THMEP

HOUSESTAFF MANUAL

2002 - 2003

TABLE OF CONTENTS

  THMEP Key Faculty Listing

  Description of the Programs

  General Work Guidelines

         Lines of Responsibility

         Patient Limits

         Work Hours

         Writing Orders

         Daily notes

         Cross Coverage Notes

         Non-teaching Service Patients

         Sign-Out

         On/Off Service and Transfer of Patients

         Consultations

         Completeness of Physical Examinations

  Inpatient Admitting Protocol

  Curriculum

  Evaluations

  Medical Libraries/Medical Informatics

  Descriptions/Protocols for Medical Rotations

         TMC General Medicine Service

         TMC CCU/Cardiology Service

         General Surgery and Trauma

         Kino General Medicine Service

         Community Medicine (Private Offices)

         Geriatrics

         TMC Emergency Medicine

         Kino Emergency Medicine

         Urgent Care Clinic

         Ambulatory Specialty Clinics

         Electives

  Continuity Clinic

  Conferences

  Medical Morbidity and Mortality Conference

  Scholarly Activities

  ACLS Certification

  Learning Tools

  Clinical Laboratory

  Medical Records

  Certification & Documentation of Invasive Procedures

  Clinical Procedures Requiring Credentialing

  Time off:

         THMEP Holidays

         Vacation

         Coverage During Illness

         Policy for Resident Absence from Work

  Universal Precautions

  Sharps Injury/Bodily Fluid Exposure

  Work Exposure to Bodily Fluids

  Moonlighting Policy

  Parental Leave Policy

  Policy on Narcotics and other Prescription Medications

  Resident Support/Impaired Resident Program

  ADDENDUM #1 - Bedside Teaching

June 1, 2002

Dear Physicians:

Welcome to the Tucson Hospitals Medical Education Program and to Tucson! Each of us at THMEP and the full-time, part-time and voluntary teaching staffs at Tucson Medical Center and Kino Community Hospital are delighted you have joined us. We look forward to an exciting and productive year together.

This manual is intended to help orient you to the policies, schedules and expectations at each of the program’s various sites. While it is unlikely that you will "digest" all of this in one sitting, we hope you will read through this important manual and refer to it from time to time to clarify areas of confusion.

Because the landscape of medical education changes rapidly, and because THMEP is committed to meeting the evolving needs of our housestaff, changes in the information contained here are likely. Our core belief in the value of community-based medical education, our philosophy of education through patient care and didactics and our understanding of you as both our student and our colleague will not change.

All of us at THMEP are dedicated to helping you succeed, now and in the future. Essential to this is our ability to recognize both our successes and our troubles, and to respond to each appropriately. We look to you to share your observations with us, and we welcome your input.

We look forward to working with you during the coming year. Please do not hesitate to speak with any of us at THMEP if we can help make this year’s transition easier, or if we can help in any other way.

TUCSON HOSPITALS MEDICAL EDUCATION PROGRAM

INTERNAL MEDICINE PROGRAMS and TRANSITIONAL MEDICINE

   Robert Aaronson, M.D., Executive Director and Program Director, Internal Medicine Residency

   Tyler Kent, M.D., Transitional Program Director

   Khaled Hadeli, M.D., Associate Program Director, Internal Medicine Residency

   Charles Krone, M.D., Chairman, Department of Medicine, TMC

   Rami Khouzam, M.D., Chief Medicine Resident (2001-2002)

   TMC HOSPITALIST SECTION STAFF

         Shelley Collingham, M.D., Section Chief

         Jennifer Kempers, M.D.

         Douglas Kirkpatrick, D.O.

         William Odette, M.D.

         Simon Paul, M.D.

   KINO GENERAL MEDICINE STAFF

         Khaled Hadeli, M.D.

         Brendan Phibbs, MD

         Simon Paul, M.D.

         Guruprasad Raju, MD

         Bijay Sanjeev, MD

         Sharon Walters, MD

   THMEP SECTION CHIEFS

   CARDIOLOGY

   HEMATOLOGY-ONCOLOGY

         Lionel Faitelson, M.D. (TMC)

         Haroon Ahmad, M.D.

         Brendan Phibbs, M.D. (Kino)

        Eric Ruhe, M.D. (TMC)

   NEPHROLOGY

         Mohammed Sikder, M.D.

         Jonathon Insel, M.D.

   MEDICAL NEUROLOGY

        William Lujan, M.D.

   GASTROENTEROLOGY

   PULMONARY/CRITICAL CARE

         Charles Krone, M.D.

         Thomas Rotkis, M.D. PhD

   GENERAL MEDICINE

   REHABILITATION MEDICINE

         Arthur Goldberg, M.D.

         Jon Larson, M.D.

   GERIATRICS

   SURGERY/TRAUMA

         Steven Wool, M.D. (TMC)

         Steven Porter, M.D. (Trauma)

         Leonard Ditmanson, M.D. (Kino)

         Terrance Adkins, MD (General Surgery)

   DESCRIPTION OF PROGRAMS

         All rotations are one calendar month in duration.

         The R1 year (Internship) includes: 

7 months TMC General Medicine/Critical Care

2 months Kino General Medicine/Critical Care

1 month Community Medicine

1 month Kino Emergency Medicine

1 month of Anesthesia

         The R2 year (Junior Residency) includes: 

5 months TMC General Medicine/Critical Care

2 months Kino General Medicine/Critical Care

1 month Community Medicine

1 month TMC Urgent Care Center

1 month Kino Ambulatory Specialty Clinics

2 months of electives

         The R3 (Senior Residency) includes: 

3 months TMC General Medicine/Critical Care

2 months Kino General Medicine/Critical Care

1 month TMC Emergency Medicine

1 month Geriatrics

3 months of electives.

         The Preliminary R1 year includes: 

6 months TMC General Medicine/Critical Care

1 month Kino Emergency Medicine

5 months of electives

         The Transitional R1 year includes: 

4 months TMC General Medicine/Critical Care

1 month Kino General Medicine

1 month TMC Trauma

1 month TMC General Surgery

1 month Kino Emergency Medicine

4 months of electives

             Please also refer to the individual descriptions of each service for any specific requirements.

1)

   Lines of Responsibility

   The lines of responsibility, on both inpatient and outpatient rotations, are based on the following principals:

·        An attending physician is ultimately responsible for every patient.

·        Optimal resident education requires meaningful clinical responsibilities, including the opportunity to make major management and treatment decisions, with appropriate attending input and supervision.

·        The resident’s clinical independence will progressively increase, commensurate with the resident’s evolving abilities. However, an attending physician will remain ultimately responsible.

·        To accomplish all of the above, timely, thorough and open communication between residents and attendings is essential.

·        On inpatient ward or CCU rotations, the intern’s clinical responsibilities are centered on the care of his or her patients. The intern is the front-line, primary physician for the patient during hospitalization. The intern is under the immediate direction of the team’s second or third year resident. The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, contributes to intern education and ensures appropriate attending communication and oversight. The resident is expected to alert the attending or the Program Director/Associate Program Director of any real or perceived difficulties faced in patient management or the proper functioning of the medical team.

·        On subspecialty or ambulatory rotations, housestaff responsibilities vary depending upon the service. Lines of responsibility remain, with the attending ultimately responsible for patient care. The houseofficer’s role may vary from primary physician, to consultant, to manager of a single aspect of a patient’s multisystem disease. Many elective rotations include experiences with all of these. Specific expectations of the resident should be discussed with the attending at the beginning of the rotation.

2)

   Patient Limits

   The following limits apply to all inpatient medical services at TMC and Kino Community Hospital:

·        No intern shall admit more than 5 new patients in 24 hours, or 8 new patients in 48 hours.

·        No intern shall be responsible for the ongoing care of more than 12 patients.

·        Each second or third year resident should admit (or oversee the admission of) no more than 10 patients per 24 hours, and no more than 16 patients per 48 hours.

·        A second or third year resident shall be responsible for the ongoing care of no more than 24 patients at any one time, including those patients cared for by intern(s) under his/her supervision.

kept" by the resident throughout the patient's hospitalization. A certain amount of "patient shifting" between interns or teams may be required, as determined by the resident, with oversight by the Chief Resident.

Once the limits described above have been met, you are required to refuse new admissions. Please explain to the attending physician why you are unable to accept the patient and refer any misunderstandings to the THMEP office.

However, you should respond immediately to any real or perceived life-threatening emergency, even if a patient limit has been reached. Unless patients can be shifted or discharged immediately to allow for this admission, the attending physician should assume total care for the patient as soon as possible (within minutes to a few hours). Any difficulties with this should be referred immediately to the Program Director, Associate Program Director or the THMEP office.

Any requests by an attending physician to supersede any of these limits must be refused but immediately referred to the Program Director if at TMC, or the Associate Program Director if at Kino.

3)

   Work Hours

·        When averaged over any month long rotation, no resident should work more than 80 hours per week.

·        In general, night call is every 4^th night on all inpatient services. Call may also be required for Community Medicine and during some electives. In the event of resident illness, scheduling adjustments will be made, and call may increase to no more than every 3^rd night, on average.

·        On average, each resident will have at least one full day off per week.

·        During Emergency Medicine, shifts must not exceed 12 hours, and must be separated by at least 8 hours off work.

·        Schedule changes: Any changes to the published schedule must first be approved by the THMEP office.

4)

   Writing Orders

5)

   Daily Notes (inpatient services)

6)

   Cross Coverage Notes

7)

   Non-teaching Service Patients

8)

   Sign-out

9)

   On/Off Service and Transfer of Patients

• On the day after admission (TMC):

• When transferring a patient between services::

• At the end of the month (both TMC and Kino):

10)

   Consultations

Medical consults may also be requested at TMC. The TMC Hospitalist on duty must be contacted and must agree to serve as the supervising attending consultant. Up to 2 consults may be performed by the day call team and 1 consult may be done by the night call team.

11)

   Completeness of Physical Examinations

             The following protocol is sent periodically to all admitting Teaching Attendings:

1)

2)

3)

4)

After the resident and the intern have seen the patient, one of them will call you to discuss their assessment and plan.

·        Please use this opportunity to teach (physical findings, data, differential diagnosis, diagnostic options and therapy) and to lay any appropriate ground rules (e.g., "You need not call me if…").

5)

6)

The intern or resident must write all non-STAT orders. As such, it is essential that you and the housestaff communicate daily. Communication via the chart is not encouraged, as it minimizes meaningful interaction.

* If you must write a STAT order, please involve the housestaff immediately, so they may contribute to the ongoing management of the patient.^*

7)

The housestaff will assist in the discharge planning for the patient, and the intern will dictate a discharge summary. A copy of this will be sent to your office.

* The Program Requirements published in July 2001 by the Accreditation Council for Graduate Medical Education (ACGME) mandates that the housestaff "must write all orders for patients under their care. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident’s patient, the attending or subspecialty resident must communicate his or her action to the resident in a timely manner" (V.E.3.).

* If we do not comply with this, we will lose our national accreditation and, ultimately, our residency program!"

Residents are encouraged to discuss the curriculum with their attendings, especially during subspecialty months, when it can help focus didactics on essential clinical topics. The curriculum can also assist each resident in planning self-study, both during clinical rotations and when reviewing for board examinations.

  EVALUATIONS:

It is essential that evaluators be honest. They should write down their criticisms and concerns in a constructive manner, and discuss them in a timely manner with the subject of the appraisal. Likewise, the person being evaluated should realize that an honest critique is part of the learning process, and is essential to maintenance of professionalism.

A formal Clinical Evaluation Exercise (CEX) is performed during internship, and all residents are required to take the In-Training Examination yearly. Medical records are also reviewed, with feedback sent to the residents.

  MEDICAL LIBRARIES/MEDICAL INFORMATICS

THMEP has provided a PC in both the TMC Medical Library and the call room solely for housestaff use, including literature searches, medical education software use, and general computer needs. The password for the library computer is "THMEP". The Medical Library staff is available to instruct you in computer searches or other general computer issues.

TMC is a local Internet Service Provider (ISP), allowing for ready access to the Internet from most PC terminals around the hospital, including free access to MDConsult, Medline, Arizona Health

Information Network (AZHIN) and other useful databases. Dial-up access from home and general computer assistance can be obtained by calling the Computer Help Desk at 324-1212. TMC also offers free computer classes for a variety of computer applications. Class schedules are available in the Medical Library. For additional information and registration, call 324-2340.

The Kino Community Hospital Medical Library also offers on-line access to Grateful Med and other major medical databases through CompuServe.

  PROTOCOL FOR THE TMC GENERAL MEDICINE SERVICE

The patients admitted to the general medicine service may be referred by either community-based physicians on our teaching staff or by TMC’s Hospitalists, a group of full-time, TMC-based inpatient physicians. The admitting physician serves as the management attending during the patient’s hospitalization, developing day-to-day management plans with the housestaff, and bearing ultimate responsibility for the patient’s care.

On weekdays between 7 a.m.- 1 p.m. all general medicine/ICU admissions are distributed to the three medicine teams according to a night-call/off-call/day-call rotation (i.e. every 3^rd day). Medicine/ICU admissions until 1 p.m. should be called to the day-call resident, who will direct each patient to one of the interns on the day-call team.

Night call is every fourth night, from about 3 p.m. to 7 a.m., with the CCU team taking night call in rotation with the three general medicine teams. The night call team admits patients to both the general medicine service and to the CCU service. All second and third year residents meet briefly at Morning Checkout Rounds at 7 a.m. where the Chief Resident directs the transfer of patients to the appropriate teams, sign-out occurs, and patients are discussed.

The Chief Resident may change the time of Day call, Long call and daily CCU call. For example, with low admission rates Day call might be ended at 1 p.m., with Night call starting then. The goal is to remove time restrictions on Day call teams as long as THMEP does not lose patients by capping too early.

Morning Work Rounds are carried out by each team. The entire team should be present from 7 a.m. to 9 a.m. to facilitate contact with attendings and consults. However, Rounds should be started as early as necessary so that orders are written before morning conferences begin. Resident/intern teaching should be done at this time. After conferences, patient status and the program of AM orders should be reviewed prior to sign-out.

Morning report (Resident Report or Intern Report) is held four days per week: Resident Report (R2’s and R3’s) is held from 11 a.m. to noon, Tuesday, Thursday and Friday (Friday Resident Report is dedicated to Evidence Based Medicine); Intern Report (R1’s) is from 11 a.m. to noon on Monday. Each team’s second or third year resident is expected to carry the intern’s beepers and to help with urgent Intern work during Intern report.

Teaching Rounds are from 9 a.m. to 10 a.m. on Monday, Tuesday, Thursday and Friday with the teaching attending of the month. These rounds re distinct from management rounds with admitting physicians, and are intended to be didactic.

ICU Rounds occur from 10 a.m. to 11 a.m. on Monday, Wednesday and Friday and are intended to be primarily didactic. They start at the portable CXR board in radiology and then move to the bedside.

A series of Core Lecture in Internal Medicine is telecast from the U of Arizona on Tuesdays 9-10 a.m. The tapes are shown for Friday noon conference.

Hematology/Oncology seminars are held on Wednesdays, from 11 a.m. to noon.

Noon Conference occurs daily. See Daily Conference Schedule.

Attendance at conferences is required when on CCU or wards at TMC or Kino. They fulfill requirements from the RRC which accredits our program. And conferences constitute the bulk of formal teaching at THMEP. Interns and Residents contribute to several conferences by 1.) patient care presentations 2.) formal topic presentations and 3.) participation in dimensions. The day's activities should be planned accordingly, and conferences should start on time.

Ad hoc Management Rounds with admitting physicians should occur every day.

Chief Resident Rounds occur daily from 2 – 3 p.m. with the night-call team

Afternoon Check-Out On every inpatient rotation, housestaff are expected to communicate essential patient information to the covering house officer before leaving for the day. Each house officer departing for home or continuity clinic should also inform the hospital operator to whom he or she has singed-out before leaving the hospital.

Except for afternoons when a house officer is in continuity clinic, no team’s Resident should checkout for the night before the team’s Interns are ready to leave. Each house officer leaving the hospital should check-out to a corresponding member of the night-call team, and should notify the hospital operator of this prior to leaving the hospital.

Weekly continuity clinic at Kino Community Hospital is an ongoing responsibility for each categorical medicine house officer. The THMEP office may cancel continuity clinic only for THMEP holidays, vacation and scheduling conflicts during Emergency Room rotations. Housestaff should checkout to the corresponding house officer on the night-call team and alert the operator of this prior to leaving for continuity clinic. Housestaff are not expected to return to the hospital after clinic, unless they are on night-call.

TMC General Medicine Intern Responsibilities

The intern is the front-line, primary physician for the patient during hospitalization. He or she is under the immediate direction of the team’s second or third year resident, and ultimately answerable to the admitting physician for each patient. The intern is responsible for admitting all patients to his or her service. The intern will do the history and physical under the supervision of the resident, who will then direct the intern in the formulation of an assessment and plan and will discuss this plan with the admitting physician. The intern will then write a brief admission note and dictate a complete admission note immediately. The intern should also write an acceptance note when a CCU/PPCU patient is transferred to the general medicine service.

The intern will, whenever possible, pre-round on his or her patients prior to Morning Work Rounds. The intern will formulate a patient plan for the day with the resident, communicate this to the admitting physician and come to a consensus with the admitting physician, and write all orders. The intern (or the resident, if needed) will write daily progress notes on each patient and additional notes as the clinical situation dictates. These progress notes should include a problem-oriented assessment and plan. The progress notes should serve to document the patient’s clinical status and the intern’s assessment and plan. The chart should not be a forum for sharing one’s attitudes or feelings about the patient or the patient’s care.

The intern should be the first physician called by the medical floor or ICU for questions or problems. However, the intern should, without hesitation, involve the team’s second or third year resident or the admitting physician whenever appropriate. The intern will perform all invasive procedures under the guidance of a credentialed resident or attending physician. (See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures." )

Discharge summaries are to be dictated by the intern as quickly as possible, and certainly within 48 hours. Copies should be sent to the admitting physician, the patient’s primary care physician and to any consulting physicians to facilitate transfer of important clinical information to the outpatient setting.

As above, unless delayed by a real or potential patient emergency, the intern is expected to attend all general medicine service functions (Grand Rounds, morning work rounds, teaching rounds, intern report, noon conference, afternoon seminars, etc.).

TMC General Medicine Resident (R2 and R3) Responsibilities

The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, and ensures appropriate attending communication and oversight. The resident is also responsible for the educational progress, both practical and theoretical, of the team’s interns and medical students, if any.

The resident will see each new admission to the team’s service, with the intern whenever possible, and will write a brief admission note on each patient. The resident will review the intern’s progress notes and will initial each to indicate agreement after writing any necessary comments. The resident should also write a brief acceptance note and speak with the CCU resident whenever a CCU/Cardiology patient is transferred to the general medicine service.

The resident will assist and supervise invasive procedures performed by the intern when appropriate. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Unless delayed by a real or potential patient emergency, the resident will attend all general medicine service functions (Grand Rounds, morning check-out rounds, morning work rounds, teaching rounds, resident report, noon conference, afternoon seminars, etc.). In addition, the resident should cover for the interns during Intern Report, holding their beepers and helping with their work during this period.

Each General Medicine Resident is expected to prepare an Evidence-Based Medicine seminar during one Friday Resident Report

The General Medicine Residents are expected to suggest appropriate patient names for Pathology/Laboratory Medicine seminar, Radiology conference and other clinical conferences.

The third year resident, with the CCU resident, is expected to organize monthly Morbidity and Mortality conferences. Each death on the medicine or CCU teaching services should be recorded on an M & M sheet (obtainable at THMEP), submitted to the THMEP office and briefly reported at

M & M conference. Two or three patients who suffered either mortality or significant morbidity are fully presented and discussed.

  PROTOCOL FOR THE TMC CCU/CARDIOLOGY SERVICE

Community-based cardiologists on our teaching staff usually refer the patients admitted to the CCU service, although other members of the teaching staff may admit to the teaching service with a cardiologist consulting. The admitting physician serves as the management attending during the patient’s hospitalization, developing day-to-day management plans with the residents, and bearing ultimate responsibility for the patient’s care. Ad hoc management rounds with the admitting physicians should occur every day.

All admissions to the CCU service between 7 a.m. and 3 p.m., Monday-Friday, should be called directly to the CCU resident, who will assign the patient to a CCU intern. During weekends, the on-call resident (General Medicine or CCU) takes admission calls. Patients may also be admitted to the CCU service through activation of the A.C.T. (Acute Cardiac Treatment) team, which includes the CCU housestaff.

Night call is every fourth night, from about 3 p.m. to 7 a.m., with the CCU team taking night call in rotation with the three medicine teams. The night call team admits patients to both the general medicine service and to the CCU service. All second and third year residents on the medicine and CCU services meet for brief Morning Checkout Rounds at 7 a.m. to 7:15 a.m., where the Chief Resident directs the transfer of patients to the appropriate teams, and sign-out occurs, and patients are discussed.

The CCU team carries out Morning Work Rounds on the CCU and PCCU, facilitating contact with the admitting physicians and consultants. Work Rounds are attended by the whole team, and are an important time for management decision-making and for resident-to-resident education. If necessary, Work Rounds are completed after morning conferences. Remember that conference attendance is expected, and orders should be written before conferences begin.

Morning report (Resident Report or Intern Report) is held four days per week: Resident Report (R2’s and R3’s) is held from 11 a.m. to noon, Tuesday, Thursday and Friday (Friday Resident Report is dedicated to Evidence Based Medicine); Intern Report (R1’s) is from 11 a.m. to noon on Monday. The CCU resident is expected to carry the interns’ beepers and to help with Intern work during Intern report.

Teaching Rounds are generally held on the CCU at 9 a.m. on Monday, Wednesday and Friday, although the times may vary.

Cardiology Conference occurs every Monday at noon.

Hematology/Oncology Seminars are held on Wednesdays, from 11 a.m. to noon.

Noon Conference occurs daily, and subspecialist teaching faculty hold Afternoon Seminars for the housestaff several times a week. See the posted Daily Conference Schedule.

Ad hoc Management Rounds with admitting physicians should occur every day.

The CCU team may Check-out at 3 p.m., after the General Medicine teams conduct Afternoon Check-out Rounds. On the day following night-call, CCU housestaff may leave for home sooner (assuming their work is done), checking-out after the last scheduled educational activity of the day.

Except for afternoons when a house officer is in continuity clinic, no team’s resident should checkout for the night before the team’s interns are ready to leave. Each houseofficer leaving the hospital for clinic or until the following morning should checkout to a corresponding member of the night-call team, and should notify the hospital operator of this prior to leaving the hospital.

Weekly continuity clinic at Kino Community Hospital is an ongoing responsibility for each categorical medicine house officer. The THMEP office may cancel continuity clinic only for THMEP holidays, vacation and scheduling conflicts during Emergency Room rotations. Housestaff should check-out to the corresponding resident on the night-call team and alert the operator of this prior to leaving for continuity clinic. Housestaff are not expected to return to the hospital after clinic, unless they are on night-call.

TMC CCU Intern (R1) Responsibilities

The intern is the front-line, primary physician for the patient during hospitalization. He or she is under the immediate direction of the team’s second or third year resident, and ultimately answerable to the admitting physician for each patient. The intern is responsible for admitting all patients to his or her service. The intern will do the history and physical under the supervision of the resident, who will then direct the intern in the formulation of an assessment and plan and will discuss this plan with the admitting physician. The intern will then write a brief admission note and dictate a complete admission note immediately.

The intern will, whenever possible, pre-round on his or her sicker patients prior to morning work rounds. The intern will formulate a patient plan for the day with the resident, communicate this to the admitting physician and come to a consensus with the admitting physician, and write all orders. The intern (or the resident, if necessary) will write daily progress notes on each patient. These progress notes should include a problem-oriented assessment and plan. Additional notes should be written for, and the admitting physician should be notified about, significant changes in the patient’s clinical status. Chart notes should serve to document the patient’s clinical status, your assessment and plan. They should not be a forum for sharing one’s attitudes or feelings about the patient or the patient’s care. The CCU intern should also write a transfer note and initial transfer orders for any patient transferring off the CCU/Cardiology service to the general medicine service.

The intern should usually be the first physician called by the CCU or PCCU for questions or problems. Given the acuity of some of the patients and the problems they develop, the admitting physician may occasionally be called first, but will then involve the housestaff as soon as is reasonably possible. The intern should, without hesitation, involve the team’s resident or the admitting physician whenever appropriate. All invasive procedures performed by the intern must be done so under the guidance of a credentialed resident or attending physician. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Discharge summaries are to be dictated by the intern as quickly as possible, and certainly within 48 hours. Copies should be sent to the admitting and any consulting physicians to facilitate transfer of important clinical information to the outpatient setting.

Unless delayed by a real or potential patient emergency, the intern will attend all scheduled educational activities. These include CCU service functions (morning work rounds, teaching rounds, cardiology conferences), intern report, noon conferences and afternoon seminars.

TMC CCU Resident (R2 and R3) Responsibilities

The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, and ensures appropriate attending communication and oversight. The resident is also responsible for the educational progress, both practical and theoretical, of interns and any medical students on the team.

The resident will see each new admission to the team’s service, with the intern whenever possible, and will write a brief admission note on each patient. The resident will review the intern’s progress notes and will initial each to indicate agreement after writing any necessary comments. If the admitting physician requests that medical housestaff continue to care for a patient after transfer off the CCU or PCCU, the resident should contact the resident on the general medicine service to discuss the patient and assure an appropriate transfer of care.

The resident will assist and supervise invasive procedures performed by the intern when appropriate. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Unless delayed by a real or potential patient emergency, the resident will attend all scheduled educational activities. These include CCU service functions (morning work rounds, teaching rounds, cardiology conferences), resident report, noon conferences and afternoon seminars. In addition, the resident should cover for the interns during Intern Report, holding their beepers and performing their duties during this period.

  General Surgery and Trauma

The Transitional resident, functioning as a member of the team, is responsible for admitting history and physical examination, daily progress notes, the writing of orders, the general planning of in-house care and the continuing management of patients throughout their course. They attend one or two clinics a week for follow-up of post-hospitalization patients.

The educational goals on these services are to:

·        To develop clinical competence in the perioperative management of many of the problems encountered in general surgery and trauma.

·        To actively participate in patient care in conjunction with senior surgical residents, including management of critically ill patients on the surgical service.

·        To evaluate surgical patients preoperatively in the clinics and Emergency Room and to follow their post operative courses in the hospital and outpatient clinics.

·        To participate in the regular educational activities of the surgical service as applicable to categorical first year surgery residents.

  PROTOCOL FOR KINO COMMUNITY HOSPITAL GENERAL MEDICINE SERVICE

The Internal Medicine teaching service is composed of two teams. Each team consists of an attending physician from the department of Internal Medicine, two second or third year resident physicians and two first year interns. Residents and interns are provided by the U of A Internal Medicine residency program and the THMEP Internal Medicine and Transitional residency programs. All members are bound by the rules and regulations of the Department of Internal medicine and the bylaws of the Medical Staff of Kino Community Hospital.

Admissions:

The Internal Medicine teaching service is available for accepting any adult or adolescent patient over the age of 16 admitted to Kino Hospital with a primary medical problem. Patients under the age of 16 may rarely be accepted to the teaching service with the prior approval of the teaching attending. Admission coverage is 24 hours per day and seven days per week. Admissions may be to the intensive care unit, the medical-surgical unit or the Transitional Long-term Care unit, based on patient acuity and admission criteria of those units. Admissions may be from the Emergency Department, Kino clinics and offsite clinics, area nursing homes, transfers from other hospitals and the Pima County Adult Detention Center. Any direct admissions to the teaching service from sources other than the Emergency Department or Kino clinics must have the prior approval of the teaching attending. All admissions to the teaching service must be accompanied by a direct notification of the resident team, including information about the source of the admission and the reasons for the admission.

The call schedule for each resident and intern team is one night in four. Admissions to the teaching service between 7:00AM and 2:00 PM Monday through Friday will be assigned to the "short-call" teams. The first and second "short-call" teams may each admit up to 5 patients each. The "long-call" team will admit patients between 2:00 PM and 7:00 AM. On weekends, the "long-call" team will admit patients for 24 hours. In accordance with residency requirements, an intern will be primarily responsible for no more than five admissions per 24 hours or eight admissions per 48 hours. A resident will be responsible for no more than ten admissions per 24 hours or 16 admissions per 48 hours, including those patients admitted to the intern. It is expected that the resident and intern will function as a team in the care of all patients on their service. In the event the number of admissions exceeds these limits, the Emergency Department physician in conjunction with the medicine attending physician will coordinate care of the patient until the next admitting team assumes their care during duty hours.

All admissions must include a complete history and physical examination which can be either written legibly or dictated and must be signed. The H&P may be completed by the resident or the intern according to the delegation by the resident. Admission orders may be written by the resident or the intern, but must always be reviewed by the resident with the intern. Orders must be written prior to transport of the patient to the unit. Daily progress notes and additional notes recording procedures, events and any change in status must be written by the resident or the intern. Medical student notes cannot serve as official portions of the medical record and also require review and countersignature by the intern or resident. A dictated discharge summary must be completed within 24 hours of discharge of a patient. For patients discharged to a skilled nursing facility or transferred to another hospital, a discharge summary should be completed prior to discharge in order to accompany the patient in the transfer of care. A courtesy notification of a patient discharge to the primary care physician is also encouraged.

THMEP residents should be notified whenever their continuity clinic patients are admitted to the Kino medicine service. Each continuity clinic patient should receive an identification card from the clinic staff or resident (available through either the clinic or THMEP), which should be presented by the patient at the time of presentation to the hospital. This card identifies the resident as the patient’s primary care physician, and directs the hospital staff to alert THMEP to the patient’s admission. This allows the resident to contribute useful medical history and offers him or her the opportunity to remain involved in significant management decisions.

Teaching rounds will be conducted Monday through Friday between 8:00AM and 9:00 AM. Housestaff are expected to have made pre-rounds on their patients prior to Teaching rounds. Following Teaching rounds, radiology rounds and ICU rounds will be conducted followed by Management rounds. All attending rounds should be completed by 12:00PM. All housestaff are expected to attend all rounds, core lectures and noon conferences unless called for an emergency. Work rounds will be conducted by each resident and intern team prior to Teaching rounds in the morning and following noon conference in the afternoon. Interns and residents must sign out all patients to the "long-call" team prior to leaving the hospital. Interns and residents must remain on call for their patients until 5:00 PM.

The "long-call" team shall respond to all "Codes" called in the hospital and the "long-call" resident will run the "Code" unless the resident or the attending for that patient is available in the hospital to respond and run the "Code". The attending physician must be contacted and notified of all "Codes" and all unanticipated deaths on the service. The attending should also be notified immediately of any significant change in status of a patient or any transfer of a patient to another level of care such as the ICU or telemetry.

All housestaff will have, when averaged over a four-week period, one day off per week. However, the resident and the intern of a team should not take the same day off. Days off should be coordinated by the resident teams, but at least one second or third year resident must be available in hospital every day. Housestaff will not work more than 80 hours per week. According to residency requirements, neither interns nor residents may take vacation during the Kino inpatient medicine rotation. Because of the time demands of this service and required limitations on total work hours, medicine residents are not allowed to "moonlight" during Kino medicine rotations.

Consultations:

Internal Medicine consultations to other services are provided by the teaching service for non-urgent conditions between 9:00 AM and 4:00 PM Monday through Friday and 24 hours per day for urgent and emergent conditions. Initial evaluation and consultation is provided by the short-call resident physician, with staffing by the attending physician. The resident must discuss the patient with the attending before any suggestions are made and before the consultation note is placed in the medical record. If the attending chooses not to see the patient immediately (at the attending's discretion), the resident and the attending will arrive at a plan over the telephone. The resident will write: "This has been discussed with and agreed to by Dr. (Attending)" and will then sign the consultation note as "Dr. (Resident) for Dr. (Attending)."

All requests for Internal Medicine consultation must be accompanied by a direct notification of the resident and/or attending physician by the requesting service, identifying the patient and the reason for the consultation request. On occasion, and with the prior approval of the teaching attending, patients with primary surgical problems, including but not limited to hip fractures, who also have complex medical problems may be admitted to, or transferred to, the internal medicine teaching service and managed in conjunction with the appropriate surgical service.

  COMMUNITY MEDICINE (PRIVATE OFFICES)

Appropriate resident activities on the community medicine rotation include, but are not limited to: office hours, office-based procedures (treadmills, sigmoidoscopies, arthrocenteses, etc.), front-office and back-office education, hospital rounding, night call, house calls and nursing home visits.

The Geriatrics rotation is a multidisciplinary month, with time spent in several sites. Site specific resident responsibilities and expectations vary, and are best discussed with each site supervisor. However, all usual guidelines for resident supervision and activities pertain (see "General Work Guidelines for all Services").

Scheduling is done by the Emergency Medicine department and is coordinated with the THMEP office. Pediatrics and Emergency Medicine residents from the University of Arizona also participate in the rotation. THMEP policies regarding work hours apply. See "General Work Guidelines for all Services."

A copy of the TMC Emergency Medicine Resident Handbook will be provided at the start of the month and must be returned at the end of the rotation. The Handbook includes specific resident responsibilities, ER policies, critical pathways and useful reference materials.

  KINO EMERGENCY MEDICINE

You will receive a schedule prepared by the THMEP office. You may trade shifts with your co-residents but these must be cleared through the THMEP office and Dr. McLaughlin, ED Director. Twelve-hour shifts change over at 0700 and 1900. You are expected to arrive on time to receive sign-out from your colleague so that he or she can leave on time. Your dress should be neat and professional. Jeans and high-mileage athletic shoes are not appropriate. Scrub suits are available and encouraged.

You should expect to be regarded as a key player on the Emergency Department team. You and the attending will both be seeing patients and there is no formal selection process. After you have performed the history and physical, you will discuss each case with the attending and then proceed to order appropriate diagnostics or treatments, with his or her guidance. You will read radiographs and ECGs, and will consult with housestaff and attendings when necessary. You will get plenty of hands-on experience suturing and splinting. Endotracheal intubations and placement of central lines and chest tubes are often necessary and will be available to you, with appropriate guidance. The nursing staff normally performs placement of peripheral intravenous lines, Foley catheters, and nasogastric tubes. However, you may also perform these procedures if you desire, or if needed for credentialing purposes. The attending and nursing staff are available to help you with this. The nursing staff is generally very supportive of medical education. They like working with you, and you are encouraged to use them as an educational resource.

All guidelines for lines of responsibility and work hours pertain, as described in the section "General Work Guidelines for all Services".

  URGENT CARE CLINIC

The Urgent Care Clinic is open from 8 a.m. to 10:30 p.m. daily, although patient care usually lasts longer. Scheduling is done by the Urgent Care department and is coordinated with the THMEP office. Although shift length and times vary, THMEP policies regarding work hours remain in effect. See "General Work Guidelines for all Services."

  AMBULATORY SPECIALTY CLINICS

The Ambulatory Specialty Clinic rotation is usually conducted in the Ambulatory Clinic Building at Kino Community Hospital, although some clinics may occasionally be held at other sites. The rotation consists of outpatient experiences in gynecology, orthopedics, ENT and ophthalmology, from 8 a.m. to 5 p.m., Monday through Friday. Whenever possible, residents are asked to take an active role in patient care. However, because of the relatively brief time spent in each of these clinics and the specialized nature of many of the procedures performed, much of the rotation is purely didactic. Residents are encouraged to rely heavily on the THMEP curricula for these specialties to ensure that essential topics are addressed and that required competencies are attained. Attendance at each scheduled clinic is mandatory.

  ELECTIVES

Residents may engage in a research elective for one month of the 2^nd and/or 3^rd year with prior approval of the Program Director. Additional months of research elective may be granted on an individual basis. Other electives and all research electives require review and approval of the proposed activities.

All elective rotations are conducted under the supervision of a single directing attending, although actual clinical activities may be coordinated with several members of a practice or clinical department. Usual working hours are from 7 a.m. to 5 p.m., Monday-Friday. However, housestaff should discuss this and other expectations with the directing attending at the beginning of the month. Some elective services do require weekend and night-call work. An 80-hour work week limit applies.

  CONTINUITY CLINIC

A THMEP faculty member, who is ultimately responsible for every patient seen, supervises each clinic. As such, timely, thorough and open communication between the resident and the attending is essential.

Patients in the continuity clinics should be provided with a THMEP Physician Identification Card by the resident, a copy of which should be stapled to the Kino Hospital chart. This card identifies the resident as the patient’s primary physician and requests that the THMEP office be notified of any hospital admissions or other important medical events. The TMC Chief Resident will alert the resident of any such event. Residents are encouraged to remain involved in the care of their patients whenever they are hospitalized, communicating vital patient history to the admitting physician and contributing to medical decision-making.

Unless on night-call, house officers are not expected to return to work after continuity clinic. Before leaving for clinic, an intern should hand over unfinished work and all ongoing patient issues to his or her resident, who will then be responsible to sign-out to the appropriate night-call intern at the end of the day.

  CONFERENCES:

In addition to regular Teaching Rounds and Management Rounds

·        Mandatory for housestaff on TMC inpatient rotations; otherwise, strongly encouraged:

·        Mandatory for housestaff on Kino inpatient general medicine rotations:

·        Each THMEP resident must, at some time during the R2 or R3 years, attend each of the following meetings at least twice:

  MEDICAL MORBIDITY & MORTALITY CONFERENCE

Medical Morbidity & Mortality Conference is a vital forum for discussing untoward outcomes and opportunities to improve medical care.

1.

Patients should be referred to by their initials, not their name.

2.

A certain amount of structure and formality will hopefully facilitate discussion. To this end, the presenter will be provided with a podium and a pointer.

3.

The program should begin with the Senior resident (or his or her substitute) presenting the total number of deaths on the service, dividing these into "expected" and "unexpected" deaths. All deaths on the medical ward and CCU service should be recorded by the houseofficer involved on a Morbidity and Mortality sheet which will be saved at the THMEP office. However, only a few cases, picked by the chief resident or program director should be presented fully.

4.

Whenever possible, the intern involved in the patient’s care should present the case. When this is not possible, the responsible resident should do so.

5.

Whichever house officer presents the case should consider it his or her responsibility to contact the key physicians involved, and arrange for their attendance. If this is not possible, a substitute physician in the appropriate discipline should be asked to attend.

6.

Whenever possible, pathology and/or autopsy slides should be presented. The pathologist should be invited well ahead of time, to avoid scheduling conflicts.

7.

The case should be presented in such a way as to highlight the clinical dilemmas or medical mishaps.

8.

Next, questions should be entertained from the audience.

9.

At this point, the house officer presenting the case should be prepared to give a short synopsis of his/her opinion about what is to be learned from this case. The invited physicians should be given an opportunity to describe their opinions and offer more information about the clinical entities described. The house officers involved in the case are expected to have read sufficiently about the subject in question to discuss it from a knowledgeable perspective.

  SCHOLARLY ACTIVITIES

1.

Clinical Vignettes:

2.

Clinical Pathologic Conference/Grand Rounds:

3.

Research and Publications

  ACLS CERTIFICATION

  LEARNING TOOLS

  CLINICAL LABORATORY

  MEDICAL RECORDS

1.

All housestaff must become familiar with the accepted indications for and potential complications of each invasive procedure they perform, and must be able to knowledgeably counsel the patient on these.

2.

3.

4.

Credentialing for the performance of invasive procedures is based on three levels of clinical privileges:

Level 1 -

Level 2 -

Level 3 -

A.

Entry level procedures: Entry level procedures are simple, require limited expertise and are easily learned. The required procedures should be performed early in the PGY-1 year. Upon satisfactorily completing these procedures, Level 3 privileges are granted.

PROCEDURE

CRITERIA for Level 3 privileges

1.      Arterial line placement

4 successful, supervised procedures

2.   * Arterial Puncture

5 successful, supervised procedures

3.   * Insertion of nasal gastric     tube

3 successful, supervised procedures

4.   * Intradermal injection

1 successful, supervised procedure

5.   * Incision & drainage superfical abscess

3 successful, supervised procedures

6.   * Perform EKG

1 successful, supervised procedure

7.   * Peripheral IV lines

3 successful, supervised procedures

8.   * Subcutaneous injection

1 successful, supervised procedure

9.      Suture removal

1 successful, supervised procedure

10. * Urinary catheter female

1 successful, supervised procedure

11. * Urinary catheter male

1 successful, supervised procedure

12. * Vein Puncture

1 successful, supervised procedure

13.    Skin Punch Biopsy

1 successful, supervised procedure

14. * Breast Examination

5 successful, supervised procedures

15. * Pelvic Examination/Pap

5 successful, supervised procedures

16. * Rectal Examination

5 successful, supervised procedures

B.

  PROCEDURE

  CRITERIA for Level 2 privileges

C.

PROCEDURE

  HOLIDAYS

THMEP holidays are:

Christmas

New Year's Day

Memorial Day

July 4th

Labor Day

Thanksgiving

  VACATION

A

Interns (R1) may not take vacation from:

1.

General Medicine at Kino Community Hospital

2.

Emergency Medicine at Kino Community Hospital

3.

At the same time as another intern on the same team

4.

5.

Pediatrics (elective)

B

Residents (R2 and R3) may not take vacation from:

1.

General Medicine at either Kino Community Hospital or TMC

2.

CCU/Cardiology at TMC

3.

Pediatrics (elective)

C.

All housestaff may not take vacation during:

1.

The first week in July

2.

The last week of June, with the following exception: Interns who begin residency elsewhere on July 1 may take vacation during the last week of June providing vacation time is due and adequate coverage of the service is maintained.

  COVERAGE DURING ILLNESS

Interns

Residents

Housestaff will not be asked to give up scheduled vacation time to cover for sick residents.

  POLICY FOR RESIDENT ABSENCE FROM WORK:

  UNIVERSAL PRECAUTIONS FOR HANDLING BLOOD AND BODY FLUIDS

If a needle stick should occur, you should follow the procedures outlined on the following pages/paragraphs.

If you have any questions about proper handling of body fluids, please ask your senior resident or attending before attempting the procedure.

  SHARPS INJURY/BODILY FLUID EXPOSURE

·        Call TMC Employee Health within 8 hours of injury at extension 47106.

·        Your Hepatitis B antigen status will be determined and you will vaccinated if necessary.

·        You will receive Hepatitis B immunoglobulin prophylaxis and treatment if indicated.

·        You will be counseled and offered serial HIV AB testing.

·        You will be referred to an infectious disease physician for AZT prophylaxis if indicated.

·        The source patient, if known, will be counseled and asked to consent to HIV AB and Hep B₅A_g testing if indicated. Blood will be drawn on the source patient with consent.

  WORK EXPOSURE TO BODILY FLUIDS

Human Immunodeficiency Virus (HIV)

and Acquired Immune Deficiency Syndrome (AIDS)

1.

2.

3.

4.

NO LATER THAN EIGHTEEN (18) MONTHS after the date of possible significant exposure at work, the employee is retested and the results of the test are HIV positive or the employee has been diagnosed as positive for the presence of HIV.

·        Permission must be obtained for the specific activity from the residency Program Director. He has the prerogative to deny the request.

·        The number of hours spent on moonlighting activities must be reported monthly to the Program Director and will be documented in the resident's records.

·        Moonlighting must not interfere with the performance of your assigned patient care responsibilities and educational exercises.

·        The total number of hours permitted for both the residency and moonlighting combined may not exceed 80 hours per week averaged over a four week period.

·        THMEP will not provide medical liability insurance for any moonlighting activities.

·        You must have a regular Arizona medical license to participate in such moonlighting.

  POLICY ON NARCOTICS AND OTHER PRESCRIPTION MEDICATIONS

Services:

1)

Management Consultation

2)

Resident Support System

A.

Personal Referral Service

B.

Critical Incident Stress Management Debriefing:

C.

Behavioral Issues Counseling:

3)

Impaired Resident System

A.

Self-referral:

B.

Non-voluntary Referral:

Non-voluntary referrals are made when the resident is found to be in violation of THMEP or institutional conduct guidelines such as: prohibiting practice while under the influence of alcohol or illegal drugs, or the use, possession, sale, purchase, transfer, or negotiation for sale of drugs on institution property or the institution's Bylaws of the Professional Staff. Referrals may result from alcohol or drug testing programs or law enforcement programs. Bomex reporting will occur in such cases, and in accordance wit ARS statute 32-1451. Referrals may also result from the resident acting in violation of any hospital policy, rule, regulation, or standard of performance that, in the opinion of the hospital medical staff leadership, or Professional Staff Office Leadership, might endanger the safety or well-being of a patient or those involved in the care of the patient. Referred residents will be entered into the Impaired Resident System for tracking purposes, in accordance with BOMEX regulations. The resident will be required to agree to the terms requested including reporting of treatment progress and random alcohol and drug testing. Should a resident refuse to agree to the terms, fail to successfully complete the program, or violate the terms of the agreement, then termination of employment and privileges or other disciplinary action may be implemented and BOMEX and/or other appropriate licensing agencies will be notified. All referrals are recorded in the resident's file.

4)

Internship Mentoring Program

06/01/2001

ADDENDUM #1 - Housestaff Manual

Teaching at the Bedside

Bedside teaching should occur at least twice a week.

I.

Setting the ground rules

a.

Make sure that your team knows what you expect of them - teach professionalism

b.

Cover bedside etiquette

c.

Limit beeper interruptions

d.

Begin on time (everyone present at the start)

e.

Schedule with the patient whenever possible (Have the resident arrange.)

f.

Invite the patient's nurse when feasible (unfortunately, this is not often an option)

g.

When at the bedside, limit your use of medical jargon

II.

Introduction

a.

Have the patient's doctor (student, intern, resident, you) introduce all members of all the team.

b.

Explain the purpose of the visit

c.

Allow the patient a polite refusal (rarely necessary)

d.

Introduce yourself to family members if present; invite to stay, but only if okay with the patient.

e.

Explain that much of what you and the team discuss may not apply directly to this particular patient

f.

Invite participation and questions by the patient

g.

POSITION THE PATIENT APPROPRIATELY; position your team around the bedside

III.

The Presentation (History)

a.

Avoid beginning the presentation with a statement about the patient's gender and race; these should be obvious.

b.

Do not refer to the patient by his-her first name unless you know for sure that it is appropriate

c.

Avoid sitting on the patient's bed unless there is a reason to do so

d.

Do NOT avoid sensitive material… just treat it in a sensitive manner

e.

Allow interruptions by the patient, the students and residents, and by yourself to highlight important points or to probe in more detail

f.

Never, EVER embarrass the patient's doctor - the student/resident won't like it and neither will the patient

IV.

The Presentation (Examination)

a.

Examine the pertinent or illustrative parts yourself

b.

Invite the resident/students to examine the patient

c.

Allow the patient to participate (many will greatly appreciate hearing the murmur or feeling the spleen that the rest of you seem so excited about)

d.

Ask the team members to demonstrate proper techniques

e.

Allow time for the team members to appreciate the findings; remember that it may take a while (and some ingenuity on your part) for a student or intern to truly hear an S4 for the first time

V.

The presentation (Labs, etc.)

a.

Stay at the bedside if possible

b.

Have pertinent radiographs, EKG's, etc., available

c.

Allow the patient to review

VI.

Discussion

a.

Remind the patient that not everything said will apply to them; be explicit when what you are discussing is directly applicable

b.

Question junior team members first

c.

Avoid asking theoretical questions to the patient's primary doctor; missing them in front of the patient is quite hard on the resident/student and may belittle them in the eyes of the patient

d.

Don't allow "one-upmanship" to occur

e.

Avoid asking the "What am I thinking?" question - you know, the ones that make a point but are primarily designed to make you look good

f.

"I don't know" is an appropriate answer - both for you and for your team; it should be followed up, though, with a search for the correct answer if important