With many thanks to Alex Windhorn MD (UW Peds Class of 2016) & Peds Chiefs

• The Starting Line
• Day Senior
• Night Senior
• Resource Senior
• RAF (Resident Admission Facilitator)
• Other Helpful Tips & Strategies for Success
• Online Resources

The Starting Line

Arrange for sign-out 1-2 days in advance of starting the day senior role

• Keep in mind when receiving and giving sign-out that you are now responsible for the entire service
  • Tip: Use I-PASS format to help with systemizing and streamlining content
  • Be thoughtful about what really is pertinent, otherwise could take hours!

Discuss with your attending on your first day

• Expectations on rounds for you as the senior, your interns and medical students
• Teaching expectations
• When established check-ins will happen – after rounds and again in the evening for the night team?
• What the attending wants to be contacted about, their contact information, and how they would like to be contacted
• Your personal goals for the rotation/specifics of what you’re working on (be proactive!)
• When they would like to schedule feedback during their time on service

Discuss with your team on your first day (set a time to meet in the afternoon)

• Consider a visual/graph/poll to discuss team and individual goals
• Relay what you and your attending have agreed are expectations for the rotation
• Have your interns and medical students identify 1 or 2 specific things they are working on for the month (differential building, focused history, clinical management, etc.)
• Discuss any scheduling conundrums (someone leaving for clinic in the afternoon, outside resident days in clinic or teaching, etc.)
• How individual learning styles and how your team wants to learn and support each other during the rotation

Sign-out times and location

• Be clear about what time to show up the first day and where sign-out occurs
• If you are the day team and are going to change sign-out location, be sure the night team is aware

IPASS is our standard handoff tool

Day Senior

Morning Team Sign-out

Either 0630 or 0700, alternates daily

• Sign-up for your patients as secondary contact on CORES

Schedule Rounds on CORES

10 minutes

• Tip: Try to do this right after sign-out
  • As a senior you have a window of time that is typically uninterrupted before you get paged by an attending or interns start asking questions
  • Doing this early will score points with your attendings, team coordinator and RN case manager
  • This also helps with scheduling interpreters as soon as possible
  • Consider transport time and teaching time between specialties (it’s often better to run ahead than WAY behind)
• Print schedule for team, or ensure that it is printed by team coordinator

Pre-rounding on patients

1-5 minutes per patient, depending on acuity/complexity

• Realistically you will only be able to see 2-4 patients
  • Use your resource senior or attending if you need more eyes first thing in the morning. There should always be an early resource on weekdays.
• Prioritize sick patients first, then new patients
• Often, you will only have time to skim the Patient Summary Page on CIS and other targeted vitals/labs for each patient

Discussing plans/med student presentations

Time is dependent on the needs of your team

• At the beginning of your time on service touch base with your interns and medical student(s) about who needs time to run plans or presentations by you prior to rounds
• Set a specific time or it won’t happen
• Your resource can help you with this, especially working with medical students on presentations

Morning Report

0830-0900, except Thursdays when Grand Rounds run 0800-0900

• Definitely make this a priority even on busy mornings as you are still a learner too!  You are also setting an example for your interns by being present.
• Help interns prioritize so they can also attend (i.e. stable, established patients may not need to be seen prior to rounds)

Care Coordination Huddle

Before morning report; note-Team 4 does not have these huddles

• First and foremost, be on time
• Attendees: Team coordinator, RN case manager, gen med attending, you, social worker
• Purpose: To establish a shared mental model with care coordination and nursing about discharge needs and required follow-up (including PCP appt) for each patient.
• This is also the time to ask for care conferences and interpreters to be scheduled.
• Note: This huddle is NOT “mini-rounds” – avoid extensive discussion about medical management or plan of care.
• Aim for max 1 min per patient, shorter if no changes or no discharge readiness issues.
• What you do:
  • Start with a one-liner for each patient (can forgo this if everyone knows patient)
  • Follow next with anticipated discharge date
    • Identifying discharge criteria for each patient on rounds will make this easier and streamline discharge planning
    • It is okay to say the discharge date is unclear, but quickly review what needs to happen for discharge
    • Reference the Discharge Readiness Checklist in CIS for each patient to make sure the major categories of discharge needs are covered:
      • Education/Teaching
      • Home medical equipment
      • Medications
      • Transportation
      • Follow-up appointments
  • Discuss with your RN case manager if supplies are needed for home
    • Could include: home monitors, oxygen/respiratory support, feeding tube supplies, feeding pump, formula, CPT vest, IV antibiotics, durable medical equipment, blood pressure cuff, wound care supplies, etc.
  • Discuss with your team coordinator appointments needed after discharge
    • For subspecialty appointments, clarify who needs ambulatory transfer of care/consult orders
    • Put in orders for outpatient labs or imaging if needed

Rounds

0930-1230, except team 2 which starts rounds at 0915

• You are the team leader: set the routine
• Setting a consistent routine for rounds helps things to go more smoothly
  • Ask about out of room concerns for all patients – ask RN early, before entering room, if any issues to discuss.
  • Make sure introductions happen consistently for families.
  • You are responsible for keeping the team on time. Feel free to say “we need to move on to our next appointment, we can come back this afternoon to continue this conversation.”
  • If you can, take notes on the students’ and interns’ presentations and then give one piece of actionable and specific feedback immediately following rounds
• On subspecialty rounds:
  • You can direct interns to present to the fellow (if one is on service), if this is decided beforehand
  • Encourage interns to have independent plans even if they may be adjusted by the attending / fellow on service. You will be surprised what gen peds recommendations you can offer in addition to specialty care.  
• On general pediatrics rounds:
  • Set goals/expectations with your attending early to make this successful and fun
  • Direct interns to present to YOU
  • You should be the first to give feedback after a presentation is finished and confirm the plan of the day. Attendings will jump in if they disagree or want to provide a few teaching points to the family or team

Noon Conference

1230-1315 – REMEMBER: Thursday is intern support.  Snag their pagers!

Journal Club and Pediatric Residency Meeting (“Housestaff”) are also on Thursdays monthly.

After rounds

• Prioritize getting sign out from your resource senior (they may have afternoon clinic)
• Run the list with your team to outline what needs to be done for each patient for the day
  • Communicate clearly who is doing what for each patient.
  • Help with prioritization of consults, orders, notes, etc.
  • Try to pick a few things from each intern’s list that you can “take off their plate”, focusing on things that have less learning opportunities
• Continue to take admissions and transfers as they come
  • If your interns are really busy, you can consider taking a new admission yourself so they can focus on their current floor patients, notes, etc.

Teaching and Learning

10-15 minutes, can happen anytime but afternoon works well

• Have plan for this early on, set the expectations early!
• Fill out laminated teaching calendar in team room for the week
  • Gen Med attendings switch on Wednesday, so generally don’t schedule one that day so you can plan to meet in the afternoon to discuss expectations
• Aim for one 5-10 minute learning session per day
  • Distribute across team (you, interns, med student, attending, pharmacists, etc.)
• Teaching does NOT have to be comprehensive or in PowerPoint format; bedside physical findings and quick “chalk talks” are more likely to occur and be effective
• Consider integrating teaching time into rounds instead of afternoon to fit it in.

Afternoon until Sign-out

• Check-in with your attending and/or fellows at some point in the afternoon
  • This is a good time to discuss any evening discharges/change in plans
  • Discuss “if/thens” and what attendings want to be called for to help set the night team up for success
• See a few patients and families yourself in the afternoons, not only to check in on sick patients but also for your own well-being. Social visits are encouraged.
• Continue to take admissions and transfers
  • RAF starts covering admissions and transfers at 1700
  • Consider taking admits at 1700 if work flow allows to decrease handoffs, especially for subspecialty patients
• Look through your “To-Dos” to verify that any major plans for today were not missed
• Prepare for sign-out by updating CORES (be clear about who is doing this each day)

Evening Sign-out

Either 1800 or 1830, alternates daily

Night Senior

Evening Sign-out

Starts 1800

Post sign-out pre-rounding:

30 minutes-1 hour

• Sign up for patients and set expectations with your intern
• See any sick patients first, then consider seeing new or complex patients if warranted
• Prioritize taking sign-out from the RAF as soon as they are ready
• Take admissions/transfers

Evening rounds

Around 2200 depending on admissions

• You determine when they start
  • Try to be strategic with when admissions are coming in, nursing transitions are happening and night teaching.
• Some nursing shifts end at 2300 and they will be doing handoff. They don’t generally like to be interrupted. You will score points if you respect nursing sign-out by offering to come back or call to round
• Try to let your intern lead evening round discussions with nurses
• If you have heard in sign out that a patient will likely go home the next day, please discuss this with the overnight nurse so that any concerns from their end can be passed along to the day team
• In person midnight rounding is strongly preferred. If you are very busy, it is okay to call nurses for midnight rounds. Try not to make midnight rounding by phone your usual routine.

Midnight breakfast and teaching

0130-0200, Forest 2 lounge area

• You will get an email with the list of topics before your week of nights, make sure to reply to all with your selected topic and review the prepared curriculum
• Time for night teaching is 0130 in the Forest 2 lounge area on Monday-Thursday nights. Encourage your team to get their food before 0130 so that everyone is ready to eat and learn by 1:30am.
• Have fun with this!
• Many have opted to talk about an interesting patient on their service morning report style in addition to the scheduled curriculum
• You have a lot of one-on-one time with your intern to teach and provide feedback, take advantage of this

Resources

• You have many resources overnight even if it doesn’t always feel like it
  • Your fellow wards seniors, including team 7
  • Medical Hospitalist (7-6058)
  • Your attending
    • If possible discuss “call for” parameters and if/thens early in the night
      • You MUST CALL your attending for
        • Code Blue, RRT, and Families leaving AMA
    • That being said, you can call your attending for any question or need!
      • Uncertain of admit plan for a patient you are admitting
      • Acute management changes that you want to discuss first

Resource Senior

• When to arrive:
  • Early Resource seniors arrive at 0630 to protect morning sign-out
  • Start by going to the PICU to see if there are any early morning transfers – the goal is for these early morning PICU transfers to leave the PICU at 0700
  • If you are not the Early Resource, you show up at 0800, grab the resource phone and head to morning report
• Check in with the seniors when you arrive to let them know you are there and see if they have any needs (coaching interns/medical students, evaluating sick patients, etc.)
• Attend rounds
  • You can be a huge help for order entry with new interns, especially early in year
  • Learn about patients you will be covering either on nights or as day senior
• Take admissions and transfers
  • Orders and CORES are the priorities, if you have time to write the H&P that is great but not an expectation
• Keep in mind, while you are assigned to a pair of teams, you are a resource for everyone
  • If another team needs help you can flex to be another team’s resource
  • If another resource has their “resource day off,” the remaining resource residents need to help cover those teams.
  • If you are Early Resource for Team 1/2 and take an admission for team 6, it is best for you to keep that patient until the primary team is ready to sign-out, don’t create another hand-off by then signing it out to the 5/6 resource senior.
• Help with medical student plans and presentations
• Be another set of eyes for sick patients if needed
• Consider helping with an RRT so that the primary team can continue on with rounds
• It is a privilege to leave early, not the expectation
  • If a team senior calls out sick, the resource senior may be called upon to step into the day senior role for that team as opposed to calling in jeopardy.

RAF (Resident Admission Facilitator)

• Goal: to protect evening sign-out
• Arrive at 5pm and pick up the Team 3/4 Resource phone 7-7449
• Check in with your seniors to let them know you are here then head to the ED
• Take admissions from the ED and/or ICUs for the wards teams
  • You do not take admissions to heme/onc, ICUs or hospitalist services
  • Orders and CORES are the priorities, if you have time to write the H&P that is great but not the expectation
  • Feel free to call attendings or fellows if you have questions about admissions just like you would if you were a primary team, especially if it is regarding which place is safest for a child to be in the hospital
• Hand-off admits to the teams at 7:30 and leave the hospital by 8pm

Other Helpful Tips & Strategies for Success

Be the senior you would want to have!

• You set the tone for the team, the more you help out and stand up for your interns and help with their work flow, the more they will step up for each other. 
• A positive attitude as a leader goes a long way for team morale!
  • Be aware of microaggressions, bias,  or mistreatment of your team and patients – if you notice something, say something, whether to an attending, colleague, or to families
  • Remember your DEAR statements (Describe, Express, Ask, Reinforce) to address concerns
• Consider making a visual aid (sticker calendar, list of ideas, bingo etc.) to promote team resilience and team mission: be the keeper and promoter of this tool
• Try to help your interns get to morning report and noon conference, consider taking their pagers for uninterrupted teaching once in a while

Support a growth mindset when teaching

• Support your interns but encourage them to grow. When your intern asks you a clinical question, consider reflecting it back to them and having them think through and employ a management strategy first before offering your thoughts.
• One Minute Preceptor approach
  • First ask “what do you think is going on?”
  • Then ask for supporting evidence: “why do you think that?”
  • Then ask for their plan: “what do you want to do?”

Ask for help – early and often

• Before you call an attending or fellow for help, make a plan for what you would want to do if you were making the decision independently – you will learn more approaching your questions this way, and they will appreciate it, too!
• If you have questions about an admission from the ED, the ED attendings and fellows are great resources as well.
• Involve the chiefs early and often if you are struggling with a problem. They can help think of resources, solutions, and give you coaching!

Remember key concepts for responding to challenging situations:

• Listen (and speak) from the heart
• Your kindness and compassion as a listener is most important
• “Kiss the Boo-Boo”
• We often need to acknowledge emotions before someone feels heard
• Take cues from Improv!
• Be open: “Yes, and…”
• No blocking! (Avoid “No, but…”)

Online Resources

• Teaching materials posted on UWPeds: https://depts.washington.edu/uwpeds/
• Team 7 website: http://depts.washington.edu/uwpeds/teaching/
• HMC Peds: http://www.hmcpeds.org/ – your UW net ID login and password “hmcpeds”