Resident education through patient care
Medicine, whether as a primary care physician or specialist, is driven by patient care. In whatever capacity residents will practice in after residency they will undoubtedly admit, care for and discharge in a hospital setting. During residency residents have a limited time to learn as much as they can about practical patient care and should realize that the more patients that they admit, round on, and discharge the better they will be able to face the realities of medicine today.
Interns should have seen all their patients prior to morning report or rounds. You may not have completed notes on all of them but as long as you have laid hands and eyes on them to be sure that they are stable you are doing alright. If they aren't stable call someone...like your senior resident.
Basics of pre-rounding
Review vital signs for the past 24 hours with the goal of predicting or identifying SIRS and shock as well as initiating appropriate measures for the same. All abnormal reported vital signs must be rechecked with the appropriate equipment by the resident. Included in this is:
Temperature
Pulse
Respiratory rate
Blood pressure
Oxygen saturation
Review telemetry with the goal of treating dysrhythmias and determining the necessity of telemetry. Check the preprandial blood sugars with the goal of adjusting IVF and insulin for adequate glycemic control. Assess volume status by reviewing serial weights as well as input and output.
Review diagnostic testing, identifying and tracking disease based on serial diagnostic assessments of stress, hemostasis, electrolytes, and metabolism. Improvement, worsening, and stability of results must be addressed in progress notes and orders. Included in this is adaily review of culture and sensitivity results. Remember to interpret screening tests in the context of active disease.
Perform a progress note review, in this address concerns of nursing staff as well as review specialist recommendations and order if necessary.
Perform an order review
Review all medications, including IVF, daily and adjust accordingly.
Discontinue unnecessary nursing orders and lines
Review nutrition requirements
Review DVT prophylaxis
Review opiate-induced bowel dysfunction regimen
Screen for diliriogenic medications and interventions
Review discharge needs
This is in addition to thorough patient interview and focused physical exam.
Taking ownership for patient care
Make sure that nursing, ancillary and house staff know that this is your patient. This is fostered by face-to-face conversation regarding plan of care with the staff. If there is a method for recording your name as the primary contact for patient care make sure you do it. Make sure there is a clear communication regarding coverage and transfer of care should this be necessary.
Floor pages
Your pager is always on and you always answer in under 5 minutes. Period. If you start with this attitude you will be amazed at how infrequently you will get paged, as the staff learns how easy it is to get a hold of you they will only page you when they actually needyou.
Safe discharge planning
Discharge planning starts with admission to the hospital. An accurate home or ECF medication list should be obtained at admission and be correctly reflected in the EMR. Do not trust that the list in the EMR is correct unless you have personally verified this with the patient. If you think the patient will need rehabilitation or ECF placement order PT/OT evaluation early and review their notes.
While the patient is admitted remove Foley's as early as possible, too often discharge is complicated by iatrogenically induced urinary retention. Review the need for telemetry daily as well. Reducing unnecessary interventions and monitoring moves patients toward discharge. Review medications daily and implement the appropriate changes, so that dosing changes the day after discharge do not send the patient straight back to the ED. Get case management involved as soon as necessary by speaking to them personally. This may be as simple as concerns about transport to as serious as setting up home oxygen or hospice care. Review specialists notes for documentation of desired follow-up and follow-up testing. If this is unclear, page the specialist in question and ask. Know if and when a patient needs a PICC or a midline for continued IV therapy.
On discharge there are some key things that need to happen:
Who will the patient follow-up with? Why are they following-up? When do they need to be seen?
What diagnostic testing needs to occur prior to being seen in follow-up? Who does this information need to go to (i.e. an office fax #)?
If they are on warfarin they need an INR, if they are new to warfarin they need to be seen by the anticoagulation monitoring service.
Which of their in-patient medications do they need to continue?
Do they need counseling, education, or training prior to discharge (i.e. smoking cessation, diet, insulin injection)
Which of their prior to admission medications do they need to stop?
If you do not know what a medication is look it up!
Avoid red flags, especially patients on medications that are of the same class (multiple beta blockers or benzodiazepines or PPI/H2 blockers). Give antibiotics a definitive duration. Change doses appropriately, if a patient came in with acute decompensation of heart failure their medications need to be optimize on discharge. Someone admitted with dehydration may need reduction in diuretics. A patient with hyperkalemia should not be discharged on potassium supplements.
Counsel patients on discharge plans and medication changes
Discharge summaries need to be prompt and accurate. They must be completed within 24 hours of discharge. At a minimum they should include:
Discharge summaries must accurately reflect the medical care team including the PCP. If the patient does not have a PCP, the one assigned should be indicated.
A complete list of acute and chronic diagnoses should be listed. The status, class, or staging should be indicated (i.e. ADHF, resolved, of chronic CHF, Stage III, Class C, severe, systolic, 10/25 TTE or Hyperkalemia, resolved).
Medications should be accurate, multiple listings of the same medications is poor medical care and documentation. This can be corrected in the Discharge Nav under Orders and Rev/Unrev Meds. Subsequently you can refresh you medication lists in your discharge summary.
Following the discharge medications a brief paragraph of changes made to medications should be included.
A detailed summary of the hospital course should be listed. At the barest minimum one sentence per day of hospitalization.
In your summary carefully review the important in-patient diagnostic testing
A discharge plan must be carefully outlined, describing follow-up, pending and ordered diagnostic testing/therapy, and recommendations describing treatment after discharge.
Edit and format your summary to be a high-yield resource to the following physician.