Massachusetts General Hospital | MassGeneral Hospital for Children

Guidelines for Requiring Supervisory Physician Involvement

It has always been implicit that a resident (or an attending, for that matter) should call for assistance whenever she or he feels it would be helpful or when significant changes in a patient’s condition occur. The following guidelines have been developed to make explicit the conditions under which involvement of the supervisory physician should always be requested. Of course, any time a resident is uncertain, supervisory input should be sought without question, even if not explicating listed here.

Interns will at all times have an in-house supervisory resident available to call for assistance and supervision. Junior and senior residents will have a fellow immediately available in the PICU and an attending immediately available in the NICUs. Elsewhere, they will have an attending available for phone consultation for assistance when needed who may be requested to come evaluate a patient in person as needed. Conditions in which residents should call for assistance include, but are not limited to:

1. An unexpected deterioration in a patient’s clinical status
   
   
   • When such a change occurs, the input of a supervisory physician may be helpful to discuss ideas about the management and gauge triage needs even if their physical presence is not immediately needed.
   • A significant change in the patient’s clinical status should be documented in the medical record, along with a diagnostic and therapeutic plan.
   • Examples of such changes include: increasing respiratory distress and/or hypoxemia, changes in mental status, new arrhythmias, new hypotension, and an evolving physical exam.



2. Performance of a procedure

   a. Prior to performing a procedure that entails potential risk to the patient, the supervising resident/fellow and attending physician of record should be aware that the procedure is being performed.
   
   b. Interns should seek supervision when performing all procedures. This supervision should include:

   i. Review of the indications, risks and appropriate method for obtaining informed consent.
   
   ii. Direct supervision of any procedures the intern has not had prior experience with, and immediately available supervision, after review of the procedure, for those procedures the intern has demonstrated competence in previously.
   
   

   c. Junior and senior residents should similarly seek supervision for any procedures that they have not had prior successful experience with

   i. Contact with the supervising fellow and/or attending should be made immediately when initial attempts at a procedure by the resident or under the resident’s supervision have failed

3. Nursing concerns
   

   a. If the nurse caring for a patient feels that a supervisory resident or attending should be called after a patient has been assessed by a resident, this should be done, even if the resident feels the patient is stable. The experience of nursing colleagues is invaluable and respect for their clinical judgment must be demonstrated at all times.

4. Conflict:
   

   a. A conflict with a patient or patient’s family that requires mediation should prompt calling the supervisory resident, fellow and/or attending.

5. Fatigue:
   

   a. If a resident feels fatigue, patient volume, acuity or overwork compromises his/her capacity to give appropriate care to patients , the supervisory resident (in the case of interns) and chief resident on call (in all cases) should be called immediately to arrange for backup coverage.

6. Uncertainty:
   

   a. Interns should call for supervisory assistance at any time when a clinical or administrative concern is taking an undue amount of time to resolve

Specific conditions for which all residents are expected to call the attending of record include, but are not limited to:

• Sudden, unexpected change in patient status
• Rapid Response Calls/ Codes
• Transfer to the ICU or to another care facility
• Need for intubation
• Complex social situations -angry or hostile families
• Family requests
• Patients leaving AMA.
• Patient Death