Welcome to nights!
PLEASE MAKE SURE YOU HAVE ACCESS TO CPRS PRIOR TO THE ROTATION.
You should be physically handing the pager/phone to the bridge resident in the morning before leaving. If the bridge resident is consistently showing up late, please let the chief on call know. If you are leaving the pager/phone in the room without the bridge resident being there, the chief on call must be made aware.
Of note, there is a new CPRS Alert policy. Please ensure your CPRS alerts are at zero (have cleared all your alerts) when you rotate off of your assigned VA Night Rotation. This is meant to prevent any adverse events for our patients. VA and Program leadership will now begin to monitor this. Let me know if you have any questions or concerns.
You are expected to arrive by ~6:45pm and find the VA Bridge Resident in the call room (J413-1 on 4 West) Monday through Friday. On weekends and holidays, there is no Bridge Resident, so you will get sign-out from the late call team that evening. You should receive three things:
The physical paper sign-outs for all teams that have signed out (with verbal sign-out on important things that need to be completed overnight and on all patients with guarded conditions)
The cross-cover phone: (352) 413-7304
The resident RRT/Code phone: ext 105543
The night team provides cross-cover services to our 4 inpatient teaching teams (not the hospitalist service and not the CLC/GEM unit anymore). Remember that on nights the goal is to keep patients stable. You should not change the plan of care unless it is dictated by the patient's condition. If the patient develops acute issues that need immediate attention, then you should order what is necessary to care for the patient and remember to work up/rule out things that could harm the patient overnight.
After arriving and getting sign-out, settling into your call room, and addressing any immediate/pending issues, page/check in/exchange numbers with the night Hospitalist at 8pm. The Hospitalist pager is 413-8043 and will be your "upper-level" overnight - you will talk to them about any problems or concerns you have. Please notify them about any issues with patient care overnight. If there is a patient that is sick and may need to be upgraded to the MICU, you can call the MICU resident on call that night directly and don't have to wait for the Hospitalist's blessing. However, please make sure to let the Hospitalist know about events like this. The MICU resident phone extension is 106255, the pager is 413-3072, or just dial the operator.
The night resident is expected to admit up to 3 patients overnight for the teaching teams - the night Hospitalist will staff these patients with you and is readily available to assist you. In the morning after your shift, all teams will come to your call room to pick up sign-out and receive a verbal sign-out of all overnight events for their patients.
To access sign-out: Click on My Computer -> S: drive -> Medicine -> Shared -> Internal Medicine Residents -> Sign Out -> “____ Team Sign Out”
Teams should still be printing and giving you sign-out, but you should be able to access it on the computer should you choose to do so.
Please use the MEDICINE CROSS COVER NOTE (T) if important changes are made overnight (i.e., moving to step-down unit, legitimate chest pain you are actively working up, acute change in mentation) and be sure to document significant exam findings. For any acute patient issues overnight or whenever you are writing a medicine cross cover note, please inform the night Hospitalist and have them and day attending cosign the note! For falls, there is a designated fall note template titled PROVIDER POST FALL ASSESSMENT (T).
Please use the following templates and DO NOT modify them (including deleting certain portions like tobacco use, etc.):
H&P: “H&P MEDICINE ADMISSION HISTORY AND PHYSICAL (T)
Med Rec (see below): “ADMISSION MEDICATION RECONCILIATION (T)”
LST (see below): “LIFE-SUSTAINING TREATMENT”
Sepsis Note: “SEPSIS INITIAL (T)”
Hypoglycemia Note: “HYPOGLYCEMIA PROVIDER NOTE”
Fall: “PROVIDER POST FALL ASSESSMENT”
RRT stands for "Rapid Response Team". Please make sure to show up to every RRT and CODE BLUE/CODE ASSIST. The VA MICU Night Resident will respond to this as well. You are NOT the primary author of the RRT note which will be completed by the nursing staff, but you can addend the note if you provided significant care for the patient during the RRT.
Please answer pages as promptly as possible. If there is an RRT or Code Blue, the CISCO phone will go off and indicate where the code/RRT is. You are responsible for responding to all "inpatient" RRTs/Codes. Once you arrive at an RRT, stay and assist if the patient is on a medicine teaching service (i.e., Blue, Green, Orange, Red). If the patient is on a hospitalist, surgery, or other NON-teaching team service, you are NOT expected to stay for the RRT once the hospitalist/surgery team arrives. The "inpatient" areas include the new bed tower, medical and surgical day stay units, MRI, dialysis, and the cath lab. In addition to the night resident, the MICU nurses, a respiratory therapist, and the MICU resident/fellow on call will also respond to RRTs and codes. You are not required to write an RRT note (the MICU nurse will write one and may have either you or the MICU resident cosign the note).
Before placing initial admission orders, call your team's assigned UM to discuss and ensure the appropriate level of care is selected. This should be a discussion between the admitting team and UM to identify the most likely initial admission diagnoses for the patient and the patient’s clinical status. After hours and on weekends, UM can be reached at 10-2177 . Their job is simply to recommend a level of care based on certain clinical criteria. If you feel a patient requires a higher/different level of care based on their clinical status and are at an impasse, simply admit the patient and you can escalate to the UM Manager Patty Davis at 10-1283.
We have been asked to reduce the time between "decision to admit" and "admission orders placed" to less than 1 hour. Full orders and medication reconciliation may not happen in an hour, but our VA is requesting that Medicine Residents and Hospitalists place basic admission orders after discussion with the referring Emergency provider so that the search for a bed can begin. These should be for patients that you agree will most definitely be admitted (i.e., sepsis, NSTEMI, GI bleed, etc.). If you disagree, please document this in the chart and inform the ED provider that you will be evaluating the patient first before placing any admission orders. These orders should include:
Treating specialty and providers
Diagnosis
Level of care (acute, observation, step-down)
Telemetry (if needed)
Isolation orders and precautions, including 1:1 observation/sitter, etc. (if needed)
Additional orders can be included as well, but please ensure basic orders are entered once the discussion with the Emergency provider is complete.
All admissions require an Admission Medication Reconciliation note to be completed within CPRS. The “ADMISSION MEDICATION RECONCILIATION (T)” note is used to pull in medications prescribed to the veteran from other VA or non-VA facilities. Print this note and use to review all medications with your veteran. Please make sure to complete this note for EVERY admission in addition to your H&P +/- LST note.
This must be documented for every admission! If a patient already has a Life Sustaining Treatment (LST) note documented in the chart, then simply confirm these wishes with the veteran and proceed with the rest of your admission. If there is no LST note documented, please ensure that you complete one upon admission.
Please specify code status in this note. For patients who are full code, indicate that in the note and do not place any specific orders for these patients. For patients who are DNR/DNI and/or have specific long-term wishes (i.e., no dialysis, enteral nutrition, etc.), please click the appropriate radio buttons on the LST note to ensure the correct order(s) open for the patient and then sign these orders. See the attached LST Template for more information.
**IMPORTANT**: if a patient chooses to rescind his/her DNR/DNI status, make sure you complete a new LST note but also ensure you delete/discontinue any prior DNR/DNI orders
There is a Heart Failure Diagnosis check box in the H&P Template. If a patient is being admitted for a CHF exacerbation, please click this box as it helps the HF team track patients. The hope is that this will eventually allow the HF outpatient schedulers to schedule patients before they are discharged.
If you order an ultrasound study after normal business hours, it will be done the next day if ordered as routine and done overnight if ordered as STAT. If ordered as STAT, please contact the on-call radiology resident who will perform and interpret the study (whereas during the daytime, the ultrasound tech performs the study and the radiologist reads/interprets the study). To call the on-call radiology resident, it is easiest to call the ED at 352-548-6073 who will then give you the most up to date contact info for the on-call radiology resident.
In the rare event there is an issue with CPRS access, the VA switches all inpatient communication to paper orders. Every team room has "Downtime Folder" that includes a generic order form sheet, lab orders, radiology orders, blood bank orders, and other important forms. Orders need to be handwritten and submitted to the ward clerk. For documenting notes, you can still use Microsoft Word to document an H&P, progress note, D/C summary, etc. and then paste the information back to CPRS when it is back up and running.
If your CPRS account has been deactivated (inactivates after 90 days without use): Call National IT service desk (Ext 106093) and press secret option 4.
If need to reset your PIN for a PIV badge: Go to the T11 Police trailer behind the VA to reset your pin during normal business hours.
If you cannot login because of PIV only access: You will need to contact the help desk and ask for a temporary PIV access exemption, which will grant you 14 days to get a new PIV badge or get your exemption figured out. If you lost your badge, contact Tasharma Malone-English (email Tasharma.Malone-English@va.gov) IMMEDIATELY to start the process of obtaining a new badge as it takes a while for you to fill out a police report for the lost card and for the VA to provide you with a card.
If other computer issue not addressed above: Contact the National IT Service Desk (ext 106093).
VA TMS Issues: For things like the ACLS/BLS online training, annual VA certification, etc., email VHANFLTMSHelp@va.gov
The resident will have Friday night off.