Hospitalist Standing Order Set For Call Parameters (Example)

Here is an update to the standard order sets below after review of criticism.

After seven years as a hospitalist I have come to the conclusion that what I view as important lab and nursing information that needs to be called and what is actually called  are separated by insurmountable disagreements.  Some I'm taking the bulls by the horns and making change happen.

Critical lab values are not about patient safety.  It's about shifting liability.  Hospitals are required to define critical call parameters as a matter of accreditation.    By the time these values have become standard operating procedure, dozens of medical professionals have had a chance to provide input.  And still, the final decision does not do justice for bedside clinical medicine.  Too many variables exist that result in unnecessary interruption of nursing and physician work load to provide a paper trail of critical care notification documentation on results that are not critical, except as defined by a  black and white policy.

Since the buck stops with me, I'm taking the bulls by the horns.  I'm going to make the rules the way they should be made since it's my time being abused by hospital medical staff bylaws.  I have decided to  provide detailed orders on how to handle critical call parameters that makes clinical sense.   Patients, doctors and nurses will all win with my rules  as therapies will be initiated without delay.  Patients will get their potassium or their blood without hesitation.  Quality improves with fewer communication delays. Nursing  satisfaction might improve with reduced work flow interruption as well.

So here they are. Below is a verbatim copy of my hospitalist standing order set for call parameters.  I'm all about quality.  This is quality care at its finest.  Any and all criticisms or suggestions are welcomed.

• Standing Orders During Hospital Stay  for lab and therapies ordered by Hospitalist physician.  These orders  shall remain in effect from now until 7:00 AM on ______________ at which point all these orders shall be discontinued.

• Call all critical labs per hospital mandates to the ordering physician or physician on call for the ordering physician except as indicated below for Hospitalist physicians.  If the lab in question was not ordered by Hospitalist physician, these orders do not apply.  
• All values are in standard reported units as reported by the Hospital laboratory.
• If home medications have not been addressed by 10 pm, they shall be addressed by the day shift hospitalist the following day starting after 7am.  Please do not call to address home medications after 10 pm.
• Please do not call to obtain a DNR order.  If the patient wishes to be DNR, notify the physician during rounds the following day for an order.  If the patient becomes critically ill before then, contact the physician at that time for a DNR order.
• If the patient has an admitting diagnosis of sepsis, severe sepsis or septic shock, please do not call positive sepsis screens to Hospitalist.  I am aware.
• If you are calling to notify the physician of positive blood cultures, please have the patient's antibiotic regimen available.  If the infectious disease physician is managing the patient's infection issues, contact them for any necessary positive culture notifications, or per their call parameters.  In that case, please do not call the Hospitalist. 

• Low Serum POTASSIUM level management, instead of calling please initiate the following:
• For potassium less than or equal to 2.5, give 40 meq KCL IV  or PO every four hours times three doses only and recheck potassium one hour after last dose, unless the  following criteria apply:
• If the patient's last known hospital creatinine is greater than or equal to 2 or the patient is a dialysis patient, give only one 40 meq KCL dose IV or PO and recheck serum potassium level one hour after complete dose is administered and follow this management protocol. Calling level is not necessary
• For potassium less than or equal to 3.0 give 40 meq KCL IV or PO every four hours times two doses only and recheck potassium level one hour after last dose and follow potassium management orders indicated here, unless the following criteria apply:
• If the patient's creatitine is greater than or equal to 2, or the patient is a dialysis patient, give only one 40 meq KCL dose IV or PO and recheck serum potassium level one hour after complete dose is administered and follow this management protocol. Calling level is not necessary.
• For potassium less than or equal to 3.5 give 40 meq KCL IV or PO times one dose.  No need to recheck potassium level after infusion. 
• If the patient is a dialysis patient, only give 20 meq of KCL IV or PO times one dose. Calling level is not necessary.
• 
  
• Low Serum MAGNESIUM level management, instead of calling please initiate the following:
• For magnesium level less than or equal to 1.3, give four grams of IV magnesium over 4 hours and recheck level one hour after infusion. Calling level is not necessary
• For magnesium level less than or equal to 1.9 give two gram of IV magnesium over 2 hours.  Calling level is not necessary.

• Low Serum CALCIUM level management:
• For critical low calcium levels , instead of calling calculate the corrected calcium using the following formula 
• Corrected Calcium = (0.8* (4-patient's albumin))+ reported serum Ca.  
• If no albumin level is available, have lab run an albumin on the serum used to run the calcium and then calculate the corrected calcium level. 
• If the corrected calcium level is less than 8.5, have lab run an ionized calcium level.
• If the corrected calcium level is less than 1.1, give one gram of calcium chloride IV.  Recheck an ionized calcium the next morning.
• Calling level is not necessary.

• Low Serum PHOSPHORUS level management:
• For phosphorus level less than or equal to 1.5 give 10 mmol of potassium phosphorus IV over six hours and recheck phosphorus level the next morning. Calling level is not necessary.

• High Serum BICARBONATE (HCO3) level management:
• For elevated bicarbonate levels that require physician notification, no call is necessary.  Instead, obtain an arterial blood gas, but only if no arterial blood gas has been obtained in the last four calendar days.  If an arterial blood gas has been obtained in the last 92 hours, no further nursing action is necessary. Respiratory therapy to call critical blood gas levels.

• Low PLATELET  level management:
• Call any platelet count less than or equal to 50 (in thousands)
• only if there is clinical evidence of active bleeding (including brain hemorrhage, hematuria, active upper or lower GIB, hematoma, retroperitoneal bleed, post operative bleeding). 
• OR
• only if the most recent previous platelet count was 100 (in thousands) or greater.  If there is no previous platelet count to compare with, call only if the patient is hospital day #2 or later. 
• For any platelet count less than or equal to 20,000, give one single donor pack of platelets and recheck platelet count one hour after infusion is complete. Calling is not necessary.   If the platelet count is still less than or equal to 20,000, call Hospitalist to discuss.  Otherwise, calling is not necessary.

• Low HEMOGLOBIN level management:
• Call any hospital mandated critical anemia notification on post surgical patients to the operating surgical physician team for transfusion recommendations. Post surgical critical anemia requires surgical notification for recommendations.
• For non post surgical patients with a documented active source of bleeding.   (including gross hematuria, upper or lower gastrointestinal tract, musculoskeletal hematoma, retroperitoneal bleeding, hemothorax) please verify serial hemoglobin and transfusion parameters have been addressed.  If no parameters have been written, please call Hospitalist to clarify. If another physician service has also written transfusion and hemoglobin call parameters, follow their recommendations and cancel Hospitalist hemoglobin parameters.

• For non post surgical patients without a documented active source of bleeding
• On hospital day # 2 or later, for any hemoglobin less than or equal to 8, call Hospitalist to notify.

• On hospital day # 2 or later, for serum hemoglobin greater than 8 but less than 10 call serum hemoglobin only if the value represents a drop of 2 units or more from the prior lab draw during the hospital stay.  If no prior lab draw exists, repeat a serum hemoglobin six hours after the first draw and follow the above parameters for hemoglobin management.

• ANTICOAGULATION PT INR  management:
• If a patient has signs of active bleeding call hospitalist at any INR value.
• For INR of 3-4.9 without evidence bleeding, hold coumadin.  No further action is necessary. Calling INR is not necessary
• For INR  of 5-9 without evidence of bleeding, hold coumadin and give 2.5 mg of vitamin K enterally (PO or by feeding tube).  If patient cannot take enteral vitamin K, give 0.5 mg of  vitamin K intravenous piggyback.  Calling INR is not necessary. 
• For INR greater than 9 without evidence of bleeding, hold coumadin and give 10mg of vitamin K enterally (PO or by feeding tube).  If patient cannot take enteral vitamin K, give 2mg vitamin K intravenous piggyback. Calling INR is not necessary.  12 hours after vitamin K is given, repeat the INR and follow management per this protocol.

• Low URINE OUTPUT Management (Excluding Intensive Care Units)
• Disregard any standing orders from other physician order sets to call Hospitalist for urine output parameters and use  my urine output call parameters below.
• If you feel you must call low urine output, verify the patient has a creatinine value in the last 24 hours.  If they do not, order a serum creatinine value and wait for the result before calling. Then do the following:
• If the patient's last creatinine is 1.5 or greater,  call low urine output ONLY IF  systolic blood pressure is also less than 95 mmHg or pulse is also greater than or equal to 100 beats per minute. 
• If the patient's last creatinine is 1.4 or less, give 500 cc of normal saline over 3 hours and draw a creatinine after the normal saline infusion is complete. Then: 
• Call if creatinine is greater than or equal to 1.6.
• Call if systolic is 95mmHg or less.
• Call if heart rate is 100 beats per minute or greater. 
• Otherwise do not call low urine output.

Make sure to review my hospitalist resource center with lots of valuable information to help your clinical practice.