Ward (Merritt) Senior

Please login to your dynamic role as ward senior on MHB and tell other teams they can find you there.

Here are a few new things to note:

  1. Conditional discharges are active. Patients who can be discharged the following day (or later the same day pending tests) should have a conditional discharge order placed.  This is an official discharge order that is valid for 24hrs, pending conditions are met (ie: Steroids completed and patient stable).

–Nurses should be closing the loop with either you or your junior that the condition was met prior to discharging the patient.

–if you change your mind about discharge, make sure you d/c the conditional discharge order.

  1. Work rounds should include explicit statements about who can go today or tomorrow (and should get a conditional discharge). The short call team should run the list with the attending again after PM rounds finish to identify any other patients who can likely go the following day.

  1. Estimated date of discharge: be sure you are talking to patients about this and that the juniors are putting this in their notes along with a line about why the patient needs to remain in the hospital.

These are the main tenets of the new ward system: 

  1. You and your junior are a team so you should always be together (except on the weekends) – If there are any discrepancies in the call schedule where it says the junior is long call with the opposite senior (I try not to do this, but sometimes mistakes happen), the juniors schedule is usually the right one. Please ask if you notice this.

  1. Short call ALWAYS admits overnights(and rounds in the morning) – regardless of how many days in a row you are on short call. IF there is a big discrepancy in the number of patients on a team, the long call team could potentially help out and take some overnights.

  1. Conversely,long call ALWAYS admits during the day(and rounds in the afternoon). Please check the clinic schedule, because the long call resident is often in clinic in the morning. If this is the case, your co-resident will present your patients at social work rounds, so please give them signout on what needs to be addressed.

  1. Medicine rotators are off on the weekend. To account for the loss of a rotator on Sunday, we’ll be bringing in a PGY2 on clinic block for a short call.

  1. Weekends are staffed as one single team. Admissions should stay on the team of the resident who admitted them, unless things are very unbalanced (> ~5 patients different) and then you can make some rearrangements. Just make sure it is very clear who is going to what team.

  1. Please keep a list of all patients on your service. For M+M we may try something new where we identify the number of ED admits vs. direct admits, etc. and the different diagnoses seen on the ward service.

  1. Please keep track of the OSH transfers that are pending. This should be much easier with teletracking access. You should have a running list of these people and each day one of you should be responsible for touching base with the transfer center to see what the status of the patient is / if they have a bed. The goal of this is to help stay on top of how many pending OSH transfers there are – if, on Saturday afternoon you realize there are 6 OSH transfers, it might be helpful to discuss with the transfer center if any of them can be held until the following day when the whole team comes in.

  1. A word about neuro-onc patients: If it is a patient known to neuro-oncology, you can just communicate directly with the attending neuro-oncologist without using the resident as a go-between. Residents for the most part are not writing notes on ward patients.

Two things that have come up with afternoon rounds:

  1. All patients should have a discharge plan that can be communicated to SW in the morning, even if attending rounds are in the afternoon.By the end of afternoon rounds, you should know who can go home the next day and what are barriers to discharge. If there are questions, you should touch base in the morning with the attending.

  1. Just because rounds are in the afternoon, prerounding should still happen before work rounds. Also, notes should be done before noon conference (ideally for everyone, but especially for the long call team). Please make sure the juniors are not waiting until after rounds to write their progress notes. That defeats the purpose.

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Here is an outline of the teams and structure of the day:

Long call team: responsible for admissions that occur from about 6-6:30am through 5pm.

** You should touch base with the attending in the morning about potential discharges so that you have this information for SW rounds.

  • 7:30am-8:00am – work rounds in the 8HS conference room: this will occur with BOTH TEAMS so that all the residents can hear at least a one liner on patients as they are likely going to have to cover at some point. This will include the NPs and care coordinators as well.

  • 8:00am-12:00pm – conferences (radiology rounds, COS, morning report if it’s quiet!), morning admissions, floor work for the junior residents, etc.

  • 11:15am – Social work rounds – the long call resident will present first

  • 12:00-1:00pm – Noon conference: Please hold your junior’s pager. They really should attend – and so should you!

  • 1:00-3:00pm: Attending rounds – you will present follow ups and any new admissions from the morning.

  • 3:00-5:00pm: Admissions, teaching if there is time!

  • 5:00pm – receive sign out from short call team if possible.

  • **The ward attending should be notified of all admissions to the ward service from 8am-8pm. This is just a brief one liner – not a fully staffed admission. 

Short call team: responsible for overnight admissions, no daytime admissions

  • 7:30am-8:00am – work rounds in the 8HS conference room: this will occur with BOTH TEAMS so that all the residents can hear at least a one liner on patients as they are likely going to have to cover at some point. This will include the NPs and care coordinators as well.

  • 8:00am-10:30am – attending rounds on overnight admissions, new admissions from late in the day prior, and follow ups. Rounds on Tuesday will go from 9:00-11:30 and from 8:00-8:30 and 9:30-11:00 on Wednesdays due to conferences

  • 11:20am – Social work rounds!

  • 12:00-1:00 – Noon conference!

  • 1:00-4:00 – juniors do floor work, teaching, family meetings, etc.

  • 5:00pm – Juniors can sign out to long call team if everything is wrapped up.

The expectation is that you will stay until at least 5pm when you are the long call senior and 4pm when you are the short call senior. If things are very light on a short call day, then you should do some teaching (med students or rotators or both). At the very beginning, you should be staying until sign out to supervise the residents signing out at least once. Even when you don’t stay until sign out, please remember to review sign out with the residents daily. Also, the psychiatry rotators are brand new interns – so they are going to need more supervision.

Weekends:

Saturdays – ward senior, 24hr call junior – rounds start at 8am. Your goal should be to help the junior get everything done as fast as possible so that they are in a good place going into the 24 hr call portion. We do not have many ANF moonlighters this year, so they will be both ANF and JNF.

Sundays – ward senior, both rotators. There is no stroke senior, so you should be there for stroke rounds at 7:30am. Ward rounds will start at 8am and you may leave stroke to go to ward rounds. Regardless of if the fellow is there or not, you are the senior for the day for both teams.

Notes on the weekends:

The attending should be given a list of notes to write on Saturday – this should include the patients for the resident who is on a golden weekend. The attending should not have more notes to write than the residents. I think 10 notes is reasonable for one resident to write in a weekend day. ALL patients in stepdown should have a note written by the residents.

On SUNDAY, the attending should not have to write notes on any new patient that he/she didn’t already write a note for on Saturday. If the list is less than 20, you can just divide all the notes up between the two rotators and the attending won’t have to write any of them. If it’s more than 20, they should still write the notes on the patients covered by the resident who is off.

Team reminders:

All patients should be prerounded on before work rounds.

Afternoon rounds mean that progress notes should be done in the morning. They can be addended after rounds if there is a major change in the plan of care. Procedures should also be done in the morning (and hopefully have some results back by the afternoon). Just because the team isn’t rounding until 1pm doesn’t mean the morning is “off”

Please remind the juniors to  include an estimated date of discharge in your notes and document that the team spoke to the family (if you did in fact speak with them) in their progress notes. It’s good to think about for you and it also helps families plan ahead.

If the consult team writes a full consult note, your team can write an admission accept note. The same is true for NICU transfers coming BACK to the ward service after a stay in the NICU. If it is the first time the patient is on the ward team, they should have an admission note. The exception to the consult note rule is that if the consult was staffed by the consult attending, there should be a separate neuro admission note written.

All patients admitted before midnight need a progress note the following day.

Please, please let me know if there are questions at any time! If you have time to teach with the new system, that would be great! The goal is to do one 5-10 minute chalk talk a week!