PGY-1 Responsibility for the Admissions Pager

[armyres]

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I am currently in an Internal Medicine Residency with the US Army-

There is a question in our program about when the PGY-1's should begin carrying the admissions pager, evaluating patients in the ER, and staffing them with the attending with indirect oversight by the PGY-2/3. I want to get feedback as to when other programs allow the PGY-1's to have this responsibility. Any insight would be greatly appreciated (and how they do it in other programs). Thanks!

 

[Law2Doc]

I am currently in an Internal Medicine Residency with the US Army-

There is a question in our program about when the PGY-1's should begin carrying the admissions pager, evaluating patients in the ER, and staffing them with the attending with indirect oversight by the PGY-2/3. I want to get feedback as to when other programs allow the PGY-1's to have this responsibility. Any insight would be greatly appreciated (and how they do it in other programs). Thanks!

In my intern year we started taking call and carrying the pager the first night (ie after the two days of orientation). We always had seniors and attendings we could call for help. I think that's pretty common.

 

[thesauce]

Ditto

 

[gutonc]

Yup. My first day as an intern I was on call in the MICU and carried the ICU and code pagers. Mercifully the nurses were smart enough to bypass me and go straight to my R3 for complicated stuff (or page us both at the same time) but Day 1 is pretty much the standard.

 

[Winged Scapula]

Yep Day 1 in surgery programs too.

 

[Perrotfish]

I am currently in an Internal Medicine Residency with the US Army-

There is a question in our program about when the PGY-1's should begin carrying the admissions pager, evaluating patients in the ER, and staffing them with the attending with indirect oversight by the PGY-2/3. I want to get feedback as to when other programs allow the PGY-1's to have this responsibility. Any insight would be greatly appreciated (and how they do it in other programs). Thanks!

For us its the second rotation of any given kind. Second ward rotation, second NICU rotation, etc. The first half of the year is pretty closely supervised.

 

[armyres]

Thanks so much for your feedback.

 

[NotAProgDirector]

I don't think this will be the case at all programs. At my Internal Medicine program, the admitting pager is carried by a resident at all times. Interns carry the team pager, where nurses / consultants / others can contact the team around patients already on the service. I might send an intern to evaluate a patient first, but all admissions in PGY-1 are directly supervised by someone more senior.

 

[LucidSplash]

Day 1 in my surgery program. With the new rules last year, our program set 1 month where consults had to be seen jointly by the intern and a more senior resident. Also my program already required all incoming interns to complete the Fundamentals of Surgery modules/simulator prior to arriving for orientation. These two requirements together are the baseline my program established to meet the vague requirements. After July, interns are considered signed off to evaluate patients in the ED independently prior to calling the senior. However, they still carry the team pager (same pager for consults/floor calls at my program) from day 1.

We have not changed our requirements for carrying the code pager. We still require 10 observed line placements prior to being signed off for that.

 

[gutonc]

I don't think this will be the case at all programs. At my Internal Medicine program, the admitting pager is carried by a resident at all times. Interns carry the team pager, where nurses / consultants / others can contact the team around patients already on the service. I might send an intern to evaluate a patient first, but all admissions in PGY-1 are directly supervised by someone more senior.

To clarify, in my program, the senior got the call from the ED about admissions. Interns got everything else.

 

[nlax30]

From day 1 here interns would carry the floor team pagers which would be paged for floor calls and ED admits. For admits they would still notify others, including seniors, on the team of each admit so we all knew what was pending but generally the intern would be the one to start it and either staff with a senior or maybe even with an attending directly if they were in house and we were busy.

Exceptions would be any unit admit which we'd go at least peak on in the ER to see how stable they were and to put in some initial orders. And really for each admit we were at the least look them up in the EMR to get an idea of what was going on and to see if it was something we needed to get involved on right away.

The ICU pager was different. Usually wouldn't let intern hold that pager until at least several months in and/or until they did an ICU month.

 

[Cali2]

Day 1 (IM program), we just need to staff w/ a senior resident or attending some time before the end of the day. Up to our discretion whether we get the senior resident involved earlier.

 

[45408]

All new consults and admissions go to someone significantly more senior than the intern in our program (surgery). There are plenty of things that don't warrant a full consult or shouldn't be admitted to us, and it's hard for an intern to decide which is which. The intern is likely to be sent to go see the patient first (and might be the only one to see them for a while), but it's not their call.

 

[Top Gun]

In my residency, the system was like this: For new admissions, the ER attending called the MAR (medical admitting resident), a third-year resident who was in charge of taking admissions from the ER. The PGY 3 would go see the patient, come up with a general assessment and plan, and then decide which floor to send the patient. Then the PGY 3 would call the PGY 2, who, in turn, would call the PGY 1. The PGY 2 would write the admission orders, and the PGY 1 would do the H&P. The PGY 1 would take all floor calls, though, and call the senior if s/he needed help.

 

[Siggy]

At the main hospital (456 bed hospital) for my medical school it depends on who the admission team is.

For IM (non-surgical, non-family med patients), ED calls the senior resident for the call team. The senior assigns the patient to either an intern (2 interns per IM team, plus night float over night) or medical student. Intern/MS does an H/P, presents to the senior or attending (call team attending is in house until 10pm), orders get written by the intern or resident, and the patient gets assigned to an IM team (bounce backs go to original team, new patients are assigned the call team and redistributed to other teams as need be). The exception here is ICU patients are seen by the dedicated ICU team, not by the regular IM teams.

Surgery: ED calls the on-call intern. Based on the call either kicks it up to the resident or pages the on-call student. H&P gets done, kicked to intern, then to resident. Resident makes final call.

FM: FM only admits patients seen in the FM clinics. The AM team (8am-8pm), swing shift team (10am-11pm) rotates admissions during the day and the night team (10pm-10am) admits over night. Generally it's a resident and 2-3 students. As above, student does H&P, presents to resident, who writes orders. The exception is that the inpatient FM teams also manage their own ICU patients, and those only go to the resident.

 

[C5toC9]

At the main hospital (456 bed hospital) for my medical school it depends on who the admission team is.

For IM (non-surgical, non-family med patients), ED calls the senior resident for the call team. The senior assigns the patient to either an intern (2 interns per IM team, plus night float over night) or medical student. Intern/MS does an H/P, presents to the senior or attending (call team attending is in house until 10pm), orders get written by the intern or resident, and the patient gets assigned to an IM team (bounce backs go to original team, new patients are assigned the call team and redistributed to other teams as need be). The exception here is ICU patients are seen by the dedicated ICU team, not by the regular IM teams.

Surgery: ED calls the on-call intern. Based on the call either kicks it up to the resident or pages the on-call student. H&P gets done, kicked to intern, then to resident. Resident makes final call.

FM: FM only admits patients seen in the FM clinics. The AM team (8am-8pm), swing shift team (10am-11pm) rotates admissions during the day and the night team (10pm-10am) admits over night. Generally it's a resident and 2-3 students. As above, student does H&P, presents to resident, who writes orders. The exception is that the inpatient FM teams also manage their own ICU patients, and those only go to the resident.

Wow, medical students actually play a real role at your hospital, much more than at mine.

 

[Siggy]

Wow, medical students actually play a real role at your hospital, much more than at mine.

It's actually really nice. The admission H&P packet is 5 pages long, including a blank sheet for the resident and another blank sheet for the attending to make their notes on. This forces students to make a commitment in writing to an assessment and plan (and everyone knows to ignore that section of the H&P packet).

 

[cabinbuilder]

In my residency the call pager was 7p-7a and the on-call person (regardless of rotation) also helped in the ER from 7p to Midnight. For the first 2 calls that an intern had, an upper level did call with them to show them the ropes of how to do admissions, etc.Once the admission assesment was done then the orders were gone over with the attending via phone.

 

[tallash]

I don't think this will be the case at all programs. At my Internal Medicine program, the admitting pager is carried by a resident at all times. Interns carry the team pager, where nurses / consultants / others can contact the team around patients already on the service. I might send an intern to evaluate a patient first, but all admissions in PGY-1 are directly supervised by someone more senior.

Ditto. Definitely varies from program to program and depends a lot on cross covering responsibilities and such.

 

[Miami_med]

Here, a mid-level resident (R2 or R3) receives ED calls for evaluation. The R1 is often sent to see the patient first if appropriate. All evening consults are run by the chief on call (R4 or R5) before an attending is called. The R1 carries the floor pager from day 1. The ICU pages go to the R2 covering the ICU (sometimes even an R3 on call).

 

[SouthernSurgeon]

Ditto. Definitely varies from program to program and depends a lot on cross covering responsibilities and such.

Right. Differs widely from program to program and specialty to specialty. I wouldn't assume that because a program doesn't have interns carrying the "admit" pager they don't give their interns responsibility.

At my hospital the medicine program has all admits run through the on-call senior, who then dispos them to the appropriate junior resident or sub-specialty team.

Similar to how for my program (surgery), the consult pager is always carried by a senior - not because we don't let our interns see consults, but because it takes a little bit of experience to know how best to distribute the consults/work and get people to the appropriate team (i.e. - is this an appropriate consult for general surgery or should it go to colorectal/hepatobiliary/oncology/etc).

 

[armyres]

Here's my second question: how is this information about pager responsibility passed along? Is it through word of mouth, or is it written down somewhere? Thanks!

 

[LucidSplash]

Here's my second question: how is this information about pager responsibility passed along? Is it through word of mouth, or is it written down somewhere? Thanks!

We make our interns guess what all the rules are during the first week of work in July in our version of hell week. Incorrect performance without instruction still leads to dire consequences.

In reality, these things should be outlined for you in the department/specialty-specific portions of your orientation.