Stroke (Putnam Service) Senior

This is a high through-put service where the patients are sick with neurological and medical problems.  You will balance managing four juniors (1 Neuro PGY2, 1 Medicine PGY2, and 2 Anesthesia interns), with teaching the medical students.

General Logistics

  • Login to the stroke seniordynamic role on mobile heart beat and instruct teams they can contact you that way instead of the pager.
  • The stroke list is “_Neurology-Putnam Service”. Each morning, print two lists for the attending and the fellow.
  • There is no set long call schedule; you will be responsible for distributing admissions according to each patient’s workload, and neurological/medical complexity. Try to balance giving the rotators neurologically interesting patients, with not overloading them with very challenging cases.
  • At the beginning of the rotation, please give an overview of the expectations for each person on the team. Anesthesia interns need attention.  Many of them have not done floor rotations with Adult patients before, even later in the year (they are primarily in the ICU, OR, and CHONY).
  • Each week, please send the Medicine PGY2 to stroke consult for an afternoon, so they can see how a stroke code is run. It usually is easiest to coordinate the on the day that they are in clinic, because the other juniors will be covering their patients in the morning anyway, and then the Medicine PGY2 can follow the Stroke consult patient in the afternoon.
  • If the anesthesia residents want to do the same, you can ask them to cover each other’s patients for the afternoon.
  • Please help the consult resident acquire beds if necessary. In the same vein, try to expedite patients getting out of stepdown every day.  Changing the nursing orders for floor vitals and Neuro exams does not equate to getting them out of Stepdown, and it may require reminders to the charge nurse.

 

Weekday Schedule

~6:30 AM Chart round on your patients, and check Stroke attending and consultant

     notes.

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.

11:15 AM Interdisciplinary Rounds in 8HS conf room. DO NOT BE LATE.  *PGY2 should

     present their patients once a week at this.

12 PM noon conference in 8HS conference room *Please hold your juniors’ pagers and

     MHB during noon conference and COS*

1-5 PM Help with day work, admissions, discharges, teaching

5 PM Last admission at 5 PM. Stroke senior can leave if there are no more admissions, and juniors are in a good place.

 

WEEKENDS: 

Saturday: You plus one of the anesthesia interns. Admit until 5pm, sign out to 24hr call person. Please send a written signout to the ward senior covering on Sunday as they will be senior for both teams.

Sunday: PGY2, anesthesia intern, stroke fellow. Admit until 4pm sign out to JNF at 5.

 

Other Helpful Tips

  • Most seniors run the list with their juniors once after rounds, and again sometime in the mid-afternoon.
  • Some have found it helpful to turn on the “Flag New” tab in Eclypsis, to monitor New Orders placed by juniors. (and New Results)
  • Review overnight signout and contingency plans with juniors, especially for rotators, and especially at the beginning of the rotation.
  • Review new admissions with all juniors, with more attention to the rotators. You must check the rotators exam.
  • Try to make time to teach the med students. It is better for their learning if they are paired with the Neuro PGY2 if possible.
  • Keep your own list of all the patients on the service for the month, to help with post-discharge follow-up if necessary, but also events for M+M.
  • Find a system that works for you to keep track of things like DVT ppx, PT/OT/rehab recs, the status of the antiplatelet/statin, etc. Some people use the handoff tab and keep everything organized there. Part of your job as senior is to make sure all the correct things are ordered and on stroke there is lots of repetition.
  • Please make sure to go over the discharge summaries and (in particular) med recs before discharge. This is not always necessary for the PGY2s, but is especially important for the interns.
  • Talk to the social workers early and often! As soon as a patient is admitted you want to be thinking about what needs to be done to discharge them. If people can’t be discharged, it’s basically disastrous for the stroke service because the census builds up quickly.
  • 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.
  • At the end of the rotation, ask for feedback! You should get feedback from the stroke fellow and attendings you work with.