Plastics

General Daily Flow

• Prepare patient lists with pertinent vital signs, lab values, I's & O's, and imaging/culture results.
• Sign-out starts anytime before 6AM and occurs on the 6th floor of AIP2 tower in the surgical resident workroom between the second and third nursing station. You are responsible for grabbing the plastic surgery floor pager. There may be instances where the hand team will ask that you grab the hand pager for them and place it in the plastic surgery call room. The hand team will inform you if that is the case
• Complete orders, consults, and notes after rounding. Update the senior resident with any pertinent news, updates, results throughout the day.
• Usually you will be assigned to one or more surgical cases. If you have a first-start case (i.e. 7:30 start), ordering all pre-operative orders and consenting the patient is the priority before floor work
• If you are not assigned to any cases and have finished your floor work, you are encouraged to join ongoing cases
• Plastic surgery consults will go through the plastic surgery pager. See the patient and staff the patient with the mid-level resident. If the mid-level resident is unavailable, staff the consult with the senior/chief resident
• After all cases are completed, ensure a post op check is performed on patients being admitted to the hospital - this can be signed out to the night intern if the case finishes later in the afternoon
• Sign-out the pager to the night intern at 6PM on AIP2 6th floor

Detailed Daily Flow

Before rounds

• Print patient list: Go to plastics patient list,
• Include Room, Name, Age, Attending, Handoff To do, Blank column for columns
  
• Get vitals: temp, HR, BP, RR, sats, oxygen requirement
  
• I/Os: total in (24hrs) - In: PO/G tube in, Out: UOP, NG tubes, drains, wound vac, ostomy - for drains have current and previous day outputs
• Any recent labs - BMP, CBC, Lytes, Culture Data
  
• Any new imaging
  

Get sign out either right when you come in, or after you get numbers. Must get this before 6 am because this is when the night person leaves

*Rounds
* Chief/senior resident will text team night before regarding start time and will text team morning of regarding where to meet * Rounds are usually casual, very brief SOAP presentation with updates, overnight events, pertinent results, plans/to-do's for the day * Bring appropriate wound care supplies on rounds - RECOMMEND gathering basic supplies in your bag (kerlix, 4×4 boats, xeroform, bacitracin packets, shears, ACE wrap, tape, wound vac dressing) * Dressing changes will be done in the mornings unless otherwise stated. REMEMBER to take pictures of the wound in Haiku and on your phone. Send photos to senior resident * Before rounds start give them any patient updates that might be important to know before we start.
At each patient room give a brief synopsis of the patient SOAP
After seeing each patient, clarify anything you don’t understand with the resident and fellow
At the end of rounds we run the list. This means go through every patient on the list including the ones we did not see and clarify the plan
- After rounds
-Case management: Cris Cloney 34075
-Social worker: Rob Albrecht 86639
Case Management for plastics may page you to run the list and ask about patients that we are primary on as far as what are their dispo plans etc.
Go to preop for your assigned case with the resident assigned to your case
update h&p, mark pt (initial and date), make sure has consent
If no consent available, you should consent them for their procedure
look at the chart the night before, understand the procedure they are getting and be prepared to consent them in the morning. If you are unsure what procedure they are getting, look at the last office visit note in which the attending/PA usually lists the OR plan. You can also look at what surgery the patient was scheduled for by checking out the surgical encounter under the encounters tab.
Consent:
Procedure: xyz + possible xyz… + all other indicated procedures
Benefits: improved condition of xyz or reduction of xyz
Risks: pain, bleeding, infection, need for future surgeries, flap failure (if it’s a flap), damage to nearby structures, scarring
Alternatives/Not undergoing procedure: Continued condition of xyz, worsening of condition of xyz
If you time after preop and before case starts, the following are options:
Team breakfast
Drop orders
Write notes - Hint: Try and get Dr. Kaoutzanis’ notes done first.
Page primary teams for some patients
Go to assigned OR
Leave pager with circulator in the OR so she/he can answer your pages as they come in - ask them politely to return pages as they come in, especially if it’s the consult pager.
- After OR
After the case do post-op orders
Put in a brief op note - look in PACU discharge tab
Ask the attending what they would like as far as patient orders for home or on admission
Pain meds, abx, DVT ppx, dressings, special restrictions, IP consults
Follow-up needs
Place orders
Post op admissions:
Med reconciliation (where you continue orders that were previously held or home medications).
Don’t put the patients on antihypertensives immediately post op, check with resident when in doubt
DIEP orderset
UCH IV PCA orderset
UCH Gen surg post-op orderset
Discharge
PACU discharge orderset
Discharge instructions
Steal smartphrases to use in discharge instructions
Peggy Walsh has a lot of Chong's
Sara Douglass has a lot of Mathes'
Sometimes you can mix and match if one attending doesn't have a specific one, but make sure to change the name in the instructions
Send meds to Atrium
Sign for narcotics in the PACU by selecting print on the order and picking up the paper script at the PACU Rx printer and put in chart or send to atrium pharmacy (tube to 514)
Pre-op your next case, check-in with resident and fellow
Do any unfinished floor work including finishing notes
Consults:
If you get a consult you should let the consult resident know immediately and go and see the consult as soon as you can. The senior resident will either meet you at the consult or ask you to take pictures and send it to him Take pictures of consults and show the pics to the fellow even if they are scrubbed in Cases can be in either AOP or AIP, so look to see where the pt is and go preop them
Discharges:
For complicated patients, call to schedule an appointment (Nicole for plastics 82211, or Kaylie for hand 83372). Otherwise, make sure to put the phone numbers in their discharge instructions and type out that they need to call to schedule a follow up for in 7-10 days.
You can “T-up” discharges (Get them ready because you know they will be leaving soon)
Use discharge tab, and go through reconciliation. Restart home meds as appropriate, and d/c inpatient meds. Prescribe any pain meds or abx that may be needed (Make sure you go to the Rx printer closest to the patient to sign narcotic scripts then either put in chart or send to atrium pharmacy (tube station 514)
Surgeries involving muscles (eg flaps, tissue expanders) should go home with oxy and valium; TEs also go with antibiotics and surgical bra (Nurse may have to call central supply to get a second bra for the patient if this is needed)
Flaps should go with a 30 day script for baby aspirin, 2 weeks lovenox, oxy, valium, abdominal binder Click on the discharge order set and fill in, return precautions, clinic number, follow-up information (use dot phrases for some of this)
It will automatically pull up a “discharge pt” order that you can remove under summary
Sign these orders, make sure narcotics and/or all the scripts are “print” when you put them in. You can change this within the order. Some pts like to take their scripts to other pharmacies and you can only send them to the Atrium pharmacy. Have fellow sign scripts in the morning. When clicking “sign” it will prompt you with a screen that shows the attending's name under medication prescription, you can change this to the fellow's name, and that way they can sign it with their DEA number. Scripts print to where the pt is (eg if on the 7th floor, will print to main 7th floor nursing station script printer, if they are in PACU it will go to PACU)
On actual day of discharge, you will only need to put in a “discharge pt” order and a “discontinue IV” order

Follow-up:
In basket message to “P Plastic Surg Nurse/MA” include patient name and MRN in patient line. Write “Please schedule patient for follow-up in xyz weeks (or for a specific date if known)”
Pts usually follow up in 7-10 days from discharge.

Clinic 720-848-0800, Nurse line 720-848-0007. Hand clinic 720-848-0485
Can start discharge summary at any point, and share it. Make sure to have one signed within 24 hours of discharge.

End of day:
Update the handoff based on new information or changes throughout the day. Include plans for the following day/week if applicable ie. change wound vac tomorrow
Find your fellow (they may be in the OR) and either run the list (can do this while they are scrubbed in)/round on patients, ask what else is going on, update them on what you have done and what is going on on the floor
Sign out is at 6 PM, there may be a line so it may take some time; try to be the first one there to sign out, otherwise you will have to wait until other teams (with longer list) are done signing out
Tell night person a brief one liner and what you guys are doing for them. Assume they do not know the person because they carry 6-9 pagers on any given night.
Make sure to let them know if they need to do a postop check (eg pt just got out of the OR/still in the OR/in PACU)
Make sure to let them know if there is anything to follow up and if they should talk to someone about results: eg labs, urine output, a void if a foley was pulled…
Let them know which resident and fellow is on call for that night. Put their names, pager and cell phone numbers at the top of the list.
Miscellaneous things:
Chong and Mathes flaps get advanced to NO caffeine diets.
All flaps should be on a baby aspirin.
Gordon has his own hand discharge instructions under the discharge tab. If you search for instructions (not smartphrases), just look for Gordon and his postop instructions will come up.
Steal all the smartphrases! They are your best friend
ALWAYS put in specific wound care orders if needed, either in a nursing communication or in a wound care order. Be very specific, otherwise you will get paged a bunch and it won't be done right. Specific to the point where you tell them “use a 4 inch ACE wrap”, etc.
If you are confused, or not certain about a pt and their discharge, ask your resident, fellow or the APPs on the service. They are the ones mostly see the pts in follow ups at clinic, so they can tell you what they are looking for or what the pt needs to be sent home with specifically.
White surgery/Breast is primary on mastectomy/tissue expander combo cases

On the list, write who is the primary team
Numbers – (or 84845# universal code)
Sixth floor nutrition room: 6060#
Ninth floor supply room: 9191#
Tenth floor supply room: 0180 (of note, the master code doesn't work on this door)

Teaching Topics for Students – Flap checks, wound vac principles and how to change them, deep dermal and running subQ sutures (these are what you will do mostly in the OR).

Hand Call
History: For all pt's list their name, handedness and what they do (i.e. is fine dexterity extremely important to them, concert pianist vs receptionist). Note if the fracture is open or closed and make sure to do a neurovascular exam.
Distal radius fractures: Inject 10cc lidocaine into the fracture (area of swelling and pain) site and hang pt's arm with finger traps. This will reduce the tension on the muscles and allow the fracture to be reset.

Schedule
Monday: HAND CALL
7AM Grand Rounds in big auditorium on 1st floor AIP
4:00PM Plastics conference (630am in summer) in 6th floor conf AIP
Wednesday: HAND CALL
Once per month Mathes conference at 6:30am (not required for interns)
Friday: HAND CALL every other week (check schedule)
6:30 Hand conference
Weekends: HAND CALL every other weekend
Usually round/cross-cover on Saturday unless you change schedule. Let the fellow who is on that weekend know and ask when they want to round. Same deal for getting the list ready in the AM. If just rounding, once floor work is done you can sign out to the cross-cover intern. If cross-cover, good luck and you will be contacted by other services to get sign out from them throughout the morning/day.