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Residents

Resident roles and responsibilities 

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Patient list

The patient list is one of the lifelines of our service and helps keep our busy service organized. The Thoracic Surgery Patient lists are maintained on both HybridChart and Cerner Powerchart. HybridChart is where you will find your daily rounding assignment and helps provide all members of the team with an update on the patient’s hospital course/problems and items to follow-up on. Please be sure to add your patients and any consults to the lists prior to heading to the operating room.

HybridChart Evolve:    Website: www.hybridchart.com

 

 

 

Case assignment

Each day a text message will be sent out to members of the team that outlines man/woman power for the next day. The text will outline the current assignments for each scheduled case in the operating room, endoscopy and TSOW. The “TSOW” is the Thoracic Surgeon of the Week and is the on-call surgeon for all lung transplant and ECMO patients. Since we don’t have access to your case-logs please help keep us updated on which particular cases you may need. In general terms, the PGY-2 on service will be the primary endoscopy surgeon and PGY-4 is the general thoracic and lung transplant surgeon. If you are involved in an overnight case (transplant, on call case, etc.) please let the APP know ASAP so they can reassign your case for the next day.

 

Rounds 

Residents are responsible for checking HybridChart to obtain their daily rounding assignment. Residents should round, examine patients and develop detailed clinical plans prior to starting their operative cases for the day. During rounds it is expected that all radiographic, laboratory and diagnostic studies be reviewed. After completing morning rounds residents should send a brief text message about the patient and daily plan to both the attending surgeon and the APP of the week.

Residents are expected to execute the patient’s care plan after the plan has been confirmed with the attending surgeon. Although each resident is assigned to round on only a few patients each day it is expected that residents are able to discuss the plan of care for all patients on the service.

Since many of our patients are admitted to the CTICU please make sure to stop by the 4T workroom or call the ICU team phone (6-1909) to review the plan with the ICU team.

At the end of the day the resident should update HybridChart with any relevant information and communicate directly with the on-call teams (ICU and Thoracic Surgery) prior to leaving the hospital.

 

Operating Room

Rounds should be conducted in a manner that allows sufficient time to be present in the OR for an on time start. Trainees are expected to be in the operating room prior to induction of anesthesia. All residents are expected to have reviewed the patient history, pre-op physiologic testing and imaging prior to coming to the OR. All preoperative patient data is available in Cerner and radiologic studies available in PACS. Scheduled cases should be reviewed with an attending the day before surgery since this serves as an excellent opportunity for learning and surgical planning. Please note at the end of the handbook in the appendix that there are some pre-op templates that you can use to help prepare you for the case.

At the completion of the case:

  • Residents are expected to enter a brief operative note/procedure note within Powerchart  prior to leaving the operating room. The template is titled “Immediate Post-Operative Note."

  • The resident who was involved in the case is responsible for entering the postoperative orders for patients being admitted to the ICU or Floor. Each patient and attending physician may have different requirements, so please ask if you have any questions. Please review the general postoperative plan, feeding strategy, time for restarting home medications and pain management strategy with the attending surgeon.

  • For outpatient cases, the resident who participated in the operation will be responsible for completion of the discharge/depart orders for that patient. These are not to be signed over to individuals who were not directly involved in the case.

  • If the patient is being admitted to the ICU postoperatively please communicate with the ICU team directly. Please call them at 6-1909 or stop by the 4T workroom prior to patient’s arrival in the ICU.

 

Care of thoracic patients in the ICU 

Since the thoracic patients in the ICU are also cared for by our intensivist team it is important to make sure that we have an open line of communication. Residents are responsible for discussing the daily plan with the ICU team prior to proceeding to the OR. Residents are responsible for ordering the daily labs and radiographic studies (CXR, esophagrams, CT scans) as requested by the thoracic attending. Please do not place any orders aside from chest tube orders or radiographic orders on post-transplant patients. All other orders should be discussed with the ICU team prior to entering the order.

 

Criteria for sending a patient for swallow study

  • Able to sit out of bed in a chair

  • Fully awake and oriented, not drowsy or disoriented

 

Scheduling cases in the CVOR

  • Call CVOR to schedule the case

  • Call Valley Anesthesia to get anesthesia coverage for the case. Please clarify with the attending surgeon if a cardiac/lung transplant anesthesiologist is needed.

  • Place an order to obtain consent for the procedure and blood

  • Enter any necessary pre-operative orders. (NPO, Type and Screen, Coags, etc.)

 

Scheduling cases in endoscopy

  • Call Endoscopy to schedule the case

  • Place an order to obtain consent for the procedure

  • Enter any necessary pre-operative orders. (NPO, etc.)

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Clinics

Unless assigned operative cases, residents are expected to attend their staff surgeon’s clinics. Residents can find the clinic schedule under the schedules section.

 

Call and consults

We have a rotating call schedule for thoracic surgery. The thoracic surgery call schedule includes the Thoracic Surgery Primary call, Thoracic Surgery Attending and Thoracic Surgeon of the Week (TSOW). Senior residents and Advanced Practice Providers are usually listed for Thoracic Surgery Primary Call. All general thoracic surgery consults are directed to the “Thoracic Surgery Attending” on call. All consults and issues related to transplant patients and ECMO are directed to the TSOW.

Trainees are expected to see the patient and provide appropriate evaluation and management (E&M) and complete documentation in the medical record after discussing the patient with the attending of record. All overnight consults should be seen, have appropriate E&M documentation completed, and discussed with the responsible attending. Trainees should personally review the consults and discuss them with the attending surgeon on call.

 

Completing a Transplant Evaluation

On the thoracic surgery/lung transplant service we are often asked to evaluate patients for lung transplantation. There are a lot of parts that go into the evaluation process but thoracic surgery is only responsible for arranging the patient’s EGD, esophageal manometry and 24hr Ph studies. The EGD is scheduled by calling Endo at 63269. The manometry and 24hr pH studies are arranged by calling the Esophageal Disease Center at 6-6770. Please remember to make sure the patient has been off all PPI medication for 10 days prior to their scheduled testing.

 

Discharge process 

Residents are responsible for completing the discharge packet for their primary patients. The steps for completing the discharge packet includes:

1. Complete the Patients’ Discharge Summary in Cerner Powerchart

2. Complete the Discharge Medication Reconciliation

3. Complete the Discharge Orders

4. Call the attending’s medical assistant to communicate the follow-up plan for testing and clinic

5. Change the discharge status on hybrid chart once the patient has physically left the building.

 

Medical Students

There is occasionally a rotating medical student on the thoracic/transplant surgical service. Medical students should be made to feel a part of the surgical team and residents should take a role in their education on the service. Medical students should not be asked to provide direct patient care including pulling drains or tubes.

 

Quick Tips for Thoracic Surgery Rounds 

  • Pre-round on every patient you are assigned to see on Hybrid Chart

  • Diagnosis, operation, post-operative day

  • Gather and Review

    • Vitals, oxygen requirement

    • Input/output

  • Detailed: UOP, NG, Chest tube, drain and feeding tube outputs

    • Labs, micro, pathology

    • Review Imaging: CXR, CTs, Esophagrams

    • Quick review of meds (Confirm DVT & GI prophylaxis and bowel care regimen)

    • Make sure important home meds are restarted when appropriate

  • after surgery, if you aren’t sure just ask.

    • Nutrition

  • Current diet order

  • Tube feeds: type, rate and goal

  • Check all incisions, tubes, and drains

  • Evaluate chest tubes for presence of air leak and character of drainage

  • Remove dressings on morning of POD #1

  • Talk to bedside nurse for each patient: remember to ask about any overnight events

  • Pull tubes and drains early in the day once removal is approved by the attending

  • Start Discharge planning on every patient EARLY

    • Please communicate with case management early during the hospital stay so there are no delays on the day of discharge

    • Discharge Planning Includes:

  • Discharge Disposition: Home, SNF, Rehab

  • Nutrition: Plan for PO diet and tube feeds

  • Wound/Drain care

  • Home oxygen

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