VA Wards

Team Cap: 20 patients

• Each team gets 5 admissions when on call with 1 “holding” note (overnight) and 4 new patients during your call time

• If no holding note, then 4 patients maximum

• For Late Call, you can only receive 2 patients after 5 PM and none after 6 PM

• Interdisciplinary Rounds (Microsoft Teams)

  • Team Huddle 1: 8:45-9:15 AM

  • Team Huddle 2: 1:30-2:30 PM 

• Medicine Rounds (in person)

  • Start after Team Huddle 1

  • Participants include attending, resident, interns, students, pharmacist, case manager, charge nurse/nursing ward-leader

• Call UM after receiving an admission (phone number varies by team). 

• Clarify Code status and document in an LST note (see below).

  • This should be asked/verified on every admission.

• Notes to be completed on admission: 

  • H&P MEDICINE ADMISSION HISTORY AND PHYSICAL (T)

    • Cannot be done by a medical student

    • Ensure that code status is at the end of your note 

  • ADMISSION MEDICATION RECONCILIATION (T)

  • LIFE-SUSTAINING TREATMENT

    • Only needs to be completed if the patient wants to change their code status (e.g., Full code to DNR), or has never been done previously

• Note the new bounce policy: golden call team may not receive ED Return Admissions (same resident/intern pair).

• Patients transferred from the MICU should be returned to the teaching team that transferred the patient to the MICU whenever possible, provided that the team has the same intern/resident pair and doing so does not violate admission window rules, daily admission caps, or total team census caps.

  • TL;DR: Teams may not receive MICU return transfers on golden days.

• Must be done daily. Can copy and paste notes as long as they are updated!

  • Student notes do not count, though sub-i notes count if attending agrees to cosign and add attestation to the note

• Use “MEDICINE PROGRESS NOTE (T)” template​

  • Every note should include FEN (IVF, diet, lytes), access, prophylaxis, code status, dispo (prepopulated at the end of every note). 

• Telemetry is a prompt in every progress note. Discontinue if not needed!

• DVT prophylaxis is also a prompt; select as appropriate.

1. Should be identified on medicine rounds ideally the day prior to discharge, but at least should be completed before noon the day of discharge.

   • Attending and residents should both see the patient before rounds. 

2. Discuss the medication reconciliation with your team pharmacist (or the designated discharge pharmacist when they are off). 

   • Compare outpatient list to inpatient list.  

3. Schedule follow up appointments - the earlier, the better! 

   • Complete the clerk order in CPRS - you can ask your senior for help with this. 

4. Complete the discharge instructions with the following template: “PATIENT DISCHARGE INSTRUCTIONS (T)”​

   • You must discuss the medication reconciliation with your pharmacist BEFORE completing discharge instructions.

   • Note that the discharge order is prompted after completing instructions.

5. Discharge summaries need to be completed within 24 hours of discharge. 

   • Always tag PCP as a cosigner (can be done after signing)!

   • Note that this is a separate tab called “D/C Summ” in CPRS.

• Microsoft Edge > “Quick Links” on the right > “Call Schedules → Qgenda” > Click on relevant consult (i.e., “ID”)  > “Display” on the top left > “Real Time by Task” > Dial correct number

  • Can also hover over name of consultant for contact information

• Make sure to place a consult order! 

  • “Consults” tab in CPRS - this includes PT/OT

• For procedure team, contact Dr. Kosboth at *32-4364​, Monday-Friday, 8-5.

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)

• Progress Notes: “MEDICINE PROGRESS NOTE (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”

• D/C Summaries (see below): Use “D/C Summ” tab in CPRS

• “Tools” on the top left of CPRS > “iMedConsent Web” > log in with PIV > select the correct consent > Complete questions as prompted

  • Note that the consent for blood is “Hospital Medicine” > “Consents” > “Blood Transfusion”

  • You must bring a VA laptop or WOW with you to complete this.

• When patient or family cannot consent, call Chief of Staff

  • Ilona Schmalfuss, M.D. (352-548-6000, 106018)

  • Give Name, Location, Procedure, Indication, Attending acknowledgement. (NOT A FORMAL PRESENTATION)

If your patient needs a lumbar puncture, thoracentesis, paracentesis, joint injection, or other procedure, please consult the procedure team. If you perform a procedure yourself, please use the “INVASIVE PROCEDURE (T)” template. Remember that a PATIENT’S CONSENT IS REQUIRED PRIOR TO PERFORMING ANY PROCEDURE. If the procedure team will perform the procedure, they are expected to obtain consent.

• Long distance: “91” + area code and number

• Local: “9” + area code and number

• Vocera (VA Phone system)

  • Dial 104050

  • Say the name/designation of the person/department you want to reach - e.g., “John Smith”, “MICU Charge Nurse”, or “Room 4-2-3 Nurse”

• VA Phone number: 352-376-1611

• GREEN RESIDENT 352-890-0871

• PURPLE RESIDENT 352-890-0524

• BRIDGE/CROSS COVER 352-740-0826

• ORANGE RESIDENT 352-740-0821

• RED RESIDENT 352-721-1954

• BLUE RESIDENT 352-890-0825

This is where you will find EKGs, Radiographic imaging, PFTs, and some community consult reports (scanned care-in-the-community (CITC) consult notes).

To Access Vista Imaging:

1. Open patient chart.

2. Go to Tools  Imaging (VISTA Imaging Display).

3. Input your PIN.

4. Once logged on, you can review images, open consult reports, and review EKGs.

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)

• Progress Notes: “MEDICINE PROGRESS NOTE (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”

• D/C Summaries (see below): Use “D/C Summ” tab in CPRS

• Alerted through your team phone. 

• At the VA, SWATS are referred to as a Rapid Response. 

  • MICU resident, MICU nurse, and respiratory therapist respond in addition to the primary team and bridge resident.

• If a code blue, dial 6911 or ask staff to call the code. 

• Mon-Fri 7am – 7pm, off weekends and holidays

  • Located in (Room J413-1) 

  • Late call team holds pagers on weekends/holidays and will take sign out

• Will facilitate admissions in the AM while teams are rounding

  • They will hold cross-cover pager and phone

• Please let your bridge resident know about days off, clinic, etc. 

• If you need help, USE THEM! That’s why they’re here. Procedures, questions, problems…

Transfer within colors

• Indicates that a patient is being transferred to and from SDU, acute care, and hospice.

  • This cannot be used to convert someone from observation status.

  • Make sure that vitals frequency correlates with level of care - e.g., q4h for acute

• Use the note template “WITHIN TEAM COLOR TRANSFER (T)”​ (yes, this is a note, not an order!)

  • Transfer order is generated once the note is signed.

• When transferring to the SDU, call the nursing supervisor at 102056.

Converting observation (“obs”) to Acute Care

• Main Ordering Menu > Medicine inpatient > Discharge > “Convert Obs to Admission…”

Transferring to Shands

• First thing to do - call!

  • Before 4PM: call VA Transfer Coordinator at pager 413-3296 or x106010​

  • After 4PM or weekends, call the MOD at 106004​

• Documents​

  • Inter-facility transfer form (Note)

  • Beneficiary travel​ (Note)

  • All your normal d/c paper work - i.e., discharge instructions, discharge summary, pharmacist discharge med list (call pharmacy)

  • Non-VA care consent form

When do I upgrade to MICU?

• If starting BiPAP or CPAP for the first time (e.g., pulmonary edema, hypercapnia)

  • If they have this at home, can admit on their home settings!

• Need an insulin drip

• Need a nitro gtt for chest pain or esmolol/dilt gtt for afib with RVR

Before placing initial admission orders, it is now a requirement to call your team's assigned UM (phone numbers attached to this email) 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.  Afterhours and on weekends, UM can be reached at 10-2177 . Please do not argue with the UM advisors. 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.

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. 

This is a lot of information so please review in detail at least once prior to the start of your rotation and retain this email for future reference. Additionally, please utilize our UF Internal Medicine Google Site for reference should issues arise during your rotation. Lastly, please email me at any time should questions/concerns arise. 

• Location: My Computer → S: drive → Medicine → Shared → Internal Medicine Residents → Sign Out → “ ____ Team Sign Out”

• Update daily! 

  • Include updates on daily events, what needs to be followed up, and contingencies

  • Even if still present at work, have sign out completed by 7 pm so they can effectively answer nursing pages for you

• Print and give to the Bridge or Night Resident (Room J413-1) on weekdays, or the Late Call resident on weekends

  • Bridge/Night Resident Phone: 352-740-0826​

• See “Call Schedule” table for appropriate sign out times. 

• Note that you are expected to arrive the following day by 6:45 AM so the night resident can leave by 7 AM.

• Most importantly, use common sense - i.e., don’t leave if a patient is unstable just because you’re mid call and it’s 4 pm!

***NOTES***

Neurology prelims often do not have access to the S: drive so please ask your senior resident or co-intern to open this for you each day so that you can update your sign-out. If you don't have access to the S: drive, let me know.

• On average, you must have one day off in seven days, averaged over a four-week period. 

  • You must have 8 hours off between shifts, with a maximum 80-hour work week. Please log your duty hours at least weekly in New Innovations.

  • Some interns prefer to work a “black weekend” (both weekend days) and be off the other weekend for both days. This must be discussed with your cointern(s) and senior resident. 

• In general, interns take off a weekend day. Deviations from this should be discussed with your senior resident. 

• If you are on a two-intern team, both interns cannot take the same day off. You also cannot take off the same day as the senior resident.

• When the senior resident is off (typically a weekday, since they cannot be off when there is a covering attending), the bridge resident and attending supervise.

• This is a day that is completely off! No clinical duties, no patient care, no orders from home.

Similar to Shands, anytime you encounter a patient safety issue, please enter a Patient Safety Report (PSR). This is highly encouraged and is not meant to be punitive. The PSR will help the administration provide insight on system-wide issues to help deliver proper patient care and avoid similar events or near misses in the future. Listed below are step-by-step instructions on how to fill out a PSR at the VA:

1. Open up the North Florida South Georgia VA intranet (click on the Microsoft Edge browser on any VA computer and the home page should be the NF/SG VA Intranet)

   • Here is the link if you are unable to find the NFSG Intranet page: https://vaww.northflorida.va.gov/NORTHFLORIDA/index.asp

2. Click "Patient Safety" at the top right

3. Click "Joint Patient Safety Reporting"

4. Click “Accept DoD Notice and Login”

   • Make sure you have your PIV badge inserted

5. Click “Department of Veterans Affairs”

6. You will then see the online PSR form

   • Under “Where did the event occur”, type in “573” to select “Lake City/Gainesville, FL – VA North Florida/South Georgia Veterans Health System (573)”

   • Select "Malcolm Randall VA Medical Center"

   • Select “Medicine” (or other appropriate department/service line)

   • At the bottom, you can describe the exact details of the event in a SBAR (Situation, Background, Assessment, and Response) format

All of you should have PIV card access to the IntelliSpace PACS software at the VA. This software can be used to view images for your patients and is much smoother and faster than the Vista Imaging tool on CPRS (especially when reviewing CTs, MRIs, and ultrasounds). To access the IntelliSpace PACS software:

1. Click on the Intellispace icon on your desktop:

2. Change “Log on to” to "Gainesville."

3. Change “Logon Mode” to "Certificate."

4. Change “Locations” to “Main Location.”

5. Click “Log In.”

6. The PIV certificate window should pop up. Click “Ok.”

There is a known intermittent issue where you may experience a login error, but if you click the login button twice more it should resolve.

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).

• If need to reset your PIN for a PIV badge: Go to the T11 Police trailer behind the VA to reset your pin.

• 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).

1. https://vaww.ramp.vansoc.va.gov/SelfService/

   • Has to be done on VA computer

2. Go to self service portal, request access.

   • Fill out the form; here is some useful information to have if it asks for it

     1. Include your VA email and UF email (everyone has a VA email address, typically FirstName.LastName@va.gov)

     2. Justification for account -> “Physician on-call 24/7 for availability to review charts, answer calls/consults, place orders and follow up care on patients”

   • Facility: North Florida/South Georgia VA

   • You are a VA employee.

   • Company: VA

   • Supervisor: Matthew Kosboth

   • Choose CAG access

3. Once your approved, you can access CPRS using https://citrixaccess.va.gov/vpn/index_citrix_splash.html

4. Use the smartcard access and use your PIV card with the badge reader