PT INFO HPI PROB LIST MEDS PowerPoint Presentation, PPT - DocSlides

Slide1

PT INFO

HPI

PROB LIST

MEDSTo DoX CoverSmith, John Bob F14 1465AMR: 34520XXX56 yo male with shortness of breath for one week **Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8  2.5, likely pre-renalCefepime 1gm IV q12Colace 100mg po bidMetoprolol100mg bid---D/C Info---PMD Dr. Jones 444-2244[] f/u 7pm Na – increase IVF if Na <130[] check renal note

Safe & Effective Handoffs

Subha Airan-Javia

Penn Hospitalist Medicine

Slide2

It happened at a hospital you know…

9am rounds: 70 yo woman with DVT & h/o GI bleed

On heparin with 48 hours of very elevated ptts (>150)Altered mental status & low BP  CBC ordered1pm postcall signout: “f/u CBC

” No mention of elevated PTTs or concern for GI Bleed as potential cause of altered mental status and low BP3pm: Hgb = 4.0 Wasn’t believed, another hgb was sent, no transfusion5pm: Patient had melena, hypotension, transferred to the ICU. Repeat CBC confirmed Hgb of 4.Patient quickly coded and expired in ICU

Slide3

Think About it…

Did a poor handoff contribute to this patient outcome?Did this patients get the care that she expected from our hospital? How about the care that you and I expected?

Slide4

Fear of making a mistake and harming a patient

Natural fearYou will make errors; we all do

Did parts of the hospital system make the error easy to happen? If so, someone else needs to know (chief resident, program meeting, incident reporting system)Take care of yourself and each other

Slide5

Goals for Today

Get you ready to perform safe handoffs!

Review the importance of handoffsTeach the components of a good electronic and verbal handoffPractice handoffs in a simulated environment

Slide6

Facts

Discontinuity in the hospital is inevitable

Discontinuity is increasing in teaching hospitals due to duty hour regulationsLack of communication is the most common root cause of medical errors nationallyCommunication breakdowns during handoffs can have deleterious effects on our patients

Slide7

More Facts…Improving Handoffs is a National Patient Safety Goal (NPSG 2E)

Implement a standardized approach to “handoff” communications including an opportunity to ask and respond to questions

Slide8

Petersen, L. A. et. al. Ann Intern Med 1994;121:866-872

Being Covered by a cross-cover resident is a powerful risk factor for preventable adverse events.

Slide9

Bringing it closer to home…

ED Resident

Nightfloat JAR

Intern A - ShortcallOn Call Intern #1Intern A On Call Intern #2Intern A (now on Call)DayfloatDay 1Day 2Day 3Day 4Day 56 Residents, 7 Handoffs in 5 days

Slide10

Even more handoffs in the ICUs…

ED Resident

Primary On-Call team

Nightfloat DayfloatPrimary TeamNightfloatDay 1Day 2Day 34-5 Residents, 5 Handoffs in 48 hours

Slide11

A handoff example….

Location: Founders 14 nurses station

Time of Day: 12:30pm post-call

People: Two July interns who don’t really know each other yet.

Slide12

What did you notice?

Slide13

What did you notice?

Noisy environment

Multiple interruptions

Delivery is not standardizedNo time for questions, reiteration of plan

Slide14

Safe Handoff Practices

Slide15

Verbal Handoff Tips

Location: as quiet as possible (away from the nursing station, not in the ED)Minimize interruptionsStart patient over if unavoidable

If you are worried about the patient…say it first!Give on-call intern an opportunity to ask questions and repeat back important factsReview every patientFollow the same format/order for all patients

Slide16

Verbal Handoff Format

PROBLEM BASEDSick/Not Sick

Code status (if not full code)1-3 sentences historyPROBLEM LISTActive issues for eachRelevant Data and Meds

Crosscover listIf/then statements, anticipatory guidance

Slide17

Electronic Handoff: PurposeReference for primary team

Reference for covering provider

Repository of information

Discharge summaryA Novel

Slide18

Electronic handoff planProblem list  owned by Interns

Rest of handoff  primarily resident responsibility July – Jan

Interns should participate, edit what they can handleIncrease your share of handoff involvement

Slide19

Handoff Progress Note

Problem List50 Thousand foot view of problems with short assessment & overall plan

Important medications & radiology associated with problemsAntimicrobials, anticoagulation, immunosuppressants, NarcoticsConcise, bulleted

Slide20

Problem list≠ Assessment and plan

Slide21

Electronic Handoff Tips

Standardize: Keep info in designated locationExclude/Remove irrelevant information

Clean-up and update handoff regularly Avoid non-standard abbreviations MS: multiple sclerosis, mental status, or morphine sulfate? HL: Hyperlipidemia or Hodgkin’s Lymphoma?Summarize findings. Do not cut and paste results

Slide22

Electronic Handoff TipsProblem list should be complete, but concise

Should not be your entire progress note word for word This is the basis of your verbal handoff

Should be updated & reprioritized as new problems arise and old ones change

Slide23

SIGNOUT DISCHARGE SUMMARY

Slide24

And don’t forget…

The sign-out is a

TEAM documentRead by ALL disciplines in the hospitalUnprofessional language and statements should never be written

Slide25

Keys to a Good Handoff

The Nitty Gritty

Slide26

Approach to verbal handoff

Sick not sick

History, Hospital CourseObjective data

Upcoming plan, dispoTo do

Slide27

Approach to verbal handoff

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Diarrhea – possibly CDIff, cx pending

-Prostate ca – resected, cured

---PMH---

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

S

[H O U]

T

Slide28

Approach to verbal handoff

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Diarrhea – possibly CDIff, cx pending

-Prostate ca – resected, cured

---PMH---

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

S = SICK/NOT SICK

30 seconds

-Name

-Code Status

-Culture/Family

etc

Slide29

Approach to verbal handoff

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Diarrhea – possibly CDIff, cx pending

-Prostate ca – resected, cured

---PMH---

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

H = History

1-2 sentences (1 minute)

What brought the patient to the hospital

Similar to your ASSESSMENT statement on your A/P

Slide30

Approach to verbal handoff

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Diarrhea – possibly CDIff, cx pending

-Prostate ca – resected, cured

---PMH---

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

“

H O U

”

Active Problems, Hospital course, Objective data & Plan for each

MAIN AREA OF FOCUS

Slide31

Approach to verbal handoff

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Diarrhea – possibly CDIff, cx pending

-Prostate ca – resected, cured

---PMH---

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

T = To Do

SECOND

AREA OF FOCUS

-Go through

each

cross cover to do item, what needs to be done, rationale & action plan

-If/Then statements or other guidance

Slide32

Patient Information

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide33

Patient Information

Pt Info

Smith, John Bob

F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: DNR AAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Automatically imported from SCM

Slide34

Patient Information

Pt Info

Smith, John Bob

F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: DNR AAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Start with name & status: If you are worried about the patient, say it now - up front. Write it in the crosscover section.“John Smith is very sick” ; “I’m worried about Mrs Jones”Code Status: If not Full Code, always state this verbally. “He is DNR A”Access, Culture Limits, Precautions: mention if relevantContact information: Emergency contact for patient.“This family wants to be called with every change or new problem, even if in the middle of the night”; “No contact person has been located yet for this patient with dementia”

Slide35

History & Relevant Data

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide36

History & Relevant Data

HPI

Age, Gender

, CC short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA11/20 – desat last night, improved after diuresisDATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation MICRO:11/2 UA neg, Ur cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP floraAutomatically imported from SCM

Slide37

HPI

Age, Gender

, CC

short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA11/20 – desat last night, improved after diuresisDATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation MICRO:11/2 UA neg, Ur cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP floraHistory & Relevant DataHistory: State the chief complaint at first – once you know the diagnosis, you should UPDATE it. Short history. Admission vitals if they are relevant.“45 y/o female with abdominal pain”“89 y/o male with pneumonia.”Important Hospital Events: Mention things that could come up overnight“Desatted last night and responded to IV lasix”Data and Micro: Summarize findings, do not cut and paste results!!

Slide38

History & Relevant Data

HPI

45 y/o F w/ Shortness of breath

45yo female with history of multiple sclerosis, GERD, CAD, DM, hypothyroidism brought in by husband after 5 days h/o confusion, shortness of breath, and fever. Initial CXR negative, however CT from 11/16 showed pna suspicious for aspiration. ROS also notable for 10 pound weight loss, anorexia, and fatigue over past 6 months.Vitals on adm to ED: 100 140/80 30 88% RAGot lasix x 2 , Cefepime/Flagyl, and morphine in the ED. Duiresed in the ED to lasix through not thought to be volume overloaded by us.Also has UTI on levo, foley now outDATA:11/5 Chest CT: Heart, mediastinum, and great vessels are normal. There is mild emphysema throughout the lung fields, there is a left lower lobe consolidation new since prior CT from 1/06. Suspect aspiration MICRO:HPI45 y/o F w/ Pneumonia45 yo female admitted with shortness of breath and confusion: suspected aspiration pna. Also has 10 pound weight loss.Vitals on adm to ED: 100 140/80 30 88% RA11/18 – UTI diagnosed – now on Levo11/20 – desat last night, improved after diuresisDATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation MICRO:11/2 UA neg, Ur cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP floraToo Wordy…MUCH BETTER!

Slide39

History

HPI

Age, Gender

, CC short of breath CC: aspiration pnaPatient w/ shortness of breath for 1 week & 10 pound weight loss. Found to have lung mass & post obstructive pna.Vitals on adm to ED: 100 140/80 30 88% RA11/20 – desat last night, improved after diuresisDATA:11/3 CXR: LLL pna11/5 Chest CT: LLL consolidation MICRO:11/2 UA neg, Ur cx neg-final11/6,7,8,9 bld cx x2 ngtd11/9 sputum cx – normal OP flora

Slide40

Problem List

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide41

Problem List

Prob List

**Asp Pna – on cefepime, pox 98% 2L

**ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**Dementia-Ox1 but still able to converse and give a history---PMH----Prostate ca – resected, cured-hyperlipidemia-PTSD-chronic anemiaChronic Problems: place chronic or inactive problems at the bottom of the listList all Active Problems: Include salient points of plan and important results. “For aspiration pna – patient is on cefepime, 10 day course. He also has renal failure & hyponatremia – likely because of dehydration. Diarrhea is concerning for CDiff”Document Relevant Physical Exam Findings:“Mr S. has dementia but is able to converse well and can tell you if he is in pain”“Mr J has CHF, her lungs always have rales..”

Slide42

Info is nice to have, but too much! Makes the prob list too long to sort through in a rush

Summarize study in the Data section. Put relevance for day to day care here

Slide43

Combine related problems to save space

Slide44

Problem List

Mention things that on-call interns have been called about every night“This patient sundowns every evening…and here is the plan should it happen tonight…

”Review important exam findings and always think about including mental status “Mrs. J has severe asthma flare, lung exam is severe wheezing and little air movement on exam today”

“Mr S.has dementia and only oriented x 1, but always able to follow commands, tell you if he’s in pain, etc”

Slide45

Medications

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide46

Medications

MEDS

Cefepime 1gm IV q12

Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4Automatically imported from SCM

Slide47

MEDS

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4Medications Mention any important changes in meds:New meds, Discontinued meds, Dose Changes“For HTN he is on metoprolol, but we had to decrease his dose today because of bradycardia. So if he is hypertensive, I would use something else.” Important Meds Should Be Verbally Reviewed & Highlighted:Antimicrobials, Anticoagulants, Narcotics, Benzos“For pneumonia, patient is on cefepime, plus flagyl for possible CDiff, and warfarin for a low EF.”

Slide48

MEDS

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4MedicationsOther med info:Medications dosed by level, ordered daily, recent antibiotics, abnormal reactionsFor warfarin, use “warfarin dose daily” order

Slide49

D/C Info & To Do List

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide50

D/C Info & To Do List

To Do

---D/C Info---

PMD Dr. Jones 444-2244[] needs gi appt---To Do ---[] f/u xxx test[] check TEN panel weekly[] daily pulm noteD/C Info – Outpatient MD information, appointments to be made after discharge, any discharge related itemTo Do – Items for the primary team to do (today or later in the admission)Crosscover teams will look at this too

Slide51

Crosscover Items

Pt Info

HPI

Prob ListMEDSTo DoCrossCoverSmith, John Bob F14 1465AMR: 34520984DOB: 11/3/38DOA: 11/2/06Allergies: NKDACode: FULLAccess: RIJ 3L (11/4)Cx: >101.4Precautions: MRSAContact:Wife Mary 215-777-7777Age, Gender, CC (on DOA): short of breath CC (after dx): aspiration pnaRace, pertinent PMH, presentation to ED, HPI.-relevant ROS-relevant ED issues (vitals, meds given)-relevant things done o/n-important events during hospitalizaton11/20 – desat last night, improved after diuresisDATA:

11/3 CXR: LLL pna

11/5 Chest CT: LLL consolidation w/ air bronchograms, some LAD

MICRO:

11/2 UA neg, Ur cx neg-final

11/2,3,4,5 bld cx x2 neg-final

11/6 UA neg, cx neg-final

11/6,7,8,9 bld cx x2 ngtd

11/9 sputum cx – normal OP flora

**Asp Pna – on cefepime, still borderline

**ARF on CKD: Cr 0.8



2.5, likely 2/2 dehydration. Getting volume

**CAD – EF 10%, on coumadin for low EF

**DM – on insulin

**HTN

**Hyponatremia – likely 2/2 dehydration

**Diarrhea – possibly CDIff, cx pending

---PMH---

-Prostate ca – resected, cured

-hyperlipidemia

-PTSD

-chronic anemia

Cefepime 1gm IV q12

Colace 100mg po bid

Docusate 5mg po daily

Furosemide 20mg po daily

Metoprolol 50mg po bid

Metronidazole 500mg po bid

Warfarin 5mg po qHS

Diet: Cardiac, mech grnd, NS @ 150

---Other Med Info---

Flagyl 500mg q12 11/2-4

---D/C Info---

PMD Dr. Jones 444-2244

[] needs gi appt

---To Do ---

[] f/u xxx test

[] daily pulm note

[] f/u 7pm Na – increae IVF if Na <130

-if looks bad, consider fungal coverage

Slide52

Crosscover ItemsBE SPECIFIC

Check box for each task you need doneAvoid vague statements“try to keep an eye on…

”If you want vitals followed up on or something “eyeballed” – make a separate task for it

Slide53

Crosscover Items

CrossCover

[] f/u 7pm Na - If <130, then increase IVF to 150cc/hr

[]if any fever, delta MS, or low BP, then add vorizonazole***SICK***For Labs: give specifics“Follow up on the 7p Na – he has been hyponatremic and we think this is prerenal. Increase his IVF if Na is still lower than 130.”Write here if your patient is sick or if you are worried about the patientAnticipatory Guidance: use If…then statements“If he looks worse tonight (any fever, low BP, or called for confusion), evaluate him and add fungal coverage”

Slide54

Tips for Cross-Cover Items

Discuss each crosscover task to be done,

why it is being done (rationale), and what to do based on results (anticipatory guidance).Anticipate overnight clinical scenarios, and give the cross-cover intern guidance on what to do if they occur…If/Then statements

If the patient has a fever >101.5, then draw blood cultures and consider starting vancomycin. We are worried about a line infection

Slide55

Give specific lab & parameters:

[] 1800 Hg – if <7, trf 2u PRBC

Give recs for meds to use:

-if not, t/c 80mg IV lasixGive antibiotic preferences to start

Slide56

What are you looking for?

Slide57

Don’t get “locked in

” (anchoring bias)

Remember if/then statements are for guidanceYou should still always: EVALUATE the patient firstThen CONSIDER what they have recommended on the sign-out. Independent thought is what you get paid the big bucks for!

Slide58

Don’t feel bad!!

We are all on the same teamYou will be doing the same thing for your colleague when you are on callBe clear about what needs to be done

Avoid phrases like “If you can…”Only signout out things that need to get done overnight

Slide59

Responsibility of the Receiver

Slide60

Responsibility of the ReceiverREADBACK & RECAP

 Reiterate important parts of the plan

Take notes as you goYou will pay attention to these notes later in the night

Slide61

Responsibility of the Receiver

Be gently assertive!Suggest a quiet place, suggest to sit down, if the “giver

” of the signout does not.Do not be afraid to ask them to slow downSimilarly, do not let the receiver RUSH You!Don’t be afraid to ask them to pay attention!Do not be afraid to ask questions or repeat

If you are uncomfortable with a plan of care that is signed-out to you, get both of your residents involved.

Slide62

Responsibility of the Receiver

Eyeball sick patients early in the eveningGet a baseline for their clinical status

Write down all events overnight to relay the next morning

Slide63

Responsibility of the Receiver

MEDS

Cefepime 1gm IV q12

Colace 100mg po bidDocusate 5mg po dailyFurosemide 20mg po dailyMetoprolol 50mg po bidMetronidazole 500mg po bidMorphine SR 30mg po bidWarfarin 5mg po qHSDiet: Cardiac, mech grnd, NS @ 150---Other Med Info---Flagyl 500mg q12 11/2-4Prob List**Asp Pna – on cefepime, still borderline**ARF on CKD: Cr 0.8  2.5, likely 2/2 dehydration. Getting volume**CAD – EF 10%, on coumadin for low EF**DM – on insulin**HTN**Hyponatremia – likely 2/2 dehydration**Diarrhea – possibly CDIff, Circle or Highlight important issues on the sign-out. For Medications: Consider highlighting pressors, antibiotics, anticoagulants, narcotics

Slide64

Morning Handoff When on CallEvery call, or order placed should be verbally reviewed

Write down all calls/issues/orders placed on handoff while on call to serve as a visual reminder the next morning

IMPORTANT: any changes in medications or clinical status, new or pending results

Slide65

When to update?

As frequently as possibleLess to do at the end of the day

Busy days:Take notes on signoutUpdate at the end of the dayIf cant get to it all, update the most important info, and keep notes to update the next day

Slide66

Summary of “Best Practices”

in Handoffs

Quiet LocationMinimize InterruptionsProblem based verbal handoffStandardize both written and verbal format as much as possibleUse anticipatory guidance

Make time for questions and clarifications

Slide67

PRIVACY

Handoffs contain many patient identifiers!

Do NOT leave the hospital with themDo NOT leave them on tables, counters or anywhere other than your handsOld signouts should be placed in locked containers for shredding

Slide68

Questions?