Green Service Fellow Role
Senior fellows (2nd and 3rd year) assigned to green service will expected to function in a junior attending capacity. They will run rounds with the APPs at 930am. Senior staff will observe and provide input and advice as needed when there are any questions.
First year fellows assigned to green service will co-round with staff. As a first year, this will be an opportunity to work in a different model, perform procedures, hone in on any specific areas of educational or professional development identified with rounding ICU staff.
6N is participating in a nation-wide quality improvement initiative known as the Comprehensive Safety Based Protocol (CUSP). The Green fellow will be in charge of overseeing the following processes related to the initiative.
- Daily Goals/Quality Rounds.
Daily Goals
Instead of using the Checklist, Green service will use a Daily Goals Sheet to ensure that standard safety measures are assessed on all patients AND that specific goals are clearly stated and available to all team members at the bedside.
The Daily Goals sheet should be completed during rounds and reviewed at the end of the presentation to ensure that all team members (nurse, MDs, PAs, RT) agree on specific measures and follow up. For example, rather then saying that a patient will be diuresed as a goal – a net negative volume goal will be set for the next 24 hours with a clear plan of action. “We will give 20 mg of Lasix and reassess in the afternoon to see if we are meeting goals or if another dose needs to be given to achieve Net negative 2L.” This will be marked on the Daily Goals Sheet and will be available at the bedside.
Quality Rounds
In addition, a brief walking multi-disciplinary huddle (Quality Rounds) will occur at 830 AM. This is meant to be short (~10 min) and to assess goals/deficincies for the day on key domains.
In the afternoon, at 3pm, the Green fellow will lead Quality Rounds and use the daily goals to ensure that specific goals are being met – and if not to discuss with the team so that a plan of action can be undertaken.
PM fellow will round with the nurse team leader, using the Daily Goals Sheet to ensure that follow through has occurred. “I noticed that the team planned to remove the femoral CVC, but it’s still in. Let’s take it out.”
- VAE monitoring.
Using the online VAE tracker on hfhpulm, the fellow will round on all vented patients and enter the minimum PEEP and FiO2 for the previous calendar day. Goals for this activity will be to gain an understanding of the new CDC guidelines for measurement of ventilator associated events (VAE), Ventilator Associated complications (VAC), and Ventilator associated pneumonia (VAP). A separate document will be provided regarding this activity – with education and expectations for follow up.
- MPM Score. It will be helpful to complete MPM scores on patients during rounds. This can be found on the hfhpulm website. Staff or fellow can fill out during rounds – ideally person who isn’t leading rounds fills out score.
- Primary coverage.
This will likely only occur during periods of high/overflowing census or if PA staffing is less than three which is infrequent.
– patient:PA ratio is 1:5-6.
– if acuity is high, or multiple simlutaneous admissions, crashing patients in AM, or overflowing – PAs will ask for help with patients. Fellow should then elect which patient(s) they will see.
– if acuity is low or mostly chronic; PAs will each see 6 patients each.
Workflow
700-800AM – On-call fellow hands-off active issues on overnight or weekend patients to day-fellow and APP. This is particularly important on Monday mornings since many patients are new to the APPs. To improve hand-offs, especially weekend to Monday morning hand-off, on-line sign-out should be updated by weekend rounding fellows.
800AM – Faculty arrive by 8am so that fellows can review new patients with faculty, APP, and nurse. Faculty are expected to provide feedback on overnight management issues to post-call fellow. If faculty are delayed due to unforeseen circumstances, please notify the post-call fellow by phone.
930AM – APPs will be ready to round on all patients. APPs will try to have progress notes completed for rounds – this is subject to acuity and census of service. In order to allow rounds to proceed in a predictable fashion, we will ask that rounds proceed in order through the intensive care unit unless there are issues requiring urgent attention. Daily Goals Sheet completed by Green Fellow.
Post Rounds – VAE rounds
Afternoon – Follow up on Daily Goals with bedside review of sheets with lead nurse to ensure follow through on plans from AM. Staff new patients, assist with procedures, family meetings.
Green Service Senior Staff Role
This rotation will provide senior fellows with an opportunity to round in a more autonomous fashion. This will also provide the PCCM program with a mechanism to assess fellow’s performance as primary rounders. Areas that can be assessed:
- Clinical Decision Making
- Interactions with medical personnel
- Do fellows involve physician assistants, nurses, pharmacists, allied health care on rounds?
- Quality
- Do the fellow use quality tools?
- Daily Goals performed on every patient during rounds
- Follow through on Daily Goals in the afternoon
- Do the fellow use quality tools?
Expectations of staff:
- Arrive at 8am to review cases with post-call fellow; please call if arriving late so alternate arrangements can be made.
- Ensure that MPM scores are filled out. Most efficient method is to fill out during new patient presentations.
- Please be aware of PA staffing. Standard is three for the unit, but occasionally there will be two due to scheduling. In these instances, especially if acuity is high, fellow will be asked to cover some patients.
- Provide feedback on a daily basis in areas specified above. In particular, for senior fellow (2nd/3rd), it is useful to observe fellow and have a system for taking notes. Eg. Use a note card for each patient to take notes on feedback that you can provide one-on-one after rounds. Type of feedback can fall into the following categories:
- Communication
- Clear goal setting
- Ensuring Daily Goals are clearly elicited
- Teamwork
- Involving all disciplines on rounds (nursing, pharmacy (on-call), RT, mobility)
- Medical Decision Making