Neurology Residency

TEAM:

Stroke attending,  one senior (PGY3 or 4), 1 junior (PGY2), 1-2 APPs, stroke fellow (variable)

WHEN:

PGY-2

• Non-call days: 7AM to 5PM
• Call days: 7AM to 8PM
• Weekends: 7AM to 1PM, if not on call. No short call.

PGY-3 or 4

• Weekdays: 7AM to 5 PM
• Weekends: 7AM-1PM

WHERE:

CCD 8001

CALL:

PGY2: Q3 days on average, see specific schedule from chiefs

HOW

Stroke Codes

• PGY2/APPs respond to stroke codes from 7AM – 3PM.
• That time is split into a morning block (7-11AM) and an afternoon block (11AM-3PM).
  • Either one of the APPs or the PGY2 will cover stroke codes in each block.
  • Whoever is the responder in the morning block will have fewer primary service patients but will be expected to take any new admissions or ICU transfers in the afternoon.
• Stroke back-up, in the event of back-to-back stroke codes:
  • Stroke responder 1, stroke responder 2, fellow if available, stroke senior (after rounds), on call, EEG

Primary patients

• Primary stroke patients are split between all members of the service.
• The stroke service caps at 22-24.
  • APPs cap at 8 each.
• The stroke senior is encouraged to cover primary patients if the stroke junior is on-call and APPs are covering stroke codes; final distribution of patients is left to the discretion of the stroke senior and attending.
• PGY3 or 4 is the senior on the service and oversees PGY2s, also co-manages patients carried by junior resident

Stroke Consults

• General neurology consults triage consults and will forward the consult to the stroke senior if there is a clear vascular question/ presentation.
• Stroke senior takes stroke consults until 4PM on weekdays and 12PM on weekends.
• If stroke senior is carrying primary patients, stroke attending/fellow will be responsible for seeing stroke consults.

6:30-7AM: Uncover your pager upon arrival. Get sign-out from the night shift resident. APPs and junior start pre-rounding and work on notes. Senior oversees all patients and co-manages primary patients with stroke junior. Stroke resident (PGY2 most days, PGY3 when PGY-2 is off) covers Stroke Pager at 7AM.

7:30AM: Grand Rounds on Thursdays.

8:15 or 8:30 AM: Senior rounds with multidisciplinary team

8:30AM or 9AM: Start rounds with attending. Start with the patients of the AM stroke responder so that plan can be discussed for their patients before they break for stroke codes

12PM: Noon conference. Senior should try to let juniors go by 11:45AM to make sure they make it to conference.

1PM: On-call resident begins taking calls from ER

3PM: Stroke codes are covered by the on-call junior. Senior attends multi-disciplinary rounds with social worker, case manager, therapy team and patient advocate.

4:00PM: Attend Stroke Afternoon Report on Wednesdays. Residents, APP or fellow will have to present one of their primary patients for discussion, which will be chosen by the Stroke Fellow.

5PM: Non-call residents can give sign-out by this time if finished with their work; transfer pager coverage to pager 9203 AFTER giving sign-out. Consult and stroke pagers switch over to 9203

CONFERENCES

• Daily, 12PM – Noon conference
• Tuesday, 4PM- Neurovascular Conference
• Wednesday, 7:30 AM- Morning Report
• Wednesday, 4PM- Afternoon Stroke Report
• Thursday, 7:30 AM- Grand Rounds
• Thursday, 4PM- Tumor Board

WEEKENDS:

• PGY2 resident is off on Sunday
• Stroke senior covers stroke service primary patients and clear stroke consults on Sundays until 12PM. If the stroke service is capped and the senior is carrying patients, then the attending/fellow are expected to see and write notes on the stroke consults.
• On-call floor resident responsible for seeing  stroke codes/ equivocal stroke consults.

Attending, neurocritical care fellow (6228), 2 residents (6229) – one PGY3 and one PGY2, occasionally a medical student

WHEN:

• Weekdays: 6AM-630PM
• Weekends: 6AM until work is completed, at the discretion of the fellow

WHERE:

CCD 8N

CALL:

None

WEEKENDS:

Residents alternate weekend days and can leave after rounds, work and notes at the discretion of the fellow. This will depend on the volume of the census and the acuity of the patients.

HOW:

NICU admissions

• In the morning, the consult team is responsible for NICU admissions
• In the afternoon, admissions can be done by either the on-call junior or one of the ICU residents, if there are no active patients.

NICU transfers

• NICU Senior will notify floor and stroke senior with verified and potential transfer by 12PM.
• Fill out transfer order reconciliation: ensure that VS and neurochecks are q4 hours, I/O checks are q8 hours, remove pressors, sedation, unnecessary medications and duplicate orders
• Remove a-lines, central lines, foley.
• Verify if the patient repeat imaging, when anti-platelet and anti-coagulation can be resumed.
• Complete neuroICU transfer note.

6AM: Attend sign-out with fellows, then uncover your personal pager. PGY3 covers 6229. PGY2s will cover the 6229 on the weekend day that they are covering.

6:30AM: Chart review, (you may at times need to come in earlier if the unit census is very high).

7-8AM: Examine patients (doing ABG while seeing patients saves you time; keep syringes, needles, gauze, and tape in your pocket).

8-9AM: Rounds begin with attending. When one resident is presenting, the other resident should be placing orders. If there are active patients, then make a note of the orders that need to be placed, consults that need to be called, highlighting which ones should be a priority.

12PM: Noon conference, if not busy. Seniors should let the junior attend if there are no active patients.

1PM: Finish work, procedures, see new patients admitted to Neuro-ICU.

2PM: Multi-disciplinary rounds with social worker, case manager, therapy team and patient advocate.

4PM: Attend Afternoon Stroke Report. One of the residents will present a case, to be selected by the neuroICU fellow.

6PM: Sign out, then transfer your pager and 6229 to be covered by 6228.

NEUROICU TIPS

• Use the neuroICU scut sheet to help information organized by systems
• Touch base with the primary RN frequently, at least during pre-rounds and once during the day, to have the most up-to-date information on patients.
• Daily tasks:  replete electrolytes, renew restraints, order ABG PRN, reorder daily 24h EEG with video, daily CXR for intubated patients
• Many patients will also require AM head CTs, make sure to discuss with fellow about which patients need one
• Call same day consults early
• Be careful when carrying over notes. Make sure up-to-date info in HPI/EXAM/PLAN, use absolute dates (6/27/19 instead of yesterday, today, Thursday) to save you time from correcting post-op days/other events
• Medical students are integral parts of the team. You can assign 1-2 patients per student, but they still need to be covered by the residents and residents should still consider them as their patients
• Neurosurgery residents will sometimes rotate with the ICU team. They still take call and OR cases so sometimes may not be present for rounds or during the workday so be ready to present those patients. Remind them to let you know if that happens and cover all their tasks
• Write the discharge summary for any patient who died or was discharged (SNF/LTAC) during your rotation
• Sign-out to oncoming resident in detail. Most time-efficient way is to make sure your last notes are perfect, then email details to incoming residents
• When going off service, be courteous and order the weekly LE dopplers in advance so they are already scheduled for incoming resident

CONFERENCES

• Daily, 12PM – Noon conference
• Tuesday, 4PM- Neurovascular Conference
• Wednesday, 7:30 AM- Morning Report
• Wednesday, 4PM- Afternoon Stroke Report
• Thursday, 7:30 AM- Grand Rounds
• Thursday, 4PM- Tumor Board

TEAM:

Week of clinics involving residents from every year and multiple attendings. There will be half days at Provident Hospital starting in October.

WHERE:

DCAM 4D

WHEN:

8AM-5PM on weekdays

There are half days that are sub-specialty clinics. PGY2s and 3s should inform Dr. Lee which specialty clinics they would like. The PGY3s have a half day of Movement Clinic with Dr. Xie and the PGY4s have a half day of Ataxia clinic with Dr. Gomez and Memory Clinic with Dr. Mastrianni.

Sub-specialty clinics available:
Monday AM: MS (Reder, Cipriani, Javed), Epilepsy (Tao, Issa), Movement (Padmanaban), Sleep (Lee, virtual)
Tuesday AM: MS (Javed, Kurz, Reder), Sleep (Stacey), NM (Soliven, Rezania), Stroke (Brorson), Epilepsy (Tao, Rose), Ataxia (Gomez)
Wednesday AM: MS (Javed), Movement (Xie, Padmanaban), Neuro-onc (Park), Stroke (Mendelson) Behavioral (Mastrianni)
Friday AM: MS (Cipriani), General (Rubeiz), Stroke (Coleman), Epilepsy (Wu), Movement (Xie), NM (Rezania)

LECTURES:

Residents should attend ALL noon lectures. If actively seeing a patient, absence is excused but should attend once able.

CLINIC TIPS!!

1. Chart review ahead of time if possible. You can pre-chart on a future encounter and start a note if you want. (*If you do start the note ahead of time, make sure to refresh the note when you see the patient so it gets updated with the vitals etc)
   • Look at the chief complaint (sometimes written in the appointment notes, or in the referrals, or can look at the PCP’s note or whoever’s referring)
   • See if any relevant neurologic work up has been done – neuroimaging, EEG, EMG, encephalopathy labs
   • See if the patient has ever been seen by neurology
     • Chart review tab -> Encounters -> click the neurology filter to see any prior appointments with neurology
     • Chart review tab -> notes -> click the neurology filter to see if any notes have been written by neuro (ie seen as a consult while inpatient, admitted under neuro, clinic notes will be here too)
2. Few things you need to do for the encounter (this can be done before or after the visit)
   • Rooming tab -> Visit information -> fill out reason for visit (usually will say “appointment” or “none” but pick whatever they’re coming in for like “headache” or “foot pain”)
   • Mark as reviewed the patient’s medical hx, surgical hx, fam hx, allergies, meds, social hx. The easiest way to do this is to click on “start review” on the bottom of the blue panel on the left and then when the window below pops up, update relevant sections and click “mark as reviewed.”
3. After you see the patient and staff with the attending:
   • Order labs, imaging or workup you discussed if applicable (+ ADD ORDER button is on the bottom left)
   • Click the Wrap Up tab:
     • Fill out patient instructions (eg, what medications you’re prescribing and why, instructions for what to do next, what we think the diagnosis is)
     • Fill out the Follow-Up section: select when you want the pt to come back and in additional details you can write more details like “follow up with Dr. Yoon in 6 weeks on a Monday”
     • If you want a specific attending to see the patient with you next time, select that specific day. Like if it’s a stroke patient and you staff with Dr. Coleman on Fridays, specify for Friday.
4. After you’re done with the note and all of the above, go back to the Wrap up tab -> scroll down to “Send Chart Upon Closing Workspace” and choose the attending you staffed with, then click “Send Now”

TEAM:

General neuro attending, one PGY3 (or peds neuro PGY4), often one psych PGY1 (unless vacation or sick or pulled to other rotation), sometimes a medicine resident, sometimes medical student(s), likely a medicine resident from Weiss on a neurology rotation

WHEN:

7AM-5PM on weekdays

LECTURES:

• Psych intern and medical student should attend ALL lectures
• PGY3 if able should attend as well

CALL:

None

HOW:

7AM: Receive sign-out from the on-call resident and night shift resident on new consults, and cover neuro consult virtual pager 6378.

• Cover all ER general neuro consults until 1PM. Cover all inpatient general consults until 4:30PM.
• Defer stroke consults to stroke team if there is a clear vascular indication. If unsure how to triage a consult, err on the side of evaluating the patient to rule out any acute stroke presentation eligible for intervention, and ask PGY4/chief or attending.

12PM:  Attend noon conference if not busy, but try to let the rest of the team attend.

• Rounds timing variable. Some attendings want to round in AM and then see any additional consults in PM, others will round at 1-2 PM daily. Discuss timing of rounds with attending.
• If there are patients in the ED in the morning pending decision regarding disposition, do not defer decision until afternoon rounds. Either reach out to the attending and staff over the phone or discuss with PGY4 on floor service.
• Neuro-oncology patients need to be staffed and rounded on with Dr. Park. He may see them the next day if not available that day, but will give you recs by email or text. Make every effort to try and set a time to rounds with him rather than just discussing over the phone.

Deferring non-urgent consults:

1. From 5 PM to 7 AM on weekdays as well as all day weekends, NON-URGENT general floor consultations will be deferred to the primary consult service on the subsequent weekday
2. If consultation is requested, on-call resident should call back the consulting service.
3. On-Call resident should ascertain whether consultation is urgent and discuss with senior resident or fellow (if non-urgent stroke). This may require more information and history from the primary team. If confusion still remains, this is to be discussed with attending on service
4. If deemed to be non-urgent, on-call resident can write a brief note with preliminary recommendations with intent to see and staff the next full working weekday, Alternatively, if situation has resolved consulting resident can contact primary team to see if consultation is still deemed necessary.
   • Diagnoses that may be deemed as non-urgent can include but are not limited to:
     • History of migraines including active headache but not status migrainosus
     • History of seizures, non-active or resolved
       • Alternatively can offer to primary team to reach out to treating neurologist if outside neurologist
     • Non-localizable weakness, chronic without rapid changes
     • Non-acute neuropathy
     • Chronic Movement disorders/neurodegenerative disorder, medication management
       • Alternatively can offer to primary team to reach out to treating neurologist if outside neurologist
     • Encephalopathy, non-hyperacute
     • Consult already seen by the consult team previously in admission for same complaint
5. Alternatively, in some rare cases can be followed as an outpatient directly if minor recommendations are needed.

Exclusion Criteria:

• ER consultations
• Urgent floor consultations, which includes but is not limited to:
  • Stroke alerts
  • Concern for cord compression
  • Status epilepticus
  • Acute concern for neuromuscular type exacerbation
  • Hyperacute decrease in mental status
  • Acute neurologic issues/changes in pregnancy/OB
  • Primary team concerned about evolving process or calls back

For full details and the pediatric survival guide, click here

TEAM:

Attending, 1 senior adult neuro PGY3 or peds neuro PGY4 (7678), 1 junior adult neuro PGY2 or peds neuro PGY3,  occasionally a medical student on peds neuro, occasionally a psych intern

WHEN:

• 7AM to 5PM (must remain on campus until 5PM, must see all ER consults prior to 5PM)
• After 5 PM: pager covered by resident on home call until 7AM

LECTURES:

Attend weekly lectures on the adult side unless except:

• Mondays at noon: senior presents chief of service rounds
• Fridays at noon: EEG rounds

WHERE:

5th floor conference room of Comer (K546)

CALL:

• No call for adult PGY2s
• PGY3 adult or PGY4 peds residents (when senior on service) take home call on Monday, Wednesday, Friday, Saturday
• PGY3 peds neuro (when junior on service) take home call  on Tuesday, Thursday, Sunday starting their second block of peds inpatient

WEEKENDS:

• Each team member is required to round one weekend day per week
• Typically the senior rounds with the- attending on Saturday and continues to cover 7678 until signout to the junior at 7AM on Sunday
• On Sundays, the junior will round and finish all work on Sunday before sign out to on-call resident (or go home to start home call if peds neuro junior).
• When an adult junior is on, the person on home call on Sunday has to come in to supervise the junior in the morning.

HOW:

7AM:  Senior takes sign-out from home-call resident, covers 7678 virtual pager, and distributes patients between the senior and junior(s). Check he peds neuro consult list for any new consults. Pre-round on consults.

9AM: Rounds usually start, but rounding time depends on the attending. The senior should find out the time from attending the day before or morning of rounds.  Audrey Oetomo (peds neuro APN) is in charge of LTM admission/orders.

12PM: Attend conference , make sure to let the junior go

1PM: When Audrey is away, you may be in charge of admitting LTMs. Use peds EEG order set, check CBC, CMP, and seizure medications levels if indicated, IV access unless extenuating circumstance or very low likelihood seizure – if no IV, order IN versed as rescue medication.

See new consults and ER patients

5PM: Sign out your LTM patients to MaroonTeam, update sign-out on Epic, then transfer your pager to 7678 to home-call resident if applicable.

PGY2 with different assigned attendings every half day

PGY4 with assigned attending depending on elective

WHEN:

8AM – 4/5PM five days a week for PGY2; Tuesday-Friday for PGY4

Schedule/sites can be negotiated with coordinator Nancy Ostrowski and Dr. Pula (Northshore site program director).

PGY2 must send preferences to Nancy Ostrowski by Thursday of week prior (prefer as early as Tuesday); if sent after, then cannot accommodate as schedule already finalized and sent to attendings.

PGY4 must send email to rotation at least 1 week prior to starting with their desired experiences.

Schedule usually emailed to resident by Friday before each week.

WHERE:

Glenbrook neurology/neuro-oncology clinic for PGY2s

Variable sites for PGY4 depending on electives and attendings

CALL:

None

WEEKENDS:

Off

PAGER:

Your UCMC pager must be assigned to “out long-range” and pageable at all times.

No NorthShore pager.

EMERGENCIES/SICK/CONFERENCES:

PGY2s should contact chief residents and Dr. Lee.

PGY4s should contact the attending they are working with that day as well as the chief residents

If you are planning to attend a conference while at Northshore, please inform the chief residents to inform Northshore ahead of time

Attending, PGY3, med student(s),

PA is Melody Calla: MCalla@northshore.org, cell: 630-484-6620. You should notify prior to starting so she can tell you meeting place and time for the first day

WHEN:

8AM – 6PM five days a week

Cover consults starting 8AM. The attending gets the consults, triages and informs you about the consult. Coordinate with the attending about when to start rounds.

Cover EMU pager until 6PM when Dr. Narayanan will page to inform you she took over the pager

WHERE:

Workroom on the 2nd floor (Melody will give you detailed directions)

Code for the room 312

CALL:

None

WEEKENDS:

Off

PAGER:

Your UCMC pager must be assigned to “out long-range” and pageable at all times.

You will receive a pager from NorthShore – team there will instruct you about that pager use.

EMERGENCIES/SICK/CONFERENCES:

Contact Nancy Ostrowski (nostrowski@northshore.org,) and Dr. Angela Mark (angie.mark@gmail.com, cell 734.657.3933). Ok to text Dr. Mark on cell; if no response in 30-60 min, call office 847.570.2570 to have Dr. Mark paged.

If you are planning to attend a conference while at Northshore, please inform the chief residents to inform Northshore ahead of time and inform Melody

8:30AM – 5PM

Arrive by 8:30AM – although first EMG or Roos patient is scheduled for 9AM, the patient may get roomed 8:30AM if they arrive early. You can find the EMG schedule on EPIC under scheduling and Neurophysiology (510)

SCHEDULE:

Mondays and Tuesdays: EMG with Dr. Rubeiz

Wednesdays: EMG with Dr. Rezania (who also does Q sweat and skin biopsy)

Thursdays: ALS clinic with Dr. Roos

Fridays: EMG with Dr. Soliven (who also does single fiber)

WHERE:

DCAM 4G

CALL:

None

WEEKENDS:

Off

LECTURES:

Attend weekly as scheduled. Tell EMG attending if you cannot attend EMG lecture for any reason.

PAGER:

Your personal pager “out-on-page” should be pageable always.

HOW:

BEFORE starting: ask another resident to be your EMG test subject. You need to arrange time with EMG attending and tech to practice the nerve-conduction part on someone before the attending will let you do on patients

DURING rotation: look for a case that you can present at neuromuscular conference upon completion of EMG rotation

Minimum requirements: complete 15 EMG/NCS studies during the rotation and present a neuromuscular case

Week 1: observe EMG/NCS, start reading EMG book by Shapiro (residents’ copy is always kept on bookshelves of 4G physician work area), take-home open-book paper quiz (get from Dr. Soliven) and go over with Dr. Rezania or Soliven (75% to pass), do EMG waveform teaching software on either EMG computer (ask EMG attending to show you) (takes ~1h). You need to complete all of the above before starting to perform EMG/NCS and writing reports, which you must start by week 2, log your EMG/NCS in MedHub

Week 2-3-4: do EMG/NCS with tech, attending +/- fellow and write reports and log EMG/NCS in MedHub

Week 4: take post test (closed book) and go over it with Dr. Soliven

7AM – 5PM weekdays

Resident’s pager should be signed in and resident should be FCP for all EMU patients.

Scheduled admissions sheet posted prior Fridays in EMU control room, CCD 8582.

Can ask EMU manager (see below) for email version.

Fellow schedule for the year posted on same board.

Rounding time varies between attendings and depends on their clinic schedule of that day

WHERE:

EMU control room CCD 8582

8E patient rooms 8046 – 8049

4G in the afternoon

CALL:

None

WEEKEND:

Off

LECTURES:

Attend weekly as scheduled

CONTACTS:

EEG control room phone 44831, 61241, 61244

EEG tech portable phone 68766

EMU floor RN phone 68546

DUTIES:

• Admit patients on Mondays (sometimes also get mid-week admissions)
• Contact fellow at end of Monday to quickly run the list, write daily orders & notes, complete the sign out hand off for reach patient, and sign out daily to 9203 and on call resident at 5PM
• Round with attending Tuesday-Friday (off weekends). Some attendings also round Monday afternoon
• If patient coming after 5pm, sign this out to on call resident, SIGN & HOLD admission orders to help out (on call resident does not need to write the admission note, but does need to examine the patient, verify doses of AEDs and other meds, ensure you ordered CBC / CMP/ check all AED levels, modify the pended admission orders you wrote if needed).
• Admission orders for EMU include:
  • AED level (check everything that can be checked, even gabapentin, benzo if used for seizure control)
  • Long-term video EEG
  • Seizure order set + diet + weight
  • Sitter for intracranial EEG patients – touch base with RN too because this is a must for safety
• Every patient being discharged needs a follow-up appointment, which can be scheduled with Neuro clinic 4D 2-6222 (or email scheduleneurostaff@uchospitals.edu – be sure to ask for confirmation)
• SIGN & HOLD weekend discharge orders for fellow, who rounds alone with attending (fellow also on-call for all EEGs
• In the afternoon, read EEGs with EEG fellow/ attending (separate from EMU fellow /attending), in DCAM 4G. Log EEG reports into MedHub.
• Join EEG fellow and Dr. Rose to read evoked potentials. Residents can ask for 4G tech, Sue, who does actual capturing, to show the procedure itself.
• Join attending for intra-op monitoring, which is usually done by Dr. Rose.

• You can choose any specialty, usually it is an elective in house. We recommend maximizing exposure in your field of interest.
• Talk to the attending you want to work with and the schedule that would work out for you
• There is no “one type” of elective, you can tailor it to your interests

PGY3:

• A lot of you will choose to do away rotations. Keep in mind that those take A LOT of time and paperwork to plan, so start many months in advance
• You have 3-4 electives each to plan any way you want
• You can do research or reading elective, but you need to make sure they are signed off on by an attending

PGY4:

• You have a few months of elective in addition to the mandatory Northshore electives
• You can do those in house or as away electives or research/reading electives

IMPORTANT INFO:

• Please make sure to fill out all the paperwork and get the elective approved by GME way ahead of time. It takes a while to get everything done, there are multiple steps
• If you are on away rotation, make sure your clinic is closed and you have someone cover your pager. It cannot be forwarded to 9203
• If you are doing an elective in house, then you continue covering your own pager and keep your clinic scheduled

Before leaving for vacation, please do the following:

• Have another resident cover your pager (you CANNOT sign over to 9203 during your vacation per policy)
• Tie up loose ends that may result in pages
• Set vacation auto-reply for UCH email (include your vacation dates and something like this – “for emergencies, call 911 or visit nearest emergency. For urgent neurological matters that cannot wait until my return, page 9203 on call via UCMC operator 773.702.1000. For non-urgent/clinic issues that can wait until my return, email [insert UCH email]”
• Forward your in basket to another resident (you can cover theirs when they are on vacation)

1. E-mail Continuity Clinic PGY-4 with patient information, MRN, indication for LP (urgency of LP, what studies you want).
2. The Continuity Clinic PGY-4 will triage the case and schedule the patient for the first available Monday by sending an e-mail to ScheduleNeuroStaff@uchicagomedicine.org, and specifying that the appointment is for an LP/procedure.
   1. The running list of patients who need an LP will be added to the “LP Requests” shared list on EPIC (all the PGY4s have access to this). *Once scheduled, remove the patient from the list. The specialty comment sticky note can be used for specific information (eg, “pt will get a MRI on 7/24 and needs LP after that”).
   2. The daily clinic schedule can be accessed via the OPC Resident Clinic list.
   3. If the LP is not scheduled within 24 hours, e-mail your team’s PSR and Jordan Wirtz.
3. If the patient cannot be scheduled the following Monday but it is an urgent request, they will be scheduled for the first available Monday and added to an LP recall list (email Jordan for pt to be added to this list and she will check for cancellations/open spots), where a note can be made to schedule them sooner if a spot becomes available. 
4. If the patient is not available on Monday, residents or fellows can schedule an LP to be done during their own clinic. If they choose to schedule their patient during own clinic, please e-mail Jordan to ensure that there is room availability. 
5. If the LP attempt is unsuccessful and the patient needs to be scheduled with IR, be specific in the orders about how much CSF is needed, who to call for CSF pick-up. Try to make arrangements for who is going to pick up the CSF beforehand.  To place CSF orders, addend the previous neurology encounter (orders cannot be placed in the current IR encounter), place the orders, and release the orders.

• Aspirin – don’t need to hold
• Plavix, Brilinta – hold for 7 days
• Coumadin – INR needs to be <1.5
• Xarelto, Eliquis – 1-2 days of normal renal function, 3-5 days if impaired renal function
• For patients with a strong indication for AC/AP (LV thrombus, recent stent, etc) discuss with Dr. Kass/vascular attending and consider sending to IR instead

2.  Does the patient need coags checked?

• If it is a healthy patient with no suspicion for coagulopathy, don’t need to check
• f pt has active cancer, hx of thrombocytopenia/coagulopathy, on anticoagulation etc then coags should be checked, preferably the morning of L

3. Does the patient have prior head imaging?

•  Although technically guidelines say that imaging is not needed prior to LP unless pt has AMS, focal neurologic signs, papilledema, seizure within a week or immunocompromised state, given that this is an elective procedure and a CTH is easy to obtain, our unofficial clinic policy is for everyone to have head imaging prior to LP. If any of the above indications are present, imaging should be recent (use your judgement based on what that indication is). If none of those are present, even imaging from a year ago may suffice just to ensure that the patient doesn’t have some crazy chiari or strange anatomy.