Faulkner General Info

  • Room codes:
    • Pariser work room / conference room (on the 6th floor just before the double doors to the OR): 1-2-3-4-5-6. (NOTE work room is now combined with conference room)
    • Morning report and conferences ARE MANDATORY. There are only 10 residents at any given time at the Faulkner, so it is obvious and awkward if even a couple people miss morning report or noon conference. Faculty are often travelling from the Brigham and are booked out months in advance. You are not to miss morning report unless there is an EMERGENCY. Please let us know if you are unable to attend educational activities because rounds are taking too long.
  • Please involve the RNs in your rounds or card-flipping in the morning, and let them know early if you have any potential discharges for the day.
  • The long call resident and intern carry physical code pagers.
    • The long call resident and intern go to all rapid responses and code blues as the rapid response team. The long call resident is the rapid response leader. The FICU resident only goes to codes and is the code leader.
    • If during a rapid response it is felt that the patient will need higher level of care (FICU transfer), the rapid response leader should immediately contact the FICU resident. Patients must be accepted by the FICU resident or attending prior to transfer to the FICU; the rapid response leader is not able to directly admit patients to the FICU.

If there are any issues or concerns, please page the Faulkner chief medical resident (CMR).

Team Structure

There are four housestaff GMS teams arranged into two “dyads” (A and B). Each team has one day resident and one intern, and each dyad has one hospitalist attending (designated hospitalist A and B).

There are 4 non-teaching medicine teams called the FACT (Faulkner Attending Clinical Team) teams, each with one attending and one mid-level provider. The entire Medicine service is located on the 6th floor—GMS (housestaff) teams generally admit to 6 South and South Center and the FACT teams admit to 6 North and North Center.

The teams rotate on a Q4 call schedule as follows:

  • Long call:
    • Admits a maximum of 5 new patients + 2 holdovers/ICU callout (total 7 patients), or to team cap of 10 patients, whichever happens first (the long call team cannot admit beyond its cap).
    • There are no admissions after 7:00PM (determined by time of admission page)
    • Signs out to the twilight resident between 7PM and 10:00PM (at the discretion of the twilight resident based on workflow)
  • Post-call:
    • A normal day without admissions
    • Signs out to the twilight resident at 3:00 PM
  • Short call:
    • Takes the majority of holdovers (4 if normal census, up to 7 if extreme census)
    • If normal census and receives fewer than 4 holdovers, can admit until 2:00 PM until new patients (holdovers + new admits) reaches 4 total or the team reaches its cap of 10.
    • If intern (not resident) has clinic, no admissions after 10:00 AM.
    • Signs out to the twilight resident between 3:00 PM and 7:00 PM (at the discretion of the twilight resident based on workflow)
  • Pre-Call
    • Takes up to 0-3 holdovers per the admitting algorithm below.
    • Signs out to the twilight resident at 3:00 PM.

Twilight Resident

On weekdays (Mon-Fri):

  • Twilight resident arrives at 3:00 PM except on days when two or more day residents have clinic OR both the resident and intern on one team have clinic, then the twilight resident will come in at 12:00 PM to provide coverage.
    • Takes sign out from pre-call, post-call, and short-call teams starting at 3:00 PM
    • Takes sign out from long call team between 7PM and 10:00 PM
    • Admits up to 5 patients per night between 3:00 PM and 10:00 PM
    • Signs out to 6S moonlighter at 11:00 PM
    • Expected to hold the RRT/code pager until 11 PM when you sign out to the 6S moonlighter.
  • ‘Golden Hour’ between 6:00 PM and 7:00 PM: If the long-call team receives more than 1 admission after 6:00 PM, it is strongly suggested that they take the first of these admissions and Twilight help by taking any additional admissions between 6:00 PM-7:00 PM, which will be pass-backs to the same long-call team the next morning.
  • Teaching Encounter: around 11pm (signout time), the twilight resident and nocturnist meet briefly to discuss a case with an emphasis on an aspect of management or question that you may have. The nocturnist should reach out 1-2 hours before signout to obtain the MRN so that they can review the case; then, you can briefly discuss the case (5-10 minutes) around the time of signout.

Late BWH/OSH Transfers: Any outside hospital transfers (including BWH ED admits) after 5:00 PM should be admitted by Twilight residents to avoid long-call teams staying late. These admissions taken by the Twilight residents will be passed-back to the same long-call team the next morning.

On weekends:

  • Saturday is the twilight resident’s day off
  • Sunday
    • Arrives at 1:00 PM and takes sign out from the weekend rounder (taking care of the short call list) and post-call team (taking care of the post-call and pre-call list)
    • Takes sign out from the long-call team between 7:00 PM and 10:00 PM
    • Admits up to 5 patients between 1:00 PM and 10:00 PM
    • Signs out to the 6S moonlighter at 11:00 PM

In general: If you need in-house backup for any reason, please reach out to the FACT nocturnist, which you can find in the Paging Directory under “Medical Residents.” The 6S moonlighter and FICU moonlighter should be able to provide assistance as well as need be. If multiple rapid responses are called on a single patient on a non-medical service, recommend transfer to medicine, which should result in an admission to the nocturnist. Please do not hesitate to page the Faulkner CMR or BWH Phys for any matters.

Bounce-back Policy

Patients will bounce back to the original team if:

  • (Post hospital discharge) Patient returns to the hospital within 48 hours of discharge (for whatever reason). If the team is not physically in-house, long call will admit the patient as a passback. Bounce-backs CAN be accepted post-call.
  • (Post ICU transfer) Patient is called out from the ICU within 72 hours of transfer in. If the team is not physically in-house, the long call team will admit the patient as a passback.

Patients are not eligible to bounce back to the original team if:

  • They are not in-house AND will not be in-house the following morning to accept a passback (i.e. weekends).
  • The entire original team (intern, resident, and attending) is off service.

Bouncebacks will count toward total team census cap but will NOT count as an admission.

Night Coverage

There are no interns overnight. The overnight coverage will consist of 3 people:

  • FACT Nocturnist 1 (A,B) and FACT Nocturnist 2 (C, D) (7:00 PM – 7:30 AM): Attending-level provider who cross-covers all non-teaching patients (FACT teams) and admits preferentially to FACT, but can help with GMS admissions after 10 PM.
  • 6S Moonlighter (6 PM – 7:30 AM): Admits preferentially to FACT from 7 – 10 PM and to GMS from 10 PM – 7 AM, and cross-covers all GMS teams from 10 PM – 7 AM.
  • The FACT Nocturnists’ identities on a given night can be found under “Medical Residents” in the On-call Directory. Night pass-off is given to the 6S Moonlighter.

FHnocturnist.png

Weekends

Faulkner WER

  • Saturday: The WER covers the old patients and accepts holdovers for the golden team (Short Call on Saturday). The old patients on the pre-call team are covered by the post-call resident (the resident from the same dyad).
  • Sunday: The WER again covers the old patients for the golden team (now pre-call), and accepts holdovers for the Short Call team. The old patients on the Short Call team are covered by the post-call resident (the resident from the other dyad).

Weekend Signout

  • On Saturdays the WER can sign out to the Weekend Admitter Moonlighter starting at 1:00 PM. The post-call team can sign out to the long call resident starting at 1:00 PM. The long call team signs out to the 6S Moonlighter at 10:00PM
  • On Sundays the WER and post-call team can sign out to the Twilight Resident starting at 1:00 PM. The long call team can sign out to the Twilight Resident between 7:00 PM and 10:00 PM.

Holdover Distribution

  • Extreme Census rules will assign holdovers to long call, which is protected from holdovers to preserve admitting capacity during the day. Please note that Extreme Census rules do NOT apply on weekends because the pre-call team cannot accept holdovers. The following algorithm will be used for distributing holdovers:

FH Holdover 20170616.gif

  • Note: if Short Call is capped (at 10 patients), holdovers will overflow first to the Pre-Call team, then to the Long Call team.

Passoff and passback emails

  • Golden weekend team: The Golden weekend team will be covered by the WER. On Friday, the resident for the Saturday Short Call team (the team that will have the weekend off) will send a passoff email to the WER. On Sunday, the WER will send an updated passback email including the Short Call admits from Saturday back to the primary team.
  • Gray weekend (off Saturday) team: On Friday, the resident for the Saturday Pre-Call team will send a passoff email to the Saturday Post Call Resident. On Saturday night, the Saturday Post Call resident will send an updated passback email with no new admits.
  • Gray weekend (off Sunday) team: On Saturday, the resident for the Sunday short call team will send a passoff email to the Sunday Post Call resident. On Sunday night, the Post Call resident will send an updated passback email to the primary team. This team will receive a second passback email from the WER with the short call admits from Sunday.

Clinic

  • You can have clinic any day except your long-call day. If you notice that you have a clinic scheduled on a long call day, please alert the Faulkner and BWH chief residents.
  • If a resident is in clinic, the resident from the same dyad (same attending) will provide supervision for the intern.
  • If two or more residents are in clinic, the twilight resident will come in at 12pm to provide coverage.
  • If an intern is in clinic, they should sign their list out to their resident.
  • If a resident and an intern from the same team are both in clinic, the twilight resident will come in at 12pm to cross-cover their list.

Morning Rounds

Interns should pick up signouts from the Nocturnist by 7:00 AM at the latest in the 6th floor workroom, and have from 7:00 AM – 8:00 AM to finish pre-rounding.

Morning walk rounding should start as close to 8:00 AM as possible, or 8:30 AM at the latest. You do NOT need to have the RN join you for rounds – they have requested to NOT join for teaching/walk rounds, as they will join for IDR later in the morning.

The recommended rounds schedule is as follows:

  • 8:00-9:00 (or 8:30-9:15): one half of each dyad rounds
  • 9:00-10:00 (or 9:15-10:00): the second half of each dyad rounds
  • 10:00-11:00: all housestaff and students attend teaching conference on M-W
  • 11:00-11:30 (except on Thursday when IDR/SIBR starts at 10:30)
    • A1 and B1 SIBR rounds
    • A2 & B2 card flip on remaining patients with attending
  • 11:30-12:00:
    • A2 and B2 SIBR rounds (Glass Cubbies on 6S)
    • A1 & B1 card flip on remaining patients with attending

Interdisciplinary Rounds (IDRs)

Interdisciplinary Rounds (IDRs) are held from 11:00 AM – 12:00PM on the 6S and 6SC.
These are attended by a variety of support staff including the patients bedside RN, care coordination, nursing supervisors, physical therapy, and social work. IDRs are extremely important for coordinating care for your patients and planning disposition.

You will get a separate email about these new IDRs – they are now called “SIBR rounds”. There is a scripted format that they will follow. You lead them, and you can just follow that script. It will be sent in an email before you start here, and will have multiple copies available in the workroom in the AM.

Example Schedule:
11:00-11:30

  • A1 SIBR rounds (Glass Cubbies on 6S)
  • B1 SIBR rounds (Glass Cubbies on 6SCenter)
  • A2 & B2 card flip on remaining patients with attending

11:30-12:00

  • A2 SIBR rounds (Glass Cubbies on 6S)
  • B2 SIBR rounds (Glass Cubbies on 6SCenter)
  • A1 & B1 card flip on remaining patients with attending

Teaching Conferences

Below is a list of all the teaching conferences at the Faulkner. It is expected that housestaff will attend ALL conferences.

  • Morning Report, 10 AM – 11 AM on Mon/Tues/Wed & 12 PM – 1 PM on Fri (Pariser Conference Room)
  • Noon Conference, 12 PM – 1 PM Mon/Tues/Wed (Pariser Conference Room)
  • Medical Grand Rounds, Thursday 11:30 AM – 12:30 PM (Huvos Auditorium)
  • Radiology Rounds, Thursday 12:30 PM – 1:00 PM (Pariser Conference Room)
    • One of the staff radiologists will be available to review imaging studies on GMS patients.
  • Faulkner 5, 3PM – 3:05PM on weekdays (6S work room)
  • Attending Teaching Rounds, 7:30 AM – 8:30 AM on Fridays: Teams will meet with their attendings for breakfast and teaching. The A teams will meet with GMS Attending A in Pariser conference room, and the B teams will meet with GMS Attending B in the resident work room.

Teaching Responsibilities for Twilight and Day Teams

Faulkner 5

  • This 5 minute teaching session will occur 4 days per week at 3:00 PM in the 6S work room (the off day will be the day that the CMR is in clinic).
  • The Faulkner Chief Resident, day residents (F-GMS and FICU), and twilight resident will divide the days so that the chief and day residents each teach once and the twilight residents teaches twice during a 2-week block.
  • Teaching sessions can be on any topic, should take 5 minutes to deliver, and no more than 20 minutes to prepare.
  • Previous topics have included: transfusion reactions, hypertensive emergency, hypokalemia, pearls of managing GI bleed, indications for PPM placement, constipation management, interpreting an SPEP, diagnosing HIT, approach to hyponatremia, etc.

Other Work Flow Issues

  1. At the Faulkner, the admitting page and passoff page is one and the same. This means that when you get an admit page, the Faulkner “rule” is that the ED should be called back within 15 minutes (either by the intern or the resident). If both intern and resident are occupied, with a sick patient for example, please ask the unit secretary to call the ED back to let them know that you will be delayed. Please note that the ED can technically send the patient to the floor anytime after 15 minutes from the initial admit page (unless notified that the floor physician needs more time before passoff), even if passoff is not given.
  2. If you need additional resources to expedite patient care or if you’re getting pushback from RNs for expediting patient care, please contact the nursing supervisor at p66160 – they can be a huge resource.
  3. When you are accepting an ICU transfer, our goal is for them to the floor before 2 PM. However, due to lack of bed availability this may happen later at times.
  4. Tobacco cessation education is done at the Faulkner by respiratory therapists, however, there must be an order placed by an MD. Please order tobacco cessation education for all your patients with nicotine addiction. The order can be found by typing tobacco and is called “Tobacco cessation education.”
  5. You can ask the unit secretaries to make discharge follow-up appointments, though technically, they are not required to do so. This should be done before 2 PM on the day before discharge. The appointment will be directly entered into Epic. The unit secretaries have asked that you please specify if the patient has seen the provider before. For any same day discharges, please give a verbal heads-up to the secretary—they will do their best to make this appointment but there is no guarantee for same-day requests. Patients going to rehab do not need a follow-up appointment; just write “patient will follow-up with Dr. —– after discharge from rehab” in the discharge documentation.
  6. If you need a patient to travel somewhere on tele, unfortunately it will have to be you (intern or resident) to go with them. The only exception is if you call an RRT, in which case the ICU nurse comes and can go with the patient. For all cases of acute stroke (RRT or not), an MD must travel with the patient.
  7. Every patient admitted to GMS must have a “Patient Status.” A recommended status is included in the admission page, but use your judgment once you see the patient. It is easier to change a patient from Obs to Inpatient than vice versa. After the initial order, please do not change a patient’s admission status unless told to do so by the case manager.
  8. When you place a head CT order, please only order it as head CT (stroke protocol) if you mean for radiology to clear the CT scanner emergently.
  9. Remember to use the TELESTROKE service for any patient you or any care provider suspects an acute stroke syndrome. The “code Stroke” here at Faulkner necessitates STAT NCHCT (nurses/nurse admins know this) and also part of the workflow includes the ICU nurse bringing the telestroke machine to the patient. On this system are step-by-step instructions on contact and teleconferencing in the MGH/BWH stroke fellow to determine triage and to directly consult on decision making re: tPA immediately, or transfer to either BWH/MGH for intrarterial tPA or clot removal. DO NOT PAGE THE NEUROLOGY CONSULTANT ON CALL IN THIS SCENARIO, USE TELESTROKE.
  10. TTEs, stress tests on weekends can be done if order placed before 10am
  11. Psych consults: EtOH/drug withdrawal is handled by the “Addiction Recovery” service. The general psychiatry consult handles all other psych related questions. Also, for patients being transferred to or from the inpatient psych ward, a formal discharge is required in Epic. If a patient is coming from 2S to the GMS team and the team wants psych to continue following the patient, you will need to place a new psych consult, since the in-patient psych ward and the consult service are covered by different physicians.
  12. Please note that stress MIBI tests are NOT read at the Faulkner: You should not call the Faulkner stress labs for the results of NUCLEAR stress tests. These are read over at BWH, please call 857-307-2000 to reach the nuclear reading room.
  13. All patients traveling from the Faulkner via AMBULANCE ON DISCHARGE need a DNR/DNI form signed. In addition, patients travelling by ambulance can only be FULL CODE or DNR/DNI for now. Please work with patients and their health care proxies to make this decision early re: code status for transport.
  14. If either the team resident or intern is interested in getting Vocera, please contact John Wright at x7609.
  15. Dermatology consults: during business hours (8am-4:30pm), call Derm office at x7324 and give details to front desk staff, as well as IP Consult order in Epic. Drs. Frangos and Balash will see the patient. After hours, please page the BWH on-call attending listed by date in PPD. Specify that the patient is at the Faulkner.
  16. Phlebotomy lab draw times: 7am, 11am, 4pm, 8pm. Night round times: 1am, 4am (order these as STAT). If timed labs are required overnight at a specific time, these should be ordered STAT and communicated directly with the nurses so phlebotomy can be paged separately outside of the night round times. If you notice that routine labs are not being drawn, please file a safety/incident report so we can log a case and bring it to the attention of the nursing supervisor/phlebotomy departments.
  17. Door signage: If a patient’s name has a purple/violet backdrop, they have been flagged for potential behavioral issues, so please exercise extra caution when entering their room. If you see a foam butterfly on the door, this patient is CMO/inpatient hospice, so please try to maintain a peaceful and respectful environment outside their room
  18. Inpatient hospice care: If you have a patient who is CMO and may be appropriate for inpatient hospice, they may be eligible for inpatient hospice services at Faulkner. Faulkner has contracted with a hospice agency Care Dimensions that can provide end-of-life services for patients and their families while they are admitted. If you think you have an eligible patient, please bring this up on rounds with social work/case management and consult pain/palliative care, and they can start the screening process. You can use this sheet as a guide for orders and find the policy in Euclid under Resources in Epic: BWFHGIPTipSheetJan2019.pdf. You can always also reach out to the Palliative Consultant on call for help.
  19. “Interpreter on wheels:” These iPad-based video workstations are available for patients by requests. If you need one, please notify John Wright or Gary Williams via vocera

Computing

  • Computers on Wheels (COWs): Each team has a COW designated for the team. If your computer is not working, call IT at x7454 (device number is listed on the label on the front of the computer) and report it immediately. Please store your COWs in a safe place (ie the workroom or Pariser) so they do not walk off!
  • Paper and toner supplies for the resident workroom will be supplied by the Department of Medicine. Let the chief medical resident know when supplies are running low.

Code Pagers

You will use your usual BWH pager while you are the Faulkner. The long call resident/intern code pager is a physical blue pager that is handed off to the 6S overnight moonlighter once all housestaff lists are signed out.

Note that the FICU resident is the code leader during the day and the FICU moonlighter is the code leader at night. If you need someone intubated, you must call the ED attending after hours (or anesthesia during business hours), as they do not respond to Code Blues automatically.

Medicine Consults

Covered by GMS Hospitalist Attending from 7 AM – 7 PM and by the FACT Nocturnist Attending from 7 PM – 7 AM.

Food

  • Breakfast: A luxurious continental breakfast is provided every weekday in the 6th floor workroom starting between 7:00 – 8:00 AM. It is the long call resident’s responsibility to get it from the cafeteria.
  • Lunch: Provided at noon conference every weekday in the Pariser Conference room. On Thursdays, you can get lunch in the Pariser Conference room during radiology rounds at 12:30 PM. In the unlikely event that you miss lunch or the food runs out (which does not usually happen here) you can get a meal ticket from Susan Cohen, Kathy Hanley, or the CMR in the Department of Medicine office on the 4th floor.
  • Dinner: You will be given cafeteria meal tickets for dinner for the nights that you are on long-call. The cafeteria closes promptly at 7:00 PM and you should arrive by 6:30 PM to ensure that you can get food.

How to get here

Brigham and Women’s Faulkner Hospital
1153 Centre Street
Boston, MA 02130
(617) 983-7000

  • By shuttle bus from BWH: schedule is available here: [1]
  • By bicycle: bike racks are available in the parking garage and close to the main entrance (facing Centre St)
  • By car: parking is available at a garage behind the hospital. When you park the first day, take a ticket. After you get your Faulkner ID, visit the parking office (1st floor) to get your ticket validated, obtain a parking sticker, and get your ID activated for parking. You will need your car registration and license to get a parking sticker.
    • If you haven’t changed your ID badge to the new BWFH badge with the blue stripe at the bottom, there’s a good chance that your old badge won’t work for the parking lot. If this is the case, please stop by the ID badge office (617-983-7901) and then stop by the Parking office (617-983-4704) to ensure that you have a new badge and that it’s activated for parking. If you’re stuck at night, you can call security as you’re leaving and explain that you are a resident – they should let you out of the parking lot.
  • Please note that cab vouchers are only available to get home from a long call shift – if you’d like one before a long-call day, please page the Faulkner CMR or ask Kathy Hanley in the DOM Office on the 4th floor.

Places to know

  • Pariser Conference Room and Resident Workroom: on the 6th floor by the elevators, code 1-2-3-4-5-6; site of morning report and noon conference
  • Huvos auditorium: next to the cafeteria, on the 3rd floor; site of Medical Grand Rounds
  • Atrium conference room: on the 2nd floor above the main entrance to the hospital
  • Saslow Conference Room: on 4th floor next to the Library; location of Tuesday attending lunch rounds for Team 5 and Orientation.
  • Cafeteria: on the 3rd floor; hours posted in workroom, closes 7pm on weekdays, 6:30pm on weekends
  • Call rooms: for nightfloat resident only; located on the 5th floor down the hall from the ICU
  • Emergency room: on the 1st floor, accessible off the main hallway (see signs)
  • Pathology / Hematology / Lab: on the 1st floor, take elevator to 1R
  • Department of Medicine: on the 4th floor by the library; site of the offices of Chief Medical Resident, Chief of Medicine Scott Schissel, and executive assistants Susan Cohen and Kathy Hanley
  • Parking Office: located on the 1st floor near Admitting, open M-F 9am-3pm (door is always closed, please knock)
  • ID Office: Located on the 7th floor behind the elevators, get Faulkner ID if you are new (or lost your old ID); open 8am-4:30pm