Night Float / Sign Outs /
Patient List Management
Night Float
Emily Cantrell
Cell: 336-775-8889
Pager: 352-413-0305
Emily.Cantrell@surgery.ufl.edu
Night Float / Sign Outs /
Patient List Management
The Concept
• Night Coverage
– South Tower:
• PBS, MIS/GI, BMSE, CRS, Transplant, Plastics
– North Tower:
• Pediatric Surgery
• Vascular
– Trauma
• Trauma Junior covers Burn Surgery at night
Night Float / Sign Outs /
Patient List Management
Who can I call for help?
• In house at night:
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Trauma chief (258-9345)
Trauma junior (260-8758)
Trauma intern (413-3827)
Night float (413-0288)
CCM (494-9189)
• Chief Residents:
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Lindsey Goldstein (353-246-4177)
Makesha Miggins (336-971-5252)
Joe Campbell (353-281-3180)
Trajan Cuellar (352-642-2704)
Mike Hong (323-496-5544)
• Radiology Reading Room: 44385
Night Float / Sign Outs /
Patient List Management
The Basics
• Active response 6p – 6a
– Flexibility in the 6a to 7a hour is essential for transfer
of care.
• Signout at 6pm or else page service & get
signout
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It’s all in the details…. (don’t accept “NTD”)
Face-to-face signout, senior resident present
Help your co-interns with end of day chores
Bedside rounding for sick/dynamic patients
Get feedback from seniors re: management
• Document EVERYTHING in chart and list
Night Float / Sign Outs /
Patient List Management
Sign out
• Brief history/presentation
– Age, comorbidities, presentation, dx, operation
• Notable, relevant changes past 24hrs
– Foley, NGT removed, diet, pain meds changed
• Active issues (by systems, esp. in ICU)
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Neuro (bleed, stroke, neuro deficit, delirium/AMS)
Pulm (lung dz, pna, PE, secretions)
CV (pressors, rhythm issues, BP, baseline CAD)
GI (bowel fn status, baseline abd exam)
FEN (acid-base, lyte, fluid, nutr’n, renal-UOP)
Heme (bleeding issues, plt/inr/ptt, anticoag’d)
ID (active infex, recent cx’s, abx – on the list)
Drains/tubes/lines: where are those drains?
Wound status: open/closed, clean/infected
Night Float / Sign Outs /
Patient List Management
Sign out
• Conditional statements (if/then)
– Foreseeable issues and plan if they come up
• Plan
• Special meds (anticoag, abx, atyp pain
meds)
• Meds to avoid (over-benzo/narcs in elderly)
• Allergies -on the list
Night Float / Sign Outs /
Patient List Management
What to do after signout
• Postop checks
– Time/date note, read the op note
– Dx, procedure, SOAP (pain, CP/SOB/N/V UOP, vitals,
exam, wound, drains, labs, CXR)
• Round-- walk by & check on rest of pts
– “eyeball test” (look good, okay, not so good)
– Talk to / examine any w potential issues
– Get check-boxes done (your ‘to-do’ list)
• Respond to calls
– If any question of urgency, have nurse repeat new
vitals, and go see pt
Night Float / Sign Outs /
Patient List Management
Patient Assessment
• Nurse calls – ask for repeat vitals, go see the
patient, examine, check wounds, tubes/lines
• Types of routine calls
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Pain, nausea, insomnia
Fever, AMS
Tachycardia, hypoTN
Low UOP
Critical labs
• Assess, make a plan (or call if unsure) &
document, document, document
• Transfer to higher level of care if needed
Night Float / Sign Outs /
Patient List Management
Workflow
• Update the list (be brief / informative)
• Update room numbers (Navicare/portal)
• After midnight, print list & get it ready
– Vitals (trends), I&O, to-do check boxes
– For ICU/IMC pts 4-4:30am, update labs
– Updates/events to flag for the day team
• Bonuses (clean-up the list)
– Clean up the list: DVT/GI prophylaxis, Abx, Cx
– Help Trauma (if caught-up): alerts, terts, d/c’s
• Notes
– Pediatric and Vascular Surgery night residents write
the notes
Night Float / Sign Outs /
Patient List Management
Other tips
• Think for yourself… Nurses will make requests
all night long for pain meds, nausea meds, sleep
meds…. See every patient and only give those
out as necessary.
• Do not dismiss a fever or try to mask it w Tylenol
• ALWAYS go see patient prior to calling chief.
• Notify chief before major decisions:
– Transfers, antibiotics, transfusions, vasoactive
agents, CT scans
Night Float / Sign Outs /
Patient List Management
Admissions
• Hospital to hospital transfers and pre-op admits
– Use Navicare, go to 5E (for Gen Surg) or 6E (for Txplt)
and look at beds with pending transfers: click on all of
them to see which are coming from outside, then look at
the attending who accepted (if it’s one of ours, then you’ll
be getting called for “orders on your new patient”)
– Transfer Center (352-265-0559)
• Each patient needs Full H/P and orders in EPIC
upon arrival to the ward.
• Look thru the OSH paperwork carefully. Take extra care to find
and secure Imaging CDs/films.
• Call the Service Chief on Call or Fellow on call with
questions, to notify them of the patient’s arrival..
• Add the patient to the list.
Night Float / Sign Outs /
Patient List Management
Consults
• All general surgery consults at night
should go to the Trauma Junior.
• Pediatric Surgery and Vascular Surgery
night residents will be responsible for
seeing consults.
Night Float / Sign Outs /
Patient List Management
Other tips
• You might feel like the only person awake in
Shands but you are not alone.
• CALL YOUR CHIEF.
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They want to help
They are always available
They want to protect you
Call with questions but also be thinking of plans
Night Float / Sign Outs /
Patient List Management
Other tips
• TRAUMA.
• The NF pager is on the trauma list for a reason.
If you are not busy, you must be there.
– Experience and procedures
• Have the junior resident start teaching you how to FAST, put
in lines and chest tubes
– Just plain “Helping out the team”
– Paperwork:
• Orders- admit orders, CT orders
• H&P
• Tertiary (if you’re feeling really generous)
Night Float / Sign Outs /
Patient List Management
Take home points
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You are not alone
Document everything on chart & list both
Transfer to IMC/ICU, get CCM involved
Workflow – get postops & check-boxes
done so you are ready: for calls, help
trauma w alerts, new admits, etc.
• Be proactive – check actively on new ops,
concerning patients, active/dynamic issues
• Be friendly/responsive to nurses
Night Float / Sign Outs /
Patient List Management
Night Float / Sign Outs /
Patient List Management
Patient Census Management
Tad Kim, Vince Mortellaro
UF Surgery
(c) 682-3793
(p) 413-3222
tad.kim@surgery.ufl.edu
Night Float / Sign Outs /
Patient List Management
Overview
• Diagnosis List
• Notes (history) section
– Initial presentation
– Essential information (Abx, Cx, PAB, etc)
– Hospital Course
• Surgery section
• How to use the Name section to your
advantage
• Take Home Points
Night Float / Sign Outs /
Patient List Management
Diagnosis
• For trauma, “Fall” or “MVC” is not a dx
• If no injuries & patient had confusion, AMS,
GCS, you can use “CHI (Closed head injury)”
– Also is a valid code for coding/billing purposes
• List all secondary (not PMH) diagnoses and
complications (examples on next page). This
helps in a number of ways:
– Dictations are easier (Prim/2ndary dx are done)
– Helps chiefs for M&M
Night Float / Sign Outs /
Patient List Management
Diagnoses – Commonly Missed
Acute blood loss Hyper/Hypo-Na
anemia
Urinary tract
infection
Atelectasis (IS)
Ileus
Bacteremia
Acid-/Alkalosis
DVT/PE
Atrial flutter
Intestin obstrux
– SBO or LBO
Malnutrition
CHF(D or Sys)
Pleural effusion
Septic shock
Decubitus ulcer
– specify site
Cellulitis,seroma Aspiration
abscess,wd infx
GI bleed (site)
Urinary retention
ARF or AKI
Night Float / Sign Outs /
Patient List Management
Coding Tidbits
• Commonly omitted by residents
– Atelectasis (if we treat this with incentive
spirometry, the hospital can bill for it)
– Blood loss anemia (Anemia from blood loss)
– Excisional debridement
• Type of instrument- scissors, scalpel
• Type of tissue- necrotic, skin, fascia, muscle, bone
• Approximate depth, size, or weight removed
– Septic shock is a much higher DRG
compared to “sepsis”. The key is shock
– Wound infection
Night Float / Sign Outs /
Patient List Management
Notes section: Initial Presentation
• First line
– Age, gender, relevant past medical/prior
surgeries & presentation
– For trauma (TRE): presentation = mechanism,
LOC, GCS, FAST, Hct, SBP, (add EtOH/UDS)
• Relevant labs & studies on presentation
– WBC +/- bands/poly’s, EtOH/UDS (for TRE)
– “CT A/P- ..” or “CT hd/Csp/C/A/P/T&L spine”
• Interventions or consults (esp for TRE)
– i.e. “L CT placed”, “GI Cs (consult) pending”
Night Float / Sign Outs /
Patient List Management
Examples of initial presentation
• 56yo M PMH NIDDM/CHF w EF
35%/CRI, prior chol’y ’76, Crohn’s
s/p SBR x3 last in ’03 now p/w
N/V/abd pn x2d. WBC 14. KUB- AF
lvls, dilated SB. CT- SBO. Plan:
NPO/NGT/Resus IVF, GI Cs p.
(pending)
Night Float / Sign Outs /
Patient List Management
Examples of initial presentation
• (TRE) 26yo F PMH ADHD rest driver
in MVC RO (rollover) w ejection,
+LoC, GCS 14 (-1V), FAST neg, Hct
33, SBP 120, EtOH 200, UDS
+cocaine. Pt c/o abd and pelvic pain.
CT hd/Csp/C/A/P as above. IRangio/embolization of pelvic bleeder
Night Float / Sign Outs /
Patient List Management
Initial Information, cont’d
• Special allergies, i.e. contrast dye & type
of reaction
– especially if the reaction was anaphylaxis
• Special meds (especially anticoagulants)
– “PMH Afib on Coum”
• Next of kin information when applicable
Night Float / Sign Outs /
Patient List Management
Trauma specific information
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Mechanism (mentioned above)
LOC, GCS, FAST, Hct, SBP
EtOH & UDS results
Which CT scans or XR’s were done
DVT scans/date (Radiology section)
IVC Filter placement/date (Surg section)
List of consults following patient
Only injuries (not mechanism) go in the
diagnosis slot
Night Float / Sign Outs /
Patient List Management
Additional Information
• Antibiotics with start (& stop) date
– “Abx: Cpime/Vanc(7/4- )” (include stop date)
– Abbreviate so that it’s still recognizable
– Include last vanc trough
• Cultures – include date
– pos results (recent neg results) & usu. don’t
include sputum
– For Blood, include how many bottles of total
– “Cx: 7/2 UCx Ecoli, 7/4 BCx 2of4 MRSA”
– Abbreviations: CNS (Coag neg staph), MSSA,
MRSA, Cdif, PSA (Pseudomonas Aeruginosa)
Night Float / Sign Outs /
Patient List Management
Additional Information, cont’d
• Vancomycin trough w date of last result
– “7/3 Vtr 30.5” (put this in Abx section)
• Pre-albumin – update on Mon afternoons
– include current one w last week’s in ( )
– “PAB 8(10)” Put right before the plan: section
• Before PAB, write TF formula/goal rate
– This helps when writing transfer orders
• A section for “Plan“ at the end after Abx
– “Plan: OR w Ortho 7/12, Dispo: Rehab”
– Must update constantly to be useful
Night Float / Sign Outs /
Patient List Management
Hospital Course
• Create a block in the notes section for the
hospital course in chronological fashion
between PAB & initial presentation
– “7/2 OR. 7/3 txfr to 64, DC NGT/OOB. 7/4
Clears/POM (PO meds). 7/5 Wound
opened, W-D BID. 7/6 Fevers -> CT scanIAA (intra-abd abscess), CT-perc drain. 7/8
Reg diet, DC Drain, D/C home.”
• If the list is done right, you could perform
dictations without flipping thru the chart
Night Float / Sign Outs /
Patient List Management
Surgery section
• Reverse chronological order with the
surgery type and date in parentheses
• Separate different days with semi-colon
– “Trach/PEG(7/10); ORIF R femur(7/7); ex-lap,
splenect, NJT(7/4)
• If the full procedure is listed in the surgery
section, no need to repeat in the notes
section. Just write “7/7 Ortho OR” in notes
Night Float / Sign Outs /
Patient List Management
Using the Name section
• For TRE, “Trauma” goes under last name
– Trauma name itself goes after 1st name in ( )
• Use the First name section as a way to
alert yourself not to forget certain things:
– Prophylaxis (H,N) = heparin, nexium
– VAC dressing changes on MWF or TThSat
– “iHD (Hemodialysis) on MWF” or “CVVHD”
– “Coum”, “Hep gtt”, “Loven” for anticoagulation
• This helps you stop these when “pre-opping” the pt
– TPN (to remember to write for TPN before 12)
– i.e. “Smith, John (VAC MWF) (iHD) (COUM)”
Night Float / Sign Outs /
Patient List Management
Other minor pointers
• Use Navicare to:
– Find out room assignments fastest
– See if there are any unexpected transfers
– Status of an OR patient under OR SuiteVue
• For consults, list the actual “Date of
admission” not the date of the consult
• Update resident & student info on the list
• Designate a spot on the paper list to be for
elements needing computer-list updating
Night Float / Sign Outs /
Patient List Management
Take Home Points
• Remember to include:
– Prophylaxis, Abx, Cx, PAB, Vanc trough (if pt
is on Vanc), Goal tubefeeds
– Past medical history, special allergies / meds
• Use the first name section as an alert for
the need to write TPN, anticoag status, or
perform a VAC change
• Ideally, any new resident or the night float
you’re signing out to should be able to look
at the list and know the patient fully
Night Float / Sign Outs /
Patient List Management
Other Professional Duties
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Duty Hours – complete once a week (Tue)
HIPAA Training – yearly
Compliance (Billing) – yearly
Complete delinquent charts on portal
Be on time to conferences, M&M, etc.
• Case log entry – do these at least at the
end of the day, if not right after the case
– For the future, each operation, think of:
– Op note, orders, dictate, list, case log