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House Staff Manual

 

  

 

 

 

 

 

University of Florida

Internal Medicine

Housestaff

Manual

 

 

 

 

 

 

 

Revised 03/31/12

Table of Contents

 

i)          Program Contact Information 

ii)         Important Links 

iii)         University of Florida Department of Medicine Policy on Duty Hours 

iv)        Work Hour Log Policy 

v)         Educational Goals 

 

I.)  General Policies 

 

A.) Job Description

B.) Goals and Objectives 

C.) Days Off 

D.) Monitoring Resident Stress 

E.) Ancillary Services 

F.) Conferences and Morning Report 

G.) Attendance Policy 

H.) Bounces 

I.) Conflict Resolution Between Services 

J.) Scheduling and Scheduling Requests 

K.) Back-Up Guidelines 

L.) Order Writing 

M.) Educational Fund Guidelines 

N.) Parental Leave Policy 

O.) Policy on Regional or National Academic Conference Attendance 

 

II.)  Resident Supervision  

 

III.)  Inpatient Shands Ward Teams 

 

A.) Shands Ward Teams General Information 

B.) Shands General Medicine Teams 

C.) Shands Subspecialty Teams 

D.) Shands MICU 

E.) Shands IMC 

F.) Shands Night Team 

G.) Bridge Resident 

H.) Shands Admitting Officer of the Day (AOD) 

I.) Hospitalist Service 

 

IV.)  Inpatient VA Teams 

 

A.) General Information 

B.) Call Schedule 

C.) MICU 

D.) GEM Unit 

E.) VA Night Team 

 

V.)  Consults  

VI.)   Ambulatory 

 

A.) Continuity Clinic 

B.) Ambulatory Block 

C.) Evidence Based Medicine 

 

VII.)  Emergency Medicine Rotation  

 

VIII.)  Electives 

 

IX.)   Moonlighting

 

X.)  Evaluation of Residents 

 

A.) Evaluation Methods 

B.) Semi-Annual Evaluation Review 

C.) Housestaff Evaluation Committee 

D.) Performance Expectations 

E.) Due Process 

 

i) Program Contact Information  

 

Chairman  

Robert Hromas, M.D.     (352) 265-0655 

 

Program Director  

N. Lawrence Edwards, M.D.     (352) 265-0239 

 

Associate Program Directors  

James Smith, M.D.       (352) 265-0239 

Carolyn Stalvey, M.D.    (352) 265-0239

Matthew Kosboth, M.D.  (352) 265-0239

Michelle Rossi, M.D.     (352) 265-0239

 

Program Administrator  

Susan Major       (352) 265-0239 

 

Scheduling  

Vicki Shearin       (352) 265-0239 

 

Personnel Assistant  

Jennifer Vinson      (352) 265-0239 

 

Housestaff Office Address 

Box 100277 JHMHC 

Gainesville, FL 32610 

 

Fax number:      (352) 265-1107 

 

Chief Residents:  

Shands Teaching Hospital:         Julio Schwarz, M.D.  (352) 265-0239 

Ambulatory Medicine:         Andrea Zimmer, M.D.  (352) 265-0239 

VA Medical Center:           Alex Seamon, M.D.   (352) 376-1611, ext. 6958 

 

Chief On-Call Pager (after 5pm and weekends): (352) 413-4553  

 

ii)  Important Websites  

 

Residency Program:  www.residency.medicine.ufl.edu

Benefits:  www.med.ufl.edu/benefits/  

Division of Personnel:  www.med.ufl.edu/personel

Medicine Sharepoint Portal:  http://portal.medicine.ufl.edu  

UF Health Science Center library:  http://www.library.health.ufl.edu/  

UF/ Shands Hospital Housestaff page:  http://housestaff.medinfo.ufl.edu/ (includes all institutional policies) 

iii)  University of Florida Department of Medicine Policy on Duty Hours  

 

The ACGME defines duty hours as all clinical and academic activities related to the training program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences.  Duty hours do not include reading and preparation time spent away from the duty site.  In accordance with ACGME rules and regulations the Department of Medicine has set forth the following rules to regulate both its residency and fellowship training programs. 

 

1.  All residents and fellows will receive one day off in seven when averaged over a four-week period. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.  Each resident will therefore receive 4 days off per month. 

 

2.  In-house call must occur no more frequently than every third night.  In-house call is defined by the ACGME as those duty hours beyond the normal workday when residents are required to be immediately available in the assigned institution.  As mandated by the ACGME, at-home call will not be so frequent as to preclude rest and reasonable personal time for each trainee, but is not included in the every third night limit. 

 

3.  Trainee duty hours will be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.  Any hours spent during home call involving clinical duties will also be counted towards the 80 hour limit. 

 

4.  Continuous on-site duty will not exceed 24 consecutive hours.  Trainees may remain on duty for up to four additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical care.  During these four additional hours the trainee will not be responsible for the workup, admission, or care of a new patient. 

 

5.  Adequate time for rest and personal activities will be provided for all trainees.  There will be a minimum of 10 hours between all daily duty periods and after in-house call. 

 

6.  All residents and fellows must have all occurrence of moonlighting pre-approved by the Program Director in writing.  It is restricted to PGY-3 residents and must be in good standing within the Program.  A Moonlighting Request Form (which can be found on the residency program website) must be submitted for each shift requested at least 1 week prior to date of shift. Moonlighting must not interfere with clinical, research, or academic responsibilities (including conferences and other lectures).  Moonlighting will count towards the 80 hour work week and the 24 hour maximium shift. Residents cannot moonlight on days assigned to back up. Please see Section IX for the moonlighting policy.

 

The purpose of these duty hour rules is to ensure that the learning objectives of the program are not compromised by excessive reliance on residents and fellows to fulfill service obligations.  At

this time the ACGME rules which govern Internal Medicine training programs do not allow duty hours exceptions. 

 

iv)  Work Hour Log Policy  

The ACGME has established an 80 hour work week to ensure good patient care and adequate time for physician rest periods.  The Department of Medicine has instituted the New Innovations computer system to enable up to date monitoring of our residents’ work hours.  The residency program monitors work hours to ensure compliance with the 80 hour work week and to ensure no rotations put undue demands on residents. 

 

Completing weekly work hour logs in the New Innovations system is a requirement of the residency program.  Please refer to the webpage:  http://www.new-innov.com/login.htm.  Failure to do so in a timely manner is considered unprofessional behavior.  As with all unprofessional behavior, residents who do not complete weekly work hour logs have the potential to be placed on probation by the Housestaff Evaluation Committee.  The following policy is in place to ensure timely completion of work hour logs. 

 

1. Work hour logs of the previous week must be completed by Wednesday.

2. Two Weeks Late:  Any resident who has not yet completed two weeks of work hour logs will be given a warning letter via email and in their mailbox in the Department of Medicine.  In addition, food vouchers will not be distributed to the resident.

3. Three Weeks Late:  Any resident who has not completed three weeks of work hour logs will be sent another warning letter in the event they had not received the first one or they had been unable to complete work hour logs.

4. Four Weeks Late:  Any resident who has not completed four weeks of work hour logs will be pulled from their rotation and back up will be called in.  It is mandatory that the time back up covers the resident will be paid back.  If the resident is on elective, they will be pulled and assigned additional Friday Night Coverage.  

 

 

v)  Educational Goals of the Department of Medicine Residency Program

 

• Train fully competent general internists 

• Inspire respect for the profession they are entering 

• Provide education in a protective environment with adequate oversight 

• Role model and instill a high degree of professionalism 

• Provide an environment of camaraderie where all members feel that they are a part of the educational effort 

• Inspire the importance of life-long introspection and learning 

• Instill physicians with an understanding of the health care system as a whole, their role in the system and a desire to improve the system. 

 

 

I.)  General Policies 

 

A.) Resident Job description

 

PGY 1 (Intern)

 

POSITION SUMMARY:  The Internal Medicine resident shall function under the supervision of the attending medical staff. Often there will be an upper level resident in a supervisory role as well. The intern assists with admissions, consultations, evaluations, diagnosis and treatments of hospital and ambulatory patients. He/she may provide verbal, written and telephone orders. 

 

PROCEDURES: The following procedures must be performed under the supervision of a practitioner with clinical privileges for the procedure, a fellow or an upper level resident competent in the procedure. The procedures must be supervised until the intern meets the requirements for performance of the procedure without direct supervision. 

 

Abdominal Paracentesis

Arthrocentesis

Arterial Puncture

Biopsy of Skin

Cardiopulmary Resuscitation/Advanced Cardiopulmary Life Support

Central Venous Placement

Genital Examination, Male

Lumbar Puncture

Pelvic Examination 

Nasogastric Tube Insertion

Soft Tissue Injections

Thoracentesis

Vaginal Wet Mount Evaluation

Ventilator Management 

 

QUALIFICATIONS: Must be able and willing to establish and maintain effective working relationships with patients, families, hospital staff, attending physicians and the public; and perform high-level decision-making.

 

EDUCATION: Doctor of Medicine (MD), or Doctor of Osteopathy (DO) or equivalent

 

LICENSURE and CERTIFICATION: Current Florida training license

 

EXPERIENCE: Medical degree

 

OTHER KNOWLEDGE and SKILLS: Commensurate with degree, advancement and responsibilities

 

DEMANDS: High level decision-making; Performs highly complex and varied tasks

 

PHYSICAL DEMANDS: Ability to perform physical examination of patients; Dexterity needed to perform physical examination and procedures

 

EQUIPMENT: Demonstrates competency and dexterity with all equipment utilized in the hospital and ambulatory environment

 

RELATIONSHIPS: Reports to Internal Medicine Residency Program Director, University Florida. Adheres to policies and procedures, stated and published, of the University of Florida Internal Medicine Residency Program.

 

SUPERVISES: Medical students, occasionally PA students

 

INTERNAL RELATIONSHIPS: Fellow residents, residency program faculty and staff, hospital staff, and medical staff

 

EXTERNAL RELATIONSHIPS: Patients and families, and referring physicians

 

ESSENTIAL JOB FUNCTIONS:

◦Develops and maintains a personal program of self-study and professional growth with guidance of the Internal Medicine Residency faculty

◦Admission, consultation, evaluation, diagnosis and non-surgical treatment of patients with general medical problems. Provides safe, effective and compassionate patient care under supervision

◦Demonstrates dexterity and competency to perform all essential and required procedures and provides complete, written documentation of all procedures

◦Identifies need for patient education and orders or provides education

◦Comprehensively documents in patients’ charts in a timely and accurate manner.

◦Demonstrates awareness and sensitivity to patient and family issues, including age, gender and cultural diversity

◦Functions with an awareness and application of standard operating procedures including OSHA, HIPAA 

◦Efficiently performs in emergency situations, including adherence to established clinic and hospital-specific protocols

◦Demonstrates applied knowledge base including integration of skills as required through block rotation experiences

◦Participates actively in all educational and residency program activities and assumes responsibility for teaching other residents and medical students

◦Demonstrates awareness and applies knowledge of legal issues in all aspects of patient care, incorporating risk management skills, and quality control measures

◦Actively participates on any assigned hospital committee as a member

◦Demonstrates effective communication skills

◦Participates in the resolution of residents’ staffing conflicts and maintains flexibility regarding staffing patterns, including on-call schedule and daily schedules

◦Provides coverage for temporary staffing conflicts of the Residency program

◦Demonstrates ability for effective problem identification and resolution as well as the exercise of independent judgment

◦Participates in research and scholarly activities

◦Provides teaching, supervision and serves as a role model to other Residents.

◦Performs such duties as assigned by the Internal Medicine Residency Program Director, in accordance with the description of the Residency, to the best of his/her ability and under the highest personal bond of professional morals and ethics.

 

 

PGY 2 and 3

 

POSITION SUMMARY:  The Internal Medicine resident shall function under the supervision of the attending medical staff. On certain rotations there will be a supervising fellow as well. The resident assists with admissions, consultations, evaluations, diagnosis and treatments of hospital and ambulatory patients. He/she may provide verbal, written and telephone orders. 

 

PROCEDURES: The following procedures must be performed under the supervision of a practitioner with clinical privileges for the procedure, a fellow or another upper level resident competent in the procedure. The procedures must be supervised until the resident meets the requirements for performance of the procedure without direct supervision. 

 

Abdominal Paracentesis

Arthrocentesis

Arterial Puncture

Biopsy of Skin

Cardiopulmary Resuscitation/Advanced Cardiopulmary Life Support

Central Venous Placement

Genital Examination, Male

Lumbar Puncture

Pelvic Examination 

Nasogastric Tube Insertion

Soft Tissue Injections

Thoracentesis

Vaginal Wet Mount Evaluation

Ventilator Management 

 

QUALIFICATIONS: Must be able and willing to establish and maintain effective working relationships with patients, families, hospital staff, attending physicians and the public; and perform high-level decision-making.

 

EDUCATION: Doctor of Medicine (MD), or Doctor of Osteopathy (DO) or equivalent

 

LICENSURE and CERTIFICATION: Current Florida training license

 

EXPERIENCE: Medical degree, successful completion of a PGY-1 year

 

OTHER KNOWLEDGE and SKILLS: Commensurate with degree, advancement and responsibilities

 

DEMANDS: High level decision-making; Performs highly complex and varied tasks

 

PHYSICAL DEMANDS: Ability to perform physical examination of patients; Dexterity needed to perform physical examination and procedures

 

EQUIPMENT: Demonstrates competency and dexterity with all equipment utilized in the hospital and ambulatory environment

 

RELATIONSHIPS: Reports to Internal Medicine Residency Program Director, University Florida. Adheres to policies and procedures, stated and published, of the University of Florida Internal Medicine Residency Program.

 

SUPERVISES: Interns, Medical students, occasionally PA students

 

INTERNAL RELATIONSHIPS: Fellow residents, residency program faculty and staff, hospital staff, and medical staff

 

EXTERNAL RELATIONSHIPS: Patients and families, and referring physicians

 

ESSENTIAL JOB FUNCTIONS:

◦Develops and maintains a personal program of self-study and professional growth with guidance of the Internal Medicine Residency faculty

◦Admission, consultation, evaluation, diagnosis and non-surgical treatment of patients with general medical problems. Provides safe, effective and compassionate patient care under supervision

◦Demonstrates dexterity and competency to perform all essential and required procedures and provides complete, written documentation of all procedures

◦Identifies need for patient education and orders or provides education

◦Comprehensively documents in patients’ charts in a timely and accurate manner.

◦Demonstrates awareness and sensitivity to patient and family issues, including age, gender and cultural diversity

◦Functions with an awareness and application of standard operating procedures including OSHA, HIPAA 

◦Efficiently performs in emergency situations, including adherence to established clinic and hospital-specific protocols

◦Demonstrates applied knowledge base including integration of skills as required through block rotation experiences

◦Participates actively in all educational and residency program activities and assumes responsibility for teaching other residents and medical students

◦Demonstrates awareness and applies knowledge of legal issues in all aspects of patient care, incorporating risk management skills, and quality control measures

◦Actively participates on any assigned hospital committee as a member

◦Demonstrates effective communication skills

◦Participates in the resolution of residents’ staffing conflicts and maintains flexibility regarding staffing patterns, including on-call schedule and daily schedules

◦Provides coverage for temporary staffing conflicts of the Residency program

◦Demonstrates ability for effective problem identification and resolution as well as the exercise of independent judgment

◦Participates in research and scholarly activities

◦Provides teaching, supervision and serves as a role model to other Residents.

◦Performs such duties as assigned by the Internal Medicine Residency Program Director, in accordance with the description of the Residency, to the best of his/her ability and under the highest personal bond of professional morals and ethics.

 

B.) Goals and Objectives:  As per RRC requirements, all rotation Goals and Objectives must be reviewed at the start of each new rotation.  All of these Goals and Objectives are also located online at https://intranet.ahc.ufl.edu/colleges/medicine/medicine/ under “Goals and Objectives” of the Residency Program Web page.  This is to open a dialog regarding expectations, schedule, and educational opportunities of the rotation.  Any elective listed without an official Goals and Objectives description will not be available for the rotation until one is completed.  If you are interested in rotating on such an elective, please see the Chief Residents at least 2 months prior to starting that rotation. 

 

Please refer to the intranet webpage for available rotations and any updates to these documents throughout the remainder of your training. 

 

If you have any questions or comments about these documents, or if you want to submit changes to them, please see any of the members of the Residency Program Administration or your Attending of Record. 

 

C)  Days Off:  All members of the team need to have one day off in seven when averaged over a 4 week period, for a total of 4 days off per monthly rotation.  At the beginning of each month, the team (including the students) should sit down and determine which days team members will have off based on the call schedule.  The attending should be involved in the decision of which days the resident will have off.  The ideal days are Golden days and “Short call” days on the weekend as there are no admissions on those days The day off must be free of clinical duties.  Residents should give their pager to their attending or covering resident on their day off.  Interns should give their resident their pager on their day off or should turn it off.  If anyone is found to be engaged in patient care responsibilities on their day off, that day will not be counted, and another day off will have to be scheduled. 

 

D)  Monitoring Resident Stress:  The program has been very successful monitoring resident stress, fatigue and well-being.  The measures we instituted to improve our sensitivity to these matters have been very successful. 

 

Available Resources:  We have identified a number of available resources for residents in need of help.  We have contacts within the Psychological Department for neuropsychological testing.  We have psychologists and psychiatrists both in the medical center and within the community willing to see our residents.  Our housestaff insurance carrier, Humana, has added the University

of Florida Department of Psychology faculty to our coverage.  This allows our housestaff to seek psychological help within our institution if they choose.  We have arrangements with Dr. Ross McElroy and Dr. Holbert, faculty in our department of Psychiatry, to see residents.  Residents can contact them individually or through the chief residents if they so desire.  Finally, the Office of Graduate Medical Education provides confidential psychological and psychiatric services through the Resident Assistance Program.  Residents may self-refer to the Resident Assistance Program by calling (352)265-5493 or 1-866-643-9375. 

 

Monitoring:  We have a number of mechanisms in place to monitor resident stress and fatigue.  In addition, we use these systems to monitor for any signs of alcohol- or drug-related dysfunction. 

 

1.  Team Members:  Each month, the housestaff teams are made up of an attending, resident and two interns.  If one member of the team appears to be having difficulties, any member of that team can speak with the attending or Chief Resident. 

 

2.  Patient Care Resource Manager (PCRM):  The Department of Medicine Chairman and the Shands Chief Resident meet monthly with the Patient Care Resource Managers assigned to each inpatient floor.  One main area of discussion is residents’ performance.  Many PCRMs have a background in social work and discussion often revolves around residents’ performance and their well-being.  The Shands Chief Resident then follows up on all concerns addressed in this meeting. 

 

3.  Housestaff Advisory Council (HAC):  The HAC is composed of the Chairman, Program Director, Associate Program Directors, Chief Residents, Chief Resident-Elects, and two representatives from each PGY class (I and II).  The HAC usually meets monthly. Resident representatives are voted on by their peers, and the residents bring any concerns to their representatives. 

 

4.  Chief Residents:  The Chief Residents have always had an open-door policy for resident concerns.  The Chief pager can be reached 24 hours/7 days a week and ensures that one of the Chiefs is always available for any concerns.  The Chief Residents also monitor resident work hours as an indicator of resident stress and fatigue and ACGME compliance.

 

5.  Program Director:  Dr. Edwards is always available to address resident concerns and stresses.  He is frequently in his office for personal meetings or by phone to immediately address issues over the phone or schedule face to face meetings.  In addition, his email address is larry.edwards@medicine.ufl.edu should you need to contact him directly. 

 

6.  Department Chairman:  The Chairman holds monthly meetings with the residents at noon conference.  The structure is usually an open forum for any resident concerns.  In addition, the Chairman’s email address is accessible on the website and residents in the past have used this to address concerns to him directly.  Residents can also contact his secretary directly to schedule an appointment with him. 

 

7.  Housestaff Evaluation Committee:  The Housestaff Evaluation Committee meets throughout the year to review residents’ evaluations and on an as needed basis when housestaff performance issues require urgent intervention.  Each resident has a committee member mentor, designated by the program director, who meets with them semi-annually to review attending and PCRM evaluations, conference attendance, and procedure logs.  In addition, areas of concern the housestaff may have about stress, fatigue, the program, their future careers, or individual difficulties they are experiencing or have experienced are explored.  Any program issues that lead to undue stress are communicated by the Housestaff Evaluation Committee to the program administration so they can be evaluated and modified if necessary. 

 

E)  Ancillary Services:  Residents are not required to routinely perform ancillary services such as phlebotomy, IV placement, transportation, or clerical duties.  At both Shands and the Gainesville VA Medical Center these services should be available at all times when necessary.  If residents find themselves performing such duties that they find to be service without education, they must notify the Program Director or Chief Resident. 

 

F)  Conferences and Morning Report:  In addition to the learning that comes from working with your attending physicians and consulting services in the care of the patients, other experiences will help form the basis for your residency education.  Attendance at conferences is mandatory and sign-in is required.  Each resident is expected to achieve 60% conference attendance throughout the duration of his/her training program. 

 

Morning Report:  

There are a total of three required Morning Report formats for our residency program: Resident, Intern, and Night Team.  Attendance is required at all Morning Reports.  At Shands, the General Medicine Ward teams (Blue, Gold, Green, Orange) are expected to attend.  At Shands, the Oncology, Cardiology, and GI/Liver teams are expected to attend their subspecialty morning teaching conferences.  At the VA, the General Medicine Ward teams (Blue, Green, Orange, Red) and the GEM team are expected to attend. 

 

For Residents: At both Shands and the VA, Morning Report for Residents is held every Monday and Wednesday, from 8:00 a.m. to 8:45 a.m.  The locations are the Medicine Library for Shands and Room E-544 or H416-1 at the VA.  On Mondays, the residents have the opportunity to present patients recently admitted to their teams and to discuss challenging cases and interesting findings from the month.  The format is an open discussion facilitated by a Chief Resident (service attendings, Program Director, and Associate Program Directors also attend, schedule permitting).  On Wednesdays, the focus is the review of MKSAP questions, and the location is always the UF/Shands Department of Medicine Library. 

 

For Interns: At both Shands and the VA, Morning Report for Interns is held every Tuesday from 8:00 a.m. to 8:45 a.m.  The locations are the Medicine Library for Shands and Room E-544 or H416-1 at the VA.  For the first three months of the year, the format will be interactive talks covering a curriculum of Intern Basics.  Starting with the fourth month of the year, the interns will attend Morning Reports with the Residents. 

 

For Residents and Interns:  On Fridays, Morning Report is combined resident and intern at both Shands and the VA held from 8:00 am to 8:45 am.  The locations are the Medicine Library for Shands and the VA education building at the VA.  The format will be a single case presented by a Medicine or Specialty ward team to include initial presentation, evaluation, and management.  At the beginning of the month, there is a combined resident and intern morning report for Orientation. 

 

Night Team:  There is a Night Team Morning Report held on Tuesday and Thursday morning at 7:15 a.m. to 8:00 a.m. at the Medicine Library at Shands.  Both the Shands and VA Night Team are expected to attend.  The discussions will include systems based problems which occur overnight at Shands and the VA when admitting or cross-covering patients.  This is also a forum to provide feedback about any issues the teams are facing overnight. The Admissions Resident and Cross Cover Resident will have the opportunity to present any interesting/challenging cases seen during the rotation, and the work up and treatment of these patients will be discussed. 

 

Conferences:  The resident and interns are mandated to attend all scheduled conferences including Grand Rounds, M & M, and noon conference.  While on the wards, a reminder to the attending that the noon hour is approaching is appropriate so that the team can attend the conference.  Noon conference starts at 11:45 am at Shands in room 6120 on Monday, Tuesday, Wednesday, and Friday.  Grand Rounds is every Thursday at 11:00 a.m. in C1-11 (Communicore Building).  Nursing staff has been instructed not to page housestaff, unless it is an emergency, during these conferences.  

 

Senior talks: Presenting a senior talk is required of all PGY-3’s and fulfills a part of the ACGME requirement for scholarly activities.  Topics should be on a clinical or basic science topic, preferably on a research or quality improvement project that the resident has been involved with during his or her training. The senior talk should be approximately 30 minutes in length, and will be presented at noon conference to all house staff. Senior talks will occur in the spring.  A list of dates will be provided by the chief residents; the resident will provide the topic of the lecture when signing up for a date and this topic is subject to approval by the program director and his or her designees.

Grand Rounds Attendance:  It is expected that all residents have at least a 60% Grand Rounds Conference attendance.  Since it is the showcase conference of the Department, active attendance by residents is essential.  Attendance at Grand Rounds also counts toward the >60% overall conference attendance requirement for the program, and for PGY-III’s in good-standing it is also required to moonlight.

 

Board Review:  The Board Review curriculum consists of review of MKSAP questions and MedStudy on a weekly basis.  Specifically, 2 sessions are held per week, one during the designated Morning Report time on Wednesdays, and the other following Grand Rounds on Thursdays.  All PGY3’s are expected to attend one session per week and the PGY2’s are strongly encouraged to attend if they are not on a ward service.  If on a ward service, any PGY2 or PGY3 is expected to attend Morning Report as outlined under Attendance Policy (F).  For those PGY2’s who score below 20% on their annual in-service exam, attendance at Board Review is very strongly encouraged. 

 G)  Attendance Policy:  

Morning Report:  

For Residents on service, Residents or Interns who miss one of their mandatory morning reports, without advance notice to the Chief Resident, will be given a warning.  If a second morning report is missed without advance warning to the Chief Resident, that resident can be placed on an additional Friday night coverage at Shands or the VA.  The night of coverage will be decided upon by the Chief Residents and the currently scheduled resident can be relieved of their Friday night duties. 

 

Noon conference:  

Conference attendance at 60% is required over the academic year.  It should be remembered that the 60% mark is the average for all month including ICU, Night Team and vacation months – i.e., you need to attend virtually all Noon Conferences when you are on the wards and electives.  Noon conference attendance will be reviewed monthly for all residents.  Those not achieving an average 60% attendance rate can be placed on Friday night coverage.  The night of coverage will be decided upon by the Chief Residents and the currently scheduled resident can be relieved of their Friday night duties.  Noon conference attendance will be made available online.  

 

Credit will not be given for attendance for individuals who arrive after 12:15pm.  Credit will also not be given for attendance if a resident leaves before the end of conference.  Exceptions include leaving for clinic or a patient emergency. 

 

Board Review for PGY-3:  

For PGY-3 residents, attendance at weekly Board Review is mandatory.  Out of the two sessions per week, a PGY-3 Resident must attend at least one per week.  Any resident who misses both sessions in a week without advanced notice to the Chief Resident will be noted.  Any resident who misses both sessions in a week without advance notice to the Chief Resident for a 2nd time will be given a warning.  Any resident who misses both sessions in a week without advance notice to the Chief Resident for a 3rd time will be placed on Friday night coverage.  PGY-3 residents on Night Team, ICU, and Vacation are exempt. 

 

The currently scheduled resident for a Friday night that is relieved of their duties will be chosen according to their conference attendance in order to reward those who are diligent about their attendance at educational conferences. 

 

Additional Seminars/Learning Opportunities:  

Throughout the academic year, housestaff are offered the opportunity to participate in educational activities such as ACLS and Airway Management Certification, among others.  If a member of the housestaff registers for this type of educational activity either through the Chief Resident or independently, they are expected to attend.  Failure to do so without prior notification to the Course Director or the Chief Resident can result in the assignment of an additional Friday night coverage. 

 

H)  Bounce Policy for both Shands and the VA:  

Housestaff Associated Services:  A “bounce” is a patient who is re-admitted to its previous team when the same intern/resident pair exists on service.  This is independent of the attending physician.  This policy ensures fairness to other medicine services as well as establishing some degree of continuity of care for patients cared for by the team.  Bounces count as a new patient work-up and count towards team and individual caps.  A bounce will be worked up by their original team under the following guidelines: 

 

A.   From Monday through Friday, General Medicine bounces will be worked up by the patient’s original team until 3 p.m., for the post-call, short-call, and “golden” teams.  From 3 p.m. to 7 p.m. the resident on long-call will admit the patient as a holding note to the previous team.  This patient WILL count towards the long call resident’s team cap for admissions that day. 

 

 B.   Any bounces coming back to their original team who happen to be on long-call that day will be worked up by that team until 7 p.m.  If the bounce is within 72 hours, the patient will count toward the total team cap of 20, but will not count toward the admissions cap of 10.  If the bounce is greater than 72 hours, the patient will count toward the total team cap of 20 AND the admissions cap of 10.  Any general medicine bounces after 7:00 pm will be admitted by the night team as a bounce to the original team.  This patient will count towards the admission cap for the team who receives the patient the next day.  General Medicine patients who are “bounces” will not count towards the 2 (on Friday and Saturday) or 3 (Sunday through Thursday) “General Medicine” admissions.  Those admissions will, however, count toward the total cap of 8 for the Night Team admitting resident. 

 

C.    On the weekends and official Holidays, the post-call, short-call and “golden” teams must admit their own bounces until 12:00 p.m. (noon) at both Shands and the VA.  From 12:00 p.m. (noon) to 7:00 p.m., the long-call resident admits the bounce as a holding note to the patient’s original team.  This bounce “holding note” will count toward the long-call resident’s cap for admissions that day.  After 7:00 p.m., the Night Team admits the bounce to the original team.  This admission will count towards the total cap of the Shands Night Team and the team cap of the receiving service the next day.  The original team will assume care of the patient the following day at 7:00 a.m. in any of the scenarios above. 

 

D.   Subspecialty team bounces will be admitted by a member of that team until their admitting time ends for that calendar day.  If an intern from the team is admitting until 7:00 p.m., they must admit all bounces, including those who were followed by their fellow intern.  From the last admitting time until 7:00 a.m., the Night Team will admit bounces as holding notes to the original team.  As always these admissions will count towards Night Team admission cap as well as the subspecialty team’s total census cap. 

 

E.   Bounces do count as a short-call or long-call admission (the admitting team’s daily admission cap) if that patient returns more than 72 hours from the previous discharge.  If the patient was discharged less than 72 hours from time they presented again, then that patient counts ONLY towards the team’s total census cap (e.g. 20 on general medicine).  For example:  A long call service has 9 patients going into long call.  During that admission day, a bounce returns less than 72 hours after discharge.  That bounce patient can only count towards the total team cap (e.g. of 20 on general medicine); however, that service could admit a total of 11 patients on that day (10 + 1 bounce) since the bounce is less than 72 hours since discharged. 

 

Non-Housestaff-Associated Services:  For the Hospitalist Service at Shands, a patient is considered a bounce if the patient was discharged within the last 72 hours.  If a Hospitalist patient is transferred to the MICU or IMC, they will return to the Hospitalist service when they are transferred back out of the MICU or IMC within 72 hours.  For the Silver, Gold, and Purple Hospitalist Services at the VAMC, a patient is considered a bounce if the patient was discharged within the last 72 hours and the same attending is on service.  If a hospitalist service patient is transferred to the MICU, they will return to the hospitalist service when they are transferred back out of the MICU within 72 hours if the same attending is on service.  If a team reaches its cap of admissions or team census then overflow will be handled by the Hospitalist Service.  Backup is not to be called to admit these patients. 

 

I)  Conflict Resolution Between Services:  

Occasionally there may be instances when the primary medicine service is not satisfied with the quality of consultation provided by other services (such as surgical specialties and subspecialties, psychiatry, etc).  There also may be disputes between housestaff services.  In these instances it is the PGY-2 or 3 Resident’s responsibility to contact the service to clarify any issues. 

 

If there is no resolution to the problems between services, it is the responsibility of the Attendings on both services to discuss the matter and come to a resolution. 

 

J)  Scheduling and Schedule Requests:  

The Chief Residents are responsible for making the resident and intern schedules for each academic year.  In making the schedules, the primary responsibility of the Chief Residents is to 1) ensure that all the minimum training requirements set forth by the ACGME and ABIM are met, and 2) ensure that all teaching services are fully staffed throughout the year. 

 

At least one month prior to creating the yearly schedules, the Chief Residents will send a schedule request form to the residents. This form will guide scheduling assignments; however, it does not guarantee a request will be granted. 

 

Once the Yearly (Block) Schedule is released, all schedule changes, new requests, or switches need to be made in writing to a Chief Resident at least 4 weeks prior to the proposed change.  The Chief Residents reserve the right to deny, modify, or accept the proposed changes.  This policy is to preserve the integrity of #1 and #2 above.  

 

The official schedule is available online, posted on the medicine intranet, or “portal”, which is the DOM sharepoint site.

 

 

K)  Back-up Guidelines:

Residents and Interns will be scheduled for Back-Up to cover unforeseen absences by other housestaff.  The back-up schedule will be posted in advance so each intern and resident will know when they are responsible.  It is the responsibility of the individual member of the Housestaff to know what days they are on back-up and to plan accordingly.  It is expected and professional that the back-up resident has their pager on 24 hours a day during the days that he/she has been scheduled.  In addition, the Back-up resident/intern should be within 30 minutes of the hospital and accessible by telephone at all times that they are on back up. 

 

Both interns and residents will be assigned to a half-month block during their elective or ambulatory blocks.  During that time, they are expected to: 

 

1)  Keep their pager on 24-hours a day…no exceptions (for example, at the gym, running, etc). 

2)  Be accessible by phone. 

3)  Be available to come in within 30 minutes, 24-hours a day. 

4)  Not be out of town for any reason. 

5)  Make no definitive plans as they may be called in. 

 

It is the responsibility of the individual resident to obtain coverage for back-up in the event they have a conflict with the finalized back up schedule.  There will be at least 2 PGY-1’s and 2 PGY-2’s or PGY-3’s on back-up on any given half-month block. 

Requests can be made in writing to the Chief Residents not to be placed on back-up on a particular day (birthday, anniversary, etc); however, every request cannot be fulfilled.  As with any scheduling changes, all back-up switches must be made in writing to the Chief Resident for approval.  The back up schedule is available on the medicine intranet within the master schedule.  It is every resident’s responsibility to know when they are on back up and abide by the terms detailed above. 

 

When Will Back-Up Be Called In?  

The back-up system is designed to cover the services designated below in the instance of an unforeseen absence by a member of the housestaff.  Back-up should only be used for extreme personal illness, sudden family death, or sudden illness of an immediate family member.  Back up may also be called in if the situation arises of a resident’s fatigue, stress or extended hours. It is unprofessional and inappropriate to use back-up for planned events, foreseen absences, fellowship interviews, birthdays, or anniversaries.  The Chief Residents and the Program Administration have the right to alter and determine if a reason for back-up is appropriate. 

 

Consequences for inappropriate utilization of the back up service may include additional time on back up, additional night team, or additional Friday night coverage. 

 

If a resident feels back-up needs to be called, they will first notify the Chief Resident On-Call (413-4553).  The Chief Resident on call will make the determination if the back-up request is appropriate.  The Chief Resident on call will then notify the resident on back-up to come in to cover the service.  Failure by any resident on back-up not to answer their page or be unavailable is a serious violation of professional conduct.  This violation will be noted in the resident’s personal file.  In addition, the resident will be referred to the Housestaff Evaluation Committee for further action. 

 

Back-Up Responsibilities  

Back up responsibilities are assigned during elective or ambulatory months.  Attempts will be made not to assign back-up during the Ambulatory Block required rotation; however, this is not guaranteed.  Back-up is not assigned during rotations on inpatient wards, ER, MICU, night team, or away electives. 

 

It is each resident’s responsibility to look over their back-up schedule every month for scheduling errors.  Should back-up be required for greater than a 24 hour period, the policy is as follows: 

 

The back-up resident will come in and perform the duties of the absent resident until the absent resident is again able to perform their duties or back-up duty changes.

 

For extended back up or mitigating circumstances, the chief residents may alter the entire program’s schedule to allow for better patient care and resident education.

 

What Services are covered by Back-Up?  

All inpatient Housestaff run services will be covered by back-up in the case of an emergency.  This pertains to the general medicine services at Shands, the three sub-specialty services at Shands, the General Medicine services at the VA, the MICU at both the VA and Shands, the VA GEM unit, the Medicine Consult Service at Shands, the AOD, the Bridge residents at either Shands or the VA, the CCU, at Shands, and Night Team.  Also, backup may be required for Friday Night coverage, either on admissions or cross cover roles.  Should a resident be unable to attend their continuity clinic, the back-up resident may be asked to cover that resident’s clinic at the discretion of the Chief Residents and the Program Director.

Residents will not be asked to cover for non-housestaff associated services or for interns/residents absent from electives. 

 

The back-up responsibilities are crucial to the smooth functioning of the academic hospital system.  Should you have any further questions concerning back-up, please contact your Chief Residents. 

 

L)  Order Writing:  

At both the VA and Shands orders are to be written by interns and residents only.  In cases of emergency, attending physicians and consulting services may write orders.  If they are to do this we require that they contact the intern and/or resident taking care of the patient to inform him or her of the order.  All verbal orders must be signed within 48 hours

 

 

 Chemotherapy Orders Policy 

 

Shands Hospital  

1. All patients on chemotherapy at the time of admission should be admitted to the Hematology/Oncology Teaching Service.  Exceptions to this policy due to other mitigating medical problems may occur – but only with the permission of the Hematology/Oncology Attending Physician. 

 

2.  For patients on the Hematology/Oncology Teaching Service, only the Fellow or the Attending Physician will write chemotherapy orders. 

 

3.  For patients on the General Medicine Services, only the Oncology attending or fellow can write cancer chemotherapy orders.  The Oncology Consult Service must be notified within 24 hours of an admission of a chemotherapy patient on a General Medicine Service.  Once consulted, the Oncology Service should continue to follow the patient throughout the hospitalization. 

 

VA Hospital  

1. All chemotherapy orders at the VA for either inpatients or outpatients will be written by the attending physician. VA Memorandum 119-8 has further details governing chemotherapeutic agents. 

 

M)  Educational Fund Guidelines:

All categorical interns will be provided with Medstudy books at the start of their training. 

 

N)  Parental Leave Policy:

Please refer to the complete policy located on the Intranet.  Written copies can be obtained through the Residency Program Office.  Questions can be directed directly to the associate program directors, faculty mentors, or the chief residents.    

 

O)  Policy on Regional or National Academic Conference Attendance:  

The Department of Medicine Residency Program encourages residents to become active members in national academic, research, or special interest societies.  In doing so, the Department promotes residents to attend local, regional, and national conferences as presenters of their own research or as general attendees to further their education.  The following general guidelines and regulations should be followed to facilitate these educational opportunities:

 

1) The Department will pay for each categorical resident’s yearly membership to the American College of Physicians (ACP). 

 

2) All Residents are strongly encouraged to attend and present at the annual ACP-Florida meeting in the Fall, and the annual ACP-Florida Associates meeting in the Spring.  The Department will reimburse residents for travel and accommodations for attendance at these meetings when residents present.  The residents are responsible for making sure they have appropriate coverage for required rotation; the chiefs can provide assistance if needed.

 

3) The Department also encourages residents to attend and present regional and national meetings of recognized academic, research, or special interest societies.  If a resident plans to attend any regional or national meeting, 60 day notice needs to be provided to the Program Director and the Chief Residents to accommodate scheduling changes; the resident is responsible for making sure they have appropriate coverage for required rotation; the chiefs can provide assistance if needed. Only one such meeting will be supported each academic year.

 

4) If a resident is asked to present academic material at a regional or national meeting, funding for travel and accommodations should first be requested through the resident’s research mentor.  If funds are not available, the resident should submit in writing a request to the Program Director no later than 60 days prior to the conference.

 

5) In order to promote scholarly activity and representation at academic conferences, rotation schedules can be altered by the Chief Residents to accommodate a resident’s request.  However, at least a 60 day notice needs to be made in writing to the Chief Residents.

 

II.)  Resident Supervision 

 

Residents will be supervised by attending faculty in all patient care duties.  Attendings are available 24 hours each day to assist residents with the management of patients.  If a resident has questions or concerns related to the acute care of a patient the attending should be contacted.  At no time will an attending at Shands or the GVAMC be responsible for the supervision of more than 8 learners (including residents and students).  In the outpatient setting the precepting faculty will be responsible for no more than 4 residents during a given session. 

 

III.)  Inpatient Shands Hospital Teams 

 

There are inpatient teaching services at both the VA and Shands.  The VA has four general medicine teams and a GEM unit team serving the patients in the VA Rehabilitation Unit and Palliative Care Unit. Shands has three General Medicine Resident/Intern teams, one General Medicine Resident Hospitalist team, and three subspecialty-teaching services (GI/Liver, Oncology, and Cardiology).  The VAMC has a combined MICU/CCU.  Shands Hospital has a MICU team and the CCU rotation. 

 

A.)  Shands Ward Teams General Information:  

 

Patient Care Resource Manager (PCRM) Responsibilities:  There is one PCRM assigned to each team at Shands.  Their major role is to facilitate discharge planning and secure funding of the patient’s hospitalization. 

 

Charts:  At Shands, a history and physical should be entered by the intern (or resident if on the Green service) on every patient.  This should be done in a timely manner and should be done prior to leaving for the day.  They should be dictated stat or typed into the EMR.  Residents must write a short Resident Admission Note if the dictated H&P is not on the chart at the time the team leaves.  Residents should co-sign dictated H&P and ensure that it is placed in the chart.  It is the resident’s responsibility to ensure that no patient is without an H&P in the chart when he or she leaves the hospital. 

 

At Shands, progress notes should be entered daily on all patients.  Third year medical students should write the progress notes on their patients.  Interns must also write their own note including subjective, physical exam and assessment and plan.  The interns must read and co-sign the third year medical students progress notes daily.  Feedback on deficiencies should be given. Fourth year medical students are supervised directly by the resident.  The resident must co-sign the 4th year student’s note in addition to writing a separate progress note on their sub-I’s patients.  On the resident’s day off the attending is responsible for writing notes on the 4th year medical student’s patients. 

 

Discharge summaries are dictated by the intern if the length of stay is 4 days or less on the General Medicine services.  The Resident will dictate the Discharge summary if greater than 4 days.   Students can write the discharge summary but they need to be edited by the intern and  resident prior to placement on the chart.  Discharge summaries will be done within 48 hours of discharge.  Please refer to the dictation information sheets for the format and content of your dictation. You still must complete the electronic medical record discharge section.  Any paper portions of the charts will be picked up from the wards at approximately 10am the day after discharge.  By 12 noon the day after discharge they will be placed in a sanctuary in medical records where only physicians will have access to them in order to complete dictations.  They will remain in this sanctuary for 44 hours or until 8am on the third day after discharge.  These charts cannot leave the sanctuary.  The sanctuary is located on shelves by the receptionist in Medical Records.  Every physical portion of the chart will be scanned electronically into Epic where they can be viewed and utilized for dictation purposes.

 

Procedures will be different after a patient dies.  The Resident or intern must still fill out the discharge chart tab. The resident or intern must enter a death/discharge summary.  The physical paper chart will be taken to medical records in two hours.  From there it will go to the sanctuary and will be available until 8am on the third day after a death.  The exception to this is if the patient undergoes a post mortem then the chart will be taken to the morgue shortly after the patient dies and remain there until the post mortem is complete (a process that usually will require at least 48 hours).  These charts will also still be scanned into iHIRM.

 

Delinquent Medical Records:  The Chief Residents will be informed of delinquent dictations and charts.  Once a resident has been contacted by a Chief Resident about incomplete charts, the resident has 5 working days to contact medical records and begin to complete charts.  All chart completion in a timely manner is a professional obligation of a resident.  All residents are required to check EPIC weekly, and CPRS monthly. 

 

Cross-Cover:  Patients on housestaff-associated teams will always have a physician in-house to provide cross-coverage.  At Shands and the VA Hospital, between 7 a.m. and 7 p.m., this person is one of the long-call interns for that day; when Green Medicine (the Shands resident-run hospitalist service) is on long-call, one of the upper level residents will be responsible for cross cover.  The responsibility of Cross-Cover will be to carry the Cross-Cover pager and provide continued care to all housestaff services.  Between 7 p.m. and 7 a.m., the cross-coverage is performed by an intern, one at Shands and one at the VAMC.  If the long-call or specialty teams are still in house at 7 p.m., each intern should stop their work to sign out with the night cross-cover physician at that time.  The cross-cover physician must be given a written list of patients which includes (for each patient):  name, medical record number, patient location, allergies, code status, active issues, anticipated issues, and items that need to be checked and plans to deal with those checked out items, including what to do with abnormal results. 

 

If a resident orders an emergent study, it is the responsibility of the resident to follow-up on the study and determine a plan of care.  This should not be checked out to the night team.  Also, consents for blood transfusions or procedures should be addressed by the primary service during the daytime, not to be left to the night cross-cover physician to do. 

 

The Shands Cross-Cover intern is responsible for providing cross-coverage to the (4) general medicine teams and 2 of the 3 subspecialty teams (MCT and GI/Liver).  Cross coverage for Heme/Onc will be provided for by the resident AOD.  One member of the team on Heme/Onc is expected to answer all pages for the service until 9pm.  If a patient needs to be assessed, the AOD will do so and may involve the on call oncology fellow. They must involve the fellow for any change in level of care, including IMC or MICU transfers.  Housestaff cross-cover does not provide coverage for the Hospitalist services or for non-housestaff inpatient medicine teams (e.g. Heart Failure or MCH, MCI, MCE, Bone Marrow Transplant, GI Procedure service, or Lung Transplant service).  If you happen to be paged regarding one of these services, politely state that you are not providing coverage and that the individual who paged you should contact the primary service for cross-cover issues. 

 

The VA Cross-Cover intern may be from the Department of Medicine or Department of Anesthesiology.  This individual is responsible for the (4) housestaff teams at the VAMC plus the GEM and Palliative Care Unit. 

 

At 7 a.m. the night cross-cover physician should alert the primary teams to any events that took place overnight and furnish the sign-out sheets to the respective teams.  The cross-cover pager is then passed to one of the interns on long-call that day. 

 

On Fridays, the Shands night cross cover intern’s responsibilities will be covered by one intern from elective, ambulatory or a non-ward service.  This is done to provide a day off for the scheduled night team and will be posted online with the initial schedule. As with the rest of the schedule, it is subject to change.

 

It is only through effective check-out procedures that quality patient care and patient safety are maintained.  All housestaff at Shands must utilize the Epic patient sign out for daily updating of their sign-outs; residents should supervise intern and sub-I signouts.  The check-out will be performed in a standardized fashion using the shift handoff tool in CPRS.

 

On Call Meals:  At Shands Hospital the following restaurants are available:  Wendy’s, Hovan, Panda Express, Starbucks, Salad Creations,  Subway, Chick-fil-a, various coffee stands, and the hospital cafeteria. Food and drink options are available 24 hours a day.  There are also vending machines open 24 hours a day.  Residents have a lounge on the 6th floor of the Shands North Tower supplied with sodas, milk, water, access to a coffee maker, crackers, and cereal 24 hours a day free of charge. Also, Shands vouchers are provided to residents while on service.

 

Call Rooms:  Since ward services do not stay overnight they do not have overnight call rooms.  The Shands Night Team Resident Room has beds in case there is enough downtime to sleep.  The Shands and VA Cross-Cover intern also has a room with a bed if they would like to rest during their time on duty.  Both of these rooms have computers to check labs or review records.  There are lockers available in the night team room at Shands if you need to store anything.  These locks are not to be left on for more than one week at a time.  The MICU is also provided with private call rooms with access to a bathroom and shower.  All call rooms at Shands are code protected. At the VA, the rooms are keyed.

 

Security:  Security is available 24 hours a day.  We have asked all residents that when going to or from your car in the evening to have security escort you.  Security can be reached at 265-0109 for Shands.  At the VA you can call the operator and ask for security.  If arriving at night you can call security ahead of time so they can escort you in. 

 

Library:  There is a housestaff library located on the 4th floor of Shands in the Internal Medicine office which is available on weekdays from 8am to 5pm.  The UF Health Sciences  Library is open from Monday to Thursday from 8am to midnight.  On Friday the library closes at 7pm while on Saturday it closes at 5pm.  On Sunday the library is open from 10am to midnight.  Through the internet many resources are available to medicine residents.  In particular, Up To Date is now available on all Shands and VA computers.  Other internet resources can be accessed through the Internal Medicine Residency Web Page or through the UF Medical Library. The VA library is located on the 4th floor as well, and can be accessed during normal business hours.

 

Notification of Primary Physician:  It is the resident’s responsibility to notify a patient’s primary provider of any hospital admission.  If a patient seen in a resident’s clinic is admitted, the admitting physician must notify the clinic resident.  If the patient’s primary provider is not in the Shands system the Consultation Center (5-7999) can assist in locating the provider’s contact information. 

 

Autopsies:  Residents should attend to all autopsies on their patients.  There will be occasions for case review at Morbidity and Mortality, noon conference, and morning report.  It is important to ask family members of the deceased if they would like an autopsy, as it often is a good teaching tool, may shed light on the underlying diagnosis, and may provide an element of closure for the family. It also must be documented in the death note and on the death certificate.

 

Shands Transfer Center:  The Transfer Center coordinates requests for transfer of patients from outside hospitals and emergency departments to our hospital.  The following policy has been established to improve communication between the outside physician and the admitting team.  In addition it ensures patients are admitted to the appropriate medical service and ward.

 

1.) The Shands Hospitalist AOD accepts patients for transfer to a General medicine; once the patient arrives, they will be assigned to either a hospitalist or teaching team.

 

2.)  The transferring hospital should speak directly with the Hospitalist AOD immediately prior to transfer to provide updates on condition and arrival estimate. 

 

3.)  If a fellow or attending is contacted by an outside facility or physician for transfer of a patient, they cannot directly accept the patient to a house-staff associated general medicine team. They should either contact the Hospitalist AOD to discuss transfer of the patient. 

 

4.)  Patients requiring transfer to a housestaff-associated subspecialty service can only be accepted by the subspecialty attending or fellow. From 7am to 7pm, the resident on the subspecialty team must be informed of the patient’s acceptance for admission. From 7pm to 7am, the Night Team AOD Resident must be informed of the patient’s acceptance for admission.  An email should be sent out by these residents in case the patient arrives after their shift is complete. 

 

5.) All patients requiring MICU admission must be accepted by the MICU fellow or MICU attending. 

 

B.)  Shands General Medicine Teams:  

Call Schedule 

The General Medicine Teams (Gold, Blue, Orange, and Green) rotate long call every fourth day.  Gold, Blue, and Orange consist of one resident, two interns, and medical students.  Green consists of two residents and no interns, allowing the residents to obtain a true Hospitalist experience.  The four-day call schedule is as follows:  long-call, post-call, short-call, and “golden” day.  There is no overnight call for the inpatient teams; overnight admissions and cross-cover are handled by the night team.  All patients worked-up by housestaff including, “bounces”, MICU transfers and new admissions count towards the total team cap.  Housestaff do not admit patients to non-housestaff associated teams. 

 

Long-Call:  Admit up to 10 (ten) patients from 7am to 7pm Monday through Friday.  Up to 2 (two) holding notes may be admitted by the Night Team to the next day’s long call team.  These holding notes count towards the long call team’s admission cap for that day.  Notification of these holding notes should be posted in the appropriate team’s call room overnight; this includes any patients transferred in by the MICU.  Monday through Friday, the AOD will assign patients to the long-call and short-call teams in an alternative fashion until the short-call team reaches 5 patients or 3:00 p.m., whichever comes first.  The long call team admits patients until 7 p.m. Monday through Friday to an admission cap of 10 (ten). The following limits are set for late-afternoon admissions to General Medicine services (excluding subspecialty services): 

 

– after 4 p.m., no more than 4 patients 

– after 5 p.m., no more than 2 patients 

– after 6 p.m., no more than 1 patient 

 

Weekend long call is from 7 a.m. to 7 p.m.  During this time the long call team will admit a maximum of 10 patients as well as provide cross cover on other services once they have left for the day. 

 

Short-Call:  Admit up to 5 patients from 7 a.m. to 3 p.m. Monday through Friday. Monday through Friday starting at 7 a.m., the AOD will assign the short-call team the first patient of the day and then alternate subsequent admissions with the long-call team until 3 p.m. or to an admission cap of 5 (five), whichever comes first.  Short Call will receive one holding note at Shands but none at the VA. There is no short call Saturday, Sunday and designated Holidays. 

 

Post-call and “Golden Day”:  No new admissions.  The team should make efforts to discharge patients in an appropriate and timely manner as well as perform necessary diagnostic tests.  Teams are responsible for admission of their own “bounces” until 3 p.m. Monday through Friday and until 12p.m. Saturday, Sunday and designated Holidays when they are on a post-call or “golden” day. 

 

Caps: 

General Medicine team caps are as follows (Shands and VAMC): 

-Team cap:  20 patients  

-Short-Call:  5 patients/day (excluding < 72 hour bounces)  

-Long-Call:  10 patients/day (excluding < 72 hour bounces)  

 

GI/Liver Service (MGI)

-Team cap:  16 patients 

 

Oncology Service  (MOC)

-Team cap:  20 patients 

 

MCT 

-Team cap:  18 patients 

 

Individual intern/resident caps: 

-Resident:  20 patients  

-Intern:      10 patients  

-If during a long call one of the interns is in danger of going over 10 patients because of the uneven distribution of patients from that call day, then the resident will admit and manage those patients that were supposed to go to the intern but could not because he or she is capped at 10.  Once the intern falls below 10 patients, the resident then can transfer those additional patients back to the intern. 

 

Absolute individual intern/resident caps (per RRC/ACGME): 

-5 patient work-up per intern/24° and 10 patient work-up per Resident/24° 

-8 patient work-up per Intern/48° and 16 patient work-up per Resident/48° 

-Interns longitudinal caps are 12 patients and residents are 24 patients 

 

C.)  Shands Subspecialty Teams: 

There are three subspecialty teaching services at Shands – GI/Liver (MGI), Oncology (MOC), and Medicine Cardiology Teaching (MCT).  Oncology and Cardiology teams consist of one attending, one resident, two or three interns and occasionally medical students. The GI/Liver team has a GI attending and a Liver attending with one resident, two interns and occasionally medical students.  Patients will often be accepted for admission to a sub-specialty team, yet there may be a delay in the patient actually arriving.  Also, patients may be upgraded in status to the MICU team during their hospitalization.  Under these circumstances, the specialty teams cannot “hold” the spot for that patient to eventually return to or come to that service.  In the event that the team is capped and a previously accepted patient arrives (or comes out of the MICU), the team should make attempts to discharge patients to make room for the patient.  If this does not happen, the patient will be admitted to a general medicine service. 

 

MOC and MGI teams will not receive more than three holding notes per day.

MCT will not receive more than four holding notes per day.

 

GI/Liver:  The GI/Liver team takes admissions from 7 a.m. to 5 p.m. Monday through Friday.  Admissions between 5 p.m. and 7 p.m. Monday through Friday are handled by the Shands Bridge resident.  A member of the team MUST be in-house every day by 7 a.m. to be available to admit patients and to assume responsibility for any holding notes from the night prior.  The resident and one intern are responsible for taking admissions until 3 p.m. Saturday, and Sunday.  The team should construct a calendar indicating which team member will be staying until 3 p.m. to perform admissions for Saturday and Sunday.  If the interns are admitting and have questions, they should contact their supervising resident for assistance.  All admissions should be supervised by resident on the service at the time of admission. 

 

After 7 p.m., admissions to the housestaff-associated subspecialty teams are done by the Night Team as holding notes to the respective teams.  Overnight, admissions to the GI service should be accepted/approved by GI fellow on-call.  For Liver service acceptance overnight, this must be approved/accepted by the Liver attending on-call.  All patients must be accepted by the attending prior to admission to the service.  If that attending is not available then the on call GI fellow can accept a patient.  

 

GI/Liver team cap is 16.  This is a combination of Liver and GI patients; this is usually split as evenly as possible (and generally no more than 10 of either type of patient), but is ultimately at the discretion of the attendings on service.  Every patient admitted counts toward the cap (i.e. Bounces, MICU transfers, surgery transfers).  The night team should be informed of the team’s census at check out at 7 p.m. so they know how many they can admit to each subspecialty team.  Between 7 p.m. and 7 a.m., cross-coverage will be provided by the Night Cross-Cover intern and resident.

 

Oncology:  The Oncology team takes admissions from 7am to 7pm daily.  A member of the team MUST be in-house every day by 7 a.m. to be available to admit patients and to assume responsibility for any holding notes from the night prior.  The resident and three interns take turns staying until 7 p.m. to admit patients.  The team should construct a calendar indicating which team member will be staying until 7 p.m. to perform admissions.  This should be given to each team’s respective floor so they will know who to contact for admissions and cross cover.  If the interns are admitting and have questions, they should contact their supervising resident for assistance.  All patients should be discussed with the resident on the service at the time of admission. 

 

After 7 p.m., admissions to the housestaff-associated subspecialty teams are done by the Night Team as holding notes to the respective teams.  All patients must be accepted by the attending prior to admission to the service.  If that attending is not available then the on call fellow can accept a patient.  

 

The Oncology team cap is 20.  Every patient admitted counts toward the cap (i.e. Bounces, MICU transfers, surgery transfers).  The night team should be informed of the team’s census at check out 7 p.m., so they know how many they can admit to each subspecialty team. 

 

One member of the team must provide cross-coverage of the Heme/Onc service until 9 p.m. from home.  If a patient needs to be evaluated the AOD will do so.  From 9 p.m. to 7 a.m. the AOD will provide cross coverage. 

 

Hematologic Malignancies/BMTU:  

 

1.  The fellow’s primary focus will be on the consultative care of non-transplant hem malignancies patients.  These patients are physically located on 8E in the South tower.  This will provide an adequate number and optimal diversity of cases for the fellow to be exposed to.  The fellow will oversee the care of these patients by providing daily weekday consultative services to the primary medical team, particularly the resident/student members. 

 

2.  The fellow will write admission (attending-like) and daily progress notes that will be co-signed by the consulting Hem Malignancy/BMT attending. The primary service (Heme/Onc Teaching Service) will still remain the attendings of record. 

 

3.  The highest priority patients are those with acute leukemia/blast crisis undergoing chemotherapy or a complication from the disease/treatment.  These patients will not exceed more than 4 physical beds on 8E and there will be no more than 2 patients in the BMTU that are being followed by this fellow.  The Residents and Interns on the Heme/Onc Teaching Service will not follow patients in the BMTU.

 

4.  Patients with other non-transplant hematologic malignancies (including those >100 days after autologous transplant or >6mo after allogeneic transplant), will also be followed by the Heme Malignancy consult service with coordination of care to the appropriate degree with the primary attending oncologist. 

 

5.  The fellow will attend morning rounds and work with the resident team on 8E and be available to answer questions and make plans for procedures, chemotherapy orders and discharge planning.  Rounds should typically start at 9:30 and not extend beyond 10:30 am on this cohort of patients.  Alternative times may be at the discretion of the fellow and senior resident/hospitalist (i.e., in the event of fellow morning clinic) on the service, but daily rounding with the team MUST occur. 

 

6.  Fellows on service will be responsible for procedures related to the diagnosis and treatment of these patients such as bone marrow biopsies and intrathecal therapies whether through lumbar puncture or Omaya reservoir.  New fellows will be trained by PAs/ARNPs or more senior fellows.  

7.  The fellow will communicate with the outpatient clinic team to ensure continuity of care for discharged patents.  Kathy Williams (pager 413-7701) will be the contact nurse responsible for assisting in the transition of care and with specialty laboratory testing and acquisition. 

 

8.  As a consultant to the 8E medical service, the fellow will be responsible for giving the educational lectures to the resident team twice weekly.  This lecture will be done between 8:00 and 8:30 every Monday and Friday morning.  Fellows will be exempt from other responsibilities in order to provide these educational sessions.  The Heme Malignancy Consult attending should be present at least weekly for these teaching sessions to provide additional pearls and the perspective of experience.  The fellow on service should seek commitments from the next rotating fellow to sign up these lectures to cover at least two weeks after their rotation is over.  This sign up sheet should be posted on the door of 8E team room.  These lectures are to be delivered at a resident level of education and are intended to supplement their clinical care and board preparation.  The selection of topics is included in the table below.  The order of the presentations is at the discretion of the fellow, keeping recent clinical events and cases in mind for educational impact. 

 

9. Any request for new inpatient consultation will be triaged first by the Oncology Consult service.  If appropriate, the consult will be formally staffed and transferred to the Heme Malignancies consult team per the request of the Oncology Attending.  The ultimate decision for where these patients get admitted (8E vs BMTU) will be made by the admitting attending of record. 

 

10. Pharmacy assistance and oversight will occur via the dedicated pharmacist on 8E. 

 

Neuro Oncology: 

 

Staff/House-staff utilization for call/coverage: 

When the Neuro-Oncology Attending is the Oncology Consult Attending, he/she will work with, teach, and supervise the students/house-staff on the 8E ward & Oncology Consult Service.  

 

*The Neurosurgery residents/staff will not be involved in the care/cross-cover of the general 8E Oncology patients unless consulted.  When the Neuro-Oncology Attending is providing Neuro-Oncology Consult Attending services to patients with new or established Neuro-Oncology Issues, he/she will work with the Inpatient 8E Oncology team.  

 

*In addition, the Neuro-Oncology ARNP, Clinical Trial Coordinator, +/- Neurosurgery house-staff will be Involved, as appropriate [see below]. 

 

Algorithm for patient flow: 

 

A.  For established or new Neuro-Oncology patients, the Neurosurgery Department, and/or On-call resident will remain the first call for incoming phone-calls, ER consults, and transfer center requests.  The Neurosurgery resident will contact the medical oncology fellow on-call to discuss patient disposition if the services of medical oncology appear appropriate.  The oncology fellow will then inform the 8E house staff team.  The neurosurgery and oncology attendings may be consulted for assistance. 

 

B.  Although each patient must be individualized, scenarios such as scheduled admission for inpatient chemotherapy, oncology progression, (non-CNS) emergency, neutropenic fever, known/suspected chemotherapy toxicity, would go to the 8E Oncology Service.  Acute neurologic changes and suspicion for impending neurosurgical services would go to the Neurosurgery Service. 

 

C.  The Neurosurgery Service (or the Neuro-Oncology Attending) will be contacted by the ER if an established Neuro-Oncology patient is seen in the ER or contacted by the admitting resident for admission to the 8E Oncology Service. 

 

Algorithm for Attending Involvement: 

 

A.  Any patient admitted/transferred to the 8E Oncology Service will be admitted to the Heme/Onc Attending and primarily cared for by his/her team. 

B.  In addition to the on-service Oncology Consult Attending, the patient’s Primary Oncology

 

Attending (such as the Neuro-Oncology Attending) may be consulted on an established or new patient at the discretion of the 8E service attending.  The patient’s Primary Oncology Attending +/- their ARNP and Clinical trial Coordinator, may participate in daily notes, administration of the standard or investigational chemotherapy, etc., as requested by the 8E team. 

 

C.  If the Primary Oncology Attending (such as the Neuro-Oncology Attending) has also been consulted on an inpatient, the on-service Oncology Consult Attending and the Primary Oncology Attending will agree upon their respective levels of involvement. 

 

 Algorithm for special situations: 

 

A.  In the event that the Neuro-Oncology Attending is unavailable, his/her ARNP, study coordinator, and if applicable, the Neurosurgery service, will be available for questions/consults. 

 

B.  In the very rare events that ACGME house staff-census or duty-hours are maxed, patients not requiring chemotherapy will be admitted to the appropriate non-8E/Oncology Services. 

 

Clinical Trial Patients: 

 

Patients on Neuro-Oncology Clinical Trials, who are admitted for chemotherapy administration or care (i.e., toxicities), will also be cared for by the 8E Oncology team.  In addition, the Neuro-Oncology Attending, his/her ARNP, and his/her Clinical Trial Coordinator will work closely with the 8E team as needed. 

 

A.  The Oncology Attending will provide routine care and work with the Neuro-Oncology Clinical Trial Coordinator and Physician Investigator on maintaining protocol integrity. 

 

B.  The Clinical Trial Coordinator and Physician Investigator will be responsible for routine Clinical Trial documentation and reporting. 

 

C.  Any anticipated Clinical Trial patient admission will be reviewed with the 8E Oncology Attending.  The Clinical Trial Coordinator and/or Physician Investigator will be notified of any unanticipated admission. 

 

D.  Pre-printed trial-specific chemotherapy order forms*, trial schema, and instructions will be provided.

*located under UF Patient Care Forms Tab on the Shands Homepage. Depending on the trial, it may be listed under Research, Neurosurgery, or Oncology.  

 

E.  In-services (trial-specific and patient-specific) will be conducted by the Clinical Trial Coordinator and Physician Investigator. 

 

F.  Protocol copies are available on the 8E ward & in the Chemo-Pharmacy. 

 

G.  When the Neuro-Oncology Attending is the Oncology Consult Attending, he/she will provide the above services for inpatients receiving chemotherapy or care on inpatient Clinical Trials. 

 

Cardiology – MCT/ CCU:  The MCT team consists of two separate entities the floor service and the CCU. The floor service is under the supervision of the MCT resident.  The CCU is under the supervision of the CCU Cardiology fellow. 

 

Medicine Cardiology Teaching Service  

 

Team:  

• Cardiovascular Attending 

• Cardiovascular Fellow 

• Medicine Resident (PGY-2 or PGY-3) 

• Medicine Interns (minimum of 2 PGY-1) 

 

The MCT team is under the direct supervision of a Cardiology attending and Cardiology fellow.  Housestaff learn how to manage a wide variety of cardiovascular diseases and by the end of their rotation are expected to be proficient in evaluating patients with acute coronary syndromes.  Patients will be admitted through the Emergency Department, Cardiovascular Clinics, and as hospital-to-hospital transfers.  It is encouraged that the MCT team round with the CCU team as an educational activity if time allows. 

 

Education:  

The educational purpose of this rotation is to train Housestaff in the evaluation and management of cardiac disease in the inpatient setting.  The teaching rounds provide an important source for housestaff members in learning how to manage acute coronary syndrome, coronary artery disease, arrhythmias, congestive heart failure, and valvular heart disease.  In addition, didactic lectures will be provided by Medicine Morning Report, Cardiology Grand Rounds, and Clinical Cases Conferences. 

 

Team Cap:   18 

 

Schedule:  

The team will be responsible to be in-house from 7:00 AM to 7:00 PM seven days a week.  Each resident and intern will have one day off per week averaged over the month and the schedule will be created by the resident and approved of by the Cardiology fellow.  There is no overnight call on this service. 

 

MCT Admissions:  

 

From 7:00 AM to 5:00 PM (or 7:00 AM to 3:00 PM on weekends)

 

1)  MCT team will be first call to admit patients with a primarily cardiac complaint through the Emergency Department, hospital-to-hospital transfers, and direct admissions from the Cardiovascular Clinic(s) until they are capped. 

 

2)   If the MCT service is capped (cap is 18 patients), then the General Medicine Teaching Service (Green, Gold, Orange, Blue) on-call will admit through the Emergency Department, hospital-to-hospital transfers, and direct admissions from the Cardiovascular Clinic(s). 

 

3)  The decision to admit to MCT will occur via a discussion between the AOD and the MCT cardiology fellow, both during the day and at night. 

 

4) Patients presenting between 5pm and 7pm on weekdays and 3pm and 7pm on weekends will be admitted by the Hospitalist Service as a holding note to MCT for the following workday up to a total of 4 holding notes per day and a team cap of 18. The resident AOD will be in charge of informing the MCT teams of their holding notes.

 

From 7:00 PM to 7:00 AM  

 

1) The Night Team Admissions Medicine Resident will admit to the MCT team as holding notes for the following workday up to a total of 4 admissions (including admissions done by Hospitalists) or until the MCT service is capped (cap at 18), whichever should come first.  Admissions will be through the Emergency Department and hospital-to-hospital transfers. 

 

2)  If the MCT service is capped (cap is 18 patients), then the Night Team Admissions Medicine Resident will admit to the next day on-call General Medicine Teaching Service (Green, Gold, Orange, Blue) as a holding note.  Admissions will be through the Emergency Department and hospital-to-hospital transfers.  The Night Team Admissions Resident can only admit a total of 3 patients to the Medicine Teaching Service or until the General Medicine Teaching Service is capped (cap at 20), whichever should come first. 

 

3)  If both the MCT service (cap at 18 patients) and the General Medicine Teaching Service on-call (cap at 20 patients) should become capped, then Medicine Hospitalist Service will admit to their service through the Emergency Department and hospital-to-hospital transfers. 

 

Evaluation:  

To ensure that each housestaff member satisfy the ACGME 6 core competencies: 

1. Patient Care 

2. Medical Knowledge 

3. Interpersonal Skills and Communication 

4. Professionalism 

5. Practice-Based Learning and Improvement 

6. Systems-Based Practice 

 

CCU (pager 413-0212)  

The CCU resident admits patients to the CCU from 7:00 a.m. to 7:00 p.m. and must be in the hospital with their pager on from 7:00 a.m. to 7:00 p.m.  From 7:00 p.m. to 7:00 a.m., the Cardiology Fellow on call will admit any patients requiring CCU level of care.  This includes dictating the H & P, admission orders and providing appropriate care to stabilize the new patient.  In addition, the Cardiology Fellow should contact the CCU resident by 7 a.m. to inform them of the overnight admission(s).  If an MCT floor or IMC patient requires transfer to the CCU, the Night team will be responsible for the Transfer Summary, orders and stabilization of the patient.  This will be performed under the direct guidance and supervision of the on call cardiology fellow.  The CCU resident will follow ACGME rules regarding number of admissions per 24 and 48 hours. 

 

Patients transferred out of the CCU will go to the MCT team unless the MCT service is at its census cap.  If the MCT service is capped when it is time to move a patient out of the CCU then that patient will be cared for by the fellow and attending independent of the teaching service, or the patient will be transferred to a general medicine service.  Residents rotating in the CCU will be excused from continuity clinic duties.

 

Cross-Cover:  The Night Team Cross Cover Intern (413-4599) and Resident (413-0212) will provide cross cover on MCT (floor and IMC) and CCU patients, respectively, between the hours of 7:00 p.m. and 7:00 a.m.  If the problem is not simple, the Cardiology fellow will be called by the night team to come in and care for the patient.  The MCT resident is not to provide coverage during the day to the CCU as those patients are not under his supervision; this responsibility lies with the Cardiology fellow assigned to the MCT/CCU service or to the Cardiology fellow on call. 

 

D.)  Shands MICU: 

The Shands MICU team will be comprised of four residents and four interns.  Total required critical care experience, including MICU and CCU, will not exceed 6 months during the 3 years of residency training.  Up to an additional 2 months of critical care elective can be undertaken if approved by the program director.  Residents will not be on call more often than every 4 days.  There will be a daily lecture series presented by the MICU attending and fellows; each team member should make every effort to attend (exceptions would be the post call resident and night intern if by going they would violate work hours).  There is now 24 hour attending or fellow coverage in the Shands MICU.

 

Interns:  There will be four interns in the MICU each month.  The two teams each consist of two interns and two residents; the two teams will alternate call days.  There will be two interns scheduled on their team’s long call days; interns will be in house by 6am.  One intern will stay until 7pm, the other will leave at 1pm; this will alternate.  Their duties on these days include working up new admissions to the MICU, pre-rounding, writing notes and providing cross cover to the other team’s patients.  On short call days, there will likely only be one intern scheduled; they will be in house by 6am. Their duties on these days will include pre-rounding, writing notes on half the patients and signing out to the long call team once their work is complete.  During short call days the residents will also pre-round and write notes on half of the team’s patients.  Interns will spend a portion of their MICU rotation on a modified night float schedule; their shift will begin at 12am and they are to leave by 1pm.  Their duties will include working up new admissions overnight (this will include admitting patients to both MICU teams), cross covering both teams’ patients, pre-rounding and writing notes on their team’s patients.  Interns will have a minimum 1 day off a week averaged over the rotation length.

 

Transportation of patients has been eliminated as a job duty of the interns.  If a patient’s condition is critical then a resident may be asked to accompany nursing staff in the transportation of this patient.  This will be reserved for critical patients to ensure proper care. 

 

Residents:  There will be four residents in the MICU each month.  The two teams each consist of two interns and two residents; the two teams will alternate call days.  They take overnight call on every 4th night.  The short call resident will arrive at 6am and remain until their work is complete and adequate sign out has been provided to the long call team. They must, however, leave after 28 hours (only 24 of which can encompass new patient admissions and work-up while the last 4 hours should be transition of care).  The duties of the short call resident include pre-rounding and writing notes on half of the team’s patients and ensuring adequate sign out is provided to the long call team.  The on call resident will arrive at 8am and will rely on fellow residents and interns to present their patients on rounds that morning.  The post call resident must leave by noon the following day, no exceptions.  Residents will have at minimum of 1 day off a week.  This will occur on their golden day (i.e. long call à post call à golden day à short call à long call). 

 

Because there will be no intern coverage from 7pm-12am, the Night AOD Resident will admit patients from the ER to the MICU during these hours.  They will be responsible for evaluating the patients in the ER and discussing the case with the in house pulmonary fellow or attending.  If the patient is deemed appropriate for MICU admission, the AOD resident is responsible for writing a full H&P, placing complete orders, and discussing the patient with the night resident to ensure proper handoff once the patient is transferred to the MICU.  While the patient remains in the ER, the AOD resident is responsible for working closely with the ER to co-manage the patient and to ensure all appropriate procedures, access and consults are obtained and that patient is stabilized for transport to the MICU.  If after discussion with the MICU fellow/attending, the patient is deemed to not require MICU level care, the patient can be admitted as a holding note to the general medicine team with a short note from the MICU fellow/attending stating that the patient has been discussed with them and is stable for IMC admission.

 

Patients on Bipap/Cpap require an MICU consult; patients in the IMC must be able to be weaned off NIPPV within 8 hours and should be followed up by the MICU team.  Patients requiring 100% NRB (unless palliative care patient) require either MICU consult or to be weaned to 50% ventimask before eligible for IMC admission. Residents should never remove NIPPV from patients in the ED without a discussion and order from the ED attending and with the aid of respiratory therapy.

 

E.) Shands IMC: 

IMC patients will be cared for by the general medicine and subspecialty teams.  This is a step-up in care and will be located on unit 94 at Shands, or in an IMC level unit when unit 94 is full.  Supervision and assistance to the general medicine and subspecialty teams will be provided by the Shands Bridge resident.  The Bridge resident will be available from 7 a.m. to 7 p.m. while overnight coverage from 7 p.m. to 7 a.m. will be covered by the Shands Night Team cross cover resident.  In the A.M., to assist in pre-rounding and team rounding the Bridge resident will be the first call for all questions.  The questions and solutions will be accumulated and passed on to the team residents following team rounds.  (PLEASE SEE BRIDGE RESIDENT ROLES/RESPONSIBLITIES BELOW).

 

 F.) Shands Night Team: 

The Night Team will work from 7pm – 7am Saturday through Thursday, with Friday night off.  The team consists of two residents and one intern.  One resident is the Admitting Resident and the other is the IMC & CCU Cross-Cover resident.  The intern provides cross-cover under the supervision of the IMC Cross-Cover Resident.  The Night Team is supervised by the Ambulatory Chief Resident and the Program Director.  The team will perform admissions to housestaff-associated subspecialty teams (i.e., GI/Liver, Onc, and MCT), “bounces” to General Medicine teams and admissions to General Medicine teams as “holding notes”.  The team also provides cross-cover for all housestaff-associated services (Subspecialty and General Medicine teams).  The cross cover resident may assist the MICU team during the night in the North Tower. 

 

The night team will have Friday night off.  Friday night will be covered by 3 residents.  Days off may not be changed without prior approval of the Chief Residents in writing.  A resident will not be scheduled for more than 1.5 months of Night Team in a given year of training, with no more than 4 months over the course of the 36 months of training.  

 

The members of the Night Team will attend Night Team Morning Report on Tuesday and Thursday from 7:15 to 8:00 a.m., held in the Medicine Library. The Night Team intern from the VAMC is expected to come to Night Team morning report at Shands.  It is expected that all issues or problems with patients or colleagues overnight are documented with names, medical record numbers and times of incidents so that it may be accurately reported to the Chief Residents.  This will facilitate the necessary action to be taken to resolve the issue. 

 

Night Team Admitting Resident (413-4587).  The admission resident will sign out with the AOD at 7 a.m. and 7 p.m. for pager handoff and to review pending admissions and transfers.  From 7pm to 7am the Hospitalists (pager 413 1731) will take all calls for Medicine admissions, including from the ER, clinics, and H to H transfers.  The Hospitalists will be in contact with the Night Resident AOD to determine what the teaching services censuses are.  The Hospitalists will triage all requests for admissions and then notify the Night AOD resident for admissions to medicine teaching services, both General Medicine and Subspecialty teams.  If the resident determines that the patient should be admitted to a non-housestaff associated service (MCI, MCE, MHS, MCH, BMT, Lung Transplant, etc.), the patient should be admitted by the Night Hospitalist, pager 413-1731.  This includes all hospital-to-hospital transfer center calls for these teams. 

 

Because there will be no intern coverage from 7pm-12am, the Night AOD Resident will admit patients from the ER to the MICU during these hours.  They will be responsible for evaluating the patients in the ER and discussing the case with the in house pulmonary fellow or attending.  If the patient is deemed appropriate for MICU admission, the AOD resident is responsible for writing a full H&P, placing complete orders, and discussing the patient with the night resident to ensure proper handoff once the patient is transferred to the MICU.  While the MICU patient remains in the ER, the AOD resident is responsible for working closely with the ER to co-manage the patient and to ensure all appropriate procedures, access and consults are obtained and that patient is stabilized for transport to the MICU.  If after discussion with the MICU fellow/attending, the patient is deemed to not require MICU level care, the patient can be admitted as a holding note to the general medicine team with a short note from the MICU fellow/attending stating that the patient has been discussed with them and is stable for IMC admission.  There is a cap of 8 admissions/night.

 

MICU admissions are first priority for the night resident AOD from 7pm to 12am.  They can admit up to 8 MICU patients during this period.  As a result, general medicine admissions will be done by the hospitalist service between 7pm and 12am. 

 

 

Subspecialty admissions:  The Night Team Admitting Resident admits patients being admitted to GI/Liver (MGI), Cardiology (MCT) and Hem/Onc up to three holding notes for Heme/Onc and GI/Liver and four for MCT (including those done by the hospital or bridge from the afternoon).  For CCU patients please see the MCT/Cardiology section above.  The appropriate attending on MGI, must be informed of all Hepatology admissions and approved prior to admission to the subspecialty service.  If the resident is unable to speak to the attending then the subspecialty fellow on call must approve the admission.  GI patients must be approved by the fellow on call.  Hem/Onc patients to be admitted overnight must be approved by the Hem/Onc fellow on call.  This approval should be dictated in the H & P, including that the resident “spoke to Dr. ____ who recommended admission to…”. 

 

General Medicine admissions:  The Night Team will admit two general medicine patients as “holding” notes to the next day’s long call team.  The third general medicine admission will go to the next day’s short call team.  At the time of admission, the resident will contact the attending of the service to which the patient is admitted and discuss the case and plan.  They will admit bounces to any housestaff-associated ward teams.  After the night team has done the first three general medicine admissions, any further general medicine admissions will be done by the Hospitalists.  The exception is if a bounce needs to be admitted to a housestaff team.  This will be done by the Resident on admissions, and will count toward the cap of 8 admissions. 

 

Caps:  The Admitting Resident is responsible for up to 8 admissions per 12 hour shift.  GI/Liver and Oncology have a cap of 16 and 20 respectively, while MCT has a cap of 18.  Each Subspecialty team resident should inform the Admitting Resident of daily census so that the cap will be honored overnight.  When a Subspecialty team cap has been reached, no further patients can be admitted to that service.  Any further subspecialty patients would be admitted to a General Medicine service.  If the night team has already admitted three General Medicine patients and the subspecialty team is capped either by total team cap or three overnight holding notes (four for MCT) already admitted, then the patient would be admitted by the Hospitalists. 

 

If the resident admits their cap of 8 patients (including MCT, MGI, Heme/onc, MICU and general medicine) and has not reached the cap of General Medicine holding notes (2 on Sat and Sun, 3 on weekdays), they should ask the night Hospitalists to transfer a General Medicine patient(s) who was admitted by the Hospitalist service that night to the teaching service. The Night Hospitalists can admit a GI/Liver, Oncology or MCT to their respective teams if the team caps have not been reached and the subspecialty attending or fellow approves.  The night AOD resident is then responsible for notifying their respective teams in the morning.

 

Cross-Cover Resident (413-4496):  The cross cover resident is responsible for providing direct cross- coverage to the IMC, and will carry a separate CCU pager overnight (413-0212).  Cross-Cover resident will admit all hospital to hospital transfers being admitted to General Medicine Teaching Services (Blue, Gold, Green, Orange), MCT or MGI at the North Tower.  The Cross-Cover resident can admit up to 4 patients; caps for respective teams apply and the resident should be in communication with the resident AOD. The Cross-Cover residents will sign out to the Bridge residents at 7am and notify them of any acute issues that need to be followed up.  During the weekends the pager will be carried by the long call resident.

 

Cross-Cover Intern (413-4599):  The Cross-Cover intern provides cross-coverage of all housestaff-associated medicine teams, including Subspecialty Housestaff services but excluding Heme/Onc, MICU, IMC, and CCU.  The intern is supervised and assisted by Cross Cover Resident.  They are expected to return calls in a timely manner, and notify the nursing staff caring for a patient if there will be a delay in making it to the bedside if they are dealing with a more critical patient.  If they see a patient, they should write a brief note in the chart.  Verbal orders should be reserved for emergency situations only, and must be signed within 48 hours. 

 

If a patient goes to the IMC, MICU, CCU, has a therapeutic misadventure, or dies, the interns should call the resident and the attending responsible for the patient regardless of time of day unless the resident has specifically told you that you do not need to call.  The Cross Cover intern’s direct supervisor for problems or help with patients is the Cross Cover Night Team Resident.  If this individual is unavailable or does not answer, page the admitting resident (413-4587).  If a patient is in need of immediate attention because of instability, or if the patient needs to be transferred to the MICU, please contact the MICU team directly at 219-7970.  When the shift is complete in the morning, the intern will return the check-out sheets to the appropriate teams, notify them of any overnight problems with their patients, make sure that your verbal and telephone orders are signed, make sure that all patients that need a note have one in the chart, and give the cross-cover pager to the team on long-call that day. 

 

G.) Bridge Resident:  

VA BRIDGE:  During July, August, and September, a PGY2 or PGY3 will be assigned to function as the Bridge Resident. Duty involves Monday through Friday from 11 a.m. until 9 p.m.  The Bridge Resident has weekends off and is expected to attend his/her weekly continuity clinic.  The Bridge Resident will work on designated holidays.  The Bridge Resident will attend Grand Rounds/Noon Conference and will assist the long-call with patient care related issues, including procedures, admissions, calling consultations.  The Bridge Resident will primarily be responsible for the long-call team that day, but should assist short-call or the other ward teams to facilitate patient care after it is determined that the long-call team has been taken care of.

 

SHANDS BRIDGE:  

Schedule:  

Monday through Friday  7:00 a.m. – 7:00 p.m. 

Saturday/Sunday: Bridge will be AOD from 7am-7pm on one of the weekend days and the other is to be their day off.  This is to be worked out amongst the two residents (Bridge and AOD).  If the rotation has unequal weekend days, preference will be given to the resident will is starting or finishing an ICU or ward rotation with only one day off per week.

 

Shands Bridge Resident Pager  

413-4496 (same as the Night Cross Cover Resident) 

 

I.   General duties and responsibilities:

The general duties of the Shands Bridge Resident will be to provide assistance with patient care to all Department of Medicine housestaff-associated inpatient services.  This includes general medicine, the Hematology/Oncology service, the GI/Liver service, and Medicine Cardiology Teaching service (MCT).  Involvement may include any level of patient acuity, and may include (but is not limited to) assistance with admissions, procedures, transfers, or immediate response to acute changes in clinical status.  He/she will initiate the workup of GI/Liver service patients whose are admitted between 5:00 p.m. – 7:00 p.m.  Monday through Friday (details below). 

 

The Shands Bridge Resident will provide immediate availability and response to clinical questions or issues involving IMC-level patients whose care is directed by the housestaff services listed above.  He/she will assist in procurement of patient beds for those requiring IMC level of care and conduct active real-time re-assessment of all IMC-level patients on housestaff-associated services.  He/she will be, during his/her duty hours, the physician with whom all housestaff services will perform sign-out on IMC-level patients, and will be responsible for signing out these patients to the corresponding Night Cross Cover Resident at 7:00 p.m. 

 

The Bridge Resident is to receive sign out on any acute issues on IMC patients from the night cross cover residents and follow up on any urgent issues.  The Bridge should contact the 94 charge nurse at 9am

 

 

II.  IMC Patient Care:

  A)  Cross Cover/Sign-out on IMC Patients 

The hand-off of IMC patients (and the IMC pager) should take place: 

 At 7 a.m. & 7 p.m., between the Night Cross Cover Resident & the Shands Bridge Resident   

 The Night Cross Cover Resident is responsible for updating the list with any patients admitted to the IMC overnight 

 

 

B)  The Primary teams are responsible for updating their IMC list and checking out to the Shands Bridge Resident between the hours of 7 a.m. – 7p.m. 

 

C)  Floor patients should be signed out to the cross-cover intern (413-4599) 

 

D)  In the morning, Night Cross cover should sign out floor patients to the respective interns. IMC patients should be signed out to the team resident with the Bridge Resident present.  This way, the Bridge Resident is aware of active issues with each team’s IMC patients by way of a formal sign-out. 

 

E)  Criteria for IMC admissions have been modified effective February 1, 2008.  These are posted on the Medicine Portal site and should be used as a guide for any medicine patients on the General Medicine Teaching Services, GI/Liver, Oncology, or the hospitalist services who requires an IMC-level bed or care. 

 

III.  Rounding on IMC Patients:

By 7 a.m. the intern/resident caring for IMC patients should pre-round on these patients to identify any needs these patients may have.  Determining potential for downgrading to floor status needs to be a dynamic process.  Formal Attending Rounds should take place on IMC patients first, with preference given to those patients boarding outside of unit 94.  If possible, the Bridge Resident should round with as many teams with IMC patients as possible.  In the absence of this, the Bridge Resident should be conducting their own pre-rounds, which includes following up on any issues that came up from the night before as well as introducing themselves to the staff.  In addition, each resident (or intern if the resident is off) must communicate with the Shands Bridge Resident after rounds with the attending are done (most likely, after noon conference) to update him/her on the status of the IMC patient(s). 

 

IV.  Primary Contact for IMC Patients:

The Bridge Resident will be the first point of contact for IMC patients regarding urgent issues from nursing.  It is the responsibility of the Bridge Resident to convey both critical and non-emergent information from the nurses to the primary team.  If urgent issues arise, the Bridge Resident must immediately address them while actively involving the primary service in the management of the patient.  The day-to-day management of the IMC patients, including the determination of whether a given patient needs to be downgraded or upgraded in care, is still the responsibility of the primary team.  The IMC Bridge Resident is primarily there to respond to urgent and emergent patient care issues. 

 

V.   Order Sets: 

On the new IMC order sets, the Emergency Contact information has changed to reflect the presence of the IMC Bridge Resident (e.g. the 413-4496 pager) as well as contact information for Silver Medicine. 

 

VI.  Admission of Patients to MGI Service: 

Shands Bridge Resident will assess all admissions to the GI service between 5 p.m. and 7 p.m. Monday through Friday, including patients from the ED, the GI clinic, in the ADTU, as direct admissions to the floor, or the occasional (but increasingly rare) H to H which arrives between 5 p.m. and 7 p.m..  If the AOD is contacted about a MGI admission between 5 p.m. and 7 p.m., he/she should notify the Shands Bridge Resident to complete the admission. The Shands Bridge Resident will write orders and dictate an H&P on patients who are being admitted between 5 p.m. and 7 p.m. Monday through Friday and follow up on any preliminary diagnostic results which return before 7 p.m.  The GI service will continue to admit patients until 3 p.m. Saturday, and Sunday.  The Shands Bridge Resident will directly contact Night Team Cross Cover Resident at 7 p.m. and inform them of the admit to the MGI service as a holding note; discussion between Shands Bridge Resident and Night resident will go over what the patient is being admitted for, what the Shands Bridge Resident has done thus far, what has been ordered, and what is pending.  The Night Cross Cover Resident’s responsibilities are to:  1) to ensure that the orders are complete; 2) patient care is continued overnight.

 

In an attempt to minimize the late afternoon (5 pm – 7 pm) arrival of complicated GI and Liver hospital transfers, the GI Faculty have been instructed to not send for GI patients (GI or Liver patients) between 12 p.m. and 6 p.m., 7 days a week.  This will also be enforced with the Transfer Center such that MGI patients are not sent for during these hours.  The rationale is that our geographic radius for transfers is generally a few hours from Gainesville, and by implementing a “do not send for” policy between 12 p.m. and 6 p.m., there should be virtually no hospital transfers arriving between 5 p.m. and 7 p.m.  If any hospital-to-hospital transfers do arrive between 5 p.m. and 7 p.m., the Bridge Resident should still start the admission as usual.  As soon as possible, please notify the Shands Chief Resident via E-mail, who will investigate the sequence of events with the Transfer Center leading to the patients arrival.  The GI/Liver service is allowed to reserve ONE spot on their census for hospital to hospital transfers. 

 

VII.  Assistance to the MCT Service: 

Although the Bridge resident will be available to assist the MCT service all day, the Bridge will particularly focus on the MCT service from 4:00pm – 5:00pm from Monday to Friday.  The Bridge should contact the MCT service around 6:00pm if they have not spoken earlier in the day.  The Bridge will help the MCT service in any capacity needed, especially with orders and H&P’s for patients who are admitted or transferred to the service late in the day. 

 

VIII.  Backup for Shands Bridge Residents: 

The primary backup for the Shands Bridge Resident will be the Attending of record for the medicine team (during the day) and the Hospitalist (at night).  If a patient is becoming unstable, the next call should go through the MICU fellow or attending.  If these efforts are unsuccessful, the Chief Resident on call should be contacted to assist with the situation. 

 

H.)  Shands Admitting Officer of the Day (AOD):  

Schedule  

Monday through Friday  7:00 AM – 7:00 PM 

Saturday/Sunday: The Bridge and AOD residents will each cover the 7am-7pm AOD shift on one of the weekend days and the other is to be their day off.  This is to be worked out amongst the two residents (Bridge and AOD).  If the rotation has unequal weekend days, preference will be given to the resident will is starting or finishing an ICU or ward rotation with only one day off per week.

 

 

AOD Pager  

352-413-4587 ( Admissions Pager) 

 

 

I.   General duties and responsibilities:

The AOD is a PGY-3 resident assigned to a half-month rotation.  The job of the Shands AOD Resident is to determine destination of patients being admitted to general medicine housestaff teams, housestaff subspecialty services, and the hospitalist and Family Medicine services.  He/she will NOT function as a rotating resident in the emergency department, but rather be integrated into the emergency department.  He/she will carry the Admissions Pager (352-413-4587).  Sign-out will be in person at the beginning and end of his/her shift with the Night Team Admission Resident. 

 

AOD will also provide cross-coverage for patients on 8E (Heme-Onc), south tower.  The AOD will keep a list of all patients he/she is called to evaluate and a running list of hospital-to-hospital transfers accepted by the Chief Resident or pending direct admissions, and communicate this information to the resident he/she hands-off to at the end of shift. 

 

II.  Responsibility of the Admissions Pager [352-413-4587]:  

At 7:00 a.m. Mondays through Fridays, the Night Team Admissions Resident will physically hand the admissions pager off to AOD Resident.  The AOD will hold the admissions pager until 7:00 PM, at which time he/she will hand the pager off to the Night Team Admission Resident.  The AOD will provide cross coverage of the Heme/Onc service.  Urgent medicine consults at night will be performed by the Night AOD and will count as one of their 8 admissions. If a consult can be done in the morning the information will be passed on. 

 

III.  Duty Responsibilities:  

Physical Location:  The AOD will be physically stationed in the Emergency Department at all times during his/her duty hours.  Exceptions to this rule are triaging patients for admission outside the physical ED, or at required educational conferences such as Noon conference, Board Review, and Medical Grand Rounds (Thursday’s from 11:00 AM to 12:00 PM).  He/she will field all calls for admission to medicine services from the Emergency Department, the Access Center (ADTU), from various clinics within the Department of Medicine, the hemodialysis centers, and from the Chief Residents.  Requests for in-house transfers from other departments or for hospital-to-hospital transfers should be re-directed to the Chief Resident. 

 

Interactions within Emergency Department:  During all hours of his/her duties, the AOD will be continuously checking the ER Census and be aware of any and all admissions to Medicine services.  While he/she is not the first person to “work up” patients in the Emergency Department, he/she will be expected to embody the principles of pre-emption, integration, and expediting admissions ( “P.I.E.” ): 

] Pre-emption:  Be knowledgeable at all times of potential patients to be admitted to Medicine, even in the absence of a thorough ED workup 

] Integrated:  Provide input and be in communication with the ED physician(s) and AOD hospitalist when present about additional clarifying diagnostic studies which may help to appropriately disposition the patient 

] Expedite:  Evaluate all patients for whom Medicine is consulted by the ED.  When paged, reply to the page in less than 5 minutes.  Be responsible for writing admission orders for patients being admitted to housestaff services to facilitate their disposition to a hospital ward bed from the ED.  This requirement is waived if the admitting team is able to come down to the ED within 30 minutes; if this is not possible, the AOD will write orders and have them on the chart rack within 30 minutes. 

** Note: Orders will not be written by the AOD for Hospitalist or non-teaching services. ** 

 

 

Disposition:  The AOD is empowered to make final judgments on the destination of a patient.  If a patient is assigned to an inpatient medicine team/subspecialty team, and the inpatient medicine resident/subspecialty resident or attending feels it does not meet the team’s admission criteria, denial of admission can only be made if the inpatient medicine/subspecialty attending or hospitalist AOD writes a note declining that patient for admission to that service.  Without this documentation, the inpatient medicine service/subspecialty service is obligated to follow the AOD’s decision within 30 minutes.  If there is doubt about a patient’s condition, criteria for admission, or uncertainty of appropriate disposition, the AOD must see the patient and make this determination.  The AOD can write a note detailing his/her impression.  If the AOD feels criteria for admission are not met or that a patient should be on a non-medicine service, then the AOD resident should contact the attending to whom the patient would be admitted, the Chief Resident from 7am until noon, or the hospitalist AOD thereafter.  If attending  disagrees with the ED’s determination that a patient meets criteria for admission to a medicine service, then the attending, Chief Resident, or hospitalist AOD should add an addendum to the AOD’s note and assist with establishing appropriate follow-up for the patient. 

 

Back-up for Admissions Officer of the Day (AOD):  As this is not an Emergency Department rotation, the AOD’s primary backup will be the Chief Residents during the day and the Shands Hospitalist from noon through 7 am.  Ultimately, the Medicine Program Director will have supreme oversight on the AOD and his/her activities. 

 

I.)  Hospitalist Service (MHS):  

The Hospitalist service is a general medicine service staffed by Hospitalists.  Residents are not permitted to provide any cross-cover or admission service to the Hospitalist service or any other non-housestaff associated team.  The only exception to this rule is the assistance with the emergency care of a patient when the urgency of the situation mandates such care for the safety of the patient.  General Medicine admissions that meet the following criteria should be admitted by the Hospitalist service: 

1) Observational or social admission 

2) Admissions after Housestaff Night Team has capped (8) from all sources. From 7pm to 7am, the Night Hospitalists’ pager is 413-1731. 

 

IV.)  Inpatient VA Ward Teams  

 

A.)  General Information:  

Conferences:  The VA Resident Morning Report is Monday at 8 a.m. in the VA Medical Services Conference Room (room E-544) or in the 4 east classroom in the bed tower. Wednesday morning report is a combined board review in the Shands/UF department of Medicine Library. Attendings are invited to attend all morning reports. Intern Morning Report occurs on Tuesdays at 8:00 a.m. in the Conference Room.  Fourth year medical students rotating on VA ward services are welcome to attend on Tuesdays.  The GEM Unit resident is expected to attend Monday, Wednesday, and Friday morning report, and the GEM Unit intern the Tuesday a.m. report.  The Wednesday morning report will consist of Board Review and is required for any resident on a ward service or the GEM unit 

For Residents and Interns: 

On Fridays, there will be a combined resident and intern morning report at the VA held from 8:00 am to 8:45 am. The location is the VA education building, located just southwest to the older building.  The format will be a single case presented by a Medicine ward team from initial presentation, evaluation, and management.  At the beginning of each month, there is a combined resident and intern morning report for Orientation. 

VA Library Services:  The web based MD Consult program is available on the VA computers.  Call extension #6314 (the VA library) to request a user-name and password.  Access to the VA library is available 24 hours a day for housestaff who have library cards which are assigned by the VA library.  All VA computers also have access to Up To Date through the clinical web page. 

 

Inpatient Consults:  In addition to placing a call to the consulting service, a consult request should be placed in CPRS. 

 

Fee Basis Labs:  Some labs require a fee basis form to be completed before the lab can be performed.  The Chief of Medicine, the VA Chief Resident, and selected attendings are authorized to approve these requests.  The forms are available on the VA wards and in the Medical Services office. 

 

CPRS Notes:  Medical students and PA students may write admission notes under their respective Admission Note tabs on CPRS.  While these should be reviewed and signed by an attending physician, the official Admission History and Physical has to be entered and signed by an intern, resident, or staff physician. In additiona, and admission medication reconciliation note must be entered and a medication reconciliation must be performed on all patients admitted, every time they are admitted. Cutting and pasting a student’s H & P is illegal and unprofessional.  Daily progress notes are to be written on all patients by an intern or resident.  Patient Discharge Instructions may be entered by students, interns or residents in the usual note section; however, the official Discharge Summary has to be entered under the “Discharge Summary” tab by Residents if the length of stay is greater than 4 days or the intern if it is 4 days or less.  Discharge Summaries need to be completed within the first 24 hours of a patient’s discharge from the hospital. 

 

Team Workroom Restrictions:  The presence of prescription medications in the team workrooms is prohibited by JCAHO.  Please check your workrooms and return items to the pharmacy.  In addition, medical supplies such as needles, syringes, blood culture bottles, etc. should not be kept in team workrooms.  If you have any questions, please contact the VA Chief Resident.  Team workrooms are to be kept locked/code protected and accessed only by members of the medicine teams. 

 

CPRS Notifications:  CPRS Notifications (of canceled orders, abnormal test results, etc.) can be customized.  Click the “Tools” tab and select “Options,” then “Notifications”.  Identify the items you want on your notification list. 

 

Remote Data:  Some remote data on CPRS can be accessed from other VA hospitals.  If a patient has remote data available, “Remote Data” will appear in blue at the upper right hand corner.  Click on this tab and select the requested data sites. 

 

Discharge Medications:  Discharge medications should be reviewed and any new medications should be entered into CPRS the day before a patient’s anticipated discharge.  For anticipated weekend discharges, discharge medications should be ordered on Friday.  A separate “Medication Reconciliation” note must be generated and reviewed at the time of discharge.  This will be completed by pharmacy during the week, however it is the responsibility of the intern and/or resident on Saturday and Sunday.  Speak with your team pharmacist or VA Chief Resident if you have questions.  There is a pharmacist available on weekends to facilitate discharge medication review.

 

On Call Meals:  The VAMC provides long call interns and residents with dinner and breakfast as well as lunch on weekends.  Housestaff must show identification when picking up meals.  Vending machines are also available 24 hours a day in the basement. 

 

Security:  In a non-code situation, when it is dark or at other times as indicated, housestaff must request a security escort to the GEM unit and Nursing Home.  Housestaff are also strongly encouraged to request a security escort to Shands Hospital and to the parking lots from the VAMC. 

Contact numbers: 

VA police 4091 

MAA 6724 or 6825 

Operator (for security) 6060 

 

Call Rooms:  Call rooms are located on the 4 west floor of the GVAMC bed tower.  this room is key protected.  In the call room area there is a refrigerator for storing food and a computer to write orders or review chart information.  Working showers and bathrooms are located in the locker rooms on the first floor, or within the fourth floor call rooms of the old building, code 555.  The MICU resident at the VA has a private call room in the rear of the MICU.  This allows the resident to be in close proximity of his or her patients in case of emergency.  This call room also has a working bathroom with shower facilities. 

 

B.)  Call Schedule:  

The General Medicine Teams (Red, Blue, Orange, and Green) rotate long call every fourth day.  The four-day call schedule is as follows:  long-call, post-call, short-call, and “golden” day (no call).  All patients worked-up by housestaff including consults, “bounces,” MICU transfers and new admissions count towards the total team cap.  Housestaff do not admit patients to non-housestaff associated teams. 

 

1.  Short Call:  Admit up to 4 patients from 7 am to 3 pm Monday through Friday. Monday through Friday starting at 7 am, the short call team admits the first and second patient and alternates subsequent admissions with the housestaff associated team until 3 pm or to an admission cap of 4.  There is no short call Saturday, Sunday, or designated holidays. 

 

2.  Long Call:  Admits up to 10 patients from 7 am to 7 pm, Monday through Friday.  Monday through Friday, the long call team will start taking alternating admissions with the short call team until short call reaches their admission cap of 4 patients or at 3:00 pm, whichever comes first.  

 

 The long call team admits patients until 7 pm Monday through Friday to an admission cap of 10 (ten). 

 

 

 The long call team admits patients 7 am to 7 pm on Saturday, Sunday and designated holidays to an admission cap of ten.  

 On any given day, the long call team will admit no more than 4 patients after 4 pm, no more than 2 patients after 5 pm, and no more than 1 patient after 6 pm.  The time of an admission will be the time at which the resident is notified of the admission, not the time that the call is returned or the time at which the resident/intern sees the patient. 

 

 

 On a long call day, the housestaff not involved in cross-cover duties should complete all appropriate patient care and leave the hospital by 9 pm. 

 

 

3.  Golden Day/Post Call:  No new admissions. The team should make efforts to discharge patients in an appropriate and timely manner.  Teams are responsible for admission of their own “bounces” until 3 pm on Mondays through Fridays and until noon on Saturdays, Sundays and designated Holidays. 

 

4.  Overnight admissions:  From 7 pm to 6:30 am daily, the Overnight Admitting Physician will perform medicine admissions.  The short call resident will be available for the first admission notification at 7 am Monday through Friday, and the long call resident will be available for admission notification at 7 am on Saturday, Sunday and designated Holidays. 

 

C.)  MICU:  

The VA MICU is staffed with 4 upper level residents.  These residents monitor a total of 12 patients in the MICU/CCU.  Residents take turns taking overnight call every 4th night.  The MICU/CCU has a call room that has a bathroom and shower facility.  The long-call resident is responsible for all new admissions to the unit, while the short-call resident is responsible for assisting with daily notes, procedures, or emergencies.  The post-call resident leaves after rounds to ensure that the team members stay under the 80-hour work week requirement and under the 24+4 consecutive hour limit.  The residents each have at least one day off a week during their respective golden days that occur on Monday through Friday. 

 

D.)  GEM/Palliative Care Unit:  

The GEM unit is a long-term care facility that provides exposure to geriatrics, rehabilitative medicine, physical therapy, occupational therapy, and homecare.  The Palliative Care unit provides exposure to end-of-life care issues.  One resident and one intern are assigned to this rotation per month.  They take turns covering the weekends, thus allowing each resident an average of 1 day off per week or 4 in a month time period.  On Saturdays, the covering resident sees all of the patients on the team.  When all active issues have been addressed, the resident provides a checkout sheet to the on-call service.  On Sundays, the resident contacts the GEM unit to address acute issues.  If necessary, the resident may have to come in.  If there is nothing to address, the resident then calls the on-call team for checkout. 

 

E.)  VA Cross-Cover/Night Team:  

One intern from the long-call team will perform cross cover duties from 7 am to 7 pm after receiving proper sign out from each individual medicine housestaff service.  This intern is supervised by the senior resident and/or the attending physician on the long-call team.  At 7 pm, the long-call intern for the day will verbally check-out to the night cross-cover intern, who will perform cross-coverage for all patients cared for by housestaff services, including those in the GEM/Palliative Care unit.  The intern will cover from 7 pm – 7 am daily, except for Fridays which will serve as the intern’s day off for the week.  On Fridays, one intern or resident on an elective or ambulatory rotation will provide cross-coverage from 7 pm until 7 am. It is the responsibility of the cross cover intern to return pages in a timely fashion and document changes in clinical status or care of a patient in CPRS.  The patient’s primary team should be cosigned to the documentation and verbal check out should occur as well.  The MICU resident supervises and assists the night cross-cover intern from 7 pm to 7am.  The Overnight hospitalist (VA pager 1100) also provides attending support as needed for cross-coverage issues from 7 pm to 7 am. In fact, they should be paged and involved for any significant changes to patient conditions overnight.

The housestaff associated teams will not provide cross-coverage for patients followed by the non-housestaff associated teams, patients on the 23 hour observation service, short-stay service or patients followed solely by an attending physician or a physician extender.  If a physician is needed to evaluate any unstable medicine patient on a non-housestaff associated team, the intern or resident on call may assess the patient and provide assistance in establishing appropriate immediate medical care for the patient. 

 

F. )  VA Bridge Resident:  

During July, August, and September, a PGY2 or PGY3 will be assigned to function as the Bridge Resident.  Duty involves Monday through Friday from 11 a.m. until 9 p.m.  The Bridge Resident has weekends off and is expected to attend his/her weekly continuity clinic.  The Bridge Resident will work on designated holidays.  The Bridge Resident will attend Grand Rounds/Noon Conference and will assist the long-call with patient care related issues, including procedures, admissions, calling consultations.  The Bridge Resident will primarily be responsible for the long-call team that day, but should assist short-call or the other ward teams to facilitate patient care after it is determined that the long-call team has been taken care of. 

 

V.)  Consults  

 

A.)  Shands:  Medicine consults will be performed Monday through Friday from 8am to 5pm by the SMC (Shands Medicine Consult) Team.  The operator has the number of the attending on consults (it is listed under “Internal Medicine Consults” or “INTMCS”).  From 5pm to 7am the medicine AOD will perform urgent consults.  These will count towards their admissions cap of 8 patients per night.  If a consult is not urgent and can wait until the morning the AOD will take the information down and pass it along to the Medicine Consult Team in the morning. 

 

B.)  VA:  The VA AOD will be the contact person for medicine consults from 8 am until 5 pm on weekdays.  Appropriate medicine consults will be distributed, via the AOD, to the long-call resident team or to the hospitalist service depending on which team is “up next” for an admission.  The consult will count as an admission for admission and team caps.  The long-call resident team will handle appropriate medicine consults until 7 pm as team and admission caps allow.  If team or admission caps are met, patients requiring a medicine consult will be seen by the hospitalist team.  The night hospitalist will cover all medicine consults between 7 p.m. and 7 a.m.  Those patients seen by the night hospitalist will be followed by one of the hospitalist teams if ongoing consultative care is needed.  Any patient seen by a housestaff team in a consultative role must have that patient staffed with an attending.  The team must see the patient until services are no longer indicated, and provide written notice stating that the team is signing off the case

 

VI.)  Ambulatory  

 

A.)  Continuity Clinic  

General Information:  The continuity clinic experience is one of the most important and meaningful of the residency.  Each categorical intern will begin a one half day per week clinic at the start of their residency that will continue throughout the three years of the training program.  The intern will be assigned to one of three primary clinic sites:  VA Internal Medicine Clinic, Shands Medical Plaza Internal Medicine Clinic or Internal Medicine at Tower Hill Clinic.  The residents will remain at the same clinic site providing continuity of care for their panel of patients over the course of the three year residency.  Residents are required by the RRC to be in clinic for 108 weeks of internal medicine training. 

 

Clinic Responsibilities:  The residents will be the primary care provider for the patients in their continuity clinic, working in conjunction with the attending faculty in clinic.  As such, it will be the resident’s responsibility to follow up on all tests ordered and consults requested.  PGY-1 residents will be scheduled 3-5 patients per half day clinic.  PGY-2 residents will be scheduled 4-6 patients per half day clinic.  PGY-3 residents will be scheduled 7 patients per half day clinic.  Residents may overbook their own schedule above these numbers at their discretion.  No other overbookings are allowed without prior authorization of the resident.  Urgent Care clinics will also be scheduled at each site.  Residents on Ambulatory Rotation will cover this clinic.  This resident can be scheduled up to 5 urgent visits per afternoon.  

 

General Rules of Clinic:  Clinic attendance is mandatory.  Any change in clinic schedule must be approved by the Ambulatory Chief Resident a minimum of six weeks ahead of time and is still subject to approval by the ambulatory chief, the resident’s clinic attending, and the clinic site

 

 Professional Dress is required in clinic. Scrubs are not considered professional attire. 

 

 With the exception of vacation, no resident should be out of clinic for more than six weeks at a time. 

 

 On clinic days, interns should give their pagers to their residents.  Residents should give their pagers to their fellows, attendings, or another on-service resident. 

 

 

 Documentation of clinic visits will be done promptly.  Notes will be completed within 24 hours of the patient’s appointment.

 

 

 Residents must check with their clinic site and electronic alerts (in CPRS and/or Epic) at least weekly to return phone calls or address other issues pertaining to the continuity of their patients.  If the resident is going to be unable to check in with the clinic for more than one week (for example, on vacation), the resident must notify their preceptor and have the preceptor follow all outstanding labs and test results.

 

 

 When a patient seen in Continuity Clinic by residents is admitted to the VA or Shands Hospital, it is the responsibility of the admitting intern or resident to notify the primary care resident and inform them that their patient has been admitted to the hospital.  All H&Ps and Discharge Summaries should also be cc’ed to the primary Resident. If the resident is going to be unable to check in with clinic for more than one week (ex: vacation), the resident needs to notify his or her preceptor and have the preceptor follow all outstanding labs and test results.

 

 

Time away from Clinic:  The residents are expected to be in clinic at the assigned time every week. Clinic continues throughout all rotations with the exception of the Intensive Care Unit (Shands and VA), CCU, Night Team, Shands Bridge Resident, AOD, and Vacation.  Clinics are closed on the first day of the Night Team rotation and the day after the completion of the Night Team rotation.  Clinic will also be closed post-call should the resident be on call on their final day of an ICU rotation and their clinic day fall on the post-call day.  In addition, time away from clinic for away electives must be approved by the Program Director.  Clinics will be closed as a part of the holiday schedule. No resident may be out of their continuity clinic for more than 6 consecutive weeks.

 

Clinic schedule changes:  In certain circumstances, clinics can be changed or rescheduled. The rules regarding clinic schedule changes are as follows: 

 

1.  Clinics can be cancelled or changed with at least 45 days notice.  All requests for  cancellations and changes in the clinic schedule must be approved by the Ambulatory Chief Resident and the Program Director, and they are also subject to approval by clinic preceptors and clinic sites. It is departmental policy to avoid resident schedule changes that alter clinic schedules.

 

2.  If there is an emergent change (less than 45 days notice), such as illness or personal emergency, those patients will need to be seen by another resident (either back-up or another willing resident) unless the attending of that clinic specifically approves another plan. 

 

Narcotic Policy at the Shands Internal Medicine Clinic: Resident clinics can be particularly prone to patients with drug seeking behavior and chronic narcotic dependence. In order to minimize this problem and protect the residents, the Shands Internal Medicine Clinic has developed a strict narcotic policy. 

 

 Any patient who will be taking a controlled substance for more than 3 consecutive months must have a narcotic contract signed and in the front of the chart. 

 

 

 Patients receiving schedule II substances must come to clinic at least every three months to receive their narcotic prescriptions. 

 

 

 Narcotic prescriptions will not be mailed to patients. 

 

 

 Patients receiving schedule III-V drugs can be refilled for up to 6 months. These refills are at the resident’s discretion. 

 

 

 A reason for each controlled substance must be clearly documented in the chart. 

 

 

Patients who violate the narcotics contract may be discharged from clinic with the approval of the attending physician. 

 

Please be sure to remember the ground rules for writing narcotic prescriptions: 

 

 No other medication can be written on the same script 

 

 Always include Patient Name, Date, DEA Number and Signature on all scripts. 

 

 

 Make sure to only write for doses the drug comes in. 

 

 Do not dispense more than one month’s supply. Example: if the drug is q6 prn, you cannot write for more than 120 pills. 

 

 

B.)  Ambulatory Block 

The ambulatory block is a one month outpatient rotation which is a requirement for all categorical residents.  The purpose of this block is to educate the residents in issues pertaining to outpatient medicine as well as provide training in the ambulatory aspects of non-medicine subspecialties.  During the Ambulatory Block, residents will rotate through a combination of the following clinics: 

 

 Urgent Care 

 Neurology  

 Dermatology 

 GI

 Heme/onc 

 Nephrology

 Palliative care

 Rheumatology

*as other ambulatory opportunities and options become available, residents may be assigned to these.

 

During the Ambulatory Block, all of the categorical PGY1 interns will be supervised performing a History and Physical exam performed in a clinic setting.  In addition, the Ambulatory Block includes Tuesday morning conferences. Each resident on the ambulatory block will be required to give a 15-20 minute presentation on an outpatient topic during morning conference.  One Tuesday morning conference will be devoted to Medical Ethics and a discussion on Advanced Directives as well as case-based discussion. In addition, each PGY1 will rotate with neurology for one week of consults weeks.  The PGY-1, 2 and 3’s will spend appox 10 half days in the neurology outpatient clinics.

 

C.)  Evidence Based Medicine (EBM) 

During each academic year, residents will spend a half-month rotation on evidence based medicine.  Seven days of the rotation will be vacation time, the remaining time will be devoted to EBM

 

During EBM, residents will be assigned to an inpatient team to round with and find a clinically relevant question to investigate.  They will have some learning assignments and then perform a literature review about their clinical question.  They will then meet with the other residents on EBM as well as the ambulatory chief and the attending for the course and discuss the validity and applicability of their article and their ultimate findings.  They should then provide recommendations to the team based on what they found.  Residents learn how to critically appraise medical literature, and portions of biostatistics and epidemiology. To protect this valuable learning experience, residents are not placed on back-up call during this week and have no clinical responsibilities other than attending their continuity clinic and educational conferences.

 

Pagers must still be on during this EBM time.  Attendance and performance of all expected aspects of EBM week is mandatory.  Failure to do so will be viewed as a breach of professionalism and result in disciplinary action by the Housestaff Evaluation Committee. 

 

VII.)  Emergency Medicine Rotation 

 

Residents will work in the Emergency Department at both Shands and the VA under the supervision of Emergency Medicine faculty to provide initial care to patients with a variety of medical and surgical presentations.  This experience will involve only adult patients.  Residents will not be required to rotate in the Emergency Department for more than 3 months in the 3 years of training. Emergency department shifts will not exceed 12 hours and will be separated by a period free of clinical duties for at least 10 hours.  Residents will receive both informal and formal teaching from Emergency Medicine certified faculty.  Emergency Medicine faculty also provide conference lectures as part of our curriculum.  Residents are required to attend noon conference, Grand Rounds, and continuity clinic while on this rotation. 

 

VIII.)  Electives 

Elective time is divided during each year of the residency.  Typically, elective time increases as an individual advances through the residency program.  However, there is no guarantee elective time will be equal for all residents or necessarily increase over time.  Electives are grouped into two major categories:  Outpatient and Non-outpatient.  Outpatient medicine is a rotation spent in the Ambulatory Setting.  Each categorical resident must complete at least 3 months of outpatient medicine time during residency.  Outpatient medicine is an elective month that must be spent in an outpatient setting. 

 

A list of approved Outpatient Electives is available through Residency Homepage and directly on the medicine intranet or “portal”.  This list is frequently updated. Elective requests are approved and scheduled by the Program Director and Ambulatory Chief Resident. 

 

Non-outpatient electives are all those electives which are not primarily done in the ambulatory setting.  This includes consult services and research time.  A list of approved non-outpatient electives is available on the Residency Homepage.  This list is frequently updated.  Non-outpatient electives will be reviewed and approved by the Program Director and the Ambulatory Chief Resident.  Requests for research time, away electives and private practice electives, as well as any elective not listed on the Residency Homepage must receive prior approval from the Program Director.  To have an elective approved by the Program Director you must provide the following information:  elective description, approximate number of duty hours required per day and per week, dates of intended elective time, and the name of the elective preceptor with contact information.  This information must be provided at least 2 months prior to the intended rotation.  All elective requests are subject to a secondary approval by the Ambulatory Chief Resident in order to insure that all scheduling and continuity clinic requirements are met. 

 

Changing Electives:  Each Housestaff will complete and turn in a list of requested electives at the beginning of the academic year.  Electives will then be assigned by the Ambulatory Chief Resident for the year.  Assigned electives can be found on the webpage on the Master Schedule. 

 

Any change in electives must be submitted in writing to the Chief Residents.  Any request for changing of an elective must be submitted eight weeks in advance.  Failure to submit your schedule change request six weeks in advance may prevent you from having your request honored.  All electives have Goals and Objectives as detailed in our curriculum and should be reviewed with an attending at the beginning of the rotation. 

 

IX.) Moonlighting Policy

 

Moonlighting is considered an optional activity which, if approved, must be contained within the work hour guidelines set forth by the ACGME. Averaged over a 4 week period, trainees are limited to 80 work hours per week, including in house call activities and moonlighting. Additionally, all house staff must have 10 hours free of duty between shifts. Under no circumstance will moonlighting be allowed to create a conflict of commitment with the Resident’s core residency training program.

 

 

  1. Residents may not engage in any moonlighting activities without written approval from the Program Director or his Delegate(s)  The program director has the discretion to decide, categorically or individually, whether or not the proposed moonlighting activity is compatible with the training program requirements of our program. Therefore, he may permit, prohibit, limit, or revoke permission to moonlight as he deems appropriate.
  2. Moonlighting is only permitted at Shands & UF on the inpatient hospitalist service.
  3. All moonlighting hours must be recorded as duty hours, and logged in new innovations. Failure to do so may result in corrective action and revocation of moonlighting privileges.
  4. All moonlighting must be considered part of the 80 hour work week.
  5. No moonlighting can interfere with the ability of the resident to achieve the goals and objectives of the educational program
  6. Residents cannot moonlight while assigned to back-up.
  7. Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program.
  8. Residents must attend all scheduled clinics, ward assignments, and activities on their current rotations.
  9. Moonlighting resident’s progress and performance will be closely monitored, and any adverse effects on achievement of program goals and objectives may lead to revocation of moonlighting privileges.
  10. Moonlighting is restricted to PGY-III residents only, who meet the following requirements
    1. Conference attendance 60% or greater
    2. Remain in good-standing with the program
    3. Scored greater than the 40th percentile overall on the in-training exam from the most recent in-training exam.
    4. Residents may only moonlight while on the following rotations:
      1. Elective: any Friday or Saturday. Weekday moonlighting shifts are not permitted
      2. Ambulatory: overnight shifts on Friday or Saturday night. Weekday moonlighting shifts are not permitted
      3. EBM or Vacation: no restriction on number or types of shifts
      4. Request forms 
        1. A Moonlighting Request Form (which can be found on the residency program intranet website) must be submitted for each shift requested
        2. A Moonlighting Request Form should be submitted to one of the Chief Residents at least 1 week prior to date of the moonlighting shift; if the Chief Resident verifies that the resident is eligible, the Request Form will be forwarded to the Program Director for final approval.

 

Any moonlighting activities that are not approved will result in disciplinary action, not excluding termination.

X.) Evaluation of Residents 

 

A.)  Evaluation Methods:  

 Monthly faculty evaluation: Faculty are instructed to provide end of rotation evaluations of each resident. This information is available at any time for the resident to access online. Additionally, faculty are required to give formative feedback during the course of the rotation. This includes a mid month review of resident and intern performance based on core competencies.  Ultimately, they must complete evaluations on every resident they rotate with via the new-innovations website.

 

 

 Clinical evaluation exercise (CEX and Mini-CEX): Residents will be witnessed performing all or portions of patient encounters in a variety of settings and given feedback on their performance. 

 

 

 Continuity Clinic evaluations: Each resident will be evaluated by his/her continuity clinic preceptor every 6 months. 

 

 

 PCRM evaluations: On the inpatient services at Shands the PCRM’s will provide an evaluation for each resident that will mainly focus on the competencies of systems-based practice, professionalism, and interpersonal skills and communication. 

 

 

 In –Training Exam: Residents are required to take the ITE in each of their years of training. This test is designed as a self-assessment tool for residents to use in designing their educational course. It is also a strong predictor of future IM Board performance. The results will be reviewed with the resident during the semi-annual evaluation review, and the resident’s schedule may be modified to address identified knowledge deficits.  Residents who score <40th percentile will be assigned to an intense remediation course with weekly self study assignments to be turned into their faculty mentor.

 

 360 degree evaluations-includes, but is not limited to, evaluations by your own peers, patients, pharmacists, nursing, etc.  The majority of these are housed and completed within the new innovations website.

 

 

B.)  Semi-annual Evaluation Review:  Every 6 months the program director or his designee will meet with each resident to review his/her evaluations and progress in the program. 

 

C.)  Housestaff Evaluation Committee:  The Housestaff Evaluation Committee serves to review the performance of each resident and to determine overall competence of the resident.  This committee makes recommendations to the program director related to the promotion of residents and ultimately their board eligibility. 

 

D.)  Performance Expectations:  The Internal Medicine Training Program is based upon the concept of graded responsibility.  Each resident is expected to achieve certain performance milestones in order to pass to the next level of responsibility.  The document serves to clarify the milestones and serve as a guide to further professional development.  The milestones for the end of each year are grouped among the following areas:  patient care, medical knowledge, leadership skills, teaching skills, procedural skills, system-based practice, practice-based learning and improvement, communication skills, and professionalism.  The Housetaff Evaluation Committee will use resident self-evaluation, faculty evaluations, peer evaluations, student and PCRM evaluations, and discussion with each resident to determine whether these milestones have been met.  It is the responsibility of the Housestaff Evaluation Committee to recommend promotion of each resident to the next level of training, and the ultimate decision for promotion lies with the program director. 

 

PERFORMANCE EXPECTATIONS

Professionalism  

In accordance with the ABIM’s Project Professionalism, the Internal Medicine Residency Program will expect every resident to be professional.  This includes and is not limited to the principles of expanding individual knowledge, a dedication toward service, altruism, autonomy, accountability, morality and intergrity, and adherence to all ethical standards.  Professionalism must begin as a resident and be practiced toward fellow residents, attendings, staff, and patients. 

 

If at any time an Attending, Program Director, Chief Resident, Senior Resident (PGY 2 or PGY 3), or Intern feels a resident is acting in an unprofessional manner, consequences may result.  This can include and is not limited to speaking with a Chief Resident or Program Director, formal documentation in a resident’s personal file, reprimand by the Housestaff Evaluation Committee, suspension, or even dismisal.  Unprofessional behavior will not be tolerated. 

 

PGY-1

Professionalism:  The resident will demonstrate consistent behaviors that reflect respect, compassion, integrity, and altruism toward patients, families, and colleagues.  This is fundamental to the practice of medicine and the foundation on which all other skills are built.  Unprofessional behavior will not be tolerated. 

 

Patient Care:  The resident will demonstrate an ability to obtain an appropriately detailed history and performing an appropriately detailed physical exam in inpatient and outpatient settings.  The resident must be able to interpret the data obtained and apply this in the form of an initial management plan. 

 

Medical Knowledge:  The resident will demonstrate a basic understanding of the disease processes that commonly affect patients in inpatient and outpatient internal medicine settings.  The resident will demonstrate this knowledge through performance on the internal medicine in-training examination given in October of each year as well as in daily clinical activities supervised by senior residents and faculty. 

 

Leadership Skills:  The resident will display clinical competence to the extent that he (she) is capable of acting as the team leader. 

 

Teaching Skills:  The resident will provide teaching to the student(s) on service at a level appropriate to the learners’ ability.  This should include, but not be limited to, teaching of basic medical knowledge in the course of delivery of patient care. 

 

Procedural Skills:  The resident will demonstrate knowledge of the indications for, techniques of, and potential complications of procedures to include:  paracentesis, thoracentesis, lumbar puncture, central line placement, arterial blood gas analysis, arterial line placement, pap smears/pelvic exams, rectal exams, and breast exams. 

 

System-based Practice:  The resident will demonstrate a willingness to work with other members of the healthcare team to optimize the care of the patient.  This includes the coordination of care with the PCRM to ensure that discharge planning needs are anticipated and addressed early in the course of an inpatient admission.  The resident will possess a basic understanding of what tasks are best performed by other members of the health care team to improve the efficiency and effectiveness of patient care. 

 

Practice-based Learning and Improvement:  The resident will demonstrate an ability to reflect on his or her practice to define areas in need of improvement.  The resident will also utilize feedback from faculty, staff, and peers to analyze his/her patient care practices in an ongoing effort to improve.  The resident will also use the score on the in-training exam to reflect on areas of medical knowledge most in need of improvement. 

 

Communication Skills:  The resident will be able to communicate clearly with patients, families, coworkers, and consulting services to improve the care for his (her) patients. 

 

PGY-2

Professionalism:  The resident will demonstrate consistent behaviors that reflect respect, compassion, integrity, and altruism toward patients, families, and colleagues.  This is fundamental to the practice of medicine and the foundation on which all other skills are built. Unprofessional behavior will not be tolerated.  In addition to demonstrating professional behavior, the resident will monitor their learners for signs of unprofessional behavior that might adversely affect patient care. 

 

Patient Care:  The resident will demonstrate an ability to obtain a detailed history and physical examination including subtle findings.  The resident can analyze this data and use it to formulate a management plan for even complex inpatient and outpatient encounters.  The resident will also provide appropriate supervision of learners as judged by supervising faculty and the resident’s learners. 

 

Medical Knowledge:  The resident will demonstrate medical knowledge sufficient to effectively lead a ward team and supervise interns and students. 

 

Leadership Skills:  The resident will be proficient at leading a team of healthcare providers in the inpatient setting. 

 

Teaching Skills:  The resident will demonstrate appropriate teaching to students and interns and foster the teaching skills of the learners. 

 

Procedural Skills:  The resident will effectively perform and supervise procedures to include:  paracentesis, throracentesis, lumbar puncture, arterial puncture, blood gas analysis, central line placement, pap smears/pelvic exams, rectal exams, and breast exams. 

 

System-based Practice:  The resident will work closely with the PCRM from the time of a patient’s admission to anticipate discharge needs and facilitate transfer of care to the outpatient or long-term care setting.  The resident will also demonstrate basic knowledge of the systems in which outpatient care is practiced including prescribing in accordance with a patient’s prescription benefit plan and home care resources. 

 

Practice-based Learning and Improvement:  The resident will demonstrate an ability to analyze the primary literature as systematic reviews of literature to practice evidence-based medicine.  In addition to analyzing feedback from evaluators, the resident will demonstrate an ability to reflect on his/her practice to identify and correct areas in need of improvement. 

 

Communication Skills:  The resident will communicate effectively with patients, families, consultants, outside physicians, and staff to optimize the care of patients. 

 

PGY-3

Professionalism:  The resident will demonstrate consistent behaviors that reflect respect, compassion, integrity, and altruism toward patients, families, and colleagues.  This is fundamental to the practice of medicine and the foundation on which all other skills are built.  Unprofessional behavior will not be tolerated. In addition to demonstrating professional behavior, the resident will monitor their learners for signs of unprofessional behavior that might adversely affect patient care. 

 

Patient Care:  By the end of PGY-3, the resident demonstrates an ability to manage complex patients and educate others on the team to enhance patient care. 

 

Medical Knowledge:  The resident possesses detailed knowledge of complex medical conditions such that he/she is deemed by the program director to be sufficiently prepared for independent practice. 

 

Leadership Skills:  The resident demonstrates the ability to lead a team of providers to provide excellent care for the team’s patients. 

 

Teaching Skills:  The resident demonstrates an ability to teach learners such as students and interns effectively.  The resident also teaches colleagues at the same and higher levels.  The resident is required to demonstrate scholarly activity in the form of scientific research or in researching a topic to teach to his/her fellow residents. 

 

Procedural Skills:  The resident demonstrates technical competence and sufficient numbers of the procedures required by the ABIM for certification. 

 

System-based Practice:  The resident understands the aids to and barriers to care and effectively advocates for the patient in both inpatient and outpatient settings. 

 

Practice-based Learning and Improvement:  The resident consistently analyzes his/her practice patterns and strives to improve upon the care provided to patients.  The resident demonstrates reflective practice that will enable him/her to continually advance his/her medical knowledge and skills in practice. 

 

Communication Skills:  The resident consistently demonstrates interpersonal and communication skills that serve to establish and maintain professional relationships with patients, families, and colleagues. The resident will demonstrate these skills in the care of patients and also in the presentation of their scholarly activity to the residency program. 

 

E.)  Academic Due Process:  The Department of Medicine recognizes the dual roles of the resident as a student in graduate level training and as an employee involved in the care of patients.  All residents are expected to exhibit professional behavior in the care of patients and in the interaction with others.  Residents are evaluated in relation to the core competencies by the mechanisms outlined above.  The Housestaff Evaluation Committee (HEC) will address any deficits that are brought out in the resident evaluations and make recommendations to the Program Director.  Actions the HEC may propose include:  remediation period, probation, non-promotion, suspension, non-renewal, or dismissal.  In the event of any adverse action against him or her, the resident has a defined process for disagreeing with the action and possibly having the decision overturned.  

 

In instances where the resident exhibits deficits in the areas of academic performance, a period of remediation may be the most appropriate course of action.  If the HEC votes to impose a remediation period for the resident, the program director or his designee will meet with the resident to outline the problem areas along with a time period for remediation and an outline for the structure of the remediation.  If the resident does not successfully complete the remediation program the program may consider a prolongation of training or probation after presenting all of the facts at a meeting of the HEC.  Successful remediation will allow the resident to continue training on schedule with no further effects on his/her career except for increased monitoring during the residency training. 

 

In the event of egregious lapses in academic performance or unprofessional or unethical behavior, the resident may be placed directly on probationIn the event of a decision for probation by the HEC, the Program Director or his designee will meet with the resident to detail the accusations and present the resident with the terms and duration of probation as well as the consequences of failure to meet the terms of the probation.  If the resident successfully completes the probation period without further problems, he/she will be returned to a non-probationary status.  Failure to complete the terms of probation may lead to an extension of the probation period or possibly dismissal from the program. 

 

Dismissal or contract non-renewal will be considered in only the most egregious instances or due to repeated lapses in professional behavior or failure to comply with the terms of probation.  

The resident has the right to appeal any adverse action taken by the program.  There is a well defined mechanism for residents to address such concerns, and this is outlined in detail in the UF Housestaff Policies and Procedures Manual.  Because of the importance of these policies, they are duplicated here for easy reference. 

 

Grievances - A grievance is defined as dissatisfaction when a resident believes that any decision, act or condition affecting his or her program of study is arbitrary, illegal, unjust or creates un-necessary hardship.  Such grievance may concern, but is not limited to, the following:  academic progress, mistreatment by any University employee or student, wrongful assessment of fees, records and registration errors, discipline (other than non-renewal or dismissal) and discrimination because of race, national origin, gender, marital status, religion, age or disability, subject to the exception that complaints of sexual harassment will be handled in accordance with the specific published policies of the University of Florida and the College of Medicine (as contained in the University’s Housestaff Manual).  

 

Prior to invoking the grievance procedures described herein, the resident is strongly encouraged to discuss his or her grievance with the person(s) alleged to have caused the grievance.  The discussion should be held as soon as the resident becomes aware of the act or condition that is the basis for the grievance.  In addition, or alternatively, the resident may wish to present his or her grievance in writing to the person(s) alleged to have caused the grievance.  In either situation, the person(s) alleged to have caused the grievance may respond orally or in writing to the resident.  

 

If a resident decides against discussing the grievance with the person(s) alleged to have caused such, or if the resident is not satisfied with the response, he or she may present the grievance to the Chair.  If after discussion, the grievances cannot be resolved, the resident may contact the Associate Dean of Graduate Medical Education (ADGME).  The ADGME will meet with the resident and will review the grievance.  The decision of the ADGME will be communicated in writing to the resident and constitute the final action of the University. 

 

Suspension - The Chief of Staff of a participating and/or affiliated hospital where the resident is assigned, the Dean, the President of the Hospital, the Chair or Program Director may at any time suspend a resident from patient care responsibilities.  The resident will be informed of the reasons for the suspension and will be given an opportunity to provide information in response.  

 

The resident suspended from patient care may be assigned to other duties as determined and approved by the Chair.  The resident will either be reinstated (with or without the imposition of academic probation or other conditions) or dismissal proceedings will commence by the University against the resident within thirty (30) days of the date of suspension. 

 

Any suspension and reassignment of the resident to other duties may continue until final conclusion of the decision-making or appeal process.  The resident will be afforded due process and may appeal to the ADGME for resolution, as set forth below. 

 

Non-renewal - In the event that the Program Director decides not to renew a resident’s appointment, the resident will be provided written notice which will include a statement specifying the reason(s) for non-renewal. 

 

If requested in writing by the resident, the Chair will meet with the resident; this meeting should occur within 10 working days of the written request.  The resident may present relevant information regarding the proposed non-renewal decision.  The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident.  If the Chair determines that non-renewal is appropriate, he or she will use their best efforts to present the decision in writing to the resident within 10 days of the meeting.  The resident will be informed of the right to appeal to the ADGME as described below. 

 

Dismissal - In the event the Program Director of a training program concludes a resident should be dismissed prior to completion of the program, the Program Director will inform the Chair in writing of this decision and the reason(s) for the decision.  The resident will be notified and provided a copy of the letter of proposed dismissal; and, upon request, will be provided previous evaluations, complaints, counseling, letters and other documents that relate to the decision to dismiss the resident. 

 

If requested in writing by the resident, the Chair will meet with the resident; this meeting should occur within 10 working days of the written request.  The resident may present relevant information regarding the proposed dismissal.  The resident may be accompanied by an advisor during any meeting held pursuant to these procedures, but the advisor may not speak on behalf of the resident.  If the Chair determines that dismissal is appropriate, he or she will use their best efforts to present the decision in writing to the resident within 10 working days of the meeting. The resident will be informed of the right to appeal to the ADGME as described below. 

 

Appeal - If the resident appeals a decision for suspension, non-renewal or dismissal, this appeal must be made in writing to the ADGME within 10 working days from the resident’s receipt of the decision of the person suspending the resident or the Chair.  Failure to file such an appeal within 10 working days will render the decision of the person suspending the resident or the Chair the final agency action of the University. 

 

The ADGME will conduct a review of the action and may review documents or any other information relevant to the decision.  The resident will be notified of the date of the meeting with the ADGME; it should occur within 15 working days of the ADGME’s receipt of the appeal.  The ADGME may conduct an investigation and uphold, modify or reverse the recommendation for suspension, non-renewal or dismissal.  The ADGME will notify the resident in writing of the ADGME’s decision.  If the decision is to uphold a suspension, the decision of the ADGME is the final agency action of the University.  If the decision is to uphold the non-renewal or dismissal, the resident may file within 10 working days a written appeal to the Dean of the College of Medicine.  Failure to file such an appeal within 10 working days will render the decision of the ADGME the final action of the University. 

 

The Dean will inform the ADGME of the appeal.  The ADGME will provide the Dean a copy of the decision and accompanying documents and any other material submitted by the resident or considered in the appeal process.  The Dean will use his or her best efforts to render a decision within 15 working days, but failure to do so is not grounds for reversal of the decision under appeal.  The Dean will notify in writing the Chair, the ADGME, the Program Director and resident of the decision.  The decision of the Dean will be the final agency action of the University.  The resident will be informed of the steps necessary for the resident to further challenge the action of the University. 

 

The Housestaff Manual is a guideline for the rules and regulation of the Internal Medicine Residency Program.  The Manual will be updated on a periodic basis as the program continues to evolve.  Residents will be emailed notification of updates and the Manual can be viewed on the Medicine Portal.  Questions about the policies outlined above can be directed to the Chief Residents.

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