside of direct admissions or new NICU transfers (never been on the floor before), you do NOT need to write a full “neuro admission” note. This includes Admissions from the ED. Addending the consult note (exam and assessment/plan) will suffice.

 

Discharges

  • ALWAYS think about discharge – if a patient is going to leave the hospital soon, tell them “you may be discharged as early as tomorrow” – if you know a patient is going to be discharged the following day, start their discharge summary and talk to SW about what they need for dispo.
  • All new diagnoses of diabetes or patients with uncontrolled diabetes need a diabetes consult prior to discharge!
  • Please document the estimated date of discharge in your notes, as well with whom the EDD and plan was discussed.
  • Conditional Discharges:
    • This is an official discharge order that is good for 24hrs after it is placed. It is an order you place the day before for patients being discharged the next day based on some condition (ie. Steroids completed and patient stable; MRI completed and reviewed by team; SNF bed obtained).
    • BEFORE placing the discharge order the med rec and discharge summary must be complete. It is a good idea to start the discharge summary shortly after the patient is admitted so it doesn’t take as much time to complete.
    • When you place the order, please let the nurse know that you’ve put in the conditional discharge order. Please also let the patient know that you are anticipating they will be discharged tomorrow (pending condition). They should be ready to leave by 10am.
    • Before the nurses discharge the person they are supposed to close the loop and let you know the discharge condition has been met
    • Nurses should NOT be interpreting tests. So if the condition is an MRI is completed, they should let you know that the patient went for MRI and/or is back from MRI so that you can review the images as a team and decide on discharge.

 

Other Helpful tips:

  • The Ward attending is available at all times for questions/concerns.
  • Please review the trigger protocols (on niresidents.org) for when an attending should be notified within one hour of an event occurring.
  • Review all radiology (MRI, MRA, CT, etc) on your own, don’t just look at the reports!
  • 1:1s/cluster/restraints: 1. Please make sure in each signout under the “coverage to do” you indicate if the patient is on a 1:1/2:1/cluster/restraints and why.  2. 1:1 restraints are being renewed daily at 2pm.
  • Procedures:
    • Document Procedure and Consent Notes accurately
    • Give the RN advanced notice prior to doing a procedure (BEFORE asking the RN for Lidocaine!)
    • You MUST perform a signout with the RN.
    • When doing an LP, remember to log it into the “Procedures Log” in Medhub
    • Medical students should not be involved in lumbar punctures for CJD or blood draws for patients with hepatitis or HIV.
  • DUOTUBES MUST BE CONFIRMED BY RADIOLOGY PRIOR TO USE.
  • MED STUDENTS: This is a service with medical students!  You, as a junior resident, play a huge role in their medical education and professional development.  This is an important responsibility and one you are expected to take seriously.  Please make an effort to engage them and give them opportunities to participate in patient care. You also get the chance to serve as an advocate for Neurology!