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GMS

Team Structure

  • 2 Day Interns, 1 Twilight Intern, 1 Day Resident, 1 Twilight Resident per team. Each member is an integral part of the team and directly involved in each patient’s care.
  • [See below for changes in team structure during sub-I months].
  • 1 Night Resident. GMS night residents, please see dedicated “GMS Nightfloat Resident” section, which follows this one.

Team Members

Each position is described below. During the month on GMS, each intern and each resident will rotate between Day and Twilight positions. The schedule on Amion will clarify which position you have.

Day Interns

  • On Short days work from 7am to 5pm (10hrs + prerounding).
    • Signs out to Twilight Intern on clinic days at 1pm. Does not return after clinic.
  • On Long days work from 7am to 7pm (12hrs + prerounding), or 8am to 7pm on Sundays (11hrs + prerounding).
    • Should be responsible for one admission between 4PM-5PM.
  • On Saturdays work from 8am to 10pm (14hrs + prerounding).
    • Admits until 9pm, leaves by 10pm.
  • Responsibilities:
    • Picks up signout, including patients admitted by the Twilight Intern/Night Resident at 7am.
    • Prerounds from 7am-8:30am.
    • Attends morning huddle at 8:30am.
    • Participates in team rounds 8:45am – 10:30am.
    • Updates IPASS signouts.
    • Attends afternoon huddle at 4pm and teaching time at 4:30pm.

Twilight Intern

  • Weekdays and Sunday: 4pm-2am (10hrs).
    • Comes in at 12pm when either of the Day Interns has clinic. If as the twilight intern you need to come in early more than twice per week for clinic coverage, please contact the CMRs.
    • On the last day of the rotation, needs to leave by 11pm if going to a daytime rotation the next day. Admissions / responding clinician duties will be covered by the Twilight Resident until 12:30am and 1am respectively.
  • No Twilight Intern on Saturdays.
  • Responsibilities:
    • Primary evening admitter for the team.
    • Reviews and updates task lists using WOW (workstation on wheels) during PM huddle.
    • Completes tasks identified at afternoon huddle, including discharges.
    • Preps discharges for the morning.
    • After 5pm, takes second admission after the Long Day Intern.
    • Admits until 12:30am.
    • Updates IPASS signout indicating tasks for Night Resident (starred tasks) and Day Team.
    • Signs out patients to Night Resident at 1am.

Day Resident

  • Weekdays: 7am-5pm.
  • Replaced by Weekend Resident position on Saturdays and Sundays.
  • Responsibilities:
    • Carries code pager (GMS-B Mon / Thur; GMS-C Tue / Fri / Sun; GMS-D Wed / Sat).
    • Triages and supervises all admissions to pod 7am-5pm.
    • Reads Admission/Transfer notes for any new patients prior to rounds.
    • Leads morning huddle and rounds.
    • Attends interdisciplinary rounds (11am GMS B, C, 11:30am GMS D) on Mon-Fri.
    • Updates Estimated Discharge Date in EPIC (Progress–> Estimated Discharge Date) prior to afternoon huddle.
    • Gives verbal sign out for team patients during afternoon huddle.
    • Formal teaching 1 afternoon per week.
    • Manages team calendar including notification of Twilight Intern and Twilight Resident regarding clinic days for day team.
    • Signs out to Twilight Resident during afternoon huddle. Should not continue any clinical duties past 5pm.

Twilight Resident

  • Weekdays: 4pm-1am.
    • When Day Resident has clinic, the Twilight Resident will come in at 12pm. If as the twilight resident, you need to come in early more than twice per week for clinic coverage, please contact the CMRs. If the Twilight Resident is on a sub-i team with two Day Residents, it is up to the team to decide in advance whether the Day Residents will internally cover the list on clinic days or whether the Twilight Resident will be expected to come in early for both Day Residents. It is the Twilight Resident’s responsibility to check the Amion schedule of the Day Resident to know which days are necessary for coverage.
    • On the last day of the rotation, needs to leave by 11pm if going to a daytime rotation the next day. The nightfloat resident will come in at 10:30 pm to supervise the intern.
  • No twilight resident on Saturdays or Sundays.
  • Responsibilities:
    • Takes over responsibility for admissions from 5pm-12:30am.
    • Carries GMS Resident code pager (GMS-B Mon / Thur; GMS-C Tue / Fri; GMS-D Wed).
    • Leads afternoon huddle.
    • Formal teaching 1 afternoon per week.
    • Triages and supervises all admissions to pod after 5pm. This includes taking over supervision of admissions that may have been started by the Day Resident.
    • Assists with late discharges.
    • Assists with responding clinician responsibilities or admissions when pod is active.
    • Confirms morning discharges prepped including: STAT or cancelled labs for the morning, scripts in chart, preps discharge summary if Twilight Intern busy.
    • Updates Estimated Discharge Date in EPIC (Progress–> Estimated Discharge Date) prior to leaving.
    • Emails Day Interns regarding twilight admission assignments prior to leaving.
    • Observes 1am signout from Twilight Intern to Nightfloat Resident.

Weekend Resident

  • Saturdays and Sundays: 8am-9pm.
  • Responsibilities:
    • Takes over responsibility for admissions 8am-9pm.
    • Carries GMS Resident code pager (GMS-C Sun; GMS-D Sat).
    • Leads morning huddle and rounds.
    • Triages and supervises all admissions to pod 8am-9pm.
    • Admits any patients after the intern caps.
    • Responding clinician for the off intern’s patients.
    • Signs out to Night Resident by 10pm.
    • Confirms morning discharges prepped including: STAT or cancelled labs for the morning, scripts in chart, preps discharge summary if Twilight Intern busy.
    • Updates Estimated Discharge Date in EPIC (Progress–> Estimated Discharge Date) prior to leaving.
    • Emails Day Interns regarding twilight admission assignments prior to leaving.

Night Resident

  • Weekdays: 11:30pm-8:30am (9 hrs) (Comes in at 10:30 if Twilight Resident is going to a day rotation).
  • Saturday: 9pm-9am (12 hrs).
  • Sunday: 9pm-8am (11 hrs).
  • As elsewhere, these hours only apply to the GMS nightfloat role. When the residents are covering an ITU team, the ITU NF hours apply. See GMS nightfloat section, below.
  • Responsibilities:
    • Takes over responsibility for admissions at the times specified in the chart above.
    • Carries GMS Resident code pager.
    • Weekdays: Admits all admissions to pods after 11:30pm (until 12:30, the Twilight Intern can still admit 1 patient).
    • Saturdays: Admits all admissions to pods after 9pm. Two night residents will cover GMS together.
    • Sundays: Ensures that the Weekend Residents leave by 10pm, admits with the three GMS Twilight Interns until 12:30am, admits all admissions to pods after 12:30am.
    • 1 Night Resident will be responding clinician for patients on all 3 GMS pods from 1 AM on Sunday to Friday (2 Nightfloat Residents on Saturdays take signout and assume responding clinician duties starting at 8pm).
    • Updates IPASS signout for patients they have admitted including any major tasks for day team.
    • Emails blurbs to the Phys; assigns patients to Day Interns.
    • Attends morning report Monday-Thursday 7:30am-8:30am and nightfloat rounds on Fridays 7:30am-8am. Brings one interesting case for discussion to nightfloat rounds, with primary data if available.

Sub-Is

  • Schedule:
    • May-October, two of the GMS teams will have three sub-Is each.
    • Two Day Sub-Is will replace a Day Intern, and alternate with the Day Intern 7am-5pm and 7am-7pm together.
    • One Twilight Sub-I 4pm-2am (except the last Sunday of their rotation) will be an addition to the Twilight Intern.
    • First day of rotation, sub-Is arrive midday and are covered by Sub-I Resident.
    • On last day of rotation, sub-Is leave by 7pm.
    • Further details will be emailed to you from Alessandra Rosa Alvarez Hinijosa (email: aalvarezhinojosa@bwh.harvard.edu).
  • Changes to Team Structure:
    • Two Day Sub-Is will replace one Day Intern on the team.
    • Teams will have two Day Residents: a non Sub-I Day resident (responsible for working 1:1 with 1 Day Intern) and an additional Sub-I Day Resident (responsible for working with 2 Day Sub-I’s).
  • Supervision:
    • The Day Sub-I’s are supervised by a dedicated Sub-I Day Resident who follows their schedule, alternating Long and Short.
    • The 2 Day Sub-I’s will cover one intern list (i.e. GMS-B Intern List 1) and split the patients accordingly.
    • The non-Sub-I resident will only be responsible for working with their single Day Intern and will cover a single Intern List (i.e GMS-B Intern 2 List).
    • The Twilight Sub-I is supervised by the Twilight Resident, or Weekend Resident and Night Resident on Saturdays and Sundays.

Supervision of Interns

  • Day Resident supervises Day Interns until 5pm.
  • Twilight resident supervises Long Day Intern and Twilight Intern after 5pm (after 1pm if Day Resident in clinic).
  • Weekend Resident supervises Saturday Day Intern until 10pm, Sunday Day Intern until 7pm and Sunday Twilight Intern until 10pm.
  • Night Resident supervises Sunday Twilight Intern from 10pm to 2am.

Clinic Days

  • Day Intern in clinic: Twilight Intern comes in at 12pm (only one Day Intern can be in clinic on any given day). This is also how the ED intern’s Tuesday afternoon ED teaching is covered.
  • Day Resident in clinic: Twilight Resident comes in at 12pm.
  • Day Intern and Day Resident do not return to the pod after clinic.

Admitting Structure

  • All admissions are assigned to the residents.
    • Admitting will page admissions to the Day Resident 7am-5pm, Twilight Resident 5pm-12:30am, and Night Resident 12:30am-7am.
    • On Saturdays: Day Resident 8am-8pm, Night Resident 8pm-8am.
    • On Sundays: Day Resident 8am-9:30pm; Night Resident 9:30pm-7am.
  • Residents will triage admissions to interns
    • Interns assign patients to themselves in EPIC.
  • Census caps:
    • Team cap of 16 patients. (In 2017, teams have been at 16 patients approximately 10-15% of the time)
    • Intern cap of 9 patients.
    • Teams can uncap for patients admitted to their pod, to up to 20 patients total, even if in regular census.
    • Teams can have up to 20 at a given moment, and interns up to 10 at a given moment, if anticipating discharges.
    • It is MANDATORY that teams be honest about anticipated discharges. This is fundamental for regionalization to work.
  • Extreme Census Rules:
    • Team cap expands to 18 patients if GMS census > 117, or 20 pts per team if GMS census>122.
    • Intern cap expands to 10 patients per intern if GMS census >117.
    • Note: these are not the only actions taken during extreme census. When GMS census crosses thresholds, other actions are also taken by admitting staff including maximizing utilization of BWFH, assignment of BCMA, Montorzi, Sanchez, and Heme patients to cardiology B-teams, assignment of GMS patients to Renal PA and Pulmonary PA teams, and recruitment/activation of additional admitting resources.

Days Off

  • Interns:
    • 1 day off per week.
    • Day off is Saturday or Sunday, as specified in Amion.
  • Day / Twilight Residents:
    • 1 day off per week.
    • Day off is Saturday or Sunday, as specified in Amion.
  • Night Residents:
    • 3 days off per 2 week block.
    • Days off are either Tuesday/Monday/Tuesday, or Wednesday/Thursday/Wednesday, as specified in Amion.

Rounding

Walk Rounds

  • WHO: Interns, Resident, Attending, Staff RN.
  • WHEN: 8:45am-10:30am. Must be done by 11am.
  • WHAT: Walk Rounds, ideally bedside rounding.
    • Focused bedside presentation of all appropriate pts (should be majority).
    • New patient presentations should be brief summary rather than conveying all info in admit note.
    • Attendings and residents are expected to read all admission notes prior to rounds.
    • Focused interview of patient.
    • Focused exam for evaluation and teaching.
    • Discussion of plan with team directed to patient.

Inter-Professional Rounds

  • WHO: Nurse in charge, Resident, Care Coordinator, Social Worker, Physical Therapist, Nutrition, Speech and Swallow.
  • WHEN: 11am-11:20am (GMS B, GMS C), 11:30-11:50 am (GMS D).
  • WHAT: Discharge planning for each patient on the pod.
    • Provide brief description of patient and major goals for the day.
    • Identify clinical discharge criteria.
    • Anticipated discharge date, time, and location of disposition.
    • Address if further evaluation needed and completed.
    • Address if home equipment needed and obtained.
    • Address any special needs: special med needs, teaching, early scripts, etc.
    • Confirm that patient and family agree with discharge plan.

Daily Huddles

Morning Huddle

  • WHO: Nurse in charge, Unit Coordinator, Interns, Resident, Attending, +/- Care Coordinator.
  • WHEN: 8:30am-8:40am.
  • WHERE: On the pod.
  • WHAT:
    • Set rounding order.
    • Identification of patients needing attention.
    • Identification of potential early discharges.
    • Identification of patients requiring interpreter, arranged by Unit Coordinator.
    • Identification of patients requiring early evaluation by Care Coordinator or Physical Therapy.

Afternoon Huddle

  • WHO: Nurse in charge, Day Resident, Nurse in Charge, and Unit Coordinator.
  • WHEN: 5 pm (after team teaching).
  • GOALS:
    • Review anticipated discharges for the next day
    • Identify one before noon discharge. Twilight resident should then touch base with that patient/patient’s family to update them on plan for before-noon discharge, so that potential barriers can be identified and addressed early.

Nighttime Signout

  • WHO: Twilight Intern, Twilight Resident, Nighttime Resident.
  • WHEN: 1am.
  • WHAT:
    • Provide clinical passoff from twilight team to night resident

GMS Physical Diagnosis Rounds

Dr. Subha Ramani began a new teaching initiative on physical diagnosis during AY 2016-2017, rotating between GMS teams on Thursday afternoons (so each team has this roughly every 3 weeks). This usually can take the place of 4:00 PM teaching for the team and is slated to be 30 minutes in duration.

The idea is to have a session dedication to the physical examination of one of your patients for the whole team with Dr. Ramani or another attending. It should be a great opportunity to get some physical diagnosis teaching from an experienced clinician! The teaching resident should collaborate with the team residents to pick a patient and participate in the rounds. The team resident(s) should gather the team and meet the physical diagnosis attending at the designated time. If the teaching resident has clinic, the team residents should pick the patient and gather the team.