Night Float Curriculum

Family physicians require training that will enable them to provide comprehensive care for their patients. A large part of any family physician's practice involves hospitalization and stabilization of acutely ill patients. A thorough understanding of critical care medicine will provide the foundation for the family physician's hospital practice. This training must provide the resident the opportunity to be responsible for diagnosing and managing the major acute illnesses that affect adult patients. The critical care medicine curriculum at GRMC-Health Park is designed to provide increasing responsibility over the three-year time span. It is designed to provide training in diagnosis, stabilization, and management of critically ill patients in medicine, pediatrics, surgery and obstetrics. The first year resident is responsible primarily for admitting and stabilizing the acutely ill patient presenting to the Emergency Department or decompensating on the general medical floor. The second year critical care night float resident's responsibility is divided between directly providing patient care and teaching and supervising the junior resident. By the third year the resident is responsible for providing teaching and supervision to the other residents in the hospital at night. Family Practice Faculty are on call for admissions and consultations.

Resident Responsibilities

There are two block night float rotations during the first year of Family Practice training at GRMC Health Park with the following responsibilities. Night Float Medicine (PGY1) 1 and 2:

PGY-1: (Medicine Pager 1202)

· Will cover the areas designated to the pager service area

· Will admit family medicine patients to family medicine service

· Will review calls and admissions with the PGY-2 resident

· Will present the cases to the attending physician with senior in attendance

· Will maintain a log for all patients seen during the night

PGY-1: Ortho/Neuro ICU,PRCU, Peds, Nursery (Pagers 1129 & 2351)

· Will cover the areas designated by these pagers

· Will perform admissions for Pediatrics, Nursery, Ortho/Neuro ICU and PRCU units

· Will review admissions and floor calls with PGY-2 resident

· Will maintain a log for all patients seen during the night

During the second year one block of night float is required, Night Float Medicine 3 (PGY-2). The PGY-2 supervises first and second year residents.

PGY-2: (PAGER 1385)

· Will take calls from the Emergency Department for admissions

· Will manage the PGY-1 residents by:

o assigning patient admissions

o supervising the patient admissions

o supervising floor calls and ensuring the PGY-1 resident is being supervised for all activities

· Will demonstrate critical care medical decision making authority

· Will call the medicine senior for all transfers to the ICU during the night

· Will maintain a log of all activities supervised during the night

· Will involve the PGY-3 to the review of admissions, floor calls with the PGY-1 residents

During the third year one block of night float is required, Night Float Medicine 4 (PGY-3) with supervising responsibilities for the entire team and FHC answering service.

PGY-3: (Pager 1384)

· Will answer all answering service calls

· Will review the answering service calls with the faculty

· Will work closely with the PGY-2 monitoring the PGY-2 ability to supervise PGY-1 residents

· Will supervise PGY-2 critical care medical decision making

· Will be responsible for providing didactic sessions with the NF team

· Will supervise with PGY-2 the pediatric, nursery, ortho/neuro ICU, PRCU, medicine admissions and floor calls with the NF team.

· Will log all activities attended during the night

In addition, the night float team has the following responsibilities:

1. Respond to floor calls from general medical/surgical floors, pediatric floors, and nursery when the patient's primary nurse or physician believe that a change has occurred in a previously stable patient's status. The night float team will evaluate the patient, perform urgently needed stabilizing care as needed, discuss the case with the patient's primary physician, take any additional measures necessary including effecting transfer to another unit if necessary, and document all of the preceding in an appropriate on-call note.

2. Provide routine care needed by ICU patients at night. Routine care will be documented in a suitable progress note.

3. Evaluate and stabilize all patients admitted to the following services at night: Pediatrics; staff medicine; family health center; medical teaching/faculty if contacted by attendings all 4 ICU units. The night float team will discuss the case with the patient's primary physician, write admitting orders and document all of the preceding in an appropriate admit note.

4. Respond to calls for Code BLUE, "Bad Baby." Assist in providing stabilizing care, evaluation, and transfer as needed. Document response in an appropriate on-call note.

5. The night float team will present at Morning report on Mondays and Fridays

Night Float Medicine Goal

1. The Night float Medicine rotation will help the resident develop the knowledge and skills necessary for the care of acutely ill hospitalized patients.

Rotation Learning Objectives

Core Competency: Patient Care

Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

PGY-1 Residents are expected to:

· Perform rapid, focused work-ups on acutely ill patients admitted at night and on floor patients who decompensate at night. An emphasis is placed on accurate diagnosis and rapid stabilization, use diagnostic tests in a way that is cost effective and does not lead to delay in implementing necessary treatment, while not omitting any test that is necessary to accurate diagnosis.

· Develop a problem list for every patient, an assessment for each problem, and a plan for every problem that includes diagnostic work-up, therapy and monitoring, and patient and family education.

· Demonstrate the ability to evaluate the results of lab tests, monitoring data and response to therapy, and to be able to state what he/she will do with these data when obtained.

· Write an organized, pertinent, legible, and complete note documenting the above items.

· Demonstrate respect, compassion and empathy for patients and their families.

· Integrate the results of diagnostic studies to refine the differential diagnosis.

· Select additional diagnostic studies and therapeutic interventions based on the refined differential diagnosis, with some supervision.

· Counsel patients/families about their medical conditions and educate them about the diagnostic and treatment plan.

· Work toward completing the requirements for technical and cognitive proficiency for invasive procedures, especially those required by the ABFM and ACOFP. Perform invasive procedures under supervision until those requirements are met.

· Recognize the role of healthcare providers from other disciplines and services, and work in cooperation with those providers to provide comprehensive, patient-centered care.

PGY-2 Residents are also expected to:

· Demonstrate the ability to elicit subtle findings from the history and physical exam or to augment the physical exam with additional maneuvers as needed to support or refute a diagnostic hypothesis.

· Integrate all information from history, physical exam and diagnostic studies to develop a diagnostic and therapeutic plan with minimal supervision.

· Begin to incorporate consideration of risks, benefits, and costs into patient management plans.

· Effectively communicate the management plan to patients/families and modify that plan based on their values and preferences.

· Begin to utilize information technology to retrieve and apply current medical evidence (e.g. guidelines, original literature) to refine the patient management plan.

· Initiate and coordinate the involvement of healthcare providers from other disciplines and services to provide comprehensive, patient-centered care.

PGY-3 Residents are also expected to:

· Integrate all information from history, physical exam and diagnostic studies to develop a diagnostic and therapeutic plan at the level of a family physician without need for supervision.

· Consistently incorporate consideration of risks, benefits, and costs into patient management plans.

· Consistently utilize information technology to retrieve and apply current medical evidence (e.g. guidelines, original literature) to patient management.

· Complete the requirements for technical and cognitive proficiency for invasive procedures, especially those required by the ABFM and ACOFP.

Core Competency: Medical Knowledge

Goal: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

Progressive Learning Objectives:

PGY-1 Residents are expected to:

· Display an attitude of inquisitiveness and a desire to continuously expand their knowledge base.

· Utilize reference materials (e.g. textbooks, Up-To-Date®, pocket references) to correct deficits in knowledge related to the diagnosis and treatment of the patients for which they providing care.

· Achieve a 90% correct score on the quarterly exam or rotation quiz for any rotation they perform which has such a quiz.

PGY-2 Residents are also expected to:

· Have more in-depth understanding of diseases commonly encountered in a family medicine ambulatory clinic and on internal medicine inpatient services, as demonstrated by the ability to develop an appropriate initial diagnostic and treatment approach to these conditions, with minimal supervision.

· Utilize current medical evidence (e.g. guidelines, original literature) to correct deficits in knowledge related to the diagnosis and treatment of the patients for which they providing care.

· Develop a plan of systematic, independent study to expand their knowledge of internal medicine and its subspecialties.

PGY-3 Residents are also expected to:

· Have a basic understanding of unusual or complex diseases commonly encountered in the subspecialties of internal medicine, as demonstrated by the ability to:

o Develop an appropriate initial diagnostic and treatment approach to these conditions.

o Refer to a consultant, when appropriate.

Core Competency: Practice-Based Learning and Improvement

Goals: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

Progressive Learning Objectives:

PGY-1 Residents are expected to:

· Be able to teach medical students. Seek and accept feedback from students and use that feedback to improve their teaching and supervisory skills.

· Seek and accept feedback from attendings and supervising residents, and utilize that feedback to improve their clinical performance.

· Set short-term learning goals for each rotation. Self-evaluate their own performance relative to those goals at the beginning and end of each rotation.

· Set long-term learning goals (learning plan) for the academic year and residency with their advisor.

· Perform competency-based, semi-annual self-assessments.

· Be able to formulate clinically relevant questions related to the diagnosis and treatment of their patients’ medical conditions.

· Be familiar with common databases of medical literature (e.g. Medline) and common search engines (e.g. OVID, PubMed, etc.).

PGY-2 Residents are also expected to:

· Be able to supervise and teach medical students and interns. Seek and accept feedback from students and interns, and use that feedback to improve their teaching and supervisory skills.

· Seek and accept feedback from attendings, and utilize that feedback to improve their clinical performance.

· Set longer-range learning goals for their residency training. Develop learning plans with their advisor to help achieve those goals and a method of evaluation to determine their success in meeting them.

· Know basic methods for searching the medical literature, and be able to find original medical literature related to the diagnosis and treatment of their patients’ conditions.

· Be able to critically appraise literature related to diagnosis and treatment, and appropriately apply the results of that literature to their clinical practice.

PGY-3 Residents are also expected to:

· Be able to present effective teaching conferences, including Morning Report and a Clinical Pathological Conference.

Core Competency: Interpersonal and Communication Skills

Goals: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates.

Progressive Learning Objectives:

PGY-1 Residents are expected to:

· Provide verbal presentations that are thorough, yet succinct and pertinent, and that reflect understanding of the patients’ condition and/or support a differential diagnosis.

· Provide dictated and written notes that meet the same criteria. In addition, written notes should be legible.

· Provide written/electronic and verbal sign-out of patients that is efficient, pertinent, and explicit.

· Be open and receptive to questions and recommendations from members of the nursing staff and ancillary healthcare services.

· Develop a therapeutic relationship with patients and their families, regardless of their background.

· Be able to explain a patient’s condition and plan of care to the patient and family in terms that are understandable and appropriate.

· Be able to discuss the risks and benefits of procedures or interventions with patients and families, and obtain informed consent.

· Be able to discuss resuscitation status with patients and families, answer their questions regarding this issue, and elicit the patient’s wishes in regard to cardiopulmonary resuscitation.

· Communicate expectations to students and provide them with feedback.

· Dictate discharge summaries that succinctly summarize and convey the pertinent details of the patient’s hospitalization and post-hospitalization follow-up needs.

PGY-2 Residents are also expected to:

· Provide written senior admission notes that succinctly summarize the patient’s condition, reason for admission and management plan.

· Dictate discharge summaries that succinctly summarize and convey the pertinent details of the patient’s hospitalization and post-hospitalization follow-up needs.

· Effectively communicate verbally with consulting physicians. Be able to succinctly summarize the patient’s condition and the explicit reason(s) why consultation is being requested.

· Effectively communicate and coordinate the plan of care with nursing staff and members of ancillary healthcare services.

· Engage patients and their families in shared decision-making, especially in situations whether there is clinical uncertainty and /or ambiguity.

· Lead family/team meetings, with some support from the attending physician, including discussions of end-of-life care.

· Be able to resolve conflicts with patients/families, staff, or within the team, with some involvement of the attending physician.

· Communicate expectations to interns and students and provide them with feedback.

PGY-3 Residents are also expected to:

· Effectively communicate with junior resident physicians as a consultant, and be able to provide succinct, explicit recommendations both verbally and in writing.

· Lead family/team meetings, with minimal or no support from the attending physician, including discussions of end-of-life care.

· Be able to resolve conflicts with patients/families, staff, or within the team, with minimal or no involvement of the attending physician.

Core Competency: Systems Based Practice

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Progressive Learning Objectives:

PGY-1 Residents are expected to:

· Complete all charting/documentation/dictations in a timely manner.

· Learn the role of other members of the healthcare team, including case managers, social workers, physical/occupational/speech/respiratory therapists, dieticians, clinical pharmacists, and others.

· Recognize when their patients may benefit from the involvement of other healthcare providers, and invoke their assistance when appropriate.

· Learn what evidence-based guidelines and standardized order sets are available in our institution. Know how to find these resources, and utilize them when appropriate for patient care.

· Prescribe medications and diagnostics in accordance with the patient's health plan or obtain prior authorization/patient assistance when necessary.

PGY-2 Residents are also expected to:

· Effectively coordinate the involvement of healthcare providers from other disciplines and physicians from other specialties to provide comprehensive, patient-centered care.

· Learn to anticipate patients’ discharge needs (e.g. transportation and medication assistance; need for placement, home health care, and durable medical equipment; etc.), and begin discharge planning early in their hospitalization, with some prompting by the attending physician.

PGY-3 Residents are also expected to:

· Consistently anticipate patients’ discharge needs and begin discharge planning early in the hospitalization, with minimal or no prompting by the attending physician.

· Describe the basic systems of payment for health care, and the principal types of payers for health care.

· Demonstrate understanding of commonly used coding systems and describe the relationship between supporting documentation, accurate coding and reimbursement.

· Demonstrate understanding of basic principles of healthcare management systems.

Core Competency: Professionalism

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Progressive Learning Objectives:

PGY-1, PGY-2, and PGY-3 Residents are expected to:

· Treat all patients, regardless of background, with respect, compassion and empathy.

· Treat everyone else – nursing staff, ancillary healthcare providers, program personnel, students, residents from our own and other programs, attending physicians in all specialties, others – with respect and courtesy, and in a way that reflects positively on them as individuals and the medical profession as a whole.

· Respect patients’ autonomy and their right to make informed decisions about their own health care.

· Commit to advocating for their patients’ needs in the healthcare system, and be willing to place the patients’ needs above their own.

· Commit to provide the highest quality, most effective and most efficient care that their experience and level of training permit.

· Understand and safeguard patient confidentiality and protected health information.

· Be honest in all aspects of their professional life, including documentation of patient information, disclosure of medical errors, and acknowledgement of deficiencies in medical knowledge and clinical skills.

· Be committed to self-directed learning, self-evaluation, and self-improvement.

· Comply with the policies and expectations of the residency program, and complete administrative tasks (e.g. evaluation forms, medical records, logs) on time.

· Be willing to assist their colleagues and the program with patient care and service coverage when needed.

· Prompt completion of duties such as, but not limited to, timely reporting for clinical duties and educational activities, completion of portfolio requirements, completion of medication and other flow sheets used in the ambulatory setting, timely response to patient messages.

Core Competency: Osteopathic Principles and Practice / Osteopathic Manipulative Medicine

Goal: Osteopathic resident demonstrates a commitment to osteopathic principles and practice by including and documenting osteopathic diagnosis and treatment in their patient encounters.

PGY1 Residents are also expected to:

· Be able to complete and document an osteopathic exam.

· Perform and review osteopathic examination with osteopathic preceptor.

· Document osteopathic manipulative diagnosis and treatment in patient’s charts.

· Understand the indications and contraindications for osteopathic manipulative techniques.

PGY-2 Residents are also expected to:

· Identify when to utilize osteopathic manipulative techniques in practice.

· Recommend osteopathic manipulative techniques to appropriate patients in their continuity clinic and appropriate inpatients.

· Teach PGY 1 residents and students osteopathic examination techniques.

PGY-3 Residents are also expected to:

· Teach more advanced techniques of osteopathic manipulative medicine to junior residents and students under supervision of osteopathic attending.

· Clearly articulate the indications and contraindications for utilizing osteopathic manipulative techniques.

· Actively promote osteopathic principles and philosophy in patient care through promoting them on a daily basis.

Critical Care Learning Areas

Airway management

· Respiratory Failure

· ARDS

· Mechanical Ventilation

· O2 therapy

Electrolyte abnormalities

· Hyperkalemia

· Hyponatremia

· Hypernatremia

Acid/Base disturbance

Renal Failure

· Acute

· Chronic

Shock:

· Hemodynamic / Hypovolemic

· Cardiovascular

· Sepsis

Acute Coronary Syndrome

· Angina

· Acute MI

CHF / pulmonary edema

Respiratory tract infection

· COPD

· Asthma

· Pneumothorax

Diabetes and DKA

Mental Status Change

· Acute Confusion

· Coma

· CVA

· Seizures

· Meningitis

ETOH withdrawal

Substance abuse/overdose

GI bleed

Trauma

Medical Emergencies

· Near drowning

· Environmental injuries: Frost bite, Hypothermia, Heat injuries

Nutritional support/TPN

Monographs - See Monograph grid

Evaluation

All residents will take the assigned rotation quiz following completion of the rotation.

Residents will be evaluated by the faculty physicians assigned during the rotation

Residents following completion of the rotation will evaluate attending faculty.

Schedule

1. 5:30 PM Sign-out rounds with CCU team every Sunday-Thursday

2. 5:30 PM – 6:45 AM Respond as needed to admissions and unstable patients.

3. 6:45 AM Sign Out to CCU team or Resident of FHC patient.

4. Family Health Center is every Friday morning for all Night Float residents.

5. Wednesday afternoon conference attendance is not required unless specifically mandated by Program Director.

6. No other calls are required.

7. All night float residents are expected to attend all morning reports

No vacation is permitted on any of the Night Float rotations.

PROCEDURE DOCUMENTATION All procedures performed while on rotation are to be documented by the resident in their logs and turned in to CDE at the end of the rotation.

Genesys FP Residents - Resident Site

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