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ITU

Team Structure

  • 3 Day Interns, 1 Twilight Intern, and 2 Day Residents (alpha and beta) per team, 1 night resident covers both ITU-A and ITU-B. Each member is an integral part of the team and directly involved in each patient’s care.
  • 2 subspecialist attendings

Team Members

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

Day Interns

  • Day Interns rotate through three positions– Long call, Short 1, and Short 2.
    • One day off per week. This occurs if Short 1 falls on a Sunday or Short 2 occurs on a Saturday or a Sunday.
    • If Short 1 occurs on a Saturday, then Saturday is a day off, and Sunday switches to Twilight (see below for Twilight Intern details).
    • There will be two (2) Interns off on each Saturday, and two (2) Interns off on each Sunday. The Resident must therefore carry half of the team’s total list (i.e. Resintern) on each weekend day.
  • On Short days work from 7am to 5pm (10hrs + prerounding), or 8am to 5pm on the weekend (9hrs + prerounding).
    • Signs out to co-intern on clinic days at 12pm, or twilight if 2 interns are in clinic. Does not return after clinic.
  • On Long days work from 7am to 7pm (12hrs + prerounding), or 8am to 7pm on the weekend (11hrs + prerounding).
    • Should be responsible for one admission between 4PM-5PM.
  • Responsibilities:
    • Long intern carries ITU Intern code pager (ITU-A Mon/Wed/Fri/Sun; ITU-B Tue/Thur/Sat).
    • Picks up signout, including patients admitted by the Twilight Intern/Night Resident at 7am (8am on the weekend).
    • Prerounds from 7am-8:30am.
    • Attends morning huddle at 8:30am.
    • Participates in team rounds 8:45am – 10:30am.
    • Updates IPASS signout prior to afternoon huddle.
    • Takes pass-off with resident 4 pm – 4:30 pm.
    • Attends afternoon huddle at 4:30pm and teaching time at 5:00pm.

Twilight Intern

  • Twilight block begins on the Sunday following a Short call 1 day off on Saturday (see above).
  • Twilight block lasts for seven (7) days (i.e. Sunday through Saturday), followed by a day off on Sunday.
  • Following the conclusion of a Twilight block, the Intern begins in the Long call position on Monday.
  • Hours: 4pm-2am (10hrs).
    • Comes in at 12pm if any of the Day Interns have clinic.
    • 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 Night Resident starting at 11 PM on those nights.
  • Responsibilities:
    • Carries ITU Intern code pager (ITU-A Mon/Wed/Fri/Sun; ITU-B Tue/Thur/Sat).
    • 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 4pm, 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

  • Alpha: weekdays 7AM – 8PM. Beta: weekdays 7AM-4:30 PM.
  • Replaced by Weekend Resident position on Saturdays and Sundays.
  • Responsibilities:
    • Alpha: Takes over responsibility for admissions from 7am-7pm.
      • Leads morning huddle and rounds.
      • Triages and supervises all admissions to pod 7am-7pm.
      • Reads Admission/Transfer notes for any new patients prior to rounds.
      • Updates Estimated Discharge Date in EPIC (Progress–> Estimated Discharge Date) prior to afternoon huddle.
      • Manages team calendar including notification of Twilight Intern regarding clinic days for day team.
    • Beta: helps do work (looking up labs, entering orders, calling consults) during rounds.
      • Attends interdisciplinary rounds (11am ITU-A, 11:30am ITU-B).
      • Responsible for any resident-led afternoon teaching.

Weekend Resident (no beta resident on weekends)

  • Saturdays and Sundays: 8am-10pm.
  • Please note: Two (2) interns will be off on each Saturday and each Sunday (see Day Intern and Twilight Intern schedule above). Therefore, the Weekend Day Resident is expected to cover half of the team’s total list (i.e. Resintern) on each weekend day.
    • Takes over responsibility for admissions from 8am.
    • Leads morning huddle and rounds.
    • Triages and supervises all admissions to pod 8am-10pm.
    • Admits any patients after the intern caps.
    • Responding Clinician for the off intern’s patients after the Day Intern Short leaves.
    • 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

  • Note that there is now one night resident who covers both ITU-A and ITU-B.
  • Weekdays: 7PM-8AM (13 hrs)
  • Saturday and Sunday: 7pm-9am (14 hrs; 8:30am on Monday morning – 13.5 hrs).
  • Days off: Two days off per week, Thursday and Friday.
    • Please see “GMS Nightfloat Resident” section above for details on days off.
    • Note that GMS and ITU nightfloat hours are different
  • Responsibilities: Takes over responsibility for admissions at 7pm.
    • Carries ITU Intern code pager starting at 12:30 AM.
    • Weekdays: Admits all admissions to pod after 7 PM (supervises intern 7P -12:30A, 12:30A – 7A admits alone).
    • Weekends: Ensures that the Weekend Residents leave by 10pm, admits with the twilight intern until 12:30am, admits all admissions to pod after 12:30am.
    • Helps the GMS Nightfloat Resident(s) if needed.
    • 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.

Supervision of Interns

  • Alpha Resident supervises Day Interns until 7pm.
  • Beta resident supervises Day Interns after 12 PM if Alpha resident in clinic (in this case, the alpha and beta roles are switched – residents can decide between themselves who leads rounds).
  • Weekend Resident supervises weekend Day Intern until 7pm and weekend Twilight Intern until 10pm.
  • Night Resident supervises weekend Twilight Intern from 7pm to 2am on weekdays, 9PM-2AM on weekends.

Clinic Days

  • 2 Day Interns in clinic: The Twilight Intern comes in at 12pm. (If only 1 day intern in clinic, the other 2 day interns cross-cover internally).
  • Alpha Resident in clinic: Beta resident covers starting at 12PM, or the residents switch roles.
  • Day Interns do not return to the pod after clinic. Day Residents can determine among themselves whether to return, but usually should not.
  • Starting in AY17-18, OB interns will also have clinic on some of their short call days. Please confirm their schedule with them individually at the start of the rotation.

Admitting Structure

  • All admissions are assigned to the residents.
  • Residents will triage admissions to interns
    • Interns assign patients to themselves in EPIC.
  • Census caps:
    • Team cap of 16 patients.
    • 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 Friday, Saturday, Sunday or Monday, as specified in Amion.
  • Day Residents:
    • 1 day off per week.
    • Day off is Saturday or Sunday, as specified in Amion.
  • Night Residents:
    • 2 nights off per week, Thursday and Friday.

Daily Huddles

Morning Huddle

  • WHO: Nurse in charge, Unit Coordinator, 3 Interns, alpha/beta residents, 2 Attendings, Care Coordinator.
  • WHEN: 8:30am-8:35am.
  • WHERE: On the pod.
  • WHAT:
    • Set rounding order.
    • Identify and review patients that became unstable over night
    • Updates if any changes regarding patients scheduled for discharge that morning
    • Identify patients that can go home later today, not prepped for discharge the day before
    • Identification of patients requiring interpreter, arranged by Unit Coordinator.
    • Identify patients requiring early attention from other disciplines

Interprofessional Rounds

  • WHO: Nurse in charge, Beta resident, CCRN, SW, PT (if possible), nutrition (if possible, as needed), Speech and Swallow (if possible, as needed).
  • WHEN: 11:00-12:00 (staggered for care team participation and Radiology Rounds).
  • WHERE: On the pod.
  • WHAT:
    • Updates on planned discharges for later today.
    • Brief description of all other patients (true one liner) identifying major goal(s) for the hospitalization and what needs to get done today.
    • Anticipated discharge date (always with plan to discharge prior to noon).
    • Confirm that patient and family are aware of anticipated discharge date and have arranged transportation if going home.
    • Disposition: (Home, Home w/ Services, Facility).
    • Evaluation needed/completed (PT, SW, Nutrition, Speech Swallow, Other).
    • Home equipment needed? If yes, has it been obtained?
    • Special med needs (PA, teaching, early scripts).

Afternoon Huddle

  • WHO: Nurse in charge, Alpha resident, 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, Nighfloat Resident.
  • WHEN: 1am.
  • WHAT: Provide clinical passoff from twilight team to night resident.