GENS SERVICE RULES

TEAMS:

  • 4 teams consisting of one resident, two interns, +/- sub-I, and medical student(s)
  • Resident has long call (24+4 hours) q4days
  • Interns alternate day and night call q8 (16-hour shifts)
  • Sub-I (if applicable) that takes long call (24+4) q4days with the resident
  • 2 dayfloat residents that work with 2 of the 4 GENS teams and are present for on-call and post-call days

CAPS:

  • Day intern will have an admitting cap of 5 total patients (any combination of holdovers, transfers and new patients). The day intern begins admitting at 7 AM.
  • Night intern will have an admitting cap of 5 total patients (any combination, as above). The night intern begins admitting at 7 PM.
  • Interns have a census cap of 10 patients.
  • Residents have a census cap of 20 patients (including sub-I patients if applicable).
  • If there is a sub-I on the team, the resident can only admit 10 new patients and accept an additional 4 in-hospital transfers within a 24-hour period. These admissions and transfers should be divided amongst the sub-I and interns with the transfers generally given to the intern.
  • Once either of the General Medicine interns has reached their admitting cap, the Gens resident will sign the Gens pager (4367) over to the Hospitalist admission pager (9100).
  • If the General Medicine team has not admitted to their cap during the day, they may accept new patients for the day time cap between 5-7PM (who sees/writes the notes e.g. resident vs. intern is up to the discretion of the team based on workflow and in consideration of duty hour limitations). General medicine team should not take more than 1 patient after 6PM, however.
  • The ED/Triage MD has been informed to hold admissions after 5 AM to give to the oncoming call team.

TRANSFERS FROM ICU:

  • Patients who were previously on a housestaff gens team should return to a housestaff gens team. Patients previously on hospital medicine team should return to a hospital medicine team. If the patient was admitted directly to the ICU, they can be distributed to any general medicine service.
  • Transfers from the ICU will be triaged through the 9100 pager.

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.

WORKFLOW BY DAY:


Day 1: On Call
  • 7:00 am – Resident, day intern, and sub-I arrive at 7:00 am to resume care of established team patients. The resident signs into the GENS pager (4367) and also covers the night intern’s pager.
  • 8:30 am – Dayfloat arrives in time for rounds if needed.
  • ~8:30 am – Attending Rounds with time to be determined based on new admissions, etc.
  • 10:00 am – Dayfloat arrives if s/he has not arrived already.
  • 10:30 am – At least one member of team should attend Interdisciplinary Rounds (ITD) on 9E to discuss plan of care, dispo planning etc with multi-disciplinary team.
  • 11:30 am – Morning Report at 11:30 am
  • Attending teaching rounds may occur on call days depending on admissions and census.
  • ~4:00 pm – Dayfloat resident cross-covers from approximately 4 pm-7pm.
  • 6:00 pm – Day team should not admit more than 1 new patient after this time, assuming day team has not capped prior to this.
  • 7 pm – NF intern arrives to begin admitting and take cross-cover from dayfloat.
  • ~7:30 pm – DF departs once cross-cover handed over to night intern. 7:30 pm – Day intern finishes admissions from the day. The resident takes care of the day intern’s patients overnight.
  • 5:00 am – Night intern stops admitting or when capped.

** If the on-call day is a weekend, the dayfloat will be off. Cross-cover during weekend days will be covered by the day intern and signed over to the night intern when they arrive at 7pm.

On each call night, the resident MUST touch base with the attending as to the management plan for each patient.


Day 2: Post-Call
  • 6:00 am (but no earlier) – Day intern returns to pre-round prior to rounds.
  • 7:00-7:15 am – Post-call attending rounds start early. The order of presentations should be as follows:
    • 1. Night intern patients
    • 2. MROC patients (if applicable)
    • 3. Day intern patients
  • 9:30 am – The night intern and dayfloat should leave post-call rounds to finish work.
  • 10:30 am – Resident, night intern, and sub-I depart hospital by 10:30am. The night intern signs out to the dayfloat who is responsible for the post-call patients until at least 4pm. At least one team member attends ITD rounds on 9E (see details above)
  • 4 pm – The post-call dayfloat and day intern will sign out to the on-call dayfloat no earlier than 4pm.\

 

Day 3: Post-Post-Call
  • 7:00 am – Resident and both interns arrive.
  • 8:30 am – Attending rounds.
  • 10:30 am – ITD rounds – at least one team member should attend.
  • 11 or 11:30 am – Morning Report
  • 4 pm – Sign-out to on call gens resident no earlier than 4 pm.

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


 

Day 4: Pre-Call
  • 7:00 am – Resident and both interns arrive.
  • 8:30 am – Attending rounds.
  • 10:30 am – ITD rounds – at least one team member should attend.
  • 11 or 11:30 am – Morning Report
  • 4 pm – Sign-out to on call gens resident no earlier than 4 pm.

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


 

DAYFLOAT DUTIES:

On-call days
  • The DF and team resident are considered to have equal responsibility in educating interns and medical students.
  • On call days, the GENS DF is responsible for the following (non-exhaustive list):
    • Education of junior team members
    • Attendance at Morning Report and noon conferences
    • Team scut work, particularly to facilitate dispo of the night intern’s patients
    • Helping sub-intern with orders on the resident’s day off
  • On call days, the GENS DF is expected to be available at 10 AM.
Post-call days
  • The DF’s primary responsibility is to assist the night intern with leaving the hospital on time and providing excellent care for those patients throughout the day.
  • The DF is also expected to supervise the post-call day intern just as the team resident would do.

**Gens DF is an MROC eligible block – if it happens, it usually means you will split the MROC with the other DF.

TEACHING AND CONFERENCES:

Residents are expected to attend morning report (11:30 am or 11:00 am on Tuesdays) on all but the day off and post-call day.

The 1:15-2 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. They will also be expected to give on average 2 didactics for the MS3 students on the team per week.

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.

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.