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Document Sample
Resident Roles and Responsibilities
May 2010
How to use this handbook
Residents are responsible to know and adhere to the information in this document.
Please review this prior to each new rotation.
This document will be available on the Yale Pediatrics website:
www.yalepediatrics.org/residents
Emergency Department
Shifts are from 7:30 AM to 7:30 PM OR 7:30 PM to 7:30 AM.
It is important to arrive on time for your shifts. If you are going to be late, you
should call the ED (688-3333) to speak with the resident whose shift will be ending
when you arrive.
You are required to contact both the appropriate floor resident and the
attending of record to discuss admissions.
Lab tests and radiographic studies ordered and done in the ED are the
responsibility of the ED resident to follow up, document in the chart, and communicate
to the floor team.
When you sign out patients you have started to evaluate, it is expected that you
will complete the appropriate portions of the chart and tie up appropriate loose ends. Be
sure to complete the physical exam and the review of systems portion of the chart.
Residents are to attend mock codes in the ED whenever possible.
An attending or fellow should handle all incoming calls and transfers from outside
hospitals.
All PCC patients seen in the ED should have a brief note entered into Logician.
This note and a copy of your discharge instructions should be routed to /Clinic Chief,
PED if follow up is needed. The note can also be routed to the PCC triage nurses
(/Triage RN, PED) if phone follow-up or a follow-up appointment is needed.
Wards (ROR)
ROR has two senior residents: a senior resident whose primary responsibility is to
care for the liver and respiratory service patients (ROR-RLO senior) and a senior
resident who is primarily responsible for the care of the Hematology/Oncology patients
(ROR-HO senior).
The four-week ROR block is subdivided into two-week blocks (Wednesday
through Tuesday).
Each resident will spend 2 weeks as either the ROR-RLO or ROR-HO senior and
2 weeks as the other ROR senior or on the Moderate Sedation rotation.
ROR rotation specific conferences will occur Monday through Thursday at
10:00 AM.
On-call obligations for the ROR-RLO and ROR-HO senior residents will include
several short-calls dispersed throughout the four-week block and typically 2 Friday and
1 Saturday overnight call shifts. On-call responsibilities often include cross-coverage
of the Infant-Toddler and School Age-Adolescent services.
A ROR senior will carry the interns‘ pagers during noon conference, ROR
conference, and Intern Report, which occurs on Fridays at 10:00 AM.
ROR Service Coverage
The ROR team is primarily responsible for covering patients localized to the 7- W
pavilion which is comprised of the pediatric respiratory care unit (PRCU) and the
pediatric hematology/oncology unit. The 7-W pavilion has a maximum census of 13
patients.
The PRCU is covered by the university pediatric pulmonary service, and a total of
6 PRCU patients may be present at any given time. Should a bed become available, an
additional PRCU patient may be admitted to the 7-W pavilion, but only if this patient
requires a shorter hospital course. Should the PRCU reach maximum capacity,
overflow university pulmonary patients may be admitted as boarders to the PICU.
Although these patients will be cared for by the PICU nursing staff, the ROR team will
be the primary housestaff service.
The ROR team will be responsible for non-university pediatric pulmonary
patients who reside on the 7-W pavilion. If such patients are admitted to the PICU as
boarders, the PICU team will be the primary housestaff service for these patients.
Dependent upon the 7-W pavilion census, the pediatric hematology/oncology
service may delocalize and admit up to 4 additional patients to PICU beds. These
patients will be covered by the ROR team as well as the 7-W pavilion nursing staff.
The ROR team is also primarily responsible for the care of liver transplant service
patients admitted to the 7-W pavilion. Any liver transplant patient who is floor status,
but boarding in the PICU, will be cared for by the PICU housestaff team with the liver
transplant attending as the attending of record.
The ROR team is also responsible for any medical boarders who are admitted to
the 7-W pavilion. During periods of cross-cover when the floor is divided between the
residents assigned to the Infant-Toddler and School Age-Adolescent services, the age-
appropriate, cross-covering resident will be responsible for the admission and care of
these patients.
ROR-RLO Senior
The ROR-RLO senior is primarily responsible for the care of the respiratory and
liver patients.
Rounds with the Respiratory Medicine Team are from 9:00 to 9:30AM.
Informal rounds on the liver patients, with the inclusion of the appropriate floor
nurse, should occur from 9:30 to 10 AM. Formal rounds with the liver transplant team
occur at 1:00 PM in the Pearson conference room. The ROR-RLO senior and the
appropriate intern caring for the particular patient should attend these rounds. If either
the appropriate intern or resident is unable to attend the rounds, another resident or
intern should be designated.
The ROR-RLO senior will cover as the floor senior when the ROR-HO senior has
clinic.
ROR-HO Senior
The ROR-HO senior is primarily responsible for the care of the
Hematology/Oncology patients.
The ROR-HO senior leads rounds with the Hematology/Oncology service from
7:30 to 9:00 AM.
If possible, the ROR-HO senior will be present for all Hematology/Oncology
admissions.
The ROR-HO senior will cover as the floor senior when the ROR-RLO senior has
clinic.
Weekend
Heme/Onc round begin at 8:00am. Respiratory rounds remain at 9:00am
* Please see the dictation policy on the website.
Wards (School Age-Adolescent & Infant-Toddler)
Weekdays
7:00 AM: Brief sign-out rounds for each ward team. The entire floor team
should be present. The focus of this 15minutes is to identify changes that can be made
prior to rounds (ie: spacing nebs, discontinuing IVF, starting a diet) and to expedite
morning discharges.
7:15-8:00 AM: Interns will have 45min to pre-round, examine their patients, and
gather vital signs. Senior residents will use this time to put in orders, talk to attendings,
prepare any discharge paperwork, and complete any tasks identified during morning
sign-out.
It is expected that interns briefly examine all of their patients and communicate
with families prior to morning rounds.
8:00-8:45 AM: Morning report will take place for both floor teams. The weekly
schedule is as follows:
o Monday: senior morning report (all floor residents and night float residents are
expected to attend)
o Tuesday: intern morning report (seniors are expected to hold the interns pagers
and manage the floor/ discharge patients during this time)
o Wednesday- Friday: combined morning report where the seniors and the
interns from both floors attend. (interns will be expected to field the calls from
the floors during this time)
8:45-10:30 AM: The teaching senior leads rounds. You should make every effort to
finish rounds by 10:30 AM. The team is expected to walk round after work rounds
with the purpose of updating the families.
The teaching senior is responsible for putting together a list of films, which need to
be reviewed at radiology rounds.
Weekends
Rounds begin at 8:00 AM. Post-call interns/resiterns present all of the patients
except those of the intern coming on. The on-call intern/resitern writes all of the notes
except those of the post-call intern.
Ward Seniors – General Information
The ward senior rotation will include 3 seniors on each floor. These seniors will
rotate between the roles of Admitting Senior, Teaching Senior, and Night Senior. The
three seniors should meet prior to the beginning of the month to coordinate their
goals and plan for giving feedback to interns and medical students.
Seniors should discuss how they want to structure rounds with the ward attending
and the hospitalist at the start of the rotation, and they should re-evaluate their goals
regularly to determine what adjustments should be made.
Seniors are responsible for informing the team of goals and expectations at the
beginning of the month. They are required to give mid-way feedback by the second
Wednesday of the rotation AND end of the rotation feedback before the intern switch
day, to interns and medical students. They should also receive feedback from the team
and their attending. Feedback should include both positive attributes and areas of
weakness with suggestions for change.
The chief residents should be contacted regarding concerns and are always
available for facilitating feedback.
During rounds encourage interns to:
o Present without directly reading from their notes.
o Develop their own management plans
o Focus on organization and prioritization. Encourage short presentations of
pertinent positives and negatives and elicit differentials and plans.
o Discuss disposition criteria. Anticipate discharges.
o Take responsibility and be the primary caretaker of their patients.
Seniors should supervise and teach sub-interns. All of their orders must be
reviewed and signed. Do not give your SCM code to a sub-intern to facilitate the
entering of orders.
In the beginning of the year (and as needed throughout the year), seniors should
supervise intern sign-out.
It is the seniors’ responsibility to facilitate timely sign-out of interns (in
accordance with RRC regulations). It is the seniors‘ responsibility to take intern pagers
at 11:45 AM.
All ward seniors are expected to attend morning report, noon conference, grand
rounds, and journal club on time. All available ward seniors are expected to attend
discharge conference on time as well.
A senior resident during all conferences should carry the intern‘s pagers. In order
to avoid receiving non-emergent pages, please notify the BA when the team leaves the
floor to attend conference.
Please see the specific dictation policy on the website.
Expectations for Documentation:
A single complete admission History & Physical Examination (H&P) must be
written by a member of the housestaff for sufficient documentation on all pediatric and
pediatric subspecialty admissions. This admission H&P can be written by either an
intern or resident.
A complete history consists of a chief complaint, history of present illness, birth
history, past medical history, medication and allergy history, family history, social
history, developmental history, diet, review of systems, primary care and specialty
physicians, and immunization status.
A complete physical examination consists of vital signs, growth parameters and
percentiles, general exam, head, eyes, ears, nose, and throat exam, neck exam,
cardiovascular exam, pulmonary exam, abdominal exam, genitourinary exam,
extremity exam, musculoskeletal exam, skin exam, neurological exam, and lymphatic
exam.
If the admission H&P is written by the intern, the senior resident must write an
addendum to the note. This addendum should provide a brief summary of the patient,
including any pertinent physical examination findings, a sophisticated assessment with
a differential diagnosis, and a plan of care. By appending the intern admission H&P, it
is expected that the senior resident has reviewed the admission H&P and discussed the
assessment and plan with the intern. Contained within the senior addendum should be a
statement such as ―I have reviewed the admission H&P per Dr. (insert name here) and
agree with documented history, physical examination, assessment, and plan per Dr.
(insert name here).‖
During change of shift, if an intern admission H&P has not yet been written, the
resident may write a brief note. This brief note is analogous to the admission
addendum and should contain the same components. This brief note is not a substitute
for a complete admission H&P, and it is expected that the intern enter a complete note.
After the shift change, the incoming senior resident is expected to review the submitted
complete intern admission H&P and discuss the assessment and plan with the intern.
After the reviewing the document, the incoming senior resident should enter an
addendum stating, ―I have reviewed the Admission H&P per Dr. (insert name here),
and we have discussed the assessment and plan.‖ Only at this point will documentation
be complete.
The addendum to an admission note for pediatric surgical subspecialties, seizure
studies, pediatric psychiatry, and routine chemotherapy admissions may simply state ―I
have reviewed the admission H&P per Dr. (insert name here) and agree with
documented history, physical examination, assessment, and plan per Dr. (insert name
here).‖
An example of a complete admission addendum would be: ―The patient is a 9 yo
male with a h/o of mild intermittent asthma admitted for an acute asthma exacerbation
without status asthmaticus likely triggered by a viral URI. Physical examination is
notable for moderate respiratory distress evidenced by tachypnea and suprasternal and
intercostal retractions with a pulmonary exam revealing diffuse bilateral end-expiratory
wheezing with good air entry. The patient is afebrile. CXR in the ED shows
peribronchial cuffing and no infiltrates suggestive of pneumonia. Plan includes starting
intermittent albuterol treatments at 6 puffs Q3 to wean per hospital protocol, oral
steroids x 5 days, DFA for cohorting purposes, incentive spirometry, and asthma
education and asthma action plan. Patient will be discharged when clinically stable on
2 puffs Q4H.‖
A complete admission H&P written by a medical student, including a sub-intern,
is NOT sufficient for complete documentation. If a medical student or sub-intern
admission H&P is submitted, then an admission H&P must also be completed by a
member of the housestaff with adherence to the guidelines as stated above.
With regards to daily progress notes, notes written by interns do NOT require an
addendum by a senior resident. Daily progress notes written by medical students,
including sub-interns, MUST be appended by a member of the housestaff.
With regards to transfer and accept notes, notes written by an intern do
NOT require an addendum by a senior resident. Transfer and accept notes written by
medical students, including sub-interns, MUST be appended by a member of the
housestaff.
Please note that pediatric residents do not write admission notes on General
Pediatric Surgery patients unless pediatrics has been formally consulted.
Please keep in mind that the medical record is a legal document.
o Document the basis for your clinical judgment
o Acknowledge findings & recommendations of consulting clinicians
o Document rationale if you choose not to follow.
o Document awareness of test results.
o Document after each patient evaluation.
o Document patient informed and active participant in the care.
o Document adverse outcomes.
Do not alter, destroy or add to the record in any way
Do not make assumptions
Do not use the medical record to air grievances or assign blame
Ward Seniors – Teaching Senior
The Teaching Senior should facilitate rounds so that they are efficient,
educational, and promote communication between the members of the floor team and
nursing staff.
Patient presentations during rounds should be directed toward the Teaching
Senior who will then engage the presenter in discussion regarding strategies for patient
management and the formulation of management and discharge plans.
During rounds, the ward and hospitalist attending on each floor should be
available for consultation if requested by the Teaching Senior.
The Teaching Senior should facilitate daily family-centered walk rounds. While
on walk-rounds, the team should be accompanied by either the ward or hospitalist
attending.
After rounds are completed, the Teaching Senior should be available to see floor
patients at the request of the covering intern or medical student.
Radiology rounds typically occur at 11:00 AM or 11:15 AM, dependent on the
particular floor, and provide an opportunity to discuss the results of diagnostic imaging
tests with a pediatric attending radiologist.
If time permits, during the afternoon, the Teaching Senior should research topics
relevant to patient care and instruct the team regarding such topics.
Ward Seniors – Admitting Senior
The Admitting Senior will be responsible for admitting patients to the floor
throughout the shift.
During rounds, the Admitting Senior should assist in entering orders. After
rounds are finished, the admitting senior should assist the interns and medical students
in the completion of morning work.
Should problems arise with patients on the floor during rounds, the Admitting
Senior should be available to leave rounds to address these problems. The covering
intern may accompany the Admitting Senior if deemed appropriate.
The Admitting Senior should confer with any private pediatricians or consult
teams who wish to discuss the management of their patients during rounds. This should
be done separate from rounds to permit the continuation of rounds with minimal
interruption.
The Admitting senior should be prepared to leave conference should a patient
arrive to the floor.
Throughout the remainder of the day, the Admitting Senior will continue to admit
patients with an intern and medical student on the floor and work with the intern or
medical student to formulate differential diagnoses and management strategies for each
admission.
Ward Seniors – Clinic and Sign-out
On days when one of the ward senior residents has clinic, the other senior resident
will cover the responsibilities of both Teaching and Admitting Senior during the
afternoon. A brief sign-out should occur when one senior leaves for the day, as both
seniors should be aware of all patients on the floor and management plans for the day.
On rare days when both ward seniors are away in the afternoon, a senior resident
from another floor will assume all ward senior responsibilities for the afternoon.
One senior will cover the floor for short call, to end at 8 pm, when the Night
Senior arrives. The other Day Seniors will end their day at 4 pm with either a brief
sign-out to the other senior on their floor or a more extensive sign-out to a cross-
covering floor senior.
Ward Seniors -- Night Senior
There are two night seniors who will share the 4 main floors depending on intern
night coverage.
The Night Senior resident will serve as the senior resident from 8:00 PM until the
next morning. The Night Senior will be present at 7:00 AM for sign-out rounds and
attend morning report thereafter. If complicated patients were admitted during a
resintern night, the Night Senior should sign these patients out to the Teaching
Senior, who will present the patient on rounds.
When the Night Senior arrives, he should page the short-call senior for sign-out.
The Night Senior should receive verbal sign-out about all admissions from the ED
resident. If a patient arrives on the floor and sign-out has not been received, it is your
responsibility to call the ED (688-3333) to ask for sign-out on your patient.
After the new patient has been assessed and a management plan has been
formulated, the intern or senior should contact the primary PMD, hospitalist, or ward
attending, even if previously called by the ED.
Primary pediatricians should be called during the night and event notes should be
written if significant events occur with a patient. Significant events include issues for
which you contacted the attending of record, critical changes in the patient‘s
management plan, changes in the clinical status of the patient, or if the PICU was
consulted on the patient.
The Night Senior should be prepared to discuss evidence used to guide
management decisions made on floor patients or on new admissions.
It is expected that the two Night Seniors work as a team. Although the seniors
will be assigned to cover specific floors, work should be shared according to the flow
of the evening and the acuity of the patients on each specific ward.
Pediatric Surgical Consults
At YNHCH, pediatric residents do not formally admit or follow general pediatric
surgery patients. Pediatric residents are the primary consult service for the general
surgery patients. The surgical team will notify one of the senior pediatric residents in
the event of a consult. The pediatric surgery attending should specify whether they
prefer the Primary Care Pediatrician or the Hospitalist to staff the consult. Once the
consult is done you are responsible for discussing the consult with the appropriate
attending.
Special Circumstances
7-4/ 7-4 Overflow Beds
Although conceptualized to function primarily as a general surgical unit, medical,
as well as pediatric surgical subspecialty patients are admitted to the 7-4 unit.
Seizure study patients, general pediatric medical patients, medical pediatric
subspecialty patients, and pediatric subspecialty surgical patients who are admitted to
7-4 beds should be covered by the School Age-Adolescent team regardless of the
patient‘s age.
The four overflow beds on 7-4 should only be used when the medical or surgical
beds on all other wards, including the PICU, with the exception of a PICU crash bed,
are full. If patients are admitted to the overflow beds, the appropriate covering team
will be designated according to the age of the patient.
Liver Patients
The YNHCH pediatric residents function as the house staff for the pediatric liver
transplant patients with a transplant surgeon as the attending of record. The residents
work closely with the transplant surgery team and in coordination with pediatric
gastroenterology.
Pre-operative liver patients are admitted to the 7-2 unit.
The care of immediately post-transplanted patients occurs in the PICU with
transfer to the 7-W unit when appropriate.
Post-transplant patients are primarily admitted to the 7-W unit.
Rounds with the liver transplant service for all patients, regardless of location,
occur in the Pearson Room at 1:00 PM.
The transplant resident or fellow should be contacted with any patient care issues.
The pediatric house staff is responsible for completing hospital discharge
dictations on the liver patients.
PICU
General Information
The PICU is located on the west pavilion of the 7th floor. The PICU has 15 beds
with the capacity to flex-up to 19 beds should demand increase.
The PICU team is typically comprised of a 3rd year pediatrics resident, who
functions as the PICU senior, two or three 2nd year residents and one or two pediatrics
interns. The 2nd year residents are usually comprised of a 2nd year ED resident and either
one or two 2nd year pediatrics residents or a combined Medicine/Pediatrics resident.
Overnight coverage is often provided by a 3rd year pediatrics resident who takes
call with either an intern or 2nd year member of the PICU team. The cross-cover resident
should arrive by 4:00 PM for sign-out rounds.
The cross-covering resident is expected to stay post-call for rounds on the
weekends. The cross-covering resident will present any new patients that he admitted
and pre-round on those patients normally covered by residents who have the day off.
The cross-covering resident is expected to stay for weekend rounds regardless of how
many members of the PICU team are present for rounds that day.
PICU boarders
Patients boarding in the PICU should be discussed formally after PICU rounds
with the inclusion of the covering nurse and charge nurse. The attending of record
should be contacted to discuss the plan for the day.
A patient may not be downgraded from ICU to floor status without contacting the
accepting attending. It is the responsibility of the residents, fellows, or attending
physicians in the PICU, when transferring any patient from the PICU to another floor or
changing a patient to floor status, to notify the accepting attending.
Dependent upon the patient census on the 7-W pavilion, liver transplant patients,
who are deemed stable for admission to the general floors, may be admitted to PICU
beds. These patients are to be cared for by the PICU housestaff team with the liver
transplant attending as the attending of record.
The PICU housestaff team will be responsible for all non-university pediatric
pulmonary patients who reside in the PICU.
Although physically located in the PICU and cared for the PICU nursing staff,
university pediatric pulmonary patients will be the responsibility of the ROR team.
All non-ICU status pediatric hematology/oncology patients occupying PICU beds
will be cared for by the ROR housestaff team. In most circumstances and when nurse
staffing permits, such patients will be cared for by 7-W pavilion nurses.
PICU Senior
You should arrive at 7:00 AM to participate in sign-out rounds with the post-call
fellow.
The PICU senior is responsible for running rounds efficiently and taking
advantage of opportunities to make pertinent teaching points during rounds.
The PICU senior should be present for all admissions. You should examine the
patient with the admitting resident or intern and assist in formulating a management
plan for the patient.
The PICU senior should review all admission orders, medication orders and other
critical orders for all interns on the team.
The PICU senior should be aware of all patients in the PICU, their active issues
and general plans. You should encourage your residents and interns to contact you first
regarding questions about patient care.
The PICU senior will be responsible for helping other members of the team make
effective, pertinent, complete presentations organized by problem.
PICU Resident
Each morning, you should arrive early enough to examine your patients, gather
vitals, find lab/imaging results, and formulate an assessment and plan (by problem) on
each of your patients.
Residents should assist interns with order entry and patient care responsibilities
when the PICU senior is post-call or in clinic.
When a PICU resident is on-call with a cross-cover resident and either the
unit census or patient acuity is low, the PICU resident should be contacted first for
all patient care issues. If the unit census or acuity is high, overnight patient
coverage should be divided accordingly. The cross-cover resident should discuss
with the the PICU senior what the appropriate approach to call should be given the
acuity and capabilities of the resident on call.
The cross-cover resident will be present for all admissions. Only one admission
note is required for each admission.
When 2 PICU residents are on-call together, they should work together to admit
all of the patients and to address all patient care issues. They should both be aware of
any major events. When appropriate and as indicated by the attending and fellow, one
resident may rest while the other resident cares for all of the patients.
Post-call residents should sign-out all overnight events to the rest of the team
before rounds.
Schedule:
7:00 AM: The PICU senior and fellow will meet with the post-call fellow for
sign-out rounds.
7:30 AM: Rounds with the PICU team. The on-call resident should take notes
during rounds in order to be fully aware of the problems and plans for all patients in the
PICU for their call. Morning rounds should be treated as sign-out. Residents will
present their patients by problem.
7:30-8:30 AM: Wednesday and Thursday are PICU conferences. Friday is Cath
Conference.
11:30 AM: There will be a brief sign-out for post-call/clinic residents. This
should only serve to review any changes made since rounds, and details discussed on
rounds should not be repeated. Once the post-call resident completes notes and signs
out transfers to the floor team, he/she may leave for the day. Depending on the volume
of work, at the discretion of the PICU senior, fellow, or attending, residents may be
asked to stay post-call until noon to help out with their patients.
4:00 PM: Formal sign out rounds, which should include a ―one liner‖ on the
patient, pertinent problem list, and plan for overnight. All members of the day and on-
call team should be present for sign-out rounds.
NBSCU (Newborn Special Care Unit)
Located on 4th floor of West Pavilion. Main number is 688-2318.
4 teams (A, B, CCN, Delivery)
A: Covered by one senior resident and one practitioner in rooms 4 & 5
B: Covered by one senior resident and one practitioner in rooms 3 & 5
C: Covered by intern(s) and practitioner(s) in rooms 1, 2 & 10th Floor
Delivery: Covered by practitioners and interns during the day and on-call
intern/resident at night. Responsibilities include DR/OR/transitioning
infants/providing help to other teams when needed.
Rounds begin at 8:00 AM on weekdays. You should arrive by 7:00 AM to receive
sign-out overnight events from the post-call practitioner, as they typically leave by 7:15
AM. You should pre-round on your patients prior to rounds (find out about overnight
events, gather data from vitals sheets, check consult notes in charts, calculate
appropriate values).
Fellow and attending teaching conferences occur on Wednesday, Thursday, and
Friday mornings from 7:30 -8:00 AM.
Rounds start at 8:00AM on weekends. The post-call and on-call providers will
split the patients on their team to cover for the provider who has the day off.
Residents should write pre-rounding values legibly in their binders! This is
helpful when patients are being cross-covered by multiple providers.
Teaching conferences are at noon on Mondays, Tuesdays, and Thursdays.
Remember that you must wear hospital-issued scrubs when on-call.
Residents cross-covering in the NBSCU are expected to arrive by 4:00 PM to
receive sign-out and to be present to give sign-out at 7:00 AM the following
morning. Cross-covering residents are not expected to stay for rounds on weekdays,
but are expected to pre-round, complete progress notes, and participate in rounds on
weekends.
General Pediatric Clinic—Ambulatory
Located in the basement of LMP. Street entrance is on 789 Howard Avenue.
The General Pediatric Clinic provides acute care to PCC patients. Clinic hours are
from 9:00 AM -12:00 PM and 1:00- 5:00 PM.
Residents rotating on Ambulatory are required to attend 8:00 AM outpatient
conference. This conference takes place in the FMB 037. Breakfast will be provided.
Residents should attend noon conference and Grand Rounds. There is noon
coverage to allow residents to attend conferences in a timely manner. Interns should not
see a new patient after 11:30 AM, and residents should not see a new patient after 11:45
AM. It is the PCC Clinic Chief‘s responsibility to ensure that interns and residents are
able to leave the General Pediatric Clinic in a timely manner. If there are any patients
left in the General Pediatric Clinic when you leave for noon conference, please notify
the nurse practitioner working as lunch coverage. This includes patients waiting in
rooms for x-rays and patients requiring further assessment.
While in the General Pediatric Clinic, the first priority is to see patients. History
and physical exam findings can be typed while in the room with a patient. However,
time should not be spent completing Logician charts if there are patients waiting in
rooms to be seen. Residents can use the prepared forms provided in the PCC charting
room to keep track of their patients.
It is the responsibility of the resident to complete the billing form on every patient
seen each day.
If additional resident help is needed, it is the responsibility of the attending or
the PCC Clinic Chief to call the chiefs to request back-up according to the protocol.
Please see PCC flow sheet that is hanging in the General Pediatric Clinic hallway and
in the PCC conference room.
Follow-up issues for the evening or weekend should be discussed with the on-call
person (Resident covering PCC pager). This includes labs that need to be followed up
over the weekend.
Please look through Logician to see a well child appointment is needed prior
to discharging the patient home. Please document on the yellow form that a WCC
appointment should be made with the specific provider. The family should make this
appointment on the way out.
It is the Ambulatory resident‘s responsibility to ensure that interns are checking
the culture book. In addition, the Ambulatory resident should check the GPC schedule
for missed appointments and contact the family if appropriate. This would include
newborn weight checks, asthma follow-ups, hospital discharge follow-ups and any
other concerning issues.
Notes need to be completed in Logician by evening on the day the patient was
seen. This is to ensure that proper documentation is available in the event the patient
calls the PCC pager overnight and/or goes to the ED.
Primary Care Center – Continuity Clinic
Clinic starts at 8:40 AM. Residents are expected to attend outpatient conference at
8:00 AM prior to clinic.
Although all residents are assigned a particular clinic day, clinics may be floated
to different days of the week due to call responsibilities or if the clinic is full. It is your
responsibility to check your clinic schedule monthly.
When residents have afternoon clinic, they should participate in the pre-clinic
conference at 1:00 PM if there are no patients waiting to be seen.
Residents are responsible for following up on their patients‘ issues and labs. The
clinic chiefs will help you in this regard, and they can also be a resource to help you
with follow-up, etc.
Well Baby
Residents should pick-up a Well Baby Handbook from Dr. Eve Colson (office on
11 floor) prior to starting the Well Baby rotation if they do not already have one.
th
You will cover all staff babies (PCC patients and patients whose pediatricians
don‘t have admitting privileges) in the well baby nurseries on the 10th and 11th floors of
the West Pavilion. (You can print a list by printing Dr. Ada Fenick‘s patient list on
SCM). All babies born before 11:00 AM must be seen that day. Babies born after 11
am can have their exams deferred until the next morning.
Please confirm with parents who they will be using for a pediatrician (as
sometimes patients are erroneously assigned to your service). If you are called about a
private patient, refer the nurses to that child‘s pediatrician, regardless of the hour.
The Well Baby team should attend the 8:00 AM outpatient conference. The
Well Baby senior should go to the General Pediatric Clinic once Well Baby duties
are completed.
You are expected to complete the Newborn Nursery Record in Logician for all
patients that you see. This will serve as your note for the day of admission and the day
of discharge. Do not forget to include the hearing screen and discharge weight on the
Newborn Nursery Record. Be sure that there is an assessment and plan documented as
well. Written notes are done in the chart for any intervening days. For private patients,
two copies of the Logician summary should be printed, one to place in the chart and
one to give to the family to bring to their pediatrician.
To facilitate 11:00 AM discharges, please give the discharge talk the day prior to
discharge.
Please leave your pager number or cell phone number (in addition to the intern‘s
pager or cell phone number) on the white boards in the 10th and 11th floor nurseries. As
the Well Baby resident, you will be on 24-hour pager call. When there is an intern on
Well Baby, the intern should be first call. The senior should also know about the major
issues for the whole service and should be available 24 hours a day should the intern
require assistance. If no intern is on service, then you will be first call.
If an infant is sick overnight, you should inform the Team C provider in the
NBSCU and this provider to evaluate the patient. You do not need to come in from
home to evaluate the baby.
Dial
1st up Dial:
1st up dial will almost always be covered by one of the residents on the OPT block.
Residents on dial must have their beepers or cell phones on 24 hours a day
and they may be called at any time for coverage. Please inform the pediatric chief
residents if you prefer to be contacted by cell phone.
On weekdays, the resident on 1st up dial should attend outpatient conference at
8:00 AM, and then present to the ED to assist the ED resident with seeing patients.
Attendance at noon conference or Grand Rounds is expected. Following conference,
and if not otherwise dialed, the 1st up resident should present to the GPC to assist the
residents with seeing patients.
After 5:00 PM and on weekends, the resident on 1st up dial should be able to get to
the hospital within one hour of being called.
Dial cannot be used for planned absences—if you anticipate being away, it is your
responsibility to arrange for coverage.
2nd up Dial / 3rd up Dial:
Residents on elective will generally cover these dial positions. On weekends, and
occasionally weekdays, residents on Adolescent, Development or Moderate Sedation
may also cover them.
2nd and 3rd up dial should be within two hours of the hospital at all times.
Residents on dial must be available either by pager or cell phone 24 hours a day.
Again, please inform the pediatric chief residents if you prefer to be contacted by cell
phone.
Private Practice
You will submit choices for the elective blocks you would like to use for private
practice. This is typically done in the third year, however it may also be done in the
second year for residents interested in a career in General Pediatrics.
The chief residents will assign these sites.
Electives
You are expected to follow the elective schedules outlined by the subspecialty
departments.
When you are not scheduled for other activities, you should attend morning
report, noon conference, and discharge conference. You will be expected to present
an interesting case from your elective at morning report on a date assigned to you
by the chief residents at the beginning of the rotation.
At times you will be on dial during your elective, and you can be pulled from your
elective for coverage. If the dial system is used up, we may need to pull non-dial
residents from elective to help out.
All 2nd and 3rd year pediatrics and 3rd and 4th year medicine/pediatrics residents will
have one call-free elective per year.
Adolescent/Development
The curriculum will be at the discretion of the Adolescent or Development
director.
Please note that cross-cover call will be scheduled during these months (usually in
the NBSCU, ED, or Bridgeport floor on weekends).
Unless otherwise scheduled, you are expected to attend noon conference, grand
rounds, and discharge conference.
You will be contacted with more details prior to the rotation. Feel free to contact
Dr. Carol Weitzman (Development) or Dr. Sheryl Ryan (Adolescent) with any
questions.
Clinic Chief Resident
You will be notified of your duties as the clinic chief resident at each of the
specific sites. Please contact the attending in charge at the site if you have any
questions (Dr. Shilpa Pain at HSR, Dr. Ada Fenick at Yale). Please review the
separate clinic chief document that is on the website.
PCC: The clinic chief is responsible for giving one 8:00 AM outpatient
conference during the block. The clinic chief is also responsible for making sure the
outpatient conferences run smoothly. This includes confirming the speakers 3-5 days
prior to their conferences, ensuring that the equipment that they need will be available
and taking attendance. If you are on vacation during this block, you should confirm all
speakers beforehand and designate the Ambulatory senior to handle any issues that
arise in your absence. It is also the responsibility of the clinic chief to watch the patient
list in the General Pediatric Clinic and notify the Chief Resident if backup is needed.
PCC Pager
The PCC on-call resident is responsible for calls from 5:00 PM – 8:00 AM,
Monday through Thursday, and on weekends from 5:00 PM on Friday to 8:00 am on
Monday. The service number is (203) 785-4240. The service will have the call
schedule, and they will be paging your personal pager number. If you prefer to be
contacted by cell phone, contact the answering service to provide them with your
number.
The resident should document every patient/parent phone call in Logician.
Notes are required to be completed and signed by 8:00 AM the next morning for
weekday call and every day of the weekend for the full weekend call (i.e., by 8:00 AM
on Saturday, Sunday, and Monday).
There is a General Pediatrics attending on-call every night for help with phone
calls. The call center will have the name and pager number of the attending on call.
You are expected to contact the attending with any questions you might have about
patient management.
The resident should call the General Pediatrics attending any time between 9:00 -
9:30 PM to discuss/review all cases up to that point. During this call, the resident and
the attending should arrange for a specific time for the morning review of the patients.
The resident is encouraged to use the Interpreter Services (688-7523) to speak
with any patient/parent who does not speak English. The code for the PCC, when you
are calling from a non-hospital number, is 7220 (which is PCC-0 on the telephone).
The resident should remind patients that walk-ins are not allowed at the PCC.
Instead, appointment times been set aside at the resident‘s discretion. The resident
should document the time he told the parent to bring the child in within his/her
Logician note, and route this note to ―/on-call appts, PED‖. Appointments saved are
one each at 8:45 AM, 9:00 AM, and 9:15 AM. However, the resident should not feel
constrained by these slots in the event of further need, and should continue to
―schedule‖ onwards at 15-minute intervals if need be. The resident should not be relied
upon to schedule appointments for anyone who calls the PCC pager specifically
requesting an appointment. These patients should be asked to call the PCC during
working hours.
Those residents responsible for the PCC on-call pager will resume normal duties
the following day.
Moderate Sedation
All second year residents will be formally trained and certified to perform
sedation with the help of the Department of Anesthesia through integration into the
resident curriculum. Third year residents may be trained during an anesthesia rotation.
This is a 2-week rotation with 4 major components: 1) airway management, 2)
sedation/analgesia 3) online curriculum, examination, and simulation 4) attendance at
pediatric surgical subspecialty clinics.
The 2-week rotation is divided into two 2-week components; one week will be
spent working in the operating room with anesthesia staff and the other week will be
dedicated to learning conscious sedation with Jeff Agli.
In cooperation with the anesthesia residents, fellows, and attending physicians,
there will be a total of five weekday mornings of operating room time dedicated to
learning IV placement, the use of bag-mask ventilation, and intubations.
Residents will also gain experience with conscious sedation during five weekday
mornings by working directly with either anesthesia staff in the MRI suite or with Jeff
Agli for inpatient sedation.
Afternoon time is dedicated to attending pediatric surgical subspecialty clinics
including ENT, orthopedics, and ophthalmology. The residents should expect to attend
between 5 to 7 subspecialty clinics during the 2-week block.
When not participating in pediatric surgical subspecialty clinics, residents reading
provided materials relevant to airway management, sedation medications, pediatric pain
management and pharmacology. An online curriculum is also available to facilitate
learning these concepts.
Core lectures given by members of the Department of Anesthesia will be held for
all pediatric residents during the core conference lecture series.
The rotation will end with a written exam.
Pediatric Codes (Code 7) at Yale
To call a pediatric code at Yale, dial: 911.
You will hear ‗Code 7‘ paged overhead, and the resident with the code pager will
receive a text page.
Often times, a resident is the first to arrive for a code 7. The primary
responsibilities of the first responder are the A, B, C's. If there is more than one person,
a code leader should be established.
There are 2 pediatric residents designated as part of the pediatric code team.
These are the residents carrying the code pagers. The intern carrying the pager is
assigned to chest compressions. The senior with the pager is assigned to do the
physical exam assessment. If you are not one of the residents carrying the code pagers
and there is adequate personale present to run the code, you should not feel obligated to
stay.
Codes are an important opportunity for residents to respond to acute and emergent
care. Pediatric residents are often the first responders, and your participation is
important in order to maximize your comfort level and confidence with these situations.
The pediatric code team may also be paged overhead as the ―Blue‖ team and asked
to respond to an adult code of the ―red‖ and the ―white‖ team are have already been
called.
Conferences
Conference attendance is mandatory for all residents, and is a vital part of
your education. As part of ROC guidelines, we are asked to document resident
attendance with the purpose of tracking it and reporting back to you.
Morning Report: expected for all floor residents, residents on elective, and
residents post-ED overnight shifts
8:00 AM Outpatient Conference: expected for all residents on Outpatient (1st up,
Well Baby, and Ambulatory) and all residents who have morning continuity clinic.
Noon Conference: expected for all residents except those in the PICU, NICU, and
working a shift in the ED
Grand Rounds: expected for all residents
Discharge Conference: expected for all residents
Patient care emergencies should be prioritized over your attendance to
conferences, but it is important for your education that you attend as many as possible.
Bridgeport Hospital
Pediatrics department office (Dr. Harris Jacobs is the acting chair, Nancy Fellone
is the secretary) telephone number: (203) 384-3712.
We rotate on the pediatric floor, in the outpatient clinic, and in the NICU.
On the first day, remember to take your parking ticket from the garage with you.
The parking attendants in the hospital lobby can validate the ticket for the month. Meal
allotments will be placed on your ID card.
The pediatric ward and the NICU are on the 6th floor of the hospital. Make a left
out of the elevator and on your right will be the chair‘s office followed by the pediatrics
conference room (entry code 4-1-3).
One of the Yale Chief Residents will be present at Bridgeport at all times. Any
concerns (e.g. scheduling, attending interactions) should be brought to our attention.
To call a pediatric code at Bridgeport, dial: 77.
Floor Rotations
The Bridgeport floor is staffed with 3 residents and 2 interns. The 3 residents will
rotate between the roles of floor resident, clinic resident, and night resident.
Q4 overnight call is taken by an intern on the team, a cross-covering Amb-CC
intern, or a cross-covering resident.
Residents should discuss how they want to structure rounds with the ward
attending and the hospitalist at the start of the rotation, and they should re-evaluate their
goals regularly to determine what adjustments should be made.
The residents should meet prior to the beginning of the month to coordinate their
goals and plan for giving feedback to interns and medical students.
The residents are responsible for informing the team of goals and expectations at
the beginning of the month. They are required to give mid-way feedback by the second
Tuesday of the rotation AND end of the rotation feedback before the intern switch day,
to interns and medical students. They should also receive feedback from the team and
their attending. Feedback should include both positive attributes and areas of weakness
with suggestions for change.
The chief residents should be contacted regarding concerns and are always
available for facilitating feedback.
Weekdays:
Sign-in is at 7:00 AM. The entire team meets in the pediatric conference room
with the post-call residents who covered the floor overnight.
7:15 - 8:00 AM: Intern pre-rounding.
8:00 – 8:50 AM: Morning report on Mondays, Tuesdays, Thursdays, and
Fridays. There is typically no morning report on Wednesdays when Grand Rounds is
being held. Grand Rounds is given at 8:30 AM in the Hollander Auditorium on the 4th
floor.
9:00 – 10:30 AM: Family-centered rounds. Family centered rounds begin at 9:30
AM on Wednesdays when Grand Rounds is being held. The team will walk-round on
ALL patients on the floor including PICU status patients and surgical and surgical
subspecialty patients.
Sign-out occurs at 4:00 PM in the pediatric conference room.
Weekends:
8:00 AM: Sit rounds begin in the pediatric conference room at 8:00 AM. The
post-call intern, with the assistance of the post-call resident, is expected to pre-round on
all floor patients prior to rounds and present the patients on rounds. The post-call team
should complete the daily progress notes and then leave. The team coming on for the
day will complete all discharges and orders.
Floor Resident:
The floor resident is the leader of the ward team. He is responsible for running
daily rounds, supervising and teaching interns and students, and ensuring that work on
the floor gets done.
Daily responsibilities include: admitting new patients and assigning them to
interns and students, and covering and writing daily notes on all PICU patients.
The floor resident will maintain a discharge summary list, which includes which
intern is responsible for each dictation.
The floor resident will carry the admitting pager.
Any questionable direct admissions should be discussed with the hospitalist or
chief resident. A ―Patient Passport‖ that includes the HPI, relevant laboratory data or
diagnostic imaging results, and reason for admission should accompany direct
admissions. The charge nurse should be notified regarding any direct admissions.
Neither the floor resident nor the night resident should be the first physician to
evaluate patients in the ED. There is no such thing as ―pedi-to-see‖ on arrival to the
ED. You may be requested to evaluate patients for admission or as a pediatric consult
once the MD or PA from the ED team has initiated an evaluation.
The floor resident should receive verbal sign-out about all admissions from the
ED.
After a plan has been made, the intern or resident should contact the primary
PMD (even if called by the ED), hospitalist, or ward attending.
If patients are to be admitted to the floor from the ED, call up to the floor to make
the charge nurse aware. If the patient is to be admitted to the PICU, make certain that
the PICU attending and charge nurse are aware in addition to any other consults you
deem necessary. This is very important as the PICU is sometimes ―closed‖, and a nurse
needs to come in from home to staff it.
In a code/pediatric trauma situation, the ED staff is to be present until the patient
is stabilized. If you are left alone in a code situation in the ED, notify the Chief
Resident with specific information regarding the event.
Both residents should be present at code/pedi trauma situations – admitting pager
will notify regarding these situations (PTA = pedi trauma alert in ER). The resident
should call 3250 and have the staff page the intern or other residents.
Night Resident:
The Night resident will serve as the senior resident from 8:00 PM until the next
morning. When the Night Senior arrives, he should page the short-call senior for sign-
out. He will be present at 7:00 AM sign-out rounds, and morning report. The night
senior may leave after morning report at 9:00 AM or at 9:30 AM after Grand Rounds.
The Night resident will be responsible for reading about patients admitted at night
in order to discuss evidence used to guide their management at Morning Report.
The PMD should be called during the night and event notes should be written if
significant events occur with a patient (i.e., anything for which you contacted the
attending, any significant change in the patient‘s plan from morning rounds, any
significant change in clinical status).
The night resident is also the back-up for deliveries, should the on-call NICU
team require assistance. Names and pager numbers should be written on the white
board in the NICU.
** At times, there will be 2 residents on call together, instead of a resident and an
intern. One of the residents will be listed on Amion as ―resident‖ and one will be listed as
―intern‖. However, both people are residents, and it is up to the individual residents‘
discretion as to how the work should be divided overnight. Examples of how people have
handled this in the past include: one resident takes the admitting pager and covers the PICU
patients and one takes the Bridgeport Clinic pager and covers the floor for the whole night,
alternating responsibilities on the next call; splitting the cross-coverage of the floor patients
and alternating admissions; one resident taking all pagers, cross cover, and admissions for ½
of the call and the other resident for the other ½ of the call. Clearly, the work should be
evenly divided and distributed in a manner that is safest for patient care.
PICU:
Yale residents do not provide ongoing care in a PICU setting at Bridgeport,
including patients who are expected to be intubated more than 24 hours or who are on
cardioactive medications. If you feel that you are inappropriately taking care of
critically ill patients while at Bridgeport, please discuss this with the PICU attending.
The Chief Residents can act as facilitators in the discussion between a resident and the
PICU staff if necessary, and can assist in transfer of a patient to a more appropriate
setting in discussion with the PICU attending. Yale residents will help manage
critically ill patients in the Emergency Department, but only until they are stable
enough to be transferred to a different facility.
NICU:
2nd year Yale Pediatric Residents and nurse practitioners cover the NICU.
Residents are responsible for going to deliveries, admitting new patients and
assisting with the care of transitioning infants.
If you are scheduled for a 2-week NICU rotation, your calls during that time will
be in the NICU. The other 2 weeks of the block will either be in the clinic or on the
floor.
Morning sign-in rounds are at 8:00 AM. The post-call person pre-rounds and
gives sign-out to the day team.
Rounds begin at 9:00 AM.
Afternoon sign-out rounds are at 4:00 PM.
Anyone taking call for the first time in the NICU should ask an attending for a
tour of the NICU and L&D.
You are expected to wear Bridgeport scrubs in the NICU. Ask the BA for the key
to the scrub locker.
There are yellow and green teams that are equal in terms of acuity and number of
patients. Night coverage for Well Baby Nursery is assigned to alternating teams by
week, changing on Mondays. On weekends, both teams will work together to examine
patients, write notes, admit, and discharge nursery patients.
Post-call on weekdays, you should expect to stay until noon to continue care
for your patients, and will sign out to the practitioner at that time
Clinic Resident:
The clinic resident leads morning report two days a week from 8:00 – 9:00 AM.
Bridgeport clinic begins at 9:00 AM.
The clinic is on the second floor of 226 Mill Hill Avenue directly across the street
from the ED. The phone number is 203-384-3079; to reach the conference room the
number is 384-3350.
Check the clinic schedule to see what clinic you are participating in on a given
day (acute, specialty, off-site specialty).
Check the Bridgeport cover schedule to see if you are assigned to cover the floor
for the afternoon.
You are expected to attend noon conference daily.
The clinic resident will be responsible for covering short calls and it is a priority
to be on the floor by 4:00 pm for sign-out.
The clinic resident acts as back-up for the floor. If the floor resident needs to
―dial‖ for help, the clinic resident is the first person that will be dialed.
Hospital of St. Raphael’s
Clinic:
Located on the second floor of the hospital
Main telephone number of the clinic is (203) 789-3388. The inside line is (203)
789-3955.
Your day starts at 7:30 AM in the nursery (5th floor of hospital) except for Fridays
(Grand Rounds) and one Wednesday of the month (Neonatal M&M) when it starts at
7:15 AM. The team is responsible for rounding on babies assigned to the Staff, Hill
Health Center and Chapel Peds services. Remember to check the 6th floor to see if there
are any other admissions.
Teaching conference begins at 8:30 aM, Monday through Thursday, and is held
in the clinic. On Fridays, you will attend Grand Rounds at 8 AM.
You need to bring the yellow sheet completed on the day of discharge to the clinic
for all clinic patients.
Nursery On-Call:
The resident covering the weekend PCC pager (from Friday at 5:00 PM to
Monday at 8:00 AM) will be responsible for coming in on Saturday to round on the
staff nursery babies (not the NICU babies). The resident‘s responsibilities in the HSR
nursery end after examining the babies with the attending; they will NOT be
responsible for on-call questions about the nursery babies. Holiday coverage is
provided by the person covering the PCC pager and should be discussed with the
attending on call for well baby at St. Raph.
**** Please call or page the Chief Residents with any questions or concerns.
We‘re looking forward to a great year!
