Ground Rules for Residents on the Wards
1. Communication and Teamwork
- We expect timely and effective communication between your team members, with and including the attending. This has become one of the most important characteristics of being an effective ward resident in the new era of shift-work and increasing supervision.
- This starts on Day #1 when you discuss your expectations for everything from daily notes and work rounds to schedule templates and anticipated days off to daily handoffs to team transitions at the end of the block.
- Make sure that, on Day #1, you and your attending discuss circumstances in which they would want to be notified. For example, many attendings prefer to be notified anytime a patient dies or requires transfer to a higher level of care (i.e. the ICU).
- Make sure all team members provide other team members with cell phone numbers and pager numbers.
2. Handoffs
- It is usually the intern’s job to give and receive handoff, but effective handoffs are ultimately the resident’s responsibility, so be involved in this process early and often.
- The handoff process must include:
- Daily updates of the electronic shift handoff tool using the [.imsignout] smart phrase in EPIC
- Updating the Treatment Team in EPIC to reflect who is covering for the patient at all times
- Verbal and written communication to the covering resident/intern in a designated quiet area, including “read-back” of all to-do items and time for clarification
- Page forwarding through the operator
- INTERNS ABSOLUTELY MUST LEAVE ON-TIME, NO EXCEPTIONS EVER
3. ICU Transfers
- Transfers should generally have been staffed by the ICU attending on the day of transfer and should have a daily progress note and/or transfer note written for that day. Exceptions to this should be communicated at the time of transfer. Thorough transfer notes are expected prior to transfer for patient in-house >2 days.
- Transfers should be on the floor or at least have an assigned floor bed prior to being called in.
- The cutoff time for ICU transfers each day is 4pm.
4. Bounce-backs
- Any patient that is re-admitted within 72 hours of their discharge will bounce back to the previous treatment team regardless of the reason for re-admission.
- If they are re-admitted between 7am and 4pm, it will be the responsibility of the previous treatment team to admit the patient, including the H&P and admission orders. If the resident is not available to assist, the attending or the Day Float must assist an intern in the re-admission process.
- Between 4pm and 7am, bounce-back patients will be admitted by the hospitalist service. The responsibility for care of the patient will be transferred to the previous treatment team at 7am.
- For re-admissions beyond 72 hours but within the same academic block, a discussion between attending physicians may be had to determine on which service the patient would be most appropriately cared for.
- It is impossible to predict every scenario in which a bounce-back admission may or may not be appropriate, so it is crucial that every effort be made to communicate thoroughly and effectively with all parties involved. Utilize your attending and/or the Chief Residents if you are confused or concerned about patient safety.
5. Team Transitions
- It is difficult to anticipate every scenario that might arise with respect to team transitions at the end of each block, so, again, effective and timely communication is the key.
- Team transition planning should begin at least a few days prior to the end of the block and should include:
- Written and verbal handoff of the service between all members of the out-going and in-coming team members based on their respective roles
- Anticipation of any potential abnormalities in the usual daily routine because of a resident or intern rotating onto or off of a service post-call (i.e. “lame duck”)
- Explicit assignment of responsibilities to out-going and in-coming team members with respect to daily notes, patient orders, work rounds and attending rounds on transition days
- Effective communication of the transition plan with the attending
