West Penn Hspital /Allegheny General Hspital Medical Educatin Cnsrtium DEPARTMENT OF MEDICINE Internal Medicine Residency Prgram Handbk 2011-2012 1
Table f Cntents BLOCK SCHEDULE ROTATIONS IM,EM/IM, Transitinal, and Ostepathic Schedule 4 General Medicine Teaching Service Cre Schedule/ Night Clred Teaching 7 Hspitalist Cre Schedule/ Night Hspitalist Teaching - Descriptin, Organizatin, 11 Respnsibilities MICU Cre Schedule - Descriptin, Organizatin, Respnsibilities 14 CCU Cre Schedule - Descriptin, Organizatin, Respnsibilities 21 Medicine Cnsults - Descriptin, Organizatin, Respnsibilities 24 Bne Marrw Transplant Service- Descriptin, Organizatin, Respnsibilities 24 Onclgy - Descriptin, Organizatin, Respnsibilities 26 Subspecialty Electives - Descriptin, Organizatin, Respnsibilities 26 Neurlgy Elective 27 Emergency Rm Rtatin 27 Geriatrics 28 Away Elective 38 Cntinuity Clinic Guidelines 28 Medical Ambulatry Elective 32 GENERAL RESPONSIBILTIES Prfessinalism 34 Daily Respnsibilities 34 Patient Care 35 Dress Cde 35 Sign Out 35 Wrking Hurs 36 Paging Plicy 36 Email Plicy 37 Change in Call Schedule 37 Lectures and Cnference 37 Order Writing Plicy 37 Prcedure Plicy 38 Arrest Teams 39 Medical Recrds 40 Death Certificates 40 Crner's Cases 41 Sabbath Prgram 41 Resident Supervisin 41 ADMISSION & DISCHARGE POLICIES Requirements fr admissin t the teaching services 47 2
Limits n admissin t the Teaching Services 42 Requirements fr Discharge frm the Teaching Services 53 ADVANCEMENT USMLE Step 3 45 Clinical Cmpetency Exams 45 Prcedure Credentials 45 Criteria fr Advancement 45 EVALUATIONS Resident Evaluatin 46 Faculty Evaluatin 48 DIDACTICS 48 VACATION Sick Days 50 Maternity Leave 50 Interviews 51 Persnal Time 51 Special Rules 51 Vacatin 52 Jepardy 52 RESIDENT MISCONDUCT Due Prcess 53 Disciplinary Actin 54 Appeal Prcess 62 RESIDENT FATIGUE 62 MOONLIGHTING POLICY 64 HIPPAA POLICY 64 MISCELLANEOUS Assignment f On-Call Rms 65 Attending Runds Cnference Rms 65 Library 65 AGH Human Resurces Emplyee Assistance Prgram 65 3
Blck Scheduling Requirements Internal Medicine and Emergency Medicine/Internal Medicine Schedules The fllwing are the blck schedule requirement fr each PGY level fr the Internal Medicine and Emergency Medicine/Internal Medicine residency prgrams. One blck equals 1 mnth duratin. Internal Medicine R1 Categrical Intern Requirements General Medicine (hspitalist and clred teaching services) Medical ICU Emergency Medicine Ambulatry Electives Night Teaching R1 Categrical Ostepathic Intern Requirements General Medicine Medical ICU Night Teaching Emergency Medicine Family Medicine Elective Anesthesia Radilgy R1 Preliminary Intern Requirements General Medicine Medical ICU Emergency Medicine Ambulatry Electives R2 Categrical Resident Requirements General Medicine Medical ICU CCU Ambulatry Neurlgy Onclgy/ Bne Marrw Transplant Electives Night Teaching R3 Categrical Resident Requirements General Medicine Medical ICU 4 5 mnths 2 mnths 1 mnth 1 mnth 2 mnths 1 mnth 5 mnths 2 mnths 1 mnth 1 mnth 1 mnth 1 mnth 2 weeks 2 weeks 6 mnths 2 mnths 1 mnth 1 mnth 2 mnths 3 mnths 1 mnth 1 mnths 2 mnths 2 weeks 1 mnth 2 ½ mnths 1 mnth 2 mnths 1 mnth
Ambulatry / Ambulatry Selective Geriatrics Patient Safety Night Teaching r Medical Officer f the Day Onclgy Electives Medical Cnsults 2 mnths 1 mnth 2 weeks 2 weeks 1 mnth 3 mnths 1 mnth Internal Medicine/Emergency Medicine EM/IM R1 Categrical Intern Requirements General Medicine Flr Mnths Medical ICU Ambulatry EM/IM R2 Categrical Resident Requirements Medical ICU (cnsidered R1 level) CCU Ambulatry Sprts Medicine Neurlgy Elective EM/IM R3 Categrical Resident Requirements General Medicine Flr Mnths Medical ICU Medicine Cnsults Ambulatry Elective EM/IM R4 Categrical Resident Requirements Geriatrics Emergency Medicine Ambulatry Mini Fellwship EM/IM R5 Categrical Resident Requirements General Medicine Flr Mnths Medical ICU Ambulatry Elective 4 mnths 1 mnth 1 mnth 1 mnth 2 mnths 1 mnth 1 mnth ½ mnth ½ mnth 2 mnths 1 mnth 1 mnth 1 mnth 1 mnth 1 mnth 1 mnth 1 mnth 3 mnths 3 mnths 1 mnth 1 mnth 1 mnth Nte: The medicine elective mnths fr EM/IM residents must include at least 4 subspecialty medicine rtatins. General medicine rtatins fr EM/IM residents include clr teaching, hspitalist, r nclgy service. 5
OSTEOPATHIC TRADITIONAL ROTATING INTERNSHIP TRACKED INTO MEDICINE ROTATIONS The Ostepathic Rtating Internship addresses all AOA requirements and accmmdates individuals' learning needs and interests. Interns must wrk with the Directr f Ostepathic Medical Educatin t develp their rtatin schedule in a way that best addresses their learning needs and interests. Rtatin Blcks required Vacatin Allwed Ostepathic Categrical Internship Family Practice 1 mnth N Anesthesia/Radilgy 2 weeks/2weeks Yes, nly 1 week ER 1 mnth N MICU 2 mnth N IM day wards 5 mnths N IM night flat 1 mnth N Elective 1 mnth Yes, 2 weeks Ostepathic Traditinal Rtating Internship: PM&R Family Practice 1 mnth N Anesthesia/Radilgy 2 weeks/2 weeks N ER 1 mnth N MICU 2 mnths N IM day wards 2 mnths N IM night flat 1 mnth N Ambulatry 1 mnth N Elective 3 mnths Yes Electives must be @ least 4 weeks in specialty r subspecialty; i.e. n 2 week electives. These may include: Cardi, Pulm, GI, Rheum, ID, Renal, End, Neur, Orth, PM&R Ostepathic Traditinal Rtating Internship: Diagnstic Radilgy Family Practice 1 mnth N Anesthesia/Radilgy 2 weeks/2 weeks N ER 1 mnth N MICU 2 mnths N IM day wards 2 mnths N IM night flat 1 mnth N Ambulatry 1 mnth N Elective 3 mnths Yes Electives fr Diagnstic Radilgy may include: Cardi, Pulm, GI, Rheum, Neur, Orthpedics, Neursurgery, Anatmic Pathlgy, and/r Radilgy *N mre than tw mnths Radilgy electives 6
General Medicine Teaching Services Clr Teaching Services at AGH Mnday Tuesday Wednesday Thursday Friday 7:00AM Sign-in Resident Lunge Sign-in Resident Lunge Sign-in Resident Lunge Sign-in Resident Lunge Sign-in Resident Lunge 7:00AM Mrning Reprt Mrning Reprt Mrning Reprt Mrning Reprt Mrning Reprt 7:00AM- 8:30AM 8:30AM- 10:00AM Pre Rund Pre Rund Pre Rund Pre Rund Pre Rund Wrk Runds Wrk Runds Wrk Runds Wrk Runds Wrk Runds 10:15AM- 11:30AM Teaching Runds Teaching Runds Teaching Runds Teaching Runds Teaching Runds 11:30AM- 12Nn Lunch Lunch Lunch Lunch Lunch 12 Nn- 1:00PM Lecture Lecture Medical Grand Runds Bard Review Lecture/ M&M 1:00PM- 4:00PM Patient Care Patient Care Patient Care Patient Care Patient Care 4:00PM Earliest time t Sign ut Earliest time t sign-ut Earliest time t sign ut Earliest time t sign ut Earliest time t sign ut 7
General Medicine Teaching Service Guidelines Descriptin Patients lcated n the regular nursing flrs are divided amng five services designated by clrs blue, red, yellw, green, and purple. Teams cnsist f ne attending physician, ne R2 r R3 serving in a supervising capacity, and tw t three R1 residents wh assume primary respnsibility fr patient care. Additinally, third and furth year medical students are assigned t each team. Admitting Schedule Frm Mnday thrugh Friday, there will be three admissin cycles per day. One team (designated vernight) will be respnsible t taking admissins dne by the night flat team frm the night prir. The night flat team will rund with this team at 8:30am and leave by 10:00am. One team will be assigned t an admissin perid frm 7am-4pm. One team will be assigned t an admissin perid frm 4pm-10pm. Night Flat will arrive at 9:30pm t get sign-ut and admit until 7am, fllwed by runding with the team assigned t take the vernight admissins, fr a ttal shift f apprx. 12.5 hurs Night Flat will be assigned shifts frm Sunday night thrugh Thursday night. On Friday, the R3 assigned t the Patient Safety rtatin fr 2 weeks will cver fr the Senir assigned t admitting call n Saturday. This resident will cver the team fr the day and stay fr the vernight admitting shift with the senir assigned t the Friday 4p-7a shift. The Patient Safety senir will leave at 7am. The team assigned t Friday 4p-10p will cntinue admitting patients until 7am n Saturday. The interns will leave n Friday at 10pm and the senir will stay vernight with the Patient Safety senir and rund with ne intern returning n Saturday. This senir will fllw the rules f a 24+4 shift. After this senir signs ut, the intern will be supervised by the Saturday admitting senir. The team assigned t admit Saturday will admit frm 7a-7a. The senir will fllw a 24+4 shift. One intern will be assigned t wrk 7a-10p n Saturday and then have Sunday ff. The ther intern will be ff frm Friday int Saturday, and then wrk frm 8pm Saturday t 12pm n Sunday and be able t rund. The team assigned t admit Sunday will admit frm 7a-10p. One intern will be assigned t a 7a-10p shift and will have had Saturday ff. The ther intern will have runded n Saturday and will wrk n Sunday frm 2pm-10pm, thus having a 24h perid ff frm Saturday int Sunday. Admitting shifts will cntinuusly rtate thrugh all 5 teaching services, and fr the average mnth, each team shuld be assigned t n mre than 1 Friday and 1 Saturday admitting shift. Days ff fr bth interns and senirs wuld be based n the call schedule, with the nly wrk week day ff being the Saturday call senir ff n Friday. This wuld help t eliminate cnflicts with clinic and ptentially help with clinic scheduling. 8
Night Teaching and the team accepting vernight admissins are expected t attend mrning reprt. The team admitting frm 7a-4p wuld be excused frm perfrming wrk runds, which wuld ccur nce per week. Pre Runds Interns shuld see and examine their patients. Determine any vernight events Cllect relevant data (vitals, labs, ect.) Develp a prblem list and plan Wrk Runds (Daily, except when the team accepts vernight admissins) T be led by the senir resident. The resident and the interns will gather at patient bedside befre attending runds t discuss their patients. This will allw senir residents t see all f the patients and t examine sick, unstable, r patients with a change in status directly with the intern. They will als review pertinent physical findings, labs, and develp and plan fr the patients. Senir residents shuld als be actively teaching clinical pearls and practicing evidence-based medicine during wrk runds. PGY-1 s will learn hw t succinctly present their patients t the senir resident. Teaching Attending Runds Led by the teaching attending t discuss patient management issues and prvide dedicated teaching. At least 3 times per week, bedside runds are cnducted t prmte physical diagnsis and cmmunicatin skills. Attendings are expected t demnstrate and t bserve diagnstic skills at the bedside. During dedicated teaching time, r during patient management discussins, reading assignments may be discussed as they relate t the specific patient care issues. Residents and medical students (n clr teaching services) will be expected t cntribute t literature reviews and didactics. Gals f teaching runds include develpment f histry-taking and physical examinatin skills, casepresentatin skills, and analytic skills. Medical knwledge is als imprved by detailed discussins f the diseases encuntered in the patients n the inpatient services. Respnsibilities Supervising Resident (R2 and R3) Respnsibilities: 1. Supervise R1 daily wrk runds. 2. Supervise patient admissins and nging care fr 2 R1 s and up t 20 patients in ttal. 3. Ensure that tasks are cmpleted, studies fllwed-up n, and cnsultants called when apprpriate. 4. Serve as primary teacher and resurce fr interns. 5. Organize runds such that patient care and teaching are ptimized and efficient. 6. Actively participate in daily teaching and patient management runds. 7. Lead case management runds recgnizing patient s shrt term and lng term care needs. 8. Keep attending updated f any change in patient status during the day and night and frmulate patient care plans. 9. Review daily prgress ntes written by the intern and prvide feedback. 10. Be intimately familiar with patients medical diagnses and assist with R1 assessment and daily plan. 11. Prepare and present a teaching lecture at least nce per mnth n a Cre Tpic in inpatient medicine t runding teams. 12. On clr teaching service, prepare and present evidence-based tpic discussin at least weekly. 13. Assign shrt tpics t medical students and sub-interns t present during teaching runds. 14. Set example fr team with apprpriate wrk ethic, prfessinalism, and dedicatin. 15. Set tne fr the team with enthusiastic, evidence-based, and prfessinal apprach t patient care and intern educatin. 16. Attend radilgy runds. 9
17. Attend nn lectures presented by the Department f Medicine. 18. Attend Grand Runds weekly presented by the Department f Medicine. 19. Cmplete frmal written evaluatin fr R1 s, attending physician and medical students within 24 hurs f end f rtatin. 20. Ensure that prper sign ut f patients has been perfrmed by themselves and their interns befre leaving the hspital 21. Review and c-sign all MSIII & MSIV prgress ntes. 22. Carry the 8181 pager and delegate patients t the crrect service when n-call. R1 Respnsibilities: 1. Perfrm an independent and cmprehensive histry and thrugh physical examinatin n each patient at the time f admissin. 2. Perfrm daily prblem-fcused medical histry and physical. 3. Develp a management plan sequentially, first under directin f a senir medical resident and subsequently r cncurrently by the hspitalist r clred teaching attending. 4. Rund daily n admitted patients and frmulate assessment and plan f care. 5. Dcument findings and prvide an assessment f the patient s prblems in daily ntes. 6. A prblem list shuld be frmulated that includes ALL dcumented medical prblems (active and inactive). 7. Daily ntes MUST include differential diagnsis, wrk-up, and plans fr each active prblem. 8. Assessments are dcumented in the chart after being discussed with the supervising senir resident and/r attending physician. 9. Write all admissin rders based n plans discussed with the resident and attending physician. 10. In subsequent fllw-up f their patients, PGY1s are expected t be knwledgeable abut the details f their patients prblems and the results f diagnstic studies and therapeutic interventins. They shuld be able t present this infrmatin rally in a cncise manner during wrk runds and in discussins with attendings and cnsultants. 11. Keep electrnic sign-ut up-t-date and prvide apprpriate verbal and typed sign-ut t clleagues when transferring care, especially vernight. 12. Perfrm prcedures n their patients (with apprpriate supervisin as necessary). 13. Prvide daily prgress ntes n weekdays and crss cver ntes n the weekends. 14. Attend daily management runds with attending hspitalist and teaching runds with clred teaching attending. 15. Participate actively in daily teaching and patient management runds. 16. Keep senir resident abreast f any changes in patient status and review new management plans prir t discussin with attending. 17. Establish discharge plans early in the hspital curse. 18. Review discharge planning with case managers early and ften t identify patients shrt term and lng care needs. 19. Dictate all discharge summaries within 24 hurs. 20. Create cncise and cmprehensive transfer f service ntes when leaving a service r when the patient is transferred t a different service. 21. Attend case management runds Mnday-Friday. 22. Attend radilgy runds. 23. Attend nn lectures presented by the Department f Medicine. 24. Attend Grand Runds weekly presented by the Department f Medicine. Night Clred Teaching Night Clr Teaching Team Retains respnsibility fr patients admitted vernight until 8:30 a.m. but des nt write the daily prgress nte fr them. 10
Frm 8:30 a.m. t 10 a.m. there will be cmbined wrk/attending runds fr all admissins dne vernight by the night flat team with the night flat team and the accepting clr teaching team and attending. The night flat team is dismissed n later than 10 a.m. Night Teaching (R1) 2 Interns will be scheduled fr night flat in ne mnth blcks. One Intern will be respnsible fr up t 5 admissins per night (supervised by the senir resident r hspitalist attending) and the ther intern will be respnsible fr crss-cverage f the clr teaching teams patients. Night Teaching (R2-3) Resident will be scheduled fr night flat in 15 day blcks. Hurs are frm 10:00PM-10:00AM. Resident will supervise the interns at night fr five admissins per intern. They will als perfrm admissins fr the cardilgy service, nclgy service, hspitalist service, new cnsults at night, and unrefferred teaching patients ver the cap. Ttal patients admitted fr the Night Flat R2/R3 is 10 per night. Supervisin and teaching at night is prvided by the hspitalist attending n nights and the unreferred teaching attending wh will be assuming care f the patients n the fllwing day. Resident will prvide crss cverage frm 10:00PM-7:00AM fr nclgy, hspitalist, cardilgy and the cnsult services during the shift. All residents will meet fr sign-ut in the resident lunge befre mrning reprt except MICU and CCU residents. Night flat senirs are respnsible fr seeing and discussing with Attendings any new huse medicine cnsults during the night Night flat senir shuld call the Onclgy fellw n call with all new nclgy admissins t the nclgy hspital grup r call the private nclgy attending fr admissins t their service. If the night flat resident has capped at 10, the hspitalist attending admits any ver the cap patients (referred r unrefferrred). All senirs n night Teaching are required t attend mrning reprt Hspitalist Teaching Service and Cre Schedule Hspitalist Cre Resident Schedule Mnday Tuesday Wednesday Thursday Friday 7:00AM- 8:00AM Mrning Reprt/Pst Call Cases Mrning Reprt/ MICU /CCU Pst call cases Mrning Reprt/ Pst call cases Mrning Reprt/Pst Call Cases Mrning Reprt (prepared case discussin) 9:00AM- 9:15AM Senir Resident attends Case Management Runds Senir Resident attends Case Management Runds Senir Resident attends Case Management Runds Senir Resident attends Case Management Runds Senir Resident attends Case Management Runds 11
9:15AM- 10:00AM Wrk Runds Wrk Runds Wrk Runds Wrk Runds Wrk Runds 10:00AM- 11:30AM Attending Teaching Runds Attending Teaching Runds Attending Teaching Runds Attending Teaching Runds Attending Teaching Runds 11:00AM- 11:30AM Patient Care Patient Care Patient Care Patient Care Patient Care 11:30AM- NOON Lunch Lunch Lunch Lunch Lunch NOON-1:00PM Lecture Lecture Medical Grand Runds Bard Review Lecture 1:00PM-8:00PM Patient Care Patient Care Patient Care Patient Care Patient Care Tw Hspitalist teams will be assigned t accept new admissins fr each day. Senir residents n the Hspitalist teams will alternate with either 7AM-6PM r 7AM-8PM shifts Mnday thrugh Thursday n their admitting days, accrding t the Amin schedule. Fr Mnday thrugh Thursday, interns frm each admitting team will alternate Shrt Call and Lng Call assignments accrding t the Amin schedule. Shrt Call interns accept new admissins frm 7AM-2PM and Lng Call interns accept new admissins frm 2PM-8PM. Hspitalist Night Flat will cver the Hspitalist teams and admit Hspitalist patients frm Sunday night thrugh Friday mrning frm 8pm-7am each night. Admissins cmpleted by the Night Flat team will be distributed t the teams admitting frm the day prir. On Friday, ne admitting Hspitalist team, whse senir resident is assigned t 7AM-6PM shift, will fllw the same rules fr Shrt Call and Lng Call interns Mnday-Thursday. On Friday, ne admitting Hspitalist team will be assigned t admit until 7am Saturday. This senir resident will perfrm admissins frm 7AM Friday until 7AM Saturday and remain fr up t 4 additinal hurs t rund fr their team. One intern will wrk frm 7AM until 9PM n Friday. The ther intern will wrk 7AM-12PM Friday, leave the hspital and return frm 10PM Friday until 12PM Saturday. On Saturday, tw teams are again assigned t take new admissins. One team, whse senir resident is scheduled t admit frm 7AM-7PM, will have ne intern present frm 7AM-7PM and ne intern present frm 12PM-7PM. The ther admitting team will have ne intern present and accepting new admissins frm 7AM-9PM. A cvering senir will be present n Saturday mrning fr runding purpses nly. This team s senir resident will be admit frm 7PM until 7AM n Sunday and remain fr up t 4 hurs t rund fr their team. This team s ther intern will arrive at 9PM and take admissins until 7AM Sunday and stay until 12PM fr runding purpses. On Sunday, tw teams are again available t accept new admissins. One team will have a senir resident present frm 7AM-8PM, ne intern present frm 7AM-7PM, and anther intern present frm 2PM-8PM. The ther team will have ne intern present frm 7AM and available t accept admissins. These admissins will be precepted by the Hspitalist attending, as a cvering senir will be assigned t this team in the mrning and nt respnsible fr new admissins. Admissin caps fr any perid designated as Shrt Call r Lng Call are 4 admits per intern. All ther admitting perids frm Friday thrugh Sunday will be capped at 5 admits per intern. All shift perids and days ff are assigned as per the Amin schedule. Night flat residents wrk frm 8:00M-7:00AM. They are respnsible fr the Hspitalist admissins, Onclgy admissins and cverage, and cnsult service cverage as well as cmpleting any STAT and Pre-p cnsults during their shift. Senir resident caps are 10 new patient encunters. Hspitalist Medicine Teaching Service Guidelines 12
Descriptin Patients f Allegheny General Hspital Internal Medical Practice (AGHIM) will be preferentially admitted t this service that will be supervised by full-time in-huse Attending Physicians. Any AGH physician designated t admit t the Hspitalist service and clinic patients will be admitted t this service as well. In additin, any unreferred patient admitted after the Clr Teaching service has capped will be admitted t the Hspitalist service. Organizatin There will be fur teams, designated as Team 1, Team 2, Team 4, and Team 5 (Team 3 is the Hspitalist Cnsult service). Each team cnsists f ne attending and ne senir resident and tw interns. Admitting schedule fr interns: 1. Intern admitting schedules are described abve under the Hspitalist Cre Resident Schedule descriptin. 2. All Intern shifts and admitting perids will assigned accrding t the Amin schedule. 3. Intern caps fllw rules utlined in the ACGME Internal Medicine Prgram Requirements. N intern can accept mre than 5 new patients plus 2 medical service transfers in 24 hurs r 8 new patients in a 48 hur perid Teaching Attending Runds 1. Teaching runds are primarily intended fr training and educatin and general versight f patient management issues as they pertain t insuring the quality f patient care and educatin. Patient Management Runds 1. Management runds will be inclusive f many levels f care prviders, including nurses, case managers, pharmacists and physicians, reflective f integrated care management apprpriate t this ppulatin. Respnsibilities R1 Initial cmplete histry and physical examinatins. Cmplete differential diagnsis. Diagnstic and therapeutic care plan. Cmmunicatin daily with the senir resident and Attending f Recrd. Cmmunicatin daily with the patients and their families. Enter all rders. Prcedures (under apprpriate supervisin). Daily prgress ntes. Transfer ntes n leaving r beginning service and when the patient is transferred t a different service. Discharge summary dictatin within 24 hurs f patients discharge. Prvide adequate sign ut t the cvering intern befre leaving the hspital. While n call, crss cver the ther hspitalist patients. Attend all cnferences except mrning reprt. 13
Respnsibilities f the R2-3 Admissin nte n all patients admitted t the service. 1. Supervise wrk runds. 2. Evaluate all patients assigned t the service. 3. Cmplete prgress ntes when the patient s cnditin changes r when there is a majr change in management. 4. Supervise acting interns assigned t the service. 5. Supervise prcedures perfrmed by R1 s. 6. Participate with the hspitalists attending in discussin f cases fr teaching attending runds. 7. Cmplete frmal written evaluatin fr R1 s and attending within 24 hurs f end f rtatin. 8. Ensuring prper sign ut f by themselves and their interns t the cvering team befre leaving the hspital. 9. Attend Mrning Reprt and all cnferences. 10. Senir hspitalist resident assigned t 7A-8P shift will be respnsible fr stat cnsult cverage frm 5:00 PM-8:00 PM and signing ff cnsults t the night flat senir. 11. Night-flat hspitalist senirs are respnsible fr crss-cverage and admissins t the hspitalist teams, crss cverage and admissins t nclgy, STAT and Pre-p cnsults vernight and crss cverage fr the Cnsult services. Cnsults cunt as an admissin, and all stat cnsults must be seen and discussed with the cnsult attending and fllwed up ver night and signed ut t the daytime cnsult senir. 12. All stat cnsults ver the cap shuld be directed t the hspitalist attending. Hspitalist Night Teaching The hspitalist night teaching team cnsists f ne senir resident and tw first year residents. Senir residents spend 15 days n night teaching and interns spend ne mnth n night teaching. The night teaching team runs frm Sunday night thrugh Thursday night. The senir resident can admit patients t the hspitalist and nclgy services. He/she shuld als perfrm STAT cnsults. The cap fr all patient encunters (admissins fr hspitalist, nclgy, and cnsults) is 10. There are tw interns n night teaching. One intern admits patients and the ther intern crss- cvers admitted patients and can admit MICU transfers. Intern admissins are supervised by a senir resident r attending. The night teaching shift is frm 8PM- 8AM. Senir residents shuld attend mrning reprt. MICU Cre Schedule Table 3 MICU Intern Schedule at AGH Mnday Tuesday Wednesday Thursday Friday 6:00AM MICU Sign In MICU Sign In MICU Sign In MICU Sign In MICU Sign In 7:00AM- 9:00AM Wrk Runds/ MICU lecture Wrk Runds/ MICU lecture Wrk Runds/ MICU lecture Wrk Runds/MICU Wrk Runds/ MICU Lecture 14
Lecture 9:00AM- 11:00AM 11:00AM- 11:30AM 11:30AM- 12:00Nn Attending Runds Attending Runds Attending Runds Attending Runds Attending Runds Patient Care Patient Care Patient Care Patient Care Patient Care Lunch Lunch Lunch Lunch Lunch 12:00Nn- 1:00PM Lecture (ptinal) Lecture (ptinal) Medical Grand Runds (ptinal) Intern Reprt (ptinal) Lecture (ptinal) 1:00PM- 5:00PM Patient Care Patient Care Patient Care Patient Care Patient Care 3:30PM Sign ut Runds Sign ut Runds Sign ut Runds Sign ut Runds Sign ut Runds Pst lng call interns must sign ut by NOON OR within 29 hurs frm their start time. Interns will be n a Q5 call in the MICU, and are supervised by MICU senirs 6:00AM-6:00PM and the MICU night flat senir 6:00PM-0600AM. Interns must sign ut the care f their MICU patients t apprpriate intern and senir pst call. MICU Cre Schedule R2 and R3 MICU Resident Mnday Tuesday Wednesday Thursday Friday 0600 MICU Sign in MICU Sign in MICU Sign in MICU Sign In MICU Sign In 0600-0900 Pre Runds/MICU Lecture Series Pre Runds/MICU Lecture Series Pre Runds/MICU Lecture Series Pre Runds/MICU Lecture Series Pre Runds/MICU Lecture Series 0900-1100 Attending Runds Attending Runds Attending Runds Attending Runds Attending Runds 1100-1200 Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch 1200-1300 Lecture (ptinal) Lecture (ptinal) Medical Grand Runds (ptinal) Bard Review (ptinal) Lecture (ptinal) 1300-1800 Patient Care Patient Care Patient Care Patient Care Patient Care 15
Medical Intensive Care Unit Guidelines at AGH Descriptin Patients wh are critically ill are lcated in the MICU. Overflw patients may be lcated in ther specialty units (SICU, CCU, Trauma ICU, Neur ICU) Organizatin The service cnsists f fur senir residents (R2 r R3) wh serve in a supervisry capacity ver the 8 R1 residents per MICU mnth. The R1 resident will assume primary respnsibility fr his/her patients. Furth year medical students rtate n the unit as assigned by the Clerkship Directr. The service will be divided int three teams. There will be tw teams cnsisting f ne senir resident and tw interns that will be respnsible fr admissins and patient care during the day. There will be ne senir and tw interns respnsible fr patient care and admissins at night. There will als be a third senir resident that will serve at a flat senir wh will admit t the MICU and transfer patients ut f the MICU while the day teams are runding. Each day team will have its wn attending and runds. Admitting and n-call schedule. Admissins Cycle: MICU week days 6AM NF admissins accept team Team 1 accepts admissins frm night flat **(NF interns stay t present their admissins t the accept team during runds) 6AM-Nn AM Admissin Team Flat Senir cmpletes admissins then hands them ver t Team 2 after their runds Nn-6PM PM Admissin Teams Flat takes the call abut the admissins then ntifies team 1 OR 2 f the admissin. The team will accept admissins n a rtating basis. If Team 1 and 2 are busy with ther admissins r urgent patient matters, Flat will supervise an intern frm either team t cmplete the admissin in a timely manner. 6PM-5:30AM Night Flat Team NF team cmpletes admissins Saturday 6AM- Runds Saturday 6AM- Nn Saturday Nn- 6PM Saturday 6PM- 6AM Sunday 6AM- Runds Admissins Cycle: MICU weekend NF Admissins accept team Team 1 accepts admissin frm night flat **(NF interns stay t present their admissins t the accept team during runds) AM Admissins Team Team 2 cmpletes admissins (there is n designated Flat Senir; therefre, Team 2 senir carries the Flat pager fr the entirety f the day Saturday 6AM-Sunday 6AM) PM Admissins Teams Team 1 and 2 cmplete admissins in an alternating fashin (Team 2 senir carries the Flat pager--8651) Saturday Overnight Team 2 senir cntinues their 24 hur call and carries the Flat pager (8651) There was n Night flat team t hand admissin ver t an accept team; but, Team 2 is pst call 16
Sunday 6AM- 6PM Sunday 6PM- Mnday 6AM Day Admissins Team Sunday Overnight Team 1 AND 2 cmpletes admissins (there is n designated Flat Senir; therefre, Team 1 senir carries the Flat pager fr the entirety f the day Sunday 6AM-Mnday 6AM) Team 1 senir cntinues their 24 hur call and carries the Flat pager (8651) *Bth Team 1 and 2 stay until 6PM, until the night senir resident arrives. Patients at r befre 5:30PM must be seen and addressed by day team(s). *Pts present between 5:30PM-6PM: ideally, pt shuld be triaged by 8651 resident, and then handed ff t NF as a tp pririty admissin with brief sign ut. *Over the weekend there a senir residents take 24 hur call. The interns n night teaching the upcming week each d ne night ver the weekend (Saturday and Sunday). *Night flat is frm Sunday night thrugh Friday night. MICU Rtatin Guidelines It is imperative that the 30 hur duty limitatin be adhered t n the MICU rtatin. 1. In the interest f insuring cmpliance with this regulatin, interns will be limited t 29 hurs f duty n their call day. 2. Cmpliance will be facilitated by the MICU attending. 3. On MICU runds, the pst call interns will present the new patients first such that they can be released frm runds and attend t the tasks necessary fr patient care in a timely fashin. The intern admissin cap ver a 24 hur perid is 5 patients. The intern census cap is 10 patients. The intern may nt be ver the limit at any pint in time. The junir and senir resident admissin cap is 10 patients per 24 hurs. The junir and senir resident census cap is 15 patients per resident. The resident may nt be ver the limit at any pint in time. As per agreement f the teaching faculty, the service census cap fr the entire MICU teaching service will be established at 30. This is t be cnsidered a hard cap, and all patients admitted ver this cap are t be cared fr by the MICU attendings and fellws n an verflw service. During nrmal wrking hurs, the MICU fellws will be first call n the patients n the verflw service. During ff hurs the MICU intern n-call will be first call fr the verflw service. It is essential that the interns receive a detailed sign-ut n all verflw patients such that they can prvide reasnable vernight cverage. When the cap f 30 is exceeded, it is the senir s respnsibility t identify less cmplicated patients that can be transferred t the private service. (Hwever, the attending can make ultimate decisin abut wh ges t the private service) Teaching runds will be cmpleted at Nn. The MICU faculty will prvide a structured didactic lecture schedule with specific times fr lectures t be given t the MICU interns and residents. These lectures are t be given by the MICU attendings and fellws. R1 respnsibilities include Cmpleting the initial histry and physical exam. Frmulating a cmplete and well thught ut differential diagnsis. Designing a diagnstic and therapeutic care plan. Cmmunicating daily with senir resident, attendings, cnsultants, patients, and families. Entering all rders (except in emergency situatins when supervising fellw r senir resident may write rders) (see rder writing plicy). Perfrming r bserving prcedures (under apprpriate supervisin). 17
Preparing a sign ut fr yur patients that the R1 will review with the n-call intern befre that R1 departs fr the day Cmpleting daily prgress nte: 1. R1 residents must cllect all the data and cmplete the daily prgress ntes with assessment & plans prir t attending wrk runds. 2. R1 residents may carry his/her prgress nte during runds t aid with presentatin fluency. 3. R1 residents must cmplete an addendum nte in the event any f a change in the treatment plan, a patient s cde status, family discussins, prcedures perfrmed, r cnsultant recmmendatins, etc. 4. R1 residents must ensure that all prgress ntes are stamped with the patient s name and MRN. Sign-ut runds: 1. R1 residents must be present during 6:00AM daily sign-ut runds in the MICU. At this sign-ut, the vernight intern has an pprtunity t update his/her fellw R1 f issues regarding patient care, as well as discuss these majr issues with the supervising senir resident 2. R1 residents must be present fr sign-ut runds at 3:30PM daily t discuss their patients care plan. 3. R1 residents must ensure that the cmputer sign ut sheets are updated daily. Daily Rutine: 1. 6:00AM R1 residents shuld arrive in the MICU each day. He/she must check vernight issues, speak t nurses, examine yur patients, check labs, culture data, chest X-rays, check med list, day f antibitics, line days, ET tube days, vitals, I&Os etc. Gather, and interpret all clinical data befre 9:00AM 2. 8:15-9:00 AM- MICU lectures given by the PCCM Attendings and Fellws 3. 9:00AM t 11:30AM Attending runds. Wrk runds and teaching runds. All the ld patients are discussed thereafter. 4. 5. 11:30AM-3:30PM Patient care; cmplete lines, prcedures, cnsult fllw ups, admit new patients, eat lunch. 6. 3:30PM Sign-ut runds f the MICU team: Give ne line summary abut the patients daily updates, please mentin the upcming pssibilities and plan t address them. Whle team must be present fr sign-ut runds. 7. R1 residents are t rder rutine labs and chest x rays (when intubated) n yur patients, daily. 8. Residents are the first respnse fr new admissins unless they are invlved with attending runds r in a cde situatin. 9. If a patient is unstable, residents must physically stay with the patient until they are stabilized. 10. Residents are t ntify the attending abut new admissins, majr issues, like cde status change, invasive prcedures, and all deaths. 11. If yur patient is ready t be transferred ut please write a cmprehensive transfer nte, highlighting in details abut the events during the MICU stay. MICU n call intern: 1. R1 resident is t crss cver all the patients in the MICU fr any acute issue that ccurs. 2. R1 resident is t carry the cde pager and respnd t cdes. 3. R1 resident is t be the first line t see new admissins, alng with the senir resident. 4. R1 residents are respnsible fr transfer f patients t the flrs. This includes a verbal sign ut t the admitting team and attending assuming the care f the patient, as well as a written transfer summary in the prgress nte sectin. Respnsibilities R2-3- Day Residents See General Medicine Teaching Service. 18
Daily Prgress nte: 1. Supervising residents must prvide an rientatin t the interns advising them n hw t write the prgress nte. 2. Supervising resident must prvide read the MICU interns prgress nte and prvide them with feed back. 3. Supervising resident must include addendums when apprpriate t the patients charts abut changes in treatment plans, patients cde status, family discussins, prcedures perfrmed, etc. Sign-ut runds: 1. Supervising resident must be present at mrning sign-ut runds starting at 6:00 AM with the night senir, fellw, and bth day-senirs (+/- vernight intern). 2. Supervising residents rganize sign-ut runds at 3:30 PM. 3. Supervising resident must ensure that the cmputer sign ut is updated daily. 4. Supervising resident must reassign the day ff intern s patients t anther intern by 6:00AM. Daily Rutine: 1. 6:00AM Supervising resident must arrive in the MICU. Check vernight issues, speak t nurses, examine yur patients, check labs, culture data, chest X-rays, check med list, vitals, I&Os etc. Tuch base with interns abut any urgent issues. Make management decisins. 2. 9:00AM-11:30AM Attending runds: Wrk runds and teaching runds. Pst call intern shuld present all his/her patients first. All the ld patients are discussed thereafter. Pst call intern is allwed t break frm runds and cmplete his wrk s that he is ut f the hspital befre 1200 hurs. 3. 11:30AM-3:30PM Patient care; cmplete lines, prcedures, cnsult fllw ups, new admissins. 4. 3:30PM Sign-ut runds f the MICU team: Give ne line summary abut the patient with daily updates, please mentin the upcming pssibilities and plan t address them. Whle team must be present fr sign-ut runds. 5. Supervising residents must make sure that interns are the first line t see a new admissin unless they are in attending runds r in a cde situatin. 6. Supervising residents must aid the intern with the care f a very sick patient wh is in need f stabilizatin. 7. Supervising resident must ntify the attending abut new admissins, majr issues such as change in a patient s clinical status, changes in cde status, invasive prcedures, and all deaths. 8. Supervising residents must aid interns with daily family cmmunicatin that may include an update f daily prgress plans, cnsent fr prcedures, etc. All patients in the MICU must have cde status clarified with the patient s family. Respnsibilities f Night Flat Team: Crss-cver all f the patients in the MICU (private and nn-private). One intern crss cvers and the ther intern admits new patients. The senir resident supervises and assists with whatever is needed. Ensure that there are nly 30 patients n the teaching service. The resident shuld identify less cmplicated patients and transfer them t the private service, s when the MICU team arrives in the mrning, everyne is clear n wh they are suppsed t see. (Hwever, the attending can make ultimate decisin abut wh ges t the private service) Respnsibilities f the MICU senir cvering fr the weekend: Supervising residents wh are cvering fr the weekend have the same respnsibilities as the weekday MICU senir. Pulmnary & Critical Care fellw s respnsibility Allw the internal medicine resident t be the patient s primary prvider. Actively participate during daily teaching runds (9:00AM-11:00AM). Dcument (e.g. admissin nte, cnsultatin nte, daily nte, infrmed cnsent, prcedure nte) in the patient s medical recrd. Evaluate and manage (with apprpriate dcumentatin in the medical recrd) a grup f patients daily. Review f the treatment plan will be perfrmed with the faculty member n a daily basis. 19
Assist the internal medicine residents with patient evaluatin and management. Perfrm r assist the Medical Intern r Resident in specialized prcedures. This includes, but may nt limited t central line and pulmnary artery catheter insertins, thracentesis, chest tube insertin, and brnchscpy. Crdinate the care f patient receiving mechanical ventilatin Attend cnferences assciated with intensive care medicine (e.g. husestaff cnferences, ICU cnferences, care crdinatin cnferences, etc). Begin sign ver runds with the medical residents at 6:00AM. This shuld ccur in the intensive care unit n the 4 th flr. Discussins f previus night s admissins and any difficulties encuntered shuld be discussed at this time. A review f the expected management plans with the residents shuld be dne at this time. If the medical residents are nt present immediately at 6:00AM, a page fr thse residents nt in attendance shuld be perfrmed. Frm 6:30AM-8:00AM, begin evaluatin and management f patients with emphasis n thse patients wh require the mst attentin. Frm 8:00AM-9:00AM, make runds with the respiratry therapy staff wh is present in the MICU. The fellw shuld page the RT staff and then review with them the plans fr thse patients wh are receiving mechanical ventilatin r thers wh require emergent RT care. Frm 9:00AM-11:00AM, frmal learning runds will be dne with the faculty, pulmnary fellw, internal medicine residents, pharmacy staff, and nursing staff. During the afternn hurs, the pulmnary fellw will discuss individual patient issues with each internal medicine residents. Evaluatin and management decisins and apprpriate dcumentatin in the patient s medical recrd will be made. Frm 5:00PM-6:00PM, sign ut runds will be cnducted with the pulmnary fellw and internal medicine residents. During these runds, patient care activities fr that day will be discussed and plans made fr subsequent nging patient management thrughut the evening. At 6:00PM, cnduct face t face sign ver runds with the fellw wh is n call that evening. Frm 6:00PM-6:00AM, the fellw n call will be respnsible fr the evaluatin and management f patients wh are admitted t the MICU as well as attend t any emergent prblems that arise. He/she shuld als prvide nging care fr thse patients requiring such care during the vernight hurs. Thrughut the day, direct cntact with the faculty shuld be perfrmed t review the management plans fr thse patients in the MICU. This shuld be perfrmed n multiple ccasins thrughut the day and als when a patient s cnditin has changed significantly. MICU Transfers As a general principle, the Intensivist service is nt expected t cntinue as the primary attending service fr patients wh are transferred ff f the MICU service. In the event that a patient admitted t the MICU service has a primary care physician frm utside f the AGH system, it remains essential that the resident staff identify and ntify this primary care physician. It is als essential that effrts be made by the discharging service t ntify the primary care physician f the patient s discharge and hspital curse. In the interest f rderly transitin f patient care, the fllwing guidelines are t be applied fr the transfer f patients frm the MICU teaching service. 1. Primary care physicians wh d nt have teaching service admissin privileges may nt wish t accept transfers nt their private service frm the MICU. Early n in the MICU admissin, the resident staff shuld inquire as t whether the nn teaching attending wuld prefer t have the patient transferred t the unreferred teaching service attending at the time f transfer frm the MICU service. 2. Primary care physicians wh have teaching service admissin privileges may elect t serve as the primary attending at the time f MICU admissin. Primary care physicians wh d nt have teaching service privileges may nt serve as the primary attending fr patients wh are n the MICU teaching service. All primary care physicians will receive a mandatry cnsult when their patient is admitted t the MICU service. 3. Prir t the physical transfer f a patient ut f the MICU area, it is essential that an accepting physician be ntified f the transfer and agrees t transfer the patient t his/her service. In the 20
unlikely situatin that the attending des nt accept the transfer, the patient will remain n the service f the MICU attending. Every effrt will then be made by the Sectin Chief f the divisin f Internal Medicine, (and as a last line, the Chairman f Medicine), t assign this patient t an attending physician as sn as pssible when this ccurs. 4. When the resident speaks with the accepting attending, the cnversatin shuld be dcumented in the chart and include the date and time. 5. Fr each patient, interns must dcument the name f the PCP and the service t which the patient will be transferred. Interns must d this when the patient is admitted t the MICU. That way, if the intern is nt present, there will be n cnfusin fr the cvering residents as t wh the patient shuld be transferred t. 6. Patients wh are lcated in remte ICU lcatins, (neur IU, TICU, SICU), shuld have AN rder written in Sunrise t ntify the resident when the patient receives a flr bed (befre the patient is sent t that flr bed), s the resident has the pprtunity t btain an accepting physician befre the patient is transferred ut f the ICU. 7. The primary care physician is expected t make an effrt t becme invlved in the patient s care in the MICU such that he/she is sufficiently familiar with the patient s cnditin t accept the patient in transfer n shrt ntice. 8. Timely identificatin f the patient s primary care physician by the admitting MICU resident team is essential. Timely ntificatin f the primary care physician when his/her patient is admitted t the MICU is likewise essential. 9. When the resident has fund and accepting physician, it is the resident s respnsibility t change the name f the attending in the cmputer. 10. When cnflicts arise as t the apprpriate attending assignment fr a patient being transferred frm the MICU service, cnversatins t discuss the issue shuld be n an attending t attending basis rather than n a resident t attending basis. CCU Cre Schedule R-2 CCU Resident Mnday Tuesday Wednesday Thursday Friday 7:00AM CCU Sign In CCU Sign In CCU Sign In CCU Sign In CCU Sign In 7:00AM- 9:30AM Pre Runds Pre Runds Pre Runds Pre Runds Pre Runds 9:30AM- 11:00AM Attending Runds Attending Runds Attending Runds Attending Runds Attending Runds 11:00AM- NOON Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch Patient Care/Lunch NOON-1:00PM Lecture Lecture Medical Grand Runds Bard Review Lecture 1:00PM-6:00PM Patient Care Patient Care Patient Care Patient Care Patient Care 21
Crnary Care Unit Guidelines Descriptin Patients wh are critically ill with cardivascular prblems are lcated in the CCU. Overflw patients may be lcated in the MICU r ther specialty units (i.e. SICU, Trauma ICU, Neur ICU). Organizatin 1. The service cnsists f ne attending cardilgist, ne Cardilgy Fellw, and tw r three secnd year medical residents, and ne t tw secnd year emergency medicine resident fr a ttal f fur residents in the CCU. Furth year medical students rtate n the unit as assigned by the Clerkship Directr 2. The cap fr CCU residents is 10 patients 3. Vacatin fr medicine residents cannt be scheduled during this rtatin. Call schedule 1. Residents will rtate thrugh an internal night flat system. 2. There will be ne resident present frm 6pm-6am 3. Prir t the resident s week f nights, he/she will take call fr 24 hurs n Sunday and will be due back 6PM Mnday night. 4. The day time residents will rtate between staying until 3,4, r 6PM. Respnsibilities R2 is respnsible fr: 1. Cmpleting the intial histry and physical exam. 2. Frmulating a cmplete and well thught ut differential diagnsis. 3. Designing a diagnstic and therapeutic care plan 4. Cmmunicating with family members and attending f recrd. 5. Entering all rders (except in emergency situatin when supervising fellw may write rders. See rder writing plicy). 6. Perfrming prcedures (under apprpriate supervisin). 7. Cmpletin f daily CCU prgress ntes. 8. Cmpleting a transfer nte when a patient leaves/transfers t anther service as a means f cmmunicatin t the next care team r accepting service Fr example: at the end f the each mnth r when a patient is transferred t a critical care unit All transfers f care within the hspital must include bth a written (transfer nte) and verbal sign-ut 9. If an attending is arranging transfer f a patient frm anther hspital t a special care unit r a patient frm the ED fr evaluatin, he/she will cntact the Fellw during the nrmal wrking hurs and the CCU Resident at night and n weekends. 10. The resident will be respnsible fr patient evaluatin fr transfer frm the CCU if there is a critical bed shrtage. The resident must cntact the attending physician f recrd fr apprval f transfer. The Senir Teaching Resident r the Hspitalist at night must als be cntacted fr apprpriate assignment f patients transferred t a teaching service team. 11. Cmpleting a cde nte n all arrests and prnuncement nte when the patient des nt survive the arrest. (see belw) 12. Assisting in evaluatin f critically ill patients being cnsidered fr transfer t CCU. 13. Being immediately available t the Fellw r nursing staff shuld they need yur assistance fr patient care respnsibilities. (i.e. Resident shuld nt spend lng perids ff the unit) 22
14. Residents in CCU are exempt frm mrning reprt. Cardilgy Fellws Respnsibilities in the CCU: 1. The primary rle f the Fellw n the Crnary Care Unit rtatin is t assist in the care f critically ill patients lcated in the CCU. 2. While the minute-t-minute respnsibilities fr patients in the Crnary Care Unit belng t the residents and nursing staff, the cardilgy fellw is the senir supervisr. He/she prvides versight fr the care f all Crnary Care Unit patients and must be ntified f sudden changes in patients cnditins. He/she supervises and/r perfrms all cardilgic prcedures (i.e., elective and semi-urgent cardiversin, insertin f pacing electrdes, insertin f Swan- Ganz catheters and arterial lines fr hemdynamic mnitring, emergency pericardicentesis, etc.) and assists with insertin f artic balln pumps. It is particularly imprtant that the fellw make certain that the resident understands the hemdynamic infrmatin btained frm patients in the Crnary Care Unit, and its diagnstic and therapeutic implicatins. He/she participates in the decisin-making prcesses required fr weaning patients frm majr elements f therapy and raditelemetry, and fr the selectin f lw-risk patients fr triage, prgressive care and early discharge. It is essential that the fellw maintains nging dialgue with huse staff, attendings and surgical staff with regard t apprpriate utilizatin f beds. Fellws n the Crnary Care Unit rtatin shuld be available until 5 PM, and it is anticipated that he/she will remain in the area as needed. At AGH, there is an in- huse fellw available twenty fur hurs per day. Fellws must make frmal wrk runds with huse staff each day. These runds take place Mnday thrugh Sunday. They begin at 0700 hurs and are generally separate frm the daily teaching runds. The fellw s pinin will be slicited fr the majrity f cases discussed and presented by the huse staff. It is expected that the Crnary Care Unit fellw will have the pprtunity t engage in backgrund reading s that he/she is able t intelligently discuss varius patient prblems and ther infrmatin f a didactic nature. The fellw shuld view him/herself as a senir member f the health care team. With that title, cmes the respnsibility f ensuring that prudent care is administered t all patients, and that huse staff and students are taught state-f-the-art cardilgy. On a regular basis, a member f the cardilgy staff will cnduct teaching runds with the huse staff. It is anticipated that the Crnary Care Unit fellw will nt nly attend these runds, but als select patients and make any necessary preparatins t ensure that this is a valuable experience fr everyne. Admissins: The fellw will assist residents in facilitating admissins t the Crnary Care Unit. Every effrt shuld be made t admit patients with acute mycardial infarctin r unstable angina t the Crnary Care Unit. Any issues regarding nn-ccu lcatin f a critically ill patient must be discussed with the patient s attending physician r the CCU Directr. The fellw is t be ntified f all emergent admissins t the Unit, and is expected t play a prminent rle in planning the initial management f such patients. Percutaneus Intra-Artic Balln Pumping: Many patients in the Crnary Care Unit require intraartic balln supprt. Such prcedures shuld be perfrmed under flurscpic guidance. Depending n the clinical cnditin, this may ccur in the catheterizatin labratry r at the bedside with prtable flurscpy. When a patient is being cnsidered fr this prcedure, a secnd year cardilgy fellw shuld first be called fr preliminary evaluatin. If he cncurs with the huse ffice initiating the request, the patient s attending cardilgist shuld be cnsulted. While the nursing staff 23