MGH Step-Down Unit (SDU, Ellison 10) Curriculum

Revised: June 2012

Rotation Director:  Priyank Jain

Description of Rotation

The MGH Step Down Unit (SDU, Ellison 10) is a busy 36-bed adult inpatient unit which provides intermediate level clinical care to patients with cardiovascular disease including patients with acute coronary syndromes, decompensated heart failure, and a variety of cardiac arrhythmias.  With a particular focus on interventional cardiology, the rotation provides an important complement to the inpatient training at Cambridge Health Alliance, where trainees do not have direct experience in the management of patients pre and post cardiac catheterization and do not have other opportunities to manage patients referred for electrophysiology testing.

A third-year MGH resident (SAR) supervises five second-year MGH residents (JARs) and one Cambridge second-year resident. There are no interns assigned to the Step-Down Unit.  The Cambridge resident typically will rotate on-service a few days prior to the MGH resident change-of-service date. A supervising attending rotates every two weeks.

Medical knowledge

During the MGH Step Down Unit rotation, residents should:

• Broaden their understanding of the spectrum of severe cardiac disease and understand the use of critical care resources
• Learn indications and contraindications for and complications associated with use of interventional cardiology for ischemic heart disease and cardiac arrhythmias
• Review clinical guidelines and evidence base for the diagnosis and management of acute coronary syndromes
• Expand knowledge base related to the care of patients with cardiomyopathies 

Patient care

During the MGH Step Down Unit rotation, residents should assume primary responsibility for the care of a panel of patients admitted to the unit.  Through this work, residents should:

• Improve their skills in taking focused histories, performing pertinent physical exams and delivering concise and comprehensive presentations related to the care of patients with cardiac disease

• Strengthen skills in interpreting data from echocardiograms, EKG and telemetry monitoring, catheterization films and narrative reports, electrophysiology studies
• Increase confidence and skill in independent clinical decision-making in the care of patients with cardiac disease and appropriately engage the teaching senior, cardiology fellows and cardiology attending physicians

Interpersonal skills and communication

During the MGH Step Down Unit rotation, residents should:

• Negotiate their own roles on the rotation with the cardiology fellows and attendings, MGH senior resident, and MGH junior residents to clarify expectations and ensure effective collaborative relationships

• Communicate effectively with patients and families
• Communicate effectively with all members of the multidisciplinary health care team

Professionalism

During the MGH Step Down Unit rotation, residents should:

• Assume independent responsibility for patient care as possible but seek help as necessary in navigating an unfamiliar care system
• Behave respectfully with colleagues including effective conflict resolution, reliability, honesty, punctuality
• Demonstrate compassionate and respectful relationships with patients

Practice-based learning and improvement

During the MGH Step Down Unit rotation, residents should:

• Demonstrate curiosity and take initiative to read about patients on their own panel and on the panels of MGH junior residents
• Assume responsibility for setting personal learning goals for the rotation and seeking performance feedback from MGH faculty and senior residents
• Read the MKSAP cardiovascular medicine syllabus (see evaluation section for more information)
• Identify an interesting case and prepare a case-based teaching presentation for the MGH Cardiology Rounds teaching conference upon return to Cambridge Hospital.

During the MGH Step Down Unit rotation, residents should:

• Develop operational understanding of a tertiary care hospital including relative role of the and the Step Down Unit, the cardiology fellows and attending physicians
• Collaborate effectively with multidisciplinary care team including nurses and care managers to optimize patient care
• Manage transitions of care for patients in and out of the MGH Step Down Unit effectively
• Participate in improving the MGH SDU rotation as a clinical learning experience for Cambridge residents

Responsibilities and daily schedule

Monday-Friday

Cambridge residents admit and round on their own patients Monday through Friday (including holidays).  These patients usually arrive from the ED, cardiac catheterization lab or from a unit with a higher level of care. A nurse practitioner will admit most of the elective electrophysiology patients. Patients are admitted to private cardiologists or to the house attending cardiologist. At the time of admission, the admitting resident should clarify whether the patient will be admitted to a private cardiologist or to the house attending.  The Cambridge resident takes a maximum of two new admissions per weekday to a cap of 10 total patients. Patients to be admitted by the Cambridge resident must arrive to the SDU by 3:30PM, which will allow sign-out at 5:30 PM. Prior to leaving on Friday, the Cambridge resident must update the PEPL list and/or e-mail sign-out to the covering resident (assignment is made by the SAR).

Saturdays

A MGH resident will provide coverage of the Cambridge resident’s patient list on Saturdays. The MGH SAR will provide the name of this resident to ensure adequate sign out (as above).

Sundays

On Sundays, Cambridge residents round on their own patients but do not take any new admissions.  They are also expected to round on one of their MGH colleagues’ patients for weekend cross-coverage. At no later than 8:00AM, the MGH SAR will assign the Cambridge resident the shortest list of cross-coverage patients to round on. The MGH SAR (in addition to the Cardiology fellow and attending) will be available to assist and answer questions that the Cambridge resident may have on any of his/her patients. The Cambridge resident may sign-out to the on-call MGH JAR when the work for the day is completed (not before 1:00 PM).

Overnight Call

The program leadership at Cambridge and at MGH believe that the main value of the rotation to the Cambridge resident will be in admitting and managing patients during day time hours.  Because systems-related cross-coverage issues arise at night and require an intimate knowledge of MGH systems, Cambridge residents are not expected to take overnight call while on this rotation. 

Holidays

The MGH residency program does not have the same holiday coverage schedule as Cambridge Health Alliance. As a result you will not be provided with holiday coverage should a major holiday fall on your scheduled work day. You are expected to work Sunday through Friday weekly regardless of when holidays fall. If you do work on a holiday that is recognized by CHA, please email Linda Fowler (lfowler@challiance.org) to inform her so you can receive holiday pay.

Daily Schedule

The weekday schedule varies somewhat based on preferences of the current attending of record, but is typically organized as follows (all activities in the SDU conference room unless otherwise noted) : (please check with the SAR for the current rounding schedule)

• Second-year residents begin at ~6:45am with pre-rounding
• SDU Curriculum lecture by Attending or Cardiology Fellow 7:30 – 8:30am (No lecture on Wednesdays as interested residents may attend Cardiac Unit Grand Rounds from 8:00 –9:00am in O’Keefe Auditorium)
• Attending Rounds with the ward attending  8:30 – 9:30am
• Work Rounds with nurses 9:30am
• Noon conference takes place daily from 12:30pm–1:30pm in Potts Conference Room (attendance is required & lunch provided)
• Residents’ Report takes place daily from 4:30pm–5:30pm in Potts Conference Room (attendance encouraged)
• Cambridge Resident sign-out to overnight call resident at 5:30pm (unless work remains to be done)

One week prior to the beginning of the rotation

• Cambridge residents about to begin the rotation should contact the current Cambridge resident at MGH and arrange a time/place to pass-off the MGH Cambridge Resident pager and parking pass. If incoming Cambridge resident is not replacing an outgoing resident, pick-up the parking pass from Linda Fowler and plan to pick-up the pager at MGH on day one of the rotation. The parking pass gives Cambridge residents access to the Charles River Plaza Garage. The entrance is on Cambridge Street adjacent to the Holiday Inn.  Alternatively, residents may take public transportation exiting at the Charles Street-MGH T-stop on the Red Line. If interested in having access to the bike cage, please go to the Parking Office on the first floor of the Fruit Street garage.
• MGH and Partners are required by the state to have each clinician complete a 5-10 minute module on information safety and HIPAA.  It is called Corrective Action Plan (CAP) training.  Cambridge rotating residents must do this.  If at all possible, please try to complete it online before your first day.  Most importantly, it must be done before you are issued an ID badge at MGH.   The module is online, accessible at: www.partners.org/healthstream and requires a Partners username/password (emailed to you as a separate attachment).  It doesn’t take long.  Print and bring the “Certificate of Completion” with you on your first day to the MGH Registrar's Office,
• The incoming resident should also obtain thorough sign-out of the current resident’s patient list so that excellent patient care may be continued after the switch date.

Day one of the rotation

• The Cambridge resident has administrative responsibilities on the first morning of the rotation, and cannot join the team until these responsibilities are completed.  On your first day, the first order of business begins at 8:30am at the MGH Registrar's Office, located at 50 Staniford Street, 10^th flr, Suite 1002, Boston.  There you  will fill out an information/demographic form. Please be sure to bring a picture ID with you to the Registrar’s Office. If you have any trouble, please contact Geraldine Brown at (617) 724-7439. After receiving the completed  paper work from the resident, the Registrar will give the resident a form and a “People Soft” number to bring to the Security Office (Wang Building, Second Floor, Room WACC 232) to have an MGH ID badge made. Although printing the badge should take less than 5 minutes, it could take up to 45 minutes for it to be activated in the system.
• Next, stop by Medical Services Administration Office at Bigelow 740 to get a MGH Housestaff Manual and ask how to obtain a MGH short white coat to use during the rotation. If the MGH pager has not yet been received, pick it up at the Medical Services Administration Office at this time.
• Then, visit the Treadwell Library in the Barlett Building, across from the Wang Building. At the Treadwell Library public computer area, use one of the computers to obtain a PCIS computer password, by going to https://myprofile.partners.org, clicking on "Click here for Password-Self Service" and then providing the requested information. Next, the resident must contact the MGH Help Desk at (617) 726-5085 and tell them that House Office user class profile needs to be granted. Once you have access to the MGH computer system, you are encouraged to use the public computers to practice gaining access to the MGH computer system and to Up-To-Date. The current team roster, including photos and call schedules of the current residents can be accessed via www.amion.com. The login is “mghim” and select “SDU (Ell 10)” from the “Who’s On” drop down menu.
• After that, the Cambridge resident should report to the SDU on Ellison 10 and check-in with the SAR, who is covering the Cambridge residents’ patient list. Although not responsible for rounding on the patients of the outgoing Cambridge resident on the first day, the incoming Cambridge resident is expected to meet all of his/her patients to be rounded on the following morning and to assist the SAR in care of these patients on day one. The Cambridge resident is also expected to become familiar with the computer system on the SDU at this time.
• The Cambridge is not responsible for taking new admissions on the first day of the rotation day. The Cambridge resident is expected to start taking admissions starting at 7:00am on Tuesday morning.

End of the rotation

• On the last Friday of the rotation, the Cambridge resident is expected to finish rounding on his/her patients, sign-out to the SAR and return to the Cambridge Internal Medicine Residency Office where Betty Knudsen will administer an end-of-rotation evaluative question set taken from the Cardiology MKSAP book. Please see the evaluation section for more details.
• The final day of the rotation is a Sunday, and the Cambridge resident is expected, as usual, to round on their own patients and to round on one of their MGH colleagues’ patients for Sunday cross-coverage. The Cambridge resident may sign-out to the on-call MGH JAR when the work for the day is completed (not before 1:00 PM), and should remind the SAR that no Cambridge resident will be rounding on the following morning.
• Cambridge residents about to end their rotation should contact the incoming Cambridge resident and arrange a time/place to pass-off the MGH Cambridge resident pager, parking pass and patient list. If there is no incoming Cambridge resident, please drop off the MGH pager at the Medical Services Administration Office at Bigelow 740, and return the parking pass to Linda Fowler.

Evaluations

Evaluation of Resident

Each MGH SAR who supervises the Cambridge resident for a substantial period of time will be responsible for giving both on-going and end-of-rotation feedback to the resident and providing the Cambridge residency program with a written evaluation of the resident’s performance. Cambridge residents are also encouraged to solicit additional feedback from attending physicians and fellows. A Cambridge administrator will identity the appropriate MGH SAR(s) on amion.com (password: mghim, SAR=SDU) and e-mail (firstinitialastname@partners.org) an evaluation directly to any SAR who has spent at last one week with the Cambridge resident. The SAR can complete the evaluation in MS Word format and return it via e-mail, standard mail or fax. Alternatively, the SAR(s) can complete an electronic evaluation from the Cambridge intranet (Staffnet) via an e-mail link that will be provided. If the SAR does not respond to the first e-mail, a reminder e-mail will be sent. If no response to 2nd e-mail, the Cambridge administrator will ask the Cambridge Chief Medical Residents to contact the MGH Chief Medical Residents for assistance.

MKSAP

Throughout the rotation the Cambridge resident is expected to review MKSAP cardiology topics related to the acute coronary syndrome and other acute cardiovascular disease seen in the SDU. On the last Friday of the rotation, the Cambridge resident is expected to return to the Cambridge Hospital Internal Medicine Residency Office to take an end-of-rotation evaluative question set taken from the Cardiology MKSAP book. The Cambridge resident must report to Betty Knudsen in the Residency Program Office for the exam no later than 3pm on the last Friday of the MGH SDU rotation.

After obtaining the question set from Betty Knudsen, the Cambridge resident must complete and return the test to her by the end of the day on the final Friday of the MGH rotation.

Evaluation of Rotation

Cambridge residents are expected to complete an online evaluation form of the rotation.  Additional comments, questions, concerns, and suggestions for improvement are encouraged.