Medicine Ward Basics

Pagers
From a hospital phone dial 231 to access the automatic pager system
From outside dial 1-800-BEEP-231
To signout your pager:
"Please enter the pager number" * + your pager number (i.e. *12345)
#, 1, 1, then the covering pager number
To cancel your pager signout:
* + pager number
#, 1, 2

Dictating
From hospital phone, dial #30 to access dictation system
From outside dial 1-310-794-2001
Pager number, #
Location code, #
Work Type, #
Patient MRN, #
To mark STAT, press * after you hear the beep.
To pause, press 1; to resume, press 2; to rewind, press 3.

Dictation Codes
Location Codes	Work Type
1 = Westwood 2 = NPH 3 = Santa Monica	1 = Discharge Summary 3 = Inpatient Procedure Note 33 = Outpatient Procedure Note 4 = Inpatient Consultation 44 = Outpatient Consultation 5 = Inpatient H &P 55 = Outpatient H&P 7 = Inpatient Progress Note 77 = Outpatient Progress Note 9 = Transfer Summary 10 = Death Summary 95 = Goals of Care Note

Admit Orders (Templates in Forms Portal "General Medicine Admission Orders")

Admit to (team, R1 name & beeper, R2/3 name & beeper, attending)

Diagnosis

Condition (stable, guarded, critical)

Vitals

Activity

Allergies

Nursing

Diet

IVF

Meds

Special studies

Labs

Call HO for: T < 35.0 or > 38.5, RR < 10 or > 30, HR < 60 or > 100, SBP < 100 or > 180, DBP < 50 or > 90, O₂ saturation < 92% (adjust according to patient's specifics)
Admit Notes (Type or dictate into CDS)
Identification/Chief Complaint
History of Present Illness
Past Medical History/Past Surgical History
Allergies
Health Related Behaviors
Social History
Family History
Review Of Systems
Physical Exam
Labs/Studies
Assessment & Plan
Code Status: Ask every patient if they have an advance directive and document their wishes
Prophylaxis
DVT, delirium, fall, aspiration, constipation, C. difficile, stress ulcer (ICU)

Prerounds
Vitals
Medications (check actual medication administration record every day)
Nursing notes (in Essentris or talk to overnight nurse)
Consult notes (sometimes in the chart)
Review all EKGs and telemetry
Examine the patient
Write orders for morning labs

Daily Questions
Can I switch IV drugs to oral?
Do drug doses need to be adjusted for worsening renal/liver failure?
Can I take out the Foley? Chest tube? JP drain? Central line?
Can I advance the diet?
Is the patient getting out of bed?
Is the patient having bowel movements?
Does my patient still need a monitor?
Is the case manager making a discharge plan?

End of Day Checklist
AM labs ordered (note that not every patient needs AM labs!)
Note written
Finish tomorrow's discharge paperwork
Update signout
Signout to night float and signout pager

How to call a consult
Earlier is better. Try to call consults before noon. Otherwise wait until 1 p.m. as most fellows have noon talks.
The decision to call a consultation should be made with your resident and attending
Call the page operator (x66766) to find out the fellow on the appropriate consult service
Start with "I have a patient I'd like to discuss with you," and give the patient's name and MRN number
Give a brief, relevant history and your intended plan, then your question.
Always have a specific question (i.e. Does this patient need a pacemaker? Should we start antifungal coverage?). Don't say you just want them "on board."
In general, try to have the basic workup started. Get old or outside records as soon as possible.
On the other hand, don't wait until Friday at 4:55 p.m. to call the consult because you are waiting for the workup.
Be sure to provide the consultant with the pager of who to contact with recommendations
Read the consult notes! Sign this out to float if you are leaving. If you disagree with a recommendation and are not going to follow it, CALL the consultant and discuss it with them.
Transferring Patients
Page chief resident 91010 (R2/3)
Call accepting team (R2/3)
Call bed control (x56922) if pt will be on different ward (R2/3)
Dictate/type transfer note including physical exam, medication list, problem list and plan (R1)
Write transfer orders (R1)
Discharging Patients
The following items are necessary to discharge a patient:

Discharge Summary: R1 completes e-Discharge form, arranges follow-up, and completes prescriptions; R2/3 dictates/types a complete discharge summary with the following elements:
Date of admission
Date of discharge
R1, R2/3, attending on discharge

Discharge diagnoses (i.e. what the patient was diagnosed with during this hospital stay only)
Procedures
Consults
Brief history of present illness
Hospital course
Physical exam (same length as a SOAP note)
Discharge medications:
* New
* Changed (any prehospital medications with dose/frequency changes)
* Unchanged (any prehospital medications to be continued without changes)
* Stopped (any prehospital medications that should be stopped)
Pending studies/labs
Outpatient workup needed (i.e. anemia workup, repeat CT chest, etc.)
Disposition (i.e. where the patient is going)
Diet
Activity
Home health/PT/wound care (if applicable)
Follow-up
Note that all discharge summaries should be completed and signed within 24 hours of the patient's discharge. This is to ensure proper physician communication during this important transition of care.

Patient Discharge Instructions (printed from e-Discharge system)

Prescriptions (either printed from e-Discharge system and signed, or hand written)
Narcotics require security Rx, either from the resident or attending
All Medi-CAL prescriptions need to be on security paper (ask Chiefs for this paper)

Notify patient's PMD of discharge or schedule a post-discharge appointment with them in IMS clinic with a member of your team
If the patient needs a primary care doctor, try to see them yourself, set them up with a member of your team, or verbally communicate with whomever they are intended to establish care.
Procedure Notes

Dictate or type your notes (you can use templates in Essentris):
Place one copy in the chart and the other copy in one of the boxes located in MICU, CCU, 7E Rounding Room, or SMH Hospitalist Office. Keep one for your own records (see Appendix to track your procedures).

Include the following:
Date and time
Physicians performing procedure
Indication for procedure
Informed consent
Time out was performed
IV/PO Meds given/Anesthesia
Description of procedure
Findings, Complications
Follow-up

Code Team
The MICU resident (90090)/intern on-call (90040), CCU resident (90080)/intern on-call (90089), Obs resident (96450), J-call, and Medicine Float pagers are on the Code Team.
You will automatically be signed on when you sign on to these virtual pagers.
You can add your pager to the Code Team by calling the operator x66766.
Codes are to be run by the first person there. If you are the first person there, run the code, with the help of your senior. If you are ever uncomfortable, ask your senior to take over.
We cover codes called in RRUCLAMC inpatients, visitors, 1W CHS rehab, 200MP Nuc Med B1 level, 200MP Rad Onc B2 level, and (if after hours) the 200MP 6^th floor surgery suite.
We do not cover codes in: 200MP outpatient, CHS outpatient areas, 200MP 6^th floor (during daytime), or JSEI/JSEI OR.
***For code blue OUTSIDE RRUCLAMC, only MICU resident and CCU intern should go***.
There is one Code Blue Elevator key for the CCU team and one for the MICU team. The code blue elevator is in the East "core" of the RRUCLAMC and is clearly marked. The key should be used to summon the elevator at any time to expedite travel to the code blue.
At the conclusion of the code blue, the lead MD must write or dictate a code blue note for the medical record, and sign all paperwork, including the code blue flow sheet (which is an order sheet) and any handwritten code blue note.

Red Gurney Runs
When a visitor to the hospital "goes down", the MICU resident and CCU intern will respond to evaluate with the assistance of an ER tech/nurse who will bring a gurney. Once stabilized, the visitor is taken to the ER for further evaluation.
Declaring A Patient Deceased
You will be informed by nurse that patient has died and needs to be declared.
Be prepared to encounter the family at bedside; explain that you need to examine the patient and that they may stay.

Examination:
Check for pupillary reflexes
Observe for spontaneous breathing or movements
Auscultate for heart tones
Assess for response to pain by pinching finger nail or skin while auscultating (sternal rub can be done as well)
Note time, offer condolences, and ask family for permission for autopsy. Inform them of benefits of autopsy (will help in the education of housestaff and may identify incidental inherited diseases and thus benefit surviving family). The autopsy will not interfere with an open casket funeral; there is the option of limited autopsy, and costs are covered by the hospital.

Dictate/Type a Death Note: (R2/3 will need to dictate a complete death note, similar to a d/c summary)
Time and date of death
Describe exam
Mention that the family and attending were informed
Give a very brief history and include whether or not the patient was on comfort care protocol per family and medical team (if this is the case)
How To Float (Nuts and Bolts)
Sign on to the pager at 5 p.m. on weekdays, 12 noon on weekends
Stay on pager until 8 a.m. weekdays and weekends
Meet teams 7 a.m. next day to give verbal signout in 7E conference room 7134. Provide any notes to team.
Sign your name and float pager 91903 on orders
Call rooms on B-level of RR-UCLA, key card gets you in.

Get good sign out:
The basics (age, location)
Code status and fever workup status
Attending and threshold to call
Problem list
Important medications
Things to check and their implications (i.e. What do I do about an elevated D-dimer?)

Document, Document, Document:
See the patient
Write a brief SOAP note when called for any significant problem (such as chest pain, dyspnea, fever, abdominal pain, altered mental status, low urine output, falls, etc.)
If a patient dies, see declaring a patient deceased above.
Always write or dictate a transfer note if patient goes to ICU/CCU and notify primary attending; call patient placement to get a unit bed (x56922)
Page interns in am to let them know of any unstable patients or pending tests
***Call attending for any major changes in the patient's status***

Senior backup is always in the hospital: Page 90090 (ICU) or 90080 (CCU) to reach them or check www.amion.com for pager. Low threshold for calling them, even for simple questions or to talk through a situation. If a patient looks SICK, call senior backup EARLY.

Attendings are available 24 hours a day: they should be notified if a patient dies or codes. If there is a situation that they can help with (i.e. an upset family member, a difficult treatment dilemma, code status issues) do not hesitate to call or page them.

Resources: this book has good preliminary information on many situations that will arise on float nights. See the Table of Contents for these topics: Chest Pain, Hypotension, Hypertension, Bradycardia, Tachycardia, Transfusions, Transfusion reactions, Low urine output, Headache, Altered mental status, Respiratory failure)

Sleep Aids: you are not obligated to give a sleep aid if you think the patient is at high risk of becoming confused or altered. If you decide they can have one:
Temazepam (Restoril) 15-30 mg
Zolpidem (Ambien) 5-10 mg
Trazodone (Desyrel) 25-50 mg
Diphenhydramine (Benadryl) 25-50 mg (not a first-line choice)
Lorazepam (Ativan) IV 0.5-1 mg can be given to patients who are NPO.
Be cautious in elderly patients > 65. Would choose trazodone 25-50 mg in the elderly or Ambien. Avoid benzodiazepines and Benadryl.
If someone is delirious and agitated do not give sleep aid.

Off Monitor: in general, if a patient is on a monitor they likely need to be. It can be difficult to weigh the value of an urgent test against the patient needing a monitor. Remember, if they are off monitor they are only going with escort, not a nurse, and they may sit a while waiting for the scan. You can always accompany them yourself if the test is urgent and the transport nurse is unavailable.

Shortness of Breath:
Differential: volume overload, aspiration, COPD or asthma, pneumonia, pneumothorax, pulmonary embolus, allergic reaction, acid-base disturbance
Go see the patient
Can they talk to you? If yes, get a focused history: onset, precipitating factors, history of similar episodes. If no, move on to interventions, call for backup if unsure.
Check trend of vital signs, 24 hour total of ins and outs, current vital signs, physical exam (count the respirations yourself, listen for crackles or absent breath sounds)
Tests: STAT portable CXR, consider an ABG. Consider CT angiogram if high suspicion for PE.
Possible interventions: High flow oxygen, non-rebreather mask, furosemide if you suspect volume overload, albuterol/Atrovent, suctioning, reposition in bed to 90 degrees, intubate if necessary (call senior backup and anesthesia team captain at x78714 to intubate.
See respiratory failure in the pulmonary section for more detailed information

Uncertainty: you will not know everything! Floats are valuable learning experiences where you will test your limits and gain confidence in your ability to handle a variety of issues, but you should never feel alone, backup is a page away.