Loaded question, I know. There are lots of variables and situations. Typically, we have a lot at our disposal to be able to adequately many situations without calling the doc. I love that because it means I can handle a lot by myself (yay for autonomy!).
However, here are a few basic guidelines/rules..
1. Check to see if you have a PRN med that addresses your problem. Is their blood pressure suddenly high? See if you have some labatelol, hydralazine, clonadine, or something else. Is the patient seizing? Check and see if you’ve got some PRN Ativan.
2. Check to see if you have a nursing order that addresses your problem. Those orders can get lost in the shuffle of things. It’s been 8 hours since your patient’s foley was removed? Check to see if there’s an order to straight-cath if they haven’t voided within that time frame. Not sure if you should hold your subcut heparin the night before surgery? See if there’s an order to hold any doses. Sometimes they’re called “nursing communications” or “nursing orders” and because they’re not due tasks or meds, they can be easily overlooked.
3. Have you exhausted all of your resources? Try and anticipate their response to your problem and see if you can do any of those things before paging. Can’t get a really tough IV? Make sure your best IV started on the floor tried and if you have a critical care/rapid response/code team/flight team that’s a resource for tough starts, utilize them first. If you’ve done all of that, then I’d call the doc and say we either need to change meds or get a PICC.
4. Was there a change in vitals that is not easily addressed? If your PRN blood pressure med didn’t work or your patient was on 2L nasal cannula but now they’re on 5L and barely above 90%.. something’s going on. If it’s taking more effort than previously needed to maintain their vitals or if there is a sudden change in that, call. Even if they don’t want to do anything about it, they need to be aware of the changes. Something may be changing but it does not warrant an intervention yet, but you want to cover yourself by alerting them.
5. Do you have a protocol or policy that addresses your problem? Some units have standing orders or polices that address things so you don’t have to call every time, especially if it’s routine. Your patient’s blood sugar is 61? Your hospital probably has a hypoglycemia policy and procedure. I’d check that out first and utilize that appropriately before calling. Typically those policies tell you exactly what to do and when to notify. Tis very helpful.
The main point is to use common sense and critical thinking. In the rush of things it can be hard to have perspective. Stop, take a deep breath, and think. Sometimes what I’ll do when I’m not sure, I think to myself, “if someone else asked me what to do in this circumstance, what would I tell them?”
The toughest thing about this is learning your physicians. Some are really laid back about certain things and some are really particular and it’s difficult to predict. One doctor doesn’t care if you slightly change vent setting per protocol; but another always wants to be notified of changes like that. Take the time to learn preferences. Doctors do a lot of research and certain things are important to some that aren’t important to others.
You will call when you didn’t really need to and feel stupid. Whatever, it happens. It’s much, much better to be overly cautious. You want to be in the habit of being on the side of caution, not in the habit of letting things slide until it gets bad all of a sudden. That will burn you and your patient.
And lastly, I would write the numbers of the doctors you page frequently on a post-it and put in on the back of your badge for quick and easy reference until you get it memorized.