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For Prospective Residents

PGYIII - IPS Day, Night and RIC-IPS
Santa Monica-UCLA Medical Center

Goals

The purpose of this rotation is to provide residents with the knowledge and skills necessary to care for patients admitted to a community hospital with common medical problems. The resident will learn about the diagnosis and management of specific disease processes, improve their procedural skills and will also become familiar with the social, economic, and ethical issues unique to the practice of inpatient medicine. In addition, the resident will gain the experience necessary to determine appropriate disposition for patients discharged from the hospital.  Lastly, the resident on the IPS rotations will learn how to supervise and instruct junior residents in the care of the patient on the service.

Objectives

Residents will:

Patient Care and Medical Knowledge

1. Be able to perform a history and physical examination on all patients
2. Be able to develop a problem list, assessment and plan for all patients
3. Be able to order and interpret appropriate studies for each patient
4. Be able to assess and provide care for the wide scope of inpatient medicine seen on the Family Medicine In-Patient Service
1. Adult medical patients
2. Obstetrical patients
3. Pediatric patients
4. Surgical patients
5. Critically ill patients
6. Newborn patients
7. Psychiatric patients
8. Geriatric patients
5. Be able to perform basic Family Medicine procedures
   1. Intubations
   2. Central line placement
   3. Transcutaneous pacemaker placement
   4. Cardiac defibrillation
   5. Arterial line placement
   6. Arterial blood gas
   7. Lumbar puncture
6. Be able to discuss with patients end of life care
1. Decision making by patient or designee
2. Code status
3. Medical futility
7. Be able to coordinate care of patients using other members of the health care team
1. Social workers
2. Discharge planners
3. Physical and occupational therapists
4. Case manager
5. Home health
6. Palliative care
7. Appropriate consultats
8. Recognize and treat psychiatric issues in hospitalized patients
9. Obtain appropriate consultations from specialists and maintain clear communication with consultants
10. Be able to consent patients for procedures performed in the continuity health center
11. Be able to perform procedures offered at their continuity health center
12. Be able to utilize the skills and expertise obtained from outside rotations to provide exemplary medical care to the Family Medicine patient
13. Be able to discern proper disposition of patients, with appropriate medication and follow-up
14. Be able to adequately supervise junior residents and medical students in the care of the patient on the Family Medicine In-Patient Service

Practice Based Learning-Improvement

1. Integrate the medical aspect of disease into the context of each individual patient taking multiple factors into account
   1. Socio-economic
   2. Emotional
   3. Ethical
   4. Religious
   5. Occupational
   6. Environmental
   7. Medico-legal
   8. Behavioral
2. Be able to use the internet to access current literature about diseases experienced on the Family Medicine In-Patient Service
3. Be able to critically evaluate literature about current medical treatment of diseases experienced on the Family Medicine In-Patient Service
4. Be able to work well in the context of the Family Medicine In-Patient Team
5. Be able to be an active participant in rounds
6. Be able to work with residents, fellows and attending physicians in all areas of practice
7. Be able to implement changes in patient care based on new information obtained from Attending Rounds, clinical experience, review of the literature and other sources
8. Be able to assist the junior resident and medical student in their growth in the medical profession

Interpersonal Communication Skills

1. Communicate effectively with patients
1. Able to communicate in a manner in which the patient and the family of a patient with a medical condition requiring hospitalization can understand
1. Acute problem that hospitalized the patient
2. Chronic medical conditions the patient may have
3. Treatment plan
4. Prognosis
2. Able to listen to and address the concerns of patients and their families
2. Communicate effectively with colleagues
   1. Able to work efficiently in the context of a Medical Team in a community hospital
   2. Able to clearly communicate patient sign – out, both when giving and receiving sign – out
   3. Able to work efficiently with the support staff in the care of the hospitalized medical patient
   4. Able to provide feedback and instruction to junior residents and medical students

Professionalism

1. Demonstrate cultural competency
2. Demonstrate the ability to act in the best interests of the patients
   1. Respect for confidentiality
   2. Respect for patient autonomy
3. Be professional in all aspects of patient care
   1. Accepts personal responsibility for patients
   2. Accepts feedback in all aspects of care, including the six core competencies
   3. Timeliness
   4. Appropriate attire

Systems – Based Practice

1. Demonstrate understanding of the care of the variety of patients seen on a Family Medicine Team in the context of the current health care system in a community hospital
2. Coordinate care with ancillary services to improve the healthcare of the patient
3. Assist patients in dealing with their acute illness and any underlying chronic diseases they may have
4. Understand and able to utilize the alternatives to acute hospitalization
   1. Home infusion therapy
   2. Subacute nursing facility
   3. Acute rehabilitation facility
   4. Chronic care facility
   5. Hospice

                                               i.     Inpatient

                                              ii.     Outpatient, including home hospice

A word from your Program Directors regarding the Family Medicine In – Patient Service:

From working with fellows and attending physicians in all areas of practice, residents are expected to learn to integrate the medical aspects of disease with the socio-economic, emotional, ethical, religious, occupational, environmental, medico-legal, and behavioral aspects of disease and disease prevention.

On a personal level, the resident will learn the boundaries of personal responsibility, the skills needed to function effectively as a member of a health-care team and to incorporate quality improvement, risk management, and cost effectiveness into the decision-making process. The resident is strongly encouraged to observe the attending physicians for the qualities that make for effective leadership

Begin the road to becoming an educator.  Residents and interns have significant responsibilities for teaching medical students while on service. Many months sub-interns are also on service.  Teaching is a major component of these months.

 

Logistics:

Contacts:

Denise Sur, M.D.	Chief Resident
Director, Residency Program	Babak Ettekal, MD	p22367
(310) 319-4709, #1	Keyvan Hariri, MD	p22370
p19691	Gus Kalioundji, MD	p22371
	Gideon Kwok, MD	p22372
	(310) 319-4709 #1

 

Location:            Santa Monica – UCLA Medical Center

 

*** Page the senior resident (name is listed on the monthly assignment sheet) to determine the reporting location and time for the first day of the rotation.  You should also receive the name of the junior resident from whom you will receive your patient sign out***

 

Continuity Clinic

IPS  Day	2 clinics per week	Monday and Friday afternoon
IPS Night	2 clinics per two weeks	All day on the first Thursday of the rotation
RIC-IPS	Up to 7 clinics per week	Every half-day except for Monday and Friday afternoon

 

Call Schedule

IPS  Day	No overnight call
IPS Night	All night shifts – no overnight call
RIC-IPS	Overnight call on Saturday Night

 

Hours:

IPS Day	Sunday to Friday 7am to 7pm *
IPS Night	Sunday to Friday 7pm to 7am **
RIC-IPS	Monday to Friday 8am to 5pm***
	Saturday 7am to Sunday 7am

*- On Monday and Friday responsibilities end at 5pm, the RIC-IPS senior covers until 7

**- On the first Thursday, responsibilities run from 8am to 7am (23 hours)

***- On Monday and Friday pm, the RIC-IPS resident is in the hospital covering the service until 7pm

 

Educational Half – Day – You are expected to attend as much of EHD as possible each week.  You are excused for patient care responsibilities.

 

Additional Information – If you have any questions or concerns about your duties or responsibilities, please discuss this with your Chief Resident.  See next page for the Guidelines for IPS, including duties and responsibilities.

 

Note – The rotations differ in length.  The RIC-IPS and the IPS Day rotations are 4 weeks long, and the IPS Night rotation is 2 weeks long.
IPS  Guidelines, (Revised July 11, 2004)

 

Weekdays

0630 – 0730:            Senior/juniors receive sign-out from post-call residents.

                        Preround, get nursing input and take care of urgent patient issues.

0730 – 0815:            Educational rounds with community attending (case presentations, lectures, etc). Community attendings will be present on 3-4 days per week.  This time will also include psycho-social rounds, community CME lectures, and radiology rounds.

0815 – 0830:            Card flip with senior resident. Discuss urgent issues and potential DC’s. 

0830 – 1000:            Time to work. Call community attendings to review plan, take care of discharges, etc.

1000 – 1030:            IPS rounds:  Present case and run board with senior and IPS attending.

1030 – 1200:            Work

1200 – 1300:            Sign out to on-call team if going to afternoon clinic or post-call.

1900:                         Senior NF arrives, gets signout from day Senior.

ER-SM R1 holds a code pager when in house

 

Weekends/Holidays

0800:            Juniors and seniors sign out together. Informal resident rounds

TBA:            Informal attending rounds with on-call team; time determined by individual attendings.

 

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.

At least 1 in 7 days will be off. 

There must be at least 10 hours off for each resident between shifts.

 

Phone Numbers and Pagers

R1 call room (2105 H): x94601                        ER-R1 numeric pager: 310-737-5325

R2 call room: (2105 G ): x94466                        IPS Jr numeric pager: 310-737-5393

R3 call room:  (2105 F ): x94352                        IPS Sr numeric pager: 310-737-5310

Lounge (2105 B): x94565                                    7^th floor conf room x 93244

 

Summary of Duties

Attending on IPS Service

• Provide teaching and serve as a resource for all Service patients.
• Round daily with the IPS team, either in person or by phone, to review patient treatment plans.
• Be available by pager or phone 24 hours daily for urgent issues or admissions.
• All admissions must be approved by your attending physician, including patients transferred from other facilities

 

Residents on IPS Service

• Overall goal is for the Senior to be supervisory and called whenever things get too busy for Junior.
• Teamwork is key, at the first sign of a problem, let the Chief Resident know.
• When in doubt, patient care comes first.
• Your second priority is education.

 

Specific Duties

Post Call Junior

• Finish work and sign-out to on call junior before 30 hour work limit.
• No new patients may be accepted after 24 hours of call. 
• Residents may remain on duty for up to six additional hours to participate in didactic activities and the transfer care of patients.

 

Post-Post Call Junior

• Help the post call junior so they can leave by 12 – 1pm.
• Help team round on weekends.
• Finish work on own patients.
• Assist in any other duties that need to be done and sign-out to on-call junior w/ senior’s knowledge.
• Continuity clinic in pm.

 

Pre-Call Junior

• Help the other juniors.
• Help team round on weekends.
• Finish work on own patients.

• May be in pm clinic or day off.

 

IPS Junior on call

1) Patient Care

• Call starts at same time every day so that there is an On Call Junior in house at all times who is able to take admissions.
• Admissions:

• Les Kelley, including scheduled surgery patients who had pre-op at LKC
• Community
  • Politely decline community admits if cap filled
  • Provide a list with attending names to Senior so that an apology letter can be sent.
• Peds admits after 5 pm M-F, after Peds intern leaves on Sat or for cont clinic, all day Sun
  • Peds admits before 5 will be taken by the intern on SM-peds rotation (can be called in from Dr. Sachs office if admit before 4:30pm).
• Cap
  • Rough guideline is 5 admits per 24 hour shift
  • No strict cap on admits because no limit on LKC and Peds admits
  • Senior on call to determine cap based on other activity in house

• Codes blues:

• With senior.
• Do procedures.
• May run code at discretion of senior on call.

• Obstetrics:

• LKC OB’s:
  • Antenatal testing (NST, AFI, BPP)
  • L&D triage
  • Admissions
  • Labor management
  • Call primary resident and notify FP attending and OB backup attending.
    • PMD expected to come in and manage patient unless not permitted by schedule.
• Panel OB’s (pt’s w/out primary OB):  Check monthly OB calendar for the specific days we are covering Panel OB – generally first half of the month.
  • L&D triage
  • Precipitous delivery
  • Admission
  • Labor management.
  • Call senior on-call, and OB backup attending.
• C-Section assists
• Standby deliveries (until community attending arrives)

• Cross-cover:

• IPS cross-cover issues.
  • Make sure to write brief SOAP note
  • Update sign-out.
• Urgent cross cover issue for non-IPS patients.
  • When ER resident not in house.
  • Includes falls, CP, SOB, tele events, transfers.
  • Make sure to write brief cross-cover note. 
  • Notify PMD if actions are taken. 
  • PMD expected to follow up on tests ordered or to come in and manage patient if issue needs prolonged attention.

• Death Pronouncements:

• Brief note required. 
• Ask nurses to notify PMD and family.

• Transport pts to WW: 

• Only if there are more than 2 residents around. 
• Pt must be stable for transport.

• Procedures:

• Teaching service procedures (lines, intubations, etc.)

• Following requests are optional but please do if possible:

• Placement of Dobhoffs
• D/C central lines (unless pt is decompensating)
• CXR reads (refer to UCLA night hawk—beeper 97612 inpt, 93580 ER)

2) Administrative

• Dictations: 

• All H/P’s and D/C summaries must be dictated within 24 hrs
• Electronic copy must be sent to the attending.

• Sign-out:

• Must be done in person – not over the phone or by leaving paper signout.
• Updated daily and given to on-call Junior. 
• Please give copy also to on-call Senior.

 

IPS Senior

R3 IPS-Day:  continuity clinics Mon pm and Fri pm

Sun	Mon	Tue	Wed	Thur	Fri	Sat
7a-7p	7a-1p (or when RIC-IPS arrives)	7a-7p	7a-7p incl EHD	7a-7p	7a-1p (or when RIC-IPS arrives)
	1p-5p clinic				1p-5p clinic

 

R3 IPS-Night:  continuity clinics on first Thursday of 2 week block am and pm

Sun	Mon	Tue	Wed	Thur	Fri	Sat
				(am and pm clinic 1st wk)
7p-7a	7p-7a	7p-7a	7p-7a	7p-7a	7p-7a

 

R3:  RIC-IPS:  all clinic except for IPS coverage Mon pm, Fri pm, and Sat

Sun	Mon	Tue	Wed	Thurs	Fri	Sat
	8-12p clinic	8-12p clinic	EHD	8-12p clinic	8-12p clinic	7a-7a 24 hr call
	12-7p IPS	1p-5p clinic	1p-5p clinic	1p-5p clinic	12-7p IPS

 

1) Patient Care

• LKC admissions
  • Supervising and writing brief admit note in addition to note by IPS Jr on call.

• Briefly rounding on LKC patients daily

o      Including checking vitals, labs, studies, pertinent PE, checking/cosigning thejr resident's note, checking juniors’ orders, and making sure discharges are done in advance of 10 am rounds.

• Codes:

o      Run all codes until junior on call comfortable to take the lead.

• Approving transfers from outside hospitals:

o      Discuss with attending first to make sure medical indication is appropriate and discuss pt stability.

o      Then call bed control (Betty Mizuba 319-4577 M-F 8 to 5) or nursing supervisor (319-4745 or UCLA pager 92651) to check insurance is OK and can assign a bed.

• LKC patient phone calls from 1700-0800.

o      Includes patient calls, nursing home calls, and authorization to treat or transfer requests.

o      If patient needs urgent follow-up, e-mail Name, MR#, phone #, and request to sameday@mednet.ucla.edu. 

• CT Contrast dye standby for anaphylactic reactions.

2) Managing the IPS service

• Running rounds from 10-10:30 with the LKC attending of the week. 

o      All LKC pts will be discussed daily

o      Private patients are not the priority during this time, though senior can decide if and how to incorporate them into rounds.

• Signout in person to the senior taking over at 7 am/pm.

3) Teaching

• Early during the block
  • Contact morning report speakers to confirm.
  • Schedule replacement speakers prn.
• Near end of block
  • Review speaker list for the next incoming day senior.

4) Supervise the IPS Juniors

• Establish expectations for the team on day 1 of the service.
• Ensure that juniors are prerounding, showing up to am report and IPS rounds on time, and in general performing adequately. 

o      If not, handle the situation as the senior sees fit. 

• If attempts to address situation are unsuccessful, approach attending, chief resident, program directors.
• Be present when juniors sign out.
• Watch out for the health and well being of junior residents.

Santa Monica ER Resident  - is loosely affiliated with the IPS team when in the Emergency Room.  The Resident in the Emergency Rooms primary responsibility is to see patients in the Emergency Room.  They also are involved in emergent issues in the hospital which include:

Codes

• with IPS Junior and Senior
• Carry code pager whenever on duty in ER
• Procedures during code

 

Urgent cross-covers

• Including falls out of bed, SOB, CP.
• Consult IPS Senior prn.
• Write brief cross-cover SOAP note. 
• Notify PMD of actions taken. PMD to follow up on tests ordered. 
• Excludes patients on General Surgery/Vascular service, since there are UCLA surgery residents that cover this service. 

 

Non-urgent cross-cover

• Assist on Cesarean sections if requested by IPS team.
• Death pronouncements if requested by IPS team. 
  • Write a brief Death note.
• Push IV medications at night if requested by IPS team.
• Transport patients if requested by IPS team.

 

Codes 

 (Always hand code pager to another resident, never leave it anywhere. Hand off in person).

1. If 2 residents in house, on-call Senior runs code, on-call junior does procedures.
2. If 3 residents in house, on-call senior supervises code, on-call junior runs code, third resident does procedures.

Note:  We are responsible for all codes in the hospital even on patients on other resident services (i.e. Geri, surgery).  If you arrive and a medicine resident is running the code please make yourself available to help.