PA teams

From Virtual Rounding

PA LEAD MEDICINE (PACE) / SPECIAL PATHOGEN TEAMS (SPT)
This is meant to act as a guide for virtual rounders who are covering a PA lead service (PACE/SPT) and will review rounding, documentation, and handoff.

VIRTUAL ROUNDER EXPECTATIONS

  • The virtual rounder will be expected to do the following:
    • Pre-round on patients via EPIC Chart Review
    • Prep progress notes before rounds begin with pertinent information from chart review
    • Update progress notes during rounds
    • Update Handoff during rounds
    • Communicate with team about transitions in service attending's/PAs, ensure all team members are invited to Microsoft Teams "Morning Rounds" event

ROUNDS

  • Epic Log-in: For Job select “IP/OP Physician Assistant” & for Department select “BWH Medicine.”
  • Under Progress tab -> Select Service, make sure “Medicine” is listed.
  • When creating/editing progress note, make sure Service also says “Medicine.”
  • Daily rounds begin at 8:30AM. Virtual rounders and clinical team will connect via Microsoft Teams platform.
    • Virtual rounders will dial in remotely and share their screens on iPad.
  • Format
    • SPT Teams: The team will table round/card flip to discuss each patient’s progress & data without physically seeing the patients as a group.
    • PACE Teams: The team will follow a traditional rounding format, first reviewing clinical updates/data, and then seeing the patient on the floors
  • During rounds, data is often presented by PA/MD in the following sequence (and if applicable/available):
    • Patient one liner
    • 24 hour events
    • Subjective (if available)
    • Vitals, I/Os, daily weight
    • Physical exam (if available)
    • Labs, microbiology, imaging, other important studies
    • Medications (optional)
    • Assessment/Plan
  • It is important to follow a closed-loop communication style on rounds – stopping periodically so virtual rounder can repeat key points/tasks and have the opportunity to ask questions. Before moving onto next patient, ask the virtual rounder to signify when he/she is ready.


EPIC TEMPLATES & SMART PHRASES

To obtain access to the dot phrases:

Open any patient chart in an inpatient encounter in EPIC.
Click on Personalize to open the drop down menu.
Click on My Phrases in the drop down menu.
Click on Manage Phrases in the side bar.
Search for User: HANKINSON, ELIZABETH and Phrase -> select dot phrase & then add yourself as user

Progress Note:

  • .PACEPROGRESSNOTE -> Note template for PA lead teams (PACE/SPT)
  • .LASTCOVID -> Pulls daily COVID labs
  • .COVID19 -> Pulls COVID assessment/plan template

  Admission Note:

  • .PACEADMITNOTE -> PACE/SPT Admission note template (unlikely you would need this)
  • .LASTCOVID -> Pulls daily COVID labs
  • .COVID19 -> PCOVID assessment/plan template

Discharge Smartphrases for SPT Teams:

  • .SPUCOUNSELING – To be included in “Hospital Course” of Discharge navigator
  • .SPUDISCHARGECOVIDNEGATIVE – To be included in “Patient Instructions” of Discharge navigator
  • . SPUDISCHARGECOVIDPOSITIVE – To be included in “Patient Instructions” of Discharge navigator

Handoff:

  • .PACETODODAY – To be included in “Action Plan / To-Do” section of Handoff

PROGRESS NOTES

  • Virtual rounder will start progress note each morning.
  • To enter a progress note, click “new note” and enter the smartphrase .PACEPROGRESSNOTE
  • You will “free text” information into the following sections:
    • Subjective (can also include 24 hour events here)
    • Exam
  • Labs:
    • For SPU2/6, we recommend using the .LASTCOVID smartphrase to pull in the daily labs.
    • PACE C: use the pre-populated {labs} feature to select the daily labs
  • Microbiology & Radiology: can copy/paste data or free text
  • Assessment/Plan: Please use the Progress tab in Epic to update the assessment/plan (see screen shot below).
    • If you don’t have “Progress” on your Epic tool bar, you may need to click the “more” button on the bottom left of the Epic screen to uncover it and pin it to your sidebar.
  • When you are done updating the problem list, go back to your note and click the refresh button, so that updated assessment/plan now populates into your progress note (you can have both the note and the assessment and plan open at the same time).
  • Bundle: clinical team will update this section prior to signing note.
  • Virtual rounder will “share” the note so the PA/MD can review/sign.

IPASS Handoff

  • Virtual rounder will add daily tasks under “Action Plan / To-Do” of Epic handoff.
  • If not already populated, you can use the .PACETODODAY smartphrase to add our template (see below).

Discharge Summaries

  • Under discharge tab, virtual rounders may help edit the hospital course.
  • If there is not already content there, you can copy/paste the assessment & plan from the last progress note into the hospital course.
  • Edit the hospital course to include presenting complaints, important diagnostics (e.g., labs, microbiology, imaging), therapeutics, and clinical course (see example below).
# 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. Cellulitis improved during hospitalization. 

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

# HTN: Initially held home lisinopril, restarted after hypotension resolved. 

# T2DM: Held home metformin, covered with ISS.  

# HLD: Continued home atorvastatin.