When to call the doctor?

CABG patch kid, BSN, RN · Sep 8, 2009

Knowing when to call a doc about something on night shift is something that comes with experience; even after a year and a half as a nurse I constantly question other coworkers on when to call. Generally, any condition change for the worse warrants a call. If you are calling a rapid response or code blue, call that first, but know that the doc will still need to be called asap. Say you are calling a rapid response on a pt who just dropped their BP to 80/50. You will need to call the doc to get orders to treat and transfer to ICU for example. Or if your pt has an O2 sat of 86% on 2LNC, call the RRT, put the pt on a non-rebreather, then call the doc. Those are just some examples. In those situations, you should have your charge nurse or another nurse there to help you with the pt, while you as the primary nurse will be responsible for telling your support team the pt history, current situation leading up to the problem, etc.

For nonemergent situations, you should limit calls to the docs as much as possible. Always ask another senior nurse before calling, until you have a strong idea on what requires a call. Reason is, a lot of nurses will be calling that doctor when they are covering; often docs are on call for multiple other doctors at a time, and they need to be well rested for the procedures etc that they have to do the next day. Just my :twocents:

Key_ · Sep 9, 2009

Say you are calling a rapid response on a pt who just dropped their BP to 80/50. You will need to call the doc to get orders to treat and transfer to ICU for example.

For a different view, on the floor I work on we wouldn't normally call a rabid on a BP of 80/50. I work on a tele unit and if we had a blood pressure like that we would call the Dr and probably treat with fluid, and if that didn't work, a drip. If they still had issues and were symptomatic, then probably send to the ICU. With the O2 we just turn it up, but we do usually have orders to titrate. If they have breathing treats ordered, get one. We wouldn't call the Dr unless we felt that lasix was needed, we couldn't get their sats up, or if they were in distress. But I have also been told that if you can work our tele floor you can work anywhere, so it probably just varies by hospital.

But with a rapid our rule is to call if you "are worried about a patient". So they could mean just about anything.

Going back to the pressure, if it was low and the heart rate was way high, and the patient was light headed, sweating, and confused, then yea, call a rabid. It just varies by patient.

But I do agree with asking coworkers. I have been a nurse for a little over year and I ask other nurses all the time if they would call or not. As a general rule we don't call on labs unless they are critical. But that can vary by patient again. Say a patient has a potassium of 3.2 and frequent PVCs, then go ahead and call, but if the potassium is 3.2 and they are fine, we wait until morning.

Now I've just said a lot and made it more confusing lol. Basically knowing comes with experience and asking coworkers.

kanzi monkey · Sep 9, 2009

. Say a patient has a potassium of 3.2 and frequent PVCs, then go ahead and call, but if the potassium is 3.2 and they are fine, we wait until morning.

Most of what Key said is similar to what happens on my floor. However, if I see a NEW value of K 3.2, I'll let the doc know so I can get to replacing it, regardless of symptoms or even if the patient is ON a monitor (I might throw one on if it's an older patient who looks like he/she might have trouble). When I work 11p-7a, a potassium of 3.2 would have already been replaced on the previous shift. If not, it should be done overnight. That's too low. I work in a surgical setting, so usually a low K has to do with fluid/lyte loss of some kind. So, even a healthy young person is at risk for a dangerous arrhythmia. If the doc's ok with it, however, I'm ok with it--usually. On the other hand, if the K is 3.4 and the patient is young and cardiac healthy--I'd wait till the next lab draw. (if it's less than 3.4, I'll always call--mostly because this is very unusual in a pt without a history of potassium deficiency, or in a pt who is actually stable).

As far as RR goes--we have a protocol. I can't quote it to you since I don't have it in front of me. Basically our RR is for grossly abnormal vital signs that don't respond to basic interventions after a certain amount of time. O2 sat

It's nice to have a posted list of protocols "when to call RR". So, you don't have to debate it. Just call it if one of your VS fits the criteria, or if you don't feel comfortable or have adequate support.

RR is awesome. It's not a code. Everyone knows that. You can call it when you think it's needed because THE PATIENT isn't as stable as you're comfortable with. That's all. It's not about you, or bothering anyone--it's about the patient.

RNperdiem, RN · Sep 9, 2009

Before calling the doctor, I like to recheck the blood pressure and get a full set of vital signs.

An asleep patient with an 80/50 BP can have a higher pressure when awake and the cuff is put back in proper position.

Before calling the doctor, I think of anything I can do first.

I might try a breathing treatment on someone in mild respiratory distress. Check your PRN meds for anything available that you can use.

So when you do call the doctor, you will have a full set of vital signs there, and you can explain what you tried that didn't work.

nursemike, ASN, RN · Sep 9, 2009

You'll get a feel for this over time, and checking with more experienced nurses isn't a bad idea. Keeping your charge appraised is a very good idea. Paging a doctor unnecessarily is better than not paging when you should.

My facility still doesn't have a formal RRT. Our code team is our RRT, although sometimes you can just page the STAT nurse for some backup. If you call a code prematurely, people will roll their eyes and shake their heads, but then they will tell you, if you think you need to call a code, call it. Better three false alarms than a failure to rescue. But you're less apt to call a false alarm if your charge and more experienced co-workers are involved.

I've been lucky to have docs to deal with who've helped me learn when to page--usually in a nice way. I've paged at 0500 labs and had the conversation conclude with, "By the way, we always look at labs before we round (at 0700)." So I don't page at that hour unless it's a critical value or otherwise of particular concern. Our neurosurgeons and neurologists on call usually round on their own around midnight, so I try to take care of as much routine stuff as possible around then. I don't know the off-service residents as well and am less likely to see them on the floor, so I'll page them sooner.

There will always be some docs who'll give you crap about paging. I don't get too bent out of shape if they're a little testy. If I think they have a valid point, I'll learn from it, but if I think I was right, I'll insist they do their job or I'll find someone who will. The resident who reams you for calling about chest pain will sing a different tune after his senior resident reams him. Conversely, some very new residents may ask what you think they should do. Fine, if you or a coworker know, but sometimes what they should do is get in touch with someone who knows what they should do.

maxthecat · Sep 9, 2009

This is something your preceptor should be going over with you. Besides general criteria, whether or not you call will vary with the individual doctor. You need to have a set of notes on individual physician protocols before you complete orientation.

Once you are on your own, I recommend you check with your charge nurse before calling.

Our hospital has just instituted a new protocol for physician calls at night. All calls must be routed through the Supervisor, who will determine if calls need to be made and will handle contacting the physicians as needed. Except in emergencies, calls will only go out every 2 hours during the night. For example, say Dr DoDo has patients on 3 different units. Questions from these units can be taken care of in one phone call at 0200 with the supervisor (who can also bring the patients' nurses in on the call if needed). The physician is waked once, as opposed to several times. It's too new to know how it's working so far, but the physicians pushed for it after fielding several calls a night.