Overall structure

There are 2 MegaTeams (AC and BD), each with 2 Residents and 3 Interns. Each MegaTeam will round as a group and the Senior Residents on the team should be familiar with all of the teams’ patients (and able to support all 3 Interns, even if they did not admit one of their patients, if the other Senior is not available). Patients will be categorized according to the Resident & Intern who admitted them (i.e. PAR score for a patient would be A1 if they were admitted by Resident A & Intern 1).

Every day, there will be one team with a Senior Resident On-Call (28 hour call, admitting 6:00am-6:00am with assistance from Night Float), one Long-Call Intern (admitting 6:00am-7:00 PM), and one Short-Call Intern (6:00am-5:00pm). They will all work together to alternate admissions throughout the day. Of note, the goal is not to admit to the Short-Call Intern before the Long-Call Intern. Instead, admissions will be distributed at the Senior Resident’s discretion accounting for patient load and complexity (e.g. if the Short-Call Intern starts the call day with 4 patients and Long-Call Intern starts with 2 patients, the first 1-2 admission should go to the Long-Call intern to keep the lists balanced, keeping in mind that the Short-Call Intern will be on Long-Call two days later).

 

Overview of Call Structure:

Senior Residents:

Day 1: On-Call

Day 2: Post-Call

Day 3: Regular

Day 4: Pre-Call or Off

 

Interns:

Day 1: Long-Call

Day 2: Post-Long Call

Day 3: Regular day or Off

Day 4: Regular day

Day 5: Short-Call

Day 6: Post-Short Call

 

Night Team: There is one night team with 1 Night Float Resident and 1 Night Float Intern.

The NF Resident will be off Friday night, NF Intern will be off Sunday night. There is a MICU ESP shift available for any PGY-2 or PGY-3 on Friday nights.

 

Bridge Resident: There is one Resident who serves as a “Bridge” Resident (2:00pm-12:00 AM M-F, 12:00pm-12:00 AM weekends)

The Bridge’s day off is Tuesday.

 

Call Day Structure

 

By 6:00am: All teams arrive. On-Call Resident signs into the admitting pager (6428) at 6:00am. Post-Call and NF Residents discuss admissions with the On-Call Fellow and determine priority of presentations. All other residents should pre-round and see their patients.

 

Approx. 6:40am: Each Intern should touch-base with their MegaTeam Residents to quickly review their patients’ plans before rounds.

 

7:00am: Rounds start with both MICU MegaTeams (AC & BD) meeting as a group to discuss a teaching case. Triage and Dayfloat should arrive and be present for rounds at this time. Triage may break off after teaching case.

 

7:15am: Rounds split, with AC and BD MegaTeams rounding separately. The Post-Call MegaTeam should prioritize presentations from the Night-Float team first. If the On-Call Resident is paged about a new admission/eval during rounds, the Triage Consult Resident or the other resident on the MegaTeam will assist during this time (with a goal of the On-Call Resident remaining on rounds, though they will still need to break off if 2 or more patients need to be evaluated at the same time). APNs may also be asked to eyeball/evaluate new consults as needed and as they are able to.

 

Approx. 9:00am: Post-Call Resident completes rounds; Post-Long Call Intern and Post-Short Call Intern take turns breaking away from rounds to run the list with APN/ED Dayfloat and Post-Call Resident once they have finished presenting any patients with the non-post call Senior. 

  • First Intern breaking off is determined by their patients’ geography OR who has least to present. The Fellows will be able to help with this in an effort to get the Post-Call Resident out of the hospital ASAP.

 

By 10:00am: Post-Call Resident leaves.

 

10:00am: Pulm/CC Morning Report if time allows (on Zoom).

 

2:00-3:00pm: MICU Lecture for all Residents and Interns.

 

3:00pm: Afternoon rounds with the On-Call Attending, Fellow, On-Call Resident, and Bridge Resident. The Fellows will present a one-liner, brief updates on the daily plan, and any critical cross-cover issues for each patient.

 

4:00pm: Teams can begin to sign-out to the Bridge Resident (or the non-call Resident on Tuesdays, the Bridge Resident’s day off – e.g. if Resident B is on-call, Resident D takes sign out). The ED Dayfloat may leave after 4pm, but should not leave until the post-call work is completed.

 

*For patients that are shared by the Non-Call Resident and an Intern who is admitting with On-Call Resident that day, the Non-Call Resident will sign out their shared patients to the Bridge Resident. 

 

5:00pm: Short-Call Intern stops admitting patients

 

7:00pm: Long-call Intern stops admitting patients.

 

7:30pm: Night Float Resident and Intern arrive and sign into admitting pager. On Tuesday (the Bridge Resident’s day off), the Night Float Resident takes sign-out from the Non-Call Resident at 7:30pm. The On-Call Resident should discuss with the NF team and Bridge Resident if there are any tasks that can be delegated to facilitate the call interns leaving on time.

 

8:00pm Short-Call Intern should leave by 8:00pm at the latest.

 

9:30pm: Long-Call Intern should leave by 9:30pm at the latest.

 

10:30pm: Bridge Resident signs-out to NF Resident and NF Intern. On slow nights, this sign-out can occur earlier (especially since sign-outs often get disrupted), but Bridge should remain FCP on cross-cover patients until Midnight. The Bridge cannot physically leave before their shift ends at midnight.

 

12:00am The NF Resident takes over the admitting pager. The On-Call Resident ties up admissions from the night, prepares for morning rounds, and helps the NF Team with cross-cover/additional admissions as needed.

 

Overnight Admissions & Re-distribution

 

Overnight admissions are distributed in the following priority:

 

1) Fill the Post-Call teams first, up to a cap of 7 patients per Intern. Prioritize filling the Post-Long Call Intern first, followed by the Post-Short Call Intern.

 

2) When the Post-Call team is capped, additional patients can be given to the non post-call Intern at the discretion of the Fellows ONLY if that intern’s non post-call Senior is working that day.  

 

3) Additional patients can be distributed to the On-Call team (divided between Long-Call Intern and Short-Call Intern), with preference given to late admits (from NF) or highly active patients, all at the discretion of the Fellows.

 

*If there is an active patient or a very late admit, the NF Resident may pass this to the Call team, even if the Post-Call team is not capped. If this is being considered, the Post-Call Resident and NF Resident should discuss with the Fellow. The Fellow makes all final decisions regarding distribution.

 

Rounding Order

 

The NF Resident is responsible for preparing the order of patient presentations for rounds.

  • The NF Resident should designate the teaching case (in discussion with the On-Call Resident and Fellow) and determine the order of rounds, optimizing efficiency so they can get out on time. 
  • General order of Post-Call presentations should be:
  1. Teaching case
  2. Night Team presents to Post-Call MegaTeam
    • If applicable, Night Team then presents overflow admits to the other (On-Call) MegaTeam
  3. Post-Call Team presents their news and olds (i.e. if Resident A is post-call, all of the “A” patients will be presented at this time, followed by all of the C patients afterwards). As above (see Call Day Structure), Post-Long Call Intern and Post-Short Call Intern take turns breaking away from rounds to run the list with APN/ED Dayfloat and Post-Call Resident once they have finished presenting any patients with the non-post call Senior. The first Intern breaking off is determined by their patients’ geography OR who has the least to present. The Fellows will be able to help with this in an effort to get the Post-Call Resident out of the hospital ASAP.
  • The On-Call MegaTeam will round geographically as a group.
  • The MICU AM Rounding Form can be used if needed

 

Intern’s guides to the MICU

MICU Orientation Guide

Other Important Points

 

MICU Evaluations and Admissions

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 (even if no “strict” ICU indication). Floor transfers from non-medicine 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. All consults should be run by the fellow, particularly if not admitting to the MICU.

 

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.

 

The On-Call Resident, Night Float Resident, or Triage Resident MUST evaluate and write a note on all patients they are called to evaluate. If the evaluating Resident feels a patient is not appropriate for admission to the MICU, they should contact the MICU Fellow and/or Attending to discuss. Only the MICU Fellow/Attending can elect not to accept a requested admission (all cases MUST be discussed). This discussion should occur before the evaluation note is written.

 

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.

 

When the MICU is Full / Busy

 

Between 10 pm and 6 am, OSH transfers will only be able to come to beds on 9N, 9S, and 8S.  When the MICU is very busy, the On-Call Resident should discuss stopping all OSH transfers with both the MICU Fellow and Attending.  If approved, the Fellow should contact the transfer center to relay this message.

 

Zeroing Out

  • If 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.

 

Service Transfer Workflow (patient transfer to General Medicine/Solid Oncology/Other Hospitalist-run services: liver, solid organ transplant, CCP etc)

* Note: 9100 = Hospitalist Attending who triages transfers to floor and holds the 9100 pager

  1. MICU decides the patient is appropriate for floor transfer and pages 9100 before writing the transfer order. If 9100 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). Transfer orders can be placed 24/7.
  2. Transfer note and transfer order reconciliation should be completed prior to transfer.
  3. 9100 will assign the patient to a specific receiving team (e.g. Gens, Hospitalist, ONC) and either:
    • Instruct MICU team to whom they should give signout, or
    • Receive signout as they themselves will be accepting the transfer
  4. Careful communication and signout are essential as clinical stability of MICU patients can change abruptly and these patients represent the highest risk transfers. The primary team/covering Resident should confirm that the patient’s clinical status remains appropriate for deescalation of care at time of physical transfer.
  5. Once verbal sign-out is given, the patient’s FCP can be changed. Of note, the receiving floor team can assume responsibility for the patient 24/7, even if the patient is still physically located in the ICU. However, the patient will remain on the MICU Master List until they are physically transferred out of the unit and should be included in cross-cover signout (so that the covering resident is familiar with the patient, in the event that they are pulled into the room by a MICU nurse for an urgent issue). The floor team will remain the primary caregiver and receive all FCP pages. Patients will be removed from the Master List once they are physically transferred out of the unit.
  6. If there are long delays in your patient getting a CCD bed, and you would like for the patient to get a bed in Mitchell, this MUST be discussed directly with 9100 before such a bed request can be made. 
  7. When transferring a patient to housestaff ONC, the default is that this patient is to be staffed by the MICU Attending in the morning.
    1. If the MICU Attending would like the patient to be staffed by the housestaff ONC team, the following must take place:
      1. Patient has to be in their floor bed before 7 AM,
      2. 9100 has to have determined that this patient will go to the housestaff team,
      3. ONC Team has to be notified before rounds. 
      4. The MICU team will then send a representative to present to the ONC Attending (can also be presented over the phone).

 

Transfers When the Primary Team is Not Present:

  1. During day sign-out, please specify the latest time you would want to be called to give signout to the receiving team. Interns, the choice is yours: we recognize that you may have afternoon or evening plans and waiting by your phone is not realistic. You are not obligated to give signout at home if it is not feasible or practical.
  2. Make sure to update the transfer note daily. This will be the document that the Night Float Resident (or the On-Call Team if the transfer occurs during the day) will use in discussing the transition plan with the receiving team.
  3. The patient’s primary MICU team should call the receiving team the following morning after 8:30 AM to “close the loop” of communication and to give a more detailed signout.

 

End of Service and Day Off Sign Out

  1. 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.
  2. Signout emails should be provided if you will be off and your intern or resident was not present the day before (e.g. you are the intern and you will be off tomorrow. The resident was post-call during the day and will be resinterning of your patients the following day).

Overview of MICU Resident Roles 

Resident Roles 

Bridge Resident

  • Primary role is cross cover.
  • Should also help the Call Team to help get the Call Interns out of the hospital on time.
  • Can provide additional help to the other teams in the unit as needed (e.g. supervising a resinterning intern, helping with procedures, easy admits, etc).

Shift: 

  • Weekdays (M-F) 2:00pm – 12:00am
  • Weekends (S/S) 12:00pm – 12:00am
  • Day off: Tuesday

Daily Schedule, Weekdays

2:00pm: Attend MICU lecture.

3:00pm: Attend PM rounds.

After PM rounds 3:30-9:30pm:

  • Take all cross-cover.
  • Work with NF Resident to alleviate burden from Call Resident, so they can focus on getting the Long- and Short-Call Interns out of the hospital on time.
  • Be available to help Call Teams as needed with evals / straightforward admits / procedures

10:30pm: Sign out to NF Intern and NF Resident (can do this earlier if everyone is free, but must stay until 12am).

12:00am: Wrap up and leave.

Daily Schedule, Weekends

12:00pm: Arrive, start taking sign out.

3:00pm-3:30pm: Attend PM rounds.

After PM rounds 3:30pm-9:30pm:

  • Take all cross-cover
  • Help Call team as needed
  • Help get Long- and Short-Call Interns out of the hospital on time
  • Available to help Call teams as needed with evals / straightforward admits / procedures

10:30pm: Sign out to the NF Intern and Moonlighting Resident on Friday and NF Resident on Sunday (can do this earlier if everyone is free, but must stay until 12am).

12:00am: Wrap up and leave.

*Note: If the Bridge helps with evals/admits, just know they will not be there in the morning to present the patient.

Bridge Day Off: Tuesday

  • On Tuesdays, the non-call Resident should stay until 7:30pm to take sign out (e.g. if Resident B is on-call, Resident D takes sign out)

 

Night Float Resident

  • Primarily responsibilities include overnight cross-cover and overnight admissions; assisted by NF Intern
  • Admits from 12am to 6am. (However, between 7:30-9:00pm they should help the On-Call Resident in any way needed, including admitting, so that they can get interns out on time). Also should take over the admitting pager if the On-Call Resident caps (7 patients per Long/Short Call Intern) but the On-Call Resident can and should help as needed.
  • Fills out MICU AM rounding form with order of presentations by 6:45am.

Daily Schedule

7:30pm: Arrives. Cover admitting pager. Should use the On-Call Resident as needed for help with both admissions and cross cover.

10:30pm: Takes sign out from Bridge (on Bridge day off, take sign out at 7:30).

6:45am: Fills out MICU AM rounding form and discusses with fellow to determine which teams will receive overnight & re-distributed patients.

Night Float Resident Day Off: Friday

 

Night Float Intern

  • Primarily cross-cover and admissions at night with NF Resident. Also participates in procedures.
  • If the NF Intern and NF Resident will not be together for an extended period of time and the NF Intern will be off of the unit (e.g. the NF Intern is off of the unit with a new admission with the On-Call Resident), the NF Resident should take over the cross-cover pager for that time. While the amount of time this happens will vary depending on admission needs and the severity of cross-cover, the focus should remain on having the NF Intern be responsible for cross-cover under the guidance of the NF Resident and On-Call Resident.

Daily Schedule

7:30pm-12:00am: Help On-Call Resident with extra admissions that the day’s Long/Short Interns were not able to take.

10:30pm: Get sign out from Bridge along with the NF Resident. On Bridge day off (Tuesday) take sign out at 7:30pm from Call team.

Patient Cap: Night Float Intern can admit up to 5 patients (5 H&Ps). Any patients that come overnight beyond 5 should go to the NF Resident or On-Call Resident alone.

Night Float Intern Day Off: Sunday

 

On-Call Resident

  • Primary role: You are the main person in charge of the unit. You will be expected to know what is going on with everyone in the unit, both on your team and on cross-cover, and to communicate with the Fellows and Attendings about active issues. You will need to fill out MICU rounding form by 6:45 am when NF Resident is off on Friday night.

Daily Schedule

6:00am–12:00am: Cover admitting pager. Field floor and ED evals with the Triage Resident (see rules below), ensuring that every patient who is not accepted to the MICU will need to have been discussed with the Fellow and have an evaluation note written. Divide admissions amongst the Long- and Short-Call Interns in an equitable way, keeping in mind that the Short-Call Intern will be Long Call in two days. All admissions and evals should be discussed with the MICU Fellow.

3:00pm: Attend PM rounds.

7:30pm-9:30pm: Catch up on day’s admissions with a focus on getting Short-Call Intern out by 8:00pm and Long-Call Intern out by 9:30pm. This means delegating tasks to other residents (ie Bridge and NF team) to get interns home on time.

9:30pm – 6:00am: Wrap-up admissions, check on admitted patients/follow-up labs etc, prepare intern/team for morning rounds. Also help NF team with cross-cover and admissions as needed.

 

Long-Call Intern

 

  • Primary Role: The Long-Call Intern will admit patients with the On-Call Resident.

Daily Schedule

6:00am – 7:30pm: Admits patients with the On-Call Resident. Will alternate admissions with the Short-Call Intern based on workflow, volume, and acuity at the discretion of the On-Call Resident

7:00pm: May receive patients until 7:00pm, but after this time they will STOP admitting in order to finish day work and finalize plans. 

7:00pm-9:00pm: Works with the On-Call Resident to run plans and finish notes

9:30pm: Should depart hospital

Patient Cap: Similar to other services, On-Call Interns should not write more than 5 H&Ps.

The cap for the Post-Call Intern will be 7 patients.

 

Short-Call Intern

 

  • Primary Role: The Short-Call Intern will admit patients with the On-Call Resident.

Daily Schedule

6:00am – 5:00pm: Admits patients with the On-Call Resident. Will alternate admissions with the Long-Call Intern based on workflow, volume, and acuity at the discretion of the On-Call Resident

5:00pm: May receive patients until 5:00pm, but after this time they will STOP admitting in order to finish day work and finalize plans. 

5:00pm-8:00pm: Works with the On-Call Resident to run plans and finish notes

8:00pm: Should depart hospital

Patient Cap: Similar to other services, On-Call Interns should not write more than 5 H&Ps.

The cap for the Post-Call Interns will be 7 patients.

 

ED Dayfloat 

Post-call help will be provided by APNs and ED Dayfloat during week; ED dayfloat on weekends. 

The ED Dayfloat should plan to arrive at 7am and round with the post-call team (both interns). They will primarily be helping the post-call team but should check in with other teams as well. 

Dayfloat Overview

  1. Staffing:
    1. The Emergency Medicine program will provide at least one ED Dayfloat Resident.
    2. When there are two ED Dayfloat Residents, at least one Dayfloat Resident must be present every day of the rotation.
  2. Schedule:
    1. The ED Dayfloat will arrive by 7:00am to actively participate on rounds, supervise the Post-Call Interns and assist any other teams.
    2. On weekdays, the ED Dayfloat should be present until afternoon rounds are complete (may not leave before 4:00pm). After 4:00pm, the ED Dayfloat is permitted to leave when the post-call team’s work is wrapped up. They should not leave if interns are still actively managing post-call patients, however they also do not need to stay if the only work left is note-writing. 
    3. On weekends or holidays, the ED Dayfloat should be present until the Post-Call Interns have wrapped up their patient care responsibilities (may not leave before 12:00pm) and the MICU fellow has been updated.
  3. Days Off:
    1. Days off will be determined in advance and located in the Internal Medicine’s Amion schedule
      1. When only one ED Dayfloat is scheduled, days off are Monday and Thursday.  
      2. When two ED Dayfloats are scheduled, each day-float gets two days off per week (weekend or weekday) but at least one day-float must be present every day of the week. Days off will be scheduled by the Internal Medicine Chief Residents at least one month in advance.

ED Dayfloat Responsibilities

  1. Supervise Interns: 
    1. Assist with all patient care (orders, consults, family meetings, procedures/road trips)
    2. Write transfer summaries if applicable (but not discharge summaries)
    3. Discharge patients if needed (discharge summaries to be completed by senior resident on service team)
    4. Update sign outs
    5. Of note, interns will also need time to write their notes; since the supervising ED Dayfloat generally does not help with this task, the Dayfloat should strongly consider covering the intern’s pager to allow her/him to complete notes without pager distraction. 
  2. Procedures/Road Trips: Assist with all MICU procedures and road trips with special focus on the post-call and call teams.
  3. Call Team Assistance: Before leaving for the day, the ED Dayfloat or APN should check in with the call team and the post-call team to see if any assistance is needed. 

 

APN

Schedule:

Weekdays: 7:00am – 7:00pm (with some exceptions)

Weekends: 7:00am – 1:00pm (with some exceptions)

 

Overview:

The APNs will be available to provide assistance when needed, prioritizing the Post-Call Team but also assisting any other teams as able. They are available to assist with all aspects of patient care, including orders, consults, family meetings, procedures/road trips, etc. On weekdays from 4:00pm-7:00pm, APNs will also assume Triage responsibilities as able.

 

Updated 6/26/2023