VA GEN MED ROTATION STRUCTURE

Department of Medicine VA GEN MED ROTATION STRUCTURE Internal Medicine Residency Program Intern/JAR Team: General Structure: During the 4 week block, teams will have 3 weeks of day coverage and 1 week of night coverage. Interns and JARs will rotate together throughout the block. General Teams: There will be a total of 8 admitting teams, Red 1-3, Blue 1-3, and Red 4 (SAR/Ex), Blue 4 (SAR/Ex). Teams 1-3 will be composed of a JAR and Intern and will take daily admissions as described below with every third day being a late day to bridge until the night team arrives. The SAR/Ex team will be composed of a SAR (and possibly also a sub-i with the long term goal of having a physician extender). This team will also admit daily except only 1 handoff on one weekend day per team. Week 1 Week 2 Week 3 Week 4 TEAM INTERN* JAR TEAM INTERN JAR TEAM INTERN JAR TEAM INTERN JAR Red 1 A A Red 1 A A Red 1 A A Red 1 B B Red 2 B B Red 2 B B Red 2 C C Red 2 C C Red 3 C C Red 3 D D Red 3 D D Red 3 D D Red NF D D Red NF C C Red NF B B Red NF A A Blue 1 E E Blue 1 E E Blue 1 E E Blue 1 F F Blue 2 F F Blue 2 F F Blue 2 G G Blue 2 G G Blue 3 G G Blue 3 H H Blue 3 H H Blue 3 H H Blue NF H H Blue NF G G Blue NF F F Blue NF E E *interns carrying over from last block Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1 2 3 4 5 6 7 Red Int/Blue Res OFF, Red Res/Blue Int OFF, 1 Late 1 Regular 1 Regular 1 Late 1 Regular Only Red Admits Only Blue Admits 2 Regular 2 Late 2 Regular 2 Regular 2 Late 1 Regular 1 Late 3 Regular 3 Regular 3 Late 3 Regular 3 Regular 2 Regular 2 Regular 3 Late 3 Regular 8 9 10 11 12 13 14 Red Res/Blue Int OFF, Red Int/Blue Res OFF, 1 Regular 1 Regular 1 Late 1 Regular 1 Regular Only Blue Admits Only Red Admits 2 Late 2 Regular 2 Regular 2 Late 2 Regular 1 Late 1 Regular 3 Regular 3 Late 3 Regular 3 Regular 3 Late 2 Regular 2 Late 3 Regular 3 Regular 15 16 17 18 19 20 21 Red Int/Blue Res OFF, Red Res/Blue Int OFF, 1 Regular 1 Late 1 Regular 1 Regular 1 Late Only Red Admits Only Blue Admits 2 Regular 2 Regular 2 Late 2 Regular 2 Regular 1 Regular 1 Regular 3 Late 3 Regular 3 Regular 3 Late 3 Regular 2 Late 2 Regular 3 Regular 3 Late 22 23 24 25 26 27 28 Red Res/Blue Int OFF, Red Int/Blue Res OFF, 1 Late 1 Regular 1 Regular 1 Late 1 Regular Only Blue Admits Only Red Admits 2 Regular 2 Late 2 Regular 2 Regular 2 Late 1 Regular 1 Late 3 Regular 3 Regular 3 Late 3 Regular 3 Regular 2 Regular 2 Regular 3 Late 3 Regular

Admissions: Mon-Fri: An admission team order list will be created each evening based largely on team census (see template below). First, the four regular call teams will be ordered 1-4 based on increasing census to receive the first 4 admissions Next, the two late call teams for the following day will be up to receive the next two overnight admissions. Lastly, the next two go to the SAR/Ex teams with the goal being to have the SAR teams open to admissions during the day. However, the order can vary based on census. After the overnight teams shift is done, the teams are re-organized as below to both maintain the general admitting order and also maximize potential for late admission. - All JAR/Intern teams can accept the same number of admissions per weekday, but the late teams are designed to be able to accept them later in the day. - The regular call teams can accept up to 2 daytime admissions + 1 overnight handoff or 4:30pm, whichever comes first. - Late call teams can accept up to 2 daytime admissions + 1 overnight handoff or 6:30pm, whichever comes first. - If a team does not receive an overnight handoff, that team can still only receive up to 2 daytime admissions. - If a team receives two overnight handoffs, they can only admit 1 patient during the day. As previously, bouncebacks do not count against daily admissions (see definition of a bounceback below). - On the weekends, the regular team accepts admissions until 4.30pm and the late team accepts admissions until 6.00pm. - SAR/Ex teams can accept 2 handoffs or 1 handoff + 1 daytime admission or two daytime admissions before 4:30pm. The late call resident (Red Resident odd days, Blue Resident even days) should sign on to the admissions pager (970-0546) in the morning. At 3:30-4PM, the late call resident is to contact Carol Howard/Bed Control at pgr 970-2742 or receive list in Surgery Conference room on 5 th Floor. After 3:30 on long call days and on the weekends, that resident is responsible for giving team assignments.

Fri and VA holidays: On Fridays and VA holidays, the structure will be similar to Mon-Thur except that regular call teams will stop admitting at 4:30pm and late call teams will stop admitting at 6:00pm. Overnight residents are asked to come in at 6:30pm on Friday-Sunday and VA Holidays. SAR/Ex service is unchanged on Fridays. Sat, Sun: Each weekend, there will be one day when all blue residents are off and red residents work, and the other day will be the opposite. Interns will be off on weekend days that residents are working. There is little flexibility in this system. Sister team residents are available for intern supervision. Also, the SAR resident is to check on the interns periodically during the day and be available for assistance with procedures, questions, etc. When the team s resident is off, those teams will not receive daytime admissions but can accept up to 2 overflows which will preferentially be given to the intern only teams that morning. On weekend days when the intern is off, the regular call team resident can accept up to 2 admissions until 4:30pm (2 regular call teams each weekend day). Handoffs are included in this number on weekends but are directed to intern-only teams first as mentioned above. The late call team can accept up to 3 admissions (handoff or daytime) until 6:00pm (see template below). Late call is listed first in this template in attempt to give that team the first opportunity at an overnight handoff if available and to try to avoid getting two patients in a row late in the afternoon for the solo resident. It is anticipated that the late call resident on the weekend will likely be the most demanding shift of this structure. Again, night teams will be asked to come in at 6:30pm on Friday-Sunday and VA Holidays. SAR/Ex service can accept only one new handoff admission on weekends for the resident who is on that day after the interns have accepted their capacity. SAR/Ex does not accept new daytime admissions on weekends.

Overnight: - The overnight intern/jar teams (and also the 2 SAR only teams on Sunday nights) can accept up to 5 patients on each of the two teams until 6:00am. - These patients will be assigned to teams overnight by one of the two residents according to census using the templates above and distributed among the teams in the morning. - Upon arriving at night, the admitting JAR for the night should sign on to 970-0546 (equivalent to Duke s 1010) and should pick up the appropriate census from the ACR door basket for the following day (e.g. on a Frid night, print and use the template for SatSun) and fill it in (IN PENCIL) according to team schedules and census for the following day. - On even numbered days of the month, the Blue team resident will cover the overnight admissions pager. - On odd numbered days of the month, the Red team overnight resident will cover the admissions pager. - Overnight, the 970-0546 pager will receive notifications of admissions from the Off-Tour- Coordinator (OTC) or MOD, and the resident will assign the admissions upon receiving the page to the next team in order on the list. - The OTC will then notify the AOD who will alert the other necessary people (ie nursing, etc). - The following morning on weekdays that are not VA holidays, the overnight resident will deliver a copy of that list to Carol Howard (Bed Control) in room A7003 (ext 7803 or pgr 970-2742). - On weekends (when Carol is off), the late call resident for that day will cover the 970-0546 pager and assign teams for admissions when he/she is paged during the daytime based on the list provided to him that morning by the overnight resident.

- After signing over the admission sheet and admission pager (970-0546), overnight residents and interns should forward their pagers to the admissions pager. This pager ideally should not go off on weekdays and will simply be a precaution to field and politely redirect incorrect pages. - On weekends, that resident will be responsible for giving team assignments as above. The 970-0546 pager will also serve as a backup pager for overnight nurses if they are having difficulty reaching the appropriate resident. - After delivering the list, it will be expected that JARs sign out patients at the bedside to the receiving JAR. - Interns are responsible for overnight cross cover and sign out cross cover events to the respective interns or SARs in the morning. - Both intern and JAR should be out of the hospital no later than 8am. - On Sunday morning, if the Saturday night team remains in the hospital later than 7am, they should not return to work on Monday morning until 24 hours have passed in order to receive 1 24 hour period off that week. For example, if the Saturday night JAR/intern leave at 8am, then they return to work at 8 am on Monday. - If this happens, they should notify the Sunday long call resident and email the Sunday night SARs. The Sunday night SARs will be expect to remain in house and covering that team on Monday morning until the new teams arrives after a full 24 hours off. - When the team that was on nights transitions back to days, they will take over the team that is coming on to nights. Yes, this does mean they won't get their old team back; however, it's pretty unlikely that too many of the patients will still be on service one week later. Also, they'll be admitting to all teams of the same color (red or blue) and covering all teams overnight so they will get to know the patients they will be taking over. - As for the transition, if the patient has been hospitalized for 4 days or is particularly complex, an interim discharge summary should be done by the offgoing resident. If a patient gets discharged on the first day a new resident is on service, the previous resident is responsible for the d/c summary. After coming back to days, it is imperative that the teams change the patient s CPRS orders to reflect the correct resident/intern teams so that there will not be any confusion by nursing. MICU Admissions: The previous rule of ICU patients are upper-level only patients is no longer true in this structure. ICU patients will now be treated in a similar fashion to all other patients except that JARs will still be responsible for reviewing and entering the transfer orders. Bouncebacks: A patient is considered a bounceback if he/she returns to the hospital within 72 hours from the time the discharge order was signed for any reason or within 7 days from the time the discharge order was signed for the same reason. If either the intern or resident is still on service, the patient should go back to that team. For ICU patients, there is no time limit. If either the intern or resident is the same, the ICU patient should go back to that team. Occasionally, there are exceptions to this rule (ie, patient only on a team for an hour two weeks ago then went to the unit). These cases can be reviewed by the ACR or CR who will make the final decision. - Bouncebacks will go to the discharging team if they are still within time that they can receive admissions that day.

- Bouncebacks will not count against daily admission totals if they are admitted directly to the discharging team. - If not, they will count as an admission for the admitting team then return to the discharging team the following day. - Bouncebacks that come in overnight count as regular admissions for the overnight teams but do not count towards the receiving teams daily admissions. Hours: Discharge Summaries: As above, when teams are transitioning to night float, if the patient has been hospitalized for 4 days or is particularly complex, an interim discharge summary should be done by the offgoing resident. If a patient gets discharged on the first day a new resident is on service, the previous resident is responsible for the d/c summary. Otherwise, discharge summaries are unchanged from previously and are the responsibility of the team JAR within 72 hours maximum of the time of discharge. Interns do discharge summaries for patients hospitalized for less than 48 hours. For patients who are initially admitted to observation status and discharged within 24 hours, a Medicine-Observation Discharge note is all that is required. Days: 7:00a-7:30p on regular call days, 7:00am-no later than 9:00pm on late call days Nights: 7:00p- no later than 8:00a except on Fri-Sun when teams are asked to come in at 6:30pm. For the day teams, it is acceptable for one of the team members to leave early if all team responsibilities have been taken care of and that team s patients are stable. The other member must stay until the night team arrives (7pm on Mon-Thur and 6:30pm on Fri-Sun and VA holidays) to sign out to the night intern. These arrangements can be worked out within the team but ideally, early days should alternate between both team members with priority favoring the upper level resident. Example Day: 7:00a: Meet in overnight team workroom. Interns receive sign out events and begin computer prerounding on old patients. Then bedside rounds if the JAR has not returned from receiving handoffs yet. JARs accompanied by medical students receive bedside handoffs of overnight admissions then meet up with his/her intern for bedside pre-rounds. - Medical students are observing only. Teaching is not expected at this time because the goal is to model efficient, safe transitions of care. 7:45a: Contact case managers/social workers regarding the days discharges 8:00a: overnight team should be out of the hospital 8:30/9:00a-11:00a: Attending Rounds. Interns or medical students present admissions from the previous day. JARs present overnight handoffs. 11:00a-11:50a (Mon-Thur): Resident Report 12:00p-1:00p: Noon Conference 1:30-2:30 (Tues): Intern Report 6:30p/7:00p: Sign out to night team when able then go home Coverage: Day interns, hospitalist teams, and SARs sign out to the oncoming night intern who signs back over to the respective teams in the morning. Only SAR teams and hospitalists can sign out to the late call resident no earlier than 5pm if their teams are completely stable. Off Days: Days: Each resident will have one weekend day off per week averaged over 4 weeks. Nights: The JAR/Intern team will work Mon pm Sunday am and be off Sunday night. A SAR will cover each team on Sunday nights.

SARs: General Structure: 1 week of Day Float (+/- 1 day), 1 week of SAR/Ex (+/- 1 day), 1 night shift (13.5 hr) SAR/Ex: A 4 th GM team consisting of a SAR, an (future extender), possibly a sub-i, and an attending designed to provide a hospitalist-like experience for the SAR and serve as source to offload patients from the newly condensed teams. - The maximum census of these services will be 7 patients per team. - These teams will be first to accept overnight handoffs and can accept 1 handoff each. - They can also accept a second handoff or one daytime admission until 2pm during the weekdays only as the team cap allows. - On weekends, one SAR will cover both teams to give the other SAR an off day, and the SAR who is on that day can accept one handoff admission to his/her own team only but no daytime admissions. - On weekdays, if the team is stable with no active issues, SARs can sign out to the late call JAR at 5:00pm who will then sign out to overnight intern. - On weekends, if both teams are stable, SARs can sign out to late call JAR any time after 2:00pm. Because of the frequent turnover of this team, functional pagers have been created and should be placed in the comment section of all admission orders: Red SAR Team Pager: 970-0241 Blue SAR Team Pager: 970-0721 Day Float: The SAR will serve as a day float to primarily support teams on short days or with residents or interns in clinic on Monday-Friday (will not be available every other Monday). They are to come in before morning report M-F. They should check in with the designated short call team marked by an asterisk on the schedule. They should then proceed to do any admissions that team gets that day. The short call team may sign out to the dayfloat at any point after they have completed their daily notes and work. The dayfloat provides cross cover only and does not handle discharge summaries, scheduled family meetings, etc that the primary team should provide. The dayfloat then signs out to the night JAR when they arrive. If there are no short call teams (Fridays and some Thursday), then the day floats should help any team that needs assistance, with preference to large census, resident/intern in clinic or late call teams. They should also provide teaching and assistance to medical students as needed. There will be no day float on weekends. Night Shift: In order to cover the JAR/Intern teams being off Sunday night, 2 teams with 1 SAR each will be implemented for that shift (6:30p-8a). Each SAR will have 1 of these shifts during the 2 week block at the end of the day float week. SARs will not be expected to be at work the following day but can stay later if needed to ensure safe handoff of care or a 24 hour off period for the previous week s night team.

Week 1: SAR Mon Tue Wed Thur Fri Sat Sun A SAR/Ex SAR/Ex SAR/Ex SAR/Ex SAR/Ex SAR/Ex OFF B SAR/Ex SAR/Ex SAR/Ex SAR/Ex SAR/Ex OFF SAR/Ex C Day Float Day Float Day Float Day Float Day Float OFF 6:30p-7a D Day Float Day Float Day Float Day Float Day Float OFF 6:30p-7a Week 2: SAR Mon Tue Wed Thur Fri Sat Sun A SAR/Ex Day Float Day Float Day Float Day Float OFF 6:30p-7a B SAR/Ex Day Float Day Float Day Float Day Float OFF 6:30p-7a C OFF at 7a SAR/Ex SAR/Ex SAR/Ex SAR/Ex SAR/Ex OFF D OFF at 7a SAR/Ex SAR/Ex SAR/Ex SAR/Ex OFF SAR/Ex ACR: ACR s will be responsible for making sure that teams are listed correctly in the computer and also for updating which residents the patient alerts are assigned to on a weekly basis. Attendings: Attendings can decide what time each day they would like to round, but it suggested to round at 8:30-9:00am. Three attending will be distributed among the six JAR/Intern teams so that each attending will have 2 teams of the same number but different color (ie Red1&Blue1; Red2&Blue2; etc.). This was designed so that on weekends an attending will have both an intern from one team and a resident from the other then the opposite the next day. It also works out better for intern backup on the weekend this way since their "sister team" resident in this design would be there. A 4 th attending will be assigned to the SAR/Ex team (Red4&Blue4). The total weekly admissions per attending will expectedly increase slightly if admission caps were reached daily. However, admissions will be distributed according to team census which should help make the previously larger teams become more balanced and manageable. The SAR/Ex service will utilize the 4 th attending to help distribute the patient load. Although there is potential for a larger number of admissions on a weekly basis and it will certainly happen in busy months, the hope is that the daily admissions per attending remains around 3-5 allowing for shorter rounds. Bed Control/AOD/OTC: - On weekdays at 7am, bed control will receive from the overnight resident a copy of the above templates filled in with the overnight admissions. This template will provide the order for team admissions throughout the day and should be transferred to the OTC when bed control leaves around 3:30pm for the afternoon. - At 7pm, that template is no longer needed and a new template will be started by the oncoming overnight resident who will sign onto the admission pager (970-0546). - After 7pm (6:30pm on Fri-Sun or VA holiday), the OTC should then page 970-0546 when new admissions arrive and the admitting resident will provide team assignments at that time. - After receiving the team assignment, the OTC should then notify the AOD who should notify other essential personnel (i.e. nursing, etc). - The only role of the resident is to provide team assignments. - The resident will not be responsible for notifying nursing staff or other similar duties and this process should continue as it was done previously. - On weekends, a resident will carry the template both during the day and at night and can be paged through the admission pager in the same manner to provide team assignments. NOTE: There is a 30min to 1hr gap between 6-7am and 6/6:30-6:30/7pm depending on the day when no teams will be accepting new patients because of transitions. It is important that bed control/aod/otc be aware of this, particularly in the case of transferred patients who sometimes show up on the floor. We should avoid having transfers arrive during these times as much as possible as this could be problematic. In these cases, the overnight resident can eyeball the patient for general stability in the morning or the late call resident can eyeball the patient for general stability in the evening until an admitting team arrives.

Maximum Daily Admissions for the Medicine Service: New Maximum Admissions/day Monday - Thursday 4 long + 8 short + 2 SAR/Ex + up to 8 from overnight that do not count towards admissions = 22 Friday 4 long + 8 short + 2 SAR/Ex + up to 8 from overnight that do not count towards admissions = 22 Saturday, Sunday 3 long + 4 short + 7 from overnight that would not count towards admissions = 14