ADMISSIONS

o    Before going to admit a child, pull up from e-chart under Transcriptions any outpatient or ED note available.  The ED physician’s H and P and provides a lot of information.   Notes from our pediatrics clinic are in there as well.   You can also review labs and x-rays.  Also, look for papers sent with the child from another ED or clinic, etc.  

 

o    Try to coordinate with the nurses and see if they want to join you when you take the history.   They ask a lot of the same questions we do and will usually just listen and fill in what they need.  They also need to know some additional information so you might let them have a minute to ask this during the history.  The nurses can then begin getting vitals on the child while you continue with your history.

 

o    When you introduce yourself to the parents, let them know that you have spoken with their doctor, reviewed the records from ED’s or clinics, etc to get acquainted with the child’s problem, but that it’s helpful to review the information first hand and make sure that all the details are complete.   By explaining this first, they will be more understanding when you ask them to repeat things that they have already said over and over again. 

 

o    Provide the parents with the team structure and write the relevant names on their white board:

   Attending------------------Consulting Attending (if applicable)

      I                                                             I

Senior Res/NP                             Resident

    I                                                             I

  Intern                                             Med student

         I 
Med student

o    You should write your Admission H+P on regular progress note paper.  The standard H&P template should only be used by the intern/resident/hospitalist; it is very confusing if a medical student writes on it.  You may also type an H &P.  At the time of admission, please put the PCP's name and phone numbers on the chart, both on the H& P form and on the discharge paperwork.  

 

o    The goal is to begin evaluation and therapy as soon as possible.  We would like to have the basic orders written on a patient within 40 minutes of their arrival.  Try to anticipate what will be needed – e.g., bili lights for a baby admitted for jaundice, an IV for severe diarrhea, and MDI or neb for a known asthmatic.   Acute hospitalization is a major event for most families and parents expect something to be done soon.  The nurse may want to get an iv started, blood drawn, a fluid bolus going, etc. immediately so please let them get started and work around those immediate patient needs. 

 

o    NPO status:Think about whether a child needs to be NPO, ex: kid with abscess in arm, kid who aspirated foreign body, kid who needs a sedated MRI and include this in the orders. 

 

o    After the initial evaluation by the medical student and intern, the plans should be discussed with the senior resident/NP first and then the attending.

 

NOTES ON ORDERS

o    Preprinted admit orders are available and should be routinely used. 

o    Make sure the child's weight is on the orders.  Usually the nurses have this quickly and t it is used to check dosages, etc.

o    Isolation:  Any proved or possible varicella, measles, or SARS cases, must be in the special negative pressure isolation rooms.  There is only one true TB/SARS high neg pressure room on the floor on the adolescent side, and any case with possible active pulmonary TB or SARS must be wearing a mask and be admitted into that room immediately.  If you are not sure, isolate them, call the on-all infection control coordinator or ID consult,  then discuss the diagnosis.  SARS masks, N –95, are available when needed as well as a vented hood for those with facial hair.   Common isolations: contact isolation (gloves as entering the room, gowns if your clothes will touch ANYTHING in the patient’s room) for RSV, croup, diarrheal illnesses, varicella, enterovirus in young children, lice, scabies, primary herpes etc; droplet isolation (surgical mask as you enter the room) for influenza, mycoplasma, bacterial meningitis, pertussis, strep; droplet and contact:  H1N1 influenza (swine flu variant),adenovirus penumonia in young children,  respiratory illness when you’re not sure  (ie:  viral vs. mycoplasma vs. pertussis), meningitis when you’re not sure  (enterovirus vs. meningococcus)  ******  Anytime you touch anything moist:   patient’s mouth, diaper, wound, blood, CSF  etc – you should be wearing gloves.  We have laminated isolation signs on the floor which list the organisms and indications on the back.   Suspected swine flu cases, require droplet and contact isolation with the door closed to their room.  N-95 or PAPR masks should be worn if suctioning, intubating, or otherwise getting close to their secretions. Family members with a cough should wear a mask when they leave the room.

o    Monitors/BP checks are often used unnecessarily.  Do not use continuous monitors unless really needed for small infants with true apnea risk or for children with rapidly changing O2 needs, etc.  Spot checks with vital signs is generally fine, and most children do not need monitors hooked up while awake.  Also think about how often each child really needs a BP, often q12 is fine.

o    Medication orders:  Include exact dosages by weight and total dose; frequency of administration; route of delivery, duration (if known), and specific "prn" criteria.     Example: Tylenol 150mg po/pr q4h prn pain/fever (=15mg/kg/dose).  Remember there are different strengths for meds, so when you talk to parents find out the correct one.  Do NOT write meds in ml, write mg as the parents may have a different formulation than our pharmacy does.  Do not put a "decimal point 0" or "  .0" after a number because the decimal may not be seen; put mcg for micrograms or spell it out.

o    Flag orders using the pull up red plastic tab on the chart door.  Med students should NOT put orders back in the cubby without having them cosigned.  Tell the nurse about orders that are ASAP or STAT.  Non-flagged orders may not be noticed for hours. 

o    Please check to make sure a code sheet with a proper weight is in the chart.

o    Abbreviations can be a problem.  You WILL be called to correct these!!  No cc, use ml; no U, use Units; etc. a list of these is at each bedside chart.

 

 

PICU TRANSFERS

When a patient is deemed to need a higher level of care in the PICU, the child’s attending should be notified immediately. The attending or resident should then notify the intensivist or charge nurse about the requested transfer, and a brief summary should be written in the chart about the patient and the reason for transfer. The resident should stay with the patient until they are physically moved to the ICU. 

If you are going to picking up a patient who is coming out of the PICU, you can go into the PICU and start reviewing the chart and typing your accept note before the patient is officially on the floor.

 

 

DISCHARGES

Discharge planning should be made as early as possible to allow the nursing staff to plan admissions. Discharge paperwork can be started DURING the admission if it is a patient that you expect can go home the same or next day. The nurses must know who is definitely going home by about noon, which is the latest time they can cancel requests for evening nurses.  Orders for medication and follow-up appointments should be written for the definite discharges before rounds if possible and immediately after rounds before noon conference otherwise.  Ward attendings should be notified as soon as possible about potential discharges. Then they might be able to see and discharge them before rounds.   Do not wait until rounds to plan for discharges.

 

Discharged patients should have follow-up with a clinic physician or a health care provider. When a specific follow-up appointment is made, the time and date should be written on the discharge summary and patient instructions sheet. This will alert the provider if the patient does not keep the appointment.  

 

For common diagnoses (eg. bronchiolitis, croup, etc), teaching sheets from the American Academy of Pediatrics (AAP) can be found on the Legacy  intranet by going to “Clinical Resources” and then “Library and Knowledege Base”.  The teaching sheets are currently located on the bottom right of the page.  It is very helpful to print these for patients going home so that they can review them and ask any questions before disharge.

 

All important information should be communicated on the discharge summary (eg, weight, lab values that need to be checked or that were abnormal, medications and dosage, etc.).  Hospital policy is to document in the chart that you personally contacted the PCP who will assume responsibility for the child. For ward patients, the resident or attending will contact the PCP.

 

Children from our well child clinic (located across the street) or one of the county clinics, are at special risk of not returning.  A PCP should be personally notified about the return visit plans; this may be done by phone call or fax from the ward.  Please ask the unit secretary to fax the discharge summary to the referring doctor.   The fax number can be found in the “Clinics” Book, by asking the family for their doctors “card” or phone number and calling the office, or by an on-line search.   Also fax any labs or consults that are pertinent to patient management. 

 

Please write very legibly on all discharge papers.  The patient’s ongoing care depends on their pediatrician being able to read your writing. 

 

 

 

DISCHARGE SUMMARIES

Notes on completing the discharge paperwork and forms:

o    The reason for admit is the chief complaint- eg. vomiting

o    The final diagnosis is the reason the child was vomiting – the unifying diagnosis for the initial admission  (examples:  rotavirus gastroenteritis or viral meningitis).   There can be no abbreviations on this line, you can never write “SAME”  and there is no point in filling it out until the day of discharge.

o    Other diagnoses might include underlying diagnoses or other things that made things more complicated (e.g. dehydration, metabolic acidosis, hypoglycemia).

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