• General Policies
  • A. Admission Workflow
  • B. Caps
  • C. Bouncebacks
  • D. MICU/CCU Transfers
  • E. Outside Hospital Transfers
  • F. CDDC/GI Admissions
  • G. Team O ^NEW
• Service Agreements & Policies
  • A. Family Medicine 
  • B. Cardiology
  • C. Hematology/Oncology
  • D. Orthopedics
  • E. Courtesy Notifications

• Schedules
  • A. Daily Schedules
  • B. Call Schedules
  • C. Conference Schedules
  • D. Day Off Policy
• Ward Logistics
  • A. Handoffs
  • B. Code Blue/RRTs
  • C. Notes/Documentation
  • D. Duty Hours
  • E. Medical Student Policies^UPDATED
  • F. Professionalism
  • G. Anonymous Feedback

A. Admission Workflow

• ED Admissions
  • ED resident/attending will place bed request to unassigned team once decision has been made to admit patient to hospital
  • SPPO will update order with assigned team and attending based on which team is next up and send page to team admission pager.
    • All admitting teams (including short and long call teams) will be assigned patients per drip beginning at 6:30AM. Short call teams will admit to 5:00PM, while long call teams will admit until 7:00PM.
    • Any teams that are capped will not be in drip for admission. Medicine resident is responsible for notifying SPPO if they are capped
    • If all teams are capped, SPPO will contact Medicine Chief Resident to discuss team assignment (see Overflow Admissions below)
  • Once notified, Medicine resident will contact ED resident/attending for signout within approximately 15 min.
    • If team is not able to immediately assume care of patient, Medicine resident will contact ED resident/attending to acknowledge and request ED continue to manage patient for 60 minutes. Within this time, Medicine resident will call back to receive full signout and assume care.
  • Once signout is complete, ED resident will flag patient as "green" on status board. Once status is changed, nursing may move patient to inpatient bed.
  
  
  
  
  
  • Outside Hospital Transfers
    • All accepted patients will be added to patient log on SharePoint by accepting hospitalist.
    • SPPO will assign incoming outside hospital transfers to admitting Medicine teams and notify respective team
    • Medicine resident will place admission orders prior to or at time of patient arrival
      • In event patient is assigned to team but does not arrive prior to signout, accepting team will place initial admission orders and start initial H&P note. Admission will be completed by crosscover night float resident once patient arrives.
    • See E. Outside Hospital Transfers below for additional details 

• Overflow Admissions
  • In event multiple or all teams are at ACGME hard cap, SPPO will contact Medicine Chief Resident to discuss assignment for patients pending admission.
  • Depending on status of other admitting teams and following discussion with program director, one or more of the following contigency plans below may be initiated:
    • Backup Resident: Resident will admit and crosscover new patients until teams are able to assume care
    • Team H Residents: Residents will admit and crosscover new patients; they may either sign patients out to ward teams, or serve as primary service depending on patient needs, team censuses per discussion with Chief Resident.
    • Family Medicine service: Family Medicine residents will admit directly to inpatient FM service per Overflow Policy (see "Overflow Policy" under Family Medicine below)
    • Nurse Practitioner: Inpatient nurse practitioners will admit patients, which will be managed under supervision of non-call attending(s)

B. Caps

• Team cap is defined as:
  • 20 patients per team
    • Note: Soft cap eliminated as of 01/2019 
• Daytime Admissions
  • Any team that reaches the cap will be out of the drip until their census drops below 20 patients
  • Teams must notify SPPO office (x8455, p6000) they are capped.
  • Teams must notify SPPO office when they are uncapped and able to re-enter drip. Patients who have received all discharge instructions and are waiting for rides (either on the floor or in the discharge lounge) do not count towards the total team census  
• Overnight Admissions
  • Teams that will be are at cap will be out of drip for all overnight admissions. 
• Overflow Admissions
  • In event all admitting teams are at cap, admissions will be assigned per Overflow policy (see Admission Workflow above)

C. Bouncebacks

• Bouncebacks follow the senior resident for the current block except in the following situations
  • Team is no-call and senior resident is not present
  • Team is at or above soft cap and other teams are open
  • It is the first or last day of the block
• If patient cannot bounceback to original team due to one of above reasons, they should be assigned to next admitting team.
  • Patient will be transferred back to original team the next day. Original team does not receive credit for admission, as staffing and workup/management will already have been initiated at this point
• During day time, if admitting team receives a patient found to be a bounceback to anothre team, senior resident should notify SPPO immediately for patient to be reassigned to appropriate team.
• Patients primarily being managed by NP who bounceback should be admitted to original team unless they are at or above soft cap. If team is open, they may take bounceback regardless of call status or presence of senior resident. These patients will be managed by NP and attending. 

D. MICU/CCU Transfers

• Patients transferred from the MICU or CCU to wards will be assigned to an admitting ward teams by SPPO office. MICU/CCU resident will be responsible for notifying SPPO if patient is bounceback to a team, Family Medicine etc. and can take patient based on Bounceback rules (see above).
• Daytime Transfers (6:30AM-5:00PM)
  • Admitting team will receive signout from MICU/CCU intern/resident. Once signed out, admitting team has primary responsibility for patient care
    • If there is a patient emergency while patient is still in ICU, MICU/CCU team should assist, if possible, and notify admitting team immediately
  • Admitting team will evaluate patient and write an accept note in EPIC
  • Admitting team will sign out patient to night float regardless of where patient is physically located
  • Management of patient over night (i.e. by Ward vs. MICU night float) will be determined by patient's physical location at 5:00PM
    • Wards crosscover resident will manage patient if on the floor
    • MICU resident will manage patient if still in ICU. Admitting team will resume care in AM.
• Long Call Transfers (5:00-7:30PM)
  • Admitting team will be assigned MICU/CCU transfer by crosscover night float resident
  • Admitting team will receive signout from MICU/CCU, evaluate patient and write an accept note.
  • All patients transferred during long-call will be managed by MICU night float resident, even if patient is physically moved to wards during evening or overnight
    • Both admitting ward team and MICU team should sign out patient to respective night float teams
• Overnight Transfers (7:30PM-6:30AM)
  • SPPO will notify admitting residents (via pager) of any MICU/CCU patients with pending transfer orders who are transferred to floor overnight
  • Admitting night float residents will log these patients and notify day teams of transfers at AM signout
  • Admitting day teams will be responsible for contacting MICU/CCU team in AM to receive signout and assume care

E. Outside Hospital Transfers

• All outside hospital transfers are accepted by the hospitalist attending on-call
  • Patients may be accepted as transfers for higher level of care, continuity, insurance issues etc.
  • On accepting patient, hospitalist will enter patient into SharePoint site, with basic details and guidance on case
  • SharePoint may be accessed via residency website, intranet, or by using this link: https://intranet.ha.uci.edu/sites/deptofmedicine/res/intmed/default.aspx
• UCI Transfer Center (x2222) may be able to provide additional details, including outside hospital records, if patient being transferred from inpatient unit. Patients being transferred from outside ER may not have records available
• Outside hospital transfers will be assigned to team by SPPO at time of acceptance. However, patient may not arrive until later in day or overnight
  • In event outside transfer does not arrive by time of signout, admitting team is responsible for entering basic admission orders and starting a skeleton H&P based on available info.
  • Patient should be signed out to night float crosscover resident, who will complete admission (with physical exam, additional orders etc) when patient arrives.

F. CDDC/GI Admissions

• Patients may require transfer from CDDC to inpatient wards under the following circumstances. Decision to admit to hospital (vs. monitor in CDDC observation unit) is at the discretion of the GI attending
  • If GI fellow/attending feel patient will require extended (>47hr) observation or higher level care immediately post-procedure
  • If patient was initially admitted to CDDC observation unit but has or will require observation or care beyond 47hrs
• GI patients to be admitted to ward will be assigned to admitting teams by SPPO
• Admitting team will assume care of patient once they have been physically transferred to inpatient unit, e.g. PPCU, floor, ICU, etc.
• • If patient has any issues while in CDDC, these should be taken care of by CDDC daytime hospitalist or GI fellow/attending
• If patient is not physically transferred to inpatient until by 5:00PM, admitting team should enter basic admission orders and start skeleton H&P (see Outside Hospital Transfers above)
• Residents, including MICU team, are not responsible for evaluating patients for admission. As noted above, decision to admit is at the discretion of the GI attending.

G. Team O

• Census
  • Team H residents
    • If total Resident census is less than 8, they can take Team O admissions up to total census of 8 and would continue to follow those primary patients
    • If their census is 8 or more, they only take Team H consults up to the Resident cap
  • Team O NP
    • Team O NP will have a cap of 8
    • Admissions then go to Team H resident if their census is less than 8, otherwise Team O Attending needs to call Chief Resident to cap Team O.
    • If Team O census is less than 8, CDDC patients count towards cap but if Team O census is more than 8, then CDDC patients still go to Team O but ED patients do not
    • All Team O patients (including Team O patients on Team H) are to be signed out to the overnight NP
  • Process to Cap Team O
    • Team O Attending can make the decision to cap Team O. Once this decision is made, the Team O Attending will inform the on-call Chief Resident who will notify SPPO
    • Team O Attending will notify on-call Chief Resident when Team O is available for resuming admissions
• Admissions
  • Team O Admissions
    • ED Physician to work with ED Case Manager to determine if a patient should be admitted to Team O
    • ED Physician enters a direct admit from clinical order as ‘medicine unassigned’
    • SPPO will notify Team O
    • NP will contact Team O Attending immediately with admission notification, and the Team O Attending will respond to ED immediately and make a decision on admission vs observation vs discharge within 30 minutes  
  • Changing Admission Class in ED 
    • Team O NP/Attending can change admission class from Observation to IP after discussion with ED Case Manager to understand necessary criteria to meet IP status and then notify SPPO/Ward team of admission without further involving ED.
    • THE QUESTION TO ASK THE ED CM IS WHAT CRITERIA WOULD QUALIFY FOR AN INPATIENT STATUS. IF THAT CRITERIA IS EXPECTED TO HAPPEN DURING THE INPATIENT STAY THEN THE PATIENT CAN BE CONVERTED TO INPATIENT STATUS. If no CM is present, then Team O NP/Attending can reach mutual agreement with ED Attending and Team O will notify SPPO/Ward Team. Team O Attending to communicate necessary IP criteria with ward attending
  • Patients converting from Observation to IP
    • Once already admitted to Team O/H, any patients that need conversion from Observation to IP status will remain on Team O/H until discharge
  • Bounce Backs
    • Bounce back patients are to return to the original team that they were discharged from
• Attending
  • Team H attending will serve as primary attending for Team O during the day
  • Nocturnist (attending assigned to Team O/CDDC) will serve as primary attending for Team O over night

Service Agreements & Policies
Criteria are summarized below for each respective service. For additional details, please see full service agreement (located under "Policies" on residency website)

A. Family Medicine

• Admission Criteria
  • In order to be admitted to Family Medicine service, patients must be ALL of the following criteria
    • Patient identifies a UCI Family Medicine or Geriatrics provider as their primary provider, and intends to follow up on discharge from hospital
    • Patient has been seen for at least 2 visits during the previous 2 years by 1) any Family Medicine resident, 2) Family Medicine provider, or 3) Geriatrics provider at their outpatient clinic site (FQHC Santa Ana, FQHC Anaheim, Gottschalk Medical Plaza, UCI Senior Center, PACE clinc (if attending is FM faculty)
    • These two visits are to be continuity visits (not just urgent urgent care)
  • To avoid disruption in continuity of care, patients should not be transferred between services after day team has acquired the patient.
  • Family Medicine/Geriatrics providers include:
  
  

  Arghami, Elham MD	Arroyo, Jeff MD	Austin Rachel	Biddy, Edna MD
  Centanni, Leah	Craemer, Elana MD	Deshpande, Prajakta MD	Doloulei, Reza MD
  Dow, Emily MD	Gibbs, Lisa MD	Haq, Cynthia MD	Khalighi, Katayoun MD
  Kilgore, David MD	Kim, Brian MD	Kroner, Christopher MD	Larsen, Kathyrn MD
  Mayorga, Jose MD	Morohashi, David MD	Nguyen, Tan MD	Prislin, Michael MD
  Raymundo, Marianita MD	Salcedo, Betzy MD	Seghal, Sonia MD	Suskin, Shea MD
  Tam, Steven MD	Tran, Huy DO	Vadecha, Nina MD	Valerie George, PA-C
  Vega, Charles MD	Vo, Baotran, MD	Whalen, Megan

C. Hematology/Oncology

• Admission Criteria and Policies
  • Patients with established diagnosis of hematologic malignancies (categories listed below) on active treatment for their neoplasm:
    • Any Acute Leukemia, Myelogenous or Lymphoblastic (AML or ALL respectively
    • Chronic Myelogenous Leukemia
    • Chronic Lymphoid Leukemia
    • Lymphoma (Hodgkins or Non-Hodgkins)
    • Multiple Myeloma
    • Myeloproliferative Neoplasms (for example P. Vera)
    • Myelodysplastic Syndromes (for example, myelofibrosis)
  • Patients with established diagnosis of hematologic malignancies but admitted for reasons other than receiving anti-neoplastic therapy will be admitted to the Hospitalists service(s) and followed by the consult service (Team S, see below).
  • Team L will have a cap of 16 patients until further notice
  • Direct admissions, admissions through the ED, and transfers from other services require the notification of and approval of the Team L attending.
  • No patient will be transferred to Team L without the express consent and agreement of the Team L attending.
  • Neuro-Oncology Primary CNS lymphoma patients will be on Team L only if receiving active anti-lymphoma treatment. Other neurologic oncology patients and neuro-oncology primary CNS lymphoma patients not receiving treatment will be on admitted to Neurology.
  • Admissions occurring (arriving on the floor) between 7:00 AM and 5:00 PM will be admitted by one of the advanced practitioners (APs) on Team L.
  • Admissions occurring outside of the above time period will be admitted by the MICU and/or night float resident with an appropriate note and orders, with the management plan developed in conjunction with the Team L attending on call. All patients must be staffed with Team L attending. 

• Cross Coverage
  • The Team L patients will be signed out to MICU and night float by one of the AP staff or Team L fellow on behalf of the entire team, with similar sign out to the faculty attending at 6:00 PM.
  • Patients on Team L needing acute management will be covered after 6:00 PM until 7:00 AM by the night float and MICU teams until further notice. It is expected that the Attending and/or Heme/Onc Fellow will be actively available throughout this time to answer questions, facilitate in diagnosis and management, and come in to evaluate patients if needed.
  • The nursing staff will be instructed to contact the NP/AP or Fellow during regular business hours M-F (0700 to 1800) for questions regarding the respective assigned patients.
  • The nursing staff will be instructed to page the night float/MICU team for emergency situations requiring immediate physician evaluation and intervention, outside of regular business hours (0700 to 1800.
  • The nursing staff will be instructed to page/contact the Team L Faculty Attending for routine questions/concerns/orders/responses to laboratory determinations, etc. from 1800 to 0700, 7 days a week.
  • During weekend days, regular business hours (0700 to 1800), a clinical fellow will be available “on call” for Team L until such time as the full compliment of APs are in place.

• Daily Workflow
  • Team L will have “working rounds” that, 1) start at 8:30 AM, 2) include the nurse assigned to each patient, and 3) incorporate multidisciplinary discharge rounds between 10:30 and 11:00.
  • The Team L attending will be responsible for the distribution of patient assignments, to be distributed equitably between members of the team (advanced practitioner, faculty attending, and/or clinical Fellow).
  • All clinics will be blocked for Team L Attending faculty, as the Attending is required to be physically available to the advanced practitioners during regular business hours M-F (0700 to 1800).

• Admission Criteria
  • All patients with documented malignancies that are non-hematologic in origin will be assigned to one of the Internal Medicine (Hospitalist) teams or other non-Team L services.
  • Patients with a presumptive diagnosis of neoplasm, hematologic or nonhematologic, will be assigned to one of the Internal Medicine (Hospitalist) teams or other non-Team L services.
  • Team S will function as a consult service for these patients.
  • If and when a diagnosis is established for a hematologic malignancy, the patient can then be transferred to Team L, with Team L attending approval.
  • Hematology/Oncology patients presenting to the ED and requiring admission will be triaged through the Team S fellow for possible admission to Team L (see above) or to another inpatient service.

• Inpatient Chemotherapy
  • Chemotherapy for patients with non-hematologic malignancies, if needed as an inpatient, will be overseen by the Team S fellow and attending being comanaged with the primary attending service (guidelines below):
  • a. Team S will be responsible for writing and submitting the orders for and the coordination of the administration of chemotherapy.
  • b. This includes, all premedications, anti-emetics, IV fluids, and post chemotherapy growth factors if needed
  • c. Team S will document the specifics and details of the chemotherapy regimen, inclusive of issues (toxicities or complications) to be aware of within the body of their consult progress note.
  • d. Team S will meet with the Medicine team and provide chemotherapy education, specific to the chemotherapy regimen and general principles of management of patients receiving chemotherapy.
  • e. Team S will provide a schedule for laboratory and radiographic monitoring and will be available for questions from the primary team.
  • The administration of chemotherapy will require coordination with chemotherapy certified nursing staff (likely from 76/78) and/or relocation of the patient to 76/78, depending upon bed and staffing availability.

• Daily Workflow
  • The usual PBG and Medical Staff requirements for timely consults and professional, timely communication will be enforced.
  • Team S faculty will have either their AM or PM clinics blocked to facilitate timely and productive interactions with the admitting teams.
  • It is the expectation that in-person communication and education will occur with the team during or juxtaposed to the Hospitalist Team rounds.
  • Patients with established diagnosis of hematologic malignancies who are admitted to other services besides Team L may be staffed by the Team L attending in conjunction with the Team S fellow.
  • Team L and Team S attendings are expected to coordinate their “rounds” with the Team S consult fellow.
  • The Team S fellow, or similarly assigned “on call” clinical fellow, will remain “on call” for outpatient calls through the call center, after hours, regardless of patient diagnosis.
  • It is the expectation that the Team S fellow will maintain communication with individual patient’s outpatient faculty attending throughout the course of their hospitalization.

D. Orthopedics

• Admission Criteria (applies only to elderly patients with fractures)
  
  • Trauma Surgery
    • >=60years with multiple trauma, including orthopedic injuries, with Orthopedics consult
    • Medicine Consult service (Team H) may be consulted, as necessary, for management of medical issues
  • Hospital Medicine
    • >=60yrs with fractures without other traumatic injuries, with Orthopedics consult

• Admission Workflow
  • Orthopedics will evaluate patients in ED and perform appropriate evaluation and splinting
  • For operative candidates, Medicine (either primary hospitalist service or Team H) will perfrom appropriate medical workup and medically optimize patient, as appropriate.
    • Patients admitted to Hospitalist service overnight will undergo preoperative evaluation by night float resident. Night float resident will staff preoperative recommendations with ICU nocturnist
  • Once optimized, Orthopedics will perform surgery within 24 hours
  • Orthopedics will be responsible for arranging followup for all patients. Follow up appointments, wound care and activity restrictions should be noted in discharge instructions and summary by Orthopedics team.

E. Courtesy Notifications

• Hematology/Oncology
  • Notify primary oncologist of any patient admitted to ward service
  • If patient requires inpatient Oncology consult, notify the Hematology/Oncology consultservice (Team S)
  • All goals of acare discussions regarding established patients need to be discussed between fellows and/or attending physicians, and should not be initiated by residents
• Nephrology
  • Notify Nephrology fellow or attending for all patients on active hemodialysis who are transitioned to comfort care.
• Transplant Nephrology
  • Notify Transplant Nephrology fellow or attending for all patients with history of renal transplant admitted to hospital
• Transplant Surgery
  • Notify Transplant Surgery resident or attending for all patients with history of organ transplant admitted to hospital
• Cardiology
  • Consult Heart Failure Nurse Practitioner for all patients admitted to the hospital with acute decompensated heart failure.
• Primary Care
  • PCPs for all patients with established care at UCI (including Pavilion III, Gottschalk Plaza, and Senior Health Center) should be notified of admission and discharge
  • On discharge, an encrypted email with brief description of hospital course and important follow-up information should be sent