MDH Direct Care (docx)

Hospital Medicine MDH Direct Care Services¶

Dogwood, Magnolia, Cedar, and Pine are the direct care services for our general medicine patients. Each service has separate MD and APP teams. Dogwood and Magnolia APP teams are staffed Monday through Friday; the Pine APP team is staffed Monday through Sunday. Although there are small differences between the teams (listed individually later in this document), there are common expectations and responsibilities. Expectations and Responsibilities: - Providers are expected to arrive and assume responsibility of the assigned team pager at 7 am. If an emergency arises and you are unable to arrive on time, you must arrange coverage for your patients starting at 7 am. - Rounding providers should assign themselves as the Attending of Record AND Sign In as “Attending Provider” for your team. These are best done as separate steps! See MDH Logistics Tips, below - The paired MD or APP is expected to help when our multidisciplinary teammates are unable to reach the other provider through the pager system. - If you would like verbal sign out from the Night providers, you should make contact with the Night providers by 7 am. Cross cover issues from overnight will be written at the bottom of the patient’s “Plan Note” sticky note and these notes should be reviewed by team providers daily. - Team based IDR rounds Mon-Fri mornings, see IDR link for schedule. - Physicians should touch base with their paired APPs each morning and see patients who require MD assessment. See “Working with APPs” in the DHM Service Guides for best practices working with our APP colleagues. - For all patients admitted to a team for more than 48 hours the MD/APP should update the problem based “Hospital Course” with an "outpatient to do" list available for transitions of care among providers. Additionally, when MD/APP has written 2 or more daily notes on a patient, the “Hospital Course” should be updated. - On weekdays M-Thurs, if the daily work is complete and the patients are stable, providers may sign out to the Long Call MD after 4 pm. Anticipatory guidance should be provided on sick or unstable pts. - On weekends Fri-Sun, if the daily work is complete and the patients are stable, providers may sign out to the Long Call APP after 4 pm. - Prior to sign out, all patients should have a formal sign out note written under the “Plan Notes” window on the “Overview” tab of the “Summary” page in Epic, using the smart phrase “.LMNOTESIGNOUT” for standard format. Any guidance or follow-up items should be written in this location and should be updated daily. - Follow up items for cross cover should be signed out to the covering provider, either verbally or via epic chat. At sign out, it is the responsibility of the team provider to ensure that the associated pager is forwarded to the covering provider. - Covering providers should resume role of “First Contact” in Epic - Going into weekends, patients from the Dogwood APP team, as well as any acute-level patients on the Magnolia APP team, should be redistributed among the MD teams based on location and census numbers; this distribution is the responsibility of the off-going providers. - All medically complex co-management patients on the Magnolia APP service should be placed on the Magnolia MD list and seen daily by this provider through the weekend. Less medically complex co-management patients on the Magnolia APP service remain on that list and should be seen by the hospitalist Consult provider over the weekend. The hospitalist Consult provider should assign themselves to the “Magnolia APP” designated pager on weekend days to cover the less complex co-management and long-term patients. - When transitioning from a weekend back to a regular weekday (when APP teams return to service), attempts should be made by on-service providers to optimize regionalization and continuity of patient care. Hospitalist Teaching Service: Two of the hospitalist services will have learners (PA students, 4th year Acting Interns) assigned to the team. Those providers who do not meet Division and Department expectations for education and teaching will not be assigned to these services. See Teaching resources in this handbook for more information.

MDH Logistics Tips¶

Daily tasks: - Sign into pager via MyUNC Health Directory. If directory not working, you can sign into the directory via Citrix MyApps or call 984.974.7272 and follow the prompts. - Assign yourself as the Attending of Record by highlighting patients, right clicking and picking “Assigning Others” with Attending box checked on the first day on service as well as each subsequent day on service for new patients added to the list. - If you click “Override 1st Contact” during this step it will lock you as 1st contact, so avoid this problem by signing in to 1st contact as below. - "Sign In" to the team and patients on your list as “Attending Provider” with a sign out time, this should set you as “First Contact” in Epic (click “Take over overlapping assignments”). It is helpful to set an end time to prevent receiving messages inappropriately. - At end of the day, sign out to the Long Call provider (before 7pm) or Night 2 provider (at 7pm) and forward your pager via the directory

Other tips - Hospital phones are listed with 5 digits starting with 4 or 5. The corresponding extensions 984-974-* or 984-215- - To reach Vocera, dial 33 or 5-4502 at the Medical Center or 22 or 5-4500 at Hillsborough. - The easiest way to reach a nurse on Vocera is to say "room #" + "nurse" (i.e. “8301 nurse”). Can also use the nurse's name (but frequently Vocera will misunderstand). Can also call the unit (ex: 33 --> "6BT") and ask the HUC to connect you to the nurse. - When switching off service, update the hospital courses and plan signout notes and contact the provider taking over to offer verbal sign out.

Team-based IDR rounds:

For the ER case manager, go to epic chat, enter "UNCH - Care Manager Emergency Department", select "group" and message them

On weekends to contact case management, go to epic chat and enter "UNCH - Care Manager Weekends", select "group" and message them

For admits from Psychiatry: Psych places a discharge order. MAO creates a new encounter. Admitter places orders and H&P in the new encounter to get them transferred to the medicine bed.

To contact the MAO search epic chat for "MAO" and click "groups" or can text/call them 919-667-4493

Team-specific information, expectations, and resources: Dogwood: This team is supposed to have most of its patients located on 6BT.

Magnolia: This is our co-management service with Orthopedic surgery and Cardiology and will often have pre- and post-operative patients on it. Please reference the Co-Management Agreement document in SharePoint.

Pine: Targeted to 7BT. No specific patient population (although notable that 7BT does not have telemetry capability). Pine APP coverage continues throughout the weekend and the MD provides support as needed.

Cedar: Targeted to 4 Oncology and the BMT Unit. For this reason, scheduled oncology/chemo admits may occasionally end up on Cedar depending on available team space. Please refer to our Chemo Guide provided by the Oncology faculty.

Cap guidelines for the MDH Direct Care Services:

The hospitalist service cap (76) has been determined by the number of patients our providers can see in a day while still providing comprehensive, quality care. - Once the cap limit is reached, MCAT service manages maximum of 8 ED patients and triages to either consult and recommend ED discharge, consult and continue to manage in ED, consult and anticipate admission to hospitalist service when space becomes available. - When our caps are reached, patient flow through the hospital is seriously limited, so all efforts to minimize time at cap should be made. - This cap number should not be lowered unless directed by DHM leadership. Below is a breakdown of how we imagine the patient distribution within our cap as well as accommodations for short staffing.

Full staffing assumes 4 MDs and 4 APPs and total service capacity of 76.

[ ] Revisions upcoming with addition of 2nd weekend APP¶

One APP Absence¶

Team MD assumes care of any patients they feel most familiar with.
Co-management patients should stay on Magnolia/Magnolia APP (this is what Ortho nursing is familiar with).
Patients otherwise distributed in a way which best achieves near-equity and regionalization in team lists (this may include other APP lists).

With one APP out, anticipated max capacity for teams are:

Dogwood MD	13
Magnolia MD	13
Pine MD	13
Cedar MD	13
APP 1	7
APP 2	7
Magnolia APP	Up to 11 (8 long-term, 3 acute)

Two APPs Absent, Weekends¶

Team MDs assume care of any patients they feel most familiar with.
Co-management patients should stay on Magnolia/Magnolia APP.
Patients otherwise distributed in a way which best achieves near-equity and regionalization in team lists (this may include other APP lists).
APP census can go to 8 when MD census >13.
Consult attending can act as point person to distribute his/her patients to Procedure or Second Shift depending on who has bandwidth that morning.
Friday PM prep for weekends:
Cedar and Dogwood APPs work with attendings to distribute patients to the MD teams according to guidance described above. Acute patients on Magnolia APP are distributed as well. Provide any sign out prn.
Magnolia APP signs co-management and long-term patients out to consult service on Friday. Consult attending covers Magnolia APP pager through the weekend and sees any long-term patients needed.
Sunday afternoon, MDs return APP patients to original APP if continuity is important

With two APPs out, anticipated max capacity for teams are:

Dogwood MD	15
Magnolia MD	15
Pine MD	15
Cedar MD	15
APP 1	8
Consult MD to triage.	11 (8 long-term patients, 3 acute)

Four APPs Absent, Pine APP out on weekend¶

Guidance as above for two APPs absent. With three APPs out, anticipated max capacity for teams are:

Dogwood MD	15
Magnolia MD	15
Pine MD	15
Cedar MD	15
Backup/APP 1	8
Consult MD to triage	11 (8 long-term, 3 acute)

The hospitalist APPs are Kelly Stepanek ACNP, Dana Mabry ACNP, Stella Mary Inigo ACNP, Kari Hackley ACNP, Dana Raines, ACNP, Cherie Somera, ACNP, and Eric Allman ACNP.

For questions or concerns, please reach out to our leadership team: Beth Ann Brubaker, MD, Med H Service Line Leader: [email protected] Dana Mabry, ACNP, Lead APP: [email protected] Andrew Donohoe, MD, Associate Chief of Clinical Operations: [email protected] David Hemsey, MD, Division Chief: [email protected]