The University of Maryland Medical Center, a private not-for-profit hospital, is a major tertiary and primary care facility with approximately 750 beds and over 38,000 admissions each year. The medical services consist of over 200 beds divided among a variety of general medicine and subspecialty services. In all units, doctors, students, nurses, clinical pharmacists and support staff work as a team to promote unified and comprehensive care for every patient.
Each medical service is a mixture of patients -- some admitted to the care of the teaching attending and others admitted by full-time faculty attendings. The residents provide the patients' primary care under the supervision of either the private full-time faculty or teaching attending. We also have robust non-teaching services where general medicine, oncology and intermediate care patients are admitted. Community physicians transfer all the care of their patients to the resident service. First year residents are responsible for the day to day evaluation and management of the patients, writing all orders on their patients. Upper level residents are the leaders of each team and hence have significant clinical and teaching responsibilities.
There are 12 medical teams at University Hospital, including 4 general medical services, 2 infectious disease services, 2 MICU Teams, 1 CCU/Telemetry Teams, and Advanced Heart Failure Service, and 2 Cancer Center services (solid tumor and leukemia). Teams on the floors and intensive care units are structured in a similar fashion with the resident as team leader supervising interns, subinterns and third year medical students. Attending rounds are held seven days each week. Call on all services is every fourth night on all services, except for the MICU and CCU where interns take call every 4th to 6th day. Admissions are strictly capped interns taking no more than 5 admissions per call. Most admissions are taken by the first year residents and subinterns, thereby providing the upper level residents with ample opportunity to supervise and lead the team.
We are compliant with the latest ACGME Duty Hour Requirements. In 2009, we implemented our 28-hour rule -- a full 18 months ahead of the ACGME's planned new rules for July 2011. Interns do not work longer than 16 hours and do not stay overnight in the hospital (except when on Night Float rotations). A fully staffed 7-day/week Night Team System ensures that interns and residents get ample rest and meet 100% of the RRC Duty Hour Requirements. Interns and residents on the general medicine and ID services take their last admission at 6 pm so they may leave the hospital by 9 PM and have 8-10 hours off between duty shifts. Upper level residents stay overnight while only while on MICU, CCU/telemetry, or Cancer Center rotations. Nocturnists and intensivists are present throughout the night shifts and assist with patient care and supervision.
The non-ICU services consist of 4 General Medicine services (Med 1-4) and 2 Infectious Disease services (Med-ID Gold and Silver). The Med 1-4 services are organized in a Team Call system with the Med-ID teams having individual call with close resident supervision. Med 1-4 consist of one resident and 2 interns who take call as a team every 4th day. Subspecialty faculty attend on Med 1, general internists on Med 2, and academic hospitalists on Med 3 and 4. The Med-ID services have ID faculty and fellow supervision, with 1 resident and 2 interns on each team. Med-ID Gold and Silver alternate q4 call. Interns take their last admission at 6 PM and sign out to the Night Team at 9 PM. Third and fourth year students are members of all teams.
The Medical Intensive Care Unit (MICU) and the Cardiac Care Units (CCU) along with our new Advanced Heart Failure Service
comprise the mainstay of the resident's training in critical care medicine at
UMMC. Interns take call every 4th to 6th day with residents taking overnight call every 4th day in both units.
Interns take their last admission at at 7 PM (leaving by 9 PM) and residents stay overnight
leaving within 28 hours post-call. Interns also do a "string of nights" in both these units as the night float intern, gaining additional clinical experience.
The MICU consists of 2 teams, each with an intensivist, 1 fellow, 2 residents, 3 interns, 1 subintern and 1-2 nurse practitioners. Our state-of-the-art 29-bed MICU has 24/7 intensivists in the MICU at all times. Intensivists, the team resident and night float intern cover the MICU at night. Intensivists, the team resident and the night float intern cover the MICU at night.
Patients with cardiac disease are admitted to CCU/Telemetry team (PCS - Primary Cardiology Service). This service was reconfigured in September 2012 to focus the residents' clinical experience in cardiology, including ischemia heart disease, MI's and arrhythmias. The PCS team cares for patients in both the geographic CCU and telemetry unit - thus obviating the need for writing transfer notes between these two units and providing enhanced continuity of care and learning. The PCS team consists of a cardiology attending, 1 fellow, 4 residents, 4 interns and 1 subintern. Hospitalists, the team resident and the night float intern cover the cardiology patients on Sunday through Thursday nights, with the fellow, resident and night float intern covering the service on Saturday and Sunday nights.
A new Advanced Heart Failure Service was established in September 2012. Second year residents rotate on this service for 2 weeks and work alongside fellows and nurse practitioners in the care of these complex patients with CHF, pulmonary hypertension, and transplant needs. Each team consists of a cardiology attending, 2 fellows, 1 resident and several nurse practitioners. There is no overnight call for the resident during this 2-week rotation. Patients are covered by a nocturnist or fellow at night.
Upper level residents rotate through the Greenebaum Cancer Center, where 4 residents care for patients on the Leukemia and Solid Tumor Services. Overnight call is also every 4th day with upper level residents working for no more than 28 hours/shift.
A variety of non-teaching services exist to care for our patients and help off-load the resident services. The Med-6 service is a non-teaching hospitalist service consisting of recent graduates from our program and PA's. Having this service provides a valuable buffer to ensure compliance with the number of admissions to the teaching service. Through their hard work, we were able to admit significantly more patients to all the medicine services in the past year, off-load the teaching services and reducing our overall length of stay -- a huge achievement. The Intermediate Care Unit (IMC) opened in September 2009 and is run by hospitalists with an interest in more critically ill patients. This service helps to off-load both MICU and floor patients who have a change in their clinical status. In the fall of 2010, Med 8 opened as a non-teaching service in the Cancer Center. All these non-teaching services have helped the Department of Medicine achieve an increase in admissions, enhance patient flow in and out of the hospital, and relieve the pressure on the teaching services. They have been essential to the success of our residency program and reflect the strong financial support we enjoy from the institution and the GME leadership at UMMC.
All teams are assisted in their daily work by an interdisciplinary team, including a case manager, physical and occupational therapists, social workers, phlebotomy and IV teams, substance abuse counselors and respiratory therapists. In 2009, UMMC hired additional discharge coordinators specifically to assist the residents in the work of preparing patients for discharge and improving efficiency. A resident partner has also joined the team and assists residents in completing clerical and other tasks necessary for optimal patient care. An extensive computer system allows residents to quickly retrieve lab data, studies, discharge summaries and scanned records. A Computerized Physician Medication Order Entry system (CPMOE) and computerized sign-out and discharge process all help to facilitate patient flow and the residents' efficiency. We implemented a fully computerized medical record system using EPIC for our ambulatory sites in the fall of 2010. A fully computerized system will be implemented for the inpatient units in the very near future. The advent of Wi-Fi workstations and connectivity permit residents to access data, enter orders and retrieve radiologic studies through PACS. Residents can also access information from off-site locations or their home via a VPN system.
Our Emergency Department is comprehensive and state-of-the-art clinical service, staffed 24/7 by outstanding faculty from the Department of Emergency Department. Approximately half the patients on the medical services are admitted through the UMMC Emergency Department, where over 50,000 patients are evaluated and treated annually. First year residents rotating through the ED function as primary physicians, caring for patients with diverse medical conditions under the supervision of full-time faculty. They evaluate patients with less acute illnesses in the Fast Track area. Maryland Express Care, an integrated consultation and critical care transport system for patients from all points within the state and region, adds diversity to the educational experience.