General Information

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General Duties:

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• Manage patients on the wards at RRMC overnight including following up labs/imaging, triaging nursing concerns/pages, and medical management of acute medical problems.

• See new consults from the Emergency room or surgical services

• Admit patient from the ED, transfers from our PICU/NICU, and transfers from outside hospitals

• Please sign into code pagers p30071, p30072, and p30073 from 5 pm to 6 am daily!

 

Logistics/Schedule:

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Weekly schedule: 

The UCLA­-N intern will work at most 6 nights in a row with 2 days off during the block.

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Where: 

Signout/homebase in Silver workroom.

 

When:

Sign out from the different services start at 5PM. Signout will start with the stepdown DOU unit NP at 5pm. Subsequently, the following teams sign out on a set schedule that rotates every night: Heme/Onc, GI, Gold, Silver. 

 

Team structure: 

1 night hospitalist, 1 night senior, and 2 night interns. Typically one intern covers the GI+Gold lists, and the other intern covers the Silver+H/O lists. However, lists can be redistributed more evenly depending on each individual team's census. Typically interns are on a 2week block, and we encourage to switch team coverage after 1week for more experience (ex: intern A covers GI+Gold for first week of nights, and then switch to Silver+H/O for second week of nights).

 

Breakdown of a night shift:

• 5PM­ sign out

• 10PM­ run the list

• 12 AM midnight rounds

• 4AM­ prepare for sign out

• 5:45am sign out to stepdown DOU unit NP in Silver workroom

• 6AM­ sign out to other teams

 

*Note: There's no set schedule for the night. Always check with your senior resident to see how he or she likes to operate.*

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Staffing:

In general, new silver patients will be staffed with the nocturnist (Silver night hospitalist). In general subspecialty admissions (ex Cardiology, Nephrology, Hem/Onc) will be staffed with the subspecialty fellow with a few exceptions:

• New GI admits overnight: staff with the GI fellow over the phone and the Silver night hospitalist in person. We recommend calling the GI fellow while the Silver night hospitalist is in the work room with you so everyone is on the same page. Please also update the GI hospitalist by email in your morning signout.

• New Neurology admits overnight: staff with Neurology first call over the phone and in person with the Silver night hospitalist.

• Questions regarding Stepdown DOU patients should be directed to  the PICU fellow.

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For questions regarding ANY patient overnight, please feel free to discuss with the nocturnist first! Otherwise please reach out to the specific subspecialty fellow such as Cardiology, Nephrology, Hem/Onc. For GI patients you can reach out to the GI hospitalist or GI fellow. For Neuro patients you can reach out to the Neuro resident.

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Teaching:  The expectation is that the night hospitalist/fellow provide formal teaching on a patient your team admitted, however due to time restraints and busy night shifts this is not always possible.  Another teaching opportunity is the night teaching power points on the moodle that your team can review overnight.  

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Pre­Rotation Assignments/To-­Dos: Review your patient lists/sign outs to familiarize yourself with the patients

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Stepdown DOU Unit Specifics:

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Stepdown patients are housed on 5W.  There is resident coverage during the night, with NP coverage during the day. Will consist of transitional patients that are cardiac, surgical, neurosurgical in need of step-down care. 

• Night residents will receive signout first from NP from 5:00pm in Silver workroom, and then from other teams

• Any questions that arise overnight should be directed to the PICU fellow

• For morning signout, NPs will come to the Silver workroom at 5:45am.  

• The NP workphone is x71613. NPs are also on SPOK pager (NP schedule here).

• The public patient list is "Pediatric Critical Care Consult" team list (System Lists -> Consults - Physician RR Follow-up -> Pediatric - Critical Care Consult). 

• The primary point of contact for these DOU patients is still the intern, like other wards patients. However, because of the acuity/complexity of the DOU patients, we ask that the intern run all issues/decisions by their senior for DOU patients overnight. 

• The DOU attending will signout patients to the night PICU attending & night PICU fellow, who is the supervisor for these DOU patients. Don't be afraid to contact the PICU fellow for any questions or to run the list.

• On midnight rounds, please prioritize DOU patients first.

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Neuro/Cardiac Transplant Specifics: ­ 

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Nighttime Signout​

• Cardiac Transplant patients

  • Please call cardiac transplant hospitalist attending directly. Pediatric residents will care for these patients overnight as first call. Please feel free to call either the Cardiology fellow, night hospitalist, or day cardiac transplant hospitalist for any questions.

• Cardiac CATH Patients:​

  • The pediatric post-cath patients should be signed out by the cardiology fellow to the residents, and the residents will help care for them overnight as first call. The cardiology fellow will discharge the patient in the morning. Please also feel empowered to page the cardiology fellow and ask for signout from here on out if you don't hear from them.

  • The adult post-cash patients are not the responsibility of the residents. Dr. Levi, Shannon and Moore care for some ACHD patients, so they will often put these on the “pediatric cardiology service” overnight, but these patients will remain in TRU/PTU overnight. For these patients either the ACHD team or the interventional attending themselves will take overnight questions and calls.

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Morning Signout

Please email overnight events to the appropriate people (GI hospitalist, Cardiac Transplant hospitalist) at 6 am. ​Sometimes the day hospitalists may not be on site until a little later. After 6 am, any concerns that arise for these patients should be directed to the hospitalist on site.

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INTern Guide

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MOST IMPORTANT RULE #1:

Never be afraid to ask for help from your senior resident if you have any questions about any patient. 

 

Also, feel free to call a pediatric rapid response (which will alert the PICU on call team as well as the charge nurse and a respiratory therapist) to your location. The institution of this team has dramatically reduced the number of Code Blues called on the pediatric ward. The only qualifier for calling rapid response is having a bad feeling about the patient. If you are sufficiently concerned, you do not have to “run it by” anyone. 

 

To call a rapid response, alert the nearest nurse, call the page operator (66766), or dial #36.

 

Sign out  

Getting sign out from the wards team can be overwhelming at first but will get easier. It is very helpful to review the patient list before starting the rotation.

 

When getting signout, you have to balance the need to get as much information as possible with efficiency. Try to get as many if/then statements as possible, especially on any action points that are being signed out to you. 

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Use the SIGNOUT Mnemonic on your code card to help streamline this process!

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It is important to identify sick patients that you and your senior resident will examine together at the beginning of the shift, and other "active" patients you would like to examine/eye­ball on your own at the start of the shift.

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Click here for commonly used signout abbreviations.

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Getting Paged

• Call the number back: 

This may be obvious, but it is very important to respond to ALL pages in a timely manner, even if it is to tell the caller that you are in the middle of something at the moment and will circle back in xxx amount of time. Ignoring pages will only get you in trouble with the nursing and ancillary staff, and more importantly can lead to poor patient care outcomes.

 

The obvious exception is a medical emergency like a rapid response or a code blue, in which case you should go to the patient's room. 

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• Assess the patient (chart and numbers): 

Medical decisions will require a background understanding of  who the patient is and what their course has been.  This is where signout and your if/then statements can be extremely helpful. If the questions is outside of the constraints of the signout  you will need to conduct a brief chart review to figure out any recent medication changes or laboratory studies. You should also take a look at their vital signs, I/O status, and in some cases, weight. 

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• Assess the patient (physical exam): 

You don’t necessarily need to examine the patient for every single medical issue, but it never hurts (and almost always helps) to take a look at the patient. Your job as the in-­house MD is to serve as the eyes, ears, and hands of the fellows and attendings, so you should err on the side of examining the patient. Under the Survival Guide section, we’ve listed for you some of the relevant details you should look for. 

 

If you’re unsure of what physical exam findings are particularly relevant for the situation, ask your senior resident. Physical exam findings will almost always be necessary if you need to consult with the specialty fellow or attending. Sometimes you will encounter resistance from family members because they don’t want the patient disturbed, so you’ll need to balance the family’s wishes with your own need to provide the patient with the best care possible.

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• Know when to defer: 

It seems that parents always want to know “the plan” at 2 AM. It’s okay to defer non urgent medical concerns to the day team, and it’s better not to say something if you’re not sure. Parents remember what’s said by all medical staff, and you don’t want to be the perpetrator of misinformation. Just remember to sign those things out to the day team and let them know the parents probably need a more detailed update after the next morning’s rounds. 

 

But please remember that you are the doctor CARING for the patient not COVERING the patient, telling a patient/family or nurse "I'm just covering" is not appropriate and unprofessional. 

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• Follow-­up: 

If you institute a plan of care in response to a page, you should follow up to see if there is a response to your intervention. For example, if you start IV fluids for low urine output, you should check back later to see if the urine output has improved. If you order an EKG, you should make sure to look at it. This may sound easy, but it can be challenging when there are many active issues on many patients. It will require careful record keeping on your part—see what system works for you and ask your fellow interns, your senior residents, or your chiefs if you have trouble or for advice.

 

Admissions and transfers

Admitting and transferring patients is the “potatoes” of being an intern on ward nights. Patients will sometimes be directly admitted to you (meaning you are responsible for the full H&P) if they have known diagnoses or are being transferred from an outside hospital. 

 

Some common direct admissions include Heme Onc patients coming in for scheduled chemotherapy, GI patients being admitted for a possible liver transplant, or patients at other institutions that require specialty or higher levels of care. This sometimes means doing some detective work through old charts or records to figure out all the nuances of the patient’s medical history. Please ask your senior resident for help if you are having trouble finding out all the details. 

 

Remember, sometimes information in the chart is incorrect, please clarify and verify all information with the family, you don't want to perpetrate incorrect information. 

 

When receiving patients for transfer, you will be given signout from the primary service (for example, the Pediatric Night Hospitalist or the PICU team), as well as a transfer summary or admission note.

 

You are responsible for physically examining the patient, reviewing the orders, and writing an acceptance note once the patient makes it to the floor. It’s important to get a sense for the urgent night­ time issues, but also remember that you will be giving signout to whomever will be taking the patient over the next morning!

 

After seeing the patient, you will be expected to review the case with your senior resident and go over the plan. Be prepared to give a brief HPI and plan over the phone to the fellow or attending; your senior will be present to help you with this conversation.

 

ED Transfers/admits

The pediatric hospitalist attending is now first call for all new consults, both sub specialty and general pediatrics, in the RR ED. Please page 90054 24hrs/day.  

 

For patients who are being admitted to Santa Monica (SM), the pediatric hospitalist will be the primary physician until the patient has been transferred to SM.  

 

If the census on the silver team is low (<6patients/intern) and there is an interesting/educational consult in the ED, the resident/intern should perform the consult with the attending.

 

For any patient being considered for admission to RR UCLA, the pediatric hospitalist will be notified first, and the hospitalist will then notify the appropriate resident service. The goal is to have the pediatric hospitalist involved with the ED care of every pediatric patient being admitted to either RR or SM.

 

For patients who are referred to the ED by a subspecialty service for admission, the pediatric hospitalist attending should be told about the patient to ensure that timely evaluation and management of these patients are provided upon arrival to triage. The hospitalist will work as a team with the ED, pediatric residents and subspecialty fellows to decide upon the plan of care. As the pediatric liaison to the ED, the hospitalist will help to implement the decided upon plan, and ensure that the patient needs are being met while they await transfer to the floor.

 

The residents of the appropriate subspecialty service will continue to be the primary physicians for these patients. This means they will continue to evaluate, counsel families, write orders, and write admitting notes for these patients.

 

If the subspecialty service is not readily available due to morning rounds, clinic, multiple admissions or sick children on the floor, the pediatric hospitalist will be able to ensure the primary team's recommendations are implemented. The pediatric hospitalist will also check on patients regularly to ensure adequate vigilance and care for patients awaiting transfer to the floor. 

 

 

Special Notes on Hem/Onc Admissions/Patients:

For patients admitted for routine chemotherapy:

Heparin Flush 100units/ml 500 units as needed for port­a­cath flush NS Flush for line care

 

Patient admitted for fever and neutropenia or already admitted and becomes febrile and neutropenic, there is an orderset to use:

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PED HEM ONC FEBRILE NEUTROPENIA ADMISSION IP

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Last update: September 2021