Stroke (Putnam) Junior

STROKE JUNIOR

The Stroke service is dynamic and works with cutting edge therapies.  This rotation will help to develop your diagnostic and examination techniques as you begin your training as a neurologist. It will also help with localization and neuroanatomy!

General Logistics

  • The patient list you will be using is “_Neurology-Putnam Service”.  Please note, this is NOT the same as the “Neurology Stroke Consult” or “Neurology Stroke Service” lists.

  • Always carry Mobile Heartbeat!

Schedule

6-6:30 AM Arrive in the 8HN Stroke Resident WorkRoom, and get signout from JNF.

     Sign back in your pager and sign over care team tab! Preround on all of your

     patients (check vital signs, examine the patients, give them updates from overnight

     events, review results of studies from overnight)

7 AM Work rounds with the NPs in the 8HS conference room.  These are quick rounds

     where you go over major/active medical and neurological issues, and talk about

     tasks that need to be completed for the day (imaging, procedures, etc.)

7:30 AM attending/fellow/team rounds Start in 8HN Stroke Resident Work Room

     Rounds until 10:30, interrupted by Chief of Service on Wednesday 8-10:30 AM.  ANF

     will present overnight admissions first, and then the day team will present

      yesterday’s admissions and follow-ups.

12 PM noon conference *required* in 8HS conference room

1-6 PM Day work, Admissions, Discharges

6 PM signout overnight tasks and contingencies to JNF.  Sign over pager to 82576.

*If you are done with your work early, and the rest of the team does not need your help, you can ask the other residents if you can signout to them.

 

Admissions

  • Admissions are done on a floating system; the senior will distribute the admissions as appropriate. The day team will admit any patient between 5:30 AM and 5 PM.

  • 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)

  • 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

  • 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.

Weekends

  • On Sunday, you will work as Junior/Senior with the help of a stroke fellow, as well as an anesthesia intern.

  • It will be your job to manage the task list for ALL patients, and supervise the anesthesia intern as well.

  • Admissions will be split between you and the anesthesia intern.

  • The attending will arrive around 7:30am for rounds (there are no “work rounds”)

  • 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)

  • You will send an email signout to the senior at the end of the day.

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

  • Post-TPA patients are also a special subset of patients you’ll take care of on the stroke service. The most important things to remember about post tPA patients are:

  • No aspirin or pharmacologic DVT prophylaxis until the 24hr HCT is done and does not have hemorrhage

  • Minimize invasive procedures (including foley), post tPA

  • Rescan for ANY change in exam or severe headache. (In general for stroke patients, you should have a low threshold to scan if they’ve had a change in exam).

  • Lifewatch is an outpatient cardiac monitoring unit, which are frequently given to stroke patients on discharge to look for occult afib/aflutter. If you do not have an account, please email Heather Luke <luke@gobio.com>, who is our representative and can help you set up an account.

  • 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.