General Surgery
Attendings
Emergency General Surgery
Attending, Resident, and APP Roles
Attending of the Week
- Lead an organized daily morning report to review all patients on the service and make daily plans. Clearly define roles of Primary and Secondary SOW attending when present:
- Define who is seeing consults for the day and signing notes
- All notes may be sent to the Primary SOW if there is confusion; it is the Primary and Secondary SOW’s responsibility to ensure all notes are routed, signed, and billed appropriately
- Define which attending is doing which patient’s case and communicate with the team
- Sign out patients to night call coverage and weekend coverage including updates of anticipated transfers – may be in person, phone call, or text. Should at minimum include anticipated transfers, active patients, and number of patients anticipated for the OR the next day
- Sign out to oncoming SOW (next week) with any complicated patients or anticipated operations that will need to go the next week
- Weekend attending should sign out to Monday SOW as well (see below)
- See relevant new consults and admissions within 24 hrs with appropriate documentation and billing
- All inpatient consults need to be appropriately managed, this includes for uncommon procedures such as VP shunts, omental harvests, gastric/jejunostomy tubes not appropriate for PEG, skin or lymph node biopsies for patients who can’t be discharged with outpatient follow up, etc. If the Surgeon of the Week is not comfortable performing these procedures, they are responsible for reaching out and coordinating care. Appropriate order would be:
- Partners of same service (eg elective group v ACS group)
- Partners of sister service (eg elective group v ACS group)
- Other services – as a reminder, other services do NOT have access to an acute room which can limit timely access to care for patients.
- Lead/delegate a weekly educational discussion topic for the team
- Weekly topic list for the year to be posted in work room
- Ensure complex patients have a single attending “quarterback” to help coordinate their ongoing care in the hospital and outpatient follow up, including seeing patients in office
- Ensure communication with primary surgeon of any complication or readmissions, though patient care responsibilities remain with Surgeon of the Week
- Keep track of complications and opportunities for improvement on a list in R3
- Orient new members to service and expectations
- Perform weekly goals and verbal feedback with residents
- Perform daily EPA app (Simpl) feedback for each resident on service
- Can be operative, pre/postoperative
Attending night and weekend coverage
- Night attending should sign out to attending of the day (SOW) by 7 am, to include expected patients, complicated patients or changes in condition, and new cases for the day. This can be accomplished in person, by phone, or by text. Weekend attending should sign out to oncoming coverage at 5 pm on Sunday night, and should also sign out to oncoming SOW any anticipated cases or complex patients.
- Night coverage should include cholecystectomies if they can start at a reasonable time (1800) and appendectomies/abscesses (midnight), and other emergencies (anytime).
- Ensure appropriate follow up of patients seen by residents overnight and discharged (eg symptomatic but not emergent fat containing hernias, non-acute gallbladders, etc.)
- Every effort should be made to complete cases on the weekend from 730-1700 as the acute room remains available during these hours. Night cases should follow recommendations as above, with some exceptions for the Saturday night timings at surgeon’s discretion.
EGS Chief Resident
- Maintain an overview of all patients on the Service, including patients in the ICU.
- Organize patients to be presented at morning report, including: daily review of new admissions over previous 24 hours, escalations of care and complications, brief updates on ICU patients
- Communicate with Primary SOW attending by 7 am daily to discuss complex patients, timing for morning report, cases to be booked/have already been booked, and correct order, and any changes in patient condition of note. This can be in person or by phone/text.
- Lead the weekly educational topics or review of articles
- Ensure an equitable distribution of patients between all team members for rounds. Focus on plan for and see the new patients. All attempts should be made to round with the junior residents on service. Ensure appropriate start time to allow for all patients to be seen prior to morning report.
- Assign residents and APPs (as able) to OR cases each morning during the night team sign-out. There should be opportunities to do teaching assistant cases when appropriate.
- Lead afternoon rounds and sign out rounds; update attending as needed
- Educate APPs, junior residents, and medical students. Oversee educational activities of the service, including appropriate educational injects during morning running of the list.
- Designate a person (resident/APP) at all times to respond to new consults. All consults are expected to be called back immediately. If both the chief resident and junior resident are in an educational activity or the OR, they must assign a team member to call back all consults.
- Consults should be seen within 30 minutes of request
- Keep track of complications and opportunities for improvement on a list in R3
- Notify attending of any important or critical issues (ie. escalation of care, codes, imaging results that change course of care).
- Ensure that all cases have been booked for the day and the following day, and communicate with attending for correct order of cases.
- Foster consistent communication with the APPS and other residents. Update team members with any new changes to plan of care made by the attending.
- Should visit and examine EVERY patient on service by end of week, including the long term players. This fosters accountability and ownership of the service. Ideal time would be during afternoon rounds if able.
- Send EPA evaluation request to attending daily.
EGS Junior Resident
- Handle the service pager much of the daytime when able. If you are going to the OR or conference, ensure that the pager has been given to an APP.
- Strive to get to the OR frequently even if it is for part of an operation (opening or closing). Should aim for 3 cases at a minimum per week
- Complete all activities assigned by the Chief Resident and coordinate activities and tasks with APPs – this includes seeing new patient consults and performing EMR tasks.
- Ensure all resident-assigned patients have daily notes.
- While usually a shared responsibility between APPs and junior resident, the Junior resident should ensure daily and weekend labs are ordered for all patients prior to the end of the day
- While usually a shared responsibility between APPs and junior resident, the Junior resident should ensure all sticky note tabs and dc summaries are up to date on Fridays and prior to leaving the service
- While usually a shared responsibility between APPs and junior resident, the Junior resident should attempt to attend Interdisciplinary Discharge Rounds daily when not in conference
- Give sign out to the night team Monday-Friday. Ensure sticky note tabs are updated appropriately daily.
- Should visit and examine EVERY patient on service by end of week, including the long term players. This fosters accountability and ownership of the service. Ideal time would be during afternoon rounds if able.
- Send EPA evaluation request to attending daily.
Emergency General Surgery APPs
- To provide excellent clinical care to General Surgery patients. APP’s will see new consults and admissions and relay information to the Chief resident and Attending, especially when both are operating.
- Foster consistent communication with the chief resident and attending.
- Act as a resource to the chief resident, including assisting with the serviced based orientation of team members and students.
- Carry the service pager during educational activities and when the residents are in the OR.
- Participate in OR cases as discussed with chief resident. Eligible APPs are expected to assist in the OR on a regular basis as determined with Attending and Chief Resident. If additional OR time is desired, discuss with attending opportunities for further exposure though recognize these may be limited depending other requirements of the service (Chief/APP only case, uncovered elective cases, etc)
- Cover elective patients on the weekend which includes daily rounds and discharges. Also help with coverage of elective surgery service when residents are off site.
- Give sign out to Night team on Saturday and Sunday nights
- While usually a shared responsibility between APPs and junior resident, APPs should attempt to attend Interdisciplinary Discharge Rounds daily and especially when residents are in conference
- Participate in KPI initiatives and present KPI board at Monday Gemba walks 830am
All Residents and APPs
- Manage all patients to ensure all appropriate imaging, labs, and applicable specialty consultations have been called and to update sticky note text with tasks and mark as completed.
- Ensure complete and thorough documentation of H&P's and Discharge Summaries.
- Keep track of complications and opportunities for improvement on a list in R3
- Ensure loop closure with the Emergency Department/Consulting resident/attending regarding admissions, consults, and plans of care
- Look at all potential schedule vacancies for each 4 week block by looking at both APP Amion schedule and resident block schedule
- Notify team when schedule changes unexpectedly during a 4 week block (team training, interviews, etc)
- Afternoon patient rounds
- Use the same standardized daily note template and minimize carry-forward errors
Elective General Surgery Service
Roles and Expectations
Junior Resident
- Complete all activities as assigned by Senior Resident
- Cover pager even when in the OR unless able to hand off to another team member out of the OR (ie senior resident)
- Ensure daily and weekend labs are ordered for all in-patients prior to end of day
- Ensure all sticky notes and discharge summaries are up to date by end of day Friday and prior to leaving the service
- Ensure all patients have notes written daily
- Sign out to night team Monday-Friday
- Review assigned cases and contact attending by no later than 6pm the night before – ok to do for a week at a time or a few days ahead of time
Senior Resident
- Create weekly schedule no later than the preceding Sunday evening
- Make sure to cover elective ACS attending cases, and transplant if no transplant resident
- Ensure all residents are assigned an average of ½ day of clinic every week on service
- Maintain an overview of all patients on the service and ensure team members are equally up to date including to changes in care plans
- Communicate with responsible attendings for all patients by 0730 – text or phone call
- Review assigned cases and contact attending by no later than 6pm the night before – ok to do for a week at a time or a few days ahead of time
- All inpatients should be rounded on by the senior and junior resident together (no splitting the list except in specific circumstances – early OR case ongoing from overnight, for example)
- Plan rounds to start early enough to accomplish
- Ensure afternoon rounds are completed daily, update responsible attending with new findings or results from pending studies; communicate any changes in patient condition (escalation of care, etc)
- Actively educate junior residents and medical students on service
- Ensure all team members attend weekly conferences and arrive ON TIME
- Communicate with other residents regarding uncovered cases, and communicate with attendings whose cases may go uncovered – preferentially cover “big” cases at Bramhall over SSC
- Complete as many teaching cases as possible
- Be available and willing to assist EGS team if not otherwise engaged – check in with EGS team prior to early dismissal, etc
- Keep track of and report complications to residency list weekly
All Residents
- Manage all patients to ensure all appropriate imaging and specialty consults, update team and stick notes with tasks and mark as completed
- Ensure thorough documentation to include H&P, DC summaries, daily notes, and brief of notes
- See all elective patients in pre-op, complete IPHR, and mark as needed (for resident covered cases, if uncovered ensure attending has been communicated with to let them know)
- Look at all potential vacancies (vacations, off days, etc) for the 4 week block and make a plan for coverage early
- Complete afternoon rounds and communicate changes to rest of team and responsible attending
- Use standardized note templates, ensure copy forward is done responsibly and that notes are ACCURATE every day
EGS team and APPs cooperation
- EGS APPs to call back new consults immediately when elective team is unavailable, assist team with seeing new consults during educational activity or if team is out of house (eg at SSC), or when asked due to conflicts (ie in the OR but patient needs to be seen sooner)
- Elective team will also check in with the EGS team when not otherwise engaged and prior to any early dismissal
Attendings
- Ensure coverage even when out of town (even if no known patients)
- Sign out to weekend SOW and night coverage about patients staying
- Communicate with residents and help formulate plans
- Be available by text, email, or call to discuss cases with residents before the surgery – resident should initiate contact as above
- Complete at least one EPA per day per resident encounter – consults, clinic, and/or OR
- Emphasize pre-operative planning steps and considerations, eg imaging studies, cardiac clearance, labs, colonoscopy, etc
- Reiterate common gen surg concepts and practice changing papers:
Jon Dreifus, MD
Lee D. Hallagan, MD
Jaswin S. Sawhney, MD
Shantanu Razdan, MD
Brittany Misercola, MD
Leslie S. Wu, MD
Jennifer Bolton, MD
Anna G Meader, MD