Service Details – Cardiology
A. Team structure
- 4 day teams (1 resident/1 intern), 1 night float team (1 resident/1 intern)
- Resident/Intern Q4 day call with Resident/Intern night float
- Day call (resident/intern): 7:00am-8:00pm
- Post-call: arrive no later than 7:00am, attending rounds at 7:30am
- NF: 8:00pm-8:30am (off Sat night)
C. Admitting flow:
- Day call admitting (7:00am-6:00pm)
- Start admitting at 7:00am & hear admissions from cardiology night float team (presented directly on attending rounds starting at 7:30)
- Can admit up to a maximum of 7 patients per call day (this includes a combination of the admissions from the night float, CCU transfers, and ED admits). The maximum number of new H&P’s on a given call day is 5 (i.e: all ED admits and direct admissions require H&P’s whereas CCU transfers and night float admissions do not need H&P’s). ALL cards admissions and CCU transfers must be triaged through 9100. If you get paged directly about an admission, make sure you let 9100 know, as they track all admissions.
- Team cap is 10 patients.
- Stop admitting at 6:00pm.
- Depart hospital at 8:30pm after signing out to cardiology NF team.
- Dr. CART from 7:00am-8:00pm: coverage areas here
- Short call on post post call day (weekdays only), rounds at 7:30 am
- Receive up to 3 holdovers from night float team, to total team cap of 8
- The night team should always give admissions preferentially to the short call team first, to fill the short call team before filling the long call team.
D. Distribution of patients from night float to long-call/short-call teams in the morning:
- Monday thru Friday:
- Short-Call takes first 3 patients (max of 3, up to cap of 8)
- The remainder of NF admissions go to long-call (max of 4, up to cap of 10)
- In the rare event that short-call is open for no patients, long-call should take a max of 4 patients from NF and the 5th patient should be handed over to the hospitalists
- Weekends (Saturday and Sunday):
- There is no short call
- The first 4 patients should go to long-call (max of 4, up to cap of 10)
- Any remaining patients should be handed over to the hospitalists.
- For example: if long-call has 5 patients on their list (open for 5), they should accept 4 patients from NF, and the 5th NF patient should go to hospitalist. The long-call cardiology team will then be open for 1 more admit during the day.
- Another example: If long-call has 7 patients (open for 3), they should accept 3 patients from NF (to cap), and the 4th and 5th NF patients should go to hospitalist. The long-call cardiology team will be done admitting for the day.
E. Night float (8:00pm-8:30am)
***NIGHT FLOAT SHOULD ALWAYS BE OPEN FOR 5 ADMISSIONS EACH NIGHT***
- Start admitting at 8:00pm, NF intern signs into ‘4279’ pager. You are open for 5 patients every night (regardless of long/short call census). Please inform 9100 how many patients will be handed over to the hospitalist in the morning.
- Cross-cover Cardiology and Housestaff Solid Oncology patients from 8:00pm to 7:00am
- Only admits Cardiology patients overnight. No Oncology admissions overnight.
- Cap 5 new admits. NO new admissions after 6:00am
- The Cardiology Night Float team may accept Cardiology OSH transfers, CCU and MICU transfers overnight. Transfers from other floor services, such as hospitalist or housestaff floor teams, should NOT occur overnight. Please call CROC with questions.
- The day teams are expected to touch base with the primary CCU/MICU teams the following morning to confirm plans of care and complete the hand-off process.
- Present to on-call/short-call teams during attending rounds at 7:30am. If you admit 5 (should always be open for 5!) and there is not enough room on the housestaff teams to accommodate all 5 patients (see examples above) page 9100 before 7am to hand off the overflow patients to hospitalists.
- Please note: short call should always be filled before long-call. Short call can accept a maximum of 3 holdovers (to cap of 8), and long-call can accept a maximum of 4 holdovers (to cap of 10). There is no short call on the weekends.
- If > 4 admissions Friday through Saturday night, patient number 5 goes to the hospitalists as a holdover in AM as there is no resident short call on the weekend.
- Dr. CART coverage from 8:00pm-7:00am
F. Saturday (night float resident/intern off)
- Day call resident scheduled for Saturday call stays overnight (24+4) & admits with the medical intern on call (MIOC)
- Patients admitted with MIOC are presented by MIOC as holdovers to the on-call resident/intern team following morning during attending rounds.
- If > 4 admissions, patient number 5 goes to the hospitalists as a holdover in AM (see above)
G. Transfer policies
- ALL Cards admissions, including OSH transfers and MICU/CCU transfers, must be triaged through 9100.
- OSH Transfers and CCU / MICU transfers can occur at any time, day or night.
- Cardiology/General Medicine Transfer Policy: Every effort should be made to limit transfers onto and off of the Housestaff Cardiology teams, given the impacts these transfers have on continuity of patient care and system capacity. However, we understand that there are rare circumstances when a patient may be better medically served on a different service. Transfers are allowable in these circumstances after an attending to attending conversation, following the guidelines outlined below. These transfers should only occur during the day (7a-6p) unless an exception is made in consultation with 9100 and the Chief Resident on Call.
- Transfers FROM Cardiology to General Medicine: Transfers from the Housestaff Cardiology service to General Medicine or Hospitalist Medicine require a discussion between the Cardiology team attending and the hospitalist triage attending covering the 9100 pager. Based on this attending-to-attending discussion, the hospitalist triage attending can either accept the transfer or provide a formal General Medicine consult. A transfer to medicine can then be initiated if deemed appropriate by the hospitalist attending after formal consultation.Transfers from Cardiology to General Medicine or Hospitalist Medicine should be reserved for medical indications only. Discharge planning and placement issues are not reasons to transfer patients between services.
- Transfers FROM Other services to Housestaff Cardiology: A patient may be transferred from another floor service to the Housestaff Cardiology service at the recommendation of the Cardiology Consult attending. If the primary service attending is requesting transfer to Housestaff Cardiology, they should initiate a Cardiology consult, if not already called. If the Cardiology consult attending agrees with or independently recommends transfer, there must be an attending to attending discussion between the Cardiology consultant and the hospitalist triage attending (covering 9100) regarding the reasons for and appropriateness of transfer. After this discussion, if the decision is made to transfer the patient to Housestaff Cardiology, the Cardiology Consult team (resident, fellow, or attending) should relay the plan of care to the on call Cardiology resident and service attending; this hand off should be in addition to the normal sign out that occurs between the primary service and accepting Cardiology team. Of note, patients in Mitchell cannot be accepted by the on call Cardiology team until they have a bed in the CCD due to geographic limitations of Housestaff Cardiology. Patients in the CCD can be accepted at any time, though transfers should be limited to the daytime when appropriate.
- For all Gens-Cards transfers: While in general, at this time, trades will not be made, if transfers create an uneven distribution between patients on housestaff and hospitalist services, 9100 should page the Chief Resident on Call to discuss a possible trade.
- On call rounds
- Cardiology night float resident/intern present directly to on call team on attending rounds
- If night float team admits 2 or less, will present directly to short call team on attending rounds.
- Attending rounds start at 7:30am
- Post call rounds
- Start at 8:30am (post call team cannot arrive earlier than 7:00am)
- Short call rounds
- May involve “cold” handoff of hold overs from NF team. Attending will perform bedside rounds for these “cold” handoffs
- Attending rounds start at 7:30am
- Pre call rounds
- Start at 8:30 am or at time agreed to by attending and team
- Day call intern receives signout and passes it on to night float intern (double hand off)
- The Cardiology call team will cross cover for Cardiology patients every day and Housestaff Solid Oncology patients on days HONC teams are not on call (Wednesday, Saturday, and Sunday).
J. Days off
- Pre call days (weekdays)
- Post post call and pre call days (weekends)
K. Night float day off
- Saturday- night resident and intern off
- Day call resident scheduled for Saturday call stays overnight (24+4) & admits with MIOC
- Senior resident’s pager should be covered by the intern on the senior’s day off
- Intern’s pager should be covered by the senior on the intern’s day off
M. Other Important Points:
- Dr. CART coverage
- Day resident/intern- CART coverage from 7:00am-8:00pm
- Night float- CART coverage from 8:00pm-7:00am
- OSH transfer
- All OSH transfers must be admitted to housestaff. Between 5pm and 8pm, ONE OSH transfer can be cross-covered on by Cardiology day team even if capped prior to giving to the night float to admit. All remaining OSH transfers will be cross-covered on by 9100 prior to being handed off to night float. After night float is capped, 9100 will have to cross cover on any additional OSH transfers to give to day admitting team on the following morning.
- If an intern is resiterning and requires assistance, he/she should contact the cardiology resident on call or medical resident on call (MROC) for assistance. The intern should also reach out to his/her attending for management decisions.
N. End of Service Sign-Out
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.
Examples of common conditions encountered on the cardiology service:
Patients with cardiovascular symptoms/signs/diagnosis to be directed to housestaff general cardiology services based on this agreed list of diagnoses:
Coronary Artery Disease
Chest pain – possible ACS
Chest pain with abnormal troponin
ESRD with elevated troponin and an acute chest pain syndrome
Chest pain with ST&TW change, not previously documented
Chest pain requiring heparin, IV nitroglycerin or platelet receptor blocker
Atypical chest pain with history of CABG
Atypical chest pain with documented new LBBB
Atypical chest pain with recent (<6 mo) revascularization
True syncope (loss of consciousness and postural tone) without focal neurologic exam or readily identifiable non-cardiac cause
Near syncope with medical complications / mitigating factors
New onset atrial fibrillation/flutter (Unrelated to acute exacerbation of a medical condition)
Atrial fibrillation/flutter with symptomatic rapid ventricular response (unrelated to acute exacerbation of a medical condition)
Admission for initiation of anti-arrhythmic drug therapy
Scheduled EP procedure admit
3rd degree heart block
Type 2 second degree heart block
Pacemaker dysfunction / infection
ICD shock requiring admission
New onset CHF (other than isolated edema related to acute exacerbation of a medical condition)
CHF exacerbation (Unrelated to acute exacerbation of a medical condition)
CHF requiring inotrope
Dyspnea thought to be CHF
PA HTN patients followed PH
Suspected prosthetic valve dysfunction
LV thrombus requiring IV anticoagulation
Anticoagulation complication / bridging requiring admission in patient whose warfarin is managed by UofC cardiologist
SBE with CHF or documented new AV block
SBE with prosthetic heart valve
Pericardial effusions requiring admission
Chronic aortic dissection with recurrent pain or uncontrolled HTN