Welcome to your community hospital rotation!
If there is only ONE nursery intern the first day (Thursday) (the other is on nights), then one of the ARs should BE PRESENT in the nursery to help them the first day. Also probably the second day as well. The nursery can be overwhelming for one brand new resident. Your help would be greatly appreciated.
If there is only one intern in the nursery for the week (second intern on QI) and there is more than 6 patients: there needs to be a second resident (usually AR) to help for that day, especially the morning.
Essential Resource Link Guide:
Essential Resource Link Guide:
ARs: Please supervise and monitor the interns in the nursery, as well. You are the leaders for them too. If they need help on busy days, make sure they have help. They are part of the team, check in with them often.
A "Pediatric Mets Team" may also be called. This is a less urgent call. A resident should go to that location. An ED nurse, nurse supervisor, and security will also respond.
Seniors: Know where the code cart is on the floor. BVM and NRB are located in each patients room.
1. Residents care for all pediatric patients that are hospitalized, whether the patients are on the surgical service, general pediatric service, or other services. For the surgical services and other services you will co-manage (Not co-follow) those patients. Co-manage is more representative because you are not just following along, you will contribute to management as equally as other specialties.
2. Please set expectations and goals for interns and students, early. This does not need to be time intensive. Goals for students should roughly be to follow 2 patients very closely BUT examine ALL patients each day (They can examine the rest of the patients after rounds.) Encourage the students to go to the bedside, not just learn from the computer but from the patient! Teach the students at the bedside. Observe students taking histories and doing exams. Give them feedback everyday with everything.
3. "Noon" conference usually at 11:30am or 1pm Mondays through Thursdays. Timing depends on resident clinic days and times. Check the noon conference schedule. Seniors should notify entire team if there is a change in time. Take note of when the community events are. Seniors should look at schedule daily and plan the day.
1. Residents care for all pediatric patients that are hospitalized, whether the patients are on the surgical service, general pediatric service, or other services. For the surgical services and other services you will co-manage (Not co-follow) those patients. Co-manage is more representative because you are not just following along, you will contribute to management as equally as other specialties.
2. Please set expectations and goals for interns and students, early. This does not need to be time intensive. Goals for students should roughly be to follow 2 patients very closely BUT examine ALL patients each day (They can examine the rest of the patients after rounds.) Encourage the students to go to the bedside, not just learn from the computer but from the patient! Teach the students at the bedside. Observe students taking histories and doing exams. Give them feedback everyday with everything.
3. "Noon" conference usually at 11:30am or 1pm Mondays through Thursdays. Timing depends on resident clinic days and times. Check the noon conference schedule. Seniors should notify entire team if there is a change in time. Take note of when the community events are. Seniors should look at schedule daily and plan the day.
ARs: Please make an effort to cover floor calls/pages for the interns so they can attend conference. We want you at conference too though, so triage priorities.
Updates:
1. Discharge summaries can be faxed automatically to outside providers by using the CC field in the Final Diagnosis tab. Saves a step, and when the desired provider is not listed in Meditech please jot down the name on the worksheet in the workroom and/or send the name to me.2. Asthma patients SHOULD ideally have a pcp follow up appointment documented in their discharge instructions. I have never been big on this but it’s a hospital quality measure that they now are looking at. So if possible we should note it in the DCI.3. Transfers out to another facility will need a DC summary not a Transfer summary, we’ve gotten much better about this! Just a reminder
4. Admissions mainly come from the ED. After you hear about an admission, then first tell your intern, then the charge nurse, so they can prepare. If you have concerns with the patient, you may discuss with the ED attending and the hospitalist attending. There is generally an effort to not delay admissions from the ED so that means tell the nurse quick and say you "accept" the patient even if you have not seen them yet if they sound OK for the floor. Most patients can be accepted right away so as to to delay admission. Obviously there will be some kids you would want to talk to the attending about or see and that is fine. The ED attendings generally know what is "floor material" or not.
5. There will be community pediatricians (or other hospitals) that call the floor to inquire about a direct admission or direct transfer, bypassing the ED. This pediatrician should always talk with the hospitalist on (Grybauskas, Balighian, Murphy, Davis). You can still discuss with them but please allow them to contact us. There is a transfer sheet.
7. Please watch the CPOE videos as soon as you can. We will give you time at St. Agnes as soon as possible if you cannot watch prior to starting clinically. These videos are essential so you know how to order, document, discharge, etc. Here is the link to the videos:
https://www.youtube.com/user/babybalighian1
8. There is a surgical and medicine residency program here. Remember to communicate well and frequent with those residents. In general, for patients under 10 a pediatric surgical attending will care for that patient. For a patient older than 10 with a non complicated problem, a general surgical attending will be the attending. In either case, the surgical residents will care for them. Make an effort to go into the rooms with the residents so that you will both be on the same page, you may learn something from them, and they from you. Pediatric residents should check surgical residents orders and prescriptions to ensure correct dosing, etc. As senior supervising resident, please cosign all intern prescriptions and check all intern medication orders.
-The surgical residents do not always communicate that they wrote an order but try and keep your eyes and ears open. Kindly remind them to let you know. To contact correct resident, check chart for last resident note and team (gold usually) and ask secretary for gold team number. If still unable, page pager 200 and ask that surgical resident. To Page at St. Agnes dial 2121, then wait and dial 3 digit pager number.
10. If you forgot your password and/or do not have access to Meditech, first call the help desk at x2070 and they often can reset your password quickly. If this does not work, let Diana, the peds secretary in the office, know (x2500), and she will simply fax in a form to get you access again. Then she will send you an email in 1-2 days with the new temporary password.
12. Discharge checklist not to forgets:
a. Discharge summary documenation
b. Asthma action plan if needed (including PMD # and follow up) done for patients with asthma. For patients going on albuterol (bronchiolitis, etc) that you have not diagnosed with asthma then you can fill out one, cross of asthma and write “wheezing action plan”.
c. Make sure we have a good contact number
d. Follow up labs cultures- make sure they will be followed up.
e. Consider a home visit.
f. Consider that your patient may need "meds in hand" at discharge.
Electronically send to PCP:
use Final Diagnosis>>CC>>Other tabs to enter any name and fax number
14. When on call, please help your intern with issues in the nursery. Go down with them. This is especially true if the intern has not had a nursery month yet.
Interns: The supervising resident should help you with nursery issues, especially if you have not done nursery yet. They should accompany you down the first several times.
15. Seniors: You are encouraged to give a talk the 3rd and 4th Fridays. Tips for the talk: be confident, be the local expert, have take home messages, bring new data if possible, and make it fun. Usually, a case works well.
16. There is speed/red light camera close to St. Agnes on Caton ave. Don’t get caught! Park in the garage. The garage is not attached to the hospital but close, closer to Wilkens ave. Please see other attached diagram.
17. Additional respiratory supplies especially emergency supplies (bag-masks) are in the patients rooms- in the closets!
18. Multidisplinary Rounds are at 10:30 with social work, discharge coordinator, pastrol care, and the charge nurse. One supervising resident must attend each day. You will quickly go over patients, whats going on with them, when they might go home. This is an excellent time to plan ahead--- what will the patient need when they go home? Meds? wound care? Nebulizer? Also a good time for social work issues.
19. During rounds, a clinical question(s) will arise in which the answer is not immediately clear. Identify one of those clinical questions that could be potentially answered by looking into the literature (i.e. EBM). Write that question down on the bottom of the signout and sign this out to the night team. They will give you an answer in the morning.
20. All patients should be placed in "observation" status as opposed to admission EXCEPT patients like patients you are sure will stay 2 nights. If the patient in observation status stays longer than 24 hours, then simply order "CHANGE FROM OBS. TO INPATIENT". DO NOT CANCEL THE OBSERVATION ORDER. If the case manager asks a resident to do this, then please do this promptly (right after multidisplinary rounds). Additionally, for children needing to stay longer than 24 hours, there needs to be an updated documentation that supports why the child needs to remain in the hospital (IVF, oxygen, other requirements, risk of being discharged now).
21. When should you call the attending with admission? Definitely call with ICU level admissions, babies under one month, children with potential surgical issues, direct admissions, transfers from other hospitals. You need not call with every admission if you feel comfortable but you are always welcome to call anytime.
22. See this video how to use the LifePak:
https://youtu.be/ASdJqtlLftc
23. On Nights: AR should be helping with Nursery admissions, etc just like the day team does.
24. This is a great rotation to do procedures such as venipunctures, IVs, etc. If you order them consider doing them yourself. We can show you how. Also you may get called down to the ED to suture, splint, reduce, incise, and puncture.
25. Please store your meditech login somewhere for next time you come back to St. Agnes.
26. Follow-up your patients. Call them the next day or two after discharge to see how they are doing, answer questions. This quick call means so much to patients and allows you to further understand natural history of diseases, how social and environmental aspects influence medicine, and is one of the most rewarding parts of medicine. Let the team know, including attending, about feedback from these calls.
27. See page to right about Evidence Based Medicine.
28. The BMS (primary care clinic) main number is 410-703-3200 for patients.
29. Please knock and ask permission before entering patient rooms, especially postpartum patients with newborns.
Helpful video about supplemental oxygen.
https://www.nejm.org/doi/full/10.1056/NEJMvcm2035240
Specific to Nursery
1. Your daily responsibilities (in relative time order) include examining the newborns, completing the daily notes, discharging babies, rounding with the neonatologist, teaching conference, and mommy talks.
2. For brand new babies: babies are blank slates and you may pick up something important such as tetrology of fallot or distended abdomen before problems arise.
3. Ask for help! The ARs on the floor are your seniors too, just like the ward interns. Contact them with clinical questions or other questions. If can also contact the Neonatologist (Drs. Borderick, Bullard, or Moloney) , NNP, or the Pediatric Hospitalist (Balighian, Grybauskas, Murphy, Davis).
4. If you find an interesting finding (murmur, hip clunk, fractured clavicle, abnormal ear), then call the floor (2525) and make sure the medical students see this too(if appropriate with the family, etc).
5. No long sleeves, wash hands, and use the baby stethoscopes when examining.
6. Please run all discharges by the attending prior to discharge. (unless discussed earlier in day about when to discharge and makes clinical sense).
7. This is a helpful website to learn more about newborns:
http://med.stanford.edu/newborns.html
8. Please knock and ask permission before entering patient rooms, especially postpartum patients with newborns.
6. Please run all discharges by the attending prior to discharge. (unless discussed earlier in day about when to discharge and makes clinical sense).
7. This is a helpful website to learn more about newborns:
http://med.stanford.edu/newborns.html
8. Please knock and ask permission before entering patient rooms, especially postpartum patients with newborns.
9.Please review the hypoglycemia protocol which is located in the workroom.
Regarding BMS newborn follow ups:
In the case of the COVID positive MOM with a newborn, BMS asks that the NICU or Newborn Nursery call the Nursing cell phone (443) 934-3256. If unsuccessful, the secondary plan is to call directly to the BMS Pediatrician providers' lines (Numbers in resident workroom).
In the case of the COVID positive MOM with a newborn, BMS asks that the NICU or Newborn Nursery call the Nursing cell phone (443) 934-3256. If unsuccessful, the secondary plan is to call directly to the BMS Pediatrician providers' lines (Numbers in resident workroom).
The baby should be coming with another asymptomatic family member and that family member should be wearing a mask or bandanna to help minimize waiting room exposure.
BMS asks that the family be given instructions to stay in the parking lot and call the Nurse number (443-934-3256) when they come to the appointment. They will then be escorted directly to an isolation room from the parking lot.
Night Resident Expectations and Tips
1. Same expectations as during the day- admissions, nursery issues, floor patients.
2. In the early part of the shift (8-10pm), mommy talks may be able to be done if the WBN interns need help.
3. If you want: You may spend time in the Pediatric ED to learn and help. The PED attendings are great.
4. Please do NOT send films (x-rays) out to "Eagle Eye" to be read at night unless it is urgent and will significantly change patient care. CT scans and MRIs will be ready overnight, however. Films will not. Please interpret those yourself, you can always discuss this with the attending.
5. We encourage you to meet the neonatal provider in person for the night (each night). Go over expectations, how you both want to communicate, what to communicate. etc.
6. We encourage you to go to ED when you can. Know who is on and what is going on.
7. Discuss the process for transfers to Saint Agnes.
8.Do not hesitate to call hospitalist for concerns for questions.
9. Be ready to discuss prior night management questions or teaching pearls with the hospitalist. We want to ensure night residents are engaged in the teaching process and feedback process.
10. If there is an admission, but they cannot come up right away at night, and they will be boarded in the ED: we ask that the night resident see the patient and prep the patient for the Day team if the night resident has the bandwidth to do that. The night resident can make any recommendations if needed to the ED as well. The night resident can help manage the patient in the ED, but they need not to if they are too busy. Usually, they would be too busy because the floor would probably be full.
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