Clinical neuroscience Service (CNS)
The Clinical Neuroscience Service (CNS) 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.
DAY 1 (FOR THE PGY-2
The day before, get signout from outgoing PGY-2 on patients that they have been covering.
The day before, touch base with the CNS senior regarding which patients you will be covering on day 1 (could be different from what they outgoing PGY-2 was covering)
Arrive by 7:00AM to the general neurology team room. Pre-round on your patients, which includes seeing them at bedside.
Be ready by 8:15AM to present your patients to the attending.
TEAM STRUCTURE
General Neurology Attending:
Ultimately responsible for the care of all patients on the service
Present for rounds (at 08:00) and available all day for any patient care issues
Usually on service in 7-day periods, starting on Fridays. Check EZcall to see who is on.
PGY-3 Senior Neurology Resident:
Lead rounds in collaboration with the attending. The senior resident should have a big picture view of all patients on the service and advise the attending of the most efficient order for rounds (e.g. which patients are likely to be discharged and should be seen expeditiously or which patients have a time-sensitive management decision to be made).
Determine patients for which each team member will have primary responsibility.
On Fridays, prepare for weekend coverage:
Determine primary patient coverage for the weekend residents.
Ensure there is a thorough sign out between the General Inpatient and General Consult teams
Oversee and assist the Psychiatry intern in caring for their assigned patients.
Maintain pending patient list for outside hospital transfers.
Direct patient care as the primary provider for some of the service patients.
As a rule-of-thumb: Senior will typically have primary responsibility for some patients if the census is >8-10.
Discuss service patients at interdisciplinary rounds every weekday at 11:00 AM to facilitate discharge planning with case management, therapy services, and social work.
Print out at least 10 lists for IDR.
This meeting is to discuss disposition, not the medical plan or your on-going assessment. Only mention what is relevant to disposition.
Ultimate responsibility for care of all patients on the service, including:
Discharge planning
Tracking pending lab results
Reviewing all orders and medication daily
Ensuring that medication reconciliation is performed appropriately
CNS Advanced Practice Provider (NP or PA):
Serve as the primary provider for patients as determined by the CNS senior neurology resident 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 disposition
APP will not always participate in AM teaching rounds if the service is busy. The APP can round with attending and senior resident immediately after teaching rounds or another time mutually agreed upon.
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 NP.
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 and as many as they feel comfortable with.
Present their patients on rounds:
They should evaluate new patients when available and present a full H&P.
For follow-up patients they will present in the SOAP format.
Utilize the Medical Student Note functionality in EPIC to write notes on their patients. 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.
They should be involved with the care of their patients, including calling consults, obtaining accurate medication lists, and assist with other tasks. They may pend orders for the Senior Resident to review and sign.
They should review as many of the medical student cases as possible with neurology resident.
COMMON ITEMS TO BE ADDRESSED BY PROVIDERS:
Medication Reconciliation: Complete medication reconciliation upon admission, transfer, and discharge if this was not completed by the admitting resident. 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 AVS so the patient has clear understanding.
Daily orders:
Ensure DVT prophylaxis is ordered (lovenox, subq hep, or SCDs)
Double check all orders to make sure they are consistent with the current plan
Treatment
Lab orders
Diet orders
PT/OT/SLP
Restraints
See information on the Inpatient Orders Information page
Patients receiving MRI must have MRI checklist performed (frequently done by nurse)
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:
It is never too early to start discharge planning: home discharges may take considerably more time to coordinate services so plan accordingly.
If your patient is ready for discharge, please update senior in the morning so that case management can be notified.
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
Follow Up Appointments
If patient needs a PCP: You can consult transitional care if the patient is discharging home 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.
If patient discharging to home and needs rapid follow-up in resident clinic: 8-6483, or send an Epic message to the resident admin staff. If a patient needs follow up with a specific attending or subspecialty, you can contact their administrator.
Family Updates
Especially while there is a visitor restriction, families should be regularly updated on the hospital course during day time hours.
Discharge order reconciliation can be performed prior to discharge date
Discharge summary:
Patients leaving for another facility need discharge summary done prior to discharge (start early)
Patients leaving for home need patient instructions (written in lay-person terms and/or utilize smart sets)
Discharge Summary must be done within 24 hours
WEEKEND SCHEDULE
There is no APP on weekends. On Fridays, the CNS senior should re-assign patients for the weekend accordingly.
Weekend A: CNS will be covered by the consults senior. Appropriate sign-out must occur on Fridays to ensure smooth transition of care. If the service is busy, discuss having the off service resident assigned to consults help with a few patients.
Weekend B: CNS senior and psychiatry intern will be working the same weekend.
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 NeuroICU, 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 APP will receive a verbal sign-out and briefly evaluate the patient. The CNS team does not take over care until the patient is physically moved from the NCCU.
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.
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/somatofoam disorders, along with headache and neurologic manifestation of systemic disease.
List the indications, contraindications, and complications of Lumbar Puncture and perform the procedure.
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.
Updated: September 2022