Who Do You Call?
At 0645, your morning bloodwork shows K+ 2.9. CrCU electrolyte replacement protocol is in place. Patient is vitally stable and in sinus rhythm. Who do you call?
MRP (Intensivist or cardiologist)
This pathway outlines who to escalate CrCU clinical concerns to based on what time it is.
NYGH CrCU Physician Coverage Schedule
Your patient is on a heparin drip for a pulmonary emoblism. Upon transfer from chair to bed, the patient is dizzy and has a witnessed fall to the floor, with moderate impact of their back against the bedrails during the fall. You settle the patient safely into bed with assistance. Patient vitals are stable post fall, GCS 15. The intensivist just started rounds at time of fall.
Emergent/red page.
Patient had a fall and is on high-risk medications.
In this case, notify CCRT MD if available or interrupt rounds to notify the intensivist.
Person(s) you may consider escalating to when you have a family member who is visiting a patient in an airborne room and refusing to put on PPE. The primary nurse, charge nurse, and other colleagues have explained the importance of wearing PPE. Family is also not using ante room to enter.
Manager
Administrator on Site
Coordinator
IPAC
It is 0700, and the patient you are caring for self-extubates. Vital signs: RR 35, Sats 85-87% on NRB, BP 181/70, HR 120. Patient has increased WOB.
Red page Medicine-On-Call and RT
When you have an emergent issue, this is used to assist the MRP (intensivist, medicine-on-call, cardiologist) with triaging calls that are received through telecommunications.
Red Page
The patient admitted for GI bleed has urine output of 20cc/hr overnight and foley is functioning well. Medicine on call was notified at 0400 and a 500cc bolus was administered without effect. It is now 0630 and the patient's VS are stable on room air, no pressors, GCS 15, no signs of bleeding. Urine output remains the same at 15-20 cc/hr. Creatinine is 62, up from 59 yesterday.
Green.
Can wait until intensivist changeover after 0730 for notification.
Admission orders are entered by this physician for a post PCI cardiology patient that was accepted by Dr. Cai at 1300, but the patient does not arrive to the unit until 2130.
Medicine-On-Call
Evening cardiology admissions (after 1800)
It is 1600. Your patient who was admitted by Dr. Bajaj for rapid atrial fibrillation requiring amiodarone infusion, is up for transfer on the Teletracker to 6W and patient has a clean bed ready. Transfer orders have not been entered by the MD.
Cardiologist (normal page)
When the on-call intensivist on evenings calls in / is called by the unit before the end of their coverage evening (typically around 1030/11 PM) to address any outstanding issues.
Tuck in Rounds
The secretary comes to you at 1830 with a microbiology report showing a preliminary positive blood culture for gram negative bacilli.
Urgent (normal page) to MRP/intensivist. MD may adjust antibiotics based on blood culture results.
Your patient's hemoglobin was 74 yesterday and bloodwork results show a hemoglobin of 68 today with no signs of bleeding. Your patient is hemodynamically stable. It is 0645.
Notify the intensivist.
You may consider deferring to when the intensivist shift starts at 0730 if you do not have additional concerns aside from the small drop in hemoglobin.
Patient is received from ED at 0300 with levophed running at 15 mcg/min through a peripheral IV. Despite additional fluids post admission, you are now running levophed at 20 mcg/min through the PIV to maintain a MAP>65.
Emergent (red page) to Medicine-On-Call.
It is 0100. Your patient suddenly has slurred speech and unilateral paralysis. Vital signs stable on room air. You red page medicine on call at 0102 and again at 0110. It is now 0125 and you have not received a response.
Intensivist-on-call.
If intensivist-on-call does not respond after >2 attempts to time-sensitive clinical scenarios, notify Medical Director (Dr. Owen).
Your patient has a tracheostomy and is being weaned with increasing trach mask trials off the ventilator. Yesterday the patient tolerated 12 hours on high flow trach mask. Today, after 3 hours of trach masking, the patient has increased WOB and desaturates, and the RT places the patient back on the ventilator.
Urgent (normal page).
There is deviation from expected clinical trajectory. In this case, MD may want to order additional interventions or diagnostics (i.e. CXR, lasix).