Team Structure

• There are 4 teams (I and III on one side, II and IV on one side).
• Staff: A total of 4 residents and 5 interns are assigned to this service at any one time. The residents consist of 3-4 UTSW residents and 0-1 Methodist residents. The interns will typically consist of 2 ER interns and 2 Methodist interns, but at certain times of year there is scheduled coverage from UTSW interns. There are also 3 nurse practitioners who are present Monday-Friday with 1 NP present over the weekend.
• Call Structure: Each team consists of 1 intern and 1 resident on a q4 call cycle. Residents do 28-hour call during the rotation. Interns do day call in a q4 cycle, and an overnight UTSW intern will admit overnight as part of a "night float" rotation.
• PA/Advanced practitioners: There are 3 advanced practitioners currently in CPICU. At least 1 NP will be present during the week, 1 NP will be present during the weekend, working from 7 am to 7 pm. They can take admissions on a call day or take patients post call to offload the post call team.
• Night rounding with the Assistant Unit Managers -- overnight, there is always an assistant nurse manager available to assist with patient issues and to ensure that orders are being completed on time. Mercy Tezock and Esther Okon are fantastic resources and will come to round with you at least once a night. Assistant Nurse Manager Schedule
  • NP Caps: Soft cap 3 patients per NP. Hard cap 5, as long as the NP census can be reduced to 3 during the day.
  • Triage: Resident triages which patients go to the intern and which patients go to the midlevel service. Can assign mild to moderate acuity/complexity, ie post procedural, stable NSTEMIs, cardiogenic shock patients without swans, stable severe sepsis. If there is uncertainty on who the patient should be assigned to, discuss with your fellow.
  • Supervision: The NPs will present, write notes, and put in orders. Residents/interns do not need to review the NPs' orders.& However, treat your NP as your "buddy". The resident/intern should be aware of the plans on the patients on their side. Resident and interns need to round with their NP on patients that overlap. That way, if a different NP as on the following day, the resident/intern can still provide information on the patient's clinical course.
  • Please allow at least 1 computer in the team room for the mid-levels. They will be a help to incoming interns and residents and can answer a number of questions.
  • Sign out: NPs will sign out to resident after day shift is over. NPs will hand off to NPs from week to weekends. Interns can talk to the NPs to learn the logistics and workflow of CPRS/VA CPICU.
  • List: the NPs will update the patient list printed daily.

Rounding and Call Rooms

Admissions, Re-Triage, Transfers

• The patients admitted to the service are those requiring ICU-level care or whose course requires ICU level nursing or monitoring.

• For patients that are admitted in the 5am-7am window period. The off going call resident is responsible for seeing the patient, stabilizing them and putting in admission orders until they can hand off to the incoming call resident and intern. This is to prevent delays in care for these tenuous patients.
• Only patients with ICU criteria should be accepted to the VA CPICU resident service. If stable, these pre/post procedure admissions should be taken by the APP (e.g. post lead extraction, post complicated PCI, tight left mains waiting for CABG, pre-transplant workup, etc.) - these can be discussed on a case-by-case basis.

Retriage Policy

• In general, the threshold to be admitted to the VA ICU is lower, than other sites. Please be conservative with retriages.
• Patients that are not felt to be appropriate for the ICU after seeing the patient:
  • Daytime Retriage: must be discussed with the attending or day fellow. Once the decision is made, then the plan(admit or retriage) can be communicated to the floor or ED team.
  • Nighttime Retriage: Needs to be discussed with the in-house pulmonary or cardiology fellow. The plan/discussion (admit or retriage) must then be communicated to the floor team or ED that requested MICU/CCU services.
• Please write a retriage note under the title "critical care note" if you retriage a patient after discussing with the on-call fellow. Add the physician (floor or ED) who requested MICU/CCU services as a co-signer, and add the language below in your note. Do not write recommendations in your note. “Discussed with overnight pulmonary/cardiology fellow. Discussed disposition plan with Dr. **** of the [hospitalist, ED, etc.] service who agreed with the plan.”
• If a transferring/admitting physician calls the MICU/CCU resident and asks the MICU/CCU resident to triage the patient to MICU/CCU or floor, this is not appropriate. If this occurs, please ask the transferring physician to state if they would like to transfer the patient to the MICU/CCU. Upon evaluating the patient, if the MICU/CCU resident feels the patient is not appropriate for MICU/CCU, please follow the above retriage procedure.

Transfers

• Transfers must be approved by attending or fellow.
• You must see the patient on the morning you transfer to ensure they are clinically appropriate for transfer.
• You must call bed control (ADT 71454) and notify them of the transfer. If you have a specific teaching team (A-C or E) you wish to send the patient to, please note that to ADT. Do not call wards teams to sign out a patient before speaking with ADT. Transfer orders should be placed before calling ADT to allow ADT to make a choice regarding which team should accept the patient.
  • Transfers from "ICU" to "Medicine" status can only be accepted by the hospitalists if the patient is physically out of the ICU. Transfers from "ICU" to "Step Down" status can be accepted by hospitalists even if the patient is physically in the ICU.
    • To reach any of the on-call hospitalists, call 325-433-9937
  • Wards teams may accept patients who are still located in the ICU regardless of status. The swing shift may only accept one ICU transfer per day.
• When giving sign out to the wards team, please ensure you know what brought them in, their ICU course and know follow up items/problems for the wards team.
• Write a transfer note written within 1-2 hours of transfer containing: 1) A brief ICU course 2) Physical exam 3) Follow up items for the new team.

Team and Admission Caps

• Total service cap: 24, Team cap of 10;
• The total cap for the NP service is 4 patients (cap of 3 if there is only 1 NP).
• No intern should take care of over 10 patients; buddy residents should be first call on and write notes for any patients over the team cap of 10.
• Admissions over this cap should be admitted and stabilized by the on-call resident and then transferred to the anesthesiology team with a pulmonary and/or cardiology consult. These patients should be watched closely by the fellow/consult team and if they are complex, can be transferred back to the unit once the teams are under cap again.
• As the combined ICU/CCU wards only have a total of 20 beds, residents may have patients located in the SICU/TICU (up to the total service cap of 24 or individual team cap of 10).

Hours and Days Off

Hours

• Day Call interns: Arrive no earlier than 5 AM (can arrive later if census is low), admit until 5 PM, sign out to night resident and depart by 9 PM.
• Non-call interns: Arrive no earlier than 5 AM (can arrive later if census is low), sign out to night resident and depart by 7 PM.
• Residents
  • Call: Arrive no earlier than 7 AM on call days, depart no later than 11 AM on post-call days.
  • Non Call days: arrive no earlier than 5 AM, depart by 7 PM. Pre-call resident is expected to stay until at least 5 PM to help the buddy team.
• Night float intern: Arrive by 7 PM, leave after presenting new admissions, no later than 9 AM
• NP: hours are 6.30am - 6.30pm, and they can admit from 7am to 4.30pm. They work on weekends but do not take night call.

Days Off

• Interns: traditionally, interns choose a pre-call day in the call cycle to take off.
• Resident: traditionally, residents choose a post post call day in the call cycle to take off.
• Which days to take off can be determined amongst your team, and will depend on many factors, including the patient load per team, the workflow of the residents (e.g. residents switching from days to nights, arrival of a new interns to the team), and the acuity of your census.

Rounds and Teaching

Nights

• The overnight night intern is responsible for admitting new patients with the on-call resident. This means writing H&P’s and presenting the admissions on the post-call morning.
• The on-call resident will perform cross cover on patients overnight from all teams. The overnight intern is invited to discuss with the senior resident ways in which they may take on additional responsibility at their discretion without expectation.
• Since there will be only one ICU resident, when additional clinical support is needed, i.e. multiple codes, procedures, multiple decompensating patients, the on-call CPICU resident is expected to call the moonlighting fellow. The fellow must be present to assist.
• A gap in 2-resident coverage may exist from 5:00 PM - 7:00 PM when the pre-call resident is free to leave and the overnight intern has not arrived. Sunday through Thursday the Swing Shift Resident is available for support. On Friday and Saturday one of the Wards Residents will stay until 7 PM and is available for additional support for the VA CPICU resident.
• The overnight moonlighting fellow is listed in Amion with login "dallasva" and name and number is listed under "ICU Night Hospitalist"
  • On the rare occasion there is no moonlighting fellow, please call the day fellow then attending if needed for any urgent situations. 
• After-hours admissions should be run by the on-call pulmonary or cardiology fellow by the resident at 10 pm. Admissions after this time can be staffed the following morning. However, any complex patients, e.g. triple pressors, high PEEP’s, etc., or decompensating patients should be discussed with the on-call pulmonary or cardiology fellow at any time with a low threshold.
• Night rounding with the Assistant Unit Managers -- overnight, there is always an assistant nurse manager available to assist with patient issues and to ensure that orders are being completed on time. Mercy Tezock and Esther Okon are fantastic resources and will come to round with you at least once a night. 
• Please refrain from using personal pagers when possible in the ICU - in order to centralize communications, please emphasize the use of team pagers.

Supervision

• There is 1 cardiology and 1 pulmonary fellow. They are expected to help residents with triage decisions and clinical management.
• If it is felt that safe care can not be provided (i.e, multiple admissions, multiple decompensating patients), you must call the fellow to come help with admissions overnight. There remains a low threshold to call the fellow if you need help with a critically ill patient.
• The overnight moonlighting fellow is listed in Amion with login "dallasva" and name and number is listed under "ICU Night Hospitalist"
  • On the rare occasion there is no moonlighting fellow, please call the day fellow then attending if needed for any urgent situations.