Goals and Objectives
- Develop an understanding of common clinical problems seen in the cardiology ICU (CCU)
- PGY-1: Understand the basic principles of assessing and managing common presentations of cardiac disease in CCU patients
- PGY-2: Learn how to manage complex presentations of disease in CCU patients.
- PGY-3: Develop advanced processes to recognize and treat complications in CCU patients with multiple medical and cardiac problems
- Competancy: Patient care, Medical knowledge
- Developing diagnosis skills
- PGY-1: Learn how to effectively use bedside clinical examination in patients with cardiac disease
- PGY-2: Demonstrate subtle bedside clinical findings in cardiology inpatients
- PGY-3: Learn how to correlate bedside clinical findings with imaging and other data in patients with cardiac diseases
- Competancy: Patient care, Medical knowledge
- Understand the differential diagnosis of common clinical scenarios seen in the CCU
- PGY-1: Develop a basic differential diagnosis for common CCU clinical scenarios
- PGY-2: Develop an expanded differential diagnosis for common CCU clinical scenarios
- PGY-3: Recognize unusual presentations of common cardiac CCU clinical situations
- Competancy: Medical knowledge
- Learn pharmacological management of common cardiac diseases seen in the CCU
- PGY-1: Learn the common medications utilized for the management of common CCU clinical problems
- PGY-2: Understand how to manage complicated clinical problems and develop specific therapeutic strategies in CCU patients
- PGY-3: Learn how to develop personalized care plans for CCU patients with intersecting clinical problems
- Competancy: Medical knowledge
- Effectively admit patients to the CCU service, develop, and execute assessment and management plans.
- PGY-1: Learn the steps required to admit a patient and initiate admission orders to the CCU. Recognize how to prioritize patient problems in seriously ill patients.
- PGY-2: Develop management plans for problems identified in patients admitted to the CCU
- PGY-3: Understand interactions between patient problems and develop advanced strategies to prioritize management in patients admitted to the CCU
- Competancy: Patient care
- Effectively execute day-to-day management of CCU patients
- PGY-1: Learn the steps required to manage CCU patients on a daily basis including a daily assessment and determining progress in clinical problems
- PGY-2: Understand how to adjust treatment plans for CCU patients based on patient progress and determine the need for additional assistance such as subspecialty consultation
- PGY-3: Recognize how to manage complex medical problems and manage both expected and unexpected complications in CCU patients.
- Competancy: Patient care
- Interdisciplinary care and discharge planning
- PGY-1: Learn how to communicate effectively with the interdisciplinary care team and anticipate patient needs for discharge and effective follow-up
- PGY-2: Recognize the unique needs of CCU patients and help integrate patient needs with available resources
- PGY-3: Learn how to manage advanced situations such as end-of-life decisions, complex transitions of care and advocate for patients when resources are limited
- Competancy: Patient care, System-based practice
- Rational ordering of lab tests and imaging studies
- PGY-1: Learn the indications for basic laboratory investigations and imaging commonly used in the CCU
- PGY-2: Learn how to interpret laboratory findings and imaging in CCU patients
- PGY-3: Gain advanced knowledge of high value principles in the ordering of laboratory studies and imaging for CCU patients
- Competancy: Practice-based learning and improvement, Medical knowledge
- Familiarity with the electronic health record and optimization of its use
- PGY-1: Develop a basic understanding of The EHR and its core components
- PGY-2: Understand and teach others on how to effectively use the electronic health record to care for cardiology patients
- PGY-3: Develop an understanding of advanced medical informatics in the care of CCU patients by utilizing additional resources in the EHR
- Competancy: Systems-based practice
- Communication and teamwork
- PGY-1: Recognize the core members of the CCU patient care team to include nurses, patient technicians, physical therapists, occupational therapists, discharge planners and hospital administration personnel
- PGY-2: Develop effective and timely communication strategies with the CCU interdisciplinary care team
- PGY-3: Use advanced communication methods to engage and coordinate care with the CCU interdisciplinary care team
- Competancy: Professionalism, Interpersonal and communication skills
- Recognizing and responding to medical error
- PGY-1: Understand the basic principles of medical error that can result in diagnostic errors or management errors in the CCU
- PGY-2: Develop an advanced understanding of preventing medical errors in the CCU and recognize the role of cognitive heuristics
- PGY-3: Develop an advanced understanding of responding to medical errors, mitigating risk and communicating error to the CCU interdisciplinary team and the patient
- Competancy: Practice-based learning and improvement
- Structure/Call Schedule
- Admissions/ Caps
- Escalation Policy
- Disposition and Transfers
- Ordersets
- New Parkland Initiatives
Structure/Call Schedule
Team Structure: Each team = 1 resident and 1 intern.
- If the intern is without a supervising resident and there are more than 10 patients on the team on a weekday, the fellow is responsible becoming 1st call provider beginning at 7:30 am for any patients over 10 (responsible for notes, fielding questions, and writing orders for the day).
- If the fellow is in clinic or it is a weekend day, this duty will fall to the buddy resident. The buddy teams (i.e. A and C; B and D) must function as a cohesive unit with sharing of patient care responsibilities across teams.
Work Hours: Post-call rounds begin at 7:30 am. From 7:30-8 the attending will take overnight admissions, and from 8-9 am teaching rounds will take place, with the exception of Wednesdays (Cardiology Grand Rounds).
- Call Intern: Arrive no earlier than 5am and must leave the hospital by 9 pm, and should stop taking new admissions by 5 pm.
- Between 5-7 pm they complete admission notes and stabilize (but not fully admit) new patients.
- Any notes not complete by 9 pm are the resident’s responsibility.
- PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.
- Call Resident: Arrive no earlier than 7am and leave no later than 11am on Post-call. The call resident will admit until 5am post-call. Any admissions thereafter should be stabilized (lines/orders needed for patient care) until the new call senior arrives for full admission.
- Post-call Intern: The intern cannot come in before 5 am (or 8 hours from the time he/she left the hospital).
- Night Intern: Arrives at 7pm and must leave by 9 am.
- Duty hours must be limited to 80 hours per week, averaged over a fluid four-week period, inclusive of all in-house call activities
- Progress notes are NOT expected before rounds.
Days Off: ACGME rules require residents/interns must average four days off in a 4 week period. More days off per week can be taken if arranged in advance and at the discretion of the attending, but no more than 5 days off for any resident or intern.
Evening Rounds (2100 - 2300): We encourage the intern on nights to round on the CVICU (15-400 side) between 2100-2300, to take care of Non-Urgent orders. In return, the nurses will try to avoid paging between midnight - 0600 AM.
Admissions/ Caps
Admission Workflow
- Cardiology fellow will triage non-HF admissions from 7a-5pm, Monday through Friday to ensure patients meet admission criteria and maintain balance of case mix and appropriate educational balance.
- On call resident: please call ADT (x20309) at 7am and 7pm to update them on how many spots remain open on your team.
- All transfers from MICU to CCU (or vice versa) must be initiated at the fellow or attending level. It is the fellow's responsibility to inform the residents about any impending ICU transfers.
Admission Cap Policies
*New changes as of 09/18/2023
- Each call cycle, the team can admit up to 7 new patients and up to 2 transfers from a medicine service in a call cycle. If the team admits seven new patients, they will no longer admit any non-critical patients.
- For example, if you admit 7 new patients and have only gotten 1 transfer, you may NOT take another new admission. You may take another transfer as long as the team cap is not met.
- *There is a reduced Team cap of 8 during the daytime (7AM-7PM) on call days. After 7PM, the cap increases to the full 10.
- *Floor-level admissions are limited to the hours of 7AM-7PM. After 7PM, only ICU or PCU level admissions will be considered for CCU admission.
- Exceptions to this would be at the discretion of the cardiology fellow and/or attending.
- Once a patient is discharged, this immediately opens space under the team cap regardless of time of day. Patients admitted and discharged in the same day count toward the new patient admission cap, but not toward the total team cap.
- For example, if you have 6 patients, discharge 2, then admit 5 new admissions, you have admitted 5 and are still open for 1 more patient (because you would meet your total team cap of 10).
- Residents may not exceed 7 new admissions or 2 transfers in an admission cycle under any circumstances.
- Non-ICU patients will be admitted to the floor.
- For ICU level patients, the attending/fellow will have to take admissions beyond this (H&P, put in orders, stabilize the patient, handoff to overnight resident with to-do's and day on-call fellow to present in the morning). Overnight resident will then be 1st call overnight for cross-cover issues.
- ICU patients over the cap will be re-distributed to the on-call team in the morning and count toward the admission cap.
- Each intern may admit no more than 5 new patients (plus two transfers) in an admitting cycle.
- There is a cap of three profile B heart failure exacerbations per call cycle.
- The first three profile B CHF exacerbations called to you should be admitted without question; there is no minimum level of CHF severity that we admit.
- After these three CHF admissions, only CHF exacerbations requiring ICU level care should be admitted by the Cardiology team.
- After you have admitted three profile B exacerbations, if the ED calls you directly with a profile B, stable HF patient, politely ask them to call the hospitalist first for them to triage.
- If there is dispute, please contact the cardiology fellow or attending to discuss with the Hospital Medicine attending.
- Re-triage of patients who are consulted on cardiology admission team but who are not deemed to be admitted for cardiac-related cases IS allowed (for example, ESRD patients with elevated troponins 2/2 dialysis deficiency, septic patients, hypertensive urgency etc.). Do NOT write a consult note on patients you are not admitting. Call the fellow if needing support or if hospitalist is requesting a note.
Education and Team Culture
- Monday through Friday, the post-call attending will teach the entire CCU team from 8-9am.
- All interns and residents (including night intern) are expected to be present and engaged during this teaching hour, even if patients are being discussed who are not on their superteam.
- Note writing and calling consults is not permitted by any resident or intern during this teaching hour in order to preserve the learning environment.
- If house staff are paged urgently, they are allowed to excuse themselves from the room to manage the urgent issues that arise.
- If a patient is decompensating and requires attending or fellow presence, please alert your fellow so that teaching rounds can be broken to facilitate patient care.
- The superteams (A/C and B/D) should act as superteams rather than four separate teams.
- The buddy resident is expected to be engaged in and participate in rounds when their buddy patients are being discussed.
- The buddy resident is strongly encouraged to know their buddy team's patients as well as their own patients, particularly for critically ill, complex, and tenuous patients.
- The buddy resident is responsible for ensuring their buddy intern is not first call on more than 10 patients.
- A house staff team may not exceed 10 patients on service at any one time. If the post-call census exceeds 10, patients should be transferred to a different cardiology team after discussion with the attending and fellow. Chief residents are available to facilitate this redistribution if needed.
- An intern may not care for more than 10 patients at any one time.
- CCU teams and CCU leadership can (and should) redistribute patients if one side is particularly unbalanced. Residents may initiate this redistribution. Chief residents are available to help facilitate redistribution if needed.
- If an intern has more than 10 patients and no supervising resident on a weekday, the fellow is responsible for becoming 1st call provider beginning at 7:30 am for any patients over 10 (responsible for notes, fielding questions, and writing orders). If the fellow is in clinic or it is a weekend day, this duty will fall to the buddy resident. The buddy teams (i.e. A and C; B and D) must function as a cohesive unit, sharing of patient care responsibilities across teams.
What if you are capped and called for a floor stable admission?
- If a team is capped (7 total new admissions or 10 total patients), you are not to accept new patients that do not require ICU level care.
- After you have reached your cap, and are called for a new admission to the Cardiology service for patients that you feel do not need ICU level care and are more appropriate for Hospital Medicine, please politely inform the ED that you have reached your cap and cannot admit any more patients. Please also call Bed Access Management to update them that you have reached your cap and cannot admit any more non-ICU patients.
Recommendation: When in doubt call your fellow and have them communicate with the hospitalist or ER physicians. Do NOT debate the triage of the patient with the HOD or ER. If you do not feel that the situation requires fellow involvement for clarification, you should probably consider admitting the patient if they have cardiac complexity or are tenuous as a "floor" patient. Remain professional at all times and escalate if you feel the most appropriate service is not clear cut.
Admissions "Over the Cap"
Patients requiring ICU care will be admitted over the admission or team cap. However, per AGCME rules Internal Medicine Residents may not exceed 7 new admissions + 2 transfers in an admission cycle under any circumstances. The patient will be admitted to CCU and should be accepted, then the attending/fellow will have to take the admission and any subsequent admissions. All admissions over the admission cap require approval of the CCU fellow.
Resident “Consult Notes" or "Block Notes"
Residents are not to write any consult or block notes, ie notes that provide recommendations. Residents can write triage notes, i.e., "Patient seen and examined. Plan discussed with fellow. Patient to be admitted to (service), not appropriate for CCU at this time." Subsequent questions regarding reasoning or recommendations should be directed to the overnight fellow. • Residents who respond to cardiology admission pages should not be giving recommendations on patients they are not admitting. • The admitting service can consult cardiology fellow overnight for urgent issues or in the morning for less urgent issues as desired.
Appropriate admissions to the cardiology service:
- Resuscitated primary cardiac arrest
- Myocardial infarction
- High probability unstable angina
- Ventricular arrhythmias Atrial arrhythmias as the primary reason for admission
- Symptomatic bradycardia or advanced heart block
- Symptomatic valvular heart disease and mechanical valve complications
- Aortic dissection
- Hypertensive emergency that requires ICU care. In general, we would like to see fewer patients started on drips in the ER and admitted to ICUs. Severe hypertension that is symptomatic and does not require ICU care should not be routinely admitted to cardiology service
- Advanced heart failure requiring hemodynamic support, ventilator support, or ICU care.
- Decompensated heart failure not meeting the above criteria, up to the admission caps (see below for details)
- Patients with other causes for volume overload (renal failure, nephrotic syndrome, liver disease) should not be admitted to the cardiology service.
- Patients with complications due to a cardiac procedure
- Cardiac device malfunction or infection
- Other diagnoses less common but primarily cardiovascular in nature
Escalation Policy
Role of the Fellow:
It is required that the on-call fellow communicates by phone with the on-call resident between 10-11 PM each night. During this call, the fellow will review all new admissions, as well as any existing patients with active or critical issues.
Resident Escalation Policy:
Housestaff must call fellow when:
- A patient is admitted to the CCU/ICU
- A patient who was on the floor/telemetry requires transfer to the CCU
- A patient newly requires pressor, intubation, or positive pressure ventilation
- A patient is admitted with a real NSTEMI or STEMI
- A major medical or procedural complication occurs
- They think a patient should be re-triaged to another service. They may not block admissions under any circumstances
- Housestaff are encouraged to call attending directly if they have any concerns or fellow is not responsive
Disposition and Transfers
Discharge etiquette:
If your patient is discharged with CHF clinic follow up, please route the discharge summary to the APP or fellow who will be seeing your patient in clinic. The best way to find who this provider will be is to go to Chart Review-->Encounters, and then look at the CHF clinic appointment. The APP/fellow assigned to see your patient will be listed in the appointment details. If your patient has been seen in the CHF clinic in the past, they'll be scheduled with the same APP or fellow the next time they're scheduled, meaning you can forward the discharge summary to the CHF provider who most recently saw your patient.
Transfers off the CCU Service:
There may be occasions when the patient's cardiac issues have resolved but needs to remain in the hospital for other significant workup. The remaining workup should be medically substantial/significant, not something such as medication titration or disposition. In these rare cases, your attending may discuss transferring the patient to a medicine team.
This can be either a teaching team or a hospitalist team. If you think the case is good for a teaching team, the CCU Resident should discuss this with the Wards Resident. Only if it is okay by the Wards Resident/Team, you may transfer to the teaching team. The teaching teams are limited to 1-2 transfers on a call day. Otherwise, you must consult the Hospitalist service to discuss transfer.
If/when the accepting team confirms they will take the patient AND you have given verbal handoff, please place a "Change Treatment Team" order. Either the CCU or the teaching team can update ADT and inform them of the transfer.
Ordersets
- Sepsis Orderset
- cardiology non-ICU (for admissions)
- CHF Admission
- cardiology only - acs nstemi/UA
- cardiology only - ACS STEMI Admission
- Therapeutic Heparin Orderset
- PRE CARDIAC CATH - inpatient
- CVTS
New Parkland 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 Sepsic Order Set slide deck.