General Pediatrics Clinic

Rotation Director

Alanna Braun, MD

Email: braunal@ohsu.edu

Pager: 11794


Overview:

Residents on our intensive outpatient general pediatrics rotation provide acute access care for patients in the resident and primary care faculty practices. This allows patients with same day needs or who are unable to get an appointment with their PCP to be seen. Often appointments are scheduled same day so throughout the day the schedule is constantly changing.

This intensive outpatient rotation in general pediatrics exposes our residents to an in depth experience in General Pediatrics from sick visits to care coordination with patients with complex needs – you will see it all. Senior residents will have experience with managing clinic flow, precepting interns and medical students, and also providing efficient direct care with busier templates.

Rotation goals and objectives:

I) Intern

a. Evaluate and manage common medical problems seen in the ambulatory clinic setting

b. Exposure to the many aspects of outpatient general pediatrics

II) Second Year

a. Work on efficiency by seeing larger patient volumes

b. Manage throughput of a busy outpatient practice

c. Practice staffing and evaluation of complex presentations

d. Providing parent call coverage with attending backup

III) Third Year

a. Practice staffing and evaluation of complex presentations

b. Manage throughput of a busy outpatient practice

c. Providing parent call coverage with attending backup

Prior to the start of the rotation:

· Review the expectations, goals and objectives of this rotation, including pertinent resources linked here

· Discuss with outgoing residents any pertinent labs/studies that need be followed up (if needed)

· Discuss with outgoing residents any patients with short interval follow up

· Turn on your pager

· Other useful tools: Haiku and Teams on your mobile device (through OHSU apps)

First day of the rotation:

Clinic is located on the 7th floor of Doernbecher Hospital by the Blue Deer sign. Please come directly after morning report or Grand Rounds.

Resident Expectations:

I) Intern

a. Complete entire history, physical exam, and formulate assessment with plan of care prior to presenting. This does not mean documentation needs to be completed, but it should be thought through.

b. Develop focused presentations and prioritized differentials

c. Complete all notes prior to leaving each day

d. As a group, first years will see the bulk of the patients – this may mean that patients assigned to seniors are reassigned to interns to prioritize increased patient experience

II) Second Year

a. Focus on furthering knowledge regarding triage and treatment of children presenting in an acute care clinic

b. Work on efficiency and flow in seeing larger patient volumes, mastering the patient evaluation skills listed above

c. Provide parent advice and triage on parent call

d. Develop virtual visit skills

e. Practice precepting interns and medical students

f. Participate in twice daily patient huddle (9am and 1pm)

III) Third Year

a. Practice 1 minute preceptor model

b. Manage clinic throughput and ensure all patients seen and given disposition in timely fashion

c. Work on efficiency and flow in seeing larger patient volumes, mastering the patient evaluation skills listed above

d. Orient Core Students (PNPs, PAs and MDs) on their first day (help them set up their schedules, dot system, access notes) and partner with them on their learning plans and help them with chart review and patient care

e. Participate in twice daily patient huddle (9am and 1pm)

f. Develop virtual visit skills

g. Provide parent advice and triage on parent call

h. You are the leader of clinic. You should take ownership of flow, teaching, and troubleshooting.

Conference

Residents are expected to attend morning report, grand rounds, and noon conference daily, as well as Academic Enrichment sessions.

You may have a virtual or in person template on the morning of your Academic Enrichment – you are expected to see appointments prior to Academic Enrichment, and later appointments will be seen by students and/or attendings.

Procedures: There are a variety of procedures done in General Pediatrics. Please take any opportunity to participate in and perform these procedures.

· Nebulizer treatments

· MDI Teaching

· Vaccine administration

· PPD/TST placement

· Point of Care Hemoglobin (Hemacue)

· Ear irrigation

· Urethral Catheterization

· Use of fluorescein dye

· Cryotherapy

· Rapid Strep Testing

· Transcutaneous Bilirubin Testing

· Silver nitrate use

· Circumcision (Schedule per Dr. Blaschke, Dr. Bakken or Dr. Stahl)

· Frenotomy (schedule per Dr. Bakken)

· Nail procedures

· Incision & drainage of abscesses

· Simple laceration repair (glue, staples)

Communication in Clinic:

Log in to Microsoft Teams whenever you are in clinic or assigned to virtual visits – nurses, schedulers (PAS), social workers and your attendings will most likely use this to communicate with you. If you are on a shared computer (e.g. a virtual suite or an exam room), you can access Teams through portal.ohsu.edu (log in through Citrix), or you can download the app from OHSU apps onto your phone.

If you are on virtual visits, PAS will page you if an appointment is added to your schedule within an hour of the start time.

Make sure to have your pager ON and with you when you are on this rotation!

Providing Quality Care

Many DCH Patients will end up getting most of their care in the “Gen Peds” clinic. While we aspire to continuity with individual clinicians, sometimes that is not possible. We have the MOST medically and socially complex pediatric patient population in the state. We serve a lot of Medicaid patients with OHSU Health. Many of these families travel long distances to see us seeking out our expertise in caring for children with medical complexity. We also care for many of the children of our OHSU Faculty and Staff, so confidentiality is also critical. We are ALL the “PCP” for these patients, and need to do our due diligence to take the best care possible of them.

Additionally, navigating the Hill campus can be difficult. Unless it is truly impossible, we encourage you to see all patients, even when they are late. We can’t know what it took for a family to get to campus to see us.

Approaching your patients:

Although you may be meeting a patient for the first time there is a wealth of information available to you in EPIC. It is critical to chart review patients you will be seeing or precepting. Our RNs will also review charts for the day, but may be looking for different things. The patient may have an acute need, but we are their medical home and responsible for meeting all their care needs as a team.

When a patient is on your schedule, please “scrub” their chart (look through to look for outstanding needs or issues requiring follow-up):

· Quick chart review: look over Health Maintenance tab, Patient Snapshot (medical history, problem list), and Referrals to make sure there are no major outstanding issues

· When you have more time: all of the above AND the last two well child visit notes, labs/imaging and look for specialist notes/appointments, as well as previous screenings (ASQ, MCHAT, vision screening, lead/Hgb, asQ suicidality questions, PHQ-9, anxiety screening, all visible in the flowsheets)

·

Questions to ask yourself and where to find answers:

      • Has this patient been seen or received care for this complaint before?

Review the last few notes, the problem list or use the “Search” function. Check to see if there are MyChart messages, phone calls or images that have been sent in.

      • Does this patient have underlying conditions?

Check medical history, meds and problem list in “Snapshot”, click on the labs and imaging tabs if you have time. Also look at allergies and declined care like immunizations which may affect patients diagnosis and treatment. Check the “Referrals” tab to see if there are open referrals.

      • Are there social needs that might affect this patient’s care?

Read notes for Behavioral Health, look at their last food insecurity screening or mental health screenings. Look in the “appointment desk” to see if they have had a lot of missed or canceled appointments

      • Is the patient up to date on their preventative care?

Hover over the “Care Gaps” item in the left chart panel. If there are missing screenings, well visits, or immunizations, try to provide that care TODAY unless time or patient acuity do not allow for this. If there is already an appointment with the PCP scheduled emphasize the importance of still coming to that appointment. If you can’t meet preventative care needs today, make a plan with your attending and the family for follow-up. It’s also good practice to review previous screenings to make sure they were normal (ASQs, MCHATs, asQ suicidality screening, depression/anxiety screening)


If you notice any issues during or after your visit that need follow-up, make sure to document it clearly in your note, notify the assigned PCP (if it’s not you), add the issue to the problem list with additional information AND add a comment to the “Specialty Notes”

General Schedule:

Clinic schedules are all in QGenda: www.qgenda.com

Log in through the “Customer Access” link, then use the “single log-in” option and use your OHSU credentials to log in to see your individual schedule. If there is an issue with this or an error in the schedule, please notify the rotation director and chief residents.

· For general pediatrics, morning clinic runs from 9am-noon. Afternoon clinic from 1pm-5pm. There is a huddle with the RN and SW at 9am and 1pm every day.

o Clinic assignments (in QGenda):

  • Res AM/PM: regular clinic shift; on a weekend/holiday, make sure to change yourself to the visit provider for patients you saw at the end of your shift.

  • NB/Lac: you are assigned to see the newborn infants discharged from the MBU with a lactation consultant. Make sure to change yourself to be the visit provider at the end of your clinic shift.

  • Weekend/Holiday Clinic: 9am to 1-2pm; you and your attending will divide and conquer to see the “Gen Peds” patients. Make sure to change yourself to be the visit provider for the patients you saw at the end of your clinic shift.

  • Virtual: you will have virtual appointments scheduled under your name; check in with your virtual attending prior to your appointments to pre-plan how you will staff.

  • Precept: (2nd and 3rd years only) This will be assigned primarily to the 3rd year residents. You will have appointment slots on your schedule for students to see, and should focus on clinic flow and precepting the interns and students on these shifts.

· Documentation when precepting interns: You generally do not need to write a note if you are seeing/precepting a patient with an intern (although in the first 6 months of the year you will need to write a brief note or take over the intern note if the attending did not see the patient).

· Documentation when precepting students: You will need to write a note if you are seeing/precepting a patient with a student and the attending has not seen the patient. You cannot attest a student note, but must write your own note. If the attending saw the patient, they may attest the student note and you may not need to write a note – clarify this with your attending, particularly if they have been more involved in a case.

  • MBU: (interns only) 7am to noon if on a weekday, 7am to 6pm on weekends; see below

o You are encouraged to have all your team’s schedules pulled up, so that if someone falls behind you can help each other out – it’s important to be flexible and look out for each other!

o Many of your appointment slots will be for same-day scheduling – just because your schedule is empty the day (or even morning) before does not mean it will not fill. Please be on time to clinic, and do not leave before the time for your last open slot has passed.

o Make sure to staff your patient with an attending before you dismiss them, unless you have explicitly discussed this with your attending ahead of time

· All clinics have scheduled end times but someone should stay until all patients have been seen and discharged from clinic

· On Saturday and Monday Holidays, clinic is open 9a-1pm. Expect to stay until you have completed your last patient visit. This may be later than 1 pm if you are waiting for lab or Xray results.

Special Schedules:

Parent Calls:

· Senior residents split parent call coverage with the exception of Fridays, which is covered by faculty

o Weekdays: Parent calls start at the end of clinic and run until the following day when clinic opens.

o Weekends: Saturdays start at 1300 (or after clinic) and Sundays start at 0800. You are technically on call until the following morning.

o Please note: After 10pm on ANY night, there is a nurse triage service handling calls but residents serve as backup. Please keep your pager with you and turned on—even while you’re sleeping.

o There is always an attending available if you have questions

  • Calls can be busy during the winter. Patients have been informed that they will receive a call back within 30 minutes

  • Calling patients back: Call through the OHSU operator (503-494-9000) in order to have the calls recorded and to protect your personal phone number. You can also call with the prefix *67 to block the number you are calling from.

  • If you make a referral into the ER, you should call the ER at 503-494-7551 to let the ED attending know the patient is coming.

  • All calls should be documented with a telephone encounter in Epic (.GENPEDSPARENTCALL). Documentation can be brief but should be complete. If sharing COVID information use dot phrase: .COVIDPTEDUCATION 

  • Second years, please page back up attending at 9:30 pm for your first two nights to review the evening calls. 

  • Reminder:  If you need to discuss an adolescent patient whose primary PCP is Dr. Sells, Serrano or Jacobs, page the on-call Adolescent Attending (not the gen peds attending).  

· Call Resources:

o The rotation director has copies of Barton Schmitt’s Pediatric Telephone Protocols that you can check out/borrow for the rotation

o The OHSU MD4Kids Symptom Checker app is helpful

o HealthyChildren.org has lots of great info for families

o Check in with your attending if you need help!

Virtual Visits:

Many attendings will join you during the video visit. If you are scheduled for academic half day and virtuals, you will be expected to do the virtual visit(s) prior to the half day starting, then your attending will take over. If a student is assigned to join you, we encourage you to co-locate with them in the virtual suite.

One attending is the virtual attending (they may be located remotely). You can find them on the clinic schedule. You can page/text/call the VV attending at the start of your session to come up with a plan. They can join the visit at any point! If you need help mid-visit, you can pause/mute the visit and say “I need to discuss with my supervising physician, I will pause the video and return shortly”.

Virtual visits are billed on total time (prep/charting as well as visit time)

Additional resources and information on virtual visits are available in the document “Virtual and Telephone visits.”

MBU Coverage:

During any particular block, 1-2 interns will individually cover Friday AMs in the MBU, usually before a weekend you will be covering the MBU. You are still expected to attend afternoon clinic.

  • Please show up at 7am to the MBU on these days to receive sign-out.

  • Do not take more than 5 patients.

  • Round with team (or with back up attending if available). Team will prioritize discharges and clinic intern's patients.

  • Please sign-out all patients to the MBU intern at ~11:30 prior to leaving. The MBU intern will serve as first call for all patients in the afternoon

  • Note: MBU interdisciplinary rounds are at 0800 on week days and 0930 on weekends. Formal rounds start at 0900

  • Attend noon conference, back to clinic for afternoon.

If you are going to be absent for all or part of a day:

Please email the rotation director, other clinic senior(s), chief on call, and Michael Grubbs if you are unable to make it to work. Please also contact chief on call as soon as possible; a verbal exchange must happen with the chief on call.

Any resident missing more than 2 days (or 4 half days) may be required to make up the difference at a future date at the discretion of the rotation director and chiefs.

Resident Resources, Helpful Tips, and Further Readings: