Triage to General Medicine 1-4 Services: Process and

Guidelines

  1. To adequately allow for high quality patient care and time for resident education, the following guidelines on admission number, distribution and timing as of 6/24/2025

    a. Strict team caps of 14 patients for all teams

    b. End of day Team Census Limits for each team of: 14 post-call, 14 no-call, 12 short call and [12 long call]{.underline}

    c. DAY ADMISSIONS:

    i.  Maximum of 2 admissions can be admitted to the Short Call
    team during the hours of [10am-2pm]{.underline} provided
    their end of workday census is expected to be 12 patients or
    less.

ii. Maximum of 2 admissions can be admitted to the Long Call
    team during the hours of [10am-4pm]{.underline} provided
    their end of workday census is expected to be 12 patients or
    less.

iii. Additional Low Census Admissions: If a day
     team has a 7am census of 6 or fewer patients, that team is
     open for an additional one admission per intern (max 2)
     between the hours of 10am-2pm on weekdays.

     1.  This includes the short call, long call, post call and
         no call teams and is In ADDITION to the above admission
         caps on short and long call days.

         a.  ie: The Short or long call teams can get 2 low
             census admissions + 2 additional "call day"
             admissions between the hours above if their 7am
             census that day was 6 or less.

     2.  The above DOES NOT apply to days where the senior
         resident is managing the service alone (Interns have
         days off) or weekends.

         a.  Attendings should see new day admissions with
             interns when the senior resident is off.

    d. NIGHT ADMISSIONS: up to 6 new admits by Night Admission Team (NAT), not including bounce backs or helping medicine cross cover with CVM or heme pts.

    i.  Maximum of 4 new admissions will be dropped off to the
    post-call team

ii. Maximum of 2 new admissions will be dropped off to the
    short-call team.

iii. No new admissions will be dropped off from the NAT to the
     no-call or long-call team except for bounce backs.

iv. All night admissions by the NAT should go to the post-call
    team first, then the short-call team as census cap above
    allows.

v.  All admits done by the NAT are initially assigned to the
    post call team. Then the NAT can redistribute the most
    straightforward admission to the short call team at 7am.

    1.  Patients admitted by a medical student should be kept on
        the medical student's team.

vi. The NAT can admit a maximum of 10 admissions in one night
    float shift, although we anticipate this will be rare. This
    includes 6 patients to the post-call and short-call team as
    above and bounce backs and assisting cross cover with
    hematology/CVM overflow.

vii. The NAT also provides backup for the medicine cross cover
     resident in the event they need assistance with CVM or
     Hematology admissions.

    e. Avoid admissions between 6 a.m. to 10 a.m realizing that the residents need to prepare and complete attending rounds (except for bounce backs and from between 9am-2pm for the long call team on weekends as below).

Weekdays:

DAY (CAP # at 7am) Drop Off Cap from NAT Day Admit Window End of Day Cap
Post Call (14) 4 X 14
No Call 0 X 14
Short Call (12) 2 10am-2pm (up to 2 admits) 12
Long Call 0 10am-4pm (up to 2 admits) 12

Weekends and Holidays:

DAY (pt CAP # at 7am) Drop Off (from NAT) Day Admit Window End of Day Cap
Post Call (14) 4 X 14
No Call 0 X 14
Short Call (12) 2 9am-12pm (up to 1 admit) 12
Long Call 0 9am-2pm (up to 2 admits) 12

  1. Ensure students and interns have daytime admissions of teaching and learning value after noon on their on-call and pre-call days.

    a. To achieve this goal, we will try to triage 1-2 admissions to the short-call and long-call teams during the day unless they are at the above census targets

    b. The triage hospitalist will save space on the call team's roster to target 6 slots available for admissions between 4 p.m. and 6am for the NAT.

    i.  Day triage will target 4 available spots for the Night
    triage hospitalist to use from 6pm-6am

.

  1. To ensure safe handoffs with transitions in care, the triage hospitalist will notify the GMED team as soon as possible when a patient has been accepted to their service from the ED or through the access center.

    a. For ACCESS patients, this handoff should occur immediately after the patient has been accepted to the GMED team so they can prepare for the admission. If a patient needs to be re-triaged due to delay in transfer the triage hospitalist will notify the GMED team and can reassign the patient to an alternative team.

    b. The triage hospitalist will share all pertinent information with the resident but try to avoid offering diagnosis and management clues so that the residents have a chance to develop their ideas independently.

    c. For patient safety reasons, if a subspecialty consultant offers a management recommendation on an access patient this should be shared with the residents.

  2. A ['bounce-back']{.underline} is patient that the current PGY2/3 - OR - Intern AND Attending previously cared for during the current GMED rotation. Triage will accept these patients back to the same service to maximize continuity of care, provided the end of day census for a team does not exceed 14 patients.

    a. 'Bounce-back' patients include patients arriving from the ED, EMH, Access center, transfers out of the TLC or transfers from other teams (ie: CVM, surgery).

    b. 'Bounce-back' admissions that occur during daytime hours (7am-4pm on weekdays and 7am-2pm on weekends) will be done by the day team that originally cared for patient (not the call team unless that is team the patient is returning to).

    i.  If the GMED day team accepting the bounce is on long call or
    short call that day, the bounce back counts as one of their
    two admissions for the day admitting hours.

ii. If the Long Call or Short Call GMED day team has already
    been triaged two admissions, and then a bounce back occurs,
    it can still be triaged to that GMED day team provided their
    census does not exceed 14 at end of day (as per f below)

    c. 'Bounce-back' admissions that occur during night admitting hours (4pm-7am on weekdays and 2pm-7am on weekends) will done by the Night Admitting Team.

    i.  Note: The Night Admitting Team is responsible for admitting
    bounce back admissions between 6-7 am. If the day team is
    present and able to help with the admission they may do so
    to allow the Night Admitting Team to start post call rounds
    at 7am -or- the day team may decide to start post call
    rounds with the Night Admitting Team intern while the Night
    Admitting Team senior completes the bounce back admission.

    d. 'Bounce-back' admissions to the post-call team that occur during post-call rounds (7am-11am) will still be triaged and done by that post call DAY team.

    e. A GMED team cannot accept a bounce-back if it puts their team above 14 [at night.]{.underline} If the Night Admitting Team was already triaged 4 admissions to post-call team and/or 2 admissions to the short-call team (ie: they met the night hour cap) and then a bounce back admission occurs, it can still go to the GMED team provided that GMED team will not exceed 14 patients or the Night Float team has not exceeded their ACGME cap of 10 admissions/shift.

    f. The GMED [Day]{.underline} Team may exceed the cap of 14 to admit a 'bounce-back' admission if they have planned discharges and their team census by the end of the calendar day is expected to be [\<]{.underline} 14 patients.

    g. If the GMED team is unable to accept the 'bounce-back' given a census of 14, the Triage Hospitalist should accept the patient to a hospitalist service.

  3. Patients that should NOT be accepted to GMED services include:

    a. CWC patients

    b. Patients in IMC requiring mechanical ventilation

    c. Patients with planned admissions post procedure (IR embolizations, TIPS, etc)

    d. Patients with care plans that require provider continuity and specify admission to a hospitalist service (behavior management plans, eating disorders, etc).

  4. Minimize boarding (i.e. suboptimal geographic placement) by prioritizing admits to F65 and D65 to the GMED services as census and admission timing allow.

  5. Have a strong and professional collaborative relationship between the admitting residents and the triage hospitalist by increasing in-person dialogue between the triage hospitalist and residents. These conversations will help with triage make decisions, when possible, with regard to:

  6. Case selection,

  7. Discussing which admissions would provide the most learning value

  8. Limiting redundancy of admissions with the same diagnoses

  9. Ability to accept patients

  10. Knowing the acuity of a current service's census

  11. Resident absences and clinics

  12. Anticipated discharges for that day

To this end, the triage hospitalist will discuss the expected census and admission targets with the two admitting Day Teams and the Night Float team.

Door controls for the GMED workrooms are 1234* for # F6/579 (GM1), badge swipe for #E5/524 (GM2), 1234* for D6/521 (GM3) and badge swipe for F5/608 (GM4).

  1. Residents will accept patients triaged to them professionally and assume the best motives of the triage faculty member. If there are systems issues that recur, then these need to be reported to the chief medical resident for root cause analysis and solutions to be derived.

  2. Admissions to GMED services can be grouped but no more than two in 1 hour and no more than three in 2 hours. There is learning value in doing this.

    a. Triage can give residents two new admissions at one time.

    b. Residents are encouraged to discuss their workflow with the triage hospitalist to ensure safe patient care and timely care for new admissions. Stable patients do not need to be seen immediately and triaging workflow during busy times is educational.

Updated 3.2025