Team Structure
Structure and Call Schedule:
Teams: 6 teams: A, B, C, D, E, F. Each team consists of 1 resident and 2 interns. There is also a night float intern from the intern Night Float rotation.
Buddy Teams: A and D are buddy teams, B and E are buddy teams, C and F are buddy teams.
Call Cycle
A Q6 long-call/short-call cycle. Residents do 28 hour in-house call on Long-call day and day call on short-call day.
Long-call -- Post-long -- Post-Post -- Short-call -- Post-Short -- Pre-Long
Day 1: A is long-call and D is short call
Day 2: B is long-call and E is short call
Day 3: C is long-call and F is short call
Day 4: D is long-call and A is short call
Day 5: E is long-call and B is short call
Day 6: F is long-call and C is short call
Service Caps
16 patients maximum per team. Long-call day: Team may take 10 new patients or 9 new patients and 1 transfer before 2 AM. Short-call day: Team may take 4 new patients or 3 new patients and 1 transfers before 2 PM.
Resident may expedite admissions (i.e. 2 admits/hr) by calling ADT (aka Bed Access Management or BAM).
Call Days
Long-Call: Admitting hours are 7am-2am. Day interns admit until 6pm. No more than two admissions (and only those called for admission after 6pm) should be "saved" for the night intern.
Short-Call: Admitting hours are 7am - 2pm.
If there is no MICU transfer on a particular call day, this does not detract from the admissions cap (i.e. can still take max number of admissions).
If you have admitted fewer than your new admissions cap patients and are at your total team cap but then discharge patients prior to 5 PM on your long-call day, or 12 PM on your short-call day, you can admit again until you hit the admission cap or the total team cap, whichever comes first. In other words, same day admit/discharges count only toward the admitting cap, not the team cap.
Rounding Times
Suggested attending rounding times are 7 AM on post-long call days and 10 AM on non-call days (residents are expected to attend morning report between 9 and 10 AM).
On short call days, patients can likely be staffed that afternoon.
Caps & Bounce Backs
A teaching team will only accept a bounce back if the resident who last took care of the patient is still on the same team AND is physically present in the hospital AND not post-long-call. There will be no bounce backs on post-long-call days and a team cannot over-cap with a bounce back (above the total team cap). Continuity with the attending or the intern does not count. The bounce back admission should be for the same chief complaint. Any bounce back admission felt by a resident to be inappropriate for the teaching team should be discussed and addressed at the attending level.
If you receive a patient that was recently discharged by a hospitalist that is currently on service, you can call ADT and politely let them know that this patient should bounce back to the hospitalist. Only consider doing this if the discharging hospitalist is still on service, as otherwise there won't be any continuity of care benefits to the patient.
Patients that are seen, admitted and transferred/discharged on the same day do count towards the new admissions and total team cap (e.g. if that is your 10th new admission and the new admission cap is 10, it does not need to be replaced with an additional admission). However, old patients who are discharged before 5pm on a long call day do not count towards the total team cap (e.g. if you go into call with 16 patients and the total team cap is 16, and a patient is discharged before 5 pm, you must take an additional admit to replace the discharged patient).
Days Off
All residents and interns should take 4-5 days off averaged over the 4-week rotation (minimum every 8th day off). Days off can be established between the resident, interns and supervising attending at the start of the rotation.
Suggested: Resident off post-post. Intern A off post-short, Intern B off pre-long (alternating)
Example: Interns take 4-5 days off for the month and will alternate taking the post-short and pre-long days off. - If intern A is off the post-short day on the first week of the rotation, they will take off the pre-long day the second week of the rotation, and so on.
Example: Residents take 4-5 days off for the month, taking the post-post day off.
Work Hours
There are no set required hours, although on your non-call days, keep in mind that the on-call interns who are admitting will be cross-covering on your patients so please do not leave until your work is complete.
Suggested hours:
- Non-call Interns / Post-call intern – 6:00-6:45 AM to 5:00-7:00 PM
- Non-call resident: arrive no later than 7 AM. When covering team alone, e.g. pre-call day, arrive no later than 6:45 to receive sign-out from overnight intern.
- On-call intern – 6 AM to 9 PM (at the latest)
- On-call resident – 7 AM to 11 AM (next day)
- Night intern – 7 PM to 8 AM (next day).
- Admits patients with on call team (maximum 5 admissions) and does cross cover from 7 PM - 7 AM
The on-call interns will admit up to 6 PM, after which interns then work on sign-out, finishing H&P's, and entering orders. At 7 PM the short call interns should sign out cross-cover on the other teams' patients to the night intern. The on-call interns should leave no later than 9 PM and come back to work no earlier than 5 AM on the post-call morning. Non-call teams: please go to the post-call team rounding room to receive brief overnight sign-out; please do so earlier than 7 AM to facilitate the overnight intern presenting for post-call rounds at 7 AM.
Order Sets
- Sepsis Orderset
- MedSurg Admission - admission orderset
- Insulin Floor Orderset- GI Bleed Order Set
- Skin and Soft Tissue Infections
- Pneumonia Antibiotic Orderset
- Therapeutic Heparin Orderset
- Transfusion Services Adult Order Set
- Paracentesis
- Thoracentesis Order Set
- LUMBAR PUNCTURE IP
- OPAT - Inpatient OPAT Referral Activation
- OPAT Outpatient IV Antibiotic Orders
- HIV FEVER LABS (optional)
Rounding Call Rooms
Rounding Rooms:
- A: 12-476.01 (400 side, far end)
- B: 13-476.01 (400 side, far end)
- C: 12-644.02 (600 side, center)
- D: 12-445.06 (400 side, center) - Shared with team E, near low numbers
- E: 12-445.06 (400 side, center) - Shared with team D, near high numbers
- F: 13-677.01 (600 side, far end)
Call Rooms
- Residents: 12-665
- Interns: 12-661
- Call room code: 2014* (Please notify the Parkland site chiefs if you find your call room has not been cleaned!)
Handoff/Cross-Cover
Hand off of patient care is a critical step that requires being systematic to avoid any potential errors. Communicating with your colleagues is an important skill, and we need to continue to build this culture of communication and collegiality. This will benefit you, your patient, and your future careers.
On your call day, you will receive signout from all other teams and the heme/onc team
Parkand Night Intern Guide
Morning Hand-off:
- What time?
All interns (or resident if your intern is off) is expected to find the overnight intern no later than 6:45 to receive in person signout. Assign yourself to your patients as soon as you arrive to relieve the night intern.
- What do we discuss?
You do not need to discuss every patient as you would for evening sign-out. You should ask about any patients you had concerns about. The night intern should give you updates on any notable overnight events.
- Where do I find the intern?
You can easily see which team is postcall that day on Amion and list of rounding rooms on the residency website
Post-Call Resident-Resident Hand-off:
- What time?
Around 10:45am, but before the post-call resident goes home
- What do we discuss?
Discuss any patients that are tenuous and may need attention. Also discussed planned procedures so that your buddy resident can plan their day accordingly. Discuss any major contingencies. Buddy Residents: This is also a good time to touch base with your buddy interns and ensure you are easily accessible
- Where do we meet?
Likely, the post-call resident would go to the buddy resident (as this team will still be rounding). You should text each other to plan on a meeting place and time.
Evening Hand-off and Early Signout:
Any team done with their work early will sign out to the short call interns. This means the short call team must stay until 7pm.
- What time?
You can sign out to the short call team before 7pm if you are done with you are work, your patients are stable, and there are no urgent follow ups. Please be mindful that your colleagues will be busy, and signing out "to do"s to the day team is generally not appropriate.
- Who do I sign out to?
If you are signing out before 7pm, you will sign out to the interns on short call. After 7pm, you will sign out to the overnight cross-cover intern. Make sure you assign the on-call team as first call.
- What do we discuss?
You will follow the .imsignout template and run your whole list of patients. You should spend additional time discussing any anticipated events, possibly unstable patients, or any unique follow ups (bed check, imaging follow up, consult follow up).
- What to avoid signing out?
Generally, any non-urgent consult notes should not be left to the overnight team, you should take ownership of your patient and do this yourself. If they are urgent, you should generally not sign out before you have this information from the consult team.
Rotation Hand-off:
- When?
This should be done no later than the Thursday before any team switch. Updates should be sent on Friday.
- What/How?
This should be done in email format with notable details of the patient as well as a "to-do" list. You are also encouraged to discuss over the phone.
General Tips:
- Please use the electronic medical records at each site to facilitate handoff.
- At CUH and Parkland, you will use the Sign Out Report located on the tool bar.
- You should use the smart phrase “.IMSIGNOUT” to standardize the information that should be in a handoff.
- The person handing off should clearly state any anticipated events and any studies that need to be followed up.
- Please be mindful of your cross cover colleagues. Do not sign out unstable patients (unless in the ICU), procedures, consents, or anything that does not need to be followed up that evening.
- At Parkland and CUH, it is also the responsibility of the person handing off the patient to designate the appropriate cross-cover house staff under Treatment Team within EPIC.
- Residents should supervise intern hand-offs during the beginning of the academic year. Leave a cross cover note if you are called to evaluate a patient overnight.
- You should always be signed into your patients as first or second call when you are in the hospital. This enables the nursing staff to find you.
Conferences
Morning Report
Morning Report: in person. Usually in 02-651 (on the way toward bridge to Anderson building). The 2nd Wednesday and 2nd Thursday of each month are in alternative location 2-602.
- Post-Long call team is excused and long call team may attend virtually, but all others are expected to join us in person.
- Please arrive on time so we can finish on time!
- ADT has been instructed to not assign admissions conference to accommodate conference attendance (let the chiefs if this is not happening correctly).
Noon Conference
Please attend virtually! Lunch is available for pick-up in the 12th floor LRC (12-513).
When to Call Your Attending
You are required to notify your attending, 24/7, in all of the following circumstances:
Before doing any of the following (time allowing):
- Procedures: Cardioversion, pericardiocentesis, thoracentesis
- Therapies: Emergency dialysis, exchange transfusion, thrombolytic therapy, or initiation of mechanical ventilation
When any of the following happen:
- Code blue or unexpected death
- Transfer to a higher level of care
- BiPAP initiated on non-ICU patient for hypoxic or hypercapnic respiratory insufficiency
- End-of-life discussions and changes in CODE STATUS. Once end-of-life discussions have taken place and a decision made, the order will need to be co-signed immediately to avoid patient safety issues.
- Order of protective custody
- Inpatient suicide attempt
- Patient leaves AMA
For wards attendings, a courtesy page is sufficient (ie, the page may read, "FYI pt **** MRN **** transferred to MICU for ****. Call with questions (your cell phone number)...).
For heme/onc cross cover patients, you should page the heme fellow on call and discuss major events and changes in clinical status.
New Parkland Ward Initiatives
Sepsis Order Set
What: Sepsis Orderset
Why: 1) to improve patient care, 2) to help us meet CMS quality metrics that help Parkland get reimbursed (and help you have the resources to continue providing quality care to your patients)
See the attached slide deck HERE.
Nurse-Driven Sitter Protocol
Parkland has a nurse-driven sitter protocol. This mean you no longer need to (and cannot) place an order for one-to-one observation. The nurses have clear criteria for which one-to-one observation can be arranged along with an algorithm on how to de-escalate or discontinue one-to-one observation (based on evidence-based indications for one-to-one observation). See the
quick-and-easy algorithm for additional details. Longer explanation of the policy available
here.
Interdisciplinary Team
- Contact information for SW and CM are also found on the patient's 'Treatment Team'
- See additional information here about the roles of SW and CM at Parkland.
Phlebotomy at Parkland
Phlebotomy Collection Schedule
How do I get in touch with Phlebotomy?
Phlebotomy Lead Pager
Transfer to Hospital Medicine
Process for Transfer to Hospital Medicine
Which patients are appropriate for transfer to hospital medicine?
Patients with no active medical issues, who are stable and awaiting placement (I.e. on IV antibiotic therapy, post covid with no active issues pending rehab). The transfer must be discussed with the attending of record prior to initiating the process.
When can patients be transferred?
Patients can only be transferred from teaching teams on call days (short and long) when the senior resident is present.
How does a transfer affect my cap?
Transferring a patient to hospital medicine means that team can admit an additional patient for that call cycle. This may include a new admit from the ER to fill that bed or a transfer from hospital medicine of a patient that has not yet been admitted, seen or worked up. This means that on a short call, the admitting cap will increase to 5 and on long call, the cap to 11. The hard team cap of 16 would still need to be observed.
How do I initiate a transfer?
Page the HOD (Hospitalist Admit) by 8 AM with a request to transfer. Once the transfer is accepted, the change provider order should be placed, and the treatment team should be updated. The resident should assign the HOD first call. HOD can then assign someone else per their preference. The resident should then update ADT as to the team change and update the total number of admits.
What if my transfer is declined?
Notify your attending. The attending can then initiate an attending-to-attending discussion.
Can I take patients from Hospital Medicine?
If HOD has several patients that are pending admission and have not yet been assigned or worked up, the HOD may suggest a reciprocal trade for a new patient. In this case, the resident team must notify ADT of the patient transfer and update the number of potential admissions.
