VA Pagers & Room Extensions

Welcome to the VA!

• Be sure your VA access works before the first day of the rotation.

• Process your CPRS alerts in a timely manner. Those that aren't are sent to Dr. Kosboth. 

• Use the Medicine H&P template and fill out the tobacco history portion as supplied. Free-handing their tobacco history will flag the H&P as incorrectly used.

• Complete your discharge summaries within 24 hours of discharge.

Team Rooms are located at the end of the halls on: Green - 4 West, Blue - 4 East, Orange - 3 East, and Red - 3 West.

CPRS: Make sure your CPRS passwords are up to date and that you can login prior to your first day. 

Pagers:

Please make a note of which pager you are assigned to on the schedule. The nursing staff and consultants will page you directly at this pager to relay patient care information so it is imperative that you keep this on you until your rotation is complete. Do not switch pagers with another intern/resident on your team. If you do, please let me know so I can update the schedule. You are only required to answer pages from 7a-7p. If you are away from the hospital and need to place orders, please call the bridge resident to assist you. ​

Off-service Interns (Psych and Anesthesia): Please page the senior resident/team the day before you start to obtain a sign out on your patients and get reporting instructions for the following day. See call schedule for pager information . You will also need to activate your "Shift Handoff Tool" by calling Clinical Informatics at 6339 or 2777.

Discharge Summaries:  All DC summaries should be completed within 24 hours of discharge. Residents will be in charge of these for the first 3 months of the year. After that time, interns should be doing discharge summaries for length of stay less than or equal to 4 days (this includes the date of admission and the date of discharge).  Residents are always ultimately responsible for all DC summaries to be completed for the team and should keep a running list on their team boards. CPRS has a DC summary template - please use this and do not alter it! Make sure you tag the primary care provided after finishing the DC summary. 

Transfer of Care: The resident will present an interns patients to the attending the first day but interns are expected to pre-round on all patients and have pertinent updates ready for rounds (vitals, exam, updates).  Interns are responsible for the notes on Day 1, and subsequent notes/presentations for those patients thereafter. Additionally, the off-going intern/resident is expected to leave a written handoff note for the incoming intern/resident detailing hospital course, active problems, and plans for disposition. There should always be a verbal and written (email) sign-out between transitioning team members 

48 Hour Obs: Any patient you believe will likely not stay longer than 48 hours should be admitted under observation status. Please see attached observation guidelines for further details. The Level of care attachment gives further examples. If patients stay longer than 48 hours, they must be converted to an inpatient acute care admission before the 48 hours expires. Please see attached Obs to Admission conversion guidelines for further details.

Acute to Obs Admission Conversion: Please see the attached short 5 slide ppt on how to properly convert obs to acute care.  You should always use the note template [ OBSERVATION CONVERSION (T) ] to initiate this process to ensure that the note gets entered correctly. 

Procedure Service: LPs, thoracentesis, paracentesis, joint injections, etc. If your patient needs a procedure, you may consult them or take care of it within your team.  If you perform a procedure make sure that you use the new "Invasive Procedure (T)" template.

Night Sign Out

Located on the T drive, please access by Windows -> My Computer -> (S:) Service -> Medicine -> Shared -> Internal Medicine Residents -> Sign Out -> Resident Sign Out Log. If you are unable to access it or it is not working correctly, please email the VA Chief Resident. The format is in the IPASS format below. It is your responsibility for the sign out to be accurate and updated nightly. 

When work is completed Early Call and Golden teams may check out at 3pm, and Mid Call at 5pm to the Bridge during the week. Sign out is to the Late Call team on weekends and may be as early as 12pm. If before 7pm, you must check out with the bridge on the weekdays and late call on the weekends before leaving for the day.

What is IPASS?

·  Illness Severity: label your patients as either stable, watcher, or unstable (IMC)

·  Patient Summary: one liner of what is going on with your patient.

·  Action List: to do list

·  Situation Awareness and Contingency Planning: our “what if” statements.

·  Synthesis by Receiver: verbal sign out

Home Care Orders:

Please see attached PowerPoint on further information on how to properly place home care orders for the veterans that need them. Make sure to have this discussion with your case manager prior to placing home care orders for your patient. 

Performing COVID Testing

If testing is required on the floors (for placement or prior to procedures or etc.), the residents should do this with proper PPE (N95, eye protection, gown, and gloves). Please do not perform this test if you are not wearing the proper PPE. If testing required in the SDU, MICU, or ED, the nursing staff can perform them. I have attached a word document with instructions to properly perform the COVID-19 testing.

COVID-19 Testing for ALL patients on Day 3 and Day 7

Starting 9/14/20, all patients admitted to the VA who have been hospitalized greater than 3 days will have a "Day 3" COVID testing and those who have been admitted greater than 7 days will have a "Day 7" COVID testing performed. Therefore, if you see these orders show up for your patients admitted for >3 days or >7 days, please do not discontinue the orders. This is a new VA policy to help detect more asymptomatic COVID patients and avoid spreading the virus further. "

Surgical Masks + Eye Coverage

The CDC recommends that that we wear eye protection in addition to a surgical mask when we see our patients to help decrease the spread of COVID-19. At the VA, we have the surgical masks with eyeshield attached to the mask instead of the goggles. These are now available to us at the bridge room aka medicine call room (J413-1). Please pick one up from the bridge room prior to the start of your shift.​

Life Sustaining Treatment (LST) Note 

Must be documented for every admission! Use this note to document code status and discuss specific long term wishes (ie- no invasive or non invasive mechanical ventilation, no artificial nutrition, etc..) for your patient. If a patient already has a Life Sustaining Treatment note (LST) 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 make sure to write one during admission. See attached document on the template of what questions you need to ask for the note. Also, as a reference, I have attached the LST note PowerPoint presentation by Dr. Rich.

Regarding code status: Patients who are full code, please indicate at the bottom of each note and do not place any specific orders for patients that are Full Code. For patients who are DNR and/or have specific long-term wishes, please click the appropriate radio buttons on the Life Sustaining Treatment note to ensure that the correct order pops up for the patient. Please see the attached LST questions which you can print out and ask your patient during admission if needed (courtesy of the VA Palliative care team).​ Listed below are specific examples for patient's code status and what to click on the LST note for the proper order to show up:

1) DNR - If a patient wants to be DNR (no CPR, defibrillation, medications, and NO mechanical ventilation) please select "Limit life-sustaining treatment (e.g., mechanical ventilation, artificial nutrition) as specified in circumstances OTHER than cardiopulmonary arrest:" button and then select "no invasive mechanical ventilation (e.g., endotracheal intubation or tracheostomy tube)" on question 6 of the LST note. Also, make sure to select "DNAR/DNR: Do not attempt CPR" radio button as well in that question. You need to select BOTH these buttons to make sure an order for "DNR" and "no invasive mechanical ventilation" pops up. 

2) DNI (CPR, defib, medications OK) - If a patient wants NO invasive mechanical ventilation but does want everything else done, then please select "Limit life-sustaining treatment (e.g., mechanical ventilation, artificial nutrition) as specified in circumstances OTHER than cardiopulmonary arrest:" button and then select "no invasive mechanical ventilation (e.g., endotracheal intubation or tracheostomy tube)" in question 6. For the second part of question 6 which asks about cardiac resuscitation -> please select "full code: attempt CPR." An order for "no invasive mechanical ventilation" should pop up only.

3) DNR but OK with invasive mechanical ventilation - If a patient only wants intubation but NO CPR, defib, or medications in the event of a cardiopulmonary arrest, then all you need to do is click "Full scope of treatment in circumstances other than cardiopulmonary arrest" and also select "DNAR/DNR: Do not attempt CPR." ​Then an order for DNR pops up but no order for "do not intubate" should pop up. 

To further clarify -> if a patient wants to be DNR and no intubation -> you need to have TWO orders "DNR" and also a "no invasive mechanical ventilation" order. This is different than in EPIC where a DNR order means both no intubation and no CPR/defib/medication in the event of cardiopulmonary arrest. 

Code Pager: The pager will have "test codes" during the day - please answer them! If there is not a test page every day, please check the battery and recharge it as necessary. The charger for the pager is located in the intern call room. Extra batteries for the CISCO phone are located in the MICU. Intern x-cover pager and CISCO code phone are carried by the long call team on the weekends.

Early Discharges: The day prior to discharge, please identify patients who may be able to leave early in the day and notify pharmacy and social work. We have also recently added an order called "anticipated discharge" found in the medicine inpatient menu which will help to notify nursing and any other services assisting with the patient's care. This will allow them to prepare this patient for discharge and you may discharge them prior to rounds after they are seen by the resident and attending during pre-rounding.

Hospital Transfers: Please read the attached updated document on proper procedure for transferring to outside hospitals (which is usually to Shands for a procedure, etc).

How to file a PSR at the VA:

Just like at Shands, anytime you encounter an patient safety issue, please make sure to enter a patient safety report (PSR). This is highly encouraged and is not 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. Please see the attached screenshots for directions on how to file a PSR. Listed below are step by step instructions to fill out a PSR at the VA:

1. Open up the VA North Florida South Georgia intranet (click on internet explorer or microsoft edge browser on a VA computer) and the home screen should be the VA NFSG  Intranet. 

• This is the same area where you look for call schedules among various other things. 

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

2. Next, click on "Patient Safety" on the top right section. 

3. Click on "Joint Patient Safety Reporting." which will then open up a new browser. 

4. Click "OK" and then click on "Authenticate with your DoD CAC, VA PIV, or ECA Certificate." 

• Make sure to have your PIV badge inserted

5. You will then see the online PSR form. 

• I have attached the screen shot for what exactly to enter on the section "Where did this enter" but to make it easier, click on the "VISN" section FIRST and select VISN 08 which will then narrow down the options from all the VA hospitals in the country to the VA hospitals in the state. 

• Then select "573 North Florida South Georgia" for VA Medical Center. 

• Lastly, select "Malcolm Randall VAMC." 

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

We strongly encourage you all to file a PSR anytime you notice any near misses or adverse patient outcomes!

Utilization Management (UM): 

The ED physicians are now required to call UM for consultation regarding level of care instead of medicine (from 07:00-23:00 M-F). Therefore, you do not have to call UM for every admission regarding level of care as we have been previously doing. You only need to call UM if there is a discrepancy on the level of care they recommend and the level of care that you desire to admit the patient under. If there is such a discrepancy, please see the instruction and UM contact info below made by Dr. Hood (VA Associate Chief of Staff for Education) for more information:

• ED providers must contact UM for admission clearance Mon – Fri 07:00 – 23:30 at extension 102177.

• To help ensure this is done, please ask ED providers for the UM recommended level of care (e.g. OBS, ACUTE, SDU) when receiving an admission.

• If they have not consulted with UM during the above hours, inform the ED provider that you are not able to admit patients without UM consultation.

• If UM does not recommend admission, please always do what is right to benefit the patient.

• If you and your attending have seen the patient and do not feel s/he will benefit from admission, you must write a note with your alternate recommendations to the ED provider.

• If you ever see a patient and your diagnosis or approach changes from the original ED assessment, be sure to consult with your UM advisor or with the UM number to get the proper level of care and guidance on any admission requirements.

• The intent is to provide better care for those who need admission and to prevent admission for those who don’t.  This will be increasingly important as the coronavirus pandemic continues to develop.

UM Contact Info:

The daytime number for UM consultations 7:00am – 3:00pm (Mon – Fri) is 102177.

The after hours numbers for UM consultations 3:00pm – 11:30pm (Mon – Fri) are: 284-0037 or 317-3575

You also can reach them by instant messaging via Microsoft Teams: Davis, Patricia Patricia.Davis3@va.gov or Weeks, Wayne Wayne.Weeks@va.gov

Please remember to call for level of care recommendation if your diagnosis or treatment plan differs from what was planned in the Emergency Department.

COMPUTER, ACCESS & IT ISSUES

If you have bee​n deactivated in CPRS (inactivates after 90 days without a login): When you log on to the VA computer, enter "vhanfl_____" as usual and enter the temporary password "1234abc." (be sure to put in the period, too). After that you can change it to whatever you like. If you have any trouble either call the CPRS help desk aka Clinical Informatics (VA ext 106339) or the National IT service desk (Ext 106093).  

If need to reset your PIN for a PIV badge: Please go to the T7 Police trailer behind the VA to reset it.  Secondarily, you can also try to contact Michelle Walker (ext 104014, email michelle.walker@va.gov) during business hours.  She is in the Medical Services office B391 in back building.

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, it grants you 14 days to get a new PIV badge or get your exemption figured out. If you lost your badge contact Michelle Walker (email michelle.walker@va.gov) right away to start on 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 a card.  Try not to lose your badge as it's very difficult and time consuming to replace.

If other computer issue not covered above: First try Clinical Informatics (VA ext 106339) or the National IT service desk (Ext 106093).  If still having trouble can contact myself and Naomi Nelson (Naomi.Nelson2@va.gov, 352-548-6000 ext 107756).

VA TMS Issues: For things like the ACLS/BLS online training, annual VA certification, etc.  Try VHANFLTMSHelp@va.gov or 352-337-2377 for local TMS support

Home CPRS Access: 

Please see below instructions and follow them step-by-step (please note, if you have already requested home access in the past and lost it, then you do not need to create a new profile (slides 2-7). 

 Please pay close attention to all the steps: 

NEW USERS (i.e. ALL INTERNS). Steps 1-2 need to be done at a VA computer

1. Follow instructions on the power point (attached below) to register your profile and request access (List Naomi R. Nelson as your supervisor; NOT Naomi Nelson). Make sure you select the one with the middle initial "R" so it is sent to the correct admin officer.

2. Follow instructions on the pdf (attached below) for Mobile Pass registry (please pick instructions based on your mobile device type)

3. To login from home, click on https://citrixaccess.va.gov

4. Click on the OTP Token and Login: 

    - username: vha08\vhanfl...(your unique login, pay attention to this back slash, for example mine is vhanflalia)

    - password

    - token: you get that from your mobile pass app on your mobile device (it resets every 30 seconds)

5. Click on R03-VISN08 -> North Florida -> NFL-CPRS 

6. Done, enjoy your home access!

​

VA TMS Issues: For things like the ACLS/BLS online training, annual VA certification, etc.  Try VHANFLTMSHelp@va.gov or 352-337-2377 for local TMS support.

Attached are helpful guides for observation admissions and transferring patients among different levels of care. 

LIFE SUSTAINING TREATMENT (LST) NOTE

How To Fill a Patient Safety Report (PSR)

HOME ACCESS for CRPS