Inpatient Services’ Schedule and Workflow:
Clinical Neuroscience Service, Stroke Service, Neurology Consult Service
Schedule
Weekdays:
07:00 Day team takes over care from Night float. Residents pre-round and start daily notes (note: resident on service should arrive by 07:00 at the latest; if they need more time to preround on their assigned patients, they should arrive earlier, but not if it would violate duty hour rules)
07:45-08:15 Morning report (Neurology Resident Library – 4th floor hospital). Every day during summer; Tuesdays and Thursdays only Sept-June.
08:00-11:00* Attending Rounds (CNS = General team room; Consult = Neurology library; Stroke= Stroke team room)
* During the Summer and on Tuesday/Thursdays: Attending Rounds begin at 08:15, after morning report
Rounds should begin promptly at 08:00 (or 08:15 as indicated). The morning schedule is tight and starting rounds on time is essential to move forward patient care and have time for teaching.
Attending and Senior map out the day so that rounds can end by 11AM. Urgent consults, ED patients and discharge priority that need to be seen early
8:15-9:00: hear about new patients from overnight resident
9:00: Start walk rounds: usually start in 4IMC then 5th floor, then boarders (CCRU, Trauma IMC, MICU), then NCCU
11:00: Senior goes to IDR in the 7th floor conference room - be sure to print at least 10 lists
11:30-12:30 Midday Didactic Conference – Resident attendance at didactic sessions is a priority. With the exception of emergent clinical issues (i.e. acute stroke, active seizures, etc.), all clinical activities should be deferred. Emergent issues should be handled by senior residents to allow juniors to attend conference. Note: conference is at 12:30 on Wednesdays.
12:30-16:00 Patient care
(14:00-16:00 Wednesdays: Grand rounds and Case Conference)
16:30-17:00 Hand-off care of patients to short-call resident using written sign-out template. The verbal hand-off should be observed by attending or senior resident to give junior residents feedback and ensure appropriate information is conveyed.
20:30 Short-call resident hands off care of patients to Night Float resident
Tuesday and Thursday Mornings:
1st Thurs of Month: BAT morning report (Stroke Team Room)
2nd Thurs of Month: Patient Safety morning report (Stroke Team Room)
Every other Tues/Thurs: Resident morning learning (Neurology Resident Library)
Weekends:
Every weekend there will be a general, consult and stroke attending on service.
On Weekend 1 the consult senior will take over the general inpatient team. An off-service PGY2 will come in for the weekend to cover the consult service. It is imperative that the consult seniors signs out patients that need to be seen to the oncoming PGY2. The stroke service will be covered by the stroke PGY2 and PGY1.
On Weekend 2 the CNS senior will cover the inpatient team with the psych PGY1, while the consult PGY2 covers the consult service. The stroke PGY4 will cover the stroke service.
There is ½ the usual resident complement on the weekends:
7:00AM-12:00PM ‘Weekend float’ resident on call for all new consults (including BATs). Inpatient teams will be rounding and will handle all questions on current patients. Inpatient teams are the back up for the Weekend call resident if multiple acute issues occur simultaneously. Weekend float stays in house until 3:00PM to back up the on call resident.
08:00-11:00 Attending Rounds
12:00 Teams may sign-out to the Long Call resident after 12:00 if all work on current patients is done and they are stable to hand-off.
12:00-20:30 Short call resident covers all new consults/admissions and cross-cover
20:30 Short-call resident hands off care of patients to Night Float resident
Attending Rounds
Night float resident:
New patients may have been seen by the Night float resident or the prior evening’s Short Call resident. These two will take turns presenting to the General inpatient, Consult, and Stroke teams. The PGY4 residents will decide on the order of presentation based on the overnight activity.
When possible, the night float resident should join the team to go see one or more of the new patients they admitted so they can get feedback on their exam and assessment.
Team member roles on rounds:
Senior resident: leads rounds
Providers or students not presenting act as facilitators:
getting the RN to bedside (prepare RN for next patient)
getting a computer to place orders
call consults
field questions on other patients
Presenting Provider:
Before rounds: review data and have problem-based management plan in mind.
Presentations: Structured and focused (see Presentation guidelines)
Nurse: Report overnight events including problems, changes in condition, and other salient issues
Attending: After presentation, set goal for each patient before walking into room.
Efficiency strategies:
Residents are expected to pre-round on the patients and have data on interval events and test results ready for rounds (Not “Discovery Rounds”).
Watch the Clock – goal ≤ 10 min per established patient
Agree to come back for more lengthy conversation with family if needed
Having a direct number to RT, PT/OT/SLP and Pharmacy may be an alternative to having them on rounds so we can get help from them in real time.
If we place orders, talk to therapies and call consults during rounds we are able to put plans into action sooner which helps throughput.
If the service is especially busy and rounding needs to continue beyond the usual morning time, the attending and senior resident will determine the most efficient plan (e.g. Attending and senior take med students to see remaining patients while junior residents do work/ see new consults; Attending goes with one resident at a time to see their patients, etc.)
Keep track of some process measures on the white board every day to see how we were doing and also to get an opportunity to debrief about rounds and get feedback. Examples:
Total time on rounds and time per patient
RN on rounds
Orders on rounds
Senior on rounds
Expectations:
Once new patients are presented, the team will embark on walk rounds.
All patients admitted to the Neurology service must be seen daily and in person by a Neurology attending physician.
It is expected that medical students carry at least 2 patients each and be fully responsible for daily case presentations.
Communication with the family should be a daily event by someone from the team. Medical students are very good for this task and should be instructed to answer what questions they can and promise to find answers to those they don’t know. It is expected that attending physicians will speak to families during the hospital stay.
Attending daily tasks
Sign admission orders daily
Review and cosign progress notes/H&Ps/Consult notes daily
PATIENTS ACCEPTED FOR TRANSFER FROM OSH
Attending:
Call senior resident on service or resident on call to tell them about patient
Write a ‘Documentation Only’ note in EPIC with the details from the initial call
Follow-up on patient status through MEC if questions arise as to whether pt remains appropriate for transfer
Senior Resident:
Place patient on Pending Patient list in Epic
Review pending neurology transfers report in Epic at the beginning and end of day to make sure there are not additional patient there who are not on the pending patient list.
Check Timeline for notes from MEC. Remove patients from pending list if transfer canceled.
Sign out pending patients to call resident
Nurses will page resident when they are notified that bed is available/when they receive report.
If concerns arise regarding whether patient remains appropriate for level of care (based on Epic review or nursing report), notify the attending on call who can follow-up with the sending provider through MEC.
Pending Patient Workflow
Clinical updates on pending patients:
In order to view Transfer list
Go to My Reports on top of EPIC toolbar
Click on "Library"
3. Type in "UMMS ADT transfer center all active requests." Make sure nothing is checked off under "Types" on the right side of the window.
4. Click "Run"
5. Patient list will appear - on top left Filter by specialty and click Neurology
6. This should show you all pending neurology transfers, what unit, accepting provider. In the bottom half of your EPIC window, you can see a timeline of when the pt was accepted and clinical updates.
CNS senior will check Transfer list every morning and prior to sign out
CNS senior responsible for signing out any patients pending transfers to short call
When a patient is accepted
Attending should make resident aware of any acceptances every morning
Nurses will page resident when they are notified that bed is available/when they receive report
Ensure from nursing that pt sounds stable for that unit
General Neurology Inpatient and Consult Attending Call schedule
Attending blocks start on Fridays for 7 days
Call shifts are from 8AM to 8AM (i.e. Attending listed under Monday starts the call shift Monday morning at 8AM and finishes Tuesday morning at 8AM)
The weekend coverage assignments are set to optimize patient coverage continuity so that either the attending or the senior resident will be present for both the inpatient and consult teams each weekend (i.e. the Inpatient attending is on the weekend with the Consult PGY4 and the Consult attending is on the weekend with the Inpatient PGY3). For this reason, weekend call swaps are discouraged.
Last Updated: September 2023