VA Resident and Patient Care Guidelines
The VA resident has the primary responsibility during their rotation for VA inpatients, consults, the ED, OR, and clinics. These responsibilities include direct patient care, documentation, and helping to coordinate the VA cross-coverage by other residents. The attendings will not micro-manage the patients. Residents must be proactive and take the initiative to solve patient care problems.
The VA resident must check in daily with the VA neurosurgery attending on call to update them about the service.
To promote continuity of patient care when the VA neurosurgery resident is not in-house and to provide an opportunity for the neurology residents to learn about neurosurgical patients, diseases, and care, all non-ICU and non-stepdown neurosurgery patients (i.e. “neurosurgery floor patients”) will be admitted to the neurology service under the auspices of the neurology attending, and will be cared for jointly by the neurosurgery and neurology services.
Daily weekday joint neurology/neurosurgery rounds on neurosurgery floor patients will be coordinated by the VA neurosurgery resident and the neurology chief resident.
The neurology service will write daily progress notes on neurosurgery floor patients, including on weekends.
The VA neurosurgery resident will write daily progress notes on all neurosurgery floor patients except when the neurosurgery floor patients have been signed out to the neurology service. Neurosurgery floor patients are signed out to neurology under the following circumstances:
- Nights – when the VA neurosurgery resident is off duty to fulfill mandatory work hour restrictions
- Weekends - when the VA neurosurgery resident is off duty to fulfill mandatory work hour restrictions
- Vacation time – when the VA neurosurgery resident is on vacation
- Scientific meetings – when the VA neurosurgery resident is in attendance at a scientific meeting (usually AANS in the Spring and CSN in the Fall) or when the neurosurgical training program is shorthanded during national meetings and in-house resident resources are concentrated at Yale
The VA neurosurgery resident should independently review all tests and studies obtained on neurosurgery floor patients.
The VA neurosurgery resident and neurology team will implement the daily care plan together.
Neurology residents will take “1st call” for patient-care issues on neurosurgery floor patients
The neurology resident will confer with the VA neurosurgery resident for all issue of substance. Any issues that cannot be satisfactorily resolved by phone consultation must be resolved by the VA neurosurgery resident at the bedside.
If the VA neurosurgery resident has signed out the service for the night, weekend, meeting, or vacation time off, the neurosurgery Chief resident (or a resident specifically designated by the chief resident) will provide phone consultation and bedside consultation for all VA neurosurgery patients, as needed.
All neurosurgery patients in the ICU or stepdown unit will be on the neurosurgery service.
Daily neurosurgery ICU rounds will be coordinated by the VA neurosurgery resident
A neurosurgery resident will round on and write notes on neurosurgery ICU and stepdown patients every day of the week. On weekends when the VA resident is taking two days off, or during VA neurosurgery resident meeting or vacation time, this will require the neurosurgery Chief resident (or their designee) to round on the VA ICU and stepdown patients and write notes.
Upon transfer out of the ICU or stepdown unit to the floor, patients will be placed on the neurology service.
Some neurosurgery floor patients may not require daily rounds or notes:
Patients without active medical problems who remain hospitalized for social reasons (e.g., receiving outpatient RT at Yale + no transportation from home available = they remain at the VA for 3 weeks) can be administratively “transferred” to “intermediate care” status. Intermediate care patients only periodic require notes and “chart checks”.
Similarly, patients can be sent out on pass overnight or over the weekend (e.g., depart Friday afternoon after RT, return Monday morning before RT). No notes are required while patients are out on pass.
All new VA neurosurgery consults must be seen and documented by a neurosurgery resident. “Phone triaging” of inpatient or ER consults is not acceptable. During times when the VA resident is scheduled to be off, if the neurosurgery chief resident is not available to see an ER consult in a timely fashion, the Chief resident may decide to enlist the assistance of the VA neurology resident after discussion with the on-call attending.
VA rules stipulate that only residents who have spent time on a neurosurgery rotation at the VA can provide care to VA patients. Thus, neurosurgery residents who have not yet rotated through the VA cannot see consults or provide care for inpatients.
Dr. Chiang and Dr. King will alternate coverage of call, clinic, inpatient care, consults, and OR staffing approximately every two weeks. Consult the VA call schedule to determine the current VA attending on call.
The neurosurgery attending physician is responsible for supervising the care of VA neurosurgery patients, and must be kept “in the loop” about significant clinical events.
When admitting patients to the VA on the neurosurgery service, the VA attending of record must be “in town”. If this is not the case, then the patient should be admitted under the VA on call attending, and transferred to another attending latter, as indicated.
Promptly notify the VA attending on call of any admissions to their service, regardless of the hour.
Attendings should be immediately notified of any significant clinical events that happen to their patients (e.g., change in neuro status, hemodynamic instability, transfer to ICU, etc.).
Notify Dr. King promptly if a patient that he is covering dies, regardless of the hour, even if the patient is DNR and the death was “expected.” Dr Chiang should be notified immediately for any emergencies. All non-emergent events require notification prior to 8am the next morning.
Non-emergency surgical treatment plans must be formulated under the guidance of an attending at least 24 hours before the scheduled time of surgery. The vA resident must meet face to face with the attending to discuss the impending surgery. To facilitate the discussion, the resident must bring to the meeting:
- Hard copies of neuroimages
- Printouts of relevant CPRS neurosurgery notes
The VA has strict guidelines for documentation of resident supervision. Residents and attendings will have to work together to ensure that these guidelines are met to fulfill our responsibilities to trainees and patients. The primary form of documentation is attending notes and co-signatures of resident notes (details below).
The VA resident has primary on-call responsibility for the VA. This includes neurosurgery inpatient coverage, inpatient consults, ER consults, and will periodically require returning to the VA after hours for issues that cannot be satisfactorily resolved via telephone or by the neurology resident.
Dr. King will be responsible for recording and distributing the VA call schedule each month. A written or email copy of the monthly VA call schedule will be distributed to the VA resident, VA page operator, Yale page operator, Yale answering service, neurosurgery Chief resident(s), neurology Chief resident, Dr. Duncan, Dr. Chiang, and Dr. King.
The VA resident call schedule will be integrated with the Yale call schedule, in consultation with the neurosurgery Chief resident(s). For each day of the month, the schedule will list the names and beeper numbers for the following:
1st call – VA beeper, usually carried by the VA neurosurgery resident (could be Yale neurosurgery on call resident during 24 hours off each week, or designated neurosurgery cross-covering resident or Yale neurosurgery on call resident when VA resident is away at meetings or vacation)
1st backup call – Yale neurosurgery on call resident (or Chief resident if Yale resident is 1st call)
2nd backup call – Yale neurosurgery Chief resident
3rd backup – VA neurosurgery attending on-call
Any proposed deviation from the publicized VA call schedule must be approved by the VA neurosurgery on call attending and needs to be communicated to both the neurosurgery and neurology chief residents.