Welcome

Welcome to the BWH Virtual Staffing team! We are excited to have you as part of this timely and important effort.

The virtual rounding / virtual staffing concept pre-existed COVID-19; however, it has gained new imminence with the anticipation of growing hospital censuses and limited staff availability during this crisis. We also view virtual staffing as a robust means of reducing infectious risk, preserving PPE, and utilizing healthy but furloughed care providers. Finally, we hope that the innovations we develop during this time have a lasting impact on how we think about delivery of inpatient care beyond the resolution of the present COVID pandemic. As such, this continues to be an evolving process as we gain more experience and iterate upon it. 

In its current form, “virtual rounders” function as a member of an inpatient team, filling an operational role similar to that of an Internal Medicine PGY-1 or PA-C. In addition to the structured roles discussed below, virtual rounders are invited to contribute to rounds and help their team as they are interested and able. Unlike an in-person intern, however, virtual rounders are not expected to develop daily care plans or serve as the “Responding Clinician” for any of the team’s patients.

We know that there is a learning curve for virtual rounders and new residents alike in becoming experienced and facile with inpatient structure, navigating Epic, etc., and that many of us may need some time and experience before all of these tasks are easy and efficient for us. That’s okay! The role of this guide is to help address these challenges and serve as a quick on-ramp and reference for the processes involved in this role.

Like the program itself, this guide continues to evolve.

Welcome aboard and thank you again for your time and dedication to this effort!

Quick Introduction

Roles and “tasks” of the virtual rounder

1. Before rounds:
   • Briefly chart review the patient list you will be covering
   • Open and “share” new daily progress notes for each patient
2. On rounds:
   • Prep and update daily progress note with overnight events, subjective, physical exam, and plan for the day
   • Add list of daily “checkboxes” (todos) in Handoff tool, and mark which ones have already been done on rounds
   • May be asked to help pull up labs, imaging, or other for team review
   • If time: begin prepping discharges for the day
   • Pending preference of in-person team: page consultants to in-person team member’s phone
3. After rounds:
   • Run the list with the in-person team
   • Finish prepping any remaining documentation (daily notes, discharges)
   • Complete any other tasks as discussed with in-person team

Daily structure

1. Daily work rounds: Begin between 8:00-8:30 am and end between 11:00 am – 1:00 pm
   • Some teams may choose to “card-flip” or “table” round; other teams may move physically from room-to-room and present outside of each room before examining the patient together.
   • Daily presentations on existing patients are usually structured as follows:
     1. Overnight events and morning check-in (intern)
     2. New data: labs, microbiology, imaging, ECG (junior/senior resident)
     3. Medications (pharmacist or resident)
     4. Assessment and plan (intern presents, junior/senior resident leads discussion, fellow/attending contributes and teaches)
     5. Discussion of disposition and/or barriers to discharge
   • Daily presentations on newly admitted patients will generally follow a similar structure preceded by a discussion of the HPI and events preceding arrival to the floor (i.e., outside hospital course, ICU course, ED course, etc).
   • Virtual rounder should prep and update daily progress notes with the day’s plan and update daily to-dos in the team’s handoff during rounds. As time allows (between patients, etc.), virtual rounder should work on prepping the day’s discharges.
2. Running the list (“RTL”): Post-rounds team “regrouping” process, lasting 5-15 minutes
   • Led by the junior/senior resident, the day’s todos for each patient will be quickly reviewed, allowing time for updates on what has already been completed during rounds. Outstanding tasks will be divvied up.
   • Each resident runs this slightly differently, and some teams may choose to forgo a formal RTL, particularly if the team or census is small or if rounds run late.
   • Virtual rounder should participate to update team on what they were able to accomplish during rounds. At this time, virtual rounder can also clarify any unclear to-dos with the team.
3. “Get stuff done” time: Generally noon-ish to mid-afternoon
   • Inpatient team will finish tasks (orders, consults, family updates, etc.) and documentation as divided in #2, complete the day’s discharges, admit new patients, and respond to acute needs.
   • Virtual rounder should use this time to finish any progress notes or discharge documentation as discussed with team and as allowed by virtual rounder’s schedule.
   • At this time, virtual rounder is not expected to remain available to help with admissions; however, if interested and available, could discuss with in-person team.
4. Afternoon check-in and sign-out: Occurs at 4:00 pm for floor teams and 7:00 pm for MICU teams
   • Junior/senior resident will run updates for the day with the team’s attending and intern.
   • Interns and junior/senior residents will sign out to twilight/night teams, finish any remaining tasks and documentation, and go home.
   • Virtual rounder is not expected to stay for or take part in this process

Technology overview

1. Microsoft Teams as a HIPAA-secure platform to facilitate both virtual rounding and internal team communication
2. The in-person team will connect using a mobile iPad and/or individual cell phones
3. Virtual rounder will screen-share their Epic application during rounds

Introducing Yourself to a New Team

Reach out ahead of time

1. Email the entire team to introduce yourself and the virtual rounding program. Below is a template email with some language you can personalize.
2. Ask what their workflow is for rounds. Do they table round and then go see patients? Walk round?
3. Tell them what you can do and ask them their preferences. For instance, some teams might use their notes to present from during rounds. Others might want to update the handoff themselves. Agree on a plan for rounds ahead of time.
4. Introduce the idea of closed-loop communication at the end of each patient and ask them to add a quick summary to their workflow at the end of each patient.
5. Add the inpatient team to the “BWH Virtual Rounding” Team in Teams.
6. Create a Teams event (don’t forget to assign it to your team’s channel) for rounds each day, and invite the inpatient team.

On the first day

If you have a problem connecting with your team the first day, you can contact the following people:

1. At BWH, page the virtual IS pager p10913
2. At Faulkner, page the virtual IS pager p61562
3. Please also email the virtual rounding program leadership to let them know that you’ve encountered a problem.

Email template

Here is an  Email Template to Introduce Yourself to a New Team . Make sure to read it over and personalize it before you send–it might not all be applicable to you or your team.

Best Practices for Success

Closed-loop communication

During rounds, someone (either the inpatient resident or the virtual rounder) should summarize the to-dos for each patient for each patient before moving on to the next patient. This allows the virtual rounder a chance to close the loop and ask any clarifying questions at the end of rounding on each patient.

Continuity

We have found that virtual and inpatient teams have had the most success working together when there is continuity between the teams. This allows for both groups to adjust to each other’s workflow and create trust between them that each can and will take care of their respective responsibilities.

Context Setting

Some teams are well-staffed and don’t necessarily feel they need help with these documentation tasks in the moment. When you join a new team, make sure to explain that the purpose of the program is to help them right now, but also to allow the virtual rounders the chance to practice and master these skills so that they can be helpful in the future as well. We want to get this training in now, before a surge arrives, while non-residents have the chance to practice and master these skills.

Preparing for Rounds

The day before your shift

1. Identify your patient list: On Epic home screen, under “available lists,” go to BWH Entity -> Admit Teams. Click on your assigned team and add it to your personal list.
2. Chart biopsy your patients:
   • Read the last progress note and look at their labs
   • Look at the Medicine handoff. This is the handoff that the day and night teams use to update each other on the events during their shift and pass along to-dos to the next team taking over.
   • Many residents also keep a short, updated personal handoff, usually in some other handoff (for example, some use “Hospital Medicine” or “Midwifery”–you can ask the resident you’re working with if they keep a personal handoff and if so which handoff they use). Please do not edit this, but it is a good place to find a quick summary of your patients
3. Add a medicine progress note smartphrase to your list of smartphrases
4. Confirm you have access to Microsoft Teams and identify your Teams channel

Navigating Microsoft Teams

Accessing the BWH Virtual Rounding Team

Make sure you are a member of and can access our BWH Virtual Rounding Team(if you cannot then please contact the team).

Before your shift

1. Make sure you have Microsoft Teams downloaded on your home computer.
2. Make sure you are a member of the “BWH Virtual Rounding” team.
3. In the top right corner of your Teams application, there is an icon with your photo. Click on that and select “Settings.” A new window will pop up, and on the left-hand side select “Privacy”. Then click “Manage Priority Access,” and add in the names of anyone who you want to be able to chat with while you are sharing your screen during virtual rounding.

At the start of your shift

1. Log into EPIC remotely on your home computer.
2. Under the “BWH Virtual Rounding” team, select the channel of the team you will be rounding with (i.e., “Rounding – ITU-A”).
3. Down at the bottom of the screen, there is an icon of a video camera. If you hover over it it will say, “Meet now.” Hit that to start a meeting in this channel.
4. Alternatively, if someone else already created and invited you to the meeting, you can find it by going to your calendar in teams and joining the meeting from there.
5. Once you’ve joined the meeting, there will be a row of buttons along the bottom of the meeting screen.
6. Share your EPIC screen by selecting the share screen button (a rectangle with an up arrow). Now everyone in the meeting can see your work in EPIC during rounds.

Getting to know Epic

Instructional Videos

We have partnered with the Brigham Educational Institute to create short, helpful instructional videos that highlight how to do specific tasks within EPIC. We are actively creating and adding new videos at this time. If there is a specific instructional video you would like to see added to the list, please let us know. Please DO NOT SHARE these outside of the team as they contain PHI.

• Setting up EPIC: Creating a personal list
• Intro to Navigating a Patient’s Chart
• How to create and prep a Progress Note
• Introduction to the Discharge Tab
• Prepping a Discharge: The Hospital Course
• Prepping a Discharge: DC Meds/DC Order Rec (NOTE: The dc order rec is a complex task requiring a lot of medicine knowledge; virtual rounders are NOT expected to complete the DC order rec while prepping discharges).

We have also created several videos to demonstrate administrative tasks to prepare and execute virtual rounding in Microsoft Teams. If there is a specific instructional video you would like to see added to the list, please let us know.

• Creating and Joining Microsoft Teams Meetings
• Screensharing and Starting/Stopping Recording during Meetings in Microsoft Teams
• Managing Team Membership and Channels in Microsoft Teams
• Identifying Onsite Team Members using Amion (Internal Medicine Resident Scheduling System)

Recorded virtual rounding examples

We have example recordings of prior virtual rounds which you can review prior to rounding. Email the BEI to get access to these.

Setting up Epic

Setting up a personal inpatient work list

Click here to see a short instructional video on how to set up a personal list and add a specific team to your list.

Navigating an inpatient chart

Click here to see a short instructional video on how to navigate around a patient’s chart.

Customizing your toolbar

One of the most useful ways to review a patient’s information within their chart is by customizing your toolbar. This are tabs that are located along the top of the chart if you click on the “Summary” tab on the left. 

You can customize these tabs. If you click the wrench symbol on the far right, you can add new tabs to your toolbar and name them what you want. We recommend giving them very short names so you can fit more tabs on the toolbar.

Useful tabs to add to your toolbar that can help you quickly access key information about the patient’s chart. These are listed below under their full formal names so you know what to select; definitely give them shorter names for your toolbar.

1. “IP Vitals”: Shows a compressed view of all VS over the past few days
2. “IP Comprehensive Flowsheet”: Shows a details flowsheet of vitals, respiratory support, ventilation settings, all continuous drips, and in and outs, blood gases. This is the best tab to see exactly what respiratory support the patient is getting (NC, oxymizer, vent, etc.) It’s also extremely helpful in ICU settings where vital signs change frequently.
3. “PHS IP Congestive Heart Failure”: The best tab for tracking CHF management, includes ins/outs, daily weights, any diuretics or BP medications, daily weights, and daily BMPs.
4. “IP Labs since admission”: A summary table that shows all lab results in an easily readable format.
5. “IP 72H Labs”: Reports labs backwards by time; the most useful section on the right shows labs that are still in-process.
6. “IP Microbiology Results”: Recent microbiology results, sorted by date with most recent results first.
7. “IP Radiology Results Last 6 Weeks”: Recent imaging, sorted by date with most recent results first.
8. “IP Current IP Meds”: A useful summary display of active medication orders. On the right-hand side the patient’s home meds are also listed for easy comparison.
9. “PHS IP MAR Provider Scheduled/Continuous/PRN Then Inactive”: The best way to verify whether a patient actually received a medication they were scheduled for–contains every single med, ordered and given, by day. The easiest way to find a particular medication is to search for it by name using CTRL-F.
10. “IP Fever/Antibiotic Dosing”: The best way to see what antibiotics the patient received and on what days, particularly for patients who had complicated infectious courses with multiple antibiotics given and switched and changed over time.
11. “IP Anticoagulation Management”: The best summary of all anticoagulants given during the hospitalization (DVT ppx, heparin gtts, oral AC, etc.) along with the relevant lab studies (PT-INR, PTT, Hgb, etc).
12. “IP Glucose Management”: The best summary of the patient’s blood sugars and all insulin given during the hospitalization.
13. “IP Pain Management”: The best summary of all pain medications given during the hospitalization.
14. “PHS IP Blood Administration Report”: The best summary of all blood products given during the hospitalization.

Smartphrases

These are invaluable tool for quickly filling in templates or phrases that you use over and over again. You can either borrow someone else’s dotphrases or you can create your own. Below are some helpful templates you can use to create your own smartphrases for your work. Some tips:

1. There are many system smartphrases that are available to all users that are extremely helpful.
2. When you create a new smartphrase, always start it with your initials.
3. You can embed smartphrases within smartphrases by using “@smartphrasename@”. For instance, if you want to include today’s date in your template, you can write “@TODAY@” in the template. Then, when you pull in that smartphrase, it will automatically populate today’s date within your note without you needing to fill it in each time.

• Here is a  Progress Note Template . Your team may have a preferred format, so adjust this based on the notes that you see from the day prior.

• Here is a  COVID19 Physical Exam Deferral Template . If you are on a COVID team and the interns are not examining their patients on a daily basis, you can insert this smartphrase in place of the physical exam.

• Here is a  Virtual Rounder Signature Template . You can use this to sign the notes you prepare.

Progress Notes

Video example

Click here to watch this short video showing how to create new progress notes in EPIC.

Generating a new daily progress note

1. To enter a progress note on a patient who was not admitted overnight, click ‘new note,’. Select the note type as “Progress Note,” and enter the name of the attending as the cosigner. Then click to copy forward yesterday’s note, which you can then edit to update with today’s plan.
2. To enter a progress note on a patient who was admitted overnight, enter your progress note smartphrase and edit it accordingly. You can copy and paste the assessment and plan from the H&P from the day before, but you have to make sure it’s up-to-date with new diagnostic results and an updated plan.

Handoff Tool

Accessing the team’s handoff

You can access the team’s handoff by going into the handoff field and typing “Medicine”. The handoff is organized in the following manner:

1. Illness severity: Usually just says Stable or Watch. Watch is reserved for patients who are sick or unstable and require extra attention by the night teams.
2. Brief Summary: Contains the patient’s up-to-date one-liner. Underneath the one-liner, day teams will write a brief summary of the day’s events for the night teams to be aware of, e.g., “3/31: Cellulitis improving. Switched to PO bactrim. Likely home tomorrow.”
3. Action Plan/To-do: This is where you should put to-dos for the team for the day during rounds (see below).
4. Situational Awareness: This is a standardized format that includes current antibiotics, current anticoagulation, most recent ejection fraction, and any other FYIs that the night teams need to know about the patient.
5. Overnight Events: As the name suggests, this is where the overnight team writes any events that occurred overnight.

Keeping track of daily to-dos

One of the most useful things the virtual rounder can do is to make sure that the daily to-do’s are updated in the Handoff for the team. However, some teams have different workflows, and some teams prefer to be working in the handoff during rounds themselves. So be sure to ask your team whether this is something they’d like you to do for them.

• Tasks are indicated using open brackets, i.e.,
  • “[ ]” for a task that is not yet done
  • “[/]” for a task that is started but not yet complete
  • “[x]” for a completed task
• Tasks can include anything that needs to be done for the patient: med changes, new labs or imaging, questions for consultants, and tasks to prepare for discharge.
• Anything you do for the patient while you are working should also go into the to-do section of the handoff for the day team to see. Make sure you check it off if you already did it so the team knows it was done.
• After you’re done for the day, the handoff could look like this:

[x] lasix 40mg IV

[/] t/b w/Renal re: any further w/u for AKI - paged to intern's phone

[ ] f/u renal US

[ ] 4pm IO check, goal net negative 500ccs - 1L

[ ] f/u 4pm BMP/Mg (ordered)

Discharge prep:

[/] hosp course updated, need to fill in PO Abx course and final anticoag regimen

[/] dc med rec clicked through, need to finalize discharge lasix dose and decide whether to restart ACEI

[/] provider f/u: requested f/u Cards appt via CTS

 

Discharge Tab

Overview of discharge process

Click here to watch a short video introduction to the various sections of the discharge tab.

Writing a hospital course

Click here to watch a short video on how to prep a hospital course.

Under the discharge tab, please edit the hospital course, which is a description of each hospital problem, the diagnostics/therapeutics undertaken, and resulting changes in the patient’s symptoms. See the end of this document for example hospital course.

• Reread the H&P to remind yourself of the presenting complaint
• Copy and paste the assessment and plan from the last progress note into the hospital course
• Edit the hospital course to include presenting complaints, important diagnostics (eg infectious w/u, CT scans), key management decisions, changes or additions to home medications, and how the patient felt at discharge.

Hospital courses should be written by problem (see example below) and each paragraph should be organized as follows:

• Begin with a section called “Brief HPI” that summarizes the patient’s HPI from admission. You can copy and paste the HPI from the admission H&P, but then you should edit it down for length to just include the most important findings (i.e., remove any long ROS that is not particularly relevant). You will see that many people also include a brief description of the patient’s course in the ED as well–this is fine to include but should also stay short.
• Then write a separating subject like something like: “——- [Hospital service] course by problem [dates of admission] ——“. Under this you will write the hospital course by problem.
• For each problem, begin with a short description of the patient’s presenting complaint and any notable exam findings on presentation.
• Then describe any pertinent lab, imaging, or other diagnostic tests.
• Summarize the key management that was done (any medications that were given, any key procedures, etc.)
• Wrap up by stating how the patient did clinically in response to that treatment and what needs to be followed-up on after the patient leaves the hospital.

Avoid giving a day-by-day summary of what happened to the patient. This tends to produce long and confusing hospital courses. Imagine that you are an outpatient provider reading this hospital course after the patient has left the hospital. What you will really want to know is the eventual outcome, key medication changes, and what if any follow-up items you need to make sure happens after discharge.

Example hospital course (please note all identifying information including dates, and vital signs have been changed in this example case).

BRIEF HPI:

85 yo M w/h/o BPH, HTN, T2DM, HLD, p/w septic shock.

The patient was in his usual state of health until two days PTA when he developed a painful rash over his L shin. The following day his wife noticed that he appeared sleepier than typical. That night he developed subjective fever and shaking chills, and became less responsive, so his wife called 911 and he was brought to the ED.

In the ED he was noted to be hypotensive and tachycardic, with BP 80s/40s, HR 110s. He was given 2L IVF and started on vanc/cefepime. Labs were notable for an elevated lactate. He was admitted to the MICU for further management.

—— HOSPITAL COURSE BY PROBLEM ——

Medical ICU, 3/24/2020-3/25/2020

General Medicine ITU-A, 3/25/2020-4/1/2020

#Septic shock: Presented with lightheadedness, found to be hypotensive and had a lactate of 4.2. Source most likely LLE cellulitis, although also found to have UTI during admission. Treated with fluids, vanc (1/1-1/5), cefepime (1/1-1/6), and transitioned to a total 14 day course of cefpodoxime (planned end date 1/14). Cellulitis improved during hospitalization.

#UTI: Found to have pan-sensitive E. coli UTI, treated with abx as above.

#HTN: Initially held home lisinopril, restarted at a lower dose of 10mg after hypotension resolved as patient’s SBPs in the hospital were in the 110s-120s.

#T2DM: Held home metformin, ISS. Restarted on discharge.

#HLD: Continued home atorva.

Writing Provider Follow-ups

There is a separate section of the discharge summary called “Provider Follow-Ups”. This is where you should put any specific action items for outpatient providers to follow-up on. You should not include routine follow-up care, only specific tasks. This is typically structured as follows:

[Name or specialty of the physician who will be following up]: [ ] Task 1 [ ] Task 2

Example Provider Follow-up Section

For example, the provider follow-up section for the above hospital course could look like this:

PCP:

[ ] f/u BPs after discharge, patient discharged on a lower dose of home lisinopril as BPs in hospital were low/normal. May require uptitration of lisinopril post-discharge.

Doing the discharge medication reconciliation (AKA the dc med rec)

Click here to watch a short video introduction to the DC Order Rec tab, i.e., the patient’s discharge medication regimen. Deciding on the patient’s discharge medications is a complex task requiring a lot of medicine knowledge, and is NOT necessary for virtual rounders to complete. What they can to do help the inpatient teams prepare for this is:

1. Look over the patients home medication list and note any home medications that are not being given in the hospital.
2. Look over the patient’s plan and note any new medications that the inpatient team has started that they will likely continue on discharge.
3. Put these notes into the “To-do” portion of the handoff for the inpatient team to review.

High Yield Resources

Tips and guidance

Quick tips: Two-pager with high-yield virtual rounding tips

See “Tip Sheet” on Virtual staffing channel nav bar, or here.

Brigopedia: The Internal Medicine residents’ Wiki, a multitude of miscellaneous resources

Go to: https://brigopedia.partners.org/ (login required), then click: “Residency Homepage” (blue button)

Amion: Online application used for staff scheduling for IM residents. Use this to understand who the onsite team members staffed to a given team are.

Go to: https://www.amion.com

• Note: you will need the login code for the residency you will be accompanying.
• Find the team that you are rounding with and note the assigned residents and interns. Date can be changed at the top of the page.