Firm Operations/Policies
Attending of Record
Please be sure you’re named as the attending of record when you accept patients from the nightfloat residents each morning. This is important to ensure that the correct doctor is contacted with lab results, by consultants, etc. A nightfloat admission sheet is faxed to admissions at the end of each of their evening shifts. This has substantially decreased confusion and patient errors that have resulted from inaccurate assignments. For each nightfloat admission or transferred patient from another service, please ask your residents to write this order, "Please admit this patient to Firm___________, Dr. (Resident name here). Bedside Rounding
With team building and improved patient care in mind, the 7A Medical Unit requests that each Medicine Firm Attending round at the bedside for their 7A patients. This process has been in place since January 15, 2007. The faculty who staff the general medicine firms have set as a minimum competency that all staff physicians will round at the bedside on at least one patient daily. Each Firm should provide the 7A NST or Charge Nurse by 8 a.m. with: - Their list of patients on 7A.
- A general idea of the anticipated time bedside rounds are planned to begin that day.
- Where and with which patient they will start their rounds.
Please note that the most effective strategy to ensure the bedside nurse is present on bedside rounds is by following the three guidelines above. The 7A HUC/Charge Nurse will: - Inform the Firm which nurse is assigned to these patients and will help identify that person so the Firm can update the nurse about timing.
- Request that the assigned nurses made a concerted effort to participate in bedside rounds with the Firm team.
*Bedside rounding should never occur on every patient, every day. Recommended to get work done while rounding (i.e., have someone entering orders in at the bedside while rounding). Call
When your team is on-call, the ER will contact you with admissions until 9 p.m. Your residents are not responsible for admitting patients between 7 p.m. – 9 p.m.; however, they are responsible for checking out the patients who come in during this time period to the nightfloat resident. Tips for taking call: - When your team is taking a lot of admissions, you might consider trying to admit some of those patients directly to yourself as “non-teaching” patients. This will decrease the likelihood that the nightfloat resident will fill. Once the nightfloat fills, the rest of the overnight admissions are the long-call attending physician’s responsibility! (This means you!)
- The Medicine Consult Service will work hard to help you when your team is overloaded. It is your responsibility to directly notify this physician of a new admission. Please do not ask the ER or Fairview Direct to do this for you. You can reach the Medicine Consult Service at job code 0330.
- You can also contact Fairview Direct at 612-672-7575 to request that we implement the "Riverside Transfer Policy" if you are dealing with a high census or an elevated level of complexity. See that policy description below.
When you are admitting a patient to yourself but not to your team: If you decide to personally admit a patient, it will not “count” as one of your team’s admissions. To avoid confusion, please admit to “Med Faculty Service/Dr. Your Last Name Goes Here.” This will inform all staff in the hospital that this particular patient is not a teaching patient, but rather is being followed by you only. Also, the hospital nursing, etc. will contact the moonlighter with questions about these patients overnight. You will need to check out your own patients to the moonlighter each evening by leaving your list for them alongside the Medicine Consult Service's list on the white board on 7A. You can reach the moonlighter by paging him/her at at 612-899-6633. Fairview Direct: The patient placement service is terrific here at Fairview. They’ll contact you with any patient transfers. They will also stay on the phone with you as you discuss the patient with the referring physician. They will next locate a room for you and enable that doctor to provide nurse checkout to the correct floor. Their number (should you hear from an ER or doctor directly) is 612-672-7575. It is really helpful to contact them when this happens because they can arrange for a bed. Census Caps - Residents may follow no greater than 16 patients per ward team. This will change to 14 patients on 7/1/09.
- Long-call firms can accept up to 6 new patients and 2 holdovers or MICU transfers daily.
- Short-call firms can accept up to 4 new patients. Please keep accepting patients until 4 new patients are physically in the hospital (can be in the ER, patient does not need to be on the floor).
- These caps are not “hard and fast”. Always do what is best for the patients and for the teams/residents. This is an opportunity to teach the residents and students about real teamwork.
Chart Audit/Chart Review ACGME requires that we review with our resident and intern at least one chart note (an admit note, or a daily progress note) with them. - We are required to complete evaluations of residents on Evalue! https://www.e-value.net.
- For sign-on and password information, contact the Medicine Program Coordinator at 612-626-5031.
Communication with Primary Care Providers - The teaching faculty have set a minimum expectation that we will communicate by phone or e-mail with every primary care physician. We believe this will ensure that the physicians responsible for our patients in the outpatient arena are well informed and thus, our patients will receive the best care.
- This task may be delegated to residents or students, but it is expected that the Firm staff will directly observe some of these communication processes in order to provider learners with constructive feedback on the process.
Days Off - Faculty – see information on weekends below.
- Residents and students: All residents and students must take one day off per week. This is an ACGME mandate!
Duty Hours - The residents are allowed to work no more than 80 hours per work week.
- They may work no greater than 30 consecutive hours.
- Residents must have a minimum of 10 hours off between shifts.
- Long-call teams need to be out of the hospital by 9:00 p.m.
Firm Director, Lead Hospitalist Contact Information - Please contact Jo Ann Wood with questions, suggestions, comments or concerns about the service.
612-625-9989 (Office)
612-899-8301 (Pager)
joannw@umn.edu (E-mail)
612-432-2133 (Cell) Holdover Distribution Policy
This is not hard and fast. The policy was developed to try to keep an even census among the four firms. - First two holdovers go to the post-call team, up to team census of 12 (14) patients.
- The next two holdovers go to the short-call team, up to census of 10 (12) patients.
- The next two should go to the long-call team, up to census of 10 (12).
- The next two should go to the pre-call team, up to census of 8 (10).
- Additional holdovers should go to long-call team, but should count as admissions if team census is over 10.
- If the post-call team did extensive work-up on a “holdover” completed by the nightfloat, it should stay with the post-call team.
- If all teams have high census, then increase the caps above to those in parentheses and notify the Chief Residents of this immediately.
- All patients, whether holdovers or new admissions, count toward firm census admissions.
Holiday Coverage - If there is a holiday, do all four firm doctors have to work it if it is a weekday? Yes.
- This happens consistently for holidays that occur on weekdays such as Memorial Day, Labor Day and Martin Luther King Day. However, it is rare for this to happen with one of the “Big Three” Holidays (Thanksgiving, Christmas, or New Year’s) on a Monday that is also a switch day. (Switch day = Change of service day for residents, students AND faculty).
Moonlighter - There is a moonlighter who is responsible for cross cover of all non-teaching patients. This resident can also admit for any subspecialty service at night, so long as the patient is considered NON-TEACHING in the morning (i.e., followed by the attending or a nurse practitioner).
- At this point in time, because this individual is so incredibly busy, we are not able to request the moonlighter to admit a patient for us if the nightfloat fills before 7 a.m. the next day.
- Please call the moonlighter to check out your “staff only” patients at 612-899-6633.
Nightfloat - There is a senior resident and an intern responsible for cross cover on all Firm patients, and for up to 6 new general medicine admissions.
- The nightfloat resident works from 9 p.m. to 8:30 a.m.
- After 9 p.m., the ER physician will no longer page you to accept new admits but will page the nightfloat directly.
- Between 7 p.m. and 9 a.m., the on-call team should begin to work up admissions, but then transfer this ongoing work to the nightfloat at 9 p.m. for completion.
- Patients whose workups that were initiated by the on-call team are likely to go to that team on the following morning. (See Holdover Distribution Policy).
- Firm faculty are required to round with the nightfloat resident at 7:30 a.m. in the physician work room on 7A when your firm is post-call. This is an ABIM RRC requirement! We must teach the nightfloat and provide this resident with constructive feedback on their work. This is a “Teaching” rather than a “Service” Rotation. If there were no new admissions, teaching is still required. Consider reviewing one of the didactic sessions on our website or asking the residents about any issues/difficulties they experienced overnight when this happens.
- If the nightfloat team exceeds the cap of 6 patients, the ER and answering service will begin to call you again with admissions. You can request that the ER write “holding orders” for these patients. This may prevent the need for you to come to the hospital to immediately admit these patients. It never hurts to make friends with your ER colleagues!
- There is a new policy in place to prevent staff and residents from becoming overwhelmed when rotating on the firms. Please see the “Riverside Transfer Policy”.
- The Chief Residents supervise the distribution of the holdovers.
- On Friday nights, the upper level resident takes call for the teaching team and is the nightfloat resident. The upper level resident can only admit 10 patients over a 24-hour period. Friday night is the most likely night the residents will cap and the attending may be called in. You can ask the ER to write holding orders for any admitted patients and sign-out the patient to the short-call physician in the morning.
Overnight Coverage of Patients not Managed by Team - If I choose to admit a patient myself, without adding them to my team’s list, to whom do I check these patients out overnight?
- Please admit to “Med Faculty Service/Dr. Your Name Goes Here”.
- You should call the Moonlighter to check out these patients each night; 612-899-6633.
Resident Clinics All residents have one half-day of clinic weekly. (See also, http://www.med.umn.edu/gim/faculty/residentclinic.html) Riverside Transfer Policy In an effort to reduce stress to residents and staff, and to enhance the ability to maximize patient safety, the Medicine Firms have implemented a new system. Any resident, at any time, can request from their attending physician that this policy be enacted. However, this system may be implemented only by the on-call attending physician. Exclusion Criteria: - Patients at high risk or decompensation
- Patients with a high likelihood of gastrointestinal bleeding
- Patients who require hemodialysis or for whom this is an impending need
- Organ transplant recipients
- UMP subspecialty patients (cystic fibrosis, etc.) unless the transfer is approved by that subspecialty service
- Transfers from out-state Minnesota hospitals who are in need of subspecialty or higher level of care
Process: - If an admission does not meet any of the above exclusion criteria and the on-call Firm is excessively stressed due to acuity or volume, the Firm Attending who is on-call must:
- Contact the Patient Placement Manager at 612-672-7575.
- Fairview Direct will begin screening all new admissions for diversion to the Riverside Campus.
Short-call - Your team is on short-call the day after your post-call day. (Recovery day).
- On this day, you can accept up to four patients. You will be on short call until you accept four patients or until 2:00 p.m.
- IMPORTANT: Once our short call team is full, please call: 612-273-2100 to inform Patient Placement Services! They will begin paging the long call staff physician from this point forward.
- You should continue to take short call until there are four patients in-house to see - NOT until you actually accept four patients some of whom are in-transit.
Sister Services These two services help each other out on long-call and short-call days. On the weekends, they cover each other. - Firms A and C
- Firms B and D
Structure - The general medicine services at University Hospital, Fairview, are the setting for the major educational activities for residents and medical students.
- Each team is made up of an upper-level resident, one intern and two medical students.
- Residents may follow no greater than 16 patients per ward team.
- Long-call firms can accept 7 new patients daily.
- Short-call firms can accept up to 4 new patients.
- These caps are not “hard and fast.” Always do what is best for the patients and for the teams/residents. It’s an opportunity to teach the residents and students about real teamwork.
Switch Week/Weekend - You can switch weeks/weekends with someone if you are able to negotiate the switch with a firm attending physician. You must inform Mary Tramel about this switch as soon as you are aware of the change so that she can inform the operators at Fairview in a timely manner.
Weekends - You are only responsible for seeing patients during one of the two weekends that you are on hospital service. On that weekend, you will also be assigned to see the patients of your colleague on the “sister” firm service.
- Our group re-evaluated this in March 2008 and the majority of doctors wanted to continue with this weekend coverage system.
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