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Orientation 2014 viola

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Orientation 2014 viola

  1. 1. New Resident Orientation Mariel Smith MD Pediatric Chief Resident 2015-16
  2. 2. What Should You Learn At MSK?  Pediatric Oncology  Basics of Chemotherapy  Pain management  Nausea and vomiting  Electrolyte imbalances  Constipation  Antibiotic management  Infections from A-Z  Dermatologic findings  Fever and neutropenia  In addition, you will gain experience working with end-of-life issues and difficult family situations
  3. 3. Organization of clinical services  The entire 9th floor is devoted to Pediatrics  9th floor is divided into three areas:  Inpatient M9  PICU  Pediatric Day Hospital (the PDH)
  4. 4. Pediatric Day Hospital (PDH)  The PDH is the outpatient side of Pediatrics at MSK  Patients come to see their primary team for everything from check-ups to chemo to transfusions to procedures  The PDH sees >150 pts per day  Most of the floor admissions come directly from PDH
  5. 5. MSK Primary Teams  Patients are assigned a Primary Team (i.e., leukemia, neuroblastoma, sarcoma) based on their primary disease at diagnosis  Followed by Primary team throughout their disease course  While inpatient, primary team will give input on their care; the fellow is the liaison for this communication  Bone Marrow Transplant (BMT, Blue Team) is its own Primary Team
  6. 6. PICU, MICU  The PICU is a 5-bed unit  Manages all unstable patients w/ exception of patients requiring CVVH/Dialysis or Oscillation  Patients requiring renal exchange or escalation of respiratory support beyond standard mechanical ventilation are transferred to NYP Cornell PICU
  7. 7. Inpatient Team Structure Two Clinical Teams Green – General Oncology/Surgery Blue – Bone Marrow Transplant
  8. 8. M9 Inpatient Service GREEN Team – General Oncology/Surgery  Attending and Fellow (1st year)  2 PGY-3 Senior Resident from Downstate  3-5 PGY1/PGY2 residents from Cornell, St. Barnabas, Harlem, Lincoln…  3 Nurse Practitioners  Each NP works ~3 days/week  Most days: 1-2 NP on the team  Schedule is posted up in the workroom
  9. 9. M9 Inpatient Service BLUE Team – Bone Marrow Transplant (BMT)  One attending, one fellow  3-4 residents from Cornell, Downstate, Metropolitan…
  10. 10. Nurse Practitioners  Incredible resource: whom to call, how to get things done, great understanding of patient pathology  Will help senior resident with admission assignments/distribution of patients in the morning  Hours are 7am-7pm  They cap at 6 patients during the week  Include them when you are assigning NPs/Residents to cross cover patients when residents go to clinic  Don’t be shy!- Ask them questions, their office number is # 6403
  11. 11. Nurses  RNs at MSK know the kids and know the oncology  Many of the kids are well- known by the nurses  If they think something is wrong, it is wrong!  If they ask you to speak to the parents or the patient, GO!
  12. 12. Nurse Case Managers  The Nurse Case Managers are wizards with discharge and insurance issues  Devin Price and Lisa Nicholson  ESSENTIAL TO COMMUNICATE DISCHARGES TO THEM EARLY!
  13. 13. Green Team Senior Resident Supervises PGY-1 and PGY-2 residents on Green  Supervises AM and PM sign-out  Updates electronic hand-offs  Works with the fellow / attending to make sure plans are being carried out by residents  Facilitates rounds by checking labs, entering orders, updating hand off tab  Communicates problems/concerns about residents to chief resident, fellow and attending  Acts as ADMITTING RESIDENT
  14. 14. Sign out/Sign In  7 am: Sign Out/Sign In  Green: Supervised by the Green team Senior; Blue Team more individualized  Night float resident comes in at 6pm and leaves after sign out at around 8am  Blue On-call resident should leave by 8:30 am  Before Rounds:  Get your pager & locator from the drawer  Pre-Rounding:  Vital signs, I/Os, PCA doses/ attempts are only in the bedside chart  Review lab results and discuss problems or questions with the senior  RENEW ORDERS for IVF and all drips (PCA, zofran drip, etc.)
  15. 15. Labs/Phlebotomy  Most labs will be back by the time you arrive in the morning  You must order routine morning labs before signing out in the evening  AM Labs are drawn by the night nurses  All labs are drawn off of central lines, including blood cultures  When labs are needed at other times, ask the patient’s RN and enter the order in the computer  If a patient does not have central access the RNs will draw the labs  You will rarely have to attempt venipuncture at MSK
  16. 16. Rounds Attending Rounds - 9am  You MUST facilitate rounds by:  Being prepared to present on your patients  Helping to look up labs, move computers when your patients are not being presented  Who goes into the patient’s room?  The Senior and the Blue resident on-call for that night should always go into the room  All Green team housestaff unless patient is on special isolation precautions or indicated by family
  17. 17. Presentations on Rounds  Presenting: New Admissions  HPI, then summary of their Onc History (which you should have read carefully before presenting)  Presenting: Patients known to the team  One liner, then the rest of your presentation by systems  Relevant lab results only
  18. 18. Radiology Rounds  Mondays, Wednesdays and Fridays at 11am in the PDH Classroom  Review all radiology for the team for the past 24 hours with the pediatric attending radiologist  When your patient’s name is called, either you or the fellow will give a one-liner about who the patient is and why you got the study  Ex: “Maggie is a 2 year old girl with Stage IV neuroblastoma who was having increased vomiting and abdominal distention and that’s why we got the CT.”
  19. 19. Conferences  About 3-4 times per week at 1:30pm in PDH classroom or workroom  Lectures given by Attendings, Fellows and Chief Resident  Residents also give short interactive case presentations prior to the end of the block  Lecture schedule posted in call room  Grand Rounds Thursday mornings at 8:30am
  20. 20. Notes  Daily notes  You may copy/forward from previous notes BUT, you must UPDATE EVERY LINE, EVERY DAY!  Yes, the Attendings DO read and sign your notes!  DO NOT hit ‘resident complete’ or forward your note to the attending until you are absolutely 100% finished  Everything in your note should be clear and correct  Your assessment should be up-to-date and specific  Your plan should be listed by systems OR problems
  21. 21. Admissions  Green Team Residents: Expect to get at least one admission every day you are not in clinic  Admissions are assigned by the Admitting Senior  Blue Team: Admissions are less common  In general, you will decide among yourselves who will do which admission  Be kind and fair to each other
  22. 22. Admissions  Admissions from 9am-5pm come from the PDH after being assessed by the Primary team  Do not wait for the patient to arrive on the floor – go to the PDH to begin the admission process with your HPI, ROS and PE.  At night, they come from UCC after being assessed by the fellow on- call  UCC is the MSK Emergency Room; it is an ED, but for established MSK patients only  The fellow will discuss the patient and plan with you and the hospitalist.  If this does not happen, PAGE THE FELLOW!
  23. 23. Admissions  Use the M9 Admissions Sheet as a Guide  Review the most recent notes  Perform a careful HPI, ROS, review meds & allergies  Bridge any gaps in their history since the last note  Do NOT do a full PMHx with the pt/family (although make sure it is in your note)  Your plan will be discussed with the senior/fellow  Orders  Use the Admission Order set in the computer for admissions!  There are order sets for Blue and Green teams  For patients in PDH can write pending orders  ask the clerk to make an ‘overflow bed’  You must print 3 copies of the Code Sheet at admission (Google ‘cornell emergency medications’)
  24. 24. Discharges  Anticipate discharges so you can get prescriptions filled and follow-up appointments set-up early on  Use the M9 Discharges sheet as your guide  Prescriptions must be given to Pharmacy a day in advance  Communicate with the case managers; setting up home- care, getting supplies, etc. requires advance planning  Discharge orders and instructions are computerized in HIS  Discharge Notes/Hospital Courses must be started on ALL patients on HD #2 and updated EVERY TUESDAY/FRIDAY
  25. 25. Resident E-mail Account  Generic read-only e-mail accounts to improve communication  GREEN: login: pedoncres; pword: green123  BLUE: login: pedbmtres; pword:blue 123
  26. 26. Weekday Call  BLUE TEAM  On weekdays, call starts at 5 pm  On-call resident is responsible for all admissions to the floor posted after 4:30 pm  Call room and meal cards available  One fellow supervises both teams and Urgent Care Center  Fellow is available to you – if not, page him/her
  27. 27. PM Signout  Blue Team PM Sign-Out: 5pm  May start as early as 4:30pm only if the person on-call is done with their work  Do not be bullied into allowing early signout if you are still completing notes!  Give good signout – make sure electronic Hand-Off is updated  Indicate clearly what might happen, and what the resident on-call should do  If labs are expected, tell the on-call resident the time they will be drawn
  28. 28. Weekday Call BLUE  Responsibilities:  Check to make sure all AM labs are appropriate  “Midnight” rounds with on-call fellow  “AM rounds” – Check VS and I/O, record AM labs  record vitals on handoffs  Notes on all admissions  Print sign-out sheets from electronic hand-off tabs on all patients (labs and meds auto-populate)  If there is a problem, there is always an NP in the PICU who is happy to help
  29. 29. Weekend Call  BLUE TEAM  Sign-out at 7 am; rounds at 9 am  On-call resident responsible for:  Daily progress notes on all patients on the service  All admissions, discharges, and transfers with notes  Midnight rounds with on-call fellow  AM vitals & I/Os of all patients  One fellow per team (unlike weekdays)  Call room on the floor is provided; meal cards for dinner are provided  Cafeteria closes early on weekends
  30. 30. Weekend Call  Green Team: Short Call (7-6pm)  There are always two residents on call  Divide patients equally  Seniors on short call: this is not a supervisory role; just carry the patients and do the work
  31. 31. Call Schedules  Adheres to ACGME rules (<80 hours/ week)  Call schedules are made monthly by the Pediatric Chief Resident  Please let the Pediatric Chief Resident know if there are any conflicts, emergencies, illness as early as you can  Mariel Smith, MD  Pager #2244, Office 212-639-6005
  32. 32. Medication Reconciliation  Definition  A process for obtaining a complete and accurate list of the patients’ current home medications, including OTC’s and herbals, and comparing the practitioner’s admission, transfer, and/or discharge orders to that list.  Accurately and completely reconcile medications  Document a complete list of the patient’s current medications upon the patient’s admission to MSKCC  This process includes a comparison of the medications the organization provides at admission, transfer, and discharge to the medications on the list.  Instructions found in Resident Manual
  33. 33. Security  M9 is a secured/card access only unit which prevents unauthorized entry on to the unit and unauthorized exit (i.e., abduction).  Residents are assigned coded ID cards to allow access to M9 during their rotation.  Refer all visitors to the Guest Services or Unit Assistants; do not allow visitors to enter or exit M9 without checking with the unit or reception staff.  Anyone attempting to leave the unit via stairwells without coded ID cards will encounter a 15 second delay before the door releases. An alarm will sound in the RN Station and in MSK Security.  The assumption is that anyone using the stairwell without a coded ID is an unauthorized departure.  If a pediatric patient is seen leaving the unit via the stairwell (assumed to be suspected abduction, missing child, or unauthorized exit of a patient) or if you hear a door alarm, you must call Security (x7866) to inform them of unauthorized departure and identify the stairwell used (i.e. North or South)  a ‘Code Pink’ will be activated.
  34. 34. Dress Code  Men  Shirts & Ties  No Jeans  Women  Business Casual  No Jeans.  No tight/ revealing / midriff exposing clothes !  All: Yes! Scrubs are only acceptable for on call days
  35. 35. Mandatory Learning Module  All resident must complete online MSK Modules  Can only be done from MSK computer  Instructions are provided with orientation packet

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