Daily Procedures & On-Call

Daily Check In/Out Procedures

Teams

All ward team members should check out together between 3:30pm-6:30pm.

All ward team interns should check in with the ward team senior residents each morning to discuss the status of their patients and divide up any new patients and responsibilities.

Senior Residents

One senior resident from the ward teams and one from the ICU/CCU will check out with the night senior resident at a posted time for ongoing cross coverage supervision.

The team senior residents do not leave the hospital before the interns on their team(s) have completed their work.

Night senior residents should check in with team senior residents prior to morning report to allow distribution of admissions that may not have been covered by interns overnight.

On-Call Schedules

On-call schedules are circulated on a monthly basis. All vacation and scheduling requests are submitted in writing prior to the first of the month preceding the scheduled request; e.g., if a resident has a vacation request for September, this request must be submitted before August 1. Every attempt is made to comply with vacation requests, but approval is not guaranteed, particularly during the months of December and June. Any changes in the on-call schedule must be approved by the Internal Medicine Department.

All residents are required to have one 24-hour period each week without patient care responsibility. Therefore, weekend cross-coverage is shared between ward senior residents, ICU senior residents, and ward and ICU/CCU interns.

Senior On-Call Schedule

Weekend on-call assignments are divided among the senior residents who are on electives; the ward and ICU/CCU senior residents share in this weekend call.

Medical Ward Intern On-Call Schedule

Each ward team is comprised of one resident and two interns along with acting interns and medical students. Each team is on long-call every third day and accepts admissions from 7am– 3pm or 3–8pm on weekdays, while on weekends admitting team is on call for 12 hours (8am–8pm). Each new patient is evaluated by the senior resident on call, along with one of the two interns on call. New admissions (up to 10) are distributed equally between two interns. Any overflow patients admitted during the night before by night float team are distributed to a team not on call.

CCU/ICU Intern On-Call Schedule

As per ACGME guidelines, no intern is involved in a 24-hour call. Maximum time allocated for service is 16 hours for first-year residents and is strictly enforced by the department. When post-call, the intern is responsible for attending teaching round and completing work rounds on his/her patients. The intern is then able to check out with his/her team senior resident and the intern on-call for the team that day. Patient care responsibility should be targeted to end at 11am so that the post-call intern can leave no later than noon.

Jeopardy Policy

Patient care responsibilities must be covered at all times. Therefore, if a resident is sick he/she must notify the Department of Medicine office as soon as possible so that the resident on jeopardy call can be notified. At night and on weekends, the admitting medical resident is notified, and he/she contacts the resident on jeopardy call. All jeopardy calls must be paid back with a comparable call at the convenience of the jeopardy resident. When on jeopardy call, a resident must be reachable by pager at all times and be available to relieve the ill resident on a timely basis. Responsibility for the sick intern's patients is delegated to the intern’s team members by the team senior resident until the jeopardy resident can get to the hospital. If possible, the team senior resident assists in this coverage. It is imperative that those covering the sick intern's patients remain in contact with the patient's attending physician(s).

Admissions

At the request of an attending physician, an admission to be covered by the internal medicine residents is evaluated by a senior medical resident, as well as an intern. The senior resident is required to evaluate the patient, write a concise admitting note, immediately write any urgent orders or those necessary to expedite the patient’s transfer to a bed (if in the ED), and notify the intern of the admission. Following the intern's history and physical examination, the senior resident reviews the differential diagnoses and proposed treatment plan for the patient. The senior resident then reviews the intern's notes and orders and ensures that the attending physician is notified of the patient's condition as promptly as possible. In general, this process should take no longer than 90 minutes.

After being notified of an admission, it is the intern's responsibility to complete the orders and have them on the chart promptly, and to notify the attending physician promptly of the therapeutic plan of action, as well as any significant changes in the patient's status. The intern's admission history and physical is expected to be thorough and include a review of the patient's past medical charts, if available. All direct admissions and requests for medical consults are discussed directly by the attending physician with the senior resident on call to assure the appropriateness of resident coverage and to ensure an optimal learning experience. Only those attending physicians who play an active role in the teaching program and are approved by the program director are eligible for resident coverage.

On-Call Limits

1. An intern is not assigned more than five patients requiring extensive workup, plus two patients requiring limited workup (e.g., most observation patients and some consults), for a maximum total of seven patients in a 24-hour period.

2. After the limits have been reached, the senior resident in charge assesses each patient and personally works out a disposition with the attending physician. Options are as follows:

  • Follow the patient through the night. This may bring the senior resident’s workload to 10 patients. Patients not covered by interns overnight are turned over to a ward team senior resident prior to morning report.
  • Turn the management of a patient beyond the tenth patient over to the other senior resident in-house. This senior may also manage up to 10 new patients on a shift. Again, those patients not covered by an intern at night are turned over to a ward team senior resident prior to morning report.
  • Consult with the attending physician on the initial orders and then turn all responsibility for further care of the patient over to the attending physician, making sure that he/she knows that the house physician can be called for a history and physical examination and/or any problems or further orders.

3. First-year residents will not be assigned more than eight new patients in a 48-hour period. Second and third-year residents will manage no more than 16 new patients in a 48-hour period.

4. A first-year resident is not to be responsible for the ongoing care of more than 12 patients at one time. A senior resident is not responsible for more than 24 patients at one time. [This excludes cross-coverage patients.]

5. Team leaders should distribute assignment of admissions to interns in such a way as to meet this requirement. If the above limits are exceeded for any reason, this should be reported to the program director, associate program director or chief resident immediately.