• Contact family for all patients, but especially for those who are altered or have baseline dementia.
  • Obtain pertinent phone numbers for contacts and establish a decision maker within the family.
• Discuss goals of care for resuscitation (code status) and surrogate decision maker in the case of an emergency for all patients.
• Decide on level of care.
  • Assess need for telemetry, pulse oximetry, isolation (respiratory, droplet, contact) and 1-1 patient sitters.
  • Consider involving nurses and respiratory therapists in the discussion as some interventions (e.g. frequent nebulizer treatments) may require higher levels of care.
• Contact the patient’s primary care provider (PCP).
  • All PCP’s should be contacted, preferably within 24 hours of admission.
• Medication reconciliation and allergy confirmation.
  • Check in with the patient:
    • Make sure he or she is taking the listed medications.
    • Inquire regarding allergies and the specific reaction to each listed medication allergy.
    • Ask about any supplements, herbal medications, or over the counter medication use.
  • If a patient doesn’t know what medications they take, consider using resources including past discharge summaries, computerized medication lists, conversations with a patient’s PCP, and records from a patient’s outpatient pharmacy to confirm their medication regimen.
• Specify hold parameters on medications when appropriate.
  • For example “hold antihypertensive medications for SBP <100, HR <60” or “hold opiate for sedation, RR <8” or “hold laxative for diarrhea”.
• Delirium precautions.
  • If appropriate, order measures to promote sleep and prevent reversal of sleep-wake cycles, order early mobilization, re-orient frequently, avoid restraints, avoid urinary catheters, avoid benzodiazepines.
• IV access.
  • Consider whether your patient needs an IV, how many and what sizes. Remember that for resuscitation, several large bore (16 and 18 gauge) IVs are superior to a triple lumen catheter.
  • Order PICCs for patients who will need long term IV antibiotics. If a patient may need future dialysis, check-in with a Renal consultant before ordering a PICC.
  • For patients with difficult access, attempt EJs or deep brachial IVs instead of central lines. Consider using ultrasound to place a peripheral IV.
• Foley vs. condom catheter vs. urinal. Remove catheters as soon as no longer indicated.
  • Accepted indications for long-term catheterization include: uncorrectable bladder outlet obstruction, intractable skin breakdown due to urinary incontinence, neurogenic bladder, and palliative care.
  • Short-term catheterization is acceptable in patients undergoing urologic surgery, critically ill patients requiring accurate urine output, and for acute urinary retention. 
  • Condom catheters can be useful for those who have difficulty using a urinal, or cannot tolerate Foley catheters. Keep in mind the infection risk is similar to that of Foley catheters.
• Involve PT/OT, social work and case management early (see discharge planning below).
• Check “final” reads of all radiologic studies. 
  • Many overnight preliminary reads change upon the final attending physician’s read.
• Smoking cessation counseling.   
  • Assess patient’s use of tobacco. Order nicotine replacement therapy (patch, lozenge, gum) to help reduce cravings during hospitalization.
  • Assess patient readiness to quit and consult respiratory therapy for education/counseling. If appropriate, prescribe nicotine replacement therapy at discharge.
• Gastric ulcer prophylaxis (GI ppx): consider for high risk critically ill patients.
  • Risks of giving GI ppx are increasing rates of aspiration pneumonia, spontaneous bacterial peritonitis and C. difficile infections, as well as impaired absorption of medications (e.g. Atazanavir), and side effects from the medications themselves (e.g. H2 blockers can cause thrombocytopenia).
  • Indications:
    • Any one of the following: history of upper GI bleed within the past year, mechanical ventilation >48 hours, bleeding diathesis (platelet count <50K, INR >1.5, aPTT >2X control not as a result of pharmacologic anticoagulation), trauma (injury severity score ≥16), spinal cord injury, severe traumatic brain injury or extensive thermal injury/burns.
    • Or both of the following: 
      • Severe sepsis (sepsis with evidence of acute organ dysfunction) or septic shock (sepsis-induced hypotension persisting despite adequate fluid resuscitation). 
      • AND use of >250mg/day hydrocortisone or equivalent (approximately: >62.5mg/day prednisone, >50mg/day methylprednisolone, >9.3mg/day dexamethasone).

Algorithm for GI ppx: local formularies may differ.

H2RA = histamine-2 receptor antagonist, PPI = proton pump inhibitor

• Deep venous thromboembolism prophylaxis (DVT ppx).
  • Consider using the Padua score to guide whether patient meets criteria for DVT ppx.
  • If patients have renal impairment (CrCl <30 mL/min) or are at the extremes of body weight (BMI <20 kg/m2 or >35 kg/m2) dose adjustments may be required, especially for low molecular weight heparins. Consider discussing with a pharmacist.
  • If the patient is already anticoagulated on another medications such as warfarin or a DOAC, they do not require additional DVT ppx.
  • Before ordering, review if there are any contraindications to DVT ppx, such as clinically significant bleeding or anticipated procedures in the subsequent 24 hours that would require the patient to not be on anticoagulation.

Padua prediction score risk assessment model: a total score of ≥4 indicates a high risk of venous thromboembolism (VTE) and should receive DVT prophylaxis.

Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 2015; 175:512.