Rotation Guidelines

6RC General Medicine Rotation

Take elevator D to the 6th floor and make a left to get to 6RC. The team A and B workrooms are across from the 50’s pod of patient rooms by the back nurse’s station. Team C’s workroom is across from the 90s pod. You can access your schedule through Amion. Days off are pre-assigned. Day shifts begin at 7 am but you are expected to arrive by 6:45 am to get sign out from the overnight intern. You should go to the call team’s workroom to get the handoff. On post-call days, rounds will begin at 7:15 am. You are not responsible for seeing each patient prior to rounding but should perform a chart review. You should also see any patients that you were informed were sick overnight. On short call and long call days, rounds will begin between 8-9 am. The exact time will depend on your attending, so discuss with them. Your responsibilities on these days will be to pre-round on all your patients, including chart review and examining all of your patients before the attending arrives.
After formal rounds, you should place orders, call consults, and work on discharges prior to noon. We have noon conference daily in the Bean Conference room (lunch is provided). Afternoons can be used to write progress notes if all your other work is done. At the end of the day, you should work closely with your senior to make sure hand-offs are appropriate and all patients are stable to be signed out to the night team. The handoff tool can be found in EPIC if you open the patient’s chart.
During the rotation, you will do between 2-4 night shifts. These will begin at 4 pm and end when you are finished rounding on overnight admissions with the team the next morning (by 12 pm at the very latest). These nights will be listed on Amion. You will be responsible for cross covering the patients on teams A, B, and C. You will also be responsible for up to 5 admissions. There will be a senior on at night to assist with admissions and answer any questions you might have.
The long call team (the team admitting overnight) will be responsible for holding the code pager during the day and at night.

VA General Medicine Rotation

You should present to your team room of the VA Medical Center by 6:45 am each day (see “Getting Around…” section for location of team rooms).
On-long call days: you should pre-round on all your patients before the attending arrives. If you have a patient in the MICU (4 West) you have to round with the MICU attending after 7:45 am depending how many patients admitted the overnight team. After MICU rounds you can round on your general medicine patients. After formal rounds, you should place orders, call consults, and work on med-reconciliations with the pharmacist in your team and discharge summaries prior to noon. Start with patients that have a scheduled van-ride. They usually leave by 11:00 am and require everything done by 10:30 am. There is a mandatory noon conference daily on the 10th floor. Lunch will be provided daily in the 10W conference room unless otherwise noted. You may also obtain lunch form the canteen on the third floor using your call money. Afternoons can be used to write notes if all your other work is done. At the end of the day, you should work closely with your senior to make sure hand-offs are appropriate and all patients are stable to be signed out to the night team. CPRS has the Hand Off tool integrated in the tool bar. Make sure you include the code status as a first thing in the coverage notes because there is a glitch in the system that does not auto-populate the code status.
Call days: You will take Q6 overnight call (See Amion for schedule). On the day before your call, you should leave by noon. Your day off is between noon on the day before your call and 4pm on your call day. Interns go to their team’s work rooms by 4:00 pm and receive the hand-off from the other teams and their own team and receive also the code pager(110). The overnight senior will be there around 6:00 pm, touch base with them with the to-do list. On your call day you will be responsible for cross cover of all the teams’ patients and up to 5 new overnight admissions including MICU patients. You have to do night rounds on the MICU patients by doing tele-ICU between 1900-2100. Go with the overnight senior to the ICU and press the green button on the walls in an empty room. Rely on your sign out to do this. In the morning, you are expected to pre-round on your old patient and alert your senior if someone requires immediate intervention. You may not have time to see all of your patients before rounds start, and that is OK, make sure you see your sickest patients first. The general medicine rounds starts around 7:00 am and you will staff the overnight admissions until ~ 8:00 am when MICU rounds start. After MICU rounds are done you can continue to round on your general medicine patients, call consults, write progress notes on your patients, discharge patients, and hand off to your senior. In theory, all should be done by noon.
Weekends: You are expected to pre-round, round, call consults and write progress notes like a normal day but if your team is not on long-call and your patients are stable the interns can sign-off to the long call team after 12 pm. If your team is on long call the intern that is not on call that day will stay cross covering the other patient’s team until the night on call intern arrives at 4:00 pm. The day intern will hand off all the patients to the night intern and give the code pager.
Paging: All VA pagers have 3 numbers. There is an icon in the computer desktops to page, alternatively you can dial 11 then the number your are trying to page and then the number your want them to call you and then # (11 + [Pager Number] + [Phone Extension] + #).
Code pager (110): The team on call will have the code pager. During the day this pager is only for code blue, during the night it is for everything.
Meal card: You can use your meal card on the canteen (3rd floor), patriot store (3rd floor) and the starbucks(1st floor). Make sure you use it only for food. You will receive this from Julie Lewis. Her office is located on the 9th floor. Ask your senior, or the VA chief if you need directions.

Inpatient Cardiology Rotation

Please present to the 4th floor of the Roy Carver Pavillion Team Workroom (make a left off elevator D, a left again into the patient wards, and the team room is the first door on your right across from the family waiting room). Your day begins at 7am, you get sign-out about your patients from the overnight CVICU resident. Your senior can help you find this and give you more information on your first day. Your responsibilities will be to pre-round on all your patients, alert the senior if anyone is sick or unstable. Remember that on the cardiology service, an important part of pre-rounding is checking the telemetry monitors for overnight events on all your patients. After formal rounds, you should place orders, call consults, and work on discharges prior to noon. We have noon conference daily in the Bean Conference Room (lunch is provided). Afternoons can be used to write notes if all your other work is done. You will sign-out to the CVICU senior at 6pm (or when your work is finished). You should work closely with your senior to make sure hand-offs are appropriate and all patients are stable to be signed out to the night team. Your days off will be determined as a team. There are no night shifts on this rotation.

MICU Night Float Rotation

Please present to the MICU (5th floor, elevator D) at 5pm on your assigned night shift. You will receive signout from the residents on both the red and the blue teams. You will be responsible for cross cover of these patients overnight, so be sure to ask questions if you are unsure of anything. Your overnight senior is always available to help if any issues or questions arise throughout the night. After you receive signout, your other main job for the night will be to take admissions. You may take up to 5 admissions in one shift. You should talk closely with your senior and fellow about the plans of care and orders for these patients. You should take the lead role in the care of these patients, including assisting with procedures, family meetings, etc. This is a good place to practice the bedside ultrasound techniques you are learning in ambulatory week.
Should you have time, a call room is located across from elevator D by the women’s nursing lockeroom (5201 RCP). The code is 2136. In the morning, you give handoff back to the day teams at 7-8am and then round and present your overnight patients to the staff. Rounds start around 9am with the intern’s patient’s first. After you present your patients, you should break from the group and begin calling consults and placing orders which were discussed on rounds. You should then update the sign out and hand these patients off to the day team. Finally, please finish progress notes for the day on the patients which you admitted. You should try to be out of the unit by noon. If you are finding delays which keep you there longer, please ask for help!

Heme-Onc Rotation

Please present to the Heme-Onc workroom on the 4th floor of John Pappajohn Pavilion (take elevator K to the 4th floor, and then the team room is past the nurses station, 2nd door on the right). You will report at 6:45 a.m. at which time you will receive hand-off from the overnight intern. Your responsibility will be to pre-round on all of your patients. Alert the senior resident early on if any of the patients are sick or unstable. After formal rounds, you should place orders, call consults, work on discharges, and write progress notes. We have noon conference every day in the Bean Conference Room (Grand Rounds on Thursday in the Alumni Auditorium), lunch is provided, and you are expected to attend. Afternoons should be spent finishing notes and admitting new patients. You can admit new patients every day between 7am-6pm. At 6pm (or when your work is finished) you will sign-out to the night float intern. You should work closely with your senior to make sure hand-offs are appropriate and all patients are stable to be signed out to the night team. You will have one weekday off each week (coordinate with your team).

Night Float Rotation

Please present to the Heme-Onc workroom on the 4th floor of John Pappajohn Pavilion (take elevator K to the 4th floor, and then the team room is past the nurses station, 2nd door on the right). You will report at 5 p.m. at which time you will receive sign-out from the Heme-Onc interns and the Med-Psych interns. The Heme-Onc interns will give an in-person hand-off in the team room. The med-psych interns will give a verbal handoff over the phone. The med-psych interns will page you when they are ready to give you sign-out. You should print a copy of the med-psych written hand-off prior to the verbal hand-off so that you can take notes (ask your senior for help accessing the list and printing the hand-off). You will be responsible for cross-cover of the med-psych and heme-onc patients overnight. Your senior resident is always available to help if you have any issues or questions arise (don’t hesitate to ask for help). After you receive sign-out, your other main responsibility will be to admit patients to the med-psych and heme-onc teams. You can admit up to 5 new patients each night. You should work closely with the senior resident to develop plans and place orders for the new admits overnight. In the morning you will present the newly admitted patients to the appropriate team and hand over their care to the day teams.

Med/Psych Rotation (Inpatient Medicine-Psychiatry Primer for the Internal Medicine Senior)

Logistics

· ► The Team

o Two interns from:

§ Med-Psych

§ Family Med-Psych

§ Neurology

§ Psychiatry

o One senior resident:

§ Internal Medicine

§ Med-Psych

o Attending physician(s):

§ Combined Med-Psych staff

§ Internal Medicine co-attending + Psychiatry co-attending.

· ► The Times

o 7:00 AM – Interns receive sign out from night float intern

o 7:15 AM – Night float intern presents overnight admissions (either to the senior and then the senior presents to the attending, or directly to the attending, but this is attending specific)

o 8:00 AM – Interdisciplinary rounds (anticipated 30-45 minutes)

§ Includes: charge nurse, pharmacy, social work, discharge navigator et al

§ Discuss discharge planning and barriers to discharge

o Noon – Educational Conference

o 2:00 PM — MIMIC – This is a project that the nurses are doing to decrease burden of pages for interns – this is an afternoon huddle located in the nurses room for the senior to directly hear from the nurses about orders that are needed, or outdated orders or issues with patients that need to be addressed. This doesn’t have to happen if the nurse’s round in the morning with the team.

o 5:00 PM – interns sign out to cross cover and can leave with exception below

o If there is an open bed and the team has heard about an internal transfer/ED admit prior to 5 they should take that admission, even if patient will hit the floor after 5. If it is an outside hospital transfer ⇒ place admit orders and start a note and the admission can then be handed off to the night team

o If there are open beds and team has not heard of admission/transfer team can go home at 5:00 PM.

· ► Schedule

o Days off

§ Senior resident: 1 weekend day off

§ Interns: 1 weekday off

§ ― Senior resident covers patients

o Half days off

§ Senior resident: the other weekend day afternoon

§ Interns: one weekend day afternoon.

· ► Helpful Mindset

o 3BT is a closed, locked medical unit with a primary team of combined-trained physicians and nurses to provide specialized medical and psychiatric care

o NOT a locked unit for other primary teams to continue to manage patients (not an open unit like the SNICU)

§ ― Reasonable & probably in best interest of patient if that team continues to follow in a consulting role.

General Workflow

· ► Pre-rounding expectations

o See all patients before attending arrives, have vitals reviewed (do know that usually labs are not back)

o In general: Interns to pre-round between 7 – 8:30AM.

· ► Senior resident expected to lead interdisciplinary rounds

o Expectations for senior resident (similar to 6RC discharge rounds):

§ What still needs to be accomplished inpatient?

§ Disposition plan

o What senior resident can expect from others:

§ Pharmacist (aka Jill) to raise issues regarding medications

§ Discharge Coordinator assists with follow up scheduling

§ Social work assists with discharge planning.

Admissions/Discharges/Transfers

· ► 3BT senior resident is responsible for triage calls Monday – Friday 7AM – 5PM

· ► Nights & weekends are covered by the night float senior

· ► Admissions: When you have an open bed, you can look over bed board and see who is most appropriate, see next section below (“common reasons for admission”).

o Patient coming from:

§ ED à Admission

§ CSU à Admission

§ UIHC Inpatient Psychiatry à Admission

§ Outside hospital à Admission

§ ICU or floor à Transfer.

· ► Discharging:

o UIHC Inpatient Psychiatry is a separate hospital

§ If a patient is transferring from 3BT to psychiatry, this is a DISCHARGE not a transfer. Discharge orders and Discharge Summary need to be completed.

§ Discharges to Inpatient Psychiatry can occur when acute medical issue resolved and there is still an acute psychiatric need for admission

§ Initiate with a page to Psychiatry Triage Pager – 5788 (this is NOT covered by the Super Triage system)

§ Bed availability is typically limiting factor

§ Triaging psychiatrist has a list of patients

§ When a bed is available, senior resident is paged for hand off

§ Intern-to-intern hand off.

o If a patient is going to Medicine or ICU, this is a transfer.

· ► The 3BT team should NEVER use the discharge readmit navigator – just discharge orders – the discharge readmit orders should actually just be called a “readmission order” and are done by the admitting team.

Common reasons for admission or transfer to 3BT

· ► Patient should have both:

o Acute medical reason for medical admission (think of being admitted to 6RC)

o Acute psychiatric reason for psychiatry admission.

· ► Alcohol withdrawal with a history of complication + psychiatric reason for admission:

o Sick enough to be in the hospital à high dose IV thiamine at least once

o Suicidal ideation, psychosis, etc. as common psychiatric reasons for admission.

· ► Agitated delirium

o If patient cannot be managed safely on the floor

§ Ex. Receiving frequent PRN anti-psychotics or physical restraints consistently.

o Psychiatry consult to evaluate the patient facilitates legal status process & may prevent unnecessary utilization of a med psych bed.

· ► Patient is being managed on the medical floor and the psychiatry consult team has written a note that they are appropriate for 3BT:

o You can always reach out to the consult team (3322) and discuss who they are most concerned about.

· ► Patient is on inpatient psychiatry and has developed a medical issue requiring inpatient hospitalization (IV antibiotics is a common reason).

The misunderstood role of med-psych

· ► Coexisting medical and psychiatric needs WITHOUT acute decompensation are insufficient to justify med-psych admit.

· ► Examples:

o Acute psychiatric problem with a medical need that could be managed outpatient

o Acute medical problem with a psychiatric need that could be managed outpatient.

· ► Transferring facilities, super triage and UIHC primary teams may not recognize the alternatives to 3BT which include:

o Inpatient psychiatry with surgical co-management consult.

o Inpatient medicine team with psychiatry consult.

· ► It is inappropriate for a team within the hospital to contact you directly to inquire about an open bed – direct them to psychiatry consult team.

Orders Nuts & Bolts

· ► 3BT admission order set will cover 80+ %

· ► Other necessary orders include:

o Legal status: Required because 3BT is a locked unit (see below for extensive legal information).

o Psych activity

§ Restricted – think of using this if patients have elopement, suicide or violent precautions.

§ Supervised III is least restrictive

§ Necessary if patient can have “pass” aka therapeutic leave of absence (TLOA)

§ TLOA also requires no precautions.

o Precautions include but not limited to:

§ Suicide/self-harm

§ Violence

§ Foreign body ingestions

§ Sexually acting out

§ Wandering

§ Elopement

§ Withdrawal.

o Occupational therapy consult order

§ Reasons for this consult include:

§ Coping skills group – anyone who can participate should have this ordered

§ Allen testing

o Recreational therapy is its own order

§ Few, if any, reasons a patient shouldn’t have this.

Legal Status

· ► How to file a legal hold and information about reasons to obtain a hold are below — section Per Dr. Kijewski

· ► Make sure the legal status orders are updated accurately:

o Voluntary: most straightforward

§ Ensure patient has capacity before signing in as voluntary

§ Avoid scribbled signature

§ Consider a monitored telephone consent.

o Voluntary per guardian

§ If the patient has a guardian, the guardian can sign them into the unit via a voluntary form or give consent via monitored phone call

§ Guardian status needs to be verified with the legal documentation uploaded into the EPIC medical record.

o Voluntary per DPOA

§ If unable to make their own decisions, can have DPOA sign them in, IF & ONLY IF there is paperwork in their media tab designating DPOA

§ DPOA can sign a voluntary form or give consent via monitored phone call

§ Next of kin CANNOT sign someone into the unit unless they have paperwork designating them as DPOA.

o Hold-hearing filed/pending

§ If a hold is filed during work hours (Monday-Friday 8:00AM-4:30PM) – a legal hearing will be scheduled

§ Paperwork from the court will be scanned into media tab when available

§ This will show when the hearing will be held

§ Once a hearing is scheduled, patient cannot be discharged until hearing is completed and/or dismissed by court, typically at request of evaluating team.

o Emergency/48 hour hold

§ This is the legal status when a hold is filed outside business hours

§ This allows up to 48 business hours for evaluation to decide whether a hold for hearing is filed for.

· ► Hearing outcomes include:

o Inpatient commitment to University of Iowa.

o Outpatient commitment to a designated clinic.

o No commitment order with subsequent dismissal of the petition.

· ► If a hearing should be dismissed prior to the date, a letter needs to be printed & sent to the psychiatry business office requesting the hearing be dismissed.

o Should be done by 3PM the day before scheduled hearing.

o Sample Letter:

§ “Dear Judicial Hospitalization Referee, Mr./Ms. Xxx has been hospitalized at the University of Iowa Hospitals and Clinics since xxx. He/she has a mental health hearing, MHMH xxxxxxx, scheduled for xxxxx. His/her condition has improved. We humbly request that the mental health hearing scheduled for xxx be dismissed. Thank you for your assistance.”

· ► Outpatient commitments

o Patients admitted on outpatient commitment can either be admitted voluntarily (while maintaining their outpatient commitment) or their outpatient commitment can be transitioned to an inpatient commitment.

o Filing for a hold during business hours will automatically initiate an outpatient commitment be transitioned back to inpatient, but a formal hearing to make this transfer will be still be scheduled and a hearing report will be due.

Per Dr. Kijewski

· Legal Status for 3BT patients:

o ► Patients can sign into the unit as a voluntary patient.

o ► If a patient has a guardian, the guardian can sign the patient in as a voluntary patient.

o ► If a patient does not have decision making capacity AND has a durable power of attorney for health care decisions, the DPOA for health care can sign the patient in as a voluntary patient.

o ► Next of kin/spouse can NOT sign a patient into the unit unless next of kin or spouse is also DPOA.

o ► Any DPOA or guardian status needs to be verified with the legal documentation uploaded into the EPIC medical record.

o ► If a patient is unwilling to be admitted or does not have a DPOA or guardian, a request for mental health commitment or 48 hour hold should be sought prior to admission.
The referring provider (ED, psychiatry consult service, outside provider) should be the one obtaining the voluntary form or the request for involuntary hospitalization as they have seen the patient.
It should NOT be the responsibility of the 3BT team.

o ► If a patient on 3BT who was admitted voluntarily requests to leave, a mental health commitment or 48 hour hold should be sought. Please do NOT discharge patients AMA or after hours without first contacting/discussing with the attending physician.

o ► Reasons for seeking mental health commitment or 48 hold include:

§ Imminent danger to self/others (suicidal, homicidal, unable to care for self, delirious).

§ Presence of a mental health diagnosis (delirium/encephalopathy/major neurocognitive disorder count).

§ And you believe that the patient is treatable.

o ► Requests for a mental health commitment are only available during regular business hours.

o ► 48 hour holds are available after hours, on weekends, and on holidays.

o ► The phone number for the magistrate on call:

§ ― (319) 325-5535

o ► There is no such thing as a “medical hold”.

· Please feel free to page/call the attending physician or Vicki Kijewski (pager 8004 or 319-855-2080) at any time with questions.

· Please see the following for information about documentation if needed:

o In EPIC, open a progress note and for type choose “Legal”:

o Choose UIHC, Commitment/Hold Note:

o This note will prompt you in terms of the next steps.

o Remember, after hours choose 48 hold on the following screen shot: