Cross-Cover Approach -Every Call
ABCDE for every page: Assess โ Bedside (go see the patient) โ Chart review โ Decide โ Execute + follow-up
- Step 1 -Get the right information from the nurse: Vitals (current + trend), mental status change, what intervention was already tried, code status, is the primary team aware?
- Step 2 -Go see the patient: Never manage cross-cover issues by phone alone. A 30-second bedside assessment (airway, breathing, circulation, mental status) tells you more than 10 minutes of chart review.
- Step 3 -Check the chart: Admitting diagnosis, active problems, recent labs/imaging, medications (what changed today?), code status, allergies.
- Step 4 -Address the acute issue: Order what's needed (stat labs, imaging, meds). Don't shotgun -think about what will change your management.
- Step 5 -Document: Brief cross-cover note -what you were called for, what you found, what you did, and follow-up plan. The primary team needs to know what happened overnight.
Common Overnight PRN Orders
| Problem | First-Line Order | Notes |
|---|
| Insomnia | Melatonin 3-5 mg PO | NOT diphenhydramine in elderly (delirium, falls). Trazodone 25-50 mg alternative. |
| Pain (mild) | Acetaminophen 650 mg PO q6h | Max 3g/day if liver disease. Scheduled > PRN for consistent control. |
| Pain (moderate) | Oxycodone 5 mg PO q4h PRN | Start low in opioid-naive. Add PEG 3350 + senna. Check last dose timing. |
| Nausea | Ondansetron 4 mg IV/PO q6h | Check QTc first. Promethazine is more sedating. Avoid metoclopramide if Parkinson's. |
| Constipation | PEG 3350 17g daily + senna 2 tabs PO QHS | If on opioids: must have a bowel regimen. Bisacodyl 10 mg PR if > 3 days. Do not use docusate (ineffective). |
| Agitation | Non-pharm first. If severe: haloperidol 0.5-2 mg IV/IM | Check QTc. Avoid in Parkinson's/Lewy body. Try reorientation, family, lights first. |
| Fever | Acetaminophen 650 mg + blood cultures ร 2 | UA + CXR. Don't reflexively add antibiotics without evaluating -call senior if sepsis concern. |
| Hypertension (asymptomatic) | Restart home meds if held. PRN: hydralazine 10 mg IV or labetalol 10 mg IV | Don't treat numbers -treat end-organ damage. Asymptomatic BP 180/100 can often wait until morning. |
| Hypoglycemia (glucose < 70) | D50 25 mL IV push (if NPO/altered) or juice + crackers (if eating) | Recheck in 15 min. Identify cause: excess insulin? missed meal? Hold offending agent. |
| Foley issues | Flush with 30 mL NS. If blocked โ replace. | If can't place โ call urology for difficult catheterization. Don't force it. |
Night Float Tips from Senior Residents
- Read sign-out BEFORE your shift starts. Know your "watchers" -the patients most likely to decompensate. See them first.
- Pre-round on the sickest patients at the start of your shift, not when they're crashing at 3 AM.
- Keep a running list of what happened overnight. Sign out in the morning should be efficient -"here's what happened, here's what I did, here's what needs follow-up."
- Eat before your shift, bring snacks, and have caffeine strategically (not at 4 AM if you want to sleep post-call).
- Batch your work: if you're going to one floor to see a patient, check if there are other pages on the same floor.
- The patient is not your enemy at 3 AM. They're scared, in pain, and in an unfamiliar place. A 30-second reassuring visit can prevent 5 more pages.
- If you're drowning, tell someone. Call your senior. Page the attending if needed. Patient safety > pride.