The following guidelines have been developed to make explicit the conditions under which involvement of the supervisory physician should always be requested.
Guidelines for Requiring Supervisory Physician Involvement
Interns will, at all times, have an in-house supervisory resident, fellow or attending 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 who is available to evaluate a patient in person as needed.
The following are explicit conditions when an attending should be contacted immediately. In addition, residents should always contact a supervising physician if they have a question or when they are uncomfortable or uncertain about patient care.
Specifically, the attending must be notified in the following cases:
1. Unexpected deterioration in a patient’s clinical status
b) Rapid response calls/ Codes
c) Transfer to a higher level of care (e.g. ICU) or to another care facility
d) Hemodynamic instability or unexpected new/increased O2 requirement
e) New fever > 101 in an immunocompromised patient
f) New neurological or psychiatric development (e.g. change in mental status, CVA, new seizure)
g) Bleeding: hemoptysis, new GI bleed
2. Abnormal/Critical lab with potential clinical significance (e.g. positive blood culture, rising creatinine)
3. Consulting another service
4. Drug reaction or medication error resulting in patient harm or requiring intervention or increased level of monitoring
5. Inability to deescalate a social situation (angry patient/family member, patient or family leaving AMA or requesting transfer to another facility)
6. Nursing Concerns - if the nurse caring for the patient feels the supervisory attending or fellow should be contacted
7. Patient or family requests to speak to attending
8. Performance of a procedure/radiology
a) Need for invasive procedure (e.g. lumbar puncture)
b) Ordering an MRI or CT
9. Unexpected pain or inability to control pain
10. Unreasonable difficulty in obtaining a time-sensitive procedure or radiological intervention
A supervisory resident and chief resident must be notified in case of fatigue:
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.
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