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 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 and for the Non-LVAD Team C patients. The Team C LVAD patients will be cross-covered by the night fellow.  
• Team C consists of APP(s) and a Team C attending
  • Team C's cap is variable and fluid (we are working on this). Team C should communicate their cap to you at the beginning of the day. If this does not occur, please reach out to them. 
  • The on-call resident (who is first call for floor admissions) will discuss all potential floor admissions with their HF faculty member before accepting onto the service, to allow consideration of admission to Team C (or alternate service as needed). Admissions to Team C predominantly are transfers from the CVICU if they are new transplant or VAD recipients and/or direct admissions from transplant/VAD Clinic.  If Team C is capped or there is an overnight admission, VAD/Transplant patients would go to the house staff team as the cap permits (see below).  These admissions may be transferred to Team C or the hospitalist service in the morning.  Any issues regarding triaging patients to Team C will be immediately escalated to the team C attending. 
• There will be an in-house CICU follow present 24/7:
  • The day CICU fellow is first call for CICU admissions to allow for safe triage and will admit when resident caps are met (see below).
  • The night CICU fellow is first call for 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 attending.
• 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.

All new CICU admissions will be discussed with an on-call CICU attending as necessary (either general cardiology or advanced HF attending, depending upon the type of patient). Daytime attending staffing will be determined in the morning based on disease state and call schedule.  The fellow will maintain a list of patients who can transfer to the hospitalists/floor services. Overnight fellow is encouraged to write a brief note on patients triaged but not accepted to the CICU. The resident will not be responsible for triage notes. There will be an advanced heart failure attending and general cardiology attending on-call each night to support the team.

Admission/Team Caps:

Total service cap (both super teams): 28 patients; each side is capped at 14 patients and each individual resident/intern team is capped at 10 patients. The ICU also is capped at 14 patients. 

Total Admission Cap (per 28 hour admitting shift): 7 total admissions. The 8th patient will be the responsibility of the fellow as below.

Night Admission Cap: Between the hours of 6pm and 5am, the call resident will admit no more than 3 total patients. The 4th patient will be the responsibility of the fellow as below.

When at cap:

• When the total service cap is reached:
  • any ICU patient beyond 14 patients, the fellow will admit, write the note, do the orders, and take primary responsibility (first call/cross cover).
• When the total admission cap is reached:
  • The 8th total admission will go to the fellow to admit if it's a CICU patient and to the Hospitalist to admit if it's a floor (non-LVAD) patient. 
• Any patient that is discharged and physically leaves the hospital after 3PM does not open up a space on the team caps or the total service cap (i.e. if there are 28 patients across all teams at 3PM, there is no space to admit more patients, even if more patients are discharged later in the day).
• When the night time admission cap is reached:
  • The 4th night admission will go the fellow if it's a CICU patient and to the Hospitalist if it's a floor (non-LVAD) patient. If a floor LVAD patient comes in overnight as the 4th admission, the resident and fellow will co-manage until the morning when the patient(s) is/are re-triaged. Any admissions after are beyond the pervue of the resident.
    • If you are not at your total cap (service, side, team, OR admission) and you feel comfortable, consider helping the fellow with the 4th admission if it happens to be a floor LVAD patient.

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 until 11 am in order to allow for the post-call resident to go home by 11:30 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).

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)