The University of Maryland Medical Center, a private not-for-profit hospital, is a major tertiary and primary care facility with approximately 700 beds and over 35,000 admissions each year. The medical services consist of nearly 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. 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, 2 CCU/Telemetry Teams, and the Solid Tumor and Leukemia Services. 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 and interns are strictly capped at 5 admissions per night. 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.
A Night Team System was started in July 2000 to ensure that interns and residents get ample sleep at night and do not work more than 80 hours/week on average. Interns and residents on the University wards take their last admission at 7 pm on weekdays so they may leave the hospital at 9 PM and ensuring 8-10 hours off between duty shifts. While on ICU, Med-ID or Cancer Center rotations, interns and residents are compliant with the 30-hour rule by leaving post-call by 12-1 pm.
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 services having individual over-night call with close resident supervision. Census is capped at 18 on all services. Med 1-4 consist of one resident and 2 interns who take call as a team every 4th night. Subspecialty faculty attend on Med 1, general internists on Med 2, and hospitalists on Med 3 and 4. Both Med-ID services have ID faculty supervision. Med-ID Gold consists of an ID fellow and 2 interns and Med-ID Silver has 1 resident and 2 interns. Med-ID Gold and Silver alternate q4 overnight call. An extensive day/night float system is in place to allow residents to go home at 9 PM when on-call. Third and fourth year students are members of all teams.
The Medical Intensive Care Unit (MICU) and the Cardiac Care Units (CCU) comprise the mainstay of the resident's training in critical care medicine at University Hospital. Call is every fourth night in both these critical care units, with residents leaving at 1 PM post-call. The MICU consists of 2 teams, each consisting of 1 fellow, 2 residents, 2 interns, 1 subintern and 1-2 nurse practitioners. A new state-of-the-art 29-bed MICU opened in May 2006. The CCU and PCU (Progressive Care Unit) underwent a major curricular change in July 2005 creating 2 parallel services -- the CCS (Complex Cardiology Service) and the PCS (Primary Cardiology Service). Each team cares for patients in both the geographic CCU and PCU - thus obviating the need for writing transfer notes between these two units and providing enhanced continuity of care and learning. Patients with CHF and transplant needs are preferentially admitted to the CCS, while patients with ischemia heart disease, MI's and arrhythmias are admitted to the PCS service. Each team consists of 1 fellow, 2 residents, 4 interns and 1 subintern.
Upper level residents rotate through the Greenebaum Cancer Center, where 4 residents care for patients on the Leukemia and Solid Tumor Services. Call is also every 4th day with residents staying overnight and departing by 1 PM post-call.
A non-teaching hospitalist service (Med 6), implemented in July 2005, consists of recent internal medicine graduates 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 reduce our overall length of stay -- a huge achievement.
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. 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) was implemented in August 2007 and we are moving to a fully computerized medical record system using EPIC in the near future. The advent of Wi-Fi workstations and connectivity permit residents to access data, enter orders and retrieve radiologic studies through PACS.
Our brand new state-of-the-art Emergency Department opened in 2002. Approximately half the patients on the medical services are admitted through the UMMC Emergency Department where over 50,000 patients are valuated and treated annually. First and second year residents rotating through the Emergency Department function as primary physicians, caring for patients with diverse medical conditions under the supervision of outstanding full-time faculty from the Department of Emergency Medicine. They evaluate patients with less acute illnesses in the Fast Track area. The Rapid Diagnostic Unit (RDU) provides care for patients expected to remain in the ED for under 24 hours, thus reducing admissions to the medicine service. 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.