Advanced Heart Failure is a unique rotation with high specialized patient care. When these patients decompensate or suffer cardiopulmonary arrest their management can be DRASTICALLYdifferent from other patients including:
- ECMO
- Emergent Mechanical Support/VAD
- Emergent Transplant
Attendings understand the complexity of the patients and EXPECT residents to notify them when significant clinical changes, decompensations, codes occur - REGARDLESS of the time of day. You should consider escalating to the attending much earlier than you would on other rotations. Please page, text or call them on their cell phones if needed.
Structure and Call Schedule
Team Structure and Roles
- There are two resident super teams, A and B; Each super team is made up of 2 resident teams
- Residents will admit both ICU and floor advanced heart failure patients.
- There will be three attendings: a general cardiologist in the ICU, two heart failure attendings for both ICU and floor patients for each super team.
- Each resident team is made up of 1 resident and 1 intern.
- Residents do q4 28-hour call.
- There will be a night float system made up of 1 resident who will be primary on cross cover patients that do not belong to the call resident.
- There will be an in-house CICU follow present 24/7:
- The day CICU fellow is the first person notified of CICU admissions to allow for safe triage and will admit when resident caps are met (see below).
- The night CICU fellow is the first person notified of CICU admissions, advanced HF/VAD/Transplant floor admissions, and emergency consults. The night fellow is also responsible for cross-covering LVAD patients on Team C.
- When a fellow admits a patient due to cap constraints, the day fellow will present that patient to the next day's on-call attending. This patient will then be assigned to the oncoming call team and count towards the oncoming call team's daily cap. There will occasionally be a daytime floor HF Fellow (separate from the CICU fellow). This HF fellow will assist with floor patients on teams A/B/C. When this fellow is not present, the HF attendings will be available for immediate assistance with these patients.
Admission/Team Caps:
There are three ways that a resident can become "capped" and no longer able to take admissions.
- Having received 7 new patients in one call cycle (ie, the 8th patient will be the responsibility of the fellow as below)
- Having reached a resident team census of 10 patients (eg, Team B4 has 10 patients)
- Having reached a total service cap of 28 patients across the two super teams (eg, Teams A1 & A3 combined have 12 patients and Teams B2 & B4 combined have 16 patients)
If any of the three conditions above are met, the resident is "capped" and no longer able to admit new patients.
When at cap and there is a new admission pending:
- Any further admissions beyond the resident cap regardless of patient acuity (ICU or floor) should not be admitted by the resident.
- Any patients requiring ICU level care or LVAD patients regardless of acuity (ICU or floor) should be admitted by the CICU fellow who will interview and examine the patient, place admission orders, write the H&P, provide "first call provider" coverage for the patient, and present the patient to the attending (if available) or sign the patient out to the oncoming fellow for the oncoming fellow to present to the attending (eg, the night fellow signing out an overnight admission for the day fellow to present to the attending in the morning).
- Any further non-LVAD patients who are appropriate for admission to the floor should be re-triaged to the hospitalist service for admission. Any patients admitted by the fellow will be assigned to the oncoming call team after the patient has been presented to the attending and this patient will count towards the team’s admission cap of 7 patients (eg, receiving 1 “holdover” admission admitted by the night CICU fellow will leave room for 6 more admissions for the resident team).
- If the service/teams become capped during the day, the patients admitted by the day fellow will go to the night fellow. The night fellow will be primary (write orders and notes, remain first call) until 7 am the next day, after which hand-off will occur between day fellow to the oncoming on-call resident/intern team.
- Patients admitted by the fellows should not be assigned to resident teams that are not on call (eg, pre-call or post-call teams)
If more than 3 admits come at night, we ask that the night resident actively assist the call resident with admissions.
Rounds:
Rounds: 7:30 AM every day. The post-call residents’ patients should be seen first to ensure that they leave on time.
7:30-8:15AM: the CICU general cardiology faculty, CICU fellow, and the CICU multidisciplinary team will round with all CICU house staff on the general cardiology CICU patients, prioritizing the post-call team's ICU patients. All teams who have general cardiology CICU patients will need to be present at this time.
By 8:00AM , the post-call HF attending will join the above CICU rounds except for Thursday, when they will join at 9:00 AM (following the transplant/VAD selection committee meeting).
After the post-call team rounds on all their CICU patients (general cardiology ICU and advanced HF ICU patients), they (house staff and advanced HF attending) will leave the CICU and round on their floor patients in order to allow for the post-call resident to go home by 11:00 am.
When the post-call team finishes their CICU rounds, the on-call team will be notified so that the on-call team (house staff and attending) can return to CICU and round on their CICU patients with the CICU fellow and multidisciplinary team. Rounds should be complete for A and B teams by 11:45am, in order for the house staff to attend noon conference.
At 0815, the on-call house staff will leave the CICU and start rounding on floor patients with their team’s advanced HF attending while the post-call house staff continues rounds in the CICU with their team’s advanced HF faculty member and the CICU fellow (9am start on Thursday).
While rounding in the CICU, there is an "ICU Checklist" available under the Summary Tab in Epic to help ensure all critical items are addressed for patients receiving critical care.
In the late afternoon, Team A and B will review new admissions and/or updates on current patients with the advanced heart failure attendings and the general cardiology CICU attending.
The night residents and fellow will run the ICU list at 10pm. If clinically appropriate, bedside rounds can occur at this time at the discretion of the fellow. Overnight fellow is expected to write a brief “attending” note on each CICU patient during 10 pm rounds.
Work Hours:
- Call resident - 7:00 AM to 11:00 AM (following day). Admits new patients 7am-5:00am the following day.
- Call intern - 6am to no later than 9pm. Stops admitting new patients at 6pm.
- Non-call resident - 6:00 AM to no later than 6 PM
- Non-call intern - 6am to no later than 7pm
- Night Cross Cover resident: 6:30pm - 6:30am
Days off:
- Residents: Every 4th day (post-post-call, including weekends)
- Interns: Every 4th day off (pre-call day, including weekends)