Clarification of orders

The goal of the on-call physician should be to fix serious problems, but leave the overall patient management plan to the primary team. If any orders are unclear, and you do not believe they will alter the care of the patient overnight, it may be best to wait and let the primary team clarify them. Remember to communicate with the person who paged, and pass on their concerns to the primary team.

Intravenous access

Patients who lose IVs overnight often have poor venous access (e.g., patients with ESRD or IV drug use). First, determine whether IV access is necessary. If a patient can wait safely until the morning, more experienced staff can place peripheral IVs or more definitive venous access like PICC lines or other catheters.  Consider whether IV medications can be given orally overnight. Calling a pharmacist for alternatives may be helpful. Some quick tips:

• Lower extremities (not in diabetics) can be a good option; consider hanging the patient’s legs off the bed to allow veins to fill and dilate.  Warm compresses may also help.
• Ultrasound guidance can be helpful for peripheral access.
• If there is no good venous access in the extremities (or if contraindicated by cellulitis, phlebitis, etc.), then you should consider external jugular or central venous line placement.
• Ask for help/supervision for an EJ until you are comfortable doing it alone.

Hyperglycemia

Insulin sliding scales used in the inpatient setting are usually poor at maintaining tight control of blood sugar, and should be used as a bridge to long-acting or nutritional insulin regimens.  When called overnight, it is important to determine whether a patient is symptomatic from hyperglycemia and what the patient’s blood sugar control has been like during the hospitalization.

• Blood sugars > 200 mg/dL initiate an osmotic diuresis.
• Steroids, inflammation, TPN, or enteral feeding can often exacerbate hyperglycemia in the diabetic patient.
• Usually, the insulin sliding scale will provide sufficient coverage for a single high blood glucose level overnight.  If the patient is asymptomatic, it is okay to just use the sliding scale without additional insulin or more frequent checks.
• However, if the patient is a risk for a hyperosmolar hyperglycemic state (admitted for this diagnosis or prior history of it), or if the patient is symptomatic (nausea, vomiting, hypovolemia, tachypnea), then the patient should be seen and evaluated. Pay attention to the last electrolyte panel, or order a new one to evaluate for an increased anion gap. Refer to: Endocrine: Diabetic Ketoacidosis and Endocrine: Hyperosmolar Non-Ketotic Coma.

Hypoglycemia

Defined as glucose < 50 mg/dL with symptoms. Some patients, however, feel symptomatic with blood sugars of 51-80 mg/dL. Frequently it is the result of excessive lowering of glucose in patients with dietary changes in the hospital (NPO status/diabetic diet). However, infection and sepsis should be considered in all hypoglycemic patients. If hypoglycemia is mild and the patient is stable, give oral glucose (e.g. orange juice). For more serious episodes of hypoglycemia, treat with 25-50g (1/2-1 amp) of intravenous dextrose (D50). If no clear cause of hypoglycemia can be found, or if the patient has any other troubling signs of infection, a full evaluation for infections is warranted.

Pain

Pain is a common, subjective complaint. Pain control is an important component of patient satisfaction. First, ask the nurse for the location of the pain, and if the pain is new or old. For new pain, always evaluate the patient. For chest or abdominal pain, also evaluate the patient (see separate sections: GI: Abdominal Pain and Night calls: Chest pain on evaluation and management). If the pain is old, review the team’s orders. Is the patient on opioids? See if the team has explicit instructions on whether it is ok to give additional pain medications, and if it’s ok to give IV opioids. If there are no clear instructions, review the patient’s medication list and comorbidities. In general, start with non-opioid methods: heat/cold packs, lidocaine patches, capsaicin cream, Tylenol (reminder: add acetaminophen-containing opioids to daily max of acetaminophen). If the patient warrants opioids, ensure that the patient is not on other sedating medications (e.g. benzodiazepines) or has comorbidities that would impair clearance (e.g. liver or renal failure). If giving an opioid to an opioid-naïve patient, start with a very low dose such as 2.5-5 mg of Oxycodone PO or 0.2 mg of Dilaudid IV (see Palliative Care: Pain management). If giving an opioid to somebody on chronic opioids, give a one-time dose of something the patient has already been taking. Patients on methadone or buprenorphine may still warrant short-acting opioids for acute pain, and due to tolerance they may require higher doses. In general, try oral over IV unless the patient has an indication for IV, is already on IV opioids, or specifically stated by the primary team. If the primary team has not given explicit instructions for pain management for patients with chronic pain, it is advisable to ask the primary team in the morning to outline what they would recommend doing if called overnight.

Insomnia

It is common to get called when patients ask for a sleeping aid. In general, try non-pharmacologic approaches first, such as minimizing unnecessary disturbances and noise, or providing earplugs or eye masks, available in some hospitals. As a first line pharmacological agent, consider melatonin 3 mg (can be increased to 6 mg). For details, see the Night Calls: Insomnia section.

Patient wants to leave AMA

If you are called overnight about a patient who wants to leave, always go talk to the patient. Ask the patient to wait until the morning when they can speak to the primary team and plans for medications and follow-up can be made. Try to elicit the patient’s concerns (e.g., uncontrolled pain, an undermanaged substance use disorder, a sick family member at home), and see if there are alternative solutions to address the patient’s concerns. Many hospitals have an emergency department social worker who may be able to help with some of these concerns. Always assess capacity (see Hospitalist 101: Decision Making Capacity) – if the patient lacks capacity in that moment, they cannot participate in the informed consent process, which is required for leaving AMA. If the patient has capacity, the provider must discuss the benefits and risks of the discharge with the patient. (Note: the AMA paperwork itself is relatively meaningless; it’s documentation of the informed consent process that is most important). If the patient still insists on leaving AMA, try to make the discharge as safe as possible (obtaining a working phone number, sending appropriate medications to the pharmacy, providing clinic contact information). Remember, the AMA discharge is potentially stigmatizing to patients, and patient-centered care supports the patients in their choices, even if their choice is for a care plan that a physician does not recommend. If the patient does not have capacity, the patient may need to be placed on an involuntary hold (see Hospitalist 101: Involuntary Holds), which would require psychiatric evaluation.