North Shore Children's Hospital
Goals and Objectives
North Shore Children’s hospital (NSCH) is a busy community based pediatric facility. It took care of 723 patients in the inpatient setting (excluding observation of 826 patients, taken care for less than 24 hours) and 13,463 in the emergency/walk-in department setting in financial year 2000. The subspecialty clinics had 2,086 visits.
The rotation is comprised of inpatient and outpatient components. In the inpatient setting, the resident part of the team consists of a junior supervisory resident and three interns. The outpatient component is two-fold. One is a supervised outpatient emergency/walk-in setting for the intern at night. The second is a sub-specialty clinic setting at NSCH ambulatory clinics. The objectives of this rotation are designed to further the residents’ development of competency in the following six areas:
I. Patient Care
II. Medical Knowledge
III. Practice-Based Learning and Improvement
IV. Interpersonal and Communication Skills
V. Professionalism
VI. Systems-Based Practice
I. Patient Care
- Residents will have primary responsibility for the management of medical patients from the time of admission until discharge or transfer. Residents work in conjunction with numerous community-based primary care attendings to coordinate care of pediatric inpatients.
- At the time of admission, residents will perform complete histories and physicals appropriate for the patient’s complaint. After evaluating the patient, they will formulate a differential diagnosis and plan appropriate diagnostic and therapeutic interventions, in coordination with the admitting pediatrician. Clinical decisions to transfer patients to a tertiary care setting will be made by the residents.
- At all times, it is the residents’ responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance.
- Residents will also participate in emergency room evaluation and outpatient clinic visits when requested. In the outpatient emergency/walk-in setting, the intern is the first to evaluate the patient and is the primary provider but discusses the case with an on-site supervisor prior to disposition. This experience is of a one-on-one patient directed teaching with the supervising physician.
- As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family. Residents will document procedures in the chart and in their personal logbooks. On this rotation, these may include:
- arterial puncture
- bladder catheterization
- intravenous catheter placement
- lumbar puncture
- nasogastric tube placement
- radiograph interpretation
- splinting and fracture management
- suturing and wound care
- venipuncture
II. Medical Knowledge
- The residents are exposed to a wide range of patient presentations in terms of age range, socioeconomic status, and diagnoses. The patients are seen in different hospital settings (the ER, outpatient subspecialty clinics or the inpatient unit). All components of history taking and physical exam are taught during their rotation.
- Residents are expected to expand their knowledge base by applying primary and secondary literature review to the patient’s conditions. Attending community pediatricians also review cases with the housestaff. Exposure to a broad range of clinical experience is expected.
- During this rotation, it is expected that residents will manage patients diagnosed with, but not limited to:
- Abdominal pain and acute appendicitis
- Fever, viral and bacterial infections in infants
- Acute psychiatric illness including major depression and suicide attempt
- Dehydration/hypovolemia/electrolyte disturbances
- Failure to thrive
- Epilepsy/seizures
- Hyperbilirubinemia
- Skin infections including cellulites and abscesses
- Renal disease (including pyelonephritis)
- Respiratory distress (including bronchiolitis, pneumonia, asthma)
III. Practice-Based Learning and Improvement
- In caring for patients, residents will utilize a broad range of published medical information available through web-based resources, as well as print textbooks and the hospital library. It is expected that decisions about patient care will be informed by review, synthesis and application of studies available in the literature. Daily work rounds will include discussion of information gathered from the literature by residents and other team members.
- Apart from daily bedside teaching, the residents participate in monthly journal clubs, case presentations and attend regularly scheduled lectures. Residents participate in core curriculum lectures via tele-link with MGH. At times these lectures will originate from NSCH with a community pediatrician discussing a pertinent primary care topic.
- Feedback from their rotation is coordinated by a residency liaison that is an attending pediatrician at NSCH. This feedback is conveyed to the respective resident and the residency program.
- All residents will take an active role teaching third and fourth year Tufts and Boston University medical students rotating on the pediatric service. This will include guiding students through history taking and physical exams, reviewing written notes and assessments, supervising students’ care for patients, and teaching procedures as is appropriate.
IV. Interpersonal and Communication Skills
- Residents will take part in daily interdisciplinary team rounds, led by the second year resident, that will include attendings, medical students, nurses, respiratory therapists, occupational and physical therapists, nutritionists, and at times social workers and case managers.
- Residents will regularly meet throughout the day with the patient and family to listen to their concerns and maintain a dialogue about the patient’s care.
- Daily notes in the chart clearly documenting patients’ progress, diagnostic results and ongoing plan will be completed in order to maintain accurate medical records and share information among team members.
- When surgical or specialty consults are indicated with resident will discuss the consult with the attending pediatrician and then communicate the appropriate clinical information to the consultant. Additional testing, transfer, and follow-up are facilitated by the resident.
- Residents will provide feedback to their co-residents, students and attendings on an ongoing basis throughout the rotation, completing written evaluations at the completion of the rotation. Similarly, they will receive regular verbal feedback and a final written evaluation from the service attending that will be placed in their permanent record. Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement.
V. Professionalism
- Residents will interact with an extremely varied patient population who come to this community children’s hospital with different cultural backgrounds and beliefs. Patients will include those living in local communities, as well as those referred from a distance for special pediatric referral.
- Residents are expected to demonstrate sensitivity and responsiveness at all times to patients’ culture, gender, sexual orientation and disabilities.
- Maintenance of patient confidentiality will be of highest priority.
- Residents will at all times demonstrate ethical and professional behavior.
- Residents will ensure that patients and families give informed consent for all aspects of care.
VI. Systems-Based Practice
- Residents are expected to provide high quality, but cost-effective health care. They will work closely with case managers and other team players to implement timely discharge plans. Home care plans, transfer to rehabilitation facilities and follow-up outpatient care will be facilitated by the residents. Decisions to involve consultation services will be made by the resident in conjunction with the healthcare team.
- Residents will communicate regularly with primary care physicians in order to deliver informed, coordinated care for hospitalized patients, and ease transition back to home. This communication will include written and verbal notifications upon admission and discharge, with frequent updates during the hospitalization.
- At all times, residents will act in accordance with the legal mandate in the Commonwealth of Massachusetts to report any suspicions of child abuse or neglect, being familiar with the process by which such suspicions are reported.
