Update To My Standardized Order Sets, In Response To Criticism

This is an updated response to the criticisms I received on my original call parameter standing order set for hospitalists.  I am a visual person.  I understand why reading tables would be easier than reading lots of words.  So I've converted my call parameters into very simply to apply tables. I understand nurses are very busy.  I don't want them to have more work to do.  I want my protocols to be make their lives easier.  I've verified with my lab exactly what the critical call parameters are and applied my protocols for what I would tell the nurse should I be called with those critical values.

Now, instead of wasting their time and mine by calling rigid critical lab values established by a rigid med staff process, I've created my own standardized intervention tables.  Instead of calling me and interrupting their work flow and mine, when the laboratory notifies the RN of a critical lab value, they can implement my therapies immediately.  And as a bonus, it reduces the number of verbal and telephone orders that I must give, which is a major safety initiative at Happy's Hospital.   A bonus for all.  Less for the RN to write.  Less for me to sign off.   They don't even have to look up the lab values every day because the parameters I've included  only kick in at hospital defined critical values. I've even given them direction should they feel they need to call non critical lab values at 3 am.   It's WIN-WIN-WIN for doctors, nurses and patients alike.  I think they're going to like it.  It can't get anymore simple than that.

• Standing Orders During Hospital Stay  for lab and therapies ordered by Hospitalist physician to remain in effect until 7am on ___________________ at which point all these orders shall be discontinued.
• Any hospital mandatory lab notifications should be directed to the ordering physician or physician on call for the ordering physician or as directed by their notification parameters except as indicated below for Hospitalist physicians.  If the lab in question was not ordered by the Hospitalist physician, these orders do not apply. 

• All values are in standard reported units as reported by the Hospital laboratory.
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 Instead of calling  lab values, please initiate the following call parameters and  electrolye administration orders:

LOW Potassium Level	Cr >1.9 OR On renal dialysis	Cr < 2 OR Not on renal dialysis
If potassium level is less than 2.6 then give:	40 meq KCl IV or PO and recheck potassium level one hours after dose is complete	40 meq KCl IV or PO every four hours for three doses only and recheck  potassium level one hour after last dose is complete.
If potassium level is less than 3.1 but greater than 2.5 give:	40 meq KCl IV or PO and recheck potassium level one hour after dose is complete.	40 meq KCl or PO every four hours for two doses only and recheck potassium level one hour after last dose is complete.
If potassium level is less than 3.6 but greater than 3 give:	It will be addressed during normal rounds.  Calling is not necessary.	It will be addressed during normal rounds.  Calling is not necessary.

LOW Magnesium Level	Action Plan
If magnesium level is less than 1.0 give:	4 grams of Magnesium IV over 4 hours and recheck level one hour after infusion.
If magnesium level is greater than 1	It will be addressed during rounds.  Calling is not necessary.

LOW Calcium Level	Is the Corrected Calcium level less than 6.5? (see below)	Is the ionized calcium level less than 1.1?	IV calcium administration
If calcium level is less than 6.5 calculate the corrected calcium  (next column)	NO:  Stop.  No nursing action is necessary. YES: Have lab run an ionized calcium level and go to the next column.	NO:  Stop.  No nursing action is necessary.  YES: Next Column	Give one gram of Calcium Chloride  IV and recheck ionized calcium level one hour after infusion. If the ionized calcium level is still less than 1.1, repeat one gram infusions of calcium chloride IV as necessary.
If calcium level is greater than or equal to  6.5, STOP.  It will be addressed during rounds.  Calling is not necessary.

calculation for 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.

LOW Phosphorus Level	IV Phosphorus administration
If phosphorus level is less than 1:	Give 10 mmol over six hours and recheck phosphorus level one hour after administration is complete.
If phosphorus level is greater than or equal to 1	No nursing action necessary.  It will be addressed during rounds. Calling is not necessary.

HIGH Serum Bicarbonate (HCO3)	Arterial blood gas	AGB Results
If greater than 39	ABG in last 72 hours? YES: no nursing action is necessary.  Calling HCO3 level is not necessary NO:  obtain a stat ABG	Respiratory Therapy to call any critical ABG results as necessary.
Less than 40 but greater than 30, no nursing action is necessary.  It will be addressed during rounds.

• Instead of calling, please initiate the following hematological call parameters and action plans.

LOW Platelet Count	Evidence of active bleeding? (see below)	No Evidence of bleeding?
Greater than 50K but less than 100K, no nursing action is necessary.  It will be addressed during rounds.
Less than or equal to 50,000 but greater than 20,000	Call to notify	No nursing action is necessary.  It will be addressed during rounds.
20,000 or less	Call to notify	Transfuse one single donor pack of platelets and recheck platelet level one hour after tranfusion is complete.  Call if platelet count is still less than 20K

Active Bleeding includes brain hemorrhage, gross hematuria, active upper or lower gastrointestinal bleeding, muscular hematoma, retroperitoneal bleed, post operative bleeding.

LOW Hemoglobin level	Post operative surgical patient?	Evidence of  active  bleeding (see above)	No Evidence of active bleeding (see above)
Less than 8.1	Yes:  Call surgeon for recommendations No:  Next column	Yes:  Follow hand written call and  transfusion parameters.  If no parameters have been written, then call to clarify No:  Next column	If hemoglobin is greater than 7 but less than 8.1, repeat hemoglobin in six hours (times one) If repeat hemoglobin is less than 7.1 transfuse 2 units packed red blood cells and recheck hemoglobin one hour after transfusion is complete.

Greater than 8

If the patient is a surgical patient, call the surgeon if you feel the hemoglobin should be called.  Otherwise, only call hospitalist if the drop represents a greater than 2 gram drop from most recent prior hemoglobin draw.  If no prior hemoglobin has been drawn, order one time draw for six hours after first draw and follow call parameters.

Anticoagulation (INR value)	Active Bleeding	No Active Bleeding
3-4.9	Call	Hold warfarin.  Calling is not necessary
5-9	Call	Hold warfarin.  Give 2.5 mg of vitamin K enterally (PO or feeding tube).  If patient cannot take enteral vitamin K, give 0.5 mg of vitamin K  by intravenous piggyback. Calling INR is not necessary.  Re check INR in 12 hours.
Greater than 9	Call	Hold warfarin.  Give 10 mg vitamin K enterally (PO or feeding tube).  If patient cannot take enteral vitamin K, give 2 mg vitamin K by intravenous piggyback and recheck INR 12 hours after vitamin K has been administered.  Calling INR is not necessary.

• Disregard any standing orders from other physician order sets to call Hospitalist for urine output parameters and use  my urine output call parameters below.

• Low URINE OUTPUT Management (Excluding Intensive Care Units)

Do you feel you need to call low urine output?	Is the patient's heart rate greater than 99 or systolic blood pressure less than 96mm HG	Does the patient have a serum creatinine drawn in the last 24 hours?	Is the serum creatinine greater than 1.4?	Is the repeat Creatinine greater than 1.7?
YES:  Next column	YES:  Call NO:  Next Column	YES:  Next Column NO:  Draw a Cr and wait for results, then go to the next column	YES:  No action necessary. Calling low urine output is not necessary NO:  Give 500 cc NS IVC over three hours and draw a serum creatinine one hour after infusion is complete. Then  Go to next column	YES:  Call NO:  No action necessary.  Calling low urine output is not necessary.

• 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 a positive sepsis screens to Hospitalist. 
• 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.