MICU Service Rules

Last edit December 15, 2016

Team:

2 attendings, 2 fellows, 4 residents, 1 day float, 2 NP’s, 8 interns, 1 NF intern, 1 NF resident

  • The service is divided into 4 teams: A, B, C, and D.
  • Each attending oversees 2 resident teams.
  • Each resident team consists of 1 resident and 2 interns.
  • The team is on call q4 with day call for the interns and overnight call (24+4 hours) for residents.
  • There is one 1 night float team: NF-I and NF-R. The team rotates in 2-week blocks.
  • There is 1 day-float resident. The dayfloat resident will assist with the post-call team as well as other needs that arise from the other teams. See separate MICU DF rules!

Census Caps:

  • Interns have a total census cap of 10 patients.
  • If an intern or resident reaches their cap, the patients will be reallocated to teams with a lower census.
  • Admitting caps are outlined below.

Call Day Structure:

6:00am: All teams arrive
6:00am: Post-call resident contacts fellow to discuss admissions and determine priority of presentations
6:30am: New call resident signs into admitting pager 6428 (MICU)
7:00am: Rounds start with all four MICU teams as a group with presentation of new patients. Dayfloat should arrive and be present for rounds at this time.
7:30am: Rounds split with A+C and B+D teams rounding separately. The attending with the post-call team should prioritize presentations from night-float, then post-day-call interns. Dayfloat should stick with post-call team (or otherwise have discussed coverage plan with APNs).
8:00am: Night-float team done with rounds and leaves to complete unfinished work
8:30am: Night-float team updates NP’s or dayfloat on progress and leaves hospital.
8:30-9:00am: Post-call day interns complete rounds; post-call resident, post-call day interns run the list with NP’s and/or dayfloat.
9:00am: Pulm/CC Morning Report if time allows (CCD 10490)
9:30am: Post-call resident leaves
~2:00pm: MICU Lecture (exact time to be set by attending/fellow)
~3:00pm: Afternoon rounds with on-call attending, fellow, and resident as well as senior residents from each team (interns if residents are off)
5:00pm: Non-call teams sign out to the on-call team. Ideally, the on-call resident should also be present and must be informed of critical details if unable to be there for the entire signout
6:00 pm: On-call day interns should stop admitting patients
Before 7:30pm: On-call resident runs the list with fellows / attending.
7:30pm: Night-float team arrives and receives signout on the unit patients from on-call team, APNs, dayfloat etc. *Dayfloat resident should not depart before other teams have finished required care for the day.
7:45pm: Night-float team rounds with on-call resident to go over patient care plan.
12 midnight: The night-float resident takes over the MICU admitting pager (6428).

Details of responsibilities, admitting caps, and work flow:


Day 1: Day and Night Call

The resident on-call and day interns will arrive at 6:00 am to begin pre-rounding on their patients. At 6:30, the resident on-call team will officially take over the admitting pager. If there are any patients that are in the process of being worked up, these patients should be handed over to the oncoming day call team. The on-call interns will admit a maximum of 5 patients each between 6:30am and 6:00pm.

Following the didactic lecture, afternoon rounds will occur (~3:00pm). The on-call resident and attending and/or fellow must be present to briefly round on the entire MICU. The non-call attending and/or fellow may be present as well, and ideally there should be a representative from each team (senior residents or interns if senior is off). Brief rounds should include a one-liner, brief updates on the daily plan, and any critical cross-cover issues for each patient.

Admissions after 6 pm should be triaged by the MICU resident with an abbreviated work-up and stabilization. Ideally, these patients are then handed off to the night intern for further management and documentation (i.e. writing the H&P).

If there are greater than 10 total new admissions between 6:00 am and 7:30 pm, the resident may call the MROC to help or the CROC to have a jeopardy resident admit additional patients, if needed. Once the night intern arrives at 7:30pm, any patients that are in the process of being worked up should be handed over. The day intern must complete their signout and depart the hospital NO LATER than 7:30pm.

As mentioned above the night-float team will arrive at 7:30 pm. The night-float team will admit up to 10 patients with the night-float intern admitting a maximum of 5 new patients between 7:30pm and 6:00am. If there are greater than 5 new admissions, the night-float resident will admit additional admissions alone up to an additional 5 new admissions. If there are > 10 admissions between 7:30 pm and 6:00 am, the MROC may assist and/or the CROC can be called to activate jeopardy.

The patients admitted by the night-float team will generally remain with the on-call team (care assumed by post-call day interns / NPs / day-float). Again, if the patient is still being actively worked up and transferred, the patient should go to the oncoming call team.

Night interns are expected to have H&Ps and signouts completed by 6 am.

At 6:00am, the MICU post-call resident will call the MICU fellow to discuss presentation structure for rounds (intern vs. resident presentations) based upon the number and complexity of admitted patients.

Admitting residents are expected to be able to present all their patients if necessary.


 

Day 2: Post-Call

Night admissions will be absorbed by the post-call day interns to ensure resident continuity of care.

On the post-call day, teams cannot arrive earlier than 6am. If the team has many patients to pre-round on, they may need to come slightly late to attending rounds. Attending rounds will start daily at 7:00am.

At 7am, the nurse practitioners and dayfloat resident arrive.

The post-call night intern will present their patients first, followed by the day intern’s new admissions, followed by old day patients. Ideally, all new admissions will be presented by 8:30 AM. If all new admissions from the past 24hrs have been presented, the MICU team should break for Pulmonary Morning report (9:00 to 9:30am).

After presenting their new admissions, the night float team must break away to “run the list” with the NP’s and/or dayfloat resident. This process must take place no later than 8:00am. If post-call resident is still rounding on new admissions, s/he will stay on rounds to present these patients. The day call interns will later be responsible for updating the sign out these patients. The night interns must leave at 8:00 am, and the post-call resident must leave the hospital no later than 9:30 am.

Once MICU rounds have completed, the teams will disperse to complete work. The post-call interns should review their plans and action items with the NP’s and/or the day-float resident.

All teams will reconvene around 2:00pm for a 60-minute didactic MICU lecture. This time may vary at the discretion of the attending and/or fellow. Following the didactic lecture, afternoon rounds will occur (~3:00pm) as described above. Teams should sign out to call team or dayfloat by 5pm. This sign out should ideally occur in front of the resident on-call +/- the MICU fellow.


Day 3: Post Post Call

Resident and interns arrive (~6:00 am) – 1 team member may be off

Work round together on established team patients
Attending Rounds at 7:00 am
Pulmonary Morning Report at 9:00 am
Attending Rounds continues at 9:30 am
MICU didactic lecture at ~2:00 pm
Afternoon rounds at ~3:00 pm


Day 4: Pre Call

Resident and interns arrive (~6:00 am) – 1 team member may be off
Work round together on established team patients
Attending Rounds at 7:00 am
Pulmonary Morning Report at 9:00 am
Attending Rounds continues at 9:30 am
MICU didactic lecture at ~2:00 pm
Afternoon rounds at ~3:00 pm

 

Night-float Responsibilities:

  1. MICU NF R/I must round and receive signout with on-call resident when they arrive at 7:30 pm.
  2. On-call MICU-R has primary admitting responsibility until midnight.
  3. MICU NF-R will take cross-cover with MICU NF-I and admit new patients after midnight or earlier if the on-call overnight resident needs assistance.
    1. In the morning, patients admitted by the MICU NF team will be absorbed by the post-call team (post-call MICU-R plus post-call MICU-I’s) unless redistributed to another team at the discretion of the MICU fellow and/or attending.
  4. Intern will generally handle all cross-cover, most admissions, and most procedures to maximize educational value.
  5. Days Off:
    1. MICU NF-R is off on Saturday. If MICU-R and MICU NF-I need additional assistance, the MROC should be called. Also the CCU moonlighter may be helpful.
    2. MICU NF-I is off on Sunday. If MICU-R and MICU NF-R need additional assistance, the MROC should be called for assistance including road trips.

 

 

Teaching/Conferences

The 2:00-3:00 pm time slots are used daily for didactic teaching (the MICU Curriculum).

The team resident is responsible for the education of the team interns and students and should consider themselves the primary teacher for these 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 and also during the hour set aside for didactics.

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 (via MedHub).

Clinics

There will be no clinics during the MICU month.

Other Important Points

Determination of team assignment will be based on patient’s arrival time at the University of Chicago in combination with the discretion of the resident.
Any patient who cannot be appropriately managed by a floor team will be considered suitable for ICU admission. These patients include, but are not limited to, acutely decompensating patients, patients in whom acute decompensation is very possible, or patients whose floor care is limited by inadequate nursing or ancillary support.

Some non-medicine services routinely admit patients to the MICU: ENT, orthopedics, obstetrics/gynecology, and urology all admit their critically ill patients to the MICU rather than another ICU. Postoperative ICU admissions should uniformly be accepted unless decided otherwise by the MICU attending. Floor transfers from these services should be handled just as floor transfers from medicine are, but being mindful that non-medicine services have different overnight staffing models (including home call) and different levels of comfort/familiarity with issues that may seem “routine” on general medicine. When in doubt (even a little), these patients should be accepted.
The MICU resident (or night float resident) MUST evaluate and write a note on all patients they are called to admit from the Emergency Department. If the MICU resident feels the patient is not appropriate for admission to the MICU, they should contact the MICU fellow and attending to discuss. Only the MICU attending can elect not to accept a requested admission from the ED.
Patients whose clinical condition and evaluation are primarily of a cardiac nature should be managed in the CCU. However, such patients who have excessive co-morbidities may be admitted to the MICU. The CCU and MICU fellows should be involved in these triage decisions.
There is NO bounce-back policy in the MICU. If a patient returns to the hospital in less than 48 hours, then the admitting team and the discharging team should discuss the appropriate disposition of the patient. The team that initially discharged the patient is not obligated to take the patient back on their service.
Residents in the MICU may not moonlight.

If your team discharges all patients:

  • If it is a weekday and you are not the on call team but have zero patients, then your team is still expected to come in for rounds, morning report/noon conference, and the afternoon MICU attending lecture. If, after this, none of the other teams need help, then you may leave for the day. This policy both ensures that you don’t miss out on valuable educational opportunities and that the other teams won’t be without much-needed spare sets of hands if things get really busy.
  • If you zero out on a weekend, there is no need for the team to come in that day.

Patient transfer to General Medicine/Solid Oncology/Other Hospitalist-run services (liver, solid organ transplant, CCP etc)

  1. MICU decides patient is appropriate for floor transfer and pages 9100 before writing transfer order. If triage pager has not responded to you within 15 minutes, you may place the transfer order, but make sure it is for a CCD bed (NOT Mitchell).
  2. Transfer note and transfer order reconciliation should be completed prior to transfer and certainly before primary team departs for the day.
  3. After patient gets bed assignment, page 9100 to notify them of bed assignment 24/7. Triage MD will assign the patient to a specific receiving team (i.e. Gens, liver hospitalist, T-team) and either:
    • Instruct MICU team to whom they should give signout, or
    • Receive signout as they themselves will be accepting the transfer
    • It is important for primary team to have made a plan for who will give signout, if it is possible that the primary team will not be in the hospital at the time a patient transfer may occur. An appropriate phone number should be designated and clear to be provided to the triage MD or other necessary personnel. If the receiving team receives signout from a team other than the primary team and feels they need additional information, they should contact the transferring team the following day.
  4. Remember to promptly change the FCP after completing a transfer either into or out of the MICU.
  5. Clinical stability of MICU patients can change abruptly and these patients represent the highest risk transfers making careful communication and signout essential. The primary team/covering resident should confirm patient’s clinical status remains appropriate for deescalation of care at time of physical transfer.

Re: Solid Oncology transfers overnight

  • If a solid oncology patient is being transferred out of the MICU overnight, the patient may either be:
    • Transferred to Hospitalist Oncology Service, if they were not previously on a housestaff team
    • Covered by the MICU overnight and signed out to the on-call oncology team the next morning to avoid a double handoff, or
    • Transferred to the Oncology NF resident. If this occurs, this patient will count towards the cap of the Onc NF resident.
  • There is a priority to have patients appropriate for the Supportive Oncology service to be on that service. When deemed appropriate, solid oncology patients who were previously on a Hospitalist Oncology floor team, may be transferred out of the MICU to a housestaff team so that they may benefit from the direct management of the Supportive Oncology team including the Oncology and Palliative Care attendings.

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. The plan of care should be reviewed with the interns 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 decision of whether or not to accept a patient to the MICU does not rest with the resident on call. If a resident feels as though a patient does not require ICU admission, the case must be discussed with the ICU fellow and attending who will make final decision. The resident should write an evaluation note on all patients that they evaluate whom they do not accept to the MICU.

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.