Does anyone know if cross covering, qualifies as "ongoing patient care" It would seem to me that evaluating a patient, changing the plan of care, contacting the attending physician, and writing a progress note would easily meet this standard. However in my residency program interns frequently 'cross-cover' on the weekends upwards of 30 patients which would clearly be a violation of the Internal Medicine program guidelines which state that "no intern will be responsible for the ongoing care of more than 10 patients". And lets be clear, I'm not referring to cross covering as just holding the phone or pager and putting out fires if they arise or answering nurse pages. Have there been similar issues at anyone else's program? Thanks for your input!
Intern patient caps
- Thread starter yayayay
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Nowhere that I've ever been affiliated with ever considered cross-cover patients as counting against any 'cap.
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I think the key word here is "ongoing care." By definition, if you are cross-covering (regardless of how much work is involved) you aren't involved in the patient's ongoing care, so they don't count.
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We have 30-40 patients on our service alone. Once the interns have to cross-cover, it's more like 80-120.
Eforest and buzzme, you're telling me that you have a single intern write the day's progress notes on anywhere from 70-120 patients? I find that impossible to believe. Even assuming the most adept intern would only take ten minutes to perform a complete evaluation, staff with the attending, and write the day's progress note you're talking about a 20 hour day without breaks just to write the notes. Again, in my institution cross covering is not 'holding the phone' overnight and answering questions about patients.
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So what exactly IS cross-covering at your institution? Writing progress notes daily? WRiting progress notes on your co-intern's golden weekend? Clarify and maybe people will be able to help you.
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I assume the OP is at one of those places where weekends are covered by one or two teams and the other teams get a golden weekend. So they round on patients from another team or two, increasing their weekend census dramatically. But then on Monday morning it goes back to normal and all is well.
I suppose this is technically a violation of IM RRC rules but clearly nobody else is that worried about it. The OP could certainly bring it up to GME and the ACGME if they're comfortable with being known as the intern who killed golden weekends.
I suppose there was some ambiguity in my original post and I apologize for that. I'm just trying to improve patient care in my institution and work with these hours restrictions. Unfortunately by limiting time in the hospital it's increased hand-offs dramatically, and I'm trying to fix the scheduling issues but I've run into some push-back from higher ups. There aren't any golden weekends at my institution so I'm not ruining anything special for anyone, just trying to improve continuity of care and minimize the possibility for mistakes to be made.
Sadly at my institution they still seem to favor giving each intern one weekend day off a week, so on a team of 5 in the MICU (including night-float) 3 interns are off each weekend day. (Wouldn't make sense with math, but as one of the interns has to work one night to give the night float one day off, they are essentially off the day team on that particular weekend day). With each resident carrying 9-10 patients, as the "covering intern" you write sometimes as many as 30-35 progress notes, fewer if you're lucky and the on-call intern isn't working up a new admission. And no matter how great our signouts are, things still get missed. We haven't had a sentinel event, but our program appears to be begging for one.
At other institutions I've seen that only one resident from a team is permitted to be off any given day of the week to prevent this situation. From what I can gather this cuts down on medical error due to quality of handoff's, etc.
Just trying to make my program better guys not piss and moan! If you've got some constructive advice I'd be glad to hear it!
Sadly at my institution they still seem to favor giving each intern one weekend day off a week, so on a team of 5 in the MICU (including night-float) 3 interns are off each weekend day. (Wouldn't make sense with math, but as one of the interns has to work one night to give the night float one day off, they are essentially off the day team on that particular weekend day). With each resident carrying 9-10 patients, as the "covering intern" you write sometimes as many as 30-35 progress notes, fewer if you're lucky and the on-call intern isn't working up a new admission. And no matter how great our signouts are, things still get missed. We haven't had a sentinel event, but our program appears to be begging for one.
At other institutions I've seen that only one resident from a team is permitted to be off any given day of the week to prevent this situation. From what I can gather this cuts down on medical error due to quality of handoff's, etc.
Just trying to make my program better guys not piss and moan! If you've got some constructive advice I'd be glad to hear it!
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Nope. Cross-cover is overnight only. The primary team comes back in the morning.
But yes, the interns do routinely write 30 notes a day, every day.
I'm pretty sure writing 30-35 notes in one day, even if they are your patients only for THAT day, is an ACGME violation. Not only is it a violation, but I can see how it can be very detrimental and dangerous to the patient. Seeing 10 patients you know very well is not a problem, but it is much much harder to see patients that have ongoing issues and are only familiar with with the short bits you get from team rounds. Heck, sometimes I would prefer new admissions to taking over the care of 'old' patients that have been there even just 5-10 days. 30-35 patients, with majority you're not too familiar with, just leads to things being missed, no matter how good of an intern you are. As you get more experienced it gets easier.
The only way I see that this does not affect patient care that much is if your institution is more attending and/or fellow driven where you only write notes but the real care and all decisions even minor ones come from above.
Also, why aren't your residents helping you out with the notes, especially on those of the interns who are off that day. I hate to say this, but a solution may be having the residents do more of the work. Especially considering you are in an MICU.
I'm guessing this is not medicine / psych / neuro? I'm in IM and as an intern I don't think I would've been able to write 30 notes a day. Maybe if I was in surgery, it's possible. I've seen notes: "S> stable pain relieved by meds. O> benign belly. A> cholecystitis. P> lap chole this week. Other problems per medicine consult." and all the other stuff on the note are auto-generated stuff on the EMR note.
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Yup. Surgery.
(We almost never consult Medicine though!)
(We almost never consult Medicine though!)
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That's because you're gen surg, not ortho or neurosurg!
Things got so bad with ortho at our place that they started a non-teaching hospitalist service whose primary function is managing ortho patients. Any ortho patient with >1 chronic medical problem gets automatically admitted to the hospitalists with Ortho consulting even if all they're there for is an ORIF.
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As a resident covering on weekends, I'd sometimes write up to 50-60 notes per day. Not fun, but also not a violation, as far as I know. It was worth it to work really hard that weekend but then get other weekends off. And we had note templates, which helped a lot.
I don't think the issue is writing of notes but rather if there are enough people available to care for 30+ very sick patients simultaneously.
I don't think the issue is writing of notes but rather if there are enough people available to care for 30+ very sick patients simultaneously.
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To be fair, a large chunk of an Ortho/NSGY service is a bunch of consults. Not usually so for Gen Surg.
Again, I would guess you're in a surgical subspecialty?
The issue I have with what's happening to the OP is that he is in an MICU and is writing (I'm guessing) 10 notes on his own patients, plus 20 notes on patients he barely knows anything about. I'm also assuming that when the OP says he's 'writing notes' on these patients, that these are progress notes for the day and he gets to decide what happens to the management plan that day based on the physical and the labs that day (NOT notes that are written because he was called to see a patient).
Like I said, I guess it wouldn't be too bad if you just write notes but all decisions come from more experienced people, but interns should NEVER handle 30 MICU patients. Heck, experienced hospitalists would be stretched to see 30 patients in a 12-hour day on the floor.
I just did the math, if you're in the hospital for 16 hours, that would be 16 minutes per patient if you write 60 notes (including looking up the labs and vitals, examining the patient, informing the family of the progress if they're at bedside, AND writing the actual note - not to mention doing a quick chart review for the patients that you don't know and are only covering for). That's not even counting rounds, eating, walking around the hospital, answering pages, seeing the crumper of the day, etc. More power to you, but I'm glad I'm in the field/program I'm in and don't have to do that.
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I hope you at least get to step the patients down to the floor before d/c because if you had to do discharge summaries from the ICU too... God help ya
