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Night 1

Night 1 Admitting Provider

Night 1 provides overnight admissions to our MDH direct care services and serves as primary support for our Night 2 cross covering provider. Expectations and Responsibilities: - Shift hours are 9 pm – 7 am. - Primarily responsible for new admissions to hospitalist services (from ER, direct admissions and transfers from OSH). We work closely with the MAO team to help appropriately triage patients for the DOM admitting services. - The Night 1 provider may staff urgent consults with the resident. Non-urgent consults may be deferred to the Consult Team in the morning. - The Night 1 provider should sign into the Medicine Consult Attending pager on arrival (123-0746), to help the residents to identify the appropriate provider if needed. The MAO carries the admission pager for the MDH services. - Provide assistance to Night 2 for cross-cover issues on existing patients. - Hospitalist faculty (not moonlighters) are responsible for distributing patients from the New Admit list to the rounding teams. Please refer to the process outline below. This distribution should occur between 5AM and 6AM so that teams are set when the rounders arrive at 7. - The day teams will arrive at the office at or before 7AM. Sign out a brief summary of the patient’s issue and specific items of the plan for follow-up to the appropriate day provider. If daytime providers are running late, they may call in for sign out by phone. You are not obligated to remain if providers are unavailable by 7AM.

Admission expectations: - When admitting a patient to the hospitalist services, you are expected to perform a full History and Physical, including updating Problem List, PMH, Family and Social Hx and Medication Reconciliation through the appropriate Epic process. Please review the Admissions section on the DHM SharePoint site for more details. Consider using the .HMNOTEHP smart phrase for the history and physical note. - For admission orders: - All new admissions / transfers to the hospitalist service should be placed on the “Med H New Admit” list as the primary team (designated in the ADT1 order). In the “Place Patient Bed” order, you should list your name as both the “admitting” and “attending” provider. - Hospitalist faculty (non-moonlighters) are responsible for distributing the H New Admit patients to the rounding teams prior to 6AM with attempts made to facilitate regionalization and equity amongst the teams. - When a moonlighter is working CH Night 1, responsibility for distributing patients in the morning falls to the HBR night provider. Please include the Hospitalist PRN order set with your admission orders (this helps reduce cross cover pages later on). For each admission, place a formal sign out note under the “Plan Notes” window on the “Overview” tab of the “Summary” page in Epic using “.LMNOTESIGNOUT” for a standard format. The sign out note should contain pertinent diagnoses/issues and “to do” list for daytime hospitalist. For appropriate patients, we will admit from the UNC Emergency Department to the rounding teams at the Hillsborough Campus.  If you feel that a patient may be appropriate for HBR, please discuss this with the MAO and the provider at HBR, who will provide the attending assignment for the admission.  Use this information when placing the Place Patient in Bed order and make sure to select “Hillsborough Campus” from the drop down menu “Preferred Facility”.  You are still responsible for completing admission orders and the H&P. Tips when busy Our goal is having a “place patient in bed” order within 1 hour from receiving the call from the ED. If you are unable to meet this goal due to workload, please communicate where the request is in the queue and how long you expect it will be before orders are placed. This goes a long way to setting expectations and having a discussion about re-triage if needed (patient already has a bed, etc). Being clear, yet flexible, goes a long way. Suggested script: “There are _ direct admissions and ___ patients who I have already been called about. I am happy to see this patient, but I expect it will be _ before I could have orders in.”

Process for identifying new admissions: The ER will call the MAO with admissions to the Department of Medicine and they are responsible for assigning an appropriate team. The MAO will label all hospitalist admissions as “NEEDS TO BE SEEN” and page an appropriate admitting provider. Night 1 and Swing provider should work together to triage and admit new patients. When ready to take an admission, please delete the “NEEDS TO BE SEEN” and replace it with your name in the Primary Team Sign Out Note. It is your responsibility to know that there are still admissions to be seen and to sign on to these admissions. Please communicate closely with each other to ensure admissions are being covered and that work is not being duplicated, especially if there’s a lull in admission volume.

If teams are at cap/MCAT: The MCAT team is a service designed to improve triage pathways and advance the care of medicine patients during times of insufficient team space. This team will function as a consult/support team for patients while we wait for team space to open up. Any admitting provider (resident or hospitalist) may place patients on the MCAT list. MAOs triage admissions for anticipated destination team (Hospitalist versus Teaching teams) per their usual workflow. When no team space is available, MCAT space will be used to help advance the plan of care for these patients. When teams are capped, the Night 1 admitter should perform consultations on up to 4 additional patients waiting for admission and place them on the MCAT team Currently, there is a cap of 8 patients on the MCAT service, comprised of 4 teaching patients and 4 hospitalist patients. See MCAT documents for more details.

Other resources: - The call room on the 4th floor of Anderson Pavilion across from the elevator bay is available for use. The room number is E4200B and the punch code on the door is 4-1-1 (same as the main office). There is a computer, phone, mini fridge, and cot. - There is a shared DHM workroom just outside of the Emergency Department double doors that can be used. - Please refer to the Admissions/Discharge Process Document (also in Sharepoint) for additional details regarding this workflow.

Patient Distributions (not for moonlighters)

General Targeting

Regions
Dogwood and Dogwood APP 6BT + 1 Memorial + MPCU
Pine and Pine APP 7BT + 1 Memorial + MPCU
Cedar and Cedar APP 4ONC/BMT + 1 Memorial + MPCU
Magnolia 6 GMU + 1 Memorial + MPCU
Magnolia APP (no target region) 8 Long-term. 3 Acutes (lowest acuity)
APP Teams (Pine APP, Dogwood APP, Cedar APP) No MPCU. 6 patients. Up to 7 if MDs >10.

Distributing New Admits

  • Check Lightning Bolt to confirm any absences the next day.

  • Around 5:30AM, review patients on New Admit list to get a sense for acuity/complexity.

  • Avoid step-down (or patients with likelihood to escalate to stepdown) to APP teams.

  • On Wednesday and Thursday, try to assign patients who will likely discharge by Friday to Pine and Dogwood APP since those teams dissolve.

  • Start with New Admit patients who are already in inpatient beds or have been assigned a bed as indicated on ED To Be Admitted trackboard or by the Bed Request Status column in the patient list. Distribute to MD and APP teams according to grid above. Our providers are willing to accept inequity in team lists up to 2 patients if it helps promote regionalization.

  • To assign a team, right click on the patient from within the H New Admit list and select “Assign Teams”. Enter the team name and click the box to designate it as the primary team. If providers are signed into the team, click their names as well. Next, right click again and select “Remove Teams”. Unassign the New Admit team to remove the patient from the New Admit list.

  • Often you can reduce this inequality among MD teams by also having some inequality in the APP teams (some at 6 and some at 7).

  • All MD teams can take patients in 1 Memorial and MPCU.

  • There may be New Admit patients left who do not yet have an assigned bed. These unassigned patients are an opportunity to equalize some of the team numbers if needed. Once you assign a patient to a rounding team, the PLC will try to place the patient in the correct unit if possible. Some things to keep in mind:

  • 7BT does not have telemetry/continuous pulse ox. Try not to assign patients with these orders to Pine.

  • BMT and 4onc have some exclusion criteria for patient with certain types of infections/isolation status. Try to avoid placing such patients on Cedar.

  • Patients transferred between UNCMC and HBR should follow the following pathway:

  • Primary team assignment as follows: Cedar APP if UNCMC is sending facility. HBC if HBR is sending facility.
  • Target team at receiving facility is also listed as a treatment team (not primary).
  • The admitting provider sends an epic chat with the patient attached to both rounding MDs, MAO, and ED nurse identifying the patient as a pending transfer and outlining any acute issues.
  • See flow sheet.

Additional Points

  • We do not generally move established patients from an MD or APP team to another team even if the move seems intuitive or obvious but you can set it up that way for the day providers in the morning (leave the APP team with a spot open and the corresponding MD team +1). Day providers would prefer to know about and discuss these moves before pulling the trigger.

  • When considering equity, keep in mind that Magnolia APP runs a higher census and they pull their own patients (co-management and long term). They will take up to 3 low-complexity acute patients.

  • Long-term patients on Magnolia APP should be left on that team list and will be covered by the consult/procedure attendings over the weekend.

  • Particularly complex/ill fracture patients who are admitted to MedH as primary team can go to any of our rounding teams based on where their bed is assigned (they don’t have to go to Magnolia).

  • On Friday afternoons, acute patients on Dogwood APP, Pine APP, and Magnolia APP should be handed off to MD teams according to home units.