1

INTERNAL MEDICINE TEACHING SERVICESt. Luke's Medical Center - Milwaukee, Wisconsin

Curriculum Document

Welcome to St. Luke's Medical Center and the Internal Medicine Teaching Service (IMTS). The IMTS faculty hope your experience is educational and rewarding, and that it will facilitate your understanding of hospital-based Internal Medicine.

This document will provide an overview of St. Luke's and the IMTS, so you know what to expect, and what the faculty and staff expects from you. Please read this before beginning the rotation. If there are any questions regarding the rotation please contact the Program Coordinator, Karen Wise-Acker, by phone at (414) 649-3323, or email at: karen.wise-acker@aurora.org

The IMTS Faculty and Offices:The faculty office is located in the Professional Office Building, Suite 730, 2801 W. K.K. River Pkwy

Richard Battiola, M.D., Pager # 1953, Ph# (414) 649-3323; e-mail: richard.battiola@aurora.org

Aijaz Noor, M.D. Pager # 6266, Ph# (414) 649-3323; email: aijaz.noor@aurora.org

Colleen.Nichols, M.D. Pager # 3362, Ph # (414) 649-3323; email: colleen.nichols@aurora.org

When & where to report on the first day of service: 07:00, 9th floor Center Building Conference Room

Rationale:Ward-based Internal Medicine provides an opportunity to develop a wide range of important knowledge and skills, and to meet a number of educational goals, including: exposure to a wide variety of acute in-patient adult medical problems; To enhance understanding of the pathophysiology of various diseases, improve the ability to identify and differentiate disorders, and to formulate appropriate diagnostic and therapeutic plans; To develop strong communication and interpersonal skills during interactions with physicians, ancillary staff, patients and family; To understand principles of cost effective care, systems-based practice, and care management; To gain experience working with diverse medical diseases, socioeconomic status, and cultural and ethnic backgrounds. These goals are met through the integration of direct patient care experiences under the supervision of faculty; and didactic learning, provided through lectures, conferences, and teaching rounds.

Goals and Objectives:To comply with the Accreditation Council for Graduate Medical Education (ACGME) requirements, the following specific competency-based goals and objectives have been established for this rotation

1.) Medical Knowledge:a. Demonstrate a working knowledge re: the epidemiology, natural history, pathophysiology, presenting symptoms,

physical exam findings, laboratory imaging, and other diagnostic findings, treatment options and outcomes associated with the most common and important disorders in patients admitted to a general medical ward service. Such disorders include, but are not limited to:

Acute infections, including pulmonary infections (pneumonia, bronchitis); skin, soft tissue, bone and joint infections; GU and GI infections, CNS, blood borne infections, sepsis/septic shock, and HIV-related disease.

Acute cardiovascular disease states, including CHF, acute coronary syndrome and chest pain syndromes, common arrythmias (e.g. atrial fibrillation), syncope, ischemic and hemorrhagic stroke; hypertensive emergencies, acute peripheral vascular disease, venous thromboembolic disease.

Acute pulmonary disease, including exacerbations of COPD, asthma, interstitial lung disease, acute respiratory failure, pulmonary hypertension, pleural effusions, and pleural-pulmonary disease.

2

Endocrine disorders, including complications of diabetes mellitus (DKA, non-ketotic hyperosmolar states), adrenal insufficiency, disorders of calcium homeostasis, dyslipidemias, and thyroidal illness.

Renal disease, including acute and chronic renal failure, nephrolithiasis, acid-base, electrolyte, and volume disorders.

Gastrointestinal disease, including acute GI bleeding, diahreal states, peptic ulcer disease, pancreatitis, hepatobiliary and hepatocellular disease, and malabsortive disorders.

Acute hematologic disease, including hemorrhagic disorders, coagulopathies, hypercoaguable states, acute anemia and thrombocytopenia, and hematologic malignancies.

Oncologic disease, including pulmonary, GI, GU, CNS, and other common malignancies.

Acute neurologic, psychiatric and addiction-related illness, including seizure disorders, depression, acute psychosis, altered mental status and coma, alcohol and illicit drug abuse, toxicity and withdrawal states.

2.) Patient Care:a. Be able gather and document accurate and essential information re: patients, through patient and family history, and

review of prior and current patient data bases.

b. Be able to perform a competent physical examination on patients admitted with acute medical problems.

c. Be able to develop appropriate differential diagnoses and diagnostic plans, based on disease likelihood, test characteristics (e.g. sensitivity, specificity), costs, and appraisal of risk vs. benefits involved.

d. Be able to develop, monitor, and modify management plans based on knowledge of disease and treatment options, known and potential complications, treatment outcomes, and patient utilities/wishes.

e. Be aware of the common hospital-acquired and iatrogenic complications patients are at risk for; be able to take appropriate measures to prevent, monitor for, and treat these complications when they occur. Such complications include but are not limited to: vascular access site bleeding and infections; drug-drug interactions; stress-induced GI bleeding and hyperglycemia; ventilator associated pneumonia; IV contrast and drug-induced acute renal insufficiency; pressure sores; procedure induced complications (e.g. pneumothorax, pancreatitis, foley-catheter associated UTI), insulin-induced hypoglycemia, medication errors.

f. Be able to perform common in-hospital procedures in an effective, safe and humane way. Such procedures include: IV and arterial line placement; endotracheal intubation; ACLS; lumbar puncture, thoracentesis.

g. Be able to manage an appropriate number of patients concurrently in a well organized, time-efficient & effective way.

h. Be able to recognize the need for appropriate assistance and consultation with physician and other health care staff to optimize patient care and outcomes.

3.) Practice-based learning and improvement:a. Be able to locate, appraise, and assimilate evidence from scientific studies, as published in peer-reviewed publications,

related to patients’ health problems.

b. Be able to apply principals of evidence-based medicine, including study design, test characteristics, statistical methods, etc. to appraise clinical studies and determine their applicability to and effectiveness in specific direct patient care plans.

c. Use information technology to manage information and access on-line medical information, to both enhance resident education and improve patient care.

d. Be able to systematically and honestly review and reflect one’s own performance and patient care outcomes in an attempt to better understand and improve subsequent patient care practices.

3

e. Facilitate the learning of students, other residents, and other health care professionals through reflection and constructive feedback re: direct patient care and educational experiences during the rotation.

4.) Systems-based Practice:a. To develop an awareness of all of the system resources within the hospital and health care system available in patient

care, and to become proficient in utilizing these resources to enhance patient care. This includes social services, rehabilitative care staff, financial aid staff and resources, educational resources, and others.

b. To be able to utilize, and to effectively communicate and work with physician consultants in the coordinated care of patients, including a delineation of patient care responsibilities and determination of the ultimate decision maker in patient care.

c. To be an effective member of the larger health care team through appropriate and timely communication and coordination of care with all other members.

d. To understand the principals of systems-based care, and be able to practice these principals in direct patient care, such as through the use of standardized order sets, and specific patient-care protocols (e.g. stroke protocol, ACS, community-acquired pneumonia protocol).

e. Recognize and assume the role of patient care advocate, and assist patients in understanding and dealing with system complexities.

5.) Professionalism:a. To consistently demonstrate respect, compassion, and integrity to patient and family members through both actions

and words as an important member of the health care team.

b. Recognize and assume the important role of patient care advocate, including the responsibility of understanding and providing care that is consistent with patient utilities and wishes.

c. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

d. Demonstrate an understanding of and commitment to ethical principals in the patient care setting.

e. In addition to the role of patient care provider, assume the dual role of teacher and learner, and maximize the educational experience for oneself and other team members.

6.) Interpersonal and Communication skills:a. Be able to consistently and effectively communicate patient care information, including findings, impressions and

plans, with patients, families, physician staff, and other members of the health care team.

b. Be able to provide effective, concise, and timely documentation of patient care through progress notes and dictated H&Ps, discharge summaries.

c. Create and maintain a therapeutic and ethically sound line of communication with patients and family.

d. Communicate and work effectively with non-staff physician members of the health care team, during such activities as cross coverage, pager call, multidisciplinary rounds, etc.

e. Be able to effectively present and communicate cases and team impression and plans during more formal teaching conferences and rounds.

4

A. Direct Patient Care Experience:

IMTS Structure:The IMTS consists of 4 teams: Green, Yellow, Orange, and Red. Teams include the following members:

IM Teaching Attending Senior IM Resident 2 Interns (Transitional Year and/or Internal Medicine)+/- UW or MCW M4 Student (“acting intern”)+/- MCW M3 student+/- PA Student and/or Pharmacy student

Family Medicine Teaching Service (Purple Team): In addition to the IMTS, the hospital also supports a Family Medicine Teaching Service (FMTS). Although independent from each other, these services participate in a common “Morning Report” and other conferences.

Team Member Roles and Responsibilities:

Teaching Attending Physician:Each team is assigned a " teaching attending", whose responsibilities include: supervising direct patient care on "house-case" admissions (see below); acting as a mentor and educational facilitator in didactics; and providing timely, appropriate evaluation and feedback of housestaff performance.

Senior Internal Medicine Resident:Senior residents are the team leaders and managers. Responsibilities include: maintaining an active role in all patient management; supervising team members in patient care, being available at all times to answer questions and provide direction; communicating effectively with faculty and private attendings; teaching, evaluating, and providing timely feedback to team members; organizing daily rounds, days off, and distribution of admissions. They must also be the primary overseer of medical students, reviewing history and physicals, critiquing and countersigning all notes and orders.

Interns (Transitional Year or Internal Medicine):Interns are to involve themselves as much as possible in the direct care of assigned patients: performing and dictating the initial H&Ps; making the first impressions and diagnoses; writing orders and daily progress notes; and being as involved in daily management decisions. They are responsible for learning about patient problems and disease processes, and sharing their knowledge with team members. They are expected to accept direction and feedback from residents and staff, and to seek supervision when necessary.

Senior Medical Students:Senior students function as “acting interns”, with the same roles and responsibilities as the team interns. Any references to “intern” in this document will apply to the senior medical students as well. They are to be supervised directly by the senior resident, rather than by the interns. Like interns they will share equally with interns in the distribution of patient admissions. They are to be provided opportunities to manage all patient types.

Junior Medical Students (JMS):Junior medical students will be assigned to follow 1-2 patient admissions per call day, working under the supervision of an intern assigned to the patient, and the senior resident. Junior students will not dictate, but will write admission and daily progress notes, which need to be countersigned by the supervising intern. The JMS is not required to remain in-house overnight on call days.

Physician Assistant (PA) Students:The PA students’ role is similar to the junior students’. They will work under the direct supervision of an intern in the care of assigned patients.

5

Pharmacy Students and Residents:Most pharmacy students are in their final year of school doing their clinical rotations. Some are licensed pharmacists that are pursuing the Pharm D degree through a nontraditional program. Students are expected to be on-site and available by pager from 7:30 am to 4:00 pm. They will act as full team members, attend Morning Report, participate in daily team rounds, monitor and make recommendations for optimization of drug therapy, answer drug information questions. They will also provide a Pharmacy-related formal presentation to the IMTS during one Morning Report per month.

Pharmacy residents are employees of Aurora Health Care and licensed pharmacists. Expectations are the same as for pharmacy students. Since pharmacy residents are licensed, they are able to take and write verbal orders but are not expected to do so during their rotation.

Work Hours, Work Load, and Patient Care Responsibilities:

In order to achieve the goal of providing meaningful, educational, well supervised patient care, housestaff must be available to patients, attendings, and ancillary staff, and continuity of care must be established. It is recognized that excessive work hours can lead to undue fatigue, compromising education and patient care. To accommodate these issues and to comply with the ACGME requirements, work-load, hours, and patient care responsibilities are as follows:

1. Four teams will rotate call every fourth day. All physician staff members of the departments of Internal Medicine (including all I. M. subspecialties and Neurology) may voluntarily admit patients to the on-call team. Patients from the SLMC Family Practice faculty and resident clinics are admitted to the Family Medicine Teaching Service (Purple Team).

2. Call is from 0700 to 0700. The on-call team with the help of the night-intern is responsible for admissions, emergencies, code fours, and cross-coverage for the 24 hour period. The senior resident will be in house for the full 24 hour call period and remain an additional 4 hours the following day to supervise patient care. They are expected to leave the hospital by 11:00 am in order to comply with the ACGME work hour limit. The two on call interns will begin on call responsibilities at 0700 on their on-call day. They are expected to sign out their patients to the night-intern sometime between 2000 and 2100 and leave the hospital at 2100. They will return to the hospital by 0700 their post-call day at which time the senior resident, the two returning interns and the night-intern will meet to transition the care of any admissions that occurred between 2100 and 0700. The two post-call interns are then allowed to remain in house a full work day in order to complete their work. Once their patient care responsibilities have been completed, they are allowed to leave the hospital but must continue to cover their patients by phone until 2100. Their pager status should be changed to “out on-page”. Post call interns are excused from morning report if they are rounding with their attending or need to attend to urgent patient care issues/discharges but they are expected to attend noon conference.

3. The responsibility of the night-intern will be shared amongst the pool of interns assigned to IMTS for the month. The schedule for the night intern is as follows: They are expected to be at the hospital at 2000. Between 2000 and 2100 they will take sign-out from the other interns assigned to IMTS that month. They are to page each of the day interns, including the two on call for the day and discuss the patients in need of coverage. At 2100 they assume all cross-cover responsibilities and their peers are expected to change their pager status to “out not available”. They will carry a code pager as well. They are allowed to attend and participate in all codes but are required to attend only when 2 codes are called consecutively (within 45 minutes of each other-see code 4 section).In addition they will be responsible for admitting as many as 5 new patients or until the team has reached its cap of 10. At 0700 the following morning they will meet with the senior resident of the team as well as the two day interns of that team to hand-off any night time admissions. They are then free to go home until 2000 that evening when they are expected to return for another shift. The night intern is expected to work 3 consecutive nights (Green, Red, Orange team call nights) followed by a full 37 hours off (yellow team call night off) and then 3 consecutive nights followed by 24 hours off. Day 9 of the cycle they will come in at 0700 at which time they will be assigned to a team and will assume the role of a “day” intern.

4. All IMTS housestaff are to be in the hospital by 7:00 am weekdays and 8:00 am weekends (unless you are on call and then they need to be there by 7:00 am). Housestaff are only allowed to leave the hospital

6

after they have completed all patient care responsibilities and attending all formal didactic sessions including morning report and the weekday noon-hour conference. Your pager status should always reflect your current status ie “in on page”, “out on page” or “out not available”. Pager status changes can be made by the housestaff directly while in the hospital or may be done through the SLMC operator (649-6000) when out of the hospital.

5. Housestaff are expected to maintain pager coverage from 0700 through 2100 (until covering intern obtains sign out from you) Monday through Friday and from 0800 to 1100am on weekends and holidays. If paged while out of the hospital, housestaff must provide appropriate care either by providing phone orders, returning to the hospital, or contacting the on call daytime cross cover intern for assistance. Each day, one of the “day” interns will be identified as the cross cover intern who can provide assistance if needed prior to the arrival of the “night” intern. The “day” coverage intern is expected to assist with coverage during the day if needed. The intern requesting the assistance will be required to page the “day” cross cover intern directly, provide the needed background on the patient in question and discuss the problem at hand.

6. Monday through Friday sign out will occur directly between the “night” intern and each of the day interns between the hours of 2000 and 2100. It will be the responsibility of the “night” intern to page each of the day interns (or any senior resident that may be covering for an intern who has a day off) and discuss the patients. Once this discussion has taken place the day intern is allowed to change their pager status to “out not available”. On Saturday and Sundays, interns are allowed to sign out to the “day” cross cover intern when their work is complete and the “day” cross cover intern will sign out all of the patients to the “night” intern between 2000 and 2100.

7. The yellow team has a slightly different arrangement with regards to coverage for admissions over the 24 hour span they are on call. This should not impact cross coverage however. The yellow team intern will provide cross coverage for their patients until 2100 on their non-call days just as the interns on Green, Orange, and Red teams. They will be called by the night intern between the hours of 2000 and 2100 for sign out and are allowed to change their pager status to “out not available” after providing sign out. When the yellow team is on call, the intern returning for night coverage will page each of the day interns for sign out upon their arrival to the hospital (at 2100) and will then provide cross coverage for the remainder of the night (until 0700).

8. Each housestaff member will receive a total of 4 days off over the month, to be provided approximately once per week. Off-day and day time cross cover templates will be provided to the senior resident during orientation, and are to be completed and promptly returned to the chief resident. Only 1 team resident/intern is to be off on any one day, and housestaff are not to be assigned off during on-call or immediate post-call days. When the intern/acting intern is off, they should have their pager forwarded to the senior resident and the senior resident is to provide direct coverage to and write progress notes for the intern’s patients.

All housestaff are to adhere to the ACGME work hour limits of no greater than 80 hours of in-hospital work per week

Admission, Service Closure, and Patient Volume Policies:

1. Teams will admit a maximum of 10 patients over the 24 hour call period. After this cap is reached, the senior resident is to notify the Emergency Department that the team is closed to further admissions.

2. Each intern is to admit no more than five new admissions each per 24 hour call period.3. Interns are not to provide ongoing care to any more than 12 patients at a time. If patient volume becomes

excessive, senior residents should contact full-time faculty to discuss options, which may include signing off private patients. However, no team is to sign off any patient without the consent of both faculty and the attending M.D.

Patient admission types and sources: 1. Private Admissions. (20%). Patients who have a private MD on staff. Most of these patients are admitted directly

from the Emergency Dept., with a small number being admitted directly. In this case the private M.D. has already been contacted by the E.M. physician, and has voluntarily placed the patient on the IMTS.

2. “ House-case" Admissions. (80%). Patients with no established private MD on staff, admittedfrom the E.R. These patients are placed on the IMTS and the E.M. physician will directly contact the on-call Sr. resident. House-case admissions to the IMTS are assigned and managed as follows:

7

All house-cases will be admitted to the on-call IMTS team until the team closes at a total of 10 overall admissions (both private and house-cases). The E.R. will directly page the Sr. IMTS on-call resident (pager # 56190) for all house-case admissions.

After the IMTS closes, any further housecases will be admitted directly to the Cogent Hospitalist program without any involvement of the Teaching Service.

The on-call Sr. IMTS resident is responsible for keeping track of house-case admissions, and will notify the E.R. when the IMTS is closed for admissions.

“Bounce Back Admissions”:These are patients admitted to the IMTS who had previously been discharged from the service during the same calendar month. The on-call team will admit and care for these patients through the 24 hour call period. The following morning the patient will be transferred back to the team who had previously discharged the patient, whether or not the current admission relates to the previous hospitalization. Patients discharged during previous calendar months remain with the team they are admitted to in the new month.

Cogent Bounce Back Admissions:Patients who have been hospitalized under the care of the Cogent hospitalists (without housestaff involvement) and discharged within the previous 30 days, are to be admitted to the Cogent hospitalist without IMTS involvement. Patients had been discharged by Cogent Hospitalists beyond 30 days will be considered house-cases and will be assigned and managed as such.

Working in the Emergency Department:Housestaff are encouraged to go to the E.D. to examine and help manage newly admitted patients. However,at times the E.D. is very busy and E.D. staff may request that the patient be transferred as soon as possible,before the team has fully evaluated the patient. Please be respectful and comply with these requests.

Teams are encouraged to interact with the E. D. staff in patient care. However, the E.D. staff has theultimate decision-making authority regarding patient admissions, and the IMTS housestaff may notrefuse such admissions. Questions or concerns re: the need for patient admission should be discussed withthe IMTS faculty.

Patient Care Responsibilities:Upon admission to the IMTS, patient evaluation and management will be the shared responsibility of the IMTS team and the attending physician.

IMTS Housestaff responsibilities: Full initial evaluation, including a complete H&P, data base review, and medical records review.

Direct discussion of the case with the attending on the day of admission, after the initial evaluation. For all private patient admissions, the senior resident is required to make the initial contact with the attending physician. All subsequent contact can be made by the intern or resident. For house-case admissions, the team’s teaching attending can determine if this initial contact is to be made by the senior resident or the intern. Junior medical students are not to make this initial contact unless the teaching attending agrees. Regardless of who presents, the Sr. resident is responsible for ensuring that the impressions and plans of the team are accurately represented.

The intern assigned to the case is responsible for dictating a complete H&P and writing a brief chart note outlining the management plan. The senior resident is to place a more in-depth admission note, discussing the H&P, impression and plan.

Utilizing the IMTS Admission Order form, the intern is to write all admission orders, and as many subsequent orders as feasible. All student orders must be countersigned by a resident or staff physician, and students are not permitted to give phone or verbal orders.

8

IMTS patient charts must be labeled with an IMTS sticker (available at the nursing stations), indicating team color, and housestaff assignments. This enables staff to contact the appropriate housestaff when needed.

The intern is responsible for monitoring the patient's course. He/she should evaluate patients at the bedside daily, and present and discuss the patient during rounds, and document this through daily legible, complete, and concise progress notes. Disagreements between attendings and housestaff should be resolved outside of the chart. Notes should be written in the "S.O.A.P." (Subjective, Objective, Assessment, Plan) format.

Senior residents should conduct morning rounds with the entire team as a group, to review and discuss patient management, and countersign student notes and orders. Interns do not need notes countersigned, but must review case management with the senior resident.

The intern must dictate a discharge summary within 24 hours of discharge. Housestaff are to indicate during the dictation all other physicians (including consultants, and primary care providers) who should also receive a copy.

Attending Physician Responsibilities:The attending physician or a designate must be available to the residents at all times for case discussion and supervision. The attending physician/alternate must also be available upon request within an appropriate time interval to personally assist in patient care or perform/supervise procedures.

The attending physician and resident team should communicate effectively through daily progress notes and direct discussions. Issues such as new diagnostic findings, therapeutic results, patient status changes, consultations, patient disposition, and code status, should be communicated directly and promptly between attending and housestaff.

The attending physician has the final authority regarding patient care decisions. If a resident strongly disagrees with the attending over patient management, he/she will not be expected to act against his/her judgment, but should contact the IMTS faculty for resolution.

The attending MD must see patients and write progress notes daily, documenting case supervision and communication with housestaff. Simply countersigning housestaff progress notes is not adequate.

Order Writing Guidelines:IMTS housestaff are to write all orders, except under the following circumstances:

The attending or consulting physician attempts to contact the team to discuss orders, and after a reasonable attempt, is unable to reach them.

Emergent patient care issues arise and the team is not immediately available.

Specific procedural, pre-operative, postoperative, or chemotherapy orders are written by attending or consulting specialists (including standardized orders).

The attending or consultant has discussed plans, and for convenience (e.g. the attending is at the chart), the team agrees to have the attending/consultant write orders.

Intern Cross-Coverage of IMTS Patients:On-call interns will provide cross-coverage to IMTS patients from 9:00 p.m. until 7:00 a.m. weekdays and 11:00 a.m. to 7:00 a.m. weekends.. Sign out should be concise, focus on active and potential problems, address code status and advanced directives, and identify physicians involved as consultants.

If major patient status changes arise in cross-covering patients, or if the intern has questions or concerns regarding patient care, the intern is to contact the on-call senior resident for supervision. If necessary, the resident should directly examine the patient and/or review the patient’s chart, and the team should contact the attending physician to discuss

9

management. Any significant changes in patient status or management should be documented in the progress notes, and discussed with attending M.D., and with the assigned IMTS intern the following morning.Intern Cross-Coverage of Non-IMTS Patients:The cross-covering IMTS intern, who is identified on the IMTS call schedule, provides limited coverage to non-IMTS patients, including:

1. Emergent patient care: The cross-covering intern is available for initial management of any patient requiring emergent evaluation or care, as determined by the nurse or attending physician. The intern is to evaluate and initiate treatment, then contact the attending physician, who is to assume further care. The on-call IMTS senior resident is available for intern backup and supervision. This service does not relieve the attending from the responsibility of providing timely patient care.

2. Peripheral I.V. access: the cross-covering intern will provide back-up to nurses unable to obtain I.V. access only for patients on the IMTS. An in-house anesthesiologist is available 24 hours/day and may be consulted to obtain I.V. access in difficult or emergent situations.

3. Death Pronouncements: State law mandates that a licensed physician pronounce patients deceased. Unlicensed physicians, including cross-covering interns, and/or licensed nurses, can report the "probability of death" to the attending physician, who may then officially pronounce the patient dead by phone. The nurse is responsible for notifying the attending of this "probability of death". The cross-covering intern is available upon attending physician request to determine probability of death under complicated circumstances such as a medical examiner's case, or upon a patient's family's request. Otherwise cross-covering intern involvement in not required in this.

These guidelines are designed to unburden housestaff from non-educational, service-related patient care, making them more available for admissions and evaluation of teaching service patients. Exceptions to these guidelines may occur, and common sense will dictate actions.

Code 4's (ACLS)Code 4's are run by the "code team", which is comprised of the on-call IMTS team, nurses, respiratory therapists, and pharmacists. The Sr. resident must respond to and direct all codes, unless the patient's attending or consulting physician is available and assumes responsibility. The intern is encouraged to attend to attend all codes but is only required to attend when two codes are called consecutively (within approximately 45 minutes of each other). This is to ensure that someone from the IMTS service is always present at codes. In the event that two codes are called consecutively, the senior resident may be occupied at the first code so the intern must attend the second code. The on-call senior resident and one intern will carry code pagers, which must be transferred to the on-call team at 07:30 each morning. At the end of the code, the participating resident must write a progress note, sign the code order and feedback sheet, and notify the patient’s attending physician.

Guidelines for use of Consultants:Teams should discuss the use of consultants with the attending promptly, so that consults can be obtained in atimely fashion. Although the attending M.D. has the final word regarding which consultants are utilized, housestaff areencouraged to make requests based on their experiences with consultants as care providers and teachers.Teams are encouraged to use consultants who are supervising other housestaff, to maximize theeducational experience of all of our housestaff.

When obtaining a consult, the team must contact the consultant directly to discuss the case. Simplyentering an order for consultation (which should also be done) or leaving a message for a consultant isnot adequate. It is also acceptable to contact and discuss the case with the housestaff working with that consultant rather than the consultant themselves.

The team should request that the consultant re-contact them after seeing the patient, to discuss impressionsand plans. Advise the consultant who and how to contact. Consultants should also be advised if the teamwill be unavailable because of work hour requirements.

By hospital policy, consultations are mandatory for the following patients:

A. All ventilator patients expected to be intubated for greater than 24 hours. Any pulmonologist,

10

anesthesiologist, or critical care specialist may be consulted.

B. All patients admitted to the coronary care unit (CCU) must be seen by a staff physician (attendingor consultant) within 2 hours of admission. It is not the team's responsibility to ensure that staff physicians adhere to this policy.

ICU PoliciesMedical ICU Patients

House case ICU patients that go directly from the ER to the ICU1. Patients will be admitted directly to the intensivists. The medical teams will not be involved2. When these patients are ready to be transferred to the floor, the IMTS team on call for the day of the

transfer will accept 1 transfer as long as it is transferred out of the ICU before 11:00am. This will count as an admission toward the teams cap of 10 patients for the day. All remaining transfers for the day will be transferred to Cogent

House cases that were on the floor and need to be transferred to the ICU1. AMG Intensivist will assume care of the patient2. House staff will communicate a summary of the case directly to the AMG Intensivist at the time of

transfer3. House staff will continue to follow the patient peripherally—they will not write notes nor will they write

orders but they will stay familiar with the case to optimize the transition of care back to the floor4. When the patient is stable and ready for transfer to the floor the original admitting team will accept the

patient back to their service on whatever day they are ready for transfer as long as communication of the transfer occurs before 12:00 pm (patient doesn’t have to be physically moved by 12:00 pm). This can even occur on a post call day. If it happens to be the original teams call day, this patient will count as their 1 transfer out of the unit for the day and will count as an admission toward their cap of 10.

5. If the patient is transferred back to the team on a non-call day (before 12:00 pm), it is just accepted and doesn’t count toward any admission caps

6. If the patient is transferred out of the ICU after 12:00 pm, the team on call for the day will accept the patient, count it as an admit toward their cap, and bounce the patient back to original admitting team the next day

7. Every effort should be made to transfer these patients before 12:00 pm. To minimize bounce backs

Neuro ICU

If the ER calls a neurosurgeon with a house case that needs to be admitted to the Neuro ICU and the neurosurgeon requests that the patient be admitted to the teaching service the teaching service should oblige. The teaching attending would be listed as the attending and the neurosurgeon as a consultant. An intensivist consult can be requested by the teaching team if needed.

Procedure Policies:Team members will have the opportunities to perform invasive procedures. Guidelines:

1. No procedures are to be done by anyone without adequate experience unless supervised by someone experienced and certified in the procedure.

2. If residents need staff supervision for procedure certification, arrange this with the attending physician. With the attending physicians’ approval, teaching faculty may be available to supervise procedures.

3. All procedures should be documented in the progress notes, and a procedure note should be dictated and sent to the Medical Education Office (to SSMC c/o B. Young for senior IM residents; to SLMC c/o Karen Wise-Acker for TY interns) to be placed in the residents file.

IMTS Teaching Attending Rounds: two types of attending rounds:

11

Teaching Rounds: The ACGME requires "regularly scheduled" teaching rounds, conducted on a formal basis at least three days per week for a minimum of four and one-half hours per week. These rounds should focus on issues more general than the immediate management of patients assigned to the team's care. As the ACGME describes, "generally, a few cases are presented on teaching rounds as a basis for discussion of such points as interpretation of clinical data, pathophysiology, differential diagnosis, and specific management of the patient". These rounds must intermittently include "direct bedside interaction with the patient, which should include personal evaluation of the history and physical exam by the teaching attending".

Management Rounds by the Physician of Record: These are direct management rounds conducted on IMTS patients for whom the teaching attending is also the physician of record, such as house-case patients. In conducting management rounds, all physicians of record have the responsibility to interact at appropriate intervals with his/her patients and to communicate effectively with the housestaff. As the ACGME states, "Although these rounds may offer many educational opportunities, they are not to be confused with or take the place of separate teaching rounds".

Evaluations:

Teaching attendings are to provide day-to-day feedback to team members, as well as a verbal and written evaluation at the end of the month. Clinical competence will be assessed based on the ACGME “core competencies”: Medical Knowledge; Clinical Skills; Communication and Interpersonal Skills; Systems-Based Practice; Practice-Based Learning and Improvement; Professionalism. Housestaff will also evaluate the faculty, attending physicians, other team members and the rotation in general, by completing evaluations on an on-line system, “E-value” (for AHC residents) or on paper (for students) at the end of the month.

B. Didactic Learning Experience:

Conferences and Lectures:A number of conferences are provided, many designed specifically for housestaff. Unless involved in urgent patient care or post-call and unable to meet work-hour limits, housestaff are required to attend and actively participate in conferences, listed below:

Morning Report: Weekdays (M,T,W, Thur) 10:30-11:15 a.m. / /Fridays 7:00-8:00 a.m.: 9th floor Center conference room. All IMTS housestaff will meet with faculty to present and discuss selected cases. Teams are to bring pertinent EKGs, x-rays, or other data. Unless otherwise scheduled, the pre-call team will be assigned, and will work with the chief resident to choose, present, and lead a case discussion. Teams are encouraged to invite consultants to participate, and are responsible for informing interns assigned to Radiology about any pertinent radiology imaging to be reviewed or discussed. In addition to the pre-call team presentations, a number of scheduled conferences will be held during Morning Report, including:

Cardiology/CCU Conference: Fridays 7:00-08:00 a.m.: 9th floor Center conference room: Faculty and housestaff from the Cardiology Consult and Cardiac Care Unit (CCU) Service will participate, with case and topic discussions.

Clinical Pathology Conference: Last Wed/month; Interesting cases with pathologic material presented and discussed by pathology and AMTS housestaff and faculty.

Grand Rounds Speaker Conference: Thursdays, 10:30-11:15 a.m. Sept-May: When available, Grand Rounds speakers attend morning report, and cases related to their expertise are presented.

IMTS-Emergency Medicine Conference: 3rd Monday/month; Interesting cases admitted through E.R. discussed by AMTS members and Emergency Medicine staff and residents.

Noon-time Conferences (at times conference run concurrently):

12

Summer Acute Care Lecture Series: Monday - Friday (July and August); noon; see monthly Summer Lecture Series calendar for location. A series of housestaff-oriented clinical lectures, mostly dealing with medical urgencies. Refer to the monthly schedule for topics.

Internal Medicine Medical Knowledge/Clinical Skills Lectures: Monday and Tuesday; noon; Medical Education Conference Room. Refer to the weekly schedule for topics.

Practice-Based Learning and Improvement (PBLI) Conference: 4th Monday each month- 12:00- 1:00 pm, Med Ed Conf. Room. Each team will review a case which involved a less than optimal or unexpected outcome, whether iatrogenic or not. Related topic(s) to be reviewed by team Sr. resident.

Radiology Conference: 3rd Tuesday; noon; Medical Education Conference Room. Interesting imaging studies and topics from AMTS cases are reviewed with the radiology staff and residents.

Endocrinology Case Conference: Tuesdays; noon; HS2; Interesting endocrinology cases are presented and discussed by attendings and housestaff.

Pharmacology Grand Rounds: Last Tuesday noon of month; Stiemke Auditorium

Journal Club: Wednesdays; noon; 9th Floor Conference Room. Review and discussion of case-based critical assessment, evidence-based medicine concepts, journal articles.

Cardiology Conference: Wednesday, noon; Cardiac Catheterization lab (second floor). Topic-based didactic conferences provided by Cardiology fellowship program faculty.

Medical Grand Rounds: Thursdays; noon; Stiemke Auditorium.

Resident/Staff Case Conference: Fridays; noon; Medical Education Conference Room. Case presentations and discussions by Transitional Year and Family Medicine faculty and residents.

Core Competencies Case Conference: Last Friday each month; noon; Med Ed Conf. Room. Case presentations and discussions by Internal Medicine/TY and Family Medicine faculty and residents that focus significantly on competencies beyond Medical Knowledge and Patient Care, (i.e. Systems-based practice, Professionalism, Communication and interpersonal skills, Practice-based learning and improvement).

C. Facilities, Miscellaneous:

PagingPagers are provided and should be used for all in-hospital paging. New pager batteries are obtained from the Medical Education Office on the 9th floor. Full directions for pager use are provided. Please change pager status as your availability status changes. Text paging is available through the internet (www.arch.net), using the pager’s 10 digit phone number.

Pager or office numbers for staff physicians can be found on-line at any computer terminal, under “provider directory”, available on the Aurora web-site home page. Do not call the operator to obtain pager numbers.

Computerized Patient Census Lists:IMTS faculty and housestaff can obtain a team patient census through the “Cerner Powerchart” program available on most on-site computers. This list is obtained by entering into the computer the following digits for each team:

Red team 9984Orange team 9987Green team 9988Yellow team 9989

Patients will only be added to this list if the unit secretaries recognize them as being on an IMTS team. It is important that the initial order on all IMTS patients states "Admit patient to IMTS (color) team". As described above, teams must

13

ensure that IMTS stickers are placed on the front of the charts and filled out with the correct information. Teams are to use the IMTS standardized admission order set.

Medical Records:

1. All H&Ps and discharge summaries are to be dictated by the resident, intern, or senior student. Your pager number is your physician I.D. number. Full dictation instructions are available on the floors and in the medical records department.

2. All senior student orders and notes must be countersigned by an M.D., usually the resident.

3. Physician housestaff may give verbal or phone orders to qualified nursing staff, but these must be countersigned within 48 hours.

4. Discharge summaries must be dictated in full (without abbreviations), listing the diagnoses, procedures, consultants, complications, discharge medications and discharge disposition of the patient. See below for details and a sample discharge summary

5. All team members should sign Medical Records a minimum of bi-weekly to complete all medical record obligations including signing of orders, performing dictations and signing dictations. All records must be completed by the end of the rotation.

Call Room/Office Space:Team meeting space is available on the 8th and 9th floor Center building. All housestaff are assigned lockers on the 9th floor for storage of personal items. Individual call rooms are available on the 9th floor for each on-call resident/intern, senior medical student, and PA student (not available for Jr medical students). Please keep these rooms in good order.

Library:Library hours are from 8:00 a.m. to 10:00 p.m. Monday through Friday. The library (located in the hospitalbasement) is available to medical staff 24 hours a day, 7 days a weeks by contacting the security office.Resources and services include a large number of hard copy and on-line texts and journals. Librarian staffare available to assist in both hard copy and on-line literature searches and article procurement. A largenumber of on-line resources are available through the Aurora Intranet site, which can be accessed at any time from any computer in the hospital.

Rehabilitation UnitSt. Luke's has a separate rehabilitation unit. Transfers to this unit require a dictated discharge summary from the medical floor and an admission H & P, with admission orders to the rehab unit. Patients can only be admitted to the rehab unit by a physiatrist. Whether the IMTS follows a patient after transfer to the rehab unit is determined by the attending physician.

Although separate O.T., P.T., and, speech therapy consults may be obtained, patients you anticipate transferring to rehabilitation unit may be best served by an early consultation to a physiatrist, who can initiate and orchestrate the various therapy modalities and speed transfer.

A Rehabilitation Admission Coordinator will follow and document patient’s acceptance or alternative recommendations on the interdisciplinary discharge planning communication sheet in the patient chart. Several criteria need to be addressed in considering a patient for admission to Rehab: (1) deficits in mobility, safety, self-cares, (2) motivation and ability to respond to verbal and/or visual stimuli, (3) ability to tolerate 3 hours of therapy per day, and (4) medical and neurological stability.

Radiology

14

Staff radiologists are in-house during day-time hours, and a Senior Radiology resident is available by pager (222-4657) week days from 7:00 a.m.- 5 p.m. for discussion and consultation. A Radiology resident is available during night-time by contacting the Schroeder Radiology Dept. at 649- 7917. Housestaff are encouraged to discuss the use of Radiologic procedures with the Radiologists directly to enhance education and patient care. An on-line radiology program- “Visual PACS”- is available on many computers throughout the hospital to review individual images. AHC-based housestaff are trained in the use of this system, and can assist other team members.

Magnetic Meal Cards: Housestaff will be given electronic meal cards by the Medical Education Department on their first day of the rotation.

IMTS Format to be used for Discharge Summaries

Please use the following format when dictating discharge summaries, which must be completed within 24 hours of discharge. Be certain to have copies sent to all physicians significantly involved in the patients care and those who will be assuming follow-up (if such physicians are not on St. Luke's staff please indicate their address). The summary should be complete but concise, conveying the necessary information without rehashing every detail of the hospitalization.

Admit Date / Discharge Date

Primary Discharge Diagnosis:Acute Inferior Myocardial Infarction with Congestive Heart Failure - resolved, and transient 3rd degree AV heart block - resolved

Secondary Discharge Diagnosis:Coronary Artery DiseaseHypertensionTobacco AbuseHistory of Peptic Ulcer Disease

Procedures:Cardiac Catheterization, low level stress test

Consultants:

Complications:IV site infection - resolved

Disposition / Followup:Discharged to home, F/U in office in 2 weeks

Hospital Course:This should be a brief, chronologic summary of the hospital stay highlighting the presentation, management, and clinical course of the patient. Comment on those factors that will assist to those caring for the patient in the future. If the case was particularly complex, try to summarize, referencing specific items in the chart (such as a consultation or study report) without repeating them verbatim. It may be helpful at the end to briefly describe the patient's discharge examination and data base (e.g. weight, Cr, INR, BNP) that can be used for comparison in the future.

* Discharge medications should NOT be dictated in discharge summary. This should be included in the depart summary

15

16

Follow-Up Alternatives Information Sheet

Free Clinic List

Bread of Healing Clinic Saint Ben’s Clinic For the Homeless1821 N. 16th Street 1027 N 9th StreetMilwaukee, WI 53205 Milwaukee, WI 53226414-374-8890 414-765-0606Fax 414-374-8896 Fax 414-765-0226

Clinca Latina Health Center – Spanish Speaking 16th Street Clinic1238 S. 16th Street 1032 S. 16th StreetMilwaukee, WI 53204 Milwaukee, WI 53215414-645-6665 414-672-1353Fax 414-645-6732 Fax 414-672-4265

Family House Clinic Walkers Point Clinic – Lottery3300 North 11th Street 611 W. National AvenueMilwaukee, WI 53205 Milwaukee, WI 53205414-374-8890 414-384-1400Fax 414-374-8896 Fax 414-672-7012

Greater Milwaukee Clinic9330 W. Lincoln AvenueWest Allis, WI 53227414-546-3733Fax 414-546-1707

Madre Angela Family Clinic1308 S. Ceasar E Chavez DriveMilwaukee, WI 53204414-671-5410Fax 414-672-4265

Martin Luther King Clinic2555 North MLK DriveMilwaukee, WI 53212414-372-8080Fax 414-372-4102

o:\wpdata\amts\IMTS.10.11.doc