Inpatient: Detailed Information
On the inpatient unit we are able to admit moderately sick patients, but if a patient is expected to need nebs q 2hrs for more than 8 hours or require too much nursing care you will need to transfer them to Anchorage directly from the ER. We now have Pediatric Early Warning Signs (PEWS) scoring and protocols for evaluating pediatric patients in the ER prior to admission and on the inpatient unit after admission. This scoring allows us to anticipate kids that might need a higher level of care and transfer.
In general, vital signs on the unit are done every four hours. Diapers can be weighed for strict I’s & O’s if necessary. The nurses are able to place IV’s and draw blood. Parents typically room in with their children; however, siblings under the age of fifteen are not allowed on the ward overnight. Children who require continuous IV drips, central lines, close monitoring, imaging or evaluation not available at YKHC or who require a PICU care are transported to ANMC or Providence Hospital in Anchorage. Occasionally we will admit a patient that is pretty sick, but is felt to have a good chance of improving. If this is not happening in the expected length of time, if the nursing or RT staff is uncomfortable with the patient or if you feel the patient is getting worse—do not hesitate to transfer the patient to Anchorage.
Admissions come from the outpatient clinics or the Emergency Room (and a very occasional direct admit). Usually the provider seeing the patient in the ER or clinic will call the pediatrician on call to get an accepting physician. We take all CPP patients and will accept non CPP patients as we can to help the family medicine service with their workload. We do not take care of behavioral health patients (Title 47) even if they are a CPP patient, but we are available to consult on their medical management.
Inpatient Helpful Hints
The ward rotation can be extremely busy and organizational skills and multitasking are a must. It is best to begin rounds on the in patients as early as possible as the health aid calls begin to get pretty heavy starting at 10:00. You may have between 20 and 30 RMT consults. Some consults are routine, some urgent and some will require stabilization and transport and acting as med control. RMT as well as a lot of other unexpected emergences and urgent consults can make for an occasionally overwhelming day.
Rounds should begin with any potential discharges unless there is an unstable or concerning patient. All discharges will need to have discharge orders and discharge meds written before noon and early enough for pharmacy to have time to fill the meds and for travel home to be arranged for the patient. Begin discharges as EARLY as possible as it takes forever to make a room available for patients that may be waiting in the ER—sometimes overnight.
Reminder: Patients that are very complicated or admitted for longer than 5 days will require an off service note to facilitate the provider that will be discharging the patient.
Reminder: Progress note convention-Admission day is day number one and first progress note (the next day) is day number 2
Neonatal admission challenges…A common problem you will encounter is an infant admitted for neonatal fever that was pretreated with antibiotics in the village. This is a particular problem when the initial lumbar puncture is a bloody tap. In this case you have several options:
- Treat empirically for presumed meningitis with a full course of IV antibiotics
- Try repeating the LP in one to two days to see if it is clear of WBC’s.
- If the patient has low risk labs, exam and history, you can consider watching the patient off further antibiotics with monitoring as an inpatient for 2-3 days.
- Treat for 3 days with antibiotics until cultures are negative, and then monitor the infant off antibiotics for 48 hours.
If the infant does well off antibiotics you can consider sending them home at that time. There is no clear standard of care for this situation; the geography of our service area creates unique challenges (where else would patients receive IM antibiotics before physician evaluation because a plane can’t reach their village?!) Not to be repetitive, but feel free to ask a more experienced YK provider if a situation falls into a “grey zone”.
As the pediatrician on call, you may have several requests for consults and RMT’s at the same time. You will need to stay organized and triage inpatient responsibilities with RMT, consults, OB/neonatal and ER patient stabilizations, care management requests, getting follow up from ANMC discharges etc. You will need to constantly reassess your work load and triage accordingly. Consider the timing of flights from the village when making triage decisions; if a patient doesn’t make a routine flight (usually these are around 11 am and 3-4 pm) from the village, you may have to send a Medevac that would otherwise be unnecessary. Of course, all unstable, critical or concerning patients must take first priority whether they are in the hospital or located in the village. If you are dealing with an emergent patient or situation, you may let providers calling for less-urgent consults know that you are occupied at this time, and can help them at a later time. If you are able, you can briefly triage the consult, offer initial suggestions and provide a fuller consult when the emergent situation is resolved. If things get really bad, get help. Remember to ask for support from pediatricians in ED or outpatient setting if you are getting overwhelmed with RMT or patient care issues or need to hand off the pager due to a pending medevac.
“Curbside” consults are the norm here and you will often get bombarded with patient care questions throughout the day. If you feel you cannot answer the question adequately with the information provided then say so. Try to be as helpful as possible but take care with the recommendations you make on patients you have not interviewed or examined yourself. The consulting provider will more than likely place “consulted with Dr. (your name)” at the bot- tom of their PCC so take this aspect of your job seriously.
Occasionally you will have someone curbside you while you are in the middle of something important. Politely communicate to this provider that you cannot address their problem until you have a free moment and can give them your full attention. They will usually understand when asked to wait.
Teamwork is critical to providing good patient care especially at a busy facility such as ours. The nurses, RTs and pharmacists caring for our patients are very good clinically and they know our patient population well. If a team member communicates that they are concerned about a particular patient you should take their concern seriously. They will often be your eyes and ears as you will rarely have time to sit on the floor monitoring your inpatients. Treat the staff with respect and consider them a valuable member of your team. Recognize and appreciate their questions and ideas and give them positive feed back for a job well done.
There is only one inpatient social worker. Marcia Coffey handles social services consults, but can not help with the overwhelming number of challenges and needs the village patients have in their homes and communities. Many of our villages do not have running water and some patients do not have electricity. Lower 48 standards of hygiene can often not be met; this is not necessarly neglect—you should contact one of the “old timers” prior to consulting social services and they will be able to help you determine if the consult is appropriate.