When to call the physician?

Guidelines for Notification of Continuing Care Physicians of Changes in Resident Status*

Preamble

I. Specific signs, symptoms and laboratory values suggestive of acute illness needing immediate medical assessment (as defined below) will be reported to the attending physician charge nurse or Director of Care as soon as possible after they are identified.

II. All acute changes in resident status reported to the medical staff on an immediate basis will be assessed and documented in the medical record by the nursing staff.

III. In the event of a witnessed cardiac or respiratory arrest (for residents who have full code status i.e. level 1 care “911” will be called with later notification of the attending physician.

IV. When contacting medical on-call coverage during night and weekend hours, nursing staff will have the following information available:

A. Present problem with symptoms, signs, and results of physical assessment, including vital signs and mental status

B. Active medical diagnoses

C. Relevant information about any recent hospitalization

D. Current medications

E. Allergies

F. CPR status and/or hospitalization status ( level of care status)

G. Family contact

H. Date of last physician visit

V. Specific signs, symptoms and laboratory values suggestive of sub-acute illness (as defined below) will be reported to the attending physician by the charge nurse or Director of Care, but not on an immediate basis e.g. the next time the attending physician makes rounds.

VI. All subacute changes in resident status reported to the medical staff on a non-immediate basis will be assessed and documented in the medical record by the nursing staff.

Procedure

I. Immediate Notification (Acute) Problems

The following symptoms, signs and laboratory values should prompt immediate notification of the attending physician. Immediate implies that the family physician should be notified as soon as possible either directly or by pager/beeper

Situations requiring immediate action (ie, transport of the resident to the emergency room) with later notification of the physicians are rare.

These situations include:

1. Witnessed cardiac or respiratory arrest for residents who have full code status (call 911).

2. Rapid progression of signs or symptoms listed below before attending physician is obtained. This applies only to residents with full code status ( level 1 care)

A. Symptoms

1. Any complaint or apparent discomfort which is:

a) Sudden in onset

b) A marked change (ie, much more severe) in relationship to usual complaints

c) Unrelieved by measures which have already been prescribed (eg. Nitroglycerin for chest pain, antacid for abdominal pain, Tylenol for other pain)

2. Specific examples of symptoms (not meant to be all inclusive):

a) Shortness of breath

b) Cough

c) Chest pain, pressure or tightness

d) Nausea

e) Diarrhea

f) Musculoskeletal pain

g) Severe headache

h) Partial or complete loss of vision

i) Dizziness or unsteadiness

j) Weakness of an arm or leg

k) Slurred speech

l) New or worsening confusion

m) Suicidal thoughts

B. Signs

The following list of physical signs is not meant to be all-inclusive. Any other sign about which you are uncertain should prompt attending physician notification.

1. Change in vital signs

General Guidelines:

Temperature > 37.9 degrees

Respiratory rate >24/minute

Pulse>110 or <45/minute

Blood pressure> 200 systolic or <90 systolic

2. Any loss of consciousness

3. Any seizure activity

4. Severe bleeding

Examples:

Intractable nose bleed

Hematemesis

Melena

Bright red blood in stool (not due to hemorrhoids)

Profuse vaginal bleeding

Gross hematuria

5. Laceration requiring sutures

6. Fall with any suspected serious injury (eg. Fracture)

7. New and/or severe gastrointestinal signs (not due to fecal impaction), including

a) Nausea and vomiting

b) Diarrhea

c) Abdominal distention

8. Abnormal drainage, foul smelling discharge or wound complications

9. Sudden onset of new or severe worsening of confusion and/or agitation

10. New focal neurological sign, such as profound weakness of an extremity or slurring of speech

B. Laboratory Results

1. Any lab report, normal or abnormal, which the attending physician requests on a ‘stat’ or ‘same day’ basis

2. In the event that critical levels are received from the laboratory, the attending physician will be notified immediately by phone or beeper.

3. Any of the following unless values are consistently at this level and attending physician is aware.

a) Hematocrit <30

b) WBC >12,000

c) Sodium (Na) <125

d) Potassium (K) <3.0 or >5.5

e) Glucose <4.0 or >15

f) Creatinine >150

g) INR <2.0 or >3.0

h) Positive urine culture (>10⁵ col/ml of a pathogen) only if:

1) the patient has symptoms and is not on treatment

2) the pathogen is not sensitive to antibiotic which has been prescribed

i) X-ray report revealing an unsuspected finding which may require immediate intervention (eg. pneumonia, new long bone fracture)

C. Other

Medication error (overdose or underdose)

a) If it involves a cardiac or psychotropic drug

b) If, in your judgement, the attending physician should be notified immediately because of the nature of the medication

II. Non-immediate Notification (Subacute) Problems

The following types of problems should be reported to the attending physician, but not on an immediate basis:

Non-immediate implies that the attending physician should be informed of the problem or event, but not immediately.

A. Symptoms

1. In general, any persistent or recurrent complaint by a resident or family member that cannot be responded to satisfactorily with already existing understanding of the condition and/or orders for treatment

2. Specific examples of symptoms (not meant to be all inclusive):

Constipation	Urinary hesitancy or poor stream
Weakness or fatigue	Urinary incontinence
Diminished appetite	Vaginal discharge or spotting
Sleep difficulty	Musculoskeletal pain
Itching	Dizziness
Headache	Difficulty walking
Change in vision	Recurrent falls
Hearing loss	Memory loss
Dyspnea or orthopnea	Depressive thoughts
Difficulty swallowing
Abdominal discomfort (eg. Bloating, cramps, etc)

B. Signs

1. Signs

In general:

Any substantial change in physical condition, functional status or new physical sign which does not require immediate notification, should be discussed with the attending physician on rounds.

2. Examples of signs and changes in condition (not meant to be all inclusive)

Progressive weakness Agitation or behavioral disturbance

Diminished appetite	Edema
Weight loss or weight gain (eg. Greater than 5 pounds in a month or shorter time period)	Gait disturbance Personality change
Sleep disturbance	Forgetfulness or confusion
Difficulty swallowing	Depressed affect
Nocturia
Incontinence in urine or stool
Skin rash or pressure sore

C. Other

1. Consult reports requesting specific actions or changes in resident’s management

2. Observations in the course of routine nursing procedures that might require physician action.

For example:

a) Poorly controlled blood pressure in a patient on anti-hypertensive therapy

b) Changes in urine or accucheck values in diabetics (eg. Persistently high determinations in a patient who is normally well controlled)

c) Symptoms unresponsive to recently prescribed treatment

d) PRN medications which are never used

3. Medication errors (that do not require immediate notification)

4. Special topics concerning a patient’s family

*Adapted with permission by Dr Paddy Quail from "Guidelines for Notification of Physicians and/or Nurse Practitioners of Changes in Resident Status" Jewish Homes for the Aging of Greater Los Angeles. Dr Joseph Ouslander MD Carole Turner GNP, Doreen Delgado ANP, Dorothy Reid RN Gregg Sannes RN and Dan Osterweil MD