Hematology and Oncology Inpatient Services

Patient Population:

IP-Medicine Hematology

  • Hematologic Malignancies (established and possible)
  • Planned chemotherapy admits for induction/reinduction, Hyper-CVAD, Phase I, and ALL intensification, etc… ***
  • Benign Hematology (Hemophilia, Aplastic Anemia, ITP, AIHA, etc)*

*Sickle cell anemia to remain with General Medicine ward teams though may come to hematology at times that the general medicine services are at a critical bed /provider shortage due to high census

IP-Medicine Oncology

  • Solid Tumor Oncology (established and possible)
  • Overflow of Hematologic Malignancies
  • Planned chemotherapy admits preferably R-EPOCH and HIDACs as determined by census—inductions, Hyper-CVAD and other high-grade targeted regimens should be confined to the hematology team***

Team Census:

IP-Medicine Hematology

16 targeted ceilingthough absolute maximum of 20.

Any admission over 16 should be restricted to patients with critical needs that are only served on the inpatient hematology team (inductions for acute leukemia, aplastic anemia requiring initiation of IST, etc.). If 16 patients routine admissions should be deferred until below 16.

IP-Medicine Oncology

14 maximum though may flex up to 16

Any admission over 14 should be restricted to patients with critical needs that are only served on the inpatient oncology team (chemotherapy admits not to be deferred, etc.). If 14 patients routine admissions should be deferred until below 14.

Team Staffing:

IP-Medicine Hematology

Hematology-Oncology attending

Hematology-Oncology fellow

Internal Medicine Resident (when available)

Internal Medicine Interns x 2

IP-Medicine Oncology

Oncology attending

Internal Medicine Resident

Hematology-Oncology fellow

Internal Medicine Interns x 2

Night Staffing:

Both services covered by intern/resident/hospitalist night team

Team Office Space:

IP-Medicine Hematology

Hematology team room on CCH2 near main nursing station

IP-Medicine Oncology

Oncology team room on CCH2 near nurse manager office

Daytime Work Flow:

See separate daily workflow outline

NOTE: Rounds MUST start no later than 8:00AM—NO EXCEPTIONS AS THIS IS A DOIM EDUCATION PROGRAM POLICY ACROSS ALL SERVICES!It is also necessary for interdisciplinary rounds to begin promptly. Deviations prevent timely patient care, disrupt multiple staff members, and interferes with housestaff getting to conference on time. This is an absolute! Rounds with the housestaff (residents and fellows) also should be concluded in a timely manner to insure there is time after rounds to finalizes discharges, call consults, enter important orders, and make the required meetings/conferences. In general, rounds should not extend beyond 10:30.

Supervision and Work Roles:

(ALL DOIM CORE PROGRAM AND FELLOWSHIP SUPERVISION POLICY EXPECTATIONS ARE TO BE FOLLOWED—PLEASE REVIEW IN FULL—AVAILABLE ON-LINE)

IP-Medicine Hematology

Hematology attending

  1. See DOIM expectations
  2. On fellow’s day off, perform all duties normally performed by the hematology-oncology fellow.
  3. If/when other team member are overwhelmed, it is expected the attending will step in to perform any of the other team members’ functions as necessary to insure safe and timely patient management.

Hematology fellow

  1. See DOIM expectations
  2. See all admits and oversee intern’s admission orders/care with a brief fellow’s admission note to be entered into patient record on days that the resident is off.
  3. On Sundays, admissions to the oncology service between 3-7PM will be directly supervised by the hematology fellow.
  4. If/when other team members are overwhelmed, it is expected the fellow can step in to perform any of the other team members’ functions as necessary to insure safe and timely patient management.
  5. Perform bone marrow aspirates/biopsies and administer intrathecal chemotherapy to the patients on BOTH the hematology and the oncology inpatient teams
  6. Promptly notify resident and attending of any accepted admission—Please note that the housestaff have less than 60 minutes to enter the admit order once RFA has been placed by the ED physician.

Core housestaff (Day and Night shifts)

  1. Follow core program expectations for inpatient services

IP-Medicine Oncology

Oncology attending

  1. See DOIM expectations
  2. On fellow’s day off, perform all duties normally performed by the hematology-oncology fellow.
  3. On Sundays, admissions before 3PM will be directly supervised including the intern’s admission orders/management plans. Hematology fellow will be available to supervise between 3-7PM.
  4. If/when team members are overwhelmed, it is expected the attending will step in to perform any of the other team members’ functions as necessary to insure safe and timely patient management.

Oncology fellow

  1. See DOIM expectations
  2. Supervise interns on all management issues
  3. Provide primary patient coverage for interns with day off.
  4. On days when intern is in clinic, present the absent intern’s patients.
  5. See all admits and oversee admission orders/care with a brief fellow’s admission note to be entered into patient record.
  6. If/when other team members are overwhelmed, it is expected the fellow can step in to perform any of the other team members’ functions as necessary to insure safe and timely patient management.
  7. Promptly notify resident and attending of any accepted admission—Please note that the housestaff have less than 60 minutes to enter the admit order once RFA has been placed by the ED physician.

Core housestaff (Day and Night shifts)

  1. Follow core program expectations for inpatient services

Housestaff Days Off:

IP-Medicine Hematology

Fellow off on Saturday/Sunday as determined by the call schedule

Resident off on Sunday/Saturday as determined by the fellows’ call schedule

Interns to take off one day per week to be coordinated by both the resident and fellow with attending approval**

IP-Medicine Oncology:

Fellow off on Saturday/Sunday as determined by the call schedule

Resident off on Satday/Sunday as determined by the fellows’ call schedule

Interns to take off one day per week to be coordinated by both theresident and fellow with attending approval**

**Fellow/resident should review with the attending who will be covering for the day of anticipated absence at the beginning of the block. Resident day off is coordinated with the fellows to insure upper level coverage.

ADMISSIONS:

Please refer to the night call procedures guidelines for instructions on the handling of calls for admission/transfer from the ED, clinics and outside facilities.

NOTE: Night admissions up to 4 max combined for hematology and oncology teams by night shift should available space allow on the respective teams.

NOTE: Admissions are to be accepted if capacity exists on the appropriate service. While it is necessary to be mindful of planned admissions balanced against anticipated discharges, holding for the potential of something more urgent or declining due to lack of confirmed pathology is not an acceptable reason for deflecting an admission. Transfers from oncology to hematology once capacity allows is acceptable for patients with acute leukemia (or other high grade malignancy) who had been urgently admitted to the oncology team due to capacity limits. Otherwise, transfers are not to be allowed between the two teams.

Late Admission Coverage (5PM-7PM):

The hematology and oncology residents will alternate nights between the two Intern staying late for admissions to be rotated as determined by the residents on service for that block such that there should be one resident and intern staying each evening.

At-Home Night Call for Hematology and Oncology Attendings:

NOTE: each attending per DOIM policy is still expected to individually check-in with the night covering team between 7-9PM to make sure all questions they might have from check-out have been clear, clarify any anticipated transfers that are accepted but outstanding, etc….

Weeks 1 and 3 of Block

SaturdayHematology attending

SundayOncology attending

MondayHematology attending

TuesdayOncology attending

WednesdayHematology attending

ThursdayOncology attending

FridayHematology attending

Weeks 2 and 4 of Block

SaturdayOncology attending

SundayHematology attending

MondayOncology attending

TuesdayHematology attending

WednesdayOncology attending

ThursdayHematology attending

FridayOncology attending

Each inpatient attending should still communicate and post in the team rooms their contact information. You should also be available for call from the team about your established patients as needed should emergent questions or status change notification be indicated. These calls are obviously infrequent but more easily handled by the attending caring for the patient.

If you have activities planned that are prohibitive to being immediately available, establish a plan with your team, night MD, and on-call attending in advance to make arrangements for the period of time in question--movie or show, for example. A simple check-out may be helpful for anticipated problems. There is an attending level physician in house generally so it is not a matter of being called in. Emergent consults and new patients to either team still covered by MD on call. Issue is more for clarification-escalation issues related to existing floor patients.

Weekend Consult

Over the weekend, the hematology-oncology consults will be covered by the hematology or oncology team attending physician on call for that day