Summary of today's Noon Conference

• Please note the Department of Medicine has agreed to pay for your taxi ride home and back to work if you are too fatigued to drive. Just save your receipt and turn it into Renee

Below links can be accessed easily by clicking on labels on the right side of the blog (when accessed on a computer)

• CLICK HERE to download Dr. Ragland's powerpoint from today

• CLICK HERE to download Resident Policy Manual (also give to you at orientation)

• CLICK HERE to download CIR MOU (contract) for 2014-2015 (also give to you at orientation)

• CLICK HERE  for Review of ACGME Duty Hour requirements as given in handout today

• UCLA Employee Assistance Program  phone number 1-800-730-3859

New Pulmonary & Critical Care Medicine Faculty

We have some exciting news. Kern Medical Center has hired 2 pulmonary and critical care physician for the intensive care unit.

Stay tuned to officially welcome our new faculty!

New Rotation Announcements - Sub-Specialties, Sepsis, and more.

Attention Residents:

The following were discussed during the faculty meeting today, please pay close attention:

• If as a primary team it is decided that you will not institute the recommendations of a specialist, please document the reason. 
• ex: nephrology consulted and recommends diuresis but as a primary team you decide that this may not be beneficial to the patient due to hypotension, please note it in your progress note.
• Antibiotics are recommended within 1 hour of recognizing sepsis. When evaluation patients in the ED and recognizing sepsis, place your first dose of antibiotics in the ACTIVE ORDERS, not the delayed orders. Contact the nurse and inform them as they don't get automatic print outs of orders.
• When placing critical orders (imaging, labs, medication, etc) in ED patients. Place them in the ACTIVE orders so they are available to nursing staff immediately.
• There will be a specialty evaluation committee on 2/24/15. The objective is to evaluate the medicine specialty services. If you have any recommendations, suggestions or concerns regarding any of the medicine sub-specialties, please post (anonymously if you'd like) in the comments below.
• Please make sure that there are Internal Medicine Consults placed when seeing patients.

A Message From Glenn Goldis, Chief Medical Officer

From: Glenn Goldis, MD, CMO
Date: February 5, 2015
Subject: Confidential Communication 

In response to ACGME process improvement recommendations, I would like to begin extending my availability to any of our Residents who wish to have a “safe place” to discuss sensitive issues or topics that affect the learning environment and your experience as a Resident at KMC.

Therefore, please know that effective immediately, I am available to discuss any personal or professional issues you may wish to share. I hope to use any learning from our discussions to improve the process, operations, or function of our facility and the Residency program itself. Any topic is “fair game” and held in the strictest of confidence.

Thank you in advance for your willingness to work with me toward improving the academic and clinical services we offer here at KMC.

If you would like to arrange a time to speak with me, please contact Tracy Subriar:
Office: 661-326-2718 or
E-mail: subriart@kernmedctr.com

Glenn Goldis, MD, MMM
Chief Medical Officer
Chief Academic Officer/DIO
Kern Medical Center
1700 Mt. Vernon Ave.
Bakersfield, CA 93306
Goldisg1@kernmedctr.com
(949) 445-4758 (cell)
(661) 326-2123 (office)

Weekend Call Schedule and Dr. Duggal Endocrine

Ladies and gentlemen,

Please note the weekend call schedule has been updated on Amion to reflect the changes.

Additionally for those of you on ambulatory care, pay attention to the subspecialty schedule regarding the Endocrine rotation with Dr. Duggal.
No longer are the days set for Tuesday and Friday.
Each week the endocrine rotation days are different so that we can accommodate the Family Practice Program.

New Weekend Call Schedule Trial

We will be "beta" testing a new call schedule for the weekend to ensure that residents don't work for more than 24 hours.

The following will only apply to residents and NOT interns:

Old Schedule:
Night float Thursday 9pm - Friday 7am
Wards Friday 7am - Saturday 7am
Wards Saturday 7am - Sunday 7am
Wards Sunday 7am - Sunday 9pm
Night Float Sunday  - 9pm - Monday 7am


New Schedule
Night float Thursday 9pm - Friday 10am (13hour call)
Wards Friday 10am - Saturday 10am (24 hour call)
Wards Saturday 10am - Sunday 10am (24 hour call)
Wards Sunday 7am - Sunday 9pm (12 hour call)
Night float Float Sunday 9pm - Monday 7am

Sunday night throughout Thursday morning, The scheduling will remain the same


What does this mean?

• There will be a 3 hour window where you'll be on call WITHOUT your intern while you admit to the incoming team.
• Example: Night float is on until 10am on Friday morning. A consult comes in at 9am. The senior resident is not available yet but the intern from Platinum team is there already. The night float senior will take the consult information, triage the patient appropriately, then supervise the ward intern during the encounter with the patient. The admission will be to platinum. Once the senior arrives at 10am, there will be a senior to senior sign out.
• Example: Platinum team is now on 24 hour call from Friday 10am to Saturday 10am. A consult is called on Saturday at 8am. The Platinum senior will take the consult, triage the patient appropriately, then supervise the incoming ward intern (Purple) to see the patient. Once the next team senior (Purple) arrives at 10am, there will be a senior to senior sign out.
• We will be using a consult pager that will be passed on from senior to senior. The pager number is 307-2191. This will simplify the process for the hospital to know who to contact for medicine consults.
• This new schedule means you will come 3 hour later on the 24 hour calls so you can leave by 10am and not hit the 24 hour mark.
• We understand this sounds complicated but the alternative more simple approach to avoid  >24 hour call is to extend night float from 5 nights to 6 so we can cover friday nights and then have residents that are on non call rotations (Cards, ID, AC, Neuro, etc..) Saturday night float. ---This means you will give up 1-2 weekends off while on non call rotations

If you have any questions or confusion, please don't hesitate to call us or ask questions in the comments.

Rotation 7 Updates

OpenVista Medicine Consults
Please ensure that the Emergency Department and any other consulting specialties place an internal medicine consult when calling you. This is important to maintain hospital statistics and ensure proper billing.

Endocrinology
Outpatient endocrine with Dr. Dugal is underway. Please see Sarah's post for more details. Dr Etinger will begin having inpatient endocrine teaching rounds on Wednesday/Thursday from 2pm to 4pm in the platinum room. Everyone is invited.

NIHSS Certification

Remember, the NIHSS certification is due by 1/7/2015. Please e-mail or print your certification to Sharon
Click here for details

Mentorship Program

The deadline to meet with a mentor and complete the evaluation form is 1/30/15.
Click here for details

PostOperative Orders

According to JCAHO, post operative (post PACU) orders to floor must be placed by the surgical team. Under no circumstances is the internal medicine team to place admission orders to the floor. This issue is included in the subspecilaty guidelines (#3) that was approved by the medical executive comission on 9/2/14 

The PACU staff and surgical department has been educated regarding this matter. If the PACU calls you to place post operative transfer order to the wards, please direct them to the surgery attending, resident, or NP/PA to complete the orders. Your responsibility is to add to the medicine related orders.

Senior Resident Notes
Dr. Ragland is actively working with Dr. Johnson on revising senior resident notes at this time. This includes minimizing the senior note to containing a brief and focused assessment and plan without the physical exam or HPI. Again, these are preliminary approaches and there will "beta" testing among several rotations before these goes live.

Candidate Interviews
We have candidate interviews the following dates. There have been several residents selected to tour the residents at 11:30am with a lunch at 12:00pm followed by a program powerpoint presentation. Please plan according and inform your service attending. If you will be unable to help out please inform the chief residents and help us find someone who can cover for you. See Sharon for the powerpoint presentation.

12/18/14 - Shadi
1/7/14 - Lusanik
1/8/14 - Nada
1/13/15 - Shadi
1/14/15 - Joel
1/15/15 - Vahe

Medication reconciliation
During the quality assurance meeting this month there was an emphasis on medicine reconciliation. This is important to ensure Meaningful Use phase 2 required by the government as well as transition to eRX. Please click here for the details surrounding medication reconciliation process

Faculty Mentorship Program

Please refer to the previous post regarding the faculty  mentorship program. Please use the form and contact a mentor as required by the date specified on the form.

http://kernim.blogspot.com/2014/10/mentorship-program.html

Acute Ischemic Stroke Boot Camp!

Hey everyone,

As you know Kern Medical Center is currently in the process of  becoming a stroke center. The next few weeks will be dedicated to educate the house staff about acute stroke.

Wednesday 11/5/2014: Acute Stroke - Part 1 Lecture

Catered noon conference by Dr. Sabetian on evaluation of a patient presenting with acute stroke

Friday 11/14/2014: NIH Stroke Scale training - Part 1
Friday 11/21/2014: NIH Stroek Scale Training - Part 2

Wednesday 12/03/2014: Acute Stroke - Part 2 Lecture

The second part of the conference by Dr. Sabetian. At the end of this conference there will be a review of questions and answers in regards NIH Stroke Scale

Once the lecture series is completed, All residents are expected to complete the NIHSS certification process and provide Sharon with a copy of your certificate. This is FREE test that is taken online.

How do I get NIHSS Certified?

• Go to http://nihss-english.trainingcampus.net/
• Click Register on the left box

• Complete the registration information
• Once you are logged in click on "my activities"

• Click on Enroll Now for Certification A

• Complete the videos and answer the questions. Once you complete the certification, you will be able to print out your certificate. Either e-mail or bring a copy to Sharon's office by January 5th 2015

End of Shift - New Consult Sign Outs (URGENT)

It has come to our attention that several residents are waiting for the next call team to see new consultations. This results in delay of the assessment and treatment implementations patients. The house rules have been modified to optimize patient safety. Please read the following:

1.       Team Senior: (Sunday-Thursday): Senior of the team is responsible for the call from 7am to 9pm.  However, he or she can defer consults to the night float if they are made after 8:30pm to give time for the senior resident to finish notes. The exception to deferring consults after 8:30pm is if the consult is urgent regarding a patient who needs immediate attention.  The senior resident must obtain the consultation from the ED and sign out to the next team. There must be a blank progress note to indicate which resident/attending the patient was signed out to.

2.       Team Senior: (Friday-Saturday): Senior of the team is responsible for the call from 7am-7am. However, he or she can defer consults to the day team if they are made after 6:30am. The exception to deferring consults after 6:30am is if the consult is urgent regarding a patient who needs immediate attention. The senior resident must obtain the consultation from the ED and sign out to the next team. There must be a blank progress note to indicate which resident/attending the patient was signed out to.

In summary:

• Consults can be deferred for night float at 6:30am and for Wards at 8:30pm.
• All ED consults must be written down and signed out to the coming team
• A blank note must be written indicating the resident/attending the patient will be signed out to
• It is not the ED's responsibility to call the coming team. It is the medicine team's responsibility to ensure the consult is seen in a reasonable time

Resident Meeting 9/30/14

The following were discussed at the resident meeting, please review and comment if you have any additions.

• Several residents indicated that the surgical subspecialties are refusing to place post-operative orders to transfer back to the medical team. This has resulted in patients remaining in the PACU for longer than anticipated. 
• If this occurs, please report the incident to the adverse event line x23501 and report on the blog
• The Joint Commission: Accreditation, Health Care, Certification requires the post operative team to place post operative orders.
• This has been clearly accepted by the sub-speciality admission guidelines at the MedExec meeting, which can be found here (item #3)
• There have been multiple requests to have uniform adherence to the sub-speciality admission guidelines throughout the faculty. This will be discussed with Dr. Ragland
• ICU downgrades should be occurring before 5pm unless there is an bed availability issue. It is unsafe for patients to be handed off through 4 team (ICU to ICU-NF to Wards-NF to Medicine Team). We encourage Night Float to reject admissions to the floor until a policy is made. We will discuss this with Dr. Chandra and Dr. Ragland
• There will be a cardiology lecture series done by Comprehensive Cardiology. They are requesting that you submit bread and butter cases to be used during the lectures. We are looking for the following: Afib, Heart Failure, Cardiomyopathies, Pericarditis, Acute Coronary Syndromes, etc.. please send any cases to Sarah and Avi so we can arrange the lectures appropriately
• Please complete your duty hours and attending evaluations on time. This is an ACGME requirement

Landmark Studies

Dr. Chandra was able to provide us with a list of landmark studies that every internist should be aware of. I've attached the list below. If you cannot find a topic for journal club then present one of these studies. Please confirm with Dr. Ratnayake as he may be able to provide you with an article as well.

Pain Management Clinic at KMC

A Message from Tonya:

We have a new Pain Specialist working at KMC Clinics 2 full days per week.  We must have an approved authorization to book to his clinic.  Please submit a consult to outpatient pain specialist.  With the provider's supporting notes, we can submit for authorization approval.  His first clinic at KMC will be August 28th.  Please let me know if you have questions.

Thank you in advance,

Tonya Bennett RN BSN | Interim Clinical Director

KMC Outpatient Clinics | Kern Medical Center

1111 Columbus St. Suite 1000 | Bakersfield, CA 93305

(661)326-6502

Email: bennettt@kernmedctr.com

Urology Clinics

From Dr. Ragland:

We would like to add 4 Urology clinics to be done during Nephrology. This would increase our continuity clinic percentage to further meet requirements as well as increase our rapport with Urology to better understand pathology for consulting reasons during inpatient wards.

What do you guys think? Please comment your opinions below.

CLER Focus Areas

Residents participating in CLER visit should be familiar with this Quality and Patient Safety List and their participation in these areas.

PATIENT SAFETY focus:

• CLIP (Central line insertion practices)
• CLABSI (Central line associated bloodstream infections)
• Restraints/falls (yellow socks)
• Infection control – hand hygiene, barrier control
• Procedures- informed consent and time out
• Do not use dangerous abbreviations

HEALTHCARE QUALITY focus:

• Sepsis Bundle (refer to pocket card)
• Medical Necessity – PCOFT daily documentation
• Pain score
• Necessity for central line, PIV, oxygen, foley catheter, Review of tele strips
• Core Measures
•  Heart failure – ACEI/ARB for LVSD
• AMI – aspirin prescribed at discharge

ACLS/BLS Certification

It has come to Dr. Chandra's attention that R3 residents are leading a code blue in the ICU or the Floors without being ACLS certified. This is a serious issue.

We are working on putting together a class for all the R3s.

To reiterate: If you are not ACLS/BLS certified, UNDER ANY CIRCUMSTANCES, DO NOT LEAD ANY CODES. Have the emergency department respond

Clinica Sierra Vista - Family Practice Inpatient Service

The Family Practice program at Clinica Sierra Vista will be starting an inpatient service starting Monday 7/28/14. Please be receptive to our colleagues if they are ever in need of help with the electronic medical record system or logistical aspect of the hospital.

Thank you,

Scott Ragland, DO
Program Director

Subspecialty Patient Limit

It has come to our attention that some residents are concerned about the number of patients they are following on subspecialty rotations. Dr. Ragland and the Faculty has agreed that residents will capped at 12 patients at a time in order to maximize education value.

The following rotations are included:

• Cardiology
• Gastrointestinal
• Infectious Disease
• Nephrology
• Neurology
• Pulmonology

Radiology SpectraLinks Live Tomorrow 7/8/14

Radiology is going LIVE tomorrow with status reports of critical studies. A review of the imaging shows that there is less than 10% compliance with team labels.

Please include your team name in the History box anytime you order any type of imaging studies!

Platinum: 62499
Purple: 65289
Orange: 65279
Green: 65134
ICU: 65299

Overflow/Fatigue/Illness Jeopardy / Back Up System

Faculty has approved a back upjeopardy system for the overflows, resident fatigue, and illness.  We previously announced that Friday and Saturday night float would be mandatory for the person on for overflows, while Monday-Thursday would be a home call, well this is no longer!!!


New Rules

• One person will be assigned jeopardy call for 1 entire week
• That person is required to be at the hospital within 60 minutes of receiving the phone call that the call team has capped. 
• Any forms of euphoria enhancing activities for the resident on jeopardy is highly prohibited ;)
• The resident on call obviously cannot be out of town.
• Failure of residents complying with the jeopardy system will results in forfeit of this system and we will revert to a weekend night float system
• If you want to change which week you are on jeopardy call, you must notify Avi or myself prior to the start of the call week. You will not be allowed to change your schedule once that week has started. We preferably want a two week notice.
• If you are called in on jeopardy call. Make sure to get the pager of the senior on call as it will be difficult to explain the schedule to the operator.
• The resident on call that cap and jeopardizes another resident do not go home early, they remain in the hospital to care for the inpatient wards.
• The jeopardy call schedule will be available on Amion soon.