Night Admitting Team

Competency-Based Curriculum

Overview

This assignment blends several overlapping educational experiences. First, it offers interns and Junior/Senior Assistant Residents opportunities care for inpatients with a variety of medical illnesses during the night. This allows for greater autonomy in making critical patient care decisions. A second valuable aspect of this assignment includes the chance to independently assess, triage, and admit patients in the emergency department and to mimic the roles of attending physicians (including coordinating care choosing consultants, and communicating with attending physicians at night). And third, the residents care for patients as part of a team (developing effective communication skills, improving sign outs, reducing error during transfer of care). Finally, residents will carry out and learn the principles of general medical consultation when required.

Residents function under the direct supervision of the admitting physician caring for the patient. Additional supervision comes from the faculty and chief resident.

Principal Teaching/Learning Activities

-Resident Morning Report (RMR)—

Three mornings each week (Monday, Tuesday, & Thursday) from about 7:45- 8:45 AM all Interns, Junior Assistant Residents and Senior Assistant Residents on inpatient floor teams meet with assigned faculty to review patients admitted the previous day. Patients are presented briefly by the intern or resident who admitted them and discussed by the group, facilitated by the attending physician. The focus of the discussion is selected by the presenting resident and may reflect differential diagnosis, specific management issues, or other topics. Faculty will include general internists and subspecialists.

Each Friday from 8:00-9:00 AM the Senior residents will meet with assigned specialist attending physicians to review patients admitted the previous day. Selected patients are presented by the residents and further discussion including literature review and didactic teaching is guided by the attending physician.

-Sign-out Rounds (SR) -- Every evening, Monday through Friday, the the senior residents (Chief Resident, or his/her designate will be present during the first few months of the academic year), supervise sign-out rounds, which are attended by the out-going day team and incoming ADMITTING team. These may include topical discussions.

-Grand Rounds (GR) -- Medical Grand Rounds are held each Wednesday from 8:00 -9:00 a.m. in the Medical Center Auditorium. Formats vary and include invited guests/visiting professor presentations, clinical-pathological conferences, morbidity and mortality conference, resident presentations, or other didactic, topical, or patient related topics.

- Turnover Rounds (TR)-- Turnover rounds occur at the end/beginning of each rotation and from 6:30- 7:30 a.m. daily. These facilitate transfers of patient care from one resident to another. (Sign in Rounds are a daily version of turnover rounds.)

-Patient Safety and Quality Improvement Conference (PSQI) –Formerly the Morbidity and Mortality Conference. We now have a monthly conference dedicated to identifying issues that affect patient safety. The issues maybe as varied as knowledge gaps in care for patients with unusual diseases to errors that occur in the course of care. There is a discussion about the residents' role in preventing such issues in the future. If warranted an action plan is made with follow up at subsequent meetings.

-Autopsy Rounds (AuR) When a death occurs on any of the teaching teams the family is offered the option of performing an autopsy. If an autopsy is performed, we hold a multidisciplinary presentation of the findings that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents and faculty that were involved.

-MKSAP study pan (MKSAP)-This self directed study plan helps residents stay on track with their didactic reading and helps them evaluate their medical knowledge (strengths and areas of deficit). Residents can help develop individualized study plans to fill in any knowledge gaps and reinforce what they already know. This also helps residents develop skills and habits needed for lifelong learning.

-In-Training Examination (ITE) -- All of our residents must take this examination annually for their own assessment of progress and for edification. When examination results become available, the program director discusses these individually with residents and counsels residents about individualized study programs to facilitate their acquisition of knowledge.

Description of the Rotation

Two Interns and one Junior/Senior Assistant Resident are assigned to this service each month. Residents will care for patients and admit new patients from the emergency room. The team will be responsible for the care of all in-hospital general medicine patients on the teaching services. In addition they will evaluate and appropriately triage any patients they are consulted on by the emergency department. They will have no responsibility for patients in the critical care units.

The resident should take face-to-face verbal and written sign-outs from the out-going team. The incoming tem must become intimately familiar with all patients, especially those whose clinical status is unstable. All patients who need evaluation will be seen and appropriate notes, decisions, and dispositions effected. Residents will have the opportunity to discuss patient issues with attendings over the phone as necessary or whenever they feel that discussion would improve patient care.

Resident will also have the opportunity to discuss any questions or issues with faculty and the chief resident at morning report. The team will also be responsible for presenting all overnight events on the inpatient units as well as all patients admitted overnight. The team is expected to have completed a didactic search to answer any clinically relevant patient care questions that came up during the night. Residents have a responsibility to provide this didactic information appropriate to the incoming teams. They are expected to have relevant medical literature when appropriate to use to supplement discussion of patient management.

Goals and Objectives

The principle objective for this month is to complement other resident experiences enabling residents to learn how to function independently in assessing and caring for sick emergency room and hospitalized patients. As noted, this involves emergency room triage, routine admissions, medical consultations, and acute emergent problems.

Residents will gain familiarity, above and beyond other general medical experiences, with diagnosis, differential diagnosis, pathophysiology, management, and preventative aspects of patient care. In addition, they will develop leadership, self study and educational, and QI project development skills. They will also learn the value of developing and maintaining a portfolio.

Specific objectives:

• Master medical management of surgical, obstetrics/gynecologic, psychiatric, orthopedic and podiatric and other non-medical patients.
• Manage acute medical emergencies.
• Manage general medical patients and problems encountered in hospitalized patients (as and detailed in the critical care, cardiac care, and inpatient general medicine curricula).
• Learn the skills of receiving and giving appropriate sign-out when transferring care of a patient form one team to another.
• Learn to evaluate the transfer process and develop initiatives to improve hand-off and reduce errors.
• Master evidence-based, cost effective, contemporary management of medical patients and problems.
• Develop leadership and team-building skills.
• Master procedures that an internist is required to perform on in-hospital patients.
• Develop self-guided study skills.
• Develop and maintain a portfolio of experiences, educational activities, and scholarly endeavors, accomplishments.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

• Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.

• Mini CEXs may be used when warranted, particularly in the beginning of the academic year.

• Self-evaluation by In-service training examination scores

• MKSAP study plan (MKSAP)

• Participation and presentations at didactic conferences (DC)

• Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Principle Educational Goals by Relevent Competency

In the tables below, the principle educational goals for the Faculty Inpatient Service rotation are indicated for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.

* Legend for Learning Activities (See preceding for descriptions)
MS-Multisource evaluations
ACC-Ambulatory Care Conference
AE-Attending Evaluations
AR- Attending Rounds
AuR- Autopsy Rounds
BTB-Back to Basics
DPC-Direct Patient Care
EBM-Evidence Based Medicine
GR- Grand Rounds
ITE-In-Training Exam
JC- Journal Club
MKSAP-Knowledge Self Study Plan
MR- Management Rounds
NC- Noon Conference
DPC-Direct Patient Care
PCR-Palliative Care/Ethics Rounds
PSQI-Patient Safety/Quality Improvement
RMR- Resident Morning Report
SR- Signout Rounds
TR-Turnover Rounds

1.) Patient Care

Goals and Objectives: PGY-1	Learning Activities*	Assessment
Master basic patient interviewing skills	DPC, RMR, SR	AE, SR, RMR,
Master basic patient exam skills	DPC, RMR, SR	AE, SR, RMR,
Master basic psycho-social evaluation skills	DPC, RMR, SR	AE, SR, RMR,
Define and prioritize patients' medical problems	DPC, R MR, SR	AE, TR, SR, RMR
Generate and prioritize differential diagnoses	DPC, RMR, SR	AE, TR, SR, RMR
Develop rational, evidence-based management strategies	DPC, RMR, SR	AE, TR, PR, RMR

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Interview patients more skillfully	DPC, RMR, SR	AE, SR, R MR,
Examine patients more skillfully	DPC, RMR, SR	AE, SR, RMR,
Evaluate psycho-social issues more skillfully	DPC, RMR, SR	AE, SR, RMR,
Define and prioritize patients' medical problems	DPC, R MR, SR	AE, TR, SR, RMR
Generate and prioritize differential diagnoses	DPC, RMR, SR	AE, SR, R MR,
Develop rational, evidence-based management strategies	DPC, RMR, SR	AE, SR, RMR,
Manage a large volume of patients	DPC, RMR, SR	AE, SR, RMR,
Develop and display leadership skills and responsibility	DPC, R MR, SR	AE, TR, SR, RMR
Learn to be team leaders	DPC, RMR, SR	AE, TR, SR, RMR
Learn to be efficient teachers	DPC, RMR, SR	AE, TR, PR, RMR

2.) Medical Knowledge

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Read and expand clinically applicable knowledge base of the basic and clinical sciences	DPC, RMR, SR, MKSAP	AE, SR, RMR, , MKSAP
Access and critically evaluate medical information and scientific evidence relevant to patient care	DPC, RMR, SR, MKSAP	AE, SR, RMR, , MKSAP

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Read and expand clinically applicable knowledge base of the internal medicine specialties	DPC, RMR, SR, MKSAP	AE, SR, R MR, , MKSAP
Access and critically evaluate medical information and scientific evidence relevant to patient care	DPC, RMR, SR, MKSAP	AE, SR, RMR, , MKSAP
Teach medical students and interns	DPC, RMR, SR, MKSAP	AE, SR, RMR,, MKSAP
Read relevant articles and literature in journals	DPC, R MR, SR, MKSAP	AE, TR, SR, RMR, MKSAP

3.) Practice- Based Learning and Improvement

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Identify and acknowledge gaps in personal knowledge and skills	DPC, RMR, SR. PSQI	AE, SR, R MR, PSQI
Develop and implement strategies for filling gaps in knowledge and skills	DPC, RMR, SR, PSQI	AE, SR, RMR, PSQI
Accepts guidance from more experienced physicians and uses scientific evidence and practice outcomes for practice improvement.	DPC, RMR, SR, PSQI	AE, SR, RMR, PSQI
Readily acknowledges practice omissions (errors) determined by self or supervisors and takes corrective measures.	DPC, R MR, SR, PSQI	AE, TR, SR, RMR, PSQI

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Develop plans for practice improvement from feedback.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI
Reduces level/rate of practice omissions from PGY-1 level (errors).	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI
Improves efficiency of patient care (timelines) while maintaining quality and thoroughness.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI

4) Interpersonal Skills and Communication

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Communicate effectively with patients and families	DPC, RMR, SR	AE, SR, R MR,
Communicate effectively with physician colleagues at all levels	DPC, RMR, SR	AE, SR, RMR,
Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of patients	DPC, RMR, SR	AE, SR, RMR,
Present patient information clearly, in notes and during presentations	DPC, R MR, SR	AE, TR, SR, RMR

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Successfully communicate with patients and families in a group meeting	DPC, RMR, SR	AE, SR, R MR,
Supervise, lead, manage and teach more junior housestaff and medical students.	DPC, RMR, SR	AE, SR, RMR,
Present patient information concisely and clearly, verbally and in writing at an advanced level	DPC, RMR, SR	AE, SR, RMR,

5) Professionalism

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues while maintaining confidentially.	DPC, RMR, SR	AE, SR, R MR,
Always act in a moral, honest professional manner, and maintain appropriate relations with patients.	DPC, RMR, SR	AE, SR, RMR,
Respect and defend each patient's autonomy and privacy and always act in the patients' best interest	DPC, RMR, SR	AE, SR, RMR,

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Maintain a good record of attendance at conferences, completion of assignments, participation in clinical and didactic activities, prompt completion of dictations	DPC, RMR, SR	AE, SR, R MR,
Understand and apply principles of medical ethics toward patients, families, colleagues, and all members of the health care team	DPC, RMR, SR	AE, SR, RMR,

6) Systems-Based Practice

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Understand and utilize the multidisciplinary resources necessary to care ptimally for patients	DPC, RMR, SR	AE, SR, R MR,
Collaborate with other members of the health care team to assure comprehensive patient care	DPC, RMR, SR	AE, SR, RMR,
Use evidence-based, cost-conscious strategies in the care of patients	DPC, RMR, SR	AE, SR, RMR,

Procedures

Residents will learn, as appropriate to individual patients, the indications and contraindications and the performance of those medical procedures required by the American Board of Internal Medicine and Residency Review Committee (as detailed in the inpatient general medicine curriculum) and perform all procedures on patients under their care.

Reference List

*All residents are expected to read about their patients in an appropriate general medicine text. In addition, a vast variety of print and on-line reference material is available though the library (24-hour access for all residents) and the on-line portal. Because it is frequently updated, extensively referenced, and includes abstracts of reference articles, the program highly recommends UpToDate as an adjunctive information source. MDConsult is also a valuable resource and residents should become familiar with use as a rapid search engine for clinical information

References for the Night Admitting Team Rotation

1. Adams J, Murray R. The general approach to the difficult patient. Emergency Medicine Clinics of North America 1998; 16:689-99.
2. O'Keefe KP, Sanson TG. Elderly patients with altered mental status. Emergency Medicine Clinics of North America 1998; 4:701-15.
3. Jouriles NJ. Atypical chest pain. Emergency Medicine Clinics of North America 1998; 16:717-40.
4. Fuller GF. Falls in the elderly. American Family Physician 2000; 7:2159-68.
5. Managing falls in older people. Drug and Therapeutic Bulletin 2000; 38:68-72.
6. Mahoney J. Immobility and falls. Clinics in Geriatric Medicine 1998; 14:699-726.
7. DS Cheung, M Kharasch Evaluation of the patient with closed head trauma: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:9-23.
8. Cunningham R, Mikhail M. Management of patients with syncope and cardiac arrhythmias in an emergency department observation unit. Emergency Medicine Clinics of North America 2001; 19:105-21.
9. Meyer MD, Handler J. Evaluation of the patient with syncope: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:189-201.
10. Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:203-20. Night
11. Smith BJ: Treatment of status epilepticus. Neurology Clinics 1999; 19;347-69.
12. Michelson E, Hollrah S: Evaluation of the patient with shortness of breath: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:221- 37.
13. Pianka JD, Affronti J: Management principles of gastrointestinal bleeding. Primary Care: Clinics in Office Practice 1999; 28:239-61.
14. Peter DJ, Dougherty JM: Evaluation of the patient with gastrointestinal bleeding: An evidence based approach. Emergency Medicine Clinics of North America 1999; 17:239- 61.