Primary Care Clinic

Outpatient Rotation / Acute Care

Orientation Manual for Senior Residents

Last updated: 08/22/04

Lien Russell, MD, Medical Director of Primary Care Clinic (mobile 218-7095, office 572-6702, home 521-1680, pager 391-2851)

Andy Spooner, MD, Director, Division of General Pediatrics (mobile 619-8144, office 572-3292, home 755-8144, pager 721-4430)

As part of your Outpatient Rotation, you will be seeing patients coming to Primary Care Clinic who have not been assigned to see a particular resident. These unassigned encounters tend to be sick visits, or "acute care" visits. Since there is no clinic called "acute care clinic" (hasn't been since 1994) this rotation might best be called the Acute Care Rotation, or, more accurately, the Acute Care portion of your Outpatient Rotation.

There are several important rules to follow when you are performing the task of "Acute Care Resident":

1. Be on time (8:20 AM and 1:00 PM for morning and afternoon sessions; 9 AM on Wednesdays). If you cannot be on time, please call (572-4651 [Conference Room]) so the other residents can adjust.
2. Don’t leave until it’s over. You should not leave until every ongoing process in the clinic is either finished or can finish without your help or supervision. It can be difficult to determine when a process is finished. For example, if a child receives an injection of antibiotic at 12:05 PM, that process is over only after the child has been observed for anaphylaxis (15 minutes). You need to do a little research before you can be sure that it is OK to leave.
3. Prepare Outpatient Noon Report. See the monthly schedule to determine which day this will be. Use the attendings and your fellow house staff to come up with outpatient cases to present at this conference. Ask General Pediatrics attendings to come back you up.
4. Be a supervisor. While it’s true that there are attendings around, it is your job to run the clinic—the whole Primary Care Clinic—while you are the Acute Care resident. This means that you should:
• Take signout from PL-1s and medical students. PL-1s in clinic for their regular PCC day ("continuity" residents) will sign out directly to their attending, but everyone else signs out to you. It is very tempting to see patients on your own in order to “clear the board” and keep clinic moving, but try to resist this because your role isn’t to see the patients without an intern or student—your role is to supervise the work that they do. You can sign the students’ attendance cards if you like. Please identify exceptional performance of the part of any student or resident.
• Work with the attendings to ensure good supervision. Does every patient need a redundant exam from an attending? The answer to this question depends a lot on how you interpret the house staff supervision guidelines. Since there are multiple interpretations, you may need to take different approaches to how each attending wants to handle his or her involvement with each patient. Talk to the attendings and gauge their level of comfort with levels of supervision.
• Help the nurses and clinic staff. Ask them how they are doing with phone calls. Keep tabs on how patient check-in is going. Ask if they want help. You will have one or more shifts scheduled to work in a nurse's role so you can understand their jobs better.
• Keep tabs on the continuity residents. They may need your help. Likewise, they may be able to help you. You’re the boss—you make the call.
• Teach. This is one major activity on which you will be evaluated. Make it obvious.
• Look the part. You should dress professionally and help the residents you supervise maintain a professional appearance. This does not mean that everyone should wear a white coat (or a tie or a dress), BUT everyone does need to wear official ID, closed-toed shoes, and dress in a way that builds our patients' confidence in our professional expertise.
• Move. Keeping a clinic moving is a good skill to develop now. Everyone wants to get out in time for lunch and at 5:00 PM. You will be a hero to nursing staff, students, residents, and attendings if you see to it that the clinic finishes up on time.
5. Manage follow-up. Laboratory results, radiology results, and follow-up phone calls are an important part of your job. There is a database--a "tickler file"--to help you keep track of what needs to be followed, available as part of the Touchworks system. Use it. Your responsibilities regarding lab and radiology results include:
• Sort the Stack. As paper copies of lab results come in to the clinic, they will be stacked up for your review. The purpose of this stack is to reduce the time you have to spend on the phone tracking down results. Just go through the stack and update the tickler file before you begin calling the various labs. And do not be afraid to delegate this lab-result follow-up to other residents.
• Pull patient charts whenever your are presented with abnormal test results. This is necessary since you did not order many of the test results you are reviewing. You need to review the patient’s chart before you make a disposition. Nurses will present you with any abnormal lab result that comes in the mail. After requesting the patient chart, you may delegate the handling of these labs to the doctor who ordered it during the regular continuity session, but bear in mind that some residents may be away from PCC for 2 weeks or more at a time.
• Arrange for follow-up on weekends (this requires forethought and occasionally some creativity).
• Include useful information in the database, like whether the patient was treated for infection or referred to orthopedics. Definitely record which lab performed the test—for a given TennCare MCO, specimens must go to specific outside labs.
• Call colleagues with especially important results (think: "Would I want to know about this?").
• Act on any results you receive, and document how you acted. Always.
• Sign and date any paper reports you see.
• Do not leave the clinic until the tickler file has been updated.
6. Database Policies. The PCC "Tickler" database is a web-based tracking system for tasks generated in the clinic. The policies below apply to the use of this database.
• All orders that result in pending lab or radiography work should be entered into the database to ensure that the results are tracked and followed up upon. The exception to this rule is "routine" lab work for well-child checks.
• Acute Care Rotation and continuity residents should both use the tickler database. The database is not "for" acute care management only. This means that you, as Acute Care resident, may be stuck looking at some lab from someone's continuity encounter. That's OK... we're all in this together, right?
• After you complete a task and document it in the database, use the "Chart Note" feature to print a hard copy.
• Keep it brief. The database can generate chart notes, but we still have a paper chart that contains relevant data that you do not have to copy into the database.
• If there is a tickler item for an PCC patient that actually can wait until the next time the PCC resident is in clinic, then whoever enters the item should make the "due date" for the item the same date as the resident's next clinic date. That way, the item will not appear on the daily list until the appropriate day, and the child's own assigned PCC doc will be able to check the result in person.
• Use the database for any item that needs follow-up... not just lab items. For instance, if you feel you need to call a patient in 3 days to see how she is doing, put it in the database, dated for the day you want to call.
• The Acute Care supervisor should feel free to enlist the help of continuity docs in helping manage the lab follow-up items.
7. Pass the torch. Sign out the clinic to the next supervisor in line just like you would sign out an inpatient service. Let the oncoming resident know what they may need to pay attention to. If you document carefully the things you do, this sign-out process should be simple.
8. Chart effectively.
• Write a brief but complete note on each chart
• Maintain problem lists
• Update PMHx
• Check immunizations and immunize... even during acute-care visits
• Write down your plan
• Be sure drugs prescribed are recorded in the chart, usually by using the stickers the Touchworks system prints out with each prescription.
9. Recruit study patients. It is difficult to think about recruiting for studies in the middle of a busy clinic. Recruiting for studies is not a major responsibility of yours—but you can help the attendings greatly by keeping studies in mind and mentioning them to patients who might qualify.
10. Take call. This is probably the most unpleasant part of this rotation, but it is also the most relevant to your future general pediatric practice. At any given time, one of the senior residents is on call, as is one of the General Pediatrics attending physicians. There are many ins and outs of outpatient call, to wit:
• Hours. Call hours are from 5PM to 8AM Monday through Friday and from 8AM to 8AM on Saturdays, Sunday, and holidays. The on-call resident should have his/her beeper on at all times during these hours and be available to return telephone calls promptly. As soon as the shift begins, the on-call resident should call the UTMG answering service at 448-2981 to give the operator his/her name and beeper number just to confirm that their information is correct. Many residents give their home phone number or any other number where they might be reached in case there are pager problems.
• Answering Service Problems. Call Valarie Carwell at 448-2312 to report issues with the after-hours answering service.
• Attendings. There is an attending assigned for each day and you will be provided with a copy of the schedule, which contains pager numbers. You will also be provided with a list of home telephone numbers for each attending should you need them. The attending should have his/her beeper on at all times while on call and should notify the resident if there is some alternate plan for contact during the call period. The resident should not hesitate to contact the attending for any questions or problems. Dr. Spooner’s home phone number is 755-8144; his mobile phone is 619-8144.
• Who will call you and what will they want? Calls will usually come through the UTMG answering service from LeBonheur Triage, LeBonheur Urgent Care, LeBonheur East, Youth Villages (Boys Town, Dogwood Village, CIRT, or one of the group homes), QuickCare, or from the parent or caretaker. The calls will be in regard to patients who have UTMG pediatricians as their primary care providers. These are the patients who receive their primary medical care in the UTMG Pediatrics Primary Care Clinic (PCC) in the POB (or at Youth Villages). Please ascertain to the best of your ability that the patient does belong to us before you continue any further. If you cannot figure it out, go ahead and help the caller anyway, and sort it out later.
• What will the calls be about? The calls from the parents and caretakers will be fairly straightforward and will be for medical advice in regard to their sick child. You should listen to the complaint, obtain all of the pertinent information, and decide what action should be taken. Your action may take several forms: (1) handle problem by telephone alone, (2) see in PCC within 24 hours, (3) see in PCC at the next available appointment with the primary care resident, (4) see now in the LeBonheur Emergency Department, Urgent Care Center, or, in the case of TLC patients, QuickCare. If it's a patient who is part of the Youth Villages complex, you should know that clinic there is held on Tuesday and Friday mornings (but the people calling you know that, too). If you refer a patient to be seen at another care center, you must call and notify them that the patient is coming and has your authorization to be seen. This is common courtesy, plus the patient gets better care.
• What do I need to know about Youth Villages? Handle the calls from Youth Villages (Dogwood, Boys Town, Dogwood Village, or group homes) as you would for any other call: Provide your best medical advice. The big difference is that these kids are living under the direct care of nurses and counselors so you do not have to worry about compliance or transportation or any of those other factors that make treating kids at home a dicey proposition. Since the kids are in a setting where they can be watched very closely, you may find it less necessary to send them to the Emergency Department than you might another child.
• What about caller ID? A note of caution here. The parent will call through the UTMG answering service and you will be paged to the answering service number. It is often best to call the answering service back and have them connect you with the parent through the switchboard—many people now have Caller ID option on their telephone and you may not want the parent to have your home telephone number. Or maybe you do. Your call. Literally.
• Authorizations. The calls from LeBonheur or other hospital may be asking for authorization for the child to be seen at that particular location. You should be talking to a nurse who has assessed the child and obtained information from the parent or caregiver. You will need to decide if the child needs to be seen at this time or can be seen the next morning or at a later date by appointment. If you decide that the child needs to be seen at that time, then you should indicate on your Telephone Encounter form that you gave authorization for the child to be seen.
• What calls should I deflect? You should not be receiving calls from the well-baby nurseries. You should not be receiving calls about a patient for whom UTMG general pediatricians are not the primary care provider; you just have to politely refuse to handle these. If the patient is still seen at UTMG or has not found a new pediatrician, you should respond to that call.
• What about patients who need to be seen the next morning? You should tell the parent or caregiver to call 448-2000 at 8AM to schedule an appointment or instruct the patient to come to the office at 8AM. In the latter case, it is important that you call the office at 8AM (572-3022) and ask that the patient be scheduled. This plan should be used in the selected cases that you feel need to be seen as soon as possible. If too many patients are scheduled in this manner, it becomes quite disruptive to the registration process.
• Paperwork. You must complete a Telephone Encounter form for each telephone call that you receive. Those forms should be complete and legible – they will become part of the patient’s medical record. Record the date and time you return the call. It is especially important that you obtain the patient’s name and date of birth. Your should record the patient's primary care provider as stated on the MCO card. Bring your encounter forms to the Primary Care Clinic ASAP. You will review these forms with an attending in the Primary Care Clinic at that time and will get the forms countersigned.
• Where can I get help in making decisions and in giving advice? Each senior resident will be given a copy of Pediatric Telephone Advice, by Barton D. Schmitt, MD, to use for reference during the month. This is a good general reference that covers the typical sort of questions you may be asked. If you are ever unsure about what to do, call the attending. That is what they are there for!
11. Inpatient tracking. Please keep track of all the PCC patients that are admitted to LeBonheur. These patients will be following up with you in Primary Care Clinic. You will need to know what happened in the hospital. In addition, I think our patients appreciate visits from their Primary Care Physician (PCP) when they are in house. Here are some key points regarding this duty:
• Find out which patients are in the hospital. Our patients will generally be admitted to the general ward services (A, B, C, & D) or the various subspecialty services. The yellow admit sheet should have PCP listed. You can find out who has been admitted by bird-dogging the yellow list or by calling the Chief residents every morning (yes, they have agreed to take your call every morning.) Occasionally, we will have patients admitted to the ICU—these patients should also be tracked. You can find out if any of our patient are in the ICU by simply calling the unit.
• What does "tracking" mean? You just need to know what is happening to this patient in the hospital so that you are better equipped when you see them for follow up in the clinic. Simply review their hospital chart. You do not have to write anything in their chart, but you may want to take notes for your own benefit of important lab or radiology results and follow-up appointments.
• Do I have to do this everyday? Yes, at least one supervisor should be investigating if there are new PCC admits every day. Pediatrics has such a high turn-over rate that if you don’t investigate every day, you may miss some patients. Now if one of our patients is sitting in the hospital waiting on G-tube placement, you do not need to "track" them every day.
• Do I have to examine the patients? Yes and no. When the patients are initially admitted, you should at least lay eyes on them so that you can track improvement or progression. You should then lay eyes on them again prior to discharge. For the days in between, that is up to you.
• Pull the patient’s outpatient chart. Review the patient’s outpatient chart. Let the inpatient team know about any relevant past medical history or patient information. Keep these charts in a stack near your workstation. When these patients return to clinic, you won’t have to hunt down their chart.
• Keep track of follow up appointments in the tickler. If these patients do not show up for their follow up appointment, call them.
• Give report. Every Wednesday at 9am after grand rounds, one supervisor should attend the General Pediatrics Division Meeting (located in the small conference room next to the Attending Physician’s Dining Lounge) to give report on these patients. This is a brief report in a very casual setting.
12. Days off during the rotation should only be on weekends.
• Two residents per clinic are expected to supervise interns and students by checking out clinic patients.
• The third resident (and fourth resident during Oct, Nov, Jan, and Feb) are expected to do the following:
1. Help the single supervisor on wards
2. Help see assigned patients (aka: PCC patients), especially if someone is post-call or the board is getting full
3. Work on the tickler (this alone can occupy a person all day)
4. Answer phone calls from the queue
5. Nurse shift: You will have one or more shifts scheduled to work in a nurse's role so you can understand their jobs better.
6. Help check in acute care patients—This will help improve the flow of the clinic
7. Inpatient tracking
8. Work on Community Peds project
9. Work on QI project
10. Work on EBM lecture or outpatient noon conference
11. Read, learn, and teach interns and students