Goals and Objectives for Heme/Onc Rotation

• Develop a working knowledge of common disorders in hematology/oncology, including diagnosis and management of these disorders.  Conditions that may be seen on this service include (but are not limited to): lung, breast, colon and prostate cancers, leukemia, lymphoma, bone marrow transplantation, anemia, coagulopathies, and hypercoagulable states.
• Be able to understand the epidemiology, evaluation, prognosis, treatment patterns, complications, associated symptoms, and symptomatic treatments of common cancers.
• Learn concepts of pathophysiology and evidence-based management through daily teaching clinics at the UTSW, Parkland, and the VA.
• Gain university practice exposure at Simmons Cancer Center providing insight into academic oncology and clinical research.
• Gain a better understanding of cancer screening tests in the diagnosis and management of disease.
• Attend Hematology/Oncology conferences to develop an in-depth knowledge of hematologic/oncologic disease and current concepts in diagnosis and management.

Goals and Objectives for Inpatient Consults

Develop an understanding of hematology and oncology disorders seen in the hospital

PGY-2: Understand the principles of assessing and managing both common and complex presentations of hematology and oncology disorders in hospitalized patients.

PGY-3: Develop advanced processes to recognize and treat complications in hospitalized patients with hematology and oncology disorders in patients with multiple medical problems

Competency: Patient care, Medical knowledge

Developing diagnosis skills

PGY-2: Effectively use the bedside clinical examination and demonstrate subtle clinical findings in patients with hematology and oncology disorders

PGY-3: Learn how to correlate bedside clinical findings with imaging and other data in patients with hematology and oncology disorders

Competency: Patient care, Medical knowledge

Understand the differential diagnosis of common hematology and oncology disorders

PGY-2: Develop a differential diagnosis for common clinical scenarios in patients with hematology and oncology disorders

PGY-3: Recognize unusual presentations of common clinical situations in patients with hematology and oncology disorders

Competency: Medical knowledge

Learn pharmacological management of common hematology and oncology disorders

PGY-2: Learn the medications used in management of hematology and oncology disorders, understand how to manage complicated clinical problems, and develop specific therapeutic strategies in patients with hematology and oncology disorders

PGY-3: Learn how to develop personalized care plans for patients with hematology and oncology disorders and intersecting clinical problems

Competency: Medical knowledge

Effectively consult on inpatients, develop, and execute assessment and management plans.

PGY-2: Learn to be an effective hematology and oncology consultant. Recognize how to prioritize patient problems Develop management plans for inpatients with hematology and oncology disorders

PGY-3: Understand interactions between patient hematology and oncology disorders and other medical issues and develop advanced strategies to prioritize management

Competency: Patient care

Effectively execute day-to-day management of patients

PGY-2: Manage hematology and oncology patients, including daily assessment and assessment of progress. Understand how to adjust patient treatment plans based on patient progress and determine the need for additional assistance such as subspecialty consultation

PGY-3: Recognize how to manage complex hematology and oncology problems and manage both expected and unexpected complications.

Competency: Patient care

Interdisciplinary care and discharge planning

PGY-2: Learn how to communicate effectively with the interdisciplinary care team and anticipate patient needs for discharge and effective follow-up Recognize the unique needs of hematology and oncology patients and help integrate patient needs with available resources

PGY-3: Learn how to manage advanced situations such as end-of-life decisions, complex transitions of care and advocate for patients when resources are limited

Competency: Patient care, System-based practice

Rational ordering of lab tests and imaging studies

PGY-2: Learn how to interpret laboratory findings and imaging seen in patients with hematology and oncology disorders

PGY-3: Gain advanced knowledge of high value principles in the ordering of laboratory studies and imaging for evaluation of hematology and oncology disorders

Competency: Practice-based learning and improvement, Medical knowledge

Familiarity with the electronic health record and optimization of its use

PGY-2: Understand how to effectively use the electronic health record in the care of patients with hematology and oncology disorders.

PGY-3: Develop an understanding of advanced medical informatics in the care of patients with hematology and oncology disorders by utilizing additional resources in the EHR

Competency: Systems-based practice

Communication and teamwork

PGY-2: Develop effective and timely communication strategies with the interdisciplinary care team for patients with hematology and oncology disorders

PGY-3: Use advanced communication methods to engage and coordinate care with the interdisciplinary care team for patients with hematology and oncology disorders

Competency: Professionalism, Interpersonal and communication skills

Resources

• Recommended Textbooks
  • Washington Manual for Oncology
• Professional Society Guidelines
  • National Comprehensive Cancer Network: This is the website for the National Comprehensive Cancer Network. This website contains incredibly useful slideshows for each cancer under its "NCCN Guidelines" tab. These slideshows include diagnostic evaluation, treatment algorithms, prognostication, and evidence summaries for nearly every malignancy.
  • American Society of Clinical Oncology
  • National Cancer Institute
  • American Society of Hematology

Service Description

• This rotation is a combined hematology and oncology consultant service made up of one fellow, one resident, and one attending. 
• Meet fellow in workroom. Contact Parkland benign hematology fellow with questions.

Service Description

• This rotation is a combined hematology and oncology consultant service made up of one fellow, one resident, and one attending. 
• Meet fellow in workroom. Contact VA Heme/Onc consult fellow for questions.
• You are expected to attend morning report daily while on this rotation

Service Description

• This rotation is a combined hematology and oncology consultant service made up of one fellow, one resident, and one attending. 
• Meet fellow in workroom. Contact CUH Heme consult fellow for questions.
• You are expected to attend morning report daily while on this rotation
• You are not expected to be a primary provider during this rotation. You will assist with consults at the direction of the on service fellow

Logistics

Location: 14-445.06

Admission structure: Admit weekdays from 7:00 AM - 5:00 PM, and weekends 7:00 AM - 5:00 PM.

• There are rarely weekend elective admissions, but you may get ER admissions or transfers. Residents are welcome to coordinate with the fellow on the weekend to complete their call from home (i.e. keep pager on and come in for admissions, if needed) up until 5 PM. Overnight admissions are done by the hospitalists and patients will transfer to the service the next day at 7:00 AM. 

Sign out: After 5 PM to the short call Parkland wards team. 

Weekday Cap: 16 total patients divided evenly between 2 residents.  

Weekends: 

Team structure: One resident will work on Saturday while the other resident is off. The other resident will then work on Sunday while the first resident is off. The resident will keep all of their old patients on the weekend (this is new starting 9/2022). 

Weekend Cap: The cap on the weekend is a rolling cap of 8 patients, with a maximum of 10 patients (aka you should never write more than 10 total notes in a day).  

• The resident should discuss the division of patients for the weekend with the fellow to ensure a fair balance of patient care.  The reason the cap flexes to 10 on weekends is to help offload the fellow who is also responsible for weekend consults. Again, you will be keeping all of your old patients from the prior week, and you should only be flexing to 10 if the fellow is swamped with other primary patients and consults. The fellow will determine which 2 additional patients you take. If you feel that there is inequity, please reach out to a Parkland Chief. The resident is responsible for sign-out for all patients on the team.  

There are 3 types of admissions: 

1. Elective admissions (Preadmits) from clinic: Mostly planned chemotherapy admissions. A few require tumor workup and staging. Please read up on the patients and place the “Place in” order the day before to ensure timely admission and chemotherapy initiation.  
2. ED admits: Admissions from the ED are for complications of known cancer (i.e. neutropenic fever, spinal cord compression, or transfusions)  
   • Sometimes these patients are directly admitted from clinic. These are usually malignant hematology patients but can be solid tumor oncology patients established in the clinic or non-malignant hematology patients needing treatment (i.e. sickle cell crisis, aplastic anemia, etc).  
3. Transfers: Transfers usually come through the consult teams for initiation of treatment, or step-downs from the MICU. 

Rounding schedule: This is attending-dependent given their clinic schedules. You will usually find this out the day before.  Attendings rotate every 14 days on a Wednesday. 

Example of a typical day: 

• 7:00 AM - 8:30 AM: Pre-round on patients 
• 8:30 AM–8:45-9:00 AM: Interdisciplinary rounds right outside the 14-400 rounding room
  • (typical Qs: discharge plans, have they been approved for filgrastim/lovenox, will they need DME, do they need nutrition recs, when will the chemo finish) 
• 9:00 AM-10:00 AM: Morning report in 3.457 
• 10:00 AM - 12:00 PM: Work/admissions/AM rounds with attending if applicable 
• 12:00 PM - 1:00 PM: Noon conference in 4th floor WISH  
• 1:00 PM - 5:00 PM: Work/admissions/PM rounds - (most attendings do PM rounds)
  • We do not admit after 5:00 PM any day. After 5:00 PM admits generally go to the hospitalist/medicine teaching, and potentially get transferred to us the next morning. The fellow will handle transfers/ triaging. 
• Sign out after 5 PM to the short call wards team 
  • You should expect to work until 5pm every day. In very rare circumstances when clinical volume is low, the fellow may allow you to leave early when the work is done. However, early dismissal should only occur when offered by the fellow and under no circumstances should you leave before 5pm before discussing with the fellow. 

Tips and Tricks

General Instructions

For patients with a PICC line, please order "Maintain PICC line" order and chlorhexidine towelettes daily (type "CHG" and it will be under facility lists). Most patients will have a PICC line.  If they have a PICC, their labs should be ordered as “unit collect’’. Do not draw blood cultures out of central lines (PICC lines, mediports, etc). Do not ‘’med emergency’’ or ‘’stat orders’’ unless they truly are. Please get ‘Blood transfusion consent’ for every patient at admission at the end of H/P; sign in iMED. These patients frequently require transfusions and we don’t want the cross-cover to have to get consent at a later time. Patients should have at least a CBC and CMP drawn before start of chemo; if not ordered in treatment plan please make sure is ordered on admission, unit collect.

Of note, all patients currently need a negative COVID within 7 days of their admission, the outpatient team is responsible for arranging this (this is constantly changing and any updates on this will be communicated as thigs evolve)

Note Templates

For H&Ps, the recommended template is available as .HOHP. For progress notes, the recommended template is .HOPN.

• Notes are expected to be accurate and up to date. Please do not include results, imaging, etc if not pertinent to that day’s plan.  Please make sure day and cycle of chemo are correct.  Please list chemotherapy drugs and antimicrobial prophylaxis or treatment (with day of antibiotic) patient is receiving.

Fellow’s Admission Note

Fellows are expected to review all pertinent records and write a brief note which addresses the following:

• Diagnosis: including stage and pertinent prognostic indicators

• Response to prior treatment, if applicable Details of treatment regimen including dose adjustments if applicable

• Pertinent toxicities during previous admissions or after discharge

• Anticipated date of discharge

• Discharge medications

Discharges

The fellow writes the discharge instructions and will need to give verbal/written discharge instructions to the patient. Resident writes discharge summary (has to be completed within 24 hours from discharge). The fellow arranges follow up for lab checks, clinic appointments, and PICC-line dressing changes prior to d/c (for established patients, clinic providers are responsible for these steps and should be notified by the fellow if anything is missing).

Discharge medications: The resident is responsible for reconciling/prescribing discharge medications PRIOR to the fellow printing and giving the discharge instructions to the patient.  They will a often be included in their last heme-onc clinic note and fellow’s admission note. You can send these meds down (usually) to the PMH Discharge Pharmacy several days prior to d/c. This is especially important for Neupogen and Lovenox as these may need pre-authorization for your insured patients. Discuss this with case management on admission. If it is their first time starting these meds, please put RN communication for ‘Neupogen/ Lovenox teaching’.

Ancillary Services

• The RNs are amazing and have been doing this a long time—trust and respect their judgement when it comes to complications, clinical concerns, etc.
• HUC: This will be the person wearing a green shirt at the front desk. Usually Diane is the AM HUC and Joe is the PM HUC. 
• Care manager: Selin Joseph. She will get your pre-authorizations, funding, follow-up, etc.
• Social worker: Shenetra Morgan. She will help you get compassionate visa letters and all that other good SW stuff.
• Pharmacists: Great for helping you figure out when someone's chemotherapy is expected to end and general logistics about chemotherapy: Jeff Chan, Sarah Ryu, and Sylvia Atumah; Ext 79265. Eileen Marley is the head pharmacist and sometimes helps with things inpatient as well.
• Malignant hematology nurse navigator: Savannah Brock (aka fellows best friend, she is very familiar with the patients and assists fellows in coordinating care)

Things you should know that aren't routine on other services:

• If your patient is there for chemo, you should know what chemotherapy they are getting, when it will be given, how long it will be infused, and when they will complete chemotherapy in anticipation of discharge. Include this information in your one-liner of your presentation (i.e. “Ms. Smith, our 31year old woman with double hit DLBCL here for cycle #2 of R-EPOCH, today is day 3.” 
  • To look up what the expected chemotherapy regimen/infusion time/completion time is, there are multiple places in EPIC to see this. Go to the Navigators Tab --> Oncology --> Treatment plan. Here, you should (most of the time) find the pre-written chemotherapy orders that were completed in clinic. It should include the baseline labs, pre-medication, anti-emetics, and post-chemotherapy/discharge medications. This will give you a general idea. Call 79265 and ask the pharmacist when they started/when they will finish their chemotherapy. This is the most foolproof way.
• Neutropenic patients or hematological malignancies: Irradiated blood products only.
• Antimicrobial prophylaxis if prolonged neutropenia anticipated. Typically in our ALL and AML patients
  • (acyclovir 400 BID, Cipro 500 BID, fluconazole 200 daily or posaconazole if AML). 
• No rectal exams, lower GI instrumentation or rectal tubes in neutropenic patients.
• Blood cultures should not be repeated within 24 hours of previous ones. BM biopsies are done by fellow at bedside (you can do it too but not required for graduation). May need to hold anticoagulation prior to this (discuss with fellow)
• Make sure patients have some kind of DVT prophylaxis. If they have platelets < 50K or expected to fall <50K in the next 24 hours, no pharmacologic anticoagulation but use SCDs. Hold lovenox for LPs.
• Patients with a high risk for neutropenic fever after chemotherapy will be getting c-GSF within 24-72 hours after they complete chemo. The fellow is responsible for coordinating this, just ask if any GCSF needs to be arranged. FYI, this can be given in 1 of 3 ways:
  • Regular g-CSF (Neupogen):  Given daily, usually for 7 days, started in hospital for patients who will still be inpatient during the 24-72 hr window, may be completed outpatient and will need teaching from RN prior to discharge
  • Neulasta (pegylated g-CSF):  Injection given in clinic, last about 7 days, appointment needs to be arranged prior to discharge (fellow will coordinate this)
  • Neulasta OBI (on-body-injector):  Cool device that injects patient with pegylated g-CSF 24 hours after placing on upper arm.  Can be placed immediately after chemo completed, preventing need for patient to return to clinic.  Expensive. Must also be done in clinic and requires appointment. (fellow will coordinate this

• Neutropenic fever—definition, workup, initial management
• Spinal cord compression
• Differentiation syndrome in APML
• Cytokine release syndrome

Lumbar Punctures 

Frequent - almost always for IT chemo. When you are admitting the patient, check to see if/when they will need IT chemo (in treatment plan, also often in last heme-onc clinic note, feel free to always check with fellow). Make sure that platelet count and coags are checked prior to starting any LP. Usually you do the LP and draw the sample, then the fellow/attending administers the IT chemo while the needle is in place. You can also have IR do the LP for larger patients/ those that have had trouble in the past, or if you're busy: 73777 to talk to the IR fellow (place order first- XR Diagnostic Lumbar Puncture). To do this you MUST have INR and no anticoagulation that day; it is also weekdays only. If intrathecal chemo is to be injected during LP, please let the pharmacist (Ext 79265) know when the plan for LP is, so they can coordinate with IR/ fellow.

If sending CSF to the lab, order: Cell count, glucose, protein in EPIC. Cytology (ask your fellow) – paper form at nurses station, need to send down with patient. Flow cytometry (ask your fellow) – paper form at nurses station, need to send down with patient.

Transfusions

• Type and screens for platelets are valid for 30 days. 
• Type and screens for PRBC are valid for 72 hours.
• Afebrile patients: Transfuse one unit of platelets if < 10K, check a platelet count upon completion of transfusion, continue transfusing until platelets > 10K. 
• Febrile patients: threshold is 20K, bleeding patients is 50K; most procedures 50K. T
• Transfuse 1 unit PRBC for Hgb < 7 or if patient symptomatic.
• There is no routine need to check a post-transfusion Hb.

Engage app

Use the Engage app to communicate with the fellow, attending, or nurses while on service. Ask assistant unit manager of 14-400, Shawn (Sudarashan Pathak), for troubleshooting Engage.

QI Initiative

Historically there have been significant delays in starting chemotherapy for scheduled admits, which leads to increased length of stay and costs of care. We are doing a QI project to reduce these delays.

Interventions

List of the week's elective admissions with names and MRNs is posted on the wall in the rounding room (ask HUC if not).

Outpatient oncologist/ fellow will clearly state in their note the need for ‘admission labs’ prior to chemo.

Inpatient fellow is expected to check chemo admissions the day before the admission: make sure chemo orders are signed, consent is in place, verify if admission labs are needed, see if central line/imaging/etc are needed prior to start of chemotherapy. They will leave a note in the chart the day before, detailing the plan and Resident will pend a place in order in the hospital chart pre-admission the day before.

HUC will call patients day before admission to ask to report at 8 AM to 14-400.

HUC will call ADT at 20309 as soon as patient arrives to floor, and alert RN and MD.

Residents can start H&Ps and orders beforehand when there is downtime but will be unable to sign them until the patient arrives and ADT admits them. These can be pended however. Please review the note by the inpatient fellow in the chart review tab for lab and other needs prior to chemo (ask the fellow if any confusion). A place in order should already have been placed by the resident but please call ADT at 20309 and pend a place in order if any confusion regarding admission status.

Please see the patient ASAP upon arrival, and if they look good and labs look ok, let the fellow/attending know to put ‘’ok to treat” order. Please let RN and pharmacist know via Engage when ‘ok to treat’ order has been put in. Everyone is expected to utilize the Engage app to communicate.

Logistics

• Residents will be assigned to the inpatient bone marrow transplant unit for 2 weeks at a time with minimal exceptions. Here you will be caring for patients with a variety of hematologic malignancies as well as patients during or after autologous or allogeneic bone marrow transplant. Residents will gain an understanding of management, therapies, complications, and supportive care of patients with various hematologic malignancies.

  • BMT is split into two services, BMT/Leukemia and Lymphoma/Myeloma. The fellow will be on one service and internal medicine resident on the other. IM residents will report directly to the attending and work with APPs on their service. Attendings will make sure that the resident is assigned patients with the most educational value. 
    
    • BMT/Leukemia (Team A) service will primarily have patients with a diagnosis of Leukemia / MDS / myeloproliferative diseases / aplastic anemia and all allogeneic SCT patients (new/complications). Attending Rounds start 930 with the APP patients. Resident patients will be rounded on at 10am after morning report.
    • Lymphoma/Myeloma (Team B) service will primarily have patients with diagnosis of Lymphoproliferative neoplasms, plasma cell disorders admitted for chemotherapy, autologous SCT or CAR-T cell therapy. Rounds 10-11am
    • Residents will be notified to which service they are assigned. 
• Location: 11 South. Room 11.205 
• Hours: 7AM to 5 PM. Any admissions after 5pm will either go to the APPs, the fellow, or the evening moonlighter. Sometimes days may be later if a late admission comes in. You should get instructions from the fellow or APPs about signing out to the crosscover hospitalist.
• Days off: Residents are expected to work Sunday, which means your day off will be Saturday. 
• Team structure: One attending. One resident. One to two NPs. 

Admissions include: ER admissions, planned admissions, and transfers. Admissions occur daily and residents are expected to assist with admissions. There is a BMT admission order set available. Chemotherapy administration requires “ok to proceed” order written by fellow after history and initial labs reviewed. While discharging the patients, please use ".ALLOTRANSPLANTSUMMARY" dot phrase to write the discharge summary. This dot phrase helps the BMT team keep track of chemo/cancer-related issues longitudinally. 

Caps

There is a rolling cap of 8 patients for residents. Generally you will be carrying 8 patients, though in certain circumstances you may be asked to carry up to 10 for a day on a rolling basis under the following circumstances:

1. Any discharged patients have physically left the hospital no later than 2pm.

2. Any new admissions have been called in to be admitted no later than 2pm.

3. The APPs are also carrying an equal number of patients as the resident.

As an example, if a resident started the day with 8, discharged 1 (who physically left before 2pm), and is now available to take another patient, this will only occur if the APPs each have 7 or more patients as well and the new admission has been called in prior to 2pm. If n = the number of resident patients, the APP should never carry fewer than n-1 if a resident is being asked to take more than 8.

Please contact CUH Chief residents if this not followed.

Weekend:

You will be expected to work 1 of 2 weekend days on this service. Make sure to sign out your patients to your fellow and/or APPs covering on your day off.

Helpful Documents

General Overview for Residents

BMT Acronyms

BMT Order Tips

BMT Discharge Checklist

Goals and Objectives for Hem/Onc Clinics

Assess acute and chronic hematology and oncology disorders in the outpatient setting

PGY-2: Learn to assess acute and chronic hematology and oncology disorders and develop an advanced understanding of these disorders in the outpatient setting

PGY-3: Understand the intersections between acute and chronic hematology and oncology disorders and subtle variations in presentation

Competency: Patient care

Understand the principles of chronic hematology and oncology disease management

PGY-2: Understand the principles of chronic disease management, including problem lists and preventive care, and factors that create competing priorities with chronic hematology and oncology disorders. Understand the pharmacological management of chronic heme/onc diseases

PGY-3: Develop and utilize advanced care processes including consultation and interdisciplinary management of chronic hematology and oncology disorders

Competency: Patient care

Learn pharmacological management of common hematology and oncology disorders

PGY-2: Understand the medications used for hematology and oncology disorders and how to manage complicated health problems and develop specific therapeutic strategies

PGY-3: Learn how to develop personalized care plans for hematology and oncology patients with intersecting clinical problems

Competency: Medical knowledge

Understand the differential diagnosis of common clinical scenarios

PGY-2: Develop an expanded differential diagnosis for common hematology and oncology clinical scenarios

PGY-3: Recognize unusual presentations of common hematology and oncology clinical situations

Competency: Medical knowledge

Develop and utilize patient dashboards to engage in population management

PGY-2: Identify noncompliance or patients who are outliers in the patient dashboards

PGY-3: Develop advanced care plans with the interdisciplinary care team to manage hematology and oncology patients not meeting parameters in the patient dashboards

Competency: Systems-based practice, Practice based learning and improvement

Understand the unique outpatient needs of hematology and oncology patients

PGY-2: Recognize and understand the outpatient needs and community resources available to hematology and oncology patients

PGY-3: Learn how to work with an interdisciplinary care team to optimize the availability and utilization of community resources available to hematology and oncology patients

Competency: Patient care, Systems-based practice