Welcome

Treat the children and families as you would like to be treated yourself.  The kids come first and all the rest of us second.

 

Who Can Help Me?

Dr. John Paisley: Medical Director of the Wards as well as ID/Peds attending

Phone: 413-1161; Pager: (503)796-5655

Chief Resident / Teaching Attending / Pediatric Hospitalist

Senior Resident: Mobile Phone 503-413-1150; pager 830-4501

Weekly Ward Attending: Name and pager also non the patient list

Dr. Tracy Bumsted,  Course Director

Phone: 494-5982; or Page through OHSU

Trevor Monteith, Student Coordinator. 

Phone 494-3195, CDRC Rm 2114D

 

Dress Code

Nametag, Professional Dress- no tank tops, White coat encouraged for all students

Scrubs only if you are on call or post-call (should wear white coat over them)

 

The Team

The pediatric ward team is involved in the care of almost all of the pediatric patients on the Infant/Toddler ward and School Age Ward.  They never cover patients on the cardiology service or in the PICU.  Some routine admissions  (fever and neutropenia, some GI “clean-outs,” etc.) are managed solely by the attendings.  Some patients have cursory involvement as a safety measure  (Video EEG patients, most neurosurgery and urology patients, etc.).  By the new residency work hour rules, each intern can manage only 10 patients at a time and the senior residents can oversee only 30 patients at a time (as well as many other restrictions).  In the busy winter respiratory season, there are patients who will only be managed by their attending  (mostly ward attending patients, neurosurgery patients, etc.).  At night, all patients will have coverage available for problems.

 

The team consists of: a senior resident who is a R2 from OHSU, two pediatric interns from OHSU, and a Family Practice intern from Southwest Washington (also sometimes an intern from Providence Milwaukie).  The chief resident (Julie) serves as back up for all the children on the ward and usually covers for the senior during clinic and post call afternoons.  OHSU 3^rd year Students (4-5) are an integral part of the team and should be actively involved in admissions, discharges, and rounds. 

Attendings

This hospital admits children from all over the Portland area and state.Many community private pediatricians have privileges here and will manage their patients with the residents/students.  On admission, it is important to determine the correct attending for each child and include it in the orders.  If an attending who has admitting privileges at Legacy would like their patient primarily managed by the ward attending, it is courteous for them to call that weekly attending and ask them to assume care and explain the situation.

 

MOONLIGHTERS

We hire “moonlighters” (pediatric fellows or attendings) to provide overnight coverage when there is not a PL2 on call  (every other night) and in the evening when the PL2 is on call (5:30 p to 11:30 p weeknights, and from 1 p to 11 p on weekends/ holidays) for backup.  They are to help with admissions, oversee the admissions to the ward team, help with procedures, answer questions, provide second opinions for all pts, etc.  They try to write an H&P for all ward attending patients and bill for them.  At the request of subspecialists and private attendings, time permitting, they sometimes can also write the H&P and bill for private admissions.  They do not replace the official attending, who should be called after the evaluation, for all significant changes or lab results, problems, consults, etc. 

 

CONSULTANTS 

In some specialties, consultants are in separate practices (including Neurology, ENT, Urology, Gen Surgery, Eye).  When an attending/PCP asks for a consult, you should ask them if they have a preference.  Please ask.  If they don’t know, ask the senior/chief or the ward attending whom to contact.  Neurology alternates call between Dr. Metrick and Dr. Huffman, unit secretaries have the schedule.  If the PCP wants a consult, someone needs to call, don’t assume they did.  As professional courtesy, consults are physician to physician, and not just a written order. 

 

DAILY SCHEDULE:

 

Signout from senior/hospitalist to senior/hospitalist is from 7-7:30 am in the call-room.

ROUNDS: 10:30-12:15: Rounds where all patients are discussed in room 3317 

Conference:  12:15-1:00: Noon conference/Lunch

Signout 5:30 pm from the team to the on-call team  (moonlighter / cross-cover PL2, et al) in the call-room.

**  Weekend / holiday signouts happen at 9 am

 

·                     Friday Case Conference(7:30am, MOB West Conf Room):  The senior, teaching attending and ward attending are responsible for choosing the cases, which are presented as an unknown or interesting case for general discussion.  Coffee and yummy pastries are served.  

·                     Emanuel Pediatric Grand Rounds:  (7:30am on the 3^rd Tuesday of each month, Lorenzen Conf Center) Residents do not have to prepare for this. Be on time please. Coffee and good pastries are served. No Oreos.

·                     Emanuel Pediatric Miller Rounds:  Be sure to attend Miller Rounds. During the first week, Miller Rounds are held on Tuesday from 3-4 pm in Room 3317 to accommodate Legacy Emanuel Orientation. During subsequent weeks, Miller Rounds will be Mondays from 3-4 pm in Room 3317. There will be no Miller Rounds on the following holidays, Labor Day,  Martin Luther King, Jr Day, President’s Day, and Memorial Day.

 

DISCHARGES

Discharge planning should be made as early as possible to allow the nursing staff to plan admissions.  The nurses must know who is definitely going home by about noon, the latest time they can cancel requests for evening nurses.  Orders for medication and follow-up appointments should be written for the definite discharges in the morning. 

 

 

 

ELECTRONIC CHART (E-CHART)

We are moving to a paperless chart system slowly.  Labs, vitals, many imaging and path reports, some consult notes, etc. are on this system.  The PICU and NICU also have E-chart PLUS systems that require special clearance and training.  The electronic record, radiology images and more can be viewed on the Legacy Physician Portal on the Internet.   Call x55888 to arrange an orientation or for help if the unit secretaries and nurses cannot answer a question.

 

SIGNING CHARTS & ORDERS

All notes and orders must include date and time, legible name, professional title (M.D. or D.O.) and year of training (PGY-1, PGY-2, etc.) and Legacy Provider number (P#).  This is a legal requirement for charting and is reviewed continuously.  Verbal orders must be co-signed within 24 hours.  If there are verbal orders that you are willing to co-sign for other physicians, you may do so and save everyone a lot of time.  Verbal orders can also now be signed on E-chart. If you sign a verbal order on the chart, include the date. 

                                                                  

PHONES/PAGERS

 The residents and a few attendings carry portable phones, which work most of the time on the third floor only.  If they do not answer – page them.  

 

The intern on call always carries the 3-1151 phone and the 830-4505 pager.  The admitting resident or hospitalist on call always has 3-1150 and 830-4501. 

 

ADMISSIONS

All admissions which will be managed by the ward team should be triaged by the senior resident or pediatric hospitalist.  Call 3-1150 to arrange admission with the senior resident or call One Call at 3-BEDS to start the process.  The senior resident should call the charge nurse 3-1147 and bed control/One Call 3-8008/3-BEDS with every admission.  In the near future, the resident will conference call with the One Call nurse during the admission process to obviate the need for several calls.   The severity of illness, nursing acuity and isolation requirements of the child should be assessed immediately.  If the resident is not sure whether the child should be admitted to the ward or ICU, he/she should confer with the charge nurse, Julie, ward attending, or ICU attending regarding staffing or care needs.  If there are questions of transport safety, contact the PICU attending. You can sometimes get them in a conference call for this with the admitting doctor or clinic.  If an attending or service will manage the patient without the ward team involvement – they should call the charge nurse and bed control themselves.

 

Admission work-up may be dictated (should be signed electronically – appears in e-chart under unverified clinical notes). See the dictation instruction sheet in this book. You need to specifically ask that the dictation be sent to any other appropriate providers (primary care physician, consultants, etc.)  They are usually back in E-Chart the same day (by 11pm), sometimes within a few hours.  If you dictate, write a brief synopsis of the diagnosis and plan in the chart as well.  You can also deliver or FAX an H&P to the floor (Infant/Toddler FAX 413-2535; school age FAX 413-4557).  If you are managing the patient without the residents, orders can be left with the unit secretary.

 

FOR MOST FAMILIES, ACUTE HOSPITALIZATION IS A MAJOR EVENT AND THEY EXPECT SOMETHING TO BE DONE SOON.  THE CHARGE NURSE MAY WANT TO GET AN IV IN, BLOOD DRAWN, A FLUID BOLUS GOING, ETC IMMEDIATELY AND IT IS BEST TO LET THEM GET STARTED ON THIS; THEY MAY HAVE ANOTHER ACUTE ADMISSION COMING.

 

After the initial evaluation by the junior resident, the plans should be discussed with the senior/hospitalist first and then the private attending.

Provide the parents with the team structure:

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

       I                                                     I

Senior Res                                      Resident

       I                                                     I

  Intern                                            Med student

      I          

   MS3   

 

Nursing needs:  The nurses may not be able to staff a child on the ward if they need a lot of care.  They know the staff availability and expertise.  They may request or demand that the child be placed in the ICU.  This should almost always be honored.  This should be discussed with the family, private doctor and ICU team.  If the private physician disagrees with this assessment, (s)he must discuss it personally with the charge nurse or nurse manager.  A conference call with the attending , the charge nurse and the Intensivist may be needed.  If the child is ill enough to be moved to the PICU, the Intensivist takes over responsibility, but each case is different and this should be discussed also with all parties.

Psych consultations/admits:  Call the on-call psych social worker and present the case needs.  (S)he or the worker will arrange coverage. There is a schedule of on call doctors available. We do not have to accept medically stable psych admissions waiting for a psych bed unless they are from a Legacy institution (Emanuel, Meridian Park, Mt Hood, Good Sam/Salmon Creek).  Examples: 17 y/o girl who has suicidal thoughts, but did not take anything and is just awaiting a psych eval must stay at the non-legacy ER’s until a psych bed is available.  17-year-old medically stable girl in Meridian Park ED will be admitted to the Emanuel Children’s Hospital ward awaiting psych bed.

 

DISCHARGE SUMMARIES:

All children in the hospital longer than 48 hours or who have unusual or complicated problems or who have visited the PICU should have a formal discharge summary dictated by the intern on the day of discharge.  See the dictation instruction sheet in this book.  If the intern does not really know the patient well and the discharge summary is complicated – sometimes the attending does the dictation.  This provides for the best memory, most impact on patient care and keeps us out of hot water with the medical records and compliance people.  Dictations are automatically sent to the dictating physician and the attending physician of record only.  You need to specifically ask that the dictation be sent to any other appropriate providers (primary care physician, consultants, etc.)  Give the first name, last name and location of the practice if it is not local.   If it is imperative that the dictation be available within a few hours rather than a few days,  make the dictation a priority by pressing “0” and then “2” at some point in the dictation.

An alternative to the typed dictation is a discharge template available in E-chart.

From the E-chart main screen

Click the “LHS Clinic” Action Button on the right hand side of the screen

Click “DC Note Entry”

Click the appropriate admission

In the box type “/dcsumm” and hit the F11 button on the keyboard

Type into the form / delete out inappropriate areas or extraneous wording

On the bottom of the dictation Type “CC:   joe smith, MD”  for any other doctors you will be sending / FAXing or having the unit secretary faxing the dictation to.  Unless you print or ask someone else specifically to print and send it – it will not be sent to ANYONE.

Hit the F12 button on the keyboard to see if the formatting is crazy

Click the Save Transcription button on the left of the screen and save again when prompted.

The transcription will come up in the “All Clinical/Procedure Notes” section of Transcripts.

 

 

SURGERY PATIENTS

 

The pediatric team does not follow surgical patients routinely except for Dr. Wehby’s patients (pediatric neurosurgeon).  The ward attending serves as the backup staff pediatrician for medical questions.  Generally, we do not follow Dr. O’Hollaren (urologist), Dr. Lashley’s (urologist), Dr. Achterman (ortho), or Dr. Barmada (Ortho) patients unless specifically asked; nor do we follow peds ENT unless they (usually only Dr. Cuyler) call us.

 

CHEMOTHERAPY PATIENTS

Many are routine and the residents do not have to formally see them.  The oncologist will notify the team if the child needs to be seen and followed by the house staff.  Note that there are times when the nurses may call the housestaff with a pretty straightforward question.

 

 

EATING DISORDER PROGRAM/PATIENTS

Emanuel has a number of children in the hospital with eating disorders.  There are detailed standing orders for graded and safe refeeding.  Most are managed by Drs. Julie O’Toole, Nagmeh Moshtael and their team at the Kartini Clinic.  Some are managed by private attendings or ward attendings.

 

CONSENTS/PROCEDURE NOTES

 

The physician performing the procedure must review the PARQ (plan, alternatives, risks, questions) with the parents and document this is chart.  An LP is the most common procedure for which the housestaff use a PARQ.  Immediately after the procedure (most commonly LP), write a brief procedure note in the chart.  I usually start w/ “PARQ reviewed w/ Mother of child, questions answered”.  There is a very specific informed consent form now required by the hospital as well.

 

Most lab results are available in the computer.  Other results (especially send-outs) can be obtained by calling the lab at 413-1234.  In general, lab results are immediately available on E-Chart, so check there first.  Blood cultures are read automatically every 10 min; positive blood and CSF culture are called to the floor and the ordering physician immediately.

 

Some tests are sent out to Utah by plane Mon - Friday, and they leave our lab about noon.

 

If it is a weird test, try to make sure it gets done and in our lab by 11 am or so in case it has to be sent out.  Notify the “Referral Desk” in the lab that the specimen must go out that day  (call X31234 and ask for the referral desk or call send outs at X35106).

RADIOLOGY

Routine studies are kept in radiology and on PACS system, monitors in the PICU and a few on the wards  (one in the “fishbowl” (small room off the 3600 A side nurses station), one on the 3500 side) Dr. Bennett (our pediatric radiologist) does not routinely read all peds films; you should review problem cases with him.  Dr. Bennett should also be contacted before special procedures are scheduled and the study needs reviewed, although one of the others may be doing the study. 

 

PACS:You may need a sign on for the PACS system unless you sneak in on someone else's session.  Ask your administrative helper to get you PACS access by using an IR work request form  (copy found in the next section of this book).  Contact radiology if you need help learning to navigate PACS.   PHYSICIAN PORTAL:  PACS images are viewable on the physician portal on the internet.  The images will only be as good as the resolution on your monitor (see next section for Portal access forms).

 

If the patient needs a film for their doctor, it can be made (or the images can be burned onto a CD – less expensive). Contact the radiology file room – 413-4032.  Outside films should be kept in the patient’s “cubby” (where their blue medical record chart is stored) until they are discharged.  Do not leave outside films laying around on the wards or in call rooms.  They will disappear, and then the attending will waste a lot of time trying to track them down the next morning. 

 

ORDERS

PREPRINTED ADMIT ORDERS ARE AVAILABLE.  PLEASE USE THESE ROUTINELY.

Make sure the child's weight is on the orders.  Usually the nurses have this quickly, but it is used to check dosages, etc. Blood pressures should be q shift when stable.

Isolation:  Any proved or possible varicella or measles, and obviously SARS suspect 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, SARS and avian flu must be wearing a mask and be admitted into that room immediately.  If you are not sure, isolate them, call the on call 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.

Contact and / or droplet isolation are needed for a myriad of other conditions.  See the infection control cheat-sheet / the P drive policy or the back of the infection control signs for details.

Monitors are often used unnecessarily.  Do not use continuous monitors unless really needed for small infants (< 3-6 months old, perhaps) 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. 

Medication orders:  Include exact dosages by weight and total dose; frequency of administration; route of deliver' 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.

Flag orders using the pull up red plastic tab on the chart door.  Tell the nurse about orders that are ASAP or STAT.  Non-flagged orders may not be noticed for hours. 

 

*    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.

 

BOOKS, etc

There are several basic texts on the floor next to the charge nurse desk. There are developmental screening forms in the same area.  The library keeps a number of journals and has terminals for searches as well.  Many references (Micromedex, MD Consult, UpToDate…) and OVID (literature search engine) are available through E-chart.  Click on the icon on the top of the screen which shows several colored books.  A couple of terminals on the ward have to the internet. Ask the chief resident which ones these are.  Ask Julie if you are having troubles accessing information.
 

CALL ROOM

The call room for the senior resident and the intensivist are outside the PICU, and the intern and student call rooms are on the fourth floor.