on-call workflow: consults and pages
In general, the responsibilities and workflow for all call shifts (short call, long call on weekends, and night float) will be very similar. The bulk of the work will involve seeing new consults and returning pages.
NEW CONSULTS
It is best practice to complete one entire patient encounter prior to beginning another rather than seeing many patients and then sitting down at the end of the shift to begin documentation.
It is more efficient, as it will take you less time to document if the encounter is fresh in your mind.
Your documentation is more likely to be accurate.
The consulting team who saw you come by will not be wondering where your note is and paging you (interrupting what you are doing) to ask.
The typical workflow will be: See-Talk-Talk-Write.
See the patient – including looking through the chart and other ancillary sources of information.
Talk to your senior resident – Present your findings and assessment and agree upon course of action.
Talk to the consulting team – It is very important to close the loop on consults by getting back to the team.
Write your note and any other documentation required, such as admission orders.
This cycle will be broken only for emergent cases: BAT call, patient seizing, change in mental status, medical emergency on the inpatient service requiring urgent evaluation.
Patients do not necessarily need to be seen in the order the consults are received. Cases should be triaged based on patient acuity and location. Discuss triage decisions with your senior resident if you are not sure. Some things to keep in mind:
Direct admissions to the neurology inpatient services do not have any other physicians caring for them, so should be seen as soon as possible after arrival to ensure stability and enter basic nursing orders at a minimum.
The Emergency Department should be seen as soon as possible depending on acuity of the case.
It is the expectation that all consults received by the on-call resident during their shift will be completed by that resident. Any exception to this should be discussed with the senior resident. In appropriate situations, senior resident may advise handing consults off to the next resident on call (i.e. short call to night float or night float to day team), or will call in the back-up resident to cover some cases to get the workflow back on track. Possible exceptions include:
Multiple new consults received towards the end of the shift.
One or more patients requiring extra time due to critical status or emergent needs.
Multiple emergent cases at the same time.
For new consults, always ask for the following information:
Reason for consult
Name of Patient and MRN
Location of patient
Brief reason for admission, exam findings, relevant active medical problems
How to contact primary team or person responsible for patient
RETURNING PAGES
Try to return pages in a timely fashion. Sometimes this will be hard as you will be seeing a consult/admission, in which case you should quickly check the text message, and depending on urgency, excuse yourself or finish your history/exam.
Nurses on 4IMC and 5West or sometimes 5East will page with questions on cross-cover patients. They are supposed to follow the format:
FYI: this is something that they would like you to know or could be a non-urgent request for a particular medication; no reply is required.
REPLY: these messages require an action, be it an order, a specific question about a medication, a family member, etc. You should return these pages within 30 minutes
STAT: high priority messages. Return within 5 minutes.
If nurses are not following this format, remind them that if you are being paged, you need to know who is paging and which patient. This helps with communication and increases efficiency.
If you evaluate a patient, there should be a note written. Event note template: .UMHNEUROEVENTNOTE
You will often get paged at night to discuss a patient’s status or long-term plan with the family. These are at your discretion. If it is a patient you have been following and you have time, you can talk to the family. Otherwise, talk to patient’s nurse and explain that you are the covering resident and only have a limited amount of information about the patient. Always ask for a contact number at which the family can be called by the daytime team or advise the family to call the nurses’ station during the hours when primary team is in-house.
EXCEPTION: Family should always be informed, regardless of time of day if a patient is acutely decompensating and being moved to a higher level of care.
staffing patients, call-outs, and contacting attendings
GUIDELINES REGARDING STAFFING PATIENTS
During Call:
PGY-2 resident will staff all new patients with the PGY4 on call for the entire academic year.
PGY3 residents on call will use their discretion regarding whether a patient should be staffed at the time of consultation or whether presentation can wait until rounds.
All residents are encouraged to call their senior resident or attending whenever they have any concerns or questions.
08:00 Attending Rounds (8:15 on days with morning report):
Rounds begin with the night float resident and prior day short call resident presenting new patients (priority to go first given to night float).
Please note that the short-call resident from the prior evening is expected to present if they are on a UMMC rotation. If s/he is off-site (e.g., UMROI), s/he is expected to touch base with the senior resident on service to discuss new patients to ensure adequate continuity of care.
SEND-OUTS
If you are seeing a new consultation from the ED and determine that the patient does not require inpatient admission:
All decisions to send a patient home from the ED should be made after consultation with a PGY-4 resident and attending.
At the VA, on-call resident should discuss with the VA attending on call after discussing with the VA senior.
When in doubt: Place patient on Observation status and order testing or plan follow-up evaluation. All notes should be written in electronic format and sent to the inpatient attending (General or Stroke). Notes should be signed by attending within 24 hours
For patients where follow-up is appropriate: Send a Staff Message in EPIC to notify clinic staff to schedule patient with you (ideally within 2 weeks).
SITUATIONS WHEN ATTENDING PHYSICIANS NEED TO BE CONTACTED
Anytime there is a concern or question regarding management
Change in patient status requiring consideration of transfer to a higher level of care
Transfer to higher level of care
Patient death (expected or not)
Significant disagreements with consulting services (ie. A consulting service feels a planned procedure is no longer warranted, or a consulting service refuses a consult)
A family member requests to communicate with an attending physician, or another service attending requests to speak to the attending of our service
Difficulties with patient ownership by a clinical team (e.g. disagreement over admission to neurology vs. another service)
Unexpected need for consultation of another service
Unexpected Laboratory or Radiology Results
New admissions to the service
WHICH ATTENDING PHYSICIAN SHOULD BE CONTACTED ABOUT A PATIENT AFTER HOURS?
For new patients (not yet staffed with attending):
Attending on call
Stroke - BAT attending on call
General - General attending on call (alternates between CNS and consult attending)
Examples: Notification of new admission, send-out of new consult patient from the ED, change in status of new admission (e.g. patient admitted overnight to service with notification of new admission sent to on call attending and then later that night patient has significant change in neuro exam or need for higher level of care also conveyed to on call attending)
For established patients (staffed and known to the inpatient attending):
Inpatient attending (Stroke or CNS)
Examples: If a patient on service has change in clinical course, change in code status, patient death
Attending schedule can be viewed at https://ummsneuro.ezcall.com/
Please review the UMMC Escalation of Change in Patient Condition policy so you are aware of the chain of command.
scope of coverage: pager, phones, and Ncc consults
PAGERS AND PHONES TO BE COVERED BY THE NEUROLOGY ON-CALL RESIDENT
Pagers:
Clinical Neuroscience Service (CNS) (aka General inpatient) Pager (p6378)
General Neurology Consult Pager (p12710)
VA Neurology Pager (p11421)
Phones:
BAT Resident phone (443) 683-3001) (covered by stroke senior during the day)
Neurocritical Care phone (8-4083) (covered by NCCU fellow during the day)
Guidelines for neurology residents' role in Neuro-ICU consults
Schedule of coverage for the Neuro-ICU consult phone:
Weekdays 7am-5pm: ICU fellow (or rotating CCM fellow/attending if fellow post-call or otherwise unavailable)
Weekdays 5pm-7am: Neurology on-call resident
Weekends (5pm Friday-7am Monday): Neurology on-call resident (i.e. Weekend consult resident in morning, short call in afternoon, night float overnight)
Transferring responsibility:
During the times the neurology resident is covering (5P-7A and weekends), the ICU consult phone number will be forwarded to the resident BAT phone: (443) 683-3001.
Call forwarding the NCC consult phone (8-4083) is the responsibility of the NCCU fellow. They are expected to call forward the NCC consult number to the BAT phone by 500P. When the Fellow arrives in the morning, they will remove the call forwarding by 700A.
Guidelines for workflow when neurology resident takes first call:
The covering resident is responsible for completing any patient issues called during their shift:
New consults: fully evaluate, staff by phone with ICU attending, and write note. Add the patient to the shared NCC Consult service list in EPIC.
Prior consults: Only if called by the primary team with a concern - resident should evaluate patient, staff with ICU attending by phone, and write note
The resident will call the NeuroICU Attending On-Call to staff any consults after they are seen.
Note: The weekends that an Anesthesia attending is On-Call for the NCCU, there is a neurology attending On in the Neuro-Trauma ICU and this person should be called to staff NCCU consults. (working on getting that schedule available to residents)
The ICU Fellow & Attending are responsible for follow up. There is no expectation for the resident to round with the ICU consult team.
Short call resident is responsible for transferring all pager coverage to the Stroke Pager (0395) promptly at 5:00 PM unless stated otherwise by the senior on the service. Call 8-7446 (8-SIGN) or the operator (dial 0) to transfer over the pagers. For the 8-SIGN system:
Dial the pager ID followed by #
Then press #, 1, 1, and then pager ID that you are transferring to
NEUROCRITICAL CARE CONSULTS:
GUIDELINES FOR NEUROLOGY RESIDENTS' ROLE
Neurocritical Care phone (8-4083) (covered by NCCU fellow during the day)
Schedule of coverage for the Neuro-ICU consult phone
Weekdays 7am-5pm: ICU fellow (or rotating CCM fellow/attending if fellow post-call or otherwise unavailable)
Weekdays 5pm-7am: Neurology on-call resident
Weekends (5pm Friday-7am Monday): Neurology on-call resident (i.e. Weekend consult resident in morning, short call in afternoon, night float overnight)
Transferring responsibility
During the times the neurology resident is covering (5P-7A and weekends), the ICU consult phone number will be forwarded to the resident BAT phone: (443) 683-3001.
Call forwarding the NCC consult phone (8-4083) is the responsibility of the NCCU fellow. They are expected to call forward the NCC consult number to the BAT phone by 500P. When the Fellow arrives in the morning, they will remove the call forwarding by 700A.
Guidelines for workflow when neurology resident takes first call
The covering resident is responsible for completing any patient issues called during their shift:
New consults: patients should be evaluated as any other consult prior to staffing- obtain as much history as possible, fully examine, review data and imaging. Patient should first be briefly staffed with the senior on call then the ICU attending. Write note using .nccuconsult template. Add the patient to the shared NCC Consult service list in EPIC.
Follow up consults: Only need to be seen if called by the primary team with a concern - resident should evaluate patient, staff with ICU attending by phone, and write note (Event note template: .UMHNEUROEVENTNOTE, assign to NCCU attending for cosign)
The resident will call the NeuroICU Attending On-Call to staff any consults after they are seen. If the resident on call is a PGY2, the plan should first be discussed with the senior on call prior to calling the ICU attending/fellow.
Note: The weekends that an Anesthesia attending is On-Call for the NCCU, there is a neurology attending on in the Neuro-Trauma ICU and this person should be called to staff NCCU consults. This schedule will be available on EZcall. If no attending is posted, just call 84552.
If you are calling for a bed in the NCCU when there is an Anesthesia attending on call, you should call 84552 and speak with that attending.
The ICU Fellow & Attending are responsible for routine follow up. There is no expectation for the resident to round with the ICU consult team.
Diagnoses covered by NCCU consult service:
refractory status epilepticus
coma
increased ICP, including from hepatic encephalopathy
prognosis after cardiac arrest
AVOID using dot phrases in your plans for these consults (especially for post cardiac arrest patients). Recommendations should be individualized per patient. You can use the *** dot phrase to direct primary teams to institutional guidelines. Diagnoses covered by NCCU consult service:
short call
Short call runs from 5:00 PM to 8:30 PM, with sign-out occurring in the Neurology Library starting at 4:30 PM. The short call resident is responsible for any consults (including at the VA) and inpatient issues that come up during this time
If there are any consults called in after 8 PM, short call resident will only be responsible for seeing any that are acute in nature. This includes BATs, concern for status, sudden change in mental status, and other situations that you or your senior deem appropriate. The senior on-call will determine if the consult is acute, so keep in contact with them.
This is a busy time in the hospital and many consults can be called in. Please be in constant contact with your senior (via phone call or text, whatever is more efficient) so that s/he can help your workflow.
Short Call:
The expectation is that residents should be seeing ~1 consult per hour.
There is some wiggle room with this early on as our new PGY-2s become accustomed to their new roles as neurologists.
The short call person (weekend and weekday) should not begin to see any new consults after 10pm in order to prioritize finishing all work and leaving by 11pm.
We will maintain our rule of non-urgent consults between 8-8:30 automatically go to night float.
It is suitable to hand off 1-2 consults to the night float person. There should be a hard cap of 2, including anything called between 8-8:30.
Any hand offs should be discussed with the senior on call.
Residents are expected to leave the hospital by 11 PM in order to rest before resuming duties the next morning at 7 AM or a time period of 8 hours between work days. If for some reason the short call will not have 8 hours off, the senior resident should be notified in real time.
All consults should be staffed in real time. There should be no stacking of consults right now. We can re-consider this later in the year as people become more experienced.
If there are multiple consults pending, the short call resident should be in contact with senior regarding triage. Short Call resident should plan to see all consults that are called in before 8 PM.
After signing out to the night float resident at 8:30, the short call resident will finish up any notes or phone calls that need to be completed for the consults called in during that period. Please make sure a plan is communicated to the consulting teams before you leave.
second call
Formerly “back-up call” or “home call” resident
Calling in second call residents must go directly to chief resident → chief notifies senior on call of decision. Senior resident can call on-call chief if they find the on-call resident to be above capacity.
PGY-2 Threshold for back up
July-September
1 emergency (BAT, unstable inpatient) + 2 or more pending consults
2 or more simultaneous emergencies (BAT, Status, unstable inpatient)
With goal to leave hospital by 1030 PM (and not seeing new consults after 830 pm): back up should be called if there are more consults to do than hours left in the shift. For example if it is 6 pm and there are 4 pending consults, call person sees 2, and back up is called in. Remaining consults should be split between back up and 1 can be given to night float. During short call, if you get more than 3 consults back up should be called in.
October- February
1 emergency (BAT, unstable inpatient) + 3 or more pending consults
3 or more simultaneous emergencies (BAT, Status, unstable inpatient)
With goal to leave hospital by 1030 PM: back up should be called if there are more consults to do than hours left in the shift+1. For example if it is 6 pm and there are 4 pending consults, call person sees 3, and 1 is passed on to night float. If there are 5 pending consults at 6 pm, call person should see 3, and 2 can be handed off to night float. If there are more than 5 pending consults, back up should be called in. During short call, if you get more than 4 consults back up should be called in.
March- June
1 emergency (BAT, unstable inpatient) + 4 or more pending consults
3 or more simultaneous emergencies (BAT, Status, unstable inpatient)
With goal to leave hospital by 1030 PM: back up should be called if there are more consults to do than hours left in the shift+2. For example if it is 6 pm and there are 4 pending consults, call person sees all. If there are 5 pending consults at 6 pm, call person should see 4, and 1 can be passed off to night float. If there are 6 or more pending consults, back up should be called in.
PGY-3 back-up policy (year round)
1 emergency (BAT, unstable inpatient) + 4 or more pending consults
3 or more simultaneous emergencies (BAT, Status, unstable inpatient)
With goal to leave hospital by 1030 PM: back up should be called if there are more consults to do than hours left in the shift+2. For example if it is 6 pm and there are 4 pending consults, call person sees all. If there are 5 pending consults at 6 pm, call person should see 4, and 1 can be passed off to night float. If there are 6 or more pending consults, back up should be called in.
buddy call
During July and August, all PGY-2s will take call with a fellow PGY-3 or PGY-4 buddy. PGY-3s and PGY-4s will not be on night float until September. PGY-2s should have graduated expectations and responsibilities throughout the summer.
Learning goals for buddy call:
Accurately perform neuro exam
Take a focused history
Appropriately triage consults→ recognizing emergent consults/inpatients, prioritizing BATs, appropriately responding to clinic calls
Learn how to organize tasks on call
Develop work flow of seeing-->staffing→ talking to primary team→ note writing (See, talk, talk, write)
Develop efficiency for consult work flow:
Seeing a consult- (see the patient, staff with senior, talk to the team) → should take a little over an hour initially→ goal 1 hour by end of buddy call
Note writing initially 45 minutes→ goal 30 minutes by end of buddy call
Appropriate sign out to night float
night float
Night float starts at 8:30 PM. Just like the short call resident, the night float resident is responsible for any Neurology or Neurocritical Care consults. They will stop taking consults at 7 AM when the day teams come in. Any notes and other work that needs to be finished can be done between 7:00 AM and morning report (7:45) or rounds (8:00) on days without morning report.
Midnight Rounds
To improve communication between nursing staff and to catch any potential medical errors, the night float resident rounds with the charge nurses from C4E (Neuro IMC) and C5W (Neuro Floor) to discuss all the inpatients on Stroke and General Neurology service. Nursing has been instructed to save non-urgent issues to discuss during this time, so having this check-in will improve efficiency by preventing multiple pages during the night.
This usually occurs at midnight, but this can change depending on the workload. If you are busy, please contact the charge nurses on both floors to update them.
va neurology call
Coverage of the VA neurology pager:
Weekdays 7am-5pm: VA senior neurology resident in house. All consults called during daytime shift will be seen by the resident the same day.
Weekday evenings/nights (5pm-7am): VA senior neurology resident on call from home. The VA senior resident will be responsible for speaking with the emergency department (ED)/inpatient teams about new consults and triaging appropriately. Routine consults, such as non-acute focal weakness or medications for a neurology patient, will be seen and staffed with an attending by 11am the next day.
Weekends: (5pm Friday - 7am Monday): Weekend float neurology resident will cover the VA neurology pager.
Routine consults called:
5pm- 7am Saturday: Weekend float resident will triage calls, see and staff all consults by noon on Saturday.
7am - noon on Saturday: Weekend float resident will see and staff all consults the same day.
Noon Saturday - 7am Sunday: Weekend float resident will triage calls, see and staff all consults by noon on Sunday.
7am - noon on Sunday: Weekend float resident will see and staff all consults the same day.
Noon Sunday – 7am Monday: Weekend float resident will triage calls. Any consults will be seen and staffed by the VA senior by Monday 11am. VA senior is responsible for receiving sign out from the weekend float resident on Monday morning at 7 am.
If a PGY2 is covering weekend float, consults will be staffed over the phone with the VA senior.
Neurology Consultation Guidelines:
For BAT patients (acute onset neurologic symptoms concerning for stroke within 24 hours of presentation): VA BAT patients will be handled the same way as a BAT patient from any outside hospital: The consulting team (ED or inpatient) will call through Maryland Express Care (410-328-1234) to talk with the BAT Fellow/Attending on call. The fellow/attending will determine, based on their phone consultation, if this represents an emergent and potential intervention case that requires immediate evaluation. If so, they will call the in-house UMMC neurology resident to go to VA to evaluate patient. If a case does not meet these criteria, the BAT Fellow/Attending will advise the team to consult neurology as per above.*
All non-BAT neurology consults should be called to the VA neurology pager (p11421)
For emergent patients: Neurologic emergencies include, but are not exclusive of, acute ischemic strokes, convulsive status, or severe neuromuscular weakness with impending respiratory compromise. If the resident covering the VA pager receives a consult for a neurologic emergency, they will come in person to assist in patient management. If there is disagreement between the neurology resident and the ED/inpatient team concerning the emergent nature of the consult, there should be a direct attending to attending discussion, which can be facilitated by the neurology resident. The ultimate decision rests with the licensed onsite doctor.
For patients being admitted: The neurology resident will give preliminary recommendations by phone and will see the patient and formally staff before 11am the following day.
For patients being discharged: The neurology resident will obtain the patient’s history through discussion with the consulting team and review preliminary recommendations with the neurology attending. This process will be initiated within 1 hour of the initiation of the consult. The findings/recommendations will then be discussed with the ED team prior to patient discharge. For patients being discharged, the VA senior will place a brief note into the medical record and ensure the patient has appropriate urgent neurology clinic follow up. The ED should place a routine outpatient neurology consult in CPRS to ensure follow-up. Any changes between the verbal recommendations and the written recommendations will be called to the ED and noted within the medical record. The VA senior can also help place any imaging/lab follow-up orders the following morning.
* If the VA senior gets a direct page concerning a potential BAT patient, they will redirect the primary team to call Maryland Express Care to ensure that the on-call BAT Fellow/Attending is notified.
Last Updated: September 2023