3. Organization of clinical services
The entire 9th floor is devoted to Pediatrics
9th floor is divided into three areas:
Inpatient M9
The PICU/POU (made up of 5 beds)
Pediatric Day Hospital (the PDH)
4. Pediatric Day Hospital (PDH)
The PDH is the outpatient side of Pediatrics
at MSK
Patients come to see their primary team for
everything from check-ups to chemo to
transfusions to procedures
The PDH sees >150 pts per day
Many of the floor admissions come
directly from PDH
5. MSK Primary Teams
Patients are assigned a Primary Team (i.e., leukemia,
neuroblastoma, sarcoma) based on their primary disease
at diagnosis
Followed by Primary team throughout their disease course
While inpatient, primary team will give input on their care;
the fellow is the liaison for this communication
Bone Marrow Transplant (BMT, Blue Team) is its own
Primary Team
6. PICU, MICU
The PICU is comprised of a 5 bed unit
This unit is run by NPs and a PICU attending. There is a
full time PICU attending (Dr Killinger) who rotates on
call with NYPH-Cornell PICU attendings.
if >18 years old, then they can go to the MSK MICU on
the 11th floor
7. M9 Inpatient Service
Two clinical teams – Green and Blue
GREEN Team – General Oncology/Surgical
Attending and Fellow (1st year)
2 PGY-3 Senior Resident from Downstate
3-5 PGY1/PGY2 residents from Cornell, St. Barnabas,
Harlem, Lincoln
3 Nurse Practitioners
Each NP works ~4 days/week
Most days: 1-3 NPs/day
8. M9 Inpatient Service
BLUE Team – Bone Marrow Transplant
(BMT)
One attending, one fellow
3-4 residents from Cornell, Downstate, Metropolitan
Weekends: One attending, one fellow, one resident
9.
10. Nurse Practitioners
On the inpatient teams, they function largely in the
same capacity as residents
They carry patients just as residents and max at 5
patients
Incredible resource: whom to call, how to get things
done, great understanding of patient pathology
NPs primarily take surgical, chemo admissions and
then other oncologic admissions.
11. Nurses
RNs at MSK know the kids
and know the oncology
Many of the kids are well-
known by the nurses
If they think something is
wrong, it is wrong!
If they ask you to speak to
the parents or the patient,
GO!
12. Nurse Case Managers
The Nurse Case Managers are wizards with
discharge and insurance issues
Kevin Mcdonough (pgr 2097) (extension 3696)
ESSENTIAL TO COMMUNICATE DISCHARGES
TO THEM EARLY!
13. Green Team Senior Residents
Supervises PGY-1 and PGY-2 residents on Green
Supervises AM and PM sign-out
Updates electronic hand-offs
Works with the fellow / attending to make sure plans
are being carried out by residents
Facilitates rounds by checking labs, entering orders,
updating hand off tab
Communicates problems/concerns about residents to
chief resident, fellow and attending
Acts as ADMITTING RESIDENT
14. Green Team Senior Residents
Each resident will be responsible for half the junior
residents and be expected to know every patient on the
floor.
When a junior resident has clinic, they will sign out their
patients to their corresponding senior resident, and the
senior resident will be responsible for those patients for the
rest of the day.
When a senior resident has clinic, the other senior resident
will be responsible for all junior residents and patients.
15.
16. Sign out/Sign In
7 am: Sign Out/Sign In
Green: Supervised by the Green team Senior’s The nocturnalist/night
junior resident comes in at 6pm for sign out and will give sign out again in
the morning at 7 am.
Blue Blue Team more individualized. On-call resident should leave after
signing out all patients to corresponding residents
Pre-Rounding:
Make sure you get to know your patient!!! Make sure information on
handout is accurate for a reference during rounds
Check Vital signs, I/Os
PCA doses/ attempts are only in the bedside chart
Review lab results and discuss problems or questions with the senior and or
fellow
RENEW ORDERS for IVF and all drips (PCA, zofran drip, etc.)
17. Labs/Phlebotomy
Most labs will be back by the time you arrive in the
morning
You must order routine morning labs before signing out in
the evening. Must also order all weekend labs(Sat—Mon) on
Friday! Please order all of them STAT.
AM Labs are drawn by the night nurses
All labs are drawn off of central lines, including blood cultures
When labs are needed at other times, ask the patient’s RN and
enter the order in the computer
If a patient does not have central access, ask the RN to call
the IV or phlebotomy team
If they are not available and the lab is essential, then and only then
should you stick the patient
18. Rounds
Attending Rounds - 9am
You MUST facilitate rounds by -
Being prepared to present on your patients
Helping to look up labs, move computers when your
patients are not being presented
Who goes into the patient’s room?
The Senior and the Blue resident on-call for that
night should always go into the room
All Green team housestaff unless contact or indicated
by family and or attending
19. Presentations on Rounds
Presenting: New Admissions
HPI, then summary of their Onc History (which
you should have read carefully before presenting)
Presenting: Patients known to the team
One liner, then the rest of your presentation by
systems or problems
Relevant lab results only
*** Be aware that this can vary attending to attending***
20. Radiology Rounds
Mon, Wed, Fri at 11am, PDH Classroom
Review all radiology for the team for the past 24 hours
with the pediatric attending radiologist
When your patient’s name is called, either you or the
fellow will give a one-liner about who the patient is and
why you got the study
Ex: “Maggie is a 2 year old girl with Stage IV neuroblastoma
who was having increased vomiting and abdominal distention
and that’s why we got the CT.”
21. Conferences
On Most week-days at 1:30pm in the workroom
Lectures given by Attendings, Fellows and Chief
Resident
Residents also give short interactive case presentations
prior to the end of the block
Lecture schedule posted in call room
Grand Rounds Thursday mornings at 8:30am
22. Notes
Daily notes
You may copy/forward from previous notes
BUT, you must UPDATE EVERY LINE, EVERY
DAY!
Yes, the Attendings DO read and sign your notes!
DO NOT hit ‘resident complete’ or forward
your note to the attending until you are
absolutely 100% finished
Everything in your note should be clear and
correct
Your assessment should be up-to-date and specific
Your plan should be listed by systems OR problems
23. Resident e-mail
Every resident has an email account
To access the email:
From Hospital:
Go to startemail outlook insert username
given to you when activating your HIS username
and password. It is usually your last name and
first name initial. insert password (same one
used for HIS)
From OUTSIDE Hospital:
Go to https://mskoffice.mskcc.org/
and login as above under Outlook
24.
25. Admissions
Green Team Residents: Expect to get at least one
admission every day you are not in clinic
Admissions are assigned by the Admitting Seniors
Blue Team: Admissions are less common
In general, you will decide among yourselves who will do which
admission
Be kind and fair to each other
26. Admissions
Admissions from 9am-5pm come from the PDH after being assessed by
the Primary team
Do not wait for the patient to arrive on the floor – go to the PDH to begin
the admission process with your HPI, ROS and PE.
At night, they come from UCC after being assessed by the fellow on-
call
UCC is the MSK Emergency Room; it is an ED, but for established MSK
patients only
The fellow will discuss the patient and plan with you.
If this does not happen, PAGE THE FELLOW!
27. Admissions
Use the M9 Admissions Sheet as a Guide
Review the most recent notes
Perform a careful HPI, ROS, review meds & allergies
Bridge any gaps in their history since the last note
Do NOT do a full PMHx with the pt/family (although make sure
it is in your note)
Your plan will be discussed with the senior/fellow
Orders
Use the Admission Order set in the computer for admissions!
There are order sets for Blue and Green teams
For patients in PDH can write pending orders ask the clerk to
make an ‘overflow bed’
You must print 3 copies of the Code Sheet at admission
(Google ‘cornell emergency medications’)
28. Discharges
Anticipate discharges so you can get prescriptions
filled and follow-up appointments set-up early on
Use the M9 Discharges sheet as your guide
Prescriptions must be given to Pharmacy a day in
advance
Communicate with the case managers; setting up home-
care, getting supplies, etc. requires advance planning
Discharge orders and instructions are computerized in
HIS
Discharge Notes/Hospital Courses must be started on
ALL patients on HD #2 and updated every day!
29.
30. Weekday Call BLUE
On weekdays, call starts at 5 pm
On-call resident is responsible for all admissions to the
floor posted after 4:30 pm
Give good signout – make sure electronic Hand-Off is updated
Indicate clearly what might happen, and what the resident on-
call should do
If labs are expected, tell the on-call resident the time they will
be drawn
One fellow supervises both teams and Urgent Care Center-
-Fellow is available to you at all times, don’t be scared to
page him/her
31. Weekend Call BLUE
Sign-out at 7 am; rounds at 9 am
On-call resident responsible for:
Daily progress notes on all patients on the service
All admissions, discharges, and transfers with notes
Midnight rounds with on-call fellow
AM vitals & I/Os of all patients
One fellow per team
32. BLUE Call
Responsibilities:
Check to make sure all AM labs are appropriate
“Midnight” rounds with on-call fellow
“AM rounds” – Check VS and I/O, record AM labs record
vitals on handoffs
Notes on all admissions
Print sign-out sheets from electronic hand-off tabs on
all patients (labs and meds auto-populate)
33. Weekday Call GREEN
First and Second years will do a week of nights out of
their 4 week rotation.
Night call is from Monday thru Friday, 6pm to 7 am.
Residents will be supervised by an attending
nocturnalist and will be responsible for all the green
patients on the floor.
Residents will also be responsible for over night
admission notes
34. Weekend Call GREEN
2 residents on call
AM sign out at 7 am; rounds at 9 am
PM sign out to nocturnalist at 6 pm
On-call resident responsible for:
Daily progress notes on all patients on the service
All admissions, discharges, and transfers with notes
One fellow per team
35. Call Schedules
Adheres to ACGME rules (<80 hours/ week)
Call schedules are made monthly by the Pediatric Chief Resident
Please let the Pediatric Chief Resident know if there are any conflicts,
emergencies, illness as early as you can
Violetta Kivovich
kivovicv@mskcc.org
Pager #2244, Office x 6005
36.
37. Medication Reconciliation
Accurately and completely reconcile medications
Document a complete list of the patient’s current medications upon the patient’s
admission to MSKCC
This process includes a comparison of the medications the organization provides
at admission, transfer, and discharge to the medications on the list.
Definition
A process for obtaining a complete and accurate list of the patients’ current home
medications, including OTC’s and herbals, and comparing the practitioner’s
admission, transfer, and/or discharge orders to that list.
Instructions found in Resident Manual
38. Security
M9 is a secured/card access only unit which prevents unauthorized entry on to
the unit and unauthorized exit (i.e., abduction).
Residents are assigned coded ID cards to allow access to M9 during
their rotation.
Refer all visitors to the Guest Services or Unit Assistants; do not allow visitors
to enter or exit M9 without checking with the unit or reception staff.
Anyone attempting to leave the unit via stairwells without coded ID cards will
encounter a 15 second delay before the door releases. An alarm will sound in
the RN Station and in MSK Security.
The assumption is that anyone using the stairwell without a coded ID is
an unauthorized departure.
If a pediatric patient is seen leaving the unit via the stairwell (assumed to be
suspected abduction, missing child, or unauthorized exit of a patient) or if you
hear a door alarm, you must call Security (x7866) to inform them of
unauthorized departure and identify the stairwell used (i.e. North or South)
a ‘Code Pink’ will be activated.
39. Dress Code
Men
Shirts & Ties
No Jeans
Women
Business Casual
No Jeans.
No tight/ revealing / midriff exposing clothes !
All: Yes! Scrubs are only acceptable for on call days
40.
41. What Should You Learn At MSK?
Pediatric Oncology
Basics of Chemotherapy
Pain management
Nausea and vomiting
Electrolyte imbalances
Constipation
Antibiotic management
Infections from A-Z
Dermatologic findings
Fever and neutropenia
In addition, you will gain experience working with end-of-life
issues and difficult family situations
