Family+Practice+Inpatient+Service+Guidelines

Attending Inpatient Medicine Service (AIMS) =AIMS Basics=

v Schedule v Clinics v Evening Clinics v Admitting v New patients v Rounding v Documentation and Sign Out v Caps and Scope of Practice v Timesheets v Whom to call v Additional items
 * A new clinician starts her week on service every Sunday and ends her week the following Saturday, at which time she signs out to the following clinician.
 * Start rounding at the hospital from around 0700-0800 on weekdays (possibly earlier if you have clinic and a high patient load) and by 0800 on weekends. Expect to stay until at least 1700 on weekdays (unless you are in clinic) and until your work is done on weekends (typically 1300-1500, but varies).
 * Of the 5 weekdays you are on service, you must be available for admissions at least 2. Of the remaining 3 days:
 * On 2 you should have makeup FPCs in the afternoon or evening and not admit those days. (Evening FPCs complicate matters; see below.)
 * On 1 you have the afternoon available to you for outpatient administration at your home clinic site, or leisurely hospital work, or a specialty clinic, or even another day for admissions, as you see fit.
 * Try to schedule your 2 makeup FPCs on afternoons //other than// Monday, Wednesday, and Friday if possible, as these are days the resident medicine services are traditionally short staffed for admissions.
 * You can also schedule your makeup FPCs in the evening. See below.
 * You cannot do AM clinics or round on other services while on AIMS.
 * Evening clinics are an AIMS innovation, hence unexpected issues may arise. Below are some of the peculiarities already noted and how to handle them.
 * If you **both** admit **and** have an evening FPC on the same day, on one other day of your week on service you should not admit and should take the afternoon off. Your timesheet for the day you take the afternoon off should indicate only hours spent rounding in the morning. Even during this afternoon, however, you must be available until 17:00 by pager to respond to questions from the nurses caring for your patients. (This does not seem ideal but it is the best we’ve come up with so far.)
 * If you do not admit or take admin on the afternoon of the day of your evening clinic, you cannot bill for time spent in the hospital. In other words, you cannot extend your billing hours via evening clinic, or, put differently, to bill for the afternoon you have to either admit or do admin.
 * In general you admit 2 days per week, unless you choose to spend your administrative afternoon doing admissions.
 * It is a good (if time consuming) practice to advise the Emergency Department clerk each morning, Monday through Friday, whether you are admitting that day or not. The clerks tend to forget and pass over AIMS clinicians for admissions.
 * If you are in the hospital during the afternoon on a weekday, you should be admitting unless you are on your admin afternoon and choosing to work in the hospital, in which case whether you admit is up to you.
 * You do not admit on weekends.
 * If you schedule your makeup FPCs in the evening, you are not obliged to admit the corresponding days (though you can; see Evening Clinics, above).
 * If your service’s census is at the cap of 7 on one of your admitting days, you should still admit patients, but to resident services rather than your own service. Alternatively, you can admit to your own service in anticipation of discharges you know will put your service below the cap by the end of the day. Either technique is acceptable.
 * New patients on your service are of 3 types:
 * Patients admitted by you to your own service.
 * Patients admitted by residents to your service.
 * Patients admitted by residents to other services, but redistributed to your service in the morning by the night admits resident.
 * Traditionally, the redistributing resident //avoids// placing multiple new patients on your service on the morning of days on which you have clinic. This tradition is somewhat squishy (i.e., can’t be entirely relied upon), and you may find on a clinic day that you have one or two new patients; three would be a lot, and four would be somewhat outrageous (but has happened before). //If you do not feel you can round on any new patient on your service before leaving for clinic, advise the senior resident as early in the day as possible.// If there is no way around taking the patient onto your service (e.g., if the resident services are swamped) and you are pressed for time, ask your medicine attending for help rounding on the new patient.
 * You should not receive new patients on Saturdays. The idea behind this restriction was to decompress Saturday rounding a bit, as it is typically a longish day during which not only rounding but also preparation of off service notes must be accomplished.
 * If you have no problem accepting new patients on the last day, you are free to accept more, but keep in mind the more idiosyncratic our individual adherence to AIMS practices, the more idiosyncratic (and less consistent) will be everyone’s expectations of the service. (“Wait, why don’t you take new patients on Saturday? The last person on AIMS did!” etc.)
 * Your official roster of patients is on the board in the ICU/IMCU workroom. Increasingly (perhaps “always now”, but I'm hedging), the AIMS system list in Epic is also accurate, but trust the board.
 * On weekdays, you will ideally round with the same attending internist each day, though some weeks this will not be possible. It is recommended that you contact your attending internist on weekdays between 0900-1000 to arrange a time to round, and before 1100 on weekends.
 * The attending internist with whom you should round is listed in Amion. How precise this listing is depends on whether it is a weekday or weekend.
 * On weekdays, the attending is under Internal Medicine, then under AIMS.
 * On weekends, the attending is under Internal Medicine, and is either the Weekend or Weekend Backup internist. Call either to determine with whom you should round. You can also check the schedules posted in the ICU workroom and on all floors (i.e., 4A, 4B, 5D). It is best to contact an attending earlier to plan a time to round, rather than later.
 * Please also be sure to notify your weekday attending Monday morning whether you are privileged to practice inpatient medicine unsupervised or not. //This is very important to maintain appropriate supervision on AIMS.// If you are in doubt regarding your privileging, check with Joanna Fon in the Medical Staff Office at 925-370-5115.
 * Write (or dictate) a daily progress note on each patient on the service. If you are not privileged to practice inpatient medicine unsupervised, or even if you are but discussed a patient with a medicine attending, document the name of the internist with whom you rounded in each daily progress note (e.g., “D/W Levin MD Att. Int. Med.”).
 * Each weekday at 5PM, sign out to the ICU resident all IMCU patients (even those without active issues). Also, sign out to the floor resident all floor patients with active issues (e.g., pending to do items, worrisome symptoms, etc.).
 * On weekends, sign out the same way, only at whatever hour you are done and leaving the hospital.
 * Currently residents expect brief signout notes to be kept up to date on each patient, regardless of acuity. These are in addition to daily progress notes (and the additional time hit has not gone unnoticed; for now, however, this is the process). You can access the signout notes under “Signoff Notes” on the reports bar when viewing AIMS patients in the Patient Lists tab.
 * Write (or dictate) a discharge summary for all patients you discharge from the service.
 * Even if you cared for a patient for only one day, a dictated discharge summary is required. It is acceptable to dictate the time period for which you cared for the patient and provide salient details for just that period, referencing previous off service note(s) from prior AIMS clinicians for further details.
 * When you leave the service, be sure to write (or dictate) an off service note for any patient present on service for more than one day. //This is absolutely critical to help the AIMS clinician who ultimately discharges the patient.//
 * Note that any off service note should be dictated stat, or they may not be transcribed by the next morning.
 * The next physician on AIMS is listed in Amion. Please contact this physician on Saturday to sign out the service. Any //mutually agreed upon signout// is reasonable: quick spoken, detailed spoken, off service notes only, as long as the oncoming physician agrees. One absolutely key task at the end of your work on Saturday is to make sure your board in the ICU/IMCU workroom is up to date (though the relative importance of this may be diminishing as we come to rely on lists in Epic).
 * It is a good idea //not// to erase the names of any patients being discharged on Saturday, but rather to mark through them with a line and indicate they are slated for discharge, so that the next AIMS staff member can confirm the next morning they were in fact discharged. Again, the importance of this practice may be diminishing as Epic lists become more reliable.
 * The official cap on the service is 7 patients. This cap should probably be maintained for all providers for consistency of expectations among AIMS clinicians and residents.
 * If you want a higher cap, you are free to use one, subject to the above caveat.
 * A well known patient that has been on the AIMS service for months and in the hospital for well over a year, who is to be seen only once weekly, may or may not count toward the cap, based on negotiation with the senior medicine resident. This issue is admittedly murky and has been handled differently during different AIMS weeks.
 * Admitting when your census is already at the cap of 7 is discussed above.
 * AIMS covers medical (i.e., not surgical) patients on the regular floor (Wards 4B, 5D, and 5DP (the former peds ward)), telemetry (Ward 4A), and IMCU (Ward 3E).
 * Occasionally IMCU patients are boarded in the ICU (Ward 3D) if the IMCU is full. They are still considered to have IMCU status, however.
 * Should a patient’s condition deteriorate to the point where they must be transferred to the ICU, generally speaking they are no longer followed by AIMS staff. If the current AIMS staff member is comfortable following an ICU status patient, //with the consent of the AIMS internal medicine attending// the patient may be kept on AIMS, though the patient should definitely be transferred to a resident service on Saturday (i.e., the day the current AIMS staff member leaves the service).
 * Occasionally, admitted patients may spend one or more days boarding in the ER after their admission, waiting for an available inpatient (especially telemetry or IMCU) bed. Though this is awkward (to say the least), you are required to round daily in the ER on any such patients.
 * If a patient boarded in the ER waiting for a 4A or IMCU bed clearly would be stable on the floor, you can downgrade the bed request and occasionally get them out of the ER faster.
 * In Epic, all admission orders for patients still in the ER should be signed and held using the “Med Rec – Sign&Hold” table of contents entry. (The very similar “Med Rec – Sign” TOC entry should be used only for direct admissions to the floor or for patients who started in the ER but who have been transferred to a bed elsewhere in the hospital before their admission orders are completed.) Usually, “signed and held” admission orders are automatically “released” on transfer of the patient to the destination unit. This creates complications for ER boarders, as ER nurses cannot act on an order that has not been released, nor can every admission order be readily executed in the ER setting. (For example, PT and OT consultations are generally not performed in the ER, even if ordered on admission.) Thus part of caring for an ER boarder includes manually releasing admission orders that have been signed and held and that are necessary for care and appropriate for the ER. Releasing orders is performed via Epic's Order Management screen. //In general, admission orders for labs, diagnostic studies, and medications (including IV fluids) should be manually released when you admit a patient who currently lacks a bed assignment. Also, if by 5PM the patient still lacks a bed, their ER boarder status should be signed out to the ICU resident so she can, if needed, manually release orders for AM labs or medications to start the next day in the morning.//
 * Note that all this travail applies only to admission orders. Orders you place on subsequent days while caring for an ER boarder are automatically released, just like all orders you place on inpatients actually residing in an inpatient unit. The mentioned issues regarding orders that cannot readily be executed in the ER still apply, however.
 * If one of your patients needs a bedside procedure for which you are not privileged or which you do not feel comfortable doing alone, contact either your medicine attending or the on call medicine attending for help and supervision.
 * There are not specific privileges required to work on AIMS, but approval of the chair of the department of medicine and head of AIMS are required.
 * Depending on your level of experience (e.g., whether or not you have inpatient medicine privileges at CCRMC), you may have specific requirements for supervision by an internist while on AIMS. Please clarify supervisory requirements with the internal medicine attending on the first Monday of your AIMS weeks.
 * On weekdays spent entirely in the hospital, you may bill a maximum of 10 hours for inpatient work.
 * There is no upper limit on weekends.
 * Bill 4 hours for each clinic (afternoon or evening) or administrative afternoon.
 * If you qualify for the primary care panel management bonus, you should bill 6 hours of on call 1:4 time Monday-Friday while on AIMS.
 * For questions regarding which patients you should see (if the board or Epic is unclear, or worse yet, if they conflict!): Contact the senior resident on the internal medicine rotation.
 * On weekdays, the senior resident is the resident attached to the service labeled “3T” in the ICU/IMCU workroom.
 * On weekends, it is the senior resident on call (i.e., the ICU resident) as listed in Amion.
 * For problems determining which internal medicine attending you should work with, page Gabriela Sullivan, the Chair of Internal Medicine, at 554.
 * For coverage problems (i.e., sick and can’t round): Please call your medicine attending, if you know who it is. If not, please page Jamie Pehling at 734 or Gabriela Sullivan at 554.
 * If you have never worked AIMS before and wish to be oriented: Please page Jamie Pehling at 734 or Gabriela Sullivan at 554, or send email. You are paid up to 4 hours for orientation.
 * If you want to send email to all current AIMS clinicians (such as for finding a substitute for a given week), use the Lotus Notes group email address “AIMS Clinicians”.
 * Travel time
 * If your AIMS week clinics are PM and in NRCH, AHC, or BHC, your PM clinic roster on AIMS days does not start until 13:30, instead of the usual 13:00. For clinics at all other sites, the start time for PM clinics during AIMS is the usual 13:00.
 * The roster for any evening clinics during your AIMS week begins at 17:30, regardless of where your clinic is located.
 * Access the current AIMS schedule through Amion at [|www.amion.com], password ccrmc.