Emergency Medicine/Internal Medicine Wards Night Float Curriculum

Department:  Emergency Medicine/Internal Medicine
 
Faculty Director: Ramano Sprueil, M.D/Mark Feldman, MD, Chairman, Department of Internal Medicine
 
Hospital: Texas Health Presbyterian Hospital Dallas
 
Offered: All
 
Length of Rotation: 4 weeks
 
Maximum number of residents: 2 (PGY-1only); each PGY-1 will do the rotation twice
 
First Day Contact: Ramano Sprueil, MD (ER) - (972) 567-6782
 
First Day Time: To be arranged with Ramano Sprueil, MD (ER)
 
First Day Place: Presbyterian Hospital Emergency Room or Intenral Medicine Wards

Days Off: 6 assigned days off per month - see schedule

Hours: To be arranged during ER rotation - 11:00 p.m. to 9:00 a.m. during night float rotation

1. Course Description:

During half of the month, the resident will work in the Emergency Room of Texas Health Presbyterian Hospital Dallas.  The resident will be responsible for first-line evaluation, management and disposition of patients in the emergency room. The resident will be exposed to a diversity of cases, which will provide the resident with a wide experience in Emergency Medicine.  The resident will have constant supervision and communication with the emergency room attending.  The ACGME duty hour requirement will be strictly followed. The resident will work 10 shifts during the half month.

During the other half of the month, the night float PGY-1 resident will provide overnight coverage on the internal medicine ward service, working with upper level resident (PGY-2 or PGY-3) on call. The night float resident will work 14 night shifts (11:00 p.m. to 9:00 a.m.) during the month. Duties include admitting patients between midnight and 8:00 a.m., cross-covering patients for all PGY-1's between midnight and 8:00 a.m., covering codes with upper level resident between midnight and 8:00 a.m., and ensuring smooth transition of care of patients back to primary PGY-1 on the post-call morning.

2. Course Goals and Objectives: (based on ACGME competencies for resident education and modified for medical student education)

Patient Care: Residents are expected to provide care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life.

Objectives:

• Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures.  Examples: The resident will perform a problem-based history and physical and make appropriate diagnostic and therapeutic decisions on a patient in the emergency room as well as new and existing patients on the internal medicine wards.
   
• Make informed recommendations about preventives, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient preference.  Examples: In the emergency room setting, the resident will make decisions about admission or discharge, will educate patient regarding signs or symptoms for which to return to the ER or how to get appropriate follow-up after discharge from the ER; the resident will need to apply his/her clinical judgment to the efficient and effective management of the patient.  On the wards, the resident will perform appropriate diagnostic and theraputic interventions for patients on the internal medicine teaching service. In the ER and on the night float rotation, the resident will need to be sensitive to cross-cultural issues and religious preferences when it comes to evaluation and treatment.
    
• Develop, negotiate and implement effective patient management plans and integration of patient care.
  Example:  See above.
  
  
• Perform competently the diagnostic and therapeutic procedures considered essential to the practice of internal medicine.  Examples: In the ER the resident should perform ACLS, airway management, lumbar puncture, thoracentesis, paracentesis, arterial puncture, central line placement, joint aspiration, nasogastric tube placement, cervical smear and culture for infection. On the night float rotation, the resident should perform similar procedures including those required during MET situations for internal medicine teaching service patients.
  
  

Medical Knowledge: Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others.

Objectives:

• Apply an open-minded, analytical approach to acquiring new knowledge.  Examples: In the ER, the resident will be exposed to areas outside of Internal Medicine, including trauma, pediatrics, obstetrics and gynecology, surgery.  He/she should learn the important disease states that present to the ER in these areas, the method of evaluation and emergency management of these areas. On the night float service the resident will continue to learn principles and practice of care of the internal medicine patient.
   
• Access and critically evaluate current medical information and scientific evidence.  Examples: The resident should assess the literature regarding current guideline management of chest pain, asthma exacerbation, syncope, coma, abdominal pain, delirium, headache, stroke, hypertensive emergency, hypotension due to hypovolemeia, sepsis syndrome, cardiac arrest, ACLS protocol for unstable rhythms and other medical problems.
  
  
• Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of internal medicine. Examples: The resident should understand the cardiovascular physiology in order to understand the pathophysiology of hypotension or hypertenison, understand the physiology of pain and the pharmacology of the drugs used to manage pain in order to relive pain, etc.
  
  
• Apply this knowledge to clinical problem-solving, clinical decision-making, and critical thinking. Examples:  In the ER and on the night float service the patient should apply knowledge appropriately to the clinical management of shock, hypertensive emergency, didabetic ketoacidosis, chest pain, etc.

Practice-Based Learning and Improvement: Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices:

Objectives:

• Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.  Examples: The resident should identify a process of care that could be improved with improved knowledge and use of personnel in the ER and on the wards such as the cost effective, evidence based management of delirium; the cost-effective, evidence based management of acute abdominal pain, etc.
  
  
• Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice.  Examples:  See above.
  
  
• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care.  Examples: The resident should carefully review missed or incorrect diagnoses, inappropriately ordered tests or treatments and review the literature to improve his/her knowledge in those areas.
   
• Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education.  Examples: Use of electronic information system available in the ER and throughout the hospital to all residents.
  
  

Interpersonal and Communication Skills : Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.

Objectives:

• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.  Examples: The resident will maintain a professional relationship with his/her attending, communicating important medical information to him/her on an ongoing basis. The resident will communicate with the patient's primary care physician, as well as any consultants to facilitate the patient care; the resident will maintain professional behavior at all times when dealing with patients.
  
  
• Use effective listening, nonverbal, questioning, and narrative skills to communicate the patients. Examples: The resident will have ample and repeated opportunity to practice these skills in the ER and on the night float service.
  
  
• Interact with consultants in a respectful, appropriate manner.  Examples: See above.
  
  
• Maintain comprehensive, timely, and legible medical records.  Examples:  Maintenance of patient records in an ongoing fashion during the patient’s stay in the ER as well as after admission and throughout the hospital course.

Professionalism:  Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.

Objectives:

• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues.  Examples: See above.
  
  
• Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Examples: See above.
  
  
• Adhere to principles of confidentiality, scientific/academic integrity, and informed consent. Examples: See above.
  
  
• Recognize and identify deficiencies in peer performance.

Systems-Based Practice: Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

Objectives:

• Understand, access and utilize the resources, providers and systems necessary to provide optimal care. Examples:  The ER provides an environment where working with team members, including nursing, respiratory therapy, and social work to facilitate the care of the patient is of utmost importance.  The efficient response of other departments is also important including radiology and laboratory.
  
  
• Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.  Examples: The resident will learn how to arrange follow-up for all patients seen, understanding how to access the limited resources available to the patient without insurance or without a primary care physician.
  
  
• Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management.
  Examples: See above.
  
  
• Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.  

III. Methods of instruction:

1. Didactic (schedule, topic, faculty)

Daily residents conference 12:00-1:00 p.m. - IM Training Room
Wednesday mornings 7:30-8:00 a.m. - Clinical Ground Rounds - IM Training Room
Wednesday afternoons 12:15-1:00 p.m. - Internal Medicine Update - Haggar Hall


2. Clinical

In the ER, the PGY-1 resident is assigned to an Emergency Medicine physician with whom s/he is expected to work closely. The resident is expected to attned every noon conference except when working night shifts. On the night float rotation the PGY-1 resident will be supervised by the PGY-2 or PGY-3 resident on call as well as by attending physicians with whom s/he admits patients.