Clinical neuroscience Service (CNS)

 

The clinical neuroscience service (cns, also known as the general neurology team) is responsible for caring for patients with neurological diagnoses (e.g., minor stroke, seizure, demyelinating disease, neuromuscular weakness, etc), and patients transferring out of the nccu.

Goals & objectives

  • Be able to evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.

  • Develop appropriate differential and initiate further diagnostic testing and management for movement, neuromuscular, cognitive/behavioral, demyelinating, seizure, neuro-oncologic, and neuropsychiatric/somatoform disorders, along with headache and neurologic manifestation of systemic disease.

  • Lead interdisciplinary rounds, interacting respectfully with the other team members while advocating for appropriate patient care.

  • Counsel patient/family regarding diagnosis and treatment plan, discuss goals of care and negotiate conflicts among family/patient and the treatment team.

  • Discharge patients in a manner that ensures smooth transitions from inpatient to outpatient care.

  • Incorporate feedback and develop a learning plan.

  • Review literature to incorporate evidence-based medicine in patient care.

  • Appropriately order and interpret neuroimaging studies.

  • Clearly and completely document patient care in a timely fashion.

  • Communicate effectively with other members of the care team, both verbally and through documentation.

Location

Team room is on the 4th floor of gudelsky. Room code is 214.

Patients can be located on the neuro imc (right next to the team room) or c5w.

Team structure

Attending, Pgy-3 Neurolgoy Resident, 1-2 Psych Residents, 1 APP, 2-3 Medical Students

General Neurology Attending:

Neuro-hospitalists: Drs. Butt / Klein / Woodward / Nunez

Other attendings that will rotate on service include the consult attendings.

  • Ultimately responsible for the care of all patients on the service

  • Present for rounds (at 08:00) and available all day for patient care issues

Usually on service in 7-day blocks, starting on fridays. Check ezcall for schedule

Pgy-3 Senior Neurology Resident:

  • Lead rounds in collaboration with the attending. The senior should have a big picture view of all patients and advise the attending of the most efficient order for rounds

  • Allocate patients to each provider and medical student

  • Oversee and assist the psychiatry intern in caring for their patients.

  • Direct patient care as the primary provider for some of the patients. As a rule-of-thumb the senior will typically have primary responsibility for some patients if the census is >10.

  • Discuss patients at interdisciplinary rounds (idr) every weekday at 11:00 am to facilitate discharge planning with case management, therapy services, and social work.

    • This meeting is to discuss disposition, not the medical plan or your ongoing assessment. Only mention what is relevant to disposition.

  • Ultimate responsibility for care of all patients on the service, including:

    • Discharge planning

    • Reviewing labs, orders, and medications

    • Ensuring that medication reconciliation is performed appropriately.

  • Maintain pending patient list for outside hospital transfers.

  • Add patients to the cns list who are pending neuro icu downgrades.

  • Communicate with the charge nurse on each floor prior to walking rounds so that they can join in

  • Keep the cns data spreadsheet up-to-date (the link for the excel sheet is sent out at the beginning of the academic year by the chiefs). It is your responsibility to ensure accurate data collection which is used for m&m. On alternate weekends when an off-service resident is covering, they should be updating the spreadsheet for those days.

  • Family updates: ideally update families daily. Major changes or escalations in care should be communicated in a timely manner and documented as appropriate.

CNS Advanced Practice Provider (NP or PA):

Current schedule is 4 days a week (either mon-thurs or tues-fri).

  • Serve as the primary provider for patients as determined by the senior and attending. Patients who will typically be assigned to the app include:

    • Transfers from nccu

    • Patients in whom active neurological issues are essentially resolved and primary needs are medical and discharge planning

  • Run the list with app in the afternoon prior to sign out

Pgy-1 Psychiatry Intern:

  • Direct care provider for some of patients on the team alongside the senior resident and app.

  • Responsibilities: writing daily notes, placing orders, calling consults, discharging patients, signing out their patients to the on-call resident.

2-3 Medical Students:

  • Carry at least 2 patients each (more if they feel comfortable)

  • Present patients on rounds:

    • Evaluate new patients when available and present a full h&p

    • For follow-up patients present in the soap format

  • Utilize the medical student note functionality in epic to write notes. They can send these to the senior resident and/or attending for review and feedback.

  • If patients are amenable to having an lp performed by a medical student under the senior resident's direct supervision, this should be encouraged.

  • Should be involved with the care of their patients, including calling consults, obtaining accurate medication lists, and assist with other tasks. May pend orders for the senior resident to review and sign.

  • Students should inform you of any abscences. Inform dr. Motta and courtney as needed.

Work flow

07:00 get sign out regarding any overnight events from the night float resident

07:00-08:15 pre-round on patients, place urgent orders and consults

08:15: rounds start, usually with presentations of new admissions. Message the charge nurse on each floor when ready to see patients so that they can join.

11:00 idr (typically held in the conference room on the 7th floor)

11:30-12:30 noon conference (except wed 12:30-13:30)

Afternoon: prioritize orders, consults and discharges first, then progress notes. Update handoffs.

17:00 print list and sign out to the short call resident

WEEKEND SCHEDULE

There is no APP on weekends.

Weekend A: CNS will be covered by an off service PGY-4. Appropriate sign-out must occur on Fridays to ensure smooth transition of care. If the service is busy, discuss having the psychiatry resident assigned to Stroke to help with a few patients.

Weekend B: covered by the CNS senior and psychiatry intern

COMMON ITEMS TO BE ADDRESSED BY PROVIDERS

Medication Reconciliation:

Complete medication reconciliation upon admission, transfer, and discharge. You may need to call patient’s pharmacy (mark the drop-down list at bottom of med rec as complete and click reviewed to complete and get credit for it, otherwise will remain incomplete). Upon discharge you must indicate in the comment section the date of initiation for the medication and the date when the medication is complete. This information will transfer to the after visit summary (AVS) so the patient has clear understanding.

Daily orders:

  • Ensure DVT prophylaxis is ordered (pharmacological and mechanical)

  • Double check all orders to make sure they are consistent with the current plan

    • Treatment

    • Lab orders

    • Diet orders

    • PT/OT/SLP

    • ACTIVITY ORDERS (patient’s on strict bedrest cannot participate with therapies, and thus may delay discharge)

    • Restraints (See information on the Inpatient Orders Information page.)

  • Patients receiving MRI must have MRI checklist performed (frequently done by nurse)

  • Patients requiring any CT scan with contrast will require a contrast consent form completed by provider

Sign-out:

  • Should be continually updated throughout the day as developments arise. Please see separate Sign-out article for further guidance.

  • Please observe intern sign outs when they first start on this rotation

Discharge:

Patients on the CNS team may be discharged home or rehab (SAR vs. Acute). Occasionally they may be transferred to other services.

  • It is never too early to start discharge planning: home discharges may take considerably more time to coordinate services so plan accordingly.

  • Coordinate with Case Management:

    • ICU and 4East Case Manager is usually Sandra Worthington

    • 5West Case Manager rotates each week

    • There is an on-call case manager and social worker on the weekends

    • Keep in close contact with case management throughout the day to facilitate discharges

    • Weekend discharges: if you anticipate a patient leaving over the weekend, ensure the AVS/discharge summary are up-to-date and medication reconciliation is completed as it may be another resident covering the weekend

  • Discharge order reconciliation can be performed prior to discharge date

  • Discharge instructions: can be completed via the ADT tab. This is needed for all patients prior to discharging home.

  • Discharge summary:

    • Start the summary on the day of admission and update daily

    • All patient needs a discharge summary, however only those leaving to another facility (SAR, acute rehab, or transfers) need a discharge summary PRIOR to discharge. For those going home, you have 24-hours post discharge to complete this.

  • Follow Up Appointments

    • If patient needs a PCP: Can consult transitional care for home discharges and then also call C3 (coordcare clinic) 410-328-3117 to establish a follow up appointment with a PCP. There is also a CHF clinic that can be reached through this same number.

    • Neurology resident clinic follow up: send an Epic message to Lynette Goffin and Hannah Diggs. Use the dot phrase for scheduling

    • If a patient needs follow up with a specific neurology attending or subspecialty, you can contact their administrator (names and contact info are in the Resident Handbook).

OTHER INFO

Chain-of-command for the CNS for final decision-making, arbitration, or emergency is as follows: nurse -> junior resident -> senior resident=APP -> attending of record -> Dr. Badjatia (Vice Chair) -> Dr. Crino (Chair). For primary nursing issues : nursing -> charge nurse.

Relationship with Neuro ICU: When a patient is in the Neuro ICU, the General team is NOT the primary team and does not round or write notes on the patient. The General team is responsible for accepting transfers of patients from the ICU that no longer have critical care needs. Generally, the ICU provider will notify the senior and/or the APP of a potential downgrade after morning rounds. The senior will receive a verbal sign-out. If you have any concerns about the pending downgrade, alert your attending. The CNS team does not take over care until the patient is physically moved from the NCCU. Once they have downgraded, review all orders and update the family.

Pending patient list: The senior is responsible for maintaining the pending patient list, which is for patients who were accepted and are pending transfer from an outside hospital. The senior may be notified of an accepted patient by the attending on service, but this does not always occur. The senior is responsible for checking the Active Transfers list in Epic each day. See Inpatient Services’ Schedule and Workflow for details on how to do this.

Last Updated: July 31, 2024