Anthony Visioni, MD and Roy Phitayakorn, MD, MHPE (MEd)
IS THIS SCUT WORK OR WHAT?
The bread and butter procedures in general surgery include hernias, appendectomies, and laparoscopic cholecystectomies. However, one of the most important bread and butter procedures for a surgical intern is actually the admission of the patient. Do not be mistaken into thinking this is “scut work” or a mindless task. Admissions are an opportunity to learn the most important lesson a surgeon can learn—whom to operate on and why.
Each surgical admission should be approached in a systematic manner. Particular regard should be given to triage, time management, communication, entering orders, and avoiding common mistakes.
Choosing which patient to see first is not necessarily based on the order the pages came in or on the disease the patient has. It is the severity of each patient’s condition that dictates the order in which he or she is seen. In other words, patients are triaged.
It is helpful to know the most common diagnoses for each rotation you are on and how to work them up. However, when triaging patients, knowing the management of every surgical disease is not as important as being able to recognize several important signs of a severely ill person. These signs include fever, hypotension, and tachycardia. It goes without saying that a patient with unstable vitals needs urgent attention. However, surgery patients are the most fickle patients in the hospital. They will look good one minute and be on their way down the next. It is the ability to pick up the subtleties that make the difference. For example, an elderly patient with a heart rate of 90 does not fall into the textbook definition of tachycardia. However, when considering that the patient is on a β-blocker and his baseline heart rate is 50, this person can be considered to have a relative tachycardia and may be quite sick. Triaging patients is a skill that will improve with time, but only if it is practiced with attention to detail.
Occasionally, people have no major abnormalities of their vital signs, but there is other information that affects their priority. There are 3 “trigger words” that should raise a patient’s level of triage regardless of the vital signs. Peritonitis, free air, and ischemia should never be neglected.
Patients with the physical exam finding of peritonitis (diagnosis symptom, not a diagnosis!) are the exclusive domain of the surgeon. These patients demand prompt surgical evaluation if not immediate surgical intervention. It is important to remember that a normal computed tomographic (CT) scan in a person with a clinical exam of peritonitis is not reassuring. These patients are sick regardless of what the radiograph shows.
The same can be said for patients with free air. This is essentially synonymous with a gastrointestinal perforation, and demands a surgeon guiding the care of this patient. Patients with free air may have a relatively benign exam and stable vitals; however, they should be assumed to have the potential to worsen quickly until proven otherwise.
Ischemia is also a time-dependent condition. While more frequently seen on vascular services in the form of limb ischemia, visceral ischemia is a potentially fatal condition that needs urgent intervention. While limb ischemia is a fairly straightforward diagnosis to make, ischemic intra-abdominal organs can be subtle. Do not delay in calling a chief resident or attending because you are unsure of the diagnosis at any point, but especially when ischemia is a concern.
So, you’ve decided what order to see your patients, but how do you fit 5 admissions in before evening rounds? The key to effective time management is to develop a systematic approach and refine it throughout your first few years of residency. Chief residents and attendings can use shortcuts and pattern recognition because of years of experience. For the novice, it is more effective to use a system in which you only see a patient once and do it right, rather than to do it quickly and miss information or findings. The following paragraph will describe what we have found to be the most effective approach during our intern years. Your system will likely be somewhat different, but we hope that our approach gives you a framework from which to start.
Our first step when evaluating a patient is to realize that you are just one of many people who have interviewed this patient so far and the patient is likely in a fair amount of pain. Therefore, start with a polite introduction and state why you were asked to see the patient. Then follow the same progression of questions for every patient: history of present illness, past medical/surgical history, current medications, allergies, social history, family history, and review of systems, and then proceed to the exam. Finally, review the labs and then radiology. It is not important in what order you gather the information (eg, for some patients you may want to start by looking at the labs and imaging), what is important is that it is done the same way every time. This system ensures no missed points that may be crucial to the care of the patient.
You notice that we did not mention note writing while interviewing the patient. While it sounds counterintuitive, we believe that writing your note after obtaining all the information, and not during, will be quicker in the beginning. When you are talking with patients, they may not always want to go by your preconceived script. This is not a problem, and by letting patients tell their story in their own way they will often tell it faster. Waiting to write the note lets you focus on the patient and even perform some aspects of the physical exam during the interview. Also, by writing the note at the end of the interview and data gathering, you can synthesize it into a concise, but thorough note that will be the most beneficial to the next person who reads it. Notes written during the interview often don’t have a coherent “story line” and are less clear to the next reader.
The last step when seeing a potential surgical admission is to decide if any requests should be made for further imaging or testing or should you be calling your chief resident ASAP to book the next operating room. This step requires you to create an effective differential diagnosis and decide what further information (if any) is needed to clarify the differential. You will often make mistakes at this last step in the beginning, but it is important that you always take a stab at it—in that way you learn from each mistake and improve your admissions system.
Clear communication is extremely important in hospitals, and miscommunication is a proven major cause of medical errors. The first moment of communication in the admission process is when you find out there is a patient to be seen. This information can come from your chief resident, attending, a call from the ED, or even the nurse on the floor. Regardless of where the information comes from, there are several questions to be answered for sure. First, you need to make sure you have the right patient, typically the name, medical record number, and location. This is also the time to ask a few pointed questions to help with the triage of this patient. You should not grill the person for every aspect of this patient’s history and physical examination—that’s your job to find out. What you should do is ask for the vitals and general condition of the patient. Finally, it is important and good professional behavior to let this person know generally how long it will be before you see the patient.
Communication is also important when you talk to your chief resident about the patient you have just seen. In general, you should try to talk to your chief after each patient you see. This “check-in” will prevent you from mixing up information and also ensures that each patient’s care is initiated in a timely manner. When speaking with your chief, the key to a good patient presentation is to incorporate the important points in a clear logical manner. Invariably, there will be questions about the history, physical, labs, etc. Answer the questions confidently, but never under any circumstances lie or bend the truth—“I don’t know” is the best answer if, in fact, you don’t. Lastly, briefly present what your plan would be—this provides you an opportunity to get feedback.
After your presentation the chief or attending will outline the final plan of care for the patient; make sure you are clear on this. Asking questions to clarify a plan of care is not a sign of weakness, especially when it is for the benefit of the patient. It can also be an opportunity for you to learn, especially when the plan differs from your own attempt.
Similarly, communication is key when conveying the plan of care to the primary and covering teams in the form of a handoff. Patient handoffs are fraught with chances for medical errors. Therefore, as in all aspects of the admissions process, a systematic approach is necessary. Briefly, inform the covering team about the history of present illness, significant medical history that impacts the covering team’s care, allergies, medications, and what needs to be done. All of these points should be covered clearly and ideally written in some form of patient list.
Another important place for communication in the admissions process is between you and the nursing staff. Rarely do interns forget to talk to their chiefs, but talking to the nurses is often overlooked to the detriment of the patient. Interns should not rely solely on orders to convey information to the nursing staff. If there are important aspects of patient care that must be accomplished, then direct person-to-person communication is the best way to ensure that no mistakes are made. For admissions from the ED, one approach is to write an order asking the nurse to call you when the patient arrives on the floor.
Finally, as an intern you will often be the most visual face of a surgery service. This means that you will often have to inform patients and their families of the plan of care and patients’ progress. When admitting a patient, it is extremely important that the patient and family are made aware of the reasons for admission and the plans for the patient. Patients and families will often have questions, and you may not know all the answers. In that circumstance it is unacceptable to “fake it.” People can be very understanding for an intern who says, “I’m not sure, but I will find out for you.”
Again, a systematic, consistent approach to order entry will ensure that no orders are forgotten. This system includes actually writing the orders and then performing a medication reconciliation. There are many approaches to writing admission orders, but the mnemonic ADCVANDAML CALL-HO (pronounced “ADC Van Daml Call-HO”) has proven quite useful to many:
Admit: indicates which ward the patient is admitted to and under which attending.
Diagnosis: the patient’s diagnosis.
Condition: the general acuity of the patient (eg, stable, guarded, critical).
Vitals: how often you want nurses to perform vital signs (if you write “per routine/protocol,” know what that means for each ward).
Allergies: the patient’s known allergies, including the reactions that occur.
Nursing: these are specific orders to nursing staff for patient care (eg, dressing changes, tube management).
Diet: what the patient is allowed to eat. Be specific. Nothing (ie, NPO) is a diet.
Activity: what the patient is allowed to do and also what the nursing staff will encourage the patient to do (eg, ambulate 3 times per day).
Medications: inpatient medications the patient needs. Include prn medications for possible symptoms the patient may experience (eg, Zofran for nausea, Dilaudid for pain, Colace for constipation).
Labs/radiology: think critically about what labs the patient needs. For example, does the patient really need a daily CBC with differential or will a standard CBC suffice?
CALL-HO: this set of orders tells the nurses when to notify you. Typically these are abnormalities of vital signs, but also include patient-specific details (eg, hoarseness or expanding neck mass after thyroid surgery).
Following a simple mnemonic each time you write admission orders can provide a clear plan of care and prevent many calls to correct omissions. This technique is still useful in the age of the electronic medical record (EMR). While the EMR often provides order sets or checkboxes, even the most detailed admission order sets were designed for a disease and not a patient—there is no “Mr. Smith order set.” You should therefore systematically check your work (ie, run through this or some other mnemonic) before finalizing the orders.
Anther important aspect of admission ordering that is often overlooked is medication reconciliation. This process clarifies the patient’s home medications and determines what should be continued or held on admission. This process should extend beyond simply finding out the names and dosages of medications; it should also include why the patient is taking these medications. Does the patient with prn Xanax take her pills once per week or 3 times per day? If the answer is 3 times a day, then this patient will likely go into benzodiazepene withdrawal if the medication is withheld. Is the patient on metoprolol taking it for high blood pressure, coronary artery disease, or atrial fibrillation? Each answer has different implications for this medication and the care of the patient. Unfortunately, it is the rare patient who will remember every medication, dosage, and reason for the prescription. Using a patient’s old medical records, clinical notes, or discharge summaries will provide useful insight. When in doubt, ask a family member to bring in the actual bottles of medications the patient takes at home. If even that doesn’t work, you can call the patient’s pharmacy or PCP’s office.
AVOIDING COMMON ADMISSION MISTAKES
While the admission process may seem daunting, there are several common pitfalls that can be easily avoided. The first is to recognize when you need help. This is not a question of being weak or a challenge to your ego, but rather a matter of patient safety. There will be times when there are too many admissions to be seen in a reasonable amount of time or there are too many sick patients. These are the times to tell your chief that you need some backup. Interns need to keep their chiefs informed of pertinent or unexpected events, such as changes in a patient’s condition or concerning lab/radiology results. Another common pitfall is not following up on a test; every physician who orders a test is responsible for checking the result. For surgeons this includes looking at the radiology images themselves, not just reports. Finally, some patients are anything but routine. These patients need everyone to be clear about how to proceed, and that includes the nursing staff. When good communication exists between nurses and interns, it is to the benefit of the patient and the intern.
GO GET ’EM
To take the most benefit from each admission you have to be an active participant. While a good intern will gather information thoroughly, present it concisely, and execute the plan conscientiously, a great resident will be thinking, “What would I do if I were in charge?” With each new admission you should see the patient, make a plan, listen to the attending, and keep score. The pursuit of the perfect score is what keeps surgeons operating and helping one patient at a time.