Pediatric Inpatient Care - The Clinical Teaching Unit Teams

The majority of general and subspecialty inpatient pediatric care in Edmonton is provided at the Stollery Children’s Hospital (with the exception of newborns).  This is a tertiary/quaternary acute care hospital serving patients from the greater Edmonton area and is a referral centre for other centres in northern Alberta, the far north and beyond.   There are 5 different inpatient pediatric nursing units at the Stollery, and general pediatric patients are admitted to all of them.   Medical care for these general pediatric patients is usually provided by one of the Clinical Teaching Unit (CTU) teams.  There are always two CTU-teams in operation, and a third team is added during typically busy times (fall, winter and early spring).  During your inpatient pediatric rotation, you will work as a member of one of these CTU teams.

Purple Team is located on 4E4, and some patients may be located on 4E3 in overflow situations.Typically, the maximum amount of patients admitted under this year is 20. Members of this team include a pediatric senior resident, several first-year residents (pediatrics and other programs), several medical students and an attending physician. The role of the attending physician is to support the learning of all team members, and to supervise the medical care of all patients admitted to the team. In general, patients are returned to their own physician (family doctor or pediatrician) for follow-up care. 

Orange Team is located on 5G4, with overflow patients being located on 4D or 4C. Typically, the maximum amount of patients admitted under this year is 20. Members of this team include a pediatric senior resident, several first-year residents, several medical students, and an attending physician.  The role of the attending physician is to support the learning of all team members, and to supervise the medical care of all patients admitted to the team. In general, patients are returned to their own physician (family doctor or pediatrician) for follow-up care. 

Green Team is a smaller team that functions during our peak seasons. There are a maximum of 8-10 patients admitted to this team at any time. The team is comprised of one transitioning senior pediatric resident, one to three medical students students and an attending pediatrician. The role of the attending is to support the learning of team members, support the transition of the junior to senior resident, and to supervise the care of patients admitted under him/her.

CTU ROLES

SENIOR RESIDENT: Is responsible for the day-to-day management of all patients on the CTU. This includes the supervision of junior trainees as they care for their assigned, assessment and triage of new admissions, assessment of critically ill patients, and maintaining contact with the attending physicians. They will also carry out much of the day-to-day teaching of the junior house-staff.

JUNIOR RESIDENTS:  Provide day-to-day care for assigned patients.  Whenever possible, every attempt will be made to assign patients appropriate to the residency program and learning needs of the resident.  Depending on experience levels and patient volumes, junior residents may also be expected to assist and supervise medical students with patient care duties.  In all cases, timely communication with the senior pediatric resident is essential. 

MEDICAL STUDENTS will also be assigned several patients for whom they provide day-to-day care under the supervision of residents.  Student orders MUST BE CO-SIGNED.

MEDICAL STUDENT AND JUNIOR RESIDENT RESPONSIBILITIES FOR PATIENT CARE

ADMITTED INPATIENTS:  Residents and students on CTU are responsible for the following for each of their assigned inpatients:

·         daily (at least) assessment, including review of vital signs, nursing documentation, notes from consulting services, and results of investigations

·         presentation of findings and plan during rounds

·         incorporating findings into an updated management plan

·         daily documentation of findings and management plan in progress notes

·         communication with senior resident about any changes to patient status or management plan

·         ensuring the patient information on the “handoff” tab in connect care is up-to-date and correct

·         discharge planning and communication

·         discharge documentation (discharge summary including routing to outpatient physicians)

NEW ADMISSIONS/TRANSFERS:  Most general pediatric admissions come via the Emergency Department, and occur in the late afternoon and into the evening. When there is a new admission, the ER will call a pediatric senior triage resident.  S/he will decide which team the patient is being admitted to, and may assign the admission to a junior resident or medical student or may complete the admission themselves, depending on how many admissions are pending.  In addition, patients being transferred from NICU or PICU may come to your team and you may be asked to do a transfer. Your responsibilities when admitting/transferring a patient include:

·         conducting an appropriately complete history and physical examination

·         documentation of your findings

·         generating a problem list and management plan for each problem

·         writing accurate admission orders (including medication reconciliation for home meds) or reviewing and modifying transfer orders

·         reviewing the admission with the senior resident +/- the appropriate on-call pediatrician

CONSULTS:  Sometimes the general pediatric service is asked for a consultation on a patient admitted to another service.  There should be a clear reason for the consult (i.e. you should understand why you are being asked to see the patient).  If the senior resident asks you to do a consult, your responsibilities are similar to doing an admission.  These include:

·         conducting a history and physical examination appropriate to the question being asked

·         reviewing the results of any relevant investigations

·         formulating an answer to the question posed – this may be a diagnosis, recommendations for further investigations, recommendations for treatment, and follow-up

·         reviewing the consult with the senior resident +/- attending/on-call pediatrician

·         documenting your findings, impression and recommendations

 DAILY ROUTINE

This is a basic outline for a regular weekday on CTU, however the specific daily routine will vary somewhat, depending on the day of the week, patient volumes, and the preferences of your senior resident and attending physician.

 0730 (0700 on Thursdays and Fridays, 0800 on weekends/holidays):  Morning handover

On-call team and CTU senior residents meet in resident lounge (4H2.12) to discuss new admissions and issues from the previous night.

 0730-0900:  Patient Assessment

Junior residents and students assess each of their patients, review vitals, investigations and progress notes, and formulate a management plan for the day. 

0930-Noon:  Rounds

This may be patient-care rounds, teaching rounds, or both, depending on the preferences of the senior resident and attending.  It generally consists of a combination of bedside patient visits and group discussions about particular patient issues.  Residents and students should be prepared to present a brief summary of each of their patients during rounds, including current status and a proposed management plan. 

 Afternoons: 

Documentation, consultations, new admissions, follow-up on investigations, reassess patients, etc. etc.  If things aren’t too busy, senior residents or staff may sometimes do teaching sessions.  This is also a good time to do a bit of background reading on your patients’ conditions.

 1630 – Afternoon sign-out

Review all of your patients with the senior resident.  Make particular mention of any new issues, anything you are worried about or anticipate might become a problem, and any investigations that need to be done or followed up overnight.

1700 – Handover to on-call team – Resident Lounge

If you are on-call, you must attend.  If you are not on-call, and have already reviewed your patients with your senior, you do not need to attend. 

NOTE – your day is over once you have signed over to your senior resident AND your work is done (notes written, consults called, investigations ordered and acted upon, …)

REGULAR TEACHING ACTIVITIES

WEDNESDAY

Noon – 1600:   Pediatric resident half day 

Pediatric residents are not responsible for patient care during this time.  The remaining residents and students will divide up the wards and deal with any issues that arise and follow-up on any outstanding issues from the morning.  The senior residents sign out their pagers to their respective team attending pediatrician, and the green team staff will be in charge of coordinating admissions and transfers. If you have any questions, don’t hesitate to call them. 

THURSDAY

0800 – 0900:   Grand Rounds (Hybrid mix: in persona and on zoom)

Local and visiting speakers covering a wide range of pediatric issues.  All residents and students rotating through CTU are expected to attend.                             

FRIDAY

0800 – 0900:   Admission Rounds – Location varies.  Often WMC 3H2.53, check schedule

Interactive general pediatric case discussions led by senior residents and attended by students, residents and faculty.