FMS Staffing and Cap Policy
(Reviewed 08/2017 by Ben Davis)
DEFINITIONS:
Patients on service – Patients including moms, babies, and laboring OB patients. May include antepartum patients.
Patient equivalents – measure used to compensate for patient complexity. This document will use the word “patient” to mean patient-equivalents. See Appendix A “How to calculate patient equivalents”.
Mothers and newborns – Continuity, faculty, and Neighborcare OB laboring and postpartum patients.
Service goat – A senior resident who is assigned to be available to assist as needed for illness, busy service that is felt to be unsafe with the current team members, and other unavoidable absences including family emergencies. See Appendix B “Role of the Service Goat”
SHIFT SPECIFIC CAP
--If at any point during the day the FMS senior feels that the safety of our patients is jeopardized due to the volume of current or newly admitted patients on service they may cap the service. If you need to call in the goat for a busy service, you should temporarily cap the service until either the goat’s designated task is completed or the original team members are once again available.
--FMS senior will cap the service if >= 8 admission in a single shift. Cap in effect until admissions can be safely performed. At that time the FMS senior should all the ED back to inform them that we are accepting admissions once again.
Note:
-- The following guidelines are for WEEKDAYS
-- Always notify the program chiefs when the goat system is enacted. sfmchiefs@gmail.com
≤21 PATIENT-EQUIVALENTS ON SERVICE
Each intern can take 7 patient-equivalents, for a potential total of 21 patients on service. Exception to this is during the first FMS block for that interns (see below under “special circumstances”)
15-25 PATIENT-EQUIVALENTS ON SERVICE
Each R2 can take up to 2 patient-equivalents on their panel in addition to supervision responsibilities, for a potential total of 25 patients on service. The goat should be considered based on the acuity of the patients on service and degree of need for supervisory role from senior residents.
Stop taking no-docs and Vashon patients when there are ≥ 15 patients on service. [Strongly consider NOT taking outside clinic patients (SMG, Elderplace) when there are ≥21 active patients on service. Notify the appropriate attending – they may choose to admit on their own or may admit to hospitalist team.]
≥25 PATIENT-EQUIVALENTS ON SERVICE
Summary: Each intern will take 7 patient-equivalents on their panel (21 patients total). If additional patients are present, each R2 can take up to 2 patients (4 additional patients). An exception to this is during the first FMS blocks of the new year where interns will be capped at 5 patients each.
While we prioritize admitting patients from our continuity clinics (First Hill, DFM, Ballard) and Neighborcare. If there are more than 25 patients and/or safety is a concern, discuss with the FMS attending capping to all new admits until the following morning.
ROLE OF THE GOAT
The goat should be utilized to assist with morning rounds when the service is above cap or feels unsafe. The goat should be utilized to see the additional “R2” patients, to assist in rounding on mothers and newborns, and/or to help with managing laboring patients, especially early on in the year when there is an increased need for supervision. They will be notified as soon as possible that they will be needed for a given morning. See Appendix B “How to Implement the Intern Goat system.” When you call in the goat the FMS service should be capped if the reason for calling in the goat is a busy service. The service is re-opened to admissions once the goat has completed their designated tasks or if the original team members are once again available.
MOTHERS and NEWBORNS
-- The R2s and service chief will distribute the mothers and newborns at the discretion of the service chief.
-- If service is slow, mothers and newborns may be seen by interns with assistance from their senior on service.
-- Antepartum patients with non-OB or OB related admissions will be distributed at the discretion of the service chief or night senior.
SPECIAL CIRCUMSTANCES
Weekends: The night team and day team will distribute patients to be rounded on that day. Should a goat be necessary, the service goat will be utilized to help.
Holidays: If the service goat is called in, they will receive a floating holiday.
Active OB: If there is an active OB that is diverting time and energy to critically ill patients the senior should consider handing that OB patient off to the OB senior if on call. Can also consider the OBR1 as well if they are able to accommodate.
First FMS Block for Interns: Interns on their first FMS block will be capped at 5 patients each. Because of this the total cap for the service will come down to 19 patient equivalents total instead of 25. The total cap can change based on circumstances (Ex: Two interns on FMS for the first time and one intern on their second FMS block. Cap is 21 total patient equivalents due to the individual caps for each intern being different)
Geriatric Fellow Cap: Geri fellow cap is 6 patient equivalents. If cap exceeded, the Geriatric Fellow will notify and request assignment of the most stable patient to either Elderplace or FMS attending. This should be done at morning signout (7am)
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Appendix A
● Calculating patient equivalents:
● Floor: 1 point
● Moms & Babes: 0.5 points each (Ex: Mom and babe pair = 1 patient equivalent total)
● Stable and known to service IMCU or ICU: 1.5 point
● Unstable or new to service IMCU or ICU: 2 points
*These determinations will be made by the service chief and attending. Service chiefs may consult the program chiefs with questions or assistance
Appendix B
Role of the Service Goat:
● Senior resident who must be available (in town) 24/7 during their assigned day
● No restriction on continuity clinic and other clinics (may not be on cardiology)
● Examples of when to utilize service goat:
▪ Busy weekend service, need assistance
▪ Illness, family emergency, other unavoidable need for leave
▪ Busy weekday service, above cap
▪ 4 pm: You’re on your 6th admit of the day and overwhelmed
Appendix C
Clinic Scheduling
● Please try to avoid scheduling multiple FMS team members in clinic on the same day.
● Please try to avoid scheduling FMS team members for the first day of the block.