VGH CTU - Overnight call expectations

How call works:

• On call, we admit patients to Internal Medicine overnight. Deciding to admit vs not admit is a skill that takes time to develop and it’s not always black and white – reasons to admit include medical deterioration, failure in the community, need to expedite diagnostic workup, etc.
• Overnight call is the part of this rotation where you get to assess undifferentiated patients, conduct a thoughtful H+P to narrow your differential, propose an investigation plan and safe management strategy. Overnight, you are the patient’s physician and you will have more autonomy than during daytime rounding as it’s just you and the senior resident managing the patient.
• The senior resident will triage consults and initiate urgent management to allow time for another member of the team to fully see the consult. They will have made an admission decision and may have placed the admit order for you already.
• Consults will be informally reviewed with the Senior resident ahead of staff review to ensure no large omissions, allow for brief teaching (depending on fatigue/ability of brain to accept new information)
• Consults will be reviewed with the overnight staff until they go home and then the rest will be reviewed in the morning. Staff will usually disappear from 5-7, come for reviews, and then leave by 10/11. It is nice to have a consult done to review in the evening so one of your consults will be a handover instead of a full review the next morning. 

What the night will look like for learners:

• When you’re not doing a consult or following up on a patient, you don’t need to be in the ED – go up to call rooms and sleep.
• Senior resident will PHONE (not text) you to come down for a consult. They have already initiated urgent management for the patient, so you will have time to get to wake up and get your bearings before you start practicing medicine.
• The more efficient your consult workflow becomes, the more you get to sleep! Note the time you start the consult, and don’t let yourself get stuck (eg CareConnect/previous documentation review shouldn’t be taking more than an hour for any patient). Consider a differential diagnosis for what could be going on, as this will inform your history and physical. Go see the patient and come back to finish your note, review with the senior and place orders.
• If the staff is still in house, you can review before the morning. If not, make sure you and the senior have settled on a plan for the night. 
• After you finish a consult, make a checklist of things that need to be followed up (labs, planned reassessments). Set an alarm for these things then go to sleep. 
• I would personally advise you to quickly reassess and check labs + vitals for patients you’ve seen overnight before you go to patient assignment rounds. You don’t want to be surprised by big clinical changes when you and staff see the patient after your consult review!

Practical advice: 

• Please write your name and contact information in the Situational Awareness/Team Communication section of Provider View. Responding to nursing pages regarding your patient is also important for you to follow your case through and adjust your proposed management plan through the night.
• Remember that handovers are not a full consult review!
  • Good handovers will include key details of your consult – demographic, primary language if translator needed, pertinent medical Hx, significant social factors if present, then get to the main issues and specifically what needs to be done/followed up on for the patient. 
  • Think about this like a concise package of details and FYIs you would want to know if you were taking over care of this patient from someone else.
• Requirements to eat, drink water or perform other bodily functions are normal and expected of all humans including learners on CTU.
• You are entitled to leave after 10am post-call. If there are tasks remaining at this time, hand them over (the most relevant situation post-call would be waiting for consulted services to return your page after you finished your consult review).
• We understand that brain function slows down significantly through the night, which makes it more important to prompt yourself to keep moving in your consult. Get the key information documented, make a safe plan for your patient, and finish up.