KAISER SANTA CLARA PEDIATRIC INPATIENT CURRICULUM LUCILE PACKARD CHILDREN’S HOSPITAL AT STANFORD O’CONNOR MEMORIAL HOSPITAL FAMILY MEDICINE PROGRAM STANFORD MEDICAL SCHOOL Introduction The pediatric inpatient service at Kaiser Santa Clara Hospital provides medical and surgical care for children among a total population of 250,000 members of the Kaiser Foundation Health Plan in Santa Clara County. Approximately 20% of the population is under age 18 years. During a standard one-month rotation on the pediatric inpatient wards, residents diagnose a wide array of diseases and treat ward- to ICU-level severity of illnesses, ranging from gastroenteritis and minor trauma to septic shock and ARDS. Our full-time staff has representatives from many pediatric subspecialties including: neurology, pulmonology, cardiology, nephrology, hematology/oncology, infectious diseases, gastroenterology, critical care, surgery, and rehabilitation medicine. In 2009, a pediatric Neurosurgical program will be added as well. Each of these services consults regularly on the Inpatient Service. The PL1’s, students and cross-cover residents provide direct care of Pediatric patients with the supervision of the pediatric “Hospital Based Service” physicians (HBS, or pediatric hospitalist) and critical care physicians. He/she is encouraged to assume responsibilities in independent evaluation, differential diagnosis, diagnostic studies, procedures, therapeutic decisions and discharge planning for each patient. An in-house pediatric HBS attending and a pediatric intensivist are available for assistance and consultations at all times. All patients are Kaiser Health Plan patients who have Kaiser primary care providers; consequently, residents should manage patients and families at Kaiser in accordance with private medical standards. It is a priority for our families that the HBS attending be fully informed of the details of patient care and each Primary Care Provider is updated about each patient’s status. Family Centered Care is an integral part of Kaiser Santa Clara’s inpatient health care delivery and is one of the unique aspects of this rotation. Nationally, Patient and Family Centered Care has emerged as an exciting new trend that promotes high quality, safe care and improved patient satisfaction. Kaiser has enjoyed significant improvements in patient satisfaction while maintaining high quality care. Stanford Medical Students rotate monthly on this Pediatric Inpatient Service, and an O’Connor/San Jose Medical Center Family Practice intern rotates eight months of every year. Stanford Pediatric Residency Program interns rotate monthly with a daytime PL1 who is on service and a cross-cover PL1 who takes overnight call every fourth night. Weekly Schedule (subject to change) Time Monday Tuesday Wednesday Thursday Friday 0xxx-0830 Pre-round Pre-round Pre-round Pre-round Pre-round 0830-0915 Morning Morning Morning Morning Morning Sign-out Sign-out Sign-out Sign-out Sign-out 0915-1130 PICU/Ward PICU/Ward PICU/Ward PICU/Ward PICU/Ward Rounds* Rounds* Rounds* Rounds* Rounds* 1130-1200 Radiology Patient Care Patient Care Teaching Rounds Radiology Rounds with Drs. Dong Rounds and Jeung 1100-1230 Patient Care Patient Care Patient Care 1230-1330 Teaching Teaching Teaching Teaching Ambulatory Session** Session** Session** Session** Pediatric Inpatient Lecture Grand Series to be Rounds*** arranged 1300-1700 Patient Care Patient Care Patient Care Patient Care Patient Care 1700 Sign-out Sign-out Sign-out Sign-out Sign-out * Structure of rounds will flex for patient volume, patient need, and duty hours. ** Lunch and learn with ward attending (informal), formal presentation from backup attending, or sub-specialist presentation as time permits and as resident duty hours/continuity clinic permit. Session length will not always be one full hour but will occur during this time period. We aim to have at least 3 structured learning sessions per week (including Ambulatory Grand Rounds). *** 3 Fridays out of Month in Adjacent Medical Office Building # -1st Thursday of month. Residents will be invited if pertinent didactic material is discussed ##-2nd Thursday of Month. Conference is in Cancer Treatment Center adjacent to hospital Orientation Residents on inpatient service as well as cross-cover residents will undergo a formal orientation during the first day of the bock. A large portion of this first day will be Health Connect (HC) training. This is an EPIC based electronic medical record and computer order entry system that will go live June 20, 2009. At that time 99% of paper charting and paper orders will disappear. It is vital that residents complete HC training on their first day in order to perform as a valuable functioning member of the medical team. A training session that will be approximately 5 hours long will be required for all residents on the first day of their rotation. After completing this process along with GME required paperwork, the residents will report to the ward to become acquainted with their patients. Kaiser requires this orientation prior to delivery of patient care. The Pediatric Intensivist /A-call Hospitalist will orient you on your first day. This will include a review of your responsibilities and use of the computerized patient information system, Health Connect. A brief tour will be required showing residents the Ward, PICU, Procedure Room, Playroom, Teen Lounge, Nursing Lounge, Physician workroom, cafeteria, and pediatric call room. You will receive a Kaiser Santa Clara photo ID badge, and a meal card with a monthly allowance. A fitness room is available on site. Tariq Chaudry (email:Tariq.E.Chaudry@kp.org,pager:408-231-2378) and Jon Feldman (email:Jon.Feldman@kp.org, office 408-851-7147) currently share the role of residency site director. Susan Krause will be taking on the role of Course Coordinator and can be reached at 408-851-3836 or by email at Susan.Krause@kp.org. You should call her prior to the start of the rotation to arrange for computer access and training, complete paperwork, obtain badges and meal cards. Upon completion of your rotation at Kaiser, you need to return your badge, meal card and sign-out sheet to Susan to complete the sign-out process. Remind her if you are to return later in the year and she will keep your badge. The Pediatric Ward number is 408-851-7400. The PICU number is 408-851-7440. A spectra link (cell) phone for direct contact with the on duty ward attending is 408-851-7470. Rounds Daily patient assignments may be created by the overnight call team in conjunction with the daytime interns and students. Assignments will be recorded on the white board in the workroom. Interns will cover a maximum of 10 patients and students will carry between 3-5 patients depending on complexity. Sign-Out will start at 8:30 AM. At some point during sign-out rounds, the overnight attending will briefly (5-10 minutes) discuss management of an overnight case in an informal setting. Electronic notes that are pended in Health Connect have caused large volumes of incomplete resident notes throughout the medical system. Residents are therefore required to complete pre-rounding and have their notes completed. This is a mandate for all providers throughout the medical center. Addendums can be easily added to notes to reflect modifications in the patient plan and new data. Electronic notes can be filed but will require co-signature by attendings. Mobile computers will be available for bedside rounding. Rounds start each day at 9 AM in the PICU. Ward Rounds start immediately afterward. These are both work and teaching rounds. At times, if ward census is particularly high, the team may round on the floor and conduct less formal rounds with the PICU attending later in the day. The PL1 is responsible for pre-rounding and presenting the patients to the team. When needed, the post-call PL1 and/or HBS Attending will help with this work. Following rounds, the PL1, medical students, and HBS Attending of the week (A-call) will provide care for the patients in the PICU and Ward. They may also be asked to consult in the Emergency Department or Clinic regarding potential admissions. Sign out rounds start at 5 PM. The A2, or transport attending, is available in mornings to deal with admissions, discharges, and general issues so that rounds can be smoothly completed. The A2 goes on critical care transports requiring a physician. Recent Kaiser directives require the team to attempt to discharge patients prior to 11am. Because of this, the A2 will at times assist with discharge duties on a patient that may include some or all of the following: Discharge prescriptions Follow up appointments Daily Progress note Answer final questions for the families Residents are still expected to complete discharge summaries for their patients and are encouraged to say goodbye to families/patients with whom they have developed rapport. The A2/transport attending may offer to dictate/complete a discharge summary, they are encouraged to ask the resident if they require such assistance. **The blend between continuity and private practice medicine is a difficult one. The optimal way to maintain continuity is to start preparing for discharge as soon as possible. Considering discharge disposition each day on rounds is an integral part of resource utilization in private practice and Health Maintenance Organization medicine. Discharge Summaries are expected to be completed on the day of discharge. Health Connect allows pre-staged DC summaries to be prepped and pasted into a discharge summary. This improves a physician’s ability to edit discharge summaries without needing to wait for completion of transcription. Any note can be electronically routed to PCPs, specialists and other providers. Secure messaging provides an internal email system to send messages to providers. Phone contact may also be used. Residents should arrive in order to complete pre-rounding at notes by 830am. Residents should not arrive prior to 6am and if one perceives the need to do this, they should contact the LPCH Chiefs or Rotation Directors. If starting at 6am, residents must be cognizant of work hour guidelines. They should attempt to leave promptly at 530 pm after completion of sign-out rounds. If sign-out rounds occur late, residents should attempt to complete their work and leave as soon as possible. Residents that are on call are encouraged to start call at 7am and sign out by 1130am, with the final goal of leaving the building by noon, when post-call. Residents are required to sign out and leave rounds and/or educational activities to prevent working more than 30 consecutive hours. Residents will round on a maximum of 10 patients each morning. Attendings will assist residents as needed to prevent work hour violations, when patient volume is high, and when residents require support. The PL1 should notify an attending for support during these situations. A collaborative approach to duty hours is necessary. Residents must take responsibility for monitoring their own duty hours and planning in advance to allow for on-time departure. At the same time, there are instances in which it is impossible to complete all work and adhere to duty hours. It is at these times, the resident has the responsibility to herself and the Residency Program to notify the Attending of the necessary departure time. Remaining tasks must be signed-out. Attendings are aware of the ACGME work hour requirements and will be supportive of residents who are diligent in their efforts to complete work but volume or patient communication ,etc prevents this. While we do not expect this to be an issue, Attendings will not be supportive of situations in which residents plan poorly and choose an extended sleep rather than anticipating the needs of the day. Family Centered Care This concept of care is increasingly and successfully practiced at major pediatric centers. It involves adapting rounds and patient care to family preferences/need (within reason of course). Flexibility is paramount as needs of different families vary. Family preferences may also change during the admission. Our team is committed to responding to a family’s changing needs in order to provide better patient care and improved patient satisfaction. Family centered care in one of the cornerstones of our curriculum and one of the most important experiences to take away from Kaiser. • Altering communication styles o Remembering to minimize jargon in front of family members o Remembering to address the patient and family while presenting medical information o Learning to omit sensitive psychosocial issues during bedside rounds and present information away from the child and/or family. These vary according to family preference • Modifications to rounds o Involves different options Full multidisciplinary team rounds at the bedside including nutrition, nursing, pharmacy, etc. This is often preferred by well educated families, families with children with complex/chronic medical issues. Limited team bedside rounds with the attending and resident or student. This is often more appropriate for socially complex situations such as patients with eating disorder or families that feel intimidated or “put on display.” Rounds in nursing station/conference room with limited rounds at bedside that review daily assessment and plan for families. Student and Resident Educational Opportunities Sign-out Rounds This year ward attendings will present 5-10 minutes of clinical information or answer management questions on overnight admissions. This will be guided by the B-call/overnight attending. We will initially aim for 1-2 sessions/week. This may be scheduled to a fixed day as if scheduling difficulties occur. Inpatient Grand Rounds Pediatric Grand Rounds-Our program is beginning to return to its previous status, but is still a work in progress. The final goal is to have bi-monthly conferences from 11:30-1:30 pm for inpatient topics on the first and third Thursday of the month. Topics will be highly relevant to inpatient medicine. These sessions will be the most traditional didactic sessions residents will receive at Kaiser. Residents will need to plan pre-rounding accordingly in order to attend. Attendance will be required. As this is a work in progress, timing of the conference may change. Friday Noontime Ambulatory Topics Attendance of these lectures is recommended. Attendings will attempt to protect this time for residents and students. The conference typically occurs 3 out of 4 Fridays in the conference center in the adjacent Medical Office Building. Rounds Attendings will seek opportunities for bedside teaching and presentation of physical exam findings. Interns are expected to do the same for medical students. Ward Presentations You may be asked to present brief presentations on clinical topics pertaining to your patients. Providing literature and practicing evidence based medicine is highly encouraged and often necessary to answer difficult clinical questions while on the pediatric service. “Late Morning Report” Thursday 1130 AM with Dr. Dong and Jeung. This is a case based discussion of cases ward/picu cases. We will aim to protect the residents during these talks by answering pages and phone calls. Specialist Talks This will be scheduled as time permits with specific specialists. The goal will be to have one lecture/month on a core topic from each specialty. Topics can be adjusted based on clinical load. We will aim to protect the residents during these talks by answering pages and phone calls. Pediatric Endocrinology: Dr Misra/ Dr. Cohen (special scheduling required) Pediatric Cardiology: Dr Tannenbaum (special scheduling required) Pediatric GI: Dr Wong/ Dr Abramson Pediatric Rehab: Dr. Mandac Pediatric Neuro: Phil Sankar/Dr. Ann Lewis Hematology/Oncology: Dr. Wong Tumor Board This presentation occurs the second Tuesday of every month and focuses on our oncologic population. Patient cases are reviewed in depth and discussions of chemotherapy plans occur here. This conference has A multidisciplinary focus and patients that the residents will see during their rotation are frequently discussed. Residents will get exposure to the ambulatory side of pediatric oncologic management. Pediatric Rehabilitation Multidisciplinary Rounds Procedures Residents may have the opportunity to perform the following procedures: Peripheral intravenous line placement (can be done by request) Central line placement Endotracheal intubation Lumbar Puncture Bone Marrow Aspiration/Biopsy (Can be done by special arrangement with Oncology) Circumcision (can be done by special request) Residents will be expected to participate in mock and true codes. Phones Effective July 2009, there will be a mobile phone for resident use. This will permit nurses to directly contact residents and ensure resident involvement in all patient-care activities. Pagers The Intern will have a team text pager to facilitate communication. Interns will alternate carrying the pager and cover each other for afternoons when they are in Continuity Clinic. During rounds and educational talks, the A2 or backup/transport attending will carry all pagers and phones in order to protect the rounding team and expedite workflow. Attendings are instructed to update team members on happenings and changes that occur in resident/student patients as soon as possible. Nurses have been instructed to contact the primary intern covering the patient before calling the attending. Intern Call Schedule Interns will take call every fourth night and sign out care to the Night Team at 5 pm. This should ensure continuity of patient care and availability for patient care throughout the work week. Continuity Clinic afternoons will be an exception. Weekend Rounds Members of the team who are post call (varies by call schedule – it may be an intern or medical student) may leave after rounds are completed. The on-call team will always include one on call attending who will be present for 24 hours, an A2/transport attending who will be present for 4-8 hours depending on volume, and the on-call medical student or resident. Post call students and residents will complete rounds for their patients and leave as soon as their patients have been completed. The team will focus on completing patients assigned to post-call team members. In order to comply with duty hour regulations, the post call team member is NOT required to stay for the completion of rounds for all patients. Overnight Call 1. Overnight call is every fourth night. An HBS Attending (B-call) will be in house each night. The resident will be responsible for calls from the Pediatric Ward and PICU, consultations in the ED and admissions from the Santa Clara ED and Clinics as well as patients transferred to Santa Clara from outside locations. 2. The B-call Attending will additionally be responsible for assisting in seeing all admissions, patients in the ED, and arranging transport of patients to Santa Clara from outside locations. The B-call attending should be contacted for AM sign-out when residents arrive. 3. A Pediatric Intensivist is available as back up at all times. There are also Anesthesiology, Neonatology and Pediatric Surgical Residents available in-house. 4. The call room is located in Department 330, room number 3637 (aka call room #19). The current door code is 7470#. The attending call room is across the hall for urgent needs. The Medical student call room is in Department 335, room number 3717 (aka room #18). Bed, TV, computer, and bathroom including shower are available in call rooms. We encourage outside learning materials to be kept in call rooms if residents and students wish. 5. Kaiser staffing is done months in advance and staff members plan schedules based on expected resident coverage. If there is a conflict with the call schedule assigned by the Chiefs, please contact your Chiefs or make a schedule change with a colleague who has already rotated through Kaiser on inpatient service or cross-cover (must be approved by Chiefs). 6. The PL-1 will be expected to stay and help present overnight admissions and participate in morning sign-out rounds. They will stay no later than 10 AM, but may leave after sign-out rounds if there are no new patients to present. The goal is to be exposed to more teaching opportunities, receive feedback on care delivered overnight, and help maintain continuity of care for complicated patients. ACGME Requirements Competency-Based Goals and Objectives Patient Care • Gather essential and accurate information about patients using medical interviewing, physical examination, diagnostic studies, and developmental assessment • Make informed diagnostic and therapeutic decisions based on patient information, current scientific evidence, and clinical judgment • Develop and carry out patient care management plans • Develop procedural skills when available: venipuncture, arterial blood gas, chest physiotherapy (When Available, Kaiser offers additional opportunities such as Lumbar Puncture, Bone Marrow Biopsy, Chest Tube Placement, Central Line Placement, Arterial Line Placement, and Intubation) Medical • Know, critically evaluate, and use current medical information and scientific evidence for Knowledge patient care Interpersonal / • Communicate effectively with patients and families Communication Skills • Communicate effectively with colleagues and consultants (Communication with primary care provider and referral physicians in Kaiser network) • Work effectively with members of the patient care team (social workers, patient care coordinators, nursing staff, pediatric pharmacists, child psychiatry, child life specialists) Practice-Based • Use scientific evidence, medical literature and information to guide decision-making Learning and Improvement Professionalism • Demonstrate respect for and responsiveness to patients by accepting responsibility for continuity of care and appropriate transfers of care Systems-Based • Work effectively with case managers and members of the health care team to coordinate care Practice of children with complex and chronic illness • Use of integrated inpatient and ambulatory medical records (Health Connect) system to coordinate and track care Learning Topics/Objectives- see learning objectives appendix Resident Roles and Responsibilities Intern: • Performs the primary patient care role • Pre-rounds on patients and writes daily progress notes and orders • Presents patients on rounds and takes care of daily work associated with patient care • Performs history and physicals on new patients • Plans discharges and does prepatory work • Call every fourth night • Supervises medical students caring for your patients. Evaluation and Feedback The methods of evaluation for the Kaiser Inpatient Rotation will consist of: Global Rating Scales – E*Value and MedHub Resident Evaluations, Faculty Evaluations, Rotation Evaluations Direct Observation Checklist Inpatient Wards Record Review Checklist Inpatient Admission Review of Resource Utilization Feedback should be provided by the attending to the intern and medical student on a regular basis, but at least weekly. The focus of feedback will be on competency-based goals and objectives. Feedback to the attending should be provided by the interns and students regarding teaching, feedback delivery, workflows and efficiency. A conglomerate report will be generated for cross-cover residents and entered in MedHub. More specific feedback may be solicited by coordinators, chiefs, or program directors. Tariq Chaudry should be contacted for such requests. It is the job of the resident/student to present direct observation and record review checklists to the appropriate attendings if specified by the program. Interns and students that are on-service as well as cross- covering may present these evaluations. This year there will be a mid-rotation visit from a LPCH Pediatric Chief Resident to ensure adherence to duty hours, education, feedback, and other resident issues. Stanford medical student coordinators will be present at end of rotation for feedback and discussion of performance.
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