Teams

  • 5 medicine teams consisting of one resident, two interns, +/- sub-I, and medical student(s)
  • 1 Night Float team consisting of one resident and one intern
  • Resident has long call (24+4 hours) q5 days
  • On long call days, one intern takes day call (Call day intern) and one intern takes night call (Call night intern). The call night call intern will leave after rounds the next day. Interns on the same team should discuss prior which part of the call day they would like to take for each call day.
  • Residents and interns have short call (SC) on day 4 of call cycle. They will receive 4 hold-over patients admitted by the night float team.
  • Sub-I (if applicable) that takes long call (24+4) q5 days with the resident
  • 2 dayfloat residents

Call cycle structure

Call Post Call Day 3 Short Call Pre Call
Resident 24hr Post Call Potentially OFF SC Res-intern
Interns Day/Night DF + Day intern; Night intern Post call Res-intern SC Potentially OFF

 

Admitting

  • Residents have a census cap of 20 patients (including sub-I patients if applicable).
  • Interns have a census cap of 10 patients.
  • Call day senior signs into the gens pager (4367). Call day intern will have an admitting cap of 5 total patients (any combination of holdovers, transfers and new patients) on long call or to a cap of 10. The Call day intern begins admitting at 7 AM and stops admitting at 6 PM.
  • The call night intern will have an admitting cap of 5 total patients (any combination, as above) or to a cap of 10 on long call days. The call night intern arrives and begins admitting at 6 PM and stops admitting at 2AM (unless it is the NF intern’s or senior’s night off, on which days the call night intern stops admitting at 5AM)
  • Night Float Resident and night float intern (NF Res and NF Intern) admit 4 patients or to a short call team cap of 16. On Saturday and Sunday nights the NF team does not admit to provide a night off to the NF res and NF intern. Therefore, there is no short call on Sunday or Monday. On the night float team’s days off (Saturday and Sunday night) the night call intern and senior can admit to 5AM rather than 2AM.
  • Night Float team arrives, signs into the Night Float Admitting pager (7645), starts admitting at 8PM and stops admitting at 5AM to prepare for morning rounds. They leave at after presenting to short call teams.
  • On the 4th day of the call cycle, the short call team will receive up to 4 hold over admissions from the NF team on Tuesday through Saturday. The short call team caps at 16 including the NF admission. NF team stays to present these admissions on rounds to the short call team before leaving for the day.
  • The Post Long Call days and the Short Call days begin rounding at 7AM. Attendings are expected to be there at 7AM on these days to ensure night teams leave in a timely manner.
  • Once the day call intern, or both night interns, have reached their admitting cap, the admitting resident will sign the Gens pager (4367) over to the Hospitalist admission pager (9100).
  • The ED/Triage MD has been informed to hold admissions after 5 AM to give to the oncoming call team.
  • ALL admissions/ICU transfers/OSH transfers must come from 9100. Any admissions not from 9100 should be re-directed to page 9100 for admission.

Cross Cover

  • During weekdays, the non-long call teams sign out to the gens dayfloat resident. On Wednesdays, Gens DF will also be responsible for cross cover on HONC Mitchell patients
  • During weekends, the non-long call teams sign out to the on call day intern. On weekends, the long call intern will also be responsible for cross cover on HONC Mitchell patients
  • The night float team arrives at 8PM and begins taking cross cover from the day float (or weekend day long-call intern). Night float team is also responsible for taking cross cover on HONC Mitchell patients overnight.
  • The long call team cross covers their own day call intern’s patients at night and the Post-Post call team’s patients. The night float team cross covers on all other patients.
    • On days with team A on Call: At night, team A covers their own team plus team D
      On days with team B on Call: At night, team B covers their own team plus team E
      On days with team C on Call: At night, team C covers their own team plus team A
      On days with team D on Call: At night, team D covers their own team plus team B
      On days with team E on Call: At night, team E covers their own team plus team C
  • On the night float intern day off (NF intern day off Sunday), the night float resident cross covers
  • On the night float resident day off (NF resident day off Saturday), the night float intern cross covers with long call senior supervision

Teaching and Conferences

  • Residents are expected to attend morning report on all but the day off and post-call day.
  • The 1:00-2:00 pm time slots are open for teaching by the general medicine attending. They should be utilized on non-post call days as time permits.
  • The team resident and dayfloat resident are both equally responsible for the education of the team intern, sub-I, and students. All junior and senior residents should consider themselves the primary teachers for these trainees. We encourage senior residents to give didactics to younger trainees!
  • The team attending is responsible for the education of the entire team. It is expected that teaching will take place in combined teaching/management rounds each day with additional education sessions outside of rounds on non-post call days.
  • The team attending is expected to hand out the written curriculum at the start of the rotation and establish expectations for the rotation.
  • The team attending is expected to provide structured feedback at the mid-way point of the rotation and at the end of the month.
  • The attending is expected to provide a written evaluation on all members of the house staff team at the end of the month.

Backup Dr. Cart Coverage

  • The long call 24 hour resident is designated back-up Dr CART. During the night, the long call resident and NF resident can work out who will be back-up Dr CART throughout the evening, but if not specified the long call resident is the default

End of Service Signout

  • Signout emails at the end of your service should always be sent to both the oncoming team member you are signing out to and the intern/resident remaining on service when you leave.

Workflow Per Day

Day 1: On Long Call

  • 7:00 am – Resident, day call intern, and sub-I arrive at 7AM to resume care of established team patients. The resident signs into the GENS pager (4367) and also covers the night call intern’s pager.
  • 8 to 8:30 am – Attending Rounds with time to be determined based so team will be finished prior to morning report.
  • 10:30 am – At least one member of team should attend Multidisciplinary Rounds (MDR) to discuss plan of care, dispo planning etc with multi-disciplinary team.
  • 11:30 am – Morning Report at 11:30 am
  • 6:00 pm – Day Call intern should not admit any new patients after this time. The long call resident can take over the day call intern’s pager to ensure the day intern finishes in a timely manner. The long call resident will cross cover on the day call intern’s patients overnight.
  • 6:00 pm – Night Call intern arrives and can begin admitting with the long call resident
  • 8:00pm – Night Float Resident and Night Float intern arrive and take cross cover from dayfloat and begin admitting. The senior signs into the Night Float Admitting pager (7645)
  • 8:30 pm – DF departs once cross-cover handed over to night float intern. The long call resident takes care of the day call intern’s patients overnight.
  • 2:00 am – The night call intern stops admitting new patient or when capped. If Saturday or Sunday night the night call intern and senior continue admitting until 5AM or when capped.
  • 5:00 am – The night float intern stops admitting or when capped.

** If the long-call day is a weekend, the dayfloat will not take cross cover. Cross-cover during weekends will be covered by the day call intern and signed over to the NF intern when they arrive at 8pm.

Day 2: Post-Call

  • 6:00 am (but no earlier) – Day intern returns to pre-round prior to rounds.
  • 7:00 am – Post-call attending rounds start early. The order of presentations should be as follows:
    • 1. Night post call intern patients
    • 2. MROC patients (if applicable)
    • 3. Day post call intern patients
  • 9:30 am – The night post call intern and dayfloat should leave post-call rounds to finish work.
  • 10:30 am – Post call resident, night post call intern, and sub-I depart hospital. The night post call intern signs out to the dayfloat who is responsible for the post-call patients. At least one team member attends MDR rounds
  • The post-call dayfloat and post call day intern will sign out to the crossover dayfloat during the week and the long call day intern during the weekend.

Day 3: Post-Post-Call

  • By 7:00 am – Resident and both interns arrive.
  • Between 8:00 and 8:30 am – Attending starts rounds.
  • 10:30 am – MDR rounds – at least one team member should attend.
  • 11:30 am – Morning Report
  • Team will sign out to the crossover dayfloat during the week and the long call day intern during the weekend.

The post-post-call day is used for allowing team members days off.

Day 4: Short-Call

  • 6:00 am (but no earlier) – Interns arrive to pre-round prior to rounds.
  • 7:00 am – Short-call attending rounds start early. The order of presentations should be as follows:
    • Night Float Team presents overnight admits.
    • Day teams present at their own discretion.
  • 9:00 am – The night float team should leave for the day after rounds
  • 10:30 am – MDR rounds – at least one team member should attend.
  • 11:30 am – Morning Report
  • Team will sign out to the crossover dayfloat during the week and the long call day intern during the weekend.

Day 5: Pre-Call

  • By 7:00 am – Resident and both interns arrive.
  • Between 8:00 and 8:30 am – Attending starts rounds.
  • 10:30 am – MDR rounds – at least one team member should attend.
  • 11:30 am – Morning Report
  • Team will sign out to the crossover dayfloat during the week and the long call day intern during the weekend.

The pre-call day is used for allowing team members days off. The pre-call day is often best suited for attending teaching.

Gens Dayfloat

General Medicine Dayfloat (DF) is an inpatient block. Both Gens DFs are expected to be present every weekday. On weekdays, the DFs fulfill the two following roles: the post-call DF, and the crosscover DF. (see below)

On the weekends, only one DF needs to be present, to fill the post-call DF role. The long call day intern will take cross-cover, so there is no crosscover DF on the weekends.

Each DF will get two weekend days off during their two week block. DFs should work with each other to decide how to divide up their days off (e.g., one weekend on and one weekend off, or one weekend day off per week).

Post-Call DF

  • The post-call DF should arrive by 7 AM and round with the post-call team.
  • The post-call DF’s primary responsibility is to assist the post-call team. After the initial half of rounds, the post-call DF should break-off with the night post call intern to help him/her run the list, call consults, etc to make sure the night post call intern leaves the hospital on time. Of note, the night post call intern should write all of the H&Ps and progress notes for their patients prior to leaving the hospital for the day.
  • Throughout the day, the DF will act as the primary first contact provider for the night post call intern’s patients.
  • The DF should also supervise the other post-call intern, as the team resident normally would.
  • The DF can leave when he/she and the post-call intern finish their work for the day and both sign out to the crosscover DF. The post-call DF should not leave before the post-call intern.

Crosscover DF

  • The crosscover DF should arrive in time to attend Morning Report.
  • The crosscover DF should make themselves available to all of the general medicine teams throughout the day, to assist in team work. This includes helping the sub-I if the team’s resident is off for the day and helping interns who are res-interning.
  • The DF has a responsibility to educate interns and medical students on all teams. This includes helping with work to facilitate getting all teams to morning report and noon conferences. The DF is also encouraged to give their own lectures and teaching to both interns and medical students.
  • Once non-call day interns have finished with their work for the day, they will sign out to the crosscover DF.
  • The DF will stay until 8pm, when he/she will sign out all crosscover to the night float intern and resident.

Pagers

  • On the post-call day, the Gens post-call resident should sign over their pager to the intern or day float on service. The senior resident’s pager should also be covered overnight until the resident returns on the post-post-call day.
  • When the senior resident is on a scheduled day off, their pager should be covered by one of the interns on service.

Supervision

The team resident is responsible for ensuring the highest level of care to patients admitted to their resident team. This care is accomplished through regular supervision of the work completed by the interns and students on the team. The resident should see and evaluate all patients in a timely fashion on the night of admission. They should see and evaluate all patients on a daily basis throughout the entire admission. In both cases, the plan of care should be reviewed with the intern delivering appropriate feedback where necessary. The resident should be available by page 24 hours a day to the interns and covering team (with the exception of the day off) for questions or concerns arising in the course of patient care.

The dayfloat resident is responsible for ensuring the highest level of care to patients on their teams. This is accomplished through regular supervision of the work completed by the interns and students on the team.

The attending physician is responsible for ensuring the highest level of care to patients admitted to their resident team. This is accomplished through regular supervision of the work completed by the resident, intern and students on the team. The attending should see and evaluate all patients at admission. They should see and evaluate all patients on a daily basis throughout the entire admission. In both cases, the plan of care should be reviewed with the housestaff team delivering appropriate feedback where necessary. The attending should be available 24 hours a day to the housestaff team for question or concerns arising in the course of patient care.

 

Updated 7/15/22