DEPARTMENT OF MEDICINE
OLIVE VIEW-UCLA MEDICAL CENTER
WARD ATTENDING GUIDELINES
(Updated May 16, 2023)

Welcome to the Olive View wards.  To plan your first day on service, contact the Attending you are taking over for prior to your start date.  You can see your daily schedule at www.amion.com.

If you find you are unable to cover because of illness, etc., please contact Dr. Michael Rotblatt (mrotblatt@dhs.lacounty.gov) if you are on Teams A-D or Dr. Rick Tennant (rtennant@dhs.lacounty.gov) if you are on Teams E-H.  In the event that one of them is unavailable, please contact the other.  If neither are available please contact Dr. Laxmi Suthar (lsuthar@dhs.lacounty.gov).  In the event that you are unable to cover your shift a back-up attending will be assigned.

WARD SCHEDULE:

1. There are 3 types of call days:  Long (10 pts), medium (6 pts) and short (4 pts).  Call days are scheduled on an 8-day cycle:   Long – Post-long – no call – Short – no call – Medium – no call – no call – Long.
2. All ward attendings are expected to be in hospital by 9am daily (or 10am on long call) Monday through Friday to supervise patient care, facilitate Interdisciplinary Rounds and teach their ward teams.
3. On non-call days Monday through Friday, attendings are expected to stay in-house until 4pm to supervise and teach their ward teams.  Resident sign out begins at 4pm, hence the 4pm time mark. If your team census is light, consider using the afternoons for small group didactics and evidence-based medicine teaching. There are several resources available on our residency website at https://www.oliveviewim.org/  for your use.
4. On long call, attendings may flex their start time to 10am to accommodate for staffing patients later in the day. It is expected that the long call attending staffs at least 6 patients on the long call day and be available by phone overnight for their team.
5. Per RRC duty hour restrictions the max shift per trainee is 24+4 hours. However, all residents are limited by a “time off between shifts” requirement of 8 hours such that our program goal is still for them to leave by 10pm on typical days.
6. On long call days meet with your team for new patient rounds in the afternoon (usually 2-5pm) and finish by no later than 7pm so the interns can get their work done and leave by 10pm.  Residents stay overnight on long-call days and must leave the hospital by 11:00am the following day.  On post-long call rounds, prioritize the sickest and dischargeable pts (plus resident-admitted pts) early so you can excuse your resident by 11:00am. You will then work with the interns, who will sign out after 4pm when the night float intern arrives.
7. On short and medium call days, discuss with your resident when the best time for rounds on new patients would be (usually late morning or early-mid afternoon).  Old patients can be “card-flipped” on these days.
8. On non-call days, attending rounds should start at 9:00am and finish by 11:30am. Weekend rounds are more flexible, depending on the schedule and needs of the team. If your team says they have not had time to “run the list” and want to push back rounds, please advise them that you will run the  list with them in real time and please start rounds at 9am.
9. Good sign-outs/hand-offs are critical.  When your resident is gone (off, or post-long call) review the sign-outs with the interns before they sign-out for the day, as the resident would normally do. Sign out is 4pm on all days but on weekends interns are allowed to leave the hospital after 12pm yet must remain on-pager until verbal sign out at 4pm, and are expected to come back in for patient care issues should it be necesssary.
10. Housestaff have one scheduled day off per week.  You will need to cover for your resident during their days off.  When the interns have the day off the resident will cover, but please help (especially for large services). Please be available for intern support until the end of the day when the resident is off.
11. For after-hours questions, let your team know if they should contact you, or the “chain of command” attending. You are required to be available by phone/pager after hours (4:30PM to 8AM) on your long-call day only (and can code as Stand-by, 531) but many attendings prefer to be contacted for events on their patients during other days.
12. Noon lecture (12:00pm – 1:00pm, Mon – Fri) is required attendance (via Zoom/In-person) for all housestaff and encourage attendance for attendings. Please ensure housestaff are available for these lectures and encourage them to attend.
13. Hours and timecards:  For those who can code for overtime (OT), you are allowed a maximum of 12 hrs/week of preapproved OT (actually, 6 hours per each weekend or holiday day in your pay period).  Flex your hours as much as possible, but if you request more OT, complete an “Emergency OT Request” form from Alicia, which must be signed by your supervisor and Dr. Wali before your timecard is completed.  Code 701 ($) or 705 (comp time) with reason code 843 for OT, and code 531 (standby) without reason code when you are on long-call at home.

PATIENT CARE, DOCUMENTATION AND OTHER RESPONSIBILITIES:

1. The attending physician is responsible for the welfare of the patients, and thus needs to be involved in all major decisions.  However, attendings should also encourage the resident to be the team leader and make management decisions.  Commenting on these decisions is a more useful educational style than making your own decisions without the resident’s involvement.
2. All patients must have a History and Physical within 24 hours of admission, usually written by the intern or resident, with onset of admission defined as when “Request for Admit” was ordered. Attending documentation is required on all patients new to your ward service, including holdovers admissions and ICU transfers. This is a CMS/Joint Commission core measure.
   1. Your admission documentation can be written as an addendum to the intern’s H&P note.  If you want to write a separate admission note, please use the “History & Physical” note type, and state “see separate attending H&P note” in the addendum of the intern’s H&P.
   2. Interns must complete their H&P w/in 24 hrs of admission. There must be at least one note written every day.  This can be a separate attending note, the intern H&P, the MRAN, or an intern progress note.
   3. Please ensure completeness of the “History & Physical” note for all expected components including Social History, Family History, Review of Systems, etc.  This is a CMS/Joint Commission core measure.
   4. Your attending note must give evidence of (a) direct exam of the patient, (b) interaction with housestaff in formulating management plan, and (c) your assessment/plan.
3. Daily progress notes can be signed w/o an addendum but should be reviewed with feedback for the interns or residents on documentation.
4. For ORCHID PowerChart training, excellent YouTube videos are on:  http://www.oliveviewucla.org/orchidtraining/
5. You should help the team anticipate early in the day as well as “next-day” discharges.  All discharges must be approved by the attending, and housestaff should document this agreement in the discharge summary.
6. Appropriate documentation is essential for the hospital to obtain reimbursement. Ensure that the severity of illness and intensity of services needed for inpatient care (e.g., “pt requires continued stay for frequent nebulizer txs, IV abx, IV analgesic, persistent hypoxia, etc”) are documented in trainees notes.
7. Teach trainees to link diagnoses when appropriate (e.g., HTN and CKD à consider documenting “CKD secondary to HTN” to capture the severity of illness).
8. MS Teams is the preferred venue for communication with residents and the Interdisciplinary Team.  Please ensure you are able to log-in prior to the start of your rotation.
9. Interdisciplinary Rounds (IDR) will teleconference with your team for 10 minutes between 1:30 and 2:30 on non-call days via MS Teams.  You and/or the resident must be available to discuss your patient list. IDR patient discussions should focus on reason for continued admission and anticipated discharge needs such as primary care follow up, home health, etc.
10. On call days, communication and planning with the Interdisciplinary Team will happen asynchronously via MS Teams.
11. Foreign visitors (including non-L.A. County residents) are only eligible for emergent inpatient care.  Outpatient f/u visits (including PDC) are not allowed.  Refer these pts for care in their own county or country.
12. For questions about IDR, Utilization Management and Documentation contact the UM Dept. at x73414.
13. Procedures done by housestaff must be supervised directly by an attending, unless the resident is “competent” to perform/supervise the procedure.  Housestaff competency is documented on the Intranet.  Contact the Procedure Service (pager on AMION) during “business” hours to supervise the housestaff or complete the procedure independently.  If you supervise a procedure, the resident will send you an electronic doc to sign via MedHub.

ADMISSION CAPS, BOUNCE BACKS AND OTHER USEFUL RULES:

1. Each ward team has a “hard cap” of 20 patients (20 per resident, 10 per intern).
2. Daily call “soft caps” are as follows: Long call – 10 patients, Medium call – 6 patients, Short call – 4 patients.
3. On Long Call, the team will admit until 10pm, or until their cap is reached, whichever comes first.
   1. “6/7/8” Long call rule:  If the team has not received at least 6 patients (“on the list”) by 7pm the admission cap will decrease to a total of 8.
4. On Medium Call, the team will admit until 4pm or until their cap is reached, whichever comes first.
5. On Short Call, the team will admit until 12pm or until their cap is reached, whichever comes first.
6. A bounce-back is defined as a readmission to a medicine INTERN (or MS4) that is still on service within 14 days of discharge. Bounce-backs are accepted by the primary team:
   1. On a non-call day;
   2. On a call day, in which case the bounce-back counts toward the admission cap;
   3. On the post-Long Call day only if there were less than 10 patients during the Long Call and the total number of admissions to the resident does not exceed 10;
   4. On a resident’s day off;
   5. On an intern’s day off, except if the intern’s day off is their last day of the rotation.
7. Teams may receive bounce back patients until 2:30pm on weekdays and until 12pm on the weekends and holidays. If called to the list after these times they will be held over until the following day.  All bounce-backs must be staffed with an attending on the day they come to the service.

POST-DISCHARGE F/U:

1. For patients who have a PCP/medical home (e.g. “empaneled”), schedule post-discharge f/u with the PCP via Orchid order (Discharge Request for Hospital Follow up in Primary Care).
2. For patients who do not have a PCP/medical home:
   1. If patient needs a face-to-face appt à schedule with CCC-PDC clinic by Orchid communication. Teach interns and residents to clearly state at the end of the discharge summary what needs to be followed.
   2. Please NERF (New Empanelment Request Form) these patients and have the intern document this in the discharge summary.
3. For assistance with discharge planning, contact your UM Case Manager via MS Teams or call the UM department at x73414.

TEACHING RESPONSIBILITIES:

1. Bedside rounds are an opportunity for you to role model physician/patient interactions, teach physical exam skills, and obtain real time historical and physical examination data. Resident learners prefer bedside rounds¹ and believe they are better for patient care².  Bedside rounds are preferred by patients as well^3,4. For these reasons bedside teaching is required by attendings, and housestaff will expect them (on not all, but many patients).
2. Respect your teams’ time constraints, be brief and teach while you help manage patient care. Query your housestaff and explain your thought processes (clinical reasoning) as much as you can, and let the entire team become active participants.  You should also observe your housestaff do at least part of an H&P when on-call and give them pointers.  Take this opportunity to complete a “mini-CEX” (available on the housestaff website, oliveviewim.org).
3. Plan specific days to meet and give feedback to your housestaff; daily continuous feedback is also appreciated.  You also need to complete written evaluations for your team members at the end of the rotation, using our web-based MedHub evaluation system.  Contact the Medicine Dept. (x73205) for questions.

MEDICAL STUDENTS AND IMGS:

1. During your ward rotation you may have a 2^nd year core rotation medical student, a 4^th year sub-internship medical student and/or an international medical graduate on your service.
   • In the Fall of 2022 UCLA DGSOM transitioned to a new schedule in which clinical rotations begin part way through the second year.  As a result of this, typical “3rd year” medical students rotating on Medicine for their core rotation will now be 2nd year medical students.  They should be supervised in the same way.
2. Meet separately with the 2^nd and 4^th year students at least weekly to provide feedback.
   • For 2^nd year students feedback should include a case review or an approach to being a better physician as well as review of 1-2 written H&Ps with the student with detailed feedback.  Also observe the student examine at least 1 patient during the rotation and give feedback on his/her examination skills.  The 2^nd year students also have a UCLA requirement for you to observe a history and physical exam.
3. 2^nd year medical students should aim for 3 new patient encounters a week and should be carrying (on average) 2-3 patients at any given time.  They should work with and be supervised by the intern assigned to their patients.
4. 4^th year medical students should function as interns and are supervised by the resident.  Because of this, when the resident is off, attendings are expected to be present to co-sign orders and review and supervise signouts.
   • 4^th year medical students can receive “bounce-back” admissions according to the rules noted above.
5. Students are scheduled one day off per week. 2^nd year students also have required lectures at OVMC on Mon, Wed and Fri afternoons.
6. We have IMGs who act as medical students through a special UCLA Family Medicine training program.  They can do everything except: (1) sign notes/orders, and (2) perform procedures or “invasive” exams (pelvics, rectals).
7. If there are any questions, issues, or concerns with medical students (commendation, not performing well, questionable absences, etc.) please contact via email or page:
   • 2^nd year medical students: Clerkship Director Dr. Matthew McCullough (mmccullough3@dhs.lacounty.gov)
   • 4^th year medical students and International Medical Graduates: Clerkship Director Dr. Junya Kayano (jkayano@dhs.lacounty.gov)

If you are unable to perform your ward attending duties due to illness or emergency, please contact Dr. Rotblatt or Dr. Tennant as noted above, as soon as possible.  If you have an expected absence it is your responsibility to make arrangements for someone to cover for you.  If you have any questions, or have concerns about a team member, please contact the Program Director, Associate Program Directors or the Chief Residents.  Thank you and enjoy wards at Olive View!

Download Ward Attending Guidelines