The John H. Stroger, Jr.

Hospital Intern Survival

Guide

20122013
JOHN H. STROGER, JR.
HOSPITAL
OF COOK COUNTY
CHICAGO, ILLINOIS

Topic

Page

Responsibilities
Documentation
Admit orders
Common ward orders
-Transfusion orders
-Discharge orders
-Procedure orders
Cermak Patients
Insulin Protocols
Contrast Nephropathy Prevention Protocol

3
3
4
5
6
6
8
8
9-10
11

Helpful Topics:
Mini Mental Exam
DKA
Pharmacy Pearls
Electrolyte Replacement Guidelines
Management of Hyperphosphatemia in CKD/ESRD

11
12
12-14
14-16
16

Substance abuse
CIWA score
Alcohol abuse
Opioid dependence
Methadone program
Nicotine abuse

17
18
17-18
19
20
20

Palliative Care

20

DVT prophylaxis
Anticoagulation Guidelines
Clopidogrel Guidelines
Opioid Equianalgesic Table
Narcotic Prescription

22
23-26
26
27
28

Autopsy request
Phone Numbers
Outpatient Clinics

29
30-37
37

GMC Survival Guide

38-43

INTERN RESPONSIBILITIES:
Rounds start at 7.30 am, except post-call days at 7am:
Pre-round in selected patients (particularly sick ones) before rounds i.e. look up vitals, new labs,
consult notes and if you have time talk to your patients.
Communicate with cross cover resident for overnight events on your teams patients.
It is the R1's responsibility to pick up sign-out lists from the cross cover resident NO LATER than 7am
from the respective firm rooms.
On rounds present each case in a problem list fashion
Sign outs are at 5 pm, be ready with your sign-out lists. The sign out list is accessed through START >programs->ED database-> medicine admissions database.
On call days:
Each intern admits 5 patients, assigned by the resident
Remember: Post call days rounds start at 7 am
On weekends and holidays:
If you are on call then one intern has to take sign outs at 11 am and carry the cross-cover pager till 5pm
If not on callsign outs are at 11 am
For emergencies during cross-cover, contact the senior resident ASAP.
If you need help, please call your Chief Medical Residents (CMRs):
Firm A:
Mauricio Carballo
333-8827
Chijoke Onyenwenyi
333-8818
Firm B:
Javier Gomez
333-8832
Sanjay Patel
333-8781
Firm C:
Krzysztof Pierko
333-8801
Raj Agarwal
333-8808
CMR on call 400-8254

DOCUMENTATION

ADMIT NOTE - written by intern and addendum by R2/R3 on the day of admission
These should be typed in Cerner as a PowerNote, under Document viewing tab.
After opening a new document, click on Encounter pathway and search for Medicine H&P. You can
click on Add to favorites so you can easily access it in the future from the Favorites tab. Make
sure you include all important information including allergies, family history and social history.
Click Sign/Submit once you are done with the note and your
resident will addend and submit it.
DAILY PROGRESS NOTE - written by intern each day including day of discharge in SOAP format. You can
find progress note template in Encounter pathway by typing SOAP Note. When you are done with
your note, click Sign/Submit to indicate a completed note.

DISCHARGE SUMMARY - written by residents in Power note under Discharge SummaryInpatient,

should be complete before the DC order is placed.
PROCEDURE NOTE:
This will be done in Clinical notes under the Procedure notes tab.
Insert template (available for most common procedures e.g. abdominal paracentesis, throracocentesis,
lumbar puncture, CVC insertion)

ADMIT ORDERS
Admission orders are done in Power-Chartthese are the responsibility of the intern.
Step 1: Open patient chart and use the Power orders tab.
Step 2: Search for "Med-admission" care-set.
Step 3: Select the necessary orders, include admission type, team information, type in allergies and
update patient problem list.
Step 4: Review the orders and Sign. When asked if you would like to print the orders, click no in
order to avoid wasting paper.
Nursing orders (patient dependent):
Accuchecks AC and QHS (before meals and before bedtime)
Strict I+O in CHF, cirrhosis, renal failure
Daily/ weekly weight
Fall/ Seizure/ DT precautions
Isolation Contact, Neutropenic, Respiratory, Airborne
Neurochecks q. 1-12 hours
Direct observation (i.e. 1:1 nursing)
Restraints (need to be reviewed/ renewed every 24 hours)
Wound care NS, betadine cleaning with open or closed dressing.
If you cannot find the order you want, type it in under Nursing Orderable Generic
PLEASE COMMUNICATE ALL STAT ORDERS TO THE NURSE VERBALLY
Labs/Tests:
1. Morning labs (if required) should be ordered for 3am under routine lab. If you need a stat lab, place
necessary order as stat and call phlebotomy service. If you are drawing labs yourself select nurse
provider collect and print the label. Label the sample, place it on a biohazard bag, and tube it to the lab
by selecting 201 on the tube station panel.
2. Vancomycin trough levels should be ordered for 8am timed. If your patient requires morning labs,
order everything for 8am timed so pt is not stuck twice.
3. Nurses collect urine and stool samples. Select nurse provider collect and print label. Also enter
another order for nurse collect and choose the specimen type.
4. Respiratory therapist collect sputum samples for gram stain, AFB and fungal cultures. Order for one
sample in the morning and one in the afternoon.

Do Not Use

Potential Problem

Use Instead

U (unit)

Mistaken for 0 (zero),

the number 4, or cc

Write unit

IU (international
unit)

Mistaken for IV
(intravenous) or the
number 10

Write
international
unit

Q.D., QD, q.d., qd

(daily)
Q.O.D., QOD,
q.o.d. (every other
day)

Mistaken for each

other.
The period after Q
mistaken for I, the O
mistaken for I

Write daily
Write every
other day

Do not use trailing Decimal point is missed Write Xmg

zero
(5.0 mg should be
5 mg)
Always use a
leading zero
(.5mg should be
0.5mg)
MS
MSO4, MgSO4

Write 0.Xmg

May mean morphine

sulfate or magnesium
sulfate

Write out the

name of the
medication

COMMON WARD ORDER

Avoid writing orders during nursing shift changes: 7AM, 3PM, 11PM. Stat orders should be
accompanied by verbal communication between MD and the patient's nurse or the Charge Nurse.
REVIEW/RENEW DAILYall medications/fluids
1. Review Daily IV Fluids-no longer automatic DC
2. Parenteral Nutrition (Before 11am)
3. Restraints (Soft and Leather)
4. Direct observation, Medical and Psychiatric Nursing
5. Nebulizer treatments

RENEW Q72 HRS:

5

Narcotics-Only for Meperidine. Review all narcotics orders daily

TRANSFUSION ORDERS
Have the patient sign the Transfusion Consent Form and place in front of the chart. Without a signed
consent, blood products will not be transfused.
Order a type and screen and blood products in Cerner. You may pre-medicate patients (Tylenol 650 mg
and Benadryl 25 mg) .
Follow the on-screen instructions to determine if the patient needs leuko-irradiated or leuko-reduced
products.
PRBC
One unit will increase the hemoglobin by 1gm/dl.
In Cerner:
Type and screen expires every 72 hours
Order X units of PRBC for transfusion- type 'red blood' on order tab and select 'red blood (unit)'
Under instructions to nursing, write hold if reserved for later use
e.g. an operation
Each unit is typically transfused over 3 hours, but can be done at a faster rate if clinically indicated
Enter an indication for transfusion
If the patient has CHF, consider 20 mg of furosemide IV after transfusion (discuss this with your resident
will vary with individual patients)
Hold transfusion if temp > 2 degrees from start of transfusion and call the blood bank.
Fresh frozen plasma (FFP's)
Number of units will vary depending on INR required
Same procedure as for PRBC but typically given over 30 minutes.
Platelets
Each unit increases platelet count by 5,000 10,000
Same as above
DISCHARGE ORDERS
Ordered in CERNER as early as possible on day of discharge.
Please mention special instructions on the discharge order transportation needs, social worker needs,
family to pick-up patients, etc
Prepare discharge prescription on the day of discharge after rounds and no later than 5pm
Discharge RX will be done through e-prescribing in EnterpriseRx for all medications and supplies. All
RX will be transmitted electronically to pharmacy except controlled substances (CIICV). Plan ahead!
Send the patient to the Discharge lounge B/C Clinic. RN does not have to sign order.
The intern is responsible of the medication reconciliation. Please discuss with senior, patient and/or
caregiver any dose changes and medications to be continued or discontinued.
Ambulance patients have to be pre-discharged the day before they leave. Put on the prescription that the
patient is to leave by ambulance and the meds will be delivered to the floor. Pharmacy must receive RX
by 8am on day of discharge for same-day delivery
6

PROCEDURE ORDERS
Remember to keep patient NPO prior to procedures (if required) and restart diet after procedure.
If diabetics are to be kept NPO then omit oral hypoglycemic or hold Regular insulin but give NPH insulin and
give D5W/ 0.45 NS 30 40 ml per hour overnight.
GI procedures:
A. Colonoscopy preparation orders
1.
To schedule call 4-3251 or go to clinic R
2.
NPO after midnight patient on call for Colonoscopy in am. Clear liquid diet for the previous day
Golytely 1 gallon POhave the patient drink between 6-10 pm (if possible start earlier at 2PM) on night
before the test. Instead of Golytely you could use phosphosoda- divide into 3 parts, mix each part with 1
cup of apple juice- give each portion every half an hour
3.
Bisacodyl 2 tabs po at midnight.
4.
Fleet / water enema at 5 am until bowels clear.
B. EGD/Enteroscopy
1.
Schedule as above
2.
NPO after midnight
3.
Under nursing orders: Patient on-call for EGD in am
Cardiology procedures:
ALL CARDIOLOGY STRESS TEST PROCEDURES NEED A CARDIOLOGY NON INVASIVE FORM FILLED
Dobutamine stress test
1.
This is not a computer order, you have to schedule in clinic V
2.
NPO after midnight.
3.
Hold Beta-blockers 24 hours before the test and adequately control blood pressure.
4.
Under nursing orders: Patient on-call for Dobutamine stress test in am
5.
Dont forget to fill out the cardiology non-invasive test form
Stress EKG or Echo
1.
Talk to cardiology fellow assigned to stress test to schedule
2.
Hold beta-blockers 24 hours before the test. Patient can eat in AM
Thallium stress test
1.
Call nuclear medicine at 4-3700 or 4-3701 to schedule
2.
Fill out the cardiology non-invasive test form
3.
Order in Cerner the day of the test
4.
Order a serum pregnancy test for females
Pulmonary procedures:
Pulmonary function test
1.
Not useful if patient, acutely ill.
2.
If needed in house (i.e. Pre-op eval) may put in IRIS referral and go to clinic T to for clerk to schedule.
3.
Hold am nebulizer treatment
4.
Arrange for transportation.
7

PROCEDURES
An attending-staffed procedure service is available on weekdays to teach and assist you.
1.
Place the order using the procedure service database. This is accessed through START->programs>Dept. of Medicine Database->Procedure service database.
2.
Orders should be placed after midnight and before 11am on the day you want the procedure to be done.
If after this time then contact Procedure Service Attending (3901989).
3.
Check the database after 11.30am to know when your procedure is scheduled to be done.
It is your responsibility to consent the patient. Make sure that all the items in the consent are
filled.
4.
You do not need to bring supplies if you request this service.
5.
Instructions on how to perform the most common procedures can be found on the intranet.
Thoracocentesis
Using the Int med careset make sure you order a total protein and LDH fluid.
Click on the following items:
1.
pH ABG syringe on ice.
2.
Culture AFB, mycology, routine culture
3.
Glucose, LDH, and total protein (also collect blood sample for the same items to be sent simultaneously)
4.
Cell count separate tube
Cytologysend as much fluid as you can in a separate bag with the yellow colored 'non-gynecology
cytology' form-found at clerks station
Paracentesis
Using the Int med careset select albumin fluid and cell count every time.
Additional tests include:
Culture AFB, mycology, routine culture (using blood culture bottles), protein Cytology (form filled separately)
Order serum albumin mate to calculate SAAG (send red top tube and one peritoneal fluid tube together).
Lumbar puncture
Confirm with your resident that a CT head is not indicated before proceeding.
Using Int med careset, order CSF glucose, protein, cell count and differential, culture. Check with your
resident for additional tests.
The lab can hold extra CSF fluid for 5-7 days IF REQUESTED.

Information on patients from Cermak:

http://shccbhsweb/Intranet/Data/ComponentFiles/1289/cermak-FAQ.pdf
If no contraindications to volume expension: IV fluids (Bicarb better then NS) prior to and several hours after

General Medicine/Surgical Floor Insulin Order Guideline at John H. Stroger, Jr. Hospital of Cook County
1.

Use Diabetes Careset to place orders

2. Order fingerstick BG TID-AC & bedtime if eating (or NPO for procedures or pre-op); Q 6 hr if on
tube feeds or TPN.
3. Hemoglobin A1c order is prefilled in Diabetes Careset.
4. Start insulin on any patient with a random BG > 200mg/dl or pre-prandial BG > 180 mg/dl twice
within 24 hours. Use both basal (on all patients) and prandial (only with meals) insulin. Choose
supplemental insulin algorithm according to daily insulin requirements
5. Target BG is 100-140mg/dl preprandial.
6. Reassess patients every 24 hours.
7. Adjust patients dose according to supplemental requirements and blood sugars. Decrease if
hypoglycemia occurs.
8. If a newly diagnosed diabetic needs a glucometer, can be ordered through the Careset for
patient to take home on discharge.

Initiating
insulin

NPO

Eating

Tube
Feeds1

Insulin total dose is 0.5units/kg/day. Give 50% as prandial rapid acting insulin
divided TID-given with meals, 50% as basal insulin using glargine (Lantus)
once a day @ 2100 hours
Renal impairment: Reduce total daily dose by 50% if creatinine clearance
of <30ml/min
Dose reduction of 50% for hypoglycemia prone patients such as
hepatic/pancreatic failure, CHF stg-4
If patient is on home NPH/Reg or 70/30 BID, give 50% of total daily dose as
glargine once a day @ 2100 hours (and no rapid acting insulin)
If patient is on 3 injections/day of NPH/Reg, give 100% of current NPH as
glargine once a day @ 2100 hours
Discontinue all oral hypoglycemic medications
Start initial dosing of insulin, only if blood glucose levels satisfy criteria stated
above (# 4)
If patient is on NPH/Reg or 70/30, give 50% of total daily dose as glargine once
a day and 50% as rapid acting insulin (lispro) divided TID with meals
If pt is on oral meds (except metformin and/or TZD) continue home dose using
short acting glipizide. Start insulin, and discontinue glipizide, if criteria for
initiating insulin are met (# 4).
If on metformin, stop it; Start initial dosing of insulin if blood sugars satisfy the
criteria for insulin therapy(# 4).
If on tube feedings from home, continue home regimen. If tube feedings
initiated in-patient for diabetic patients, use initial basal dosing of insulin and
supplemental algorithm. If not diabetic, use only supplemental algorithm
After 24 hours, add total daily insulin requirements, reduce dose by 50% and
give as glargine once a day. Adjust insulin to tube feed rate and blood sugars
If TPN or tube feeds are stopped or patient is made NPO after prandial insulin
is given, start D5W

TPN1

If patient is on insulin 70/30, give 70% of daily dose as glargine once daily (no
rapid acting)
If patient is on NPH/Reg, continue 100% of NPH as glargine once daily.
Discontinue all oral hypoglycemic medications. Check capillary glucose q6h,
and use supplemental algorithm then add total daily insulin requirements and
give 50% of the total dose as glargine daily.

DO NOT ORDER STAND ALONE RAPID ACTING INSULIN (SLIDING SCALE)

Recommended protocol for insulin analog on Intranet, under Diabetes Management link at
http://shccbhsweb/Intranet/Main.aspx?tid=523&mtid=1 . Protocol of conventional insulin also available

Blood sugar target

If FBS is < 70 mg/dl or
hypoglycemic episodes
If FBS is 70-100 mg/dl
If FBS is >140mg/dl and <
200 mg/dl and no
hypoglycemic episodes
If FBS is > 200 mg/dl and
<250 mg/dl and no
hypoglycemic episodes
If FBS is >250 mg/dl and
no hypoglycemic episodes

Basal dose
adjustment
Decrease dose by 20%
May decrease dose by
10%
Increase dose by 10%
of the previous dose
Increase dose by 20%
of the previous dose
Increase dose by 30%
of the previous dose

Supplemental insulin: Refers to the amount of insulin needed to treat hyperglycemia that occurs before
meals or between meals. This is covered by lispro insulin. No supplemental insulin should be given at
bedtime.
For all patients who are insulin deficient, basal (long acting) insulin must be given to prevent DKA, even
when NPO.
ON DISCHARGE
If HgbA1C < 7% on admission: Resume pre-admission diabetic regimen
If HgbA1C > 7% on admission: Obtain total daily dose of insulin (TDD), and prescribe 70/30 insulin
- With 2/3 of TDD of insulin hour before breakfast and 1/3 of TDD hour before dinner OR
- With 1/2 of TDD of insulin hour before breakfast and 1/2 of TDD hour before dinner.

10

PREVENTION OF CONTRAST INDUCED NEPHROPATHY (CIN)

At risk patients:
Creat> 1.1
GFR<60ml/min. 1.73 m2
Diabetics
Prevention modalities:
Use US/ MRI without gadolinium/ CT without contrast
Avoid high osmolal agents (1400-1800 mOsm/Kg)
Use isoosmolal (290) rather then low osmolal (500-850)
Avoid: NSAIDs
AvoidVolume depletion

HELPFUL TOPICS
MINI-MENTAL STATUS EXAM (MMSE)
ORIENTATION
What is the Year? Season? Date? Day? Month?
Where are We? State? City? Hospital? Why are you here?
REGISTRATION
Name three objects; Ask patient to repeat all three
ATTENTION CALCULATION
Serial Sevens. Ask patient to count backward from 100
by sevens or to spell WORLD backwards
RECALL
Ask patient to recall the three objects from question above
LANGUAGE
Point to a pencil and then a watch, ask patient to name each
Ask patient to repeat "No ifs ands or buts"
Ask patient to follow 3 stage command:
Take paper in hand, fold in half, and place on floor
Ask patient to read CLOSE YOUR EYES and follow
Ask patient to write a sentence
Ask patient to copy intersecting pentagons
TOTAL
NB: Adjust for the patient's educational background and age.

5
5
3
5
3
2
1
3
1
1
1
30

CIN Prevention Guideline

Ex: bolus isotonic bicarb 3ml/Kg 1h before and rate of 1ml/Kg during and for 6hafter; or normal saline
1ml/Kg 6-12h before and after the procedure
Acethylcysteine: 1200mg PO bid the day before and the day of the procedure
Dialysis after contrast administration in dialysis patients
Diuretics only if volume overload

11

DIABETIC KETOACIDOSIS (DKA)

Clinical suspicion: h/o DM, Vomiting
Check BMP (anion gap, K+), urine/blood ketones, ABGs (pH), HBA1C , triglycerides
Begin IV fluids: 0.9% NaCl bag #1 @ 1000 ml/hr, bag #2 @ 500ml/hr.
DKA diagnosed if Ph < 7.30 and 2 out of 3 of the following are present: HCO3 <18, glucose > 250 mg/dl,
and ketone-positive
Why is your patient in DKA?
TREATMENT PHASE
Give bolus calculated per weight at 0.15 units/kg x 1
Begin IV insulin drip @ 0.1 unit/Kg/hr (Insulin drip order in cerner. Concentration will be 100 units in
100ml of 0.9% saline).
If glucose does decreases less than 50mg/dl/hr then increase drip by 50%. If it decreases more than
100mg/dl/hr then decrease drip by 25-50%.
Change IV fluids to 0.45% NaCl (if corrected Na is above 135meq/l) @ 200ml/ hr for bags # 3,4 then
125ml/hr for bags # 5-8 liters (Consider a bag with 20 mEq KCL if K+ is <4.0 mEq/l)
Begin with D5 fluids if initial glucose level < 250 (10% DKA have glucose <250)
Change IV fluids to D5/0.45% NaCl when glucose <200 mg/dl, Check blood glucose every 1-2 hr (expect
glucose fall of at least 50mg/dl/h)
Check potassium every 2-4 hrs (N.B.: IV insulin will rapidly lower K+, reaching nadir at 4-6 hours after
therapy). N.B. cautious K+ replacement inpatients with reduced GFR! Give KCl Q 3 hrs if serum
K < 5.0 mEq/L (K+ =4-5, give KCl 10mEq/hour; K+ =3-5 give 20 mEq/hour, K+ <3 give 30-50
mEq/hour)
Consider checking Magnesium, Phosphorus, venous pH, BMP, acetone every 6 hrs, Reduce laboratory
frequency when anion gap resolves.
TRANSITION TO SQ INSULIN
Must meet all 5 criteria:
1. Serum glucose below 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L)
in HHS
2. Serum anion gap <12 mEq/L (or less than the upper limit of normal for the local laboratory)
3. Serum bicarbonate 18 mEq/L
4. Venous pH >7.30
Calculate SQ dose
Known Diabetes: same dose as before DKA
Insulin nave: Extrapolate last 6h drip rate to 24 hours or 0.5-0.8 Units/ Kg. day (if no stable rate),
divided into 50% Glargine at 9pm, and 50% lispro divided tid AC
Always overlap IV insulin drip and sc insulin for 2 hours when initiating SQ insulin
PHARMACY PEARLS
LIMIT use of STAT to true emergencies/urgent situations. Use NOW or routine for most orders.
Dosing Schedule
Antibiotics, heparin, enoxaparin, hypertension meds (except isosorbide) should be dosed every X hr, not
bid, tid or qid.
Warfarin should be dosed at bedtime.
Statins should be dosed at bedtime to be effective, since cholesterol synthesis occurs overnight
Phosphorus Binders CaCo3, etc must be dosed with meals
Levothyroxine must be dosed at 7am before meals
12

Daily= 9 am
every 12 hr = 9am, 9pm
BID= 9am and 5pm
every 8 hr = 9am, 5pm, 1am
TID= 9am, 1pm, 5 pm
every 6 hr = 6am, 12pm, 6pm, 12am
QID= 9am, 1pm, 5 pm, 9pm
Non formulary drugs
Call non-formulary pager at 333-2105 from 8a-4p M-F. After hours call inpatient pharmacy 4-2180.
Online pharmacy services
For information about our formulary, go to the formulary site on the intranet, under clinician links for the
inpatient & outpatient formularies, restricted drug lists, protocols, guidelines, and drug information
resources. Go to the intranet site for the department of pharmacy for do not crush list, info for special
dosing considerations ie. statins, warfarin, sevelamer, etc
You can also find a link to the FDA website on the Stroger home page
Micromedex is available through Cerner under clinician links and through the formulary page on
the intranet.
Routine SUP/GI prophylaxis NOT recommended empirically!
Required in coagulopathic or intubated critical care patient, study by Cook et al.
Use Ranitidine (Zantac) po OR famotidine IV 1st line.
Do not continue upon discharge if stress ulcer prophylaxis was the only reason for initiating.
Drug Interactions
Automatic alerts are produced by CPOE. DO NOT IGNORE THESE. Always check for drug interactions!
Dose Adjustments
If a patient has even mild renal or hepatic insufficiency check the dose to see if a dose adjustment is
necessary. Drug are metabolized and excreted either or by both hepatic or renal pathways
Renal Failure
Medications are dosed based on creatinine clearance, NOT GFR which is reported in Cerner. To
calculate CrCl:
(140 age) * IBW = ml/min (if female, multiply by 0.85)
72 * SCr
IBW male = 50 + (2.3 x inches > 5 feet) = kg
IBW female = 45.5 + (2.3 x inches > 5 feet) = kg
Check Micromedex or Lexicomp in Up To Date for renally adjusted dosing of medication in patients with
renal failure/insufficiency .
Drug Levels
Vancomycin:
Only a trough* level needed.
Gentamicin/Tobramycin:
Trough* levels 0.5-2 mgc/mL, Peak** 5-10 mcg/mL.
13

Amikacin:
Trough* 2-8 mcg/mL, Peak** 20-30 mcg/mL
Once daily Gent/Tobramycin/Amikacin: Random levels are drawn between 6-14 hrs after infusion, use
nomogram. Daily dosing only in patients with normal kidney function and those who do not have CF.
Phenytoin:
Levels 10-20 mcg/mL.
Phenytoin unbound levels are preferred in pts with Cr>3.2 Level:1-2
Correcting for albumin C= Cobs/ (0.25 x Alb concentration + 0.1)
The unbound drug (free drug) is the active portion of drug levels
Steady state is achieved in 10 -14 days, can draw a non-steady state level in 3-5 days after load
Empiric Post load levels are not recommended. If pt is loaded draw level 18-24 hrs after load
Dose adjustment for albumin <3.2 mg/dL
Phenytoin Corrected = Phenytoin / (0.25 x alb =0.1)
*Trough: Draw 30 min before the 4th dose of new dosing regimen to ensure steady state concentration
has been achieved.
Draw a trough level to find the lowest drug concentration in the body.
**Peak: Draw 30 min after drug is completely infused. Draw a peak level to find the highest
concentration of the drug in Mild to moderate infections need a level of 5 -15 mcg/mL.
Severe/ICU infections need a level of 15-20 mcg/mL e.g. endocarditis, osteomyelitis, HAP, MIC >2,
severe skin/soft tissue infection, etc
Dialysisload with 20mg/kg (max 2g/dose), follow levels, and redose with 500mg-1000mg after HD if
random level <20mcg/mL
Patients with renal failure/ insufficiency need a dose adjustment.
Digoxin:
Narrow therapeutic index drug and renally eliminated.
Digoxin steady state is reached after 1 week in normal pts. Digoxin levels 0.5-0.8 ng/mL in elderly, 0.5-1
ng/mL in CHF.

Electrolyte Replacement Guidelines

(FOR PATIENTS WITH RENAL/HEPATIC DYSFUNCTION SEE ICU GUIDELINE ON INTRANET)
Table I: Potassium (normal lab range 3.5 5.0 mEq/L)
Potassium
Replace with
level
Less than 2.5
120 400 mEq IVPB*
mEq/L
2.5 2.9
80 200 mEq IVPB*
mEq/L
3.0 3.5
40 80 mEq IVPB* or PO
mEq/L
Signs & symptoms of hypokalemia: myalgia, weakness, cramping, hypertension, cardiac arrhythmias
Recheck potassium level 1 hour post infusion and repeat dosing if needed
Serum magnesium levels must be in the normal range to effectively replete serum potassium
*Recommended peripheral line maximum infusion rate 10 mEq/hr; Recommended central line maximum

14

infusion rate 20 mEq/hr

Consider more dilute preparation if patient has peripheral access only and/or if patient is experiencing
burning with infusion
Table II: Magnesium (normal lab range 1.8 2.7 mg/dL)
Magnesium level
< 1 mg/dL
1 1.4 mg/dL
1.5 1.8 mg/dL

Replace with
8 12 g IVPB**
4 8 g IVPB**
2-4g IVPB** OR 400mg magnesium oxide po x

3 dose

Signs & symptoms of hypomagnesemia: tetany, positive Chvosteks & Trousseaus sign, convulsions
Recheck magnesium level in 4 hours or more and repeat dosing if needed
**Max Recommended infusion rate 1 g/hr

Table III: Phosphorous replacement (normal laboratory range 2.5 4.5 mg/dL)
Phosphorous
level
Less than 1.2
mg/dL
Less than 1.2
mg/dL
1.2 1.7
mg/dL
1.2 1.7
mg/dL
1.8 2.5
mg/dL
1.8 2.5
mg/dL
Phosphorous
level

Potassium
level
Less than 4
mEq/L
More than 4
mEq/L
Less than 4
mEq/L
More than 4
mEq/L
Less than 4
mEq/L
More than 4
mEq/L
Formulary
product

1.8 2.5
mg/dL

Potassium acid
phosphate

Replace with (IV

replacement)
Potassium phosphate 45
mmol IVPB***
Sodium phosphate 45 mmol
IVPB***
Potassium phosphate 30
mmol IVPB***
Sodium phosphate 30 mmol
IVPB***
Potassium phosphate 15
mmol IVPB*** OR PO
Sodium phosphate 15 mmol
IVPB***
Replace with (PO
replacement)
500mg tablet: phosphorous
114mg (3.68 mmol) and
potassium 114mg (3.7
mEq) per tablet
Dose: 1000mg QID x 4
doses (total 29.4 mmol
phosphorous and 29.6 mEq
potassium)

Signs & symptoms of severe hypophosphatemia: myalgia, weakness, acute respiratory failure, seizures
Recheck phosphorous level 1-2 hours post infusion and repeat dosing if needed
3 mmol of potassium phosphate contains 4.4 mEq of potassium, 3 mmol of sodium phosphate contains 4
mEq of sodium
***Recommended infusion rate 5 mmol/hr

15

Electrolyte Replacement Contd. (FOR PATIENS WITH RENAL/HEPATIC DYSFUNCTION SEE ICU
GUIDELINE ON INTRANET)
Calcium should only be replaced when clinically indicated
Table IV: Calcium (normal laboratory range 8.5 10.5 mg/dL)
Signs & symptoms of hypocalcemia: tetany, muscle spasm, cramps, prolonged QT interval
Recheck calcium level 2 hours post infusion and repeat dosing if needed
Albumin adjusted calcium may not be suitable for diagnosis of hyper- and hypocalcemia in all critically ill
patients
Corrected calcium (mg/dL) = serum calcium (mg/dL) plus 0.8[4-serum albumin (g/dL)]
**** 1250 mg of calcium carbonate suspension equals 500 mg of elemental calcium
1 g calcium gluconate equals 90 mg elemental calcium
Bicarbonate
Calculated bicarb replacement in mEq =
0.1 x (goal bicarbactual bicarb) X weight (Kg)
Given orally as citric acid/sodium citrate (Bicitra, Scholls soln)
1 mL sodium citrate = 1 mEq bicarbonate
Consider IV sodium bicarbonate available as 50mEq in 50ml injection
Management of Hyperphosphatemia for Patients with Advanced CKD or ESRD

Treatment
Goals:
Step 1:
Step 2:

SERUM PHOSPHORUS LEVELS <5.5 mg/dL

SERUM CALCIUM LEVELS (corrected) 8.4-9.5 mg/dL
CALCIUM X PHOSPHORUS PRODUCT <55
LOW PHOSPHORUS DIET (800-1000 mg/d)
CHECK CORRECTED SERUM CALCIUM
[Corrected Calcium = (0.8 * (Normal Albumin - Pt's Albumin)) + Serum Ca]
Calcium level
Calcium level >10.2 mg/dL
<10.2 mg/dL

Start non-calcium based binder

Start Calcium
(e.g. Sevelamer 800mg tid
based binder
with meals)
(e.g. Calcium
carbonate

500mg tid with May increase up to 2400mg tid with meals if required
meals)

May increase
dose to
1000mg tid
with meals if
Ca <10.2
mg/dL

16

Step 3:

Notes:

If phosphorus
still >5.5 mg
/dL

If phosphorus still >5.5 mg /dL

Add Aluminum Hydroxide 5-10 ml tid with meals if

necessary (only up to 1-2 weeks)

Add noncalcium based

binder
e.g.
Sevelamer
along with
calcium if
necessary
With calcium based binders, total dose of elemental calcium should not
exceed 1500mg per day. 500mg tablet of calcium carbonate has 40%
(200mg) elemental calcium.
Ensure dietary compliance and timing of phosphorus binders before
increasing dose or adding another med.
Calcium-based (i.e. calcium carbonate or acetate) binders should not be
used in dialysis patients who are hypercalcemic (corr. calcium of >10.2
mg/dL), or whose plasma PTH levels are <150 pg/mL on 2 consecutive
measurements.

SUBSTANCE ABUSE GUIDELINES

Call SBIRT Health Counselor at 312-864-4448 for patients with substance use disorders or high risk
use of alcohol or ANY other drugs
Give all pertinent information in your message. Place the consult in POWERCHART
They will provide Screening, Brief Intervention, and Referral to Treatment if indicated.
Refer to Pocket Withdrawal Card for more details
ALCOHOL WITHDRAWAL
Assessment
Ask: Did you drink any beer/wine/liquor in the last 3 days? If YES ->
When you dont drink, do you feel shaky, have seizures, get confused? If YES -->At Risk
Assess: for current signs and symptoms of withdrawal (use CIWA-AR)
Pharmacologic Treatment
At Risk, but CIWA-AR < 8:
Give benzodiazepine x 1 dose at presentation (see dose below).
Reassess q 4 hr for 36 hours from last drink.
Provide supportive environment.
Moderate or Severe Withdrawal (CIWA-AR >8)
Diazepam 20 mg PO q 1-2 hrs until symptom resolution (preferred choice), OR
Lorazepam 2 mg PO q 1-2 hrs until symptom resolution (if elderly, severe respiratory impairment,
17

hepatic synthetic dysfunction), OR

Lorazepam 2 mg IM q 1-2 hr until symptom resolution (if NPO).
Reassess patient 1 hr after every dose, then q 4-8 hr after symptoms con
trolled. If poor control after 3 doses: continue protocol, consider transfer to close observation unit.
Appropriate treatment will prevent approx 5 cases of delirium tremens and 8 cases of seizure per 100
patients with moderate or severe withdrawal.

CIWA SCORE
NAUSEA/VOMITING
Ask, Do you feel sick to your stomach?
0 no nausea or vomiting
1 mild nausea, no vomiting
2
3
4 intermittent nausea w/ dry heaves
5
6
7 constant nausea, frequent vomiting
TREMOR - observe
0 no tremor
1 not visible, can feel at fingertips
2
3
4 moderate, with pts arms extended
5
6
7 severe, even with arms at rest
PAROXYSMAL SWEATS - observe
0 no sweat visible
1
2
3
4 beads of sweat on forehead
5
6
drenching sweats
ANXIETY
Ask, Do you feel nervous?
0 no anxiety, at ease
1 mildly anxious
2
3
4 moderately anxious
5
6
severe, equivalent to panic state
AUDITORY DISTURBANCES
Ask Do sounds seem harsh? Are you hearing things that disturb you/ you
know are not there?
0
not present
1
minimal
2- 3
moderate
4-6
moderately severe hallucinations
7
hallucinations almost continuous

AGITATION - observe
0 normal activity
1 some more than normal activity
2
3
4 Moderately fidgety & restless
5
6
7 constantly paces or thrashes about
TACTILE DISTURBANCES
Ask, Do you feel numbness, pins & needles?
0 not present
1 minimal
2
3 moderate
4 moderately severe hallucinations
5
6
7 hallucinations almost continuous
VISUAL DISTURBANCES
Ask, Does the light seem too bright? Are you seeing things that disturb you/ you
know are not there?
0 not present
1 minimal
2
3 moderate
4 moderately severe hallucinations
5
6
7 hallucinations almost continuous
HEADACHE
Ask, Does your head feel full? Like there is a band around it? Do not rate for
dizziness.
0 not present
1 very mild
2
3
4 moderate
5
6
7 severe
ORIENTATION
Ask, What day is this? Where are you? Who am I?
0 Oriented & can do serial additions
1 Cannot do additions or uncertain of date
2 Disoriented for date by <2 days
3 Disoriented for date by > 2 days
4 Disoriented for place &/or person

Delirium Tremens (symptoms of withdrawal plus disorientation, confusion, agitation, hypersympathetic

activity)
Diazepam 5 mg slow IV push q 5 min until calm, awake state (preferred choice), OR
Lorazepam 2 mg IV, then 1 mg q 5 min until calm, awake state (if elderly, severe respiratory
impairment, hepatic synthetic dysfunction).
Patient requires close observation unit. Inform Attending MD.
Assess vital signs, pulse ox & target symptoms after each IV dose. If patient requires >30 mg Diazepam
or >10 mg Lorazepam within first hour, or patient has additional unstable conditions, consult for transfer
to ICU.
Pregnant Women
CIWA < 8: Order BAL, reassess q 4 hr for 36 hours from last drink.
CIWA 8- 15: Do NOT give pharmacologic treatment, reassess q 2 hr.
CIWA > 15, first 23 wks gestation: Give Lorazepam (as above)

18

CIWA > 15, after 23 wks gestation: Give Phenobarbital 15-60 mg PO q4-6 hr, taper over 4 days. Give
Folate 4 mg daily IV or PO. If > 37 wks, add Vitamin K 5 mg daily.
Consult OB. Gestation > 26 weeks, continuous fetal monitoring appropriate.
Adjunctive Treatment
All patients:
Thiamine 100 mg PO/ IV daily , Folate 1 mg PO/ IV daily, MVI PO/ IV daily.
Magnesium & Phosphate if indicated.
Fall & seizure precautions
Reassurance, reorientation & a quiet location.
Patients with withdrawal related seizures:
No specific treatment beyond benzodiazepines.
Investigate other cause if seizures are: focal; new onset; >2;
begin after onset of DTs; assoc. w/ head trauma , focal neurological signs, or fever.
Patients with hallucinations: If pt also disoriented, treat as DTs. May add haloperidol.

Opioid Dependence
Symptoms of Opioid Withdrawal
Feel like using heroin now; anxious; restless; dilated pupils; watery eyes; runny nose; perspiring;
yawning; back, bone and muscle aches; stomach cramps; goose flesh; hot or cold flushes; shaking;
muscle twitching; nausea/vomiting.
Symptoms of Opioid Toxicity/Overdose
Pinpoint pupils, decreased responsiveness, respiratory depression.
Heroin withdrawal begins 6-12 hrs after last use, peaks 24-48 hrs, lasts 7-14 days.
Methadone withdrawal begins 24-36 hrs after last use, lasts days to weeks.
Pharmacological Treatment of Withdrawal
Treat to control symptoms/to avoid overt withdrawal .
Involuntary detoxification can interfere with medical care and is NOT advisable.
Hospitalized, medically ill patients:
Methadone 10-20 mg PO. Reevaluate in 2-4 hrs and repeat dose until symptoms controlled. Withhold
for CNS or respiratory depression.
Maximum dose generally 40mg PO/24hrs. Give daily or divided q 12.
If NPO, give two-thirds oral dose IM, divided q 12.
Discuss these options with patient:
Continue daily dose of methadone. Same dose on day of discharge.
Taper methadone dose by 15-20% starting day 3 *. Explain discharge will not be delayed to
complete a taper. (*Delay tapering if not medically stable.)
Patients must be directed to a methadone program (ambulatory) by the SBIRT service upon
discharge.
Pregnant women:
Titrate methadone: 5-10 mg po q 4 hrs until all symptoms & signs extinguished.
Establish daily dose.

19

Opioid withdrawal/detoxification contraindicated in pregnancy. Minimal symptoms in mother may

indicate fetal stress. Consult OB. Refer to methadone maintenance program.
Patients in Methadone Maintenance Treatment Program
Call program to verify daily dose & last dose (requires release of info by pt.) Most programs open 67 mornings/wk. Average daily methadone maintenance doses 60-150 mg. Do NOT give more than
40 mg/day without verification and documentation in chart.
Continue daily maintenance dose during hospitalization, convert to IM (as above) if NPO. Will need
increased methadone dose if start rifampin, carbamazepine or phenytoin.
At discharge give patient letter for methadone program with hospitalization dates, discharge diagnosis
and meds, date and amount of last methadone dose.
Treatment of Pain in Hospitalized Patients with Opioid Addiction
Patients receiving methadone for opioid addiction need a separate, short-acting drug for analgesia.
Morphine/other opioid and PCA are safe to use.
When giving an opioid analgesic to a methadone-maintained patient, expect to increase the standard
dose by ~ 25%, and to decrease the standard dosing interval by ~ 25%.
Methadone Maintenance Treatment Programs
Brass 340 E 51st, 773-869-0301.
Brass II 8000 S. Racine 773-994-2708.
Cornell 2723 N Clark 773-525-3250.
El Rincon 1874 Milwaukee 773-276-0200.
Family Guidance 310 W Chicago 773-943-6545 & 3800 W Madison 773-638-2849.
Garfield Counseling Center 4132 W Madison 312-533-0433.
HRDI 33 E 114th 773-660-4630.
New Age 1330 S. Kostner 773-542-1150.
Pilsen/Little Village 3113 W Cermak 773-277-3413.
SASI 2101 S Indiana 312-808-3210.
Smoking, Nicotine replacement and Bupropion
If physical dependence is present, negotiate the use of nicotine patches or Bupropion.
The dose of NRT should be titrated to heaviness of smoking. If smoking 15-24 cig/day, use 21mg patch.
If 10-14 cig, use 14mg patch. Initial dose is 4 weeks. Each tapered dose is for 2 weeks. Nicotine
patches are contraindicated at the time of acute coronary syndrome, malignant arrhythmia, CHF
exacerbation, pregnancy.
The standard dose of bupropion is 150 mg po daily x 3days, then 150 mg po bid for 2-3 months.
Bupropion takes 1-2 weeks to affect smoking urges. Bupropion is contraindicated in people with seizure
disorders.
Palliative care/Hospice Care
312-606-6106, Please call this number for all new consults
Eligibility Criteria for Hospice Benefit5:

The goal of hospice care is directed toward comfort and relief of symptoms, not cure. Hospice
neither hastens nor prolongs death.

20

Prognostic indicators provide guidance in determining whether or not a patient is appropriate for
hospice services (see table).
Though often plagued with inaccuracies, a prognosis of six months or less if the illness runs its
normal course, as certified by two physiciansthe patients attending physician and the hospice
medical director. This is based on the physicians clinical judgment regarding the normal course of
the individuals illness.
The patient should also meet the following criteria:
The patients condition is life limiting, and the patient and/or family have been informed of this
determination
The patient and/or family have elected treatment goals directed towards relief of symptoms
rather than curing the underlying disease

Services provided by Hospice Benefit5:

1. Medications related to the terminal illness.
2. Durable medical equipment (hospital bed, walker,
oxygen, concentrator, bedside commode, etc).
3. Coordination of care by an interdisciplinary team including physicians, nurses, home health aides,
social workers, chaplains, homemakers and volunteers with routine scheduled visits.
4. Dietary counseling and physical, occupational, speech, and respiratory therapy services as
appropriate.
5. 24 hours a day, 7 days a week access to delivery of medications, supplies, telephone triage and, as
necessary, urgent visits by hospice staff.
6. Laboratory testing and other diagnostic studies related to the care of the terminal illness.
7. Services are provided wherever a patient resides, either in a private home or in a long-term care
facility.
8. Short-term inpatient stays in a hospice facility, hospital, or
skilled care facility for management of acute symptoms.
9. Short-term continuous nursing care in the home for crisis
care of acute symptoms that can be managed at home
with extra support from the hospice team.
10. Five-day inpatient respite periods when caregivers
require a break from caregiving responsibilities.
11. Bereavement support and counseling services.
12. The benefit consists of two periods of 90 days each followed by recertification of an unlimited
number of 60-day benefit periods.
4Adapted

from Teno JM and Lynn J. Putting Advance-Care Planning into Action. Journal of Clinical
Ethics;7;No.3;Fall 1996:205-213.
5Adapted from Hospice Care: A Physicians Guide by Illinois Sate Hospice Organization.

21

DVT PROPHYLAXIS
If any patient has risk for bleeding
or actual bleeding, start
Risk Level
Low risk
<40 y old, minor procedure
NO additional risk factors
Moderate risk
40-60 years
<40 with additional risk factors and
minor surgery
High risk
>60 years
40-60 years with additional risk
factors
Highest risk
Surgery in patient with multiple risk
factors
Hip/knee arthroplasty
Major trauma

Recommended therapy
Early mobilization

Low Dose Unfractionated

Heparin (LDUH) 5000 units sc
q8h

LDUH 5000 units sc q 8h

LDUH 5000 U sc q8h + Gradual
compression device,

them on sequential compression devices (SCDs).

Please refer to the anticoagulation guidelines on the intranet for updated
information.

22

INR

Bleeding
Recommended action
present

Lower or omit warfarin dose and monitor INR more frequently

INR >
No
therapeutic
significant Resume warfarin at a lower dose when INR is in therapeutic range
range but
bleeding
<4.5
No dose reduction needed if INR is minimally elevated
Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at
No
Between
significant a lower dose when INR is in therapeutic range
4.5 and 10
bleeding
Vitamin K NOT recommended (grade 2B) per 2012 ACCP Antithrombosis guidelines

> 10

No
Hold warfarin and administer 2.5 to 5mg ORAL vitamin K (grade 2C, ACCP 2012). INR likely
significant to reduce in 24 to 48 hours. Monitor INR more frequently and administer more vitamin K as
bleeding needed. Resume warfarin at a lower dose when INR is in therapeutic range

Any INR with serious

Hold warfarin and administer 10 mg vitamin K by slow IV infusion (may repeat q12h);
or life-threatening
supplement vitamin K infusion with FFP. Monitor and repeat as needed.
bleeding

Reversal of anticoagulation with warfarin

Note: if patient is to continue warfarin therapy after high doses of Vit K, heparin should be given until the
effects of the Vit K have been reversed, and the patient is responsive to warfarin
Parenteral AnticoagulantsProphylaxis Dosing
Unfractionated
Heparin (UFH)

Enoxaparin
(Lovenox)

Fondaparinux
(Arixtra)

CrCl less than

30ml/min

RECOMMENDE
D

AVOIDrequires factor Xa
monitoring

Contraindicated
AVOID

CrCl 30-60ml/min

RECOMMENDE
D: No
adjustment
needed

Preferred
product for patients
requiring > 10 days duration

LIMIT
TREATMENT TO 7-10 DAYS

Prophylactic Dose
UFH
Hospitalized
medical, nonsurgical patients

Enoxaparin

Fondaparinux

5000 units SC
q8h

23

Surgerygeneral,
laparoscopic,
vascular

5000 units SC
q8h

30mg SC q12h OR 40mg SC q24h up

to 14 days

2.5mg SC q24h*

Gynecologic
surgery

5000 units SC
q8h

30mg SC q12h OR 40mg SC q24h up

to 14 days

2.5mg SC q24h AND intermittent

pneumatic compression1*

Thoracic surgery

5000 units SC
q8h

30mg SC q12h OR 40mg SC q24h up

to 14 days

2.5mg SC q24h*

Coronary bypass
surgery

5000 units SC
q8h

40mg SC q24h

2.5mg SC q24h*

Abdominal surgery

5000 units SC
q8h

40mg SC q24h

2.5mg SC q24h

UFH

Enoxaparin

Fondaparinux

Knee arthroplasty
with additional risk
factors

30mg SC q12h OR 40mg SC q24h up 2.5mg SC q24h*

to 14 days

Knee replacement
surgery

30mg SC q12h OR 40mg SC q24h up 2.5mg SC q24h

to 14 days

Hip replacement
surgery

30mg SC q12h OR 40mg SC q24h up 2.5mg SC q24h

to 14 days

Hip fracture
surgery with
additional risk
factors

30mg SC q12h OR 40mg SC q24h up 2.5mg SC q24h

to 14 days

Spine surgery with

additional risk
factors

30mg SC q12h

Neurosurgery

5000 units SC
q8h

Spinal cord injury

30mg SC q12h

Cancer

5000 units SC
q8h

Critical care

5000 units SC
q8h

Stroke

5000 units SC
q8h

Pregnancy

5000 units SC
q8h

Category B
40mg SC q24h

24

Heparin induced
thrombocytopenia
(HIT)

CONTRAINDICA CONTRAINDICATED
TED

* Call for
hematology consult

* Non-FDA approved indication. Referenced in ACCP 2008 Chest guidelines and clinical trials
Parenteral AnticoagulantsTreatment Dosing

CrCl less than

30ml/min
CrCl 30-60ml/min

Unfractionated
Heparin (UFH)

Enoxaparin
(Lovenox)

Fondaparinux
(Arixtra)

RECOMMENDED

CrCl 15-30ml/min1mg/kg SC q24h

CrCl less than 15ml/min: AVOID
requires factor Xa monitoring

Contraindicated

Preferred
product for patients
requiring long-term treatment

LIMIT
TREATMENT TO 7-10 DAYS

RECOMMENDED:
No adjustment
needed

AVOID

Treatment Dose
UFH

Enoxaparin

Fondaparinux

Unstable
Angina/NSTEMI

Heparin infusion
see intranet

1 mg/kg SC q12h

2.5 mg SC q24h

STEMI

Heparin infusion
see intranet

1 mg/kg SC q12h

2.5 mg SC q24h

1.5 mg/kg SC q24h (preferred) OR 1

mg/kg SC q12h

Wt Based
5mg, 7.5mg, or 10mg SC q24h
Preferred for pts > 100 Kg

Atrial
Heparin infusion
Fibrillation (bridge
see intranet
to
warfarin)
Mechanical Heart
Valve (bridge to
warfarin)

Heparin
infusionsee
intranet

1 mg/kg SC q12h

Limited data
<50 kg5mg
50-100kg7.5mg
>100kg10mg SC q24h

Cardioembolic
Stroke

Heparin
infusionsee
intranet

1.5 mg/kg SC q24h (preferred) OR 1

mg/kg SC q12h

Limited data
<50 kg5mg
50-100kg7.5mg
>100kg10mg SC q24h

Thromboembolic
Events in
Pregnancy

Heparin
infusionsee
intranet

1 mg/kg SC q12h

Limited data
<50 kg5mg
50-100kg7.5mg
>100kg10mg SC q24h

DVT/PE
Treatment

Heparin
infusionsee
intranet

1.5 mg/kg SC q24h (preferred) OR 1

mg/kg SC q12h

<50 kg5mg SC q24h

50-100kg7.5mg SC q24h
Preferred for pts > 100 Kg
10mg SC q24hr
25

DVT/PE
Treatment in
Patients with
Cancer

Heparin
infusionsee
intranet

1.5 mg/kg SC q24h

<50 kg5mg SC q24h

50-100kg7.5mg SC q24h
>100kg10mg SC q24h

Heparin Induced
Thrombocytopenia
(HIT)

Contraindicated

Contraindicated

Call for heme

consult

AVOID

AVOID

Clopidogrel (Plavix) Dosing Guidelines in Cardiac Patients

Clopidogrel dosing (loading dose and duration of therapy) should take into consideration the indications
for therapy, clinical presentation of the patient, desired time to onset of antiplatelet activity and potential
for bleeding complications. Outlined below are suggested doses and durations for dual antiplatelet
therapy (ASA + clopidogrel), derived from the published peer-reviewed literature, practice guidelines and
position papers relevant these issues.

Indication

Recommended loading and

maintenance dose

Recommended duration of therapy

Elective Bare Metal Stent (BMS)

300 mg load / 75 mg po daily

At least 4 weeks

Elective Drug Eluting Stent (DES)

300-600 mg load* / 75 mg po
daily

ACS/MI No PCI / stent

300-600 mg load* / 75 mg po
daily
300-600 mg load* / 75 mg po
daily
300-600 mg load* / 75 mg po
daily
300-600 mg load* / 75-150
mg po daily

At least 3-6 mo for Cypher (sirolimus-eluting

stent), at least 6 mo for Taxus (paclitaxeleluting stent).
Preferably 1 year for any DES
9-12 months

ACS/MI Bare Metal Stent (BMS)

ACS/MI with DES or other off-label
use of DES
DES patients who have sustained
stent thrombosis

9-12 months
Minimum 1 yr to possibly up to 2 years
Indefinite until further data are available

* While 300 mg as a single oral load is currently the FDA-approved loading dose of clopidogrel, the 600
mg loading dose has been evaluated in several published studies and appears to be safe and
associated with both more rapid onset of antiplatelet activity as well as higher levels of platelet inhibition
with the first 24 hours following loading.

Currently there are no evidence-based guidelines for amount or duration of antiplatelet therapy in
patients who have sustained drug-eluting stent thrombosis. Common practice, however has been to reload patients with 300-600 mg of clopidogrel at the time of presentation with stent thrombosis and

26

continue on 75-150 mg daily for as long as the patient can tolerate this regimen, pending the availability
of additional data.
Key references:
Hodgson JM, Stone GW, Lincoff AM et al. Late Stent Thrombosis: Considerations and Practical Advice
for the Use of DES: A report from the Society for Cardiovascular Angiography and Interventions DES
Task Force. Catheterization and Cardiovascular Interventions 2007 Jan 5th 69:001-006.
Created By Pete Antonopoulos PharmD Clinical Pharmacist and Sandeep Nathan MD, Attending
Physician, Section of Cardiology, Approved by CCBHS Section of Cardiology

OPIOID EQUIANALGESIC TABLE

DRUG

ORAL (mg)

Morphine
Hydromorp
hone
Oxycodone
Fentanyl

30
7.5

Methadone
Meperidine

20
Transdermal (TD)
25 mcg/hr =
50 mg/day of morphine
20
Not recommended

Codeine 30 200
mg + Acet
325 mg
(Tylenol #3)
Hydrocodo 30
ne 5 mg +
Acet 325
mg (Norco)
Oxycodone 20
5 mg +
Acet 325
mg
(Percocet)

PARENTERAL
(mg)
10
1.5

DURATION OF
ACTION
3-4 hrs
3-4 hrs

0.1-0.1

3-4 hrs
5-10 min, iv
48-72 hrs TD

10
75-100

6-8 hrs
2-3 hrs

--

3-4 hrs

--

3-4 hrs

--

3-4 hrs

Equianalgesic doses for adults > 50 kg body weight. Dose adjustments needed for patients with
renal/hepatic insufficiency. (Lerna MJ. Hosp Med 1988; May:11-21)
Assume methadone to be more potent than displayed in table due to its long and variable half-life.
Assume methadone to be more potent than displayed in table due to long and variable half-life.

27

NARCOTICS
NEED ATTENDING SIGNATURE, DEA Number
Schedule II (no refills):
need a printed prescription with DEA number, Requires written # (15) and Spelled out (fifteen) dosing
quantities
*Note- if the dose you want is not available, but rather is a combination of available strengths (i.e.
methadone 15mg), write out the strength available and the appropriate # of tablets required to make the
needed dose (i.e. methadone 5mg take 3 tabs (15mg) po q8hrs)

Schedule III, IV, V

Need a printed prescription and DEA number. Schedule III can have refills up to 6 mo (1 Rx with 5
refills)
*Note- make sure you write a sufficient quantity to last until the patients follow-up appointment
For a list of available medications, please see formulary page in
Micromedex, available through Cerner under clinician links

Sample Narcotic Prescription

PTs Address

Quantity (Numeric and Spelled)

Strength,
Dose,
Frequency

DEA #

Sticker

28

AUTOPSY REQUEST INFORMATION

When a patient dies, request the Hospital Death Packet which contains all the required forms:
Determine if the case is a Medical Examiners (ME) or Coroners case
Inform the family of the patients death and offer a family meeting the same or next day
Do NOT sign the Death Certificate if an autopsy is granted
Determine the next-of-kin who is able to give permission for an autopsy

Priority for next-of-kin: 1) Patient 2)

Spouse 3) Adult (>18 yrs) children 4)
Parents 5)Adult brothers/sisters 6) Other
relatives

Useful telephone numbers:

Medical examiner/Coroner: 312-666-0200
Pathology (on call pager): 312-400-5264
Morgue: 4-7523
Admitting Office (paperwork): 4-2508
Chaplain / other religions: call operator 4-6519

REQUESTING CONSENT FOR AUTOPSY

I am Dr_________, the doctor caring for your ________. I am sorry to have to tell you that he/she has
died. His/her other doctors and I believe the cause of death was ______. Every time a death occurs in
the hospital it is your right to request an autopsy.
The hospital offers this service free of charge to help answer any questions you or the doctors may have
about the cause of death, his/her disease and the care he/she received. The results of the autopsy may
help alleviate your concerns about your relatives death & can provide important information that might
help improve care for patients in the future.
An autopsy will not delay the funeral, disfigure the body, or interfere with viewing of the body. If you
prefer, a problem directed or limited autopsy can be offered.
As the next of kin you will need to sign this consent form to request the autopsy. I will explain the form to
you before you sign. If consent is given over the telephone a witness needs to hear the conversation
and sign the consent form.

29

CONSULTS
GENARAL INFORMATION

46519

For pager numbers that change everyday call 46519 or Check Plan of the Day on the
INTRANET.

MEDICINE
Allergy and immunology:

Rush 312 942-6296,

Press 0, get Resident pager

Cardiology:
-CCU on call
-Echo lab
-Echo scheduling
-Echo reading room
-Catheterization lab
-Heart failure clinic
-Carol Turner (Heart failure)
-Clinic appt (Barbara Bradford)
-ECG

Consult in Cerner
333-1922
43424
43404
43430
43404, 06, 55
43437
760-0615
43402
43432, pager 333 1687

Critical care (MICU):

333-1735

Dermatology

1st no. 760-0696, alt: 740-8087

Endocrinology

Fellow 740-2369

Gastroenterology
-GI fellow
-Endoscopy

Consult in Cerner
514-2591
43250, 43252

Hematology/ Oncology
-Appointments (Gloria)
-Fellow on call

Place consults in Cerner under hematology or medical

oncology.
47250.
740-6477

HIV

400-7040 resident on call

HIV testing
Is on the order set, just get patients verbal consent.
To obtain results: If it is negative then results will be available in 1-2 days, if positive the lab runs
30

Western Blot therefore results are delayed 10-14 days. If you want to obtain ELISA results call
ID fellow on call (below) and ask him/her to call virology for the results.
Infectious disease
-Fellow on call
-Antibiotic approval

Consult in Cerner.
760-0526.
before 4 pm 333-1704. After 4pm, call fellow on call

Nephrology
-Fellow on call
-Resident on call (After 5 pm)
-Dialysis
-Renal biopsy results

Consult in Cerner.
740-4371
740-5450
43900 43919
44600

Neurology
-Attending on call (no fellow)
-NCV/EMG/EEG

Consult in Cerner.
46519
Clinic U fill the required form

Neuropsychiatry
(Dr Klingerman)

689-2585

Occ. Med

45520

Palliative care

Consult in Cerner

Pulmonary
Consult in cerner
-Home oxygen
Call SW once patient meets criteria. In the bedside
chart write number of hours per day and liters/minute required- also on the bedside chart
document Pulse ox and PaO2. If the patient is followed by pulmonary fellow ask him to call the
home O2 nurse.
-PFTs
42900 and call fellow for approval
-Asthma
46495
Rheumatology

839-8959

OTHER DEPARTMENTS
Anesthesia:
CT surgery:
Colorectal surgery
Dental office
-Clinic D
Dietary
ENT
General surgery
GU surgery

333-1913 person on call, 333 1932

Fellow 839-8382
Consult in Cerner but
also must call fellow
47948
47723
Consult in Cerner
call 46519
333-1759
46519
31

Neurosurgery
OB/GYN
Oak Forest
Ophthalmology
Orthopedics
Pain
Plastic surgery
Podiatry
Psychiatry
-On call pager
PT/OT
Rehabilitation medicine
(Dr. Dysico)
Speech and language
Vascular surgery
-Vascular lab

839-2436
400-5257
708 687 7200
46519
46519
689-5664
46519
333-1847, office 45372
48001.
333-1918.
Both Consults in Cerner
43642
43600
46519
43640

General Medicine Clinic (GMC)

Scheduling
IRIS Lookup
IL BCCSP

48682
312 864 6415
1 888 522 1282

USEFUL NUMBERS
Administration
Admission office
Anticoagulation clinic

45500
42508
46327 refer pt through IRIS

Admitting /cross cover

Firm A
Firm B
Firm C
Family Practice

740-4815/ 839-2949
333-4375/ 740-5751
740-5161/ 400-7514
689-1477

Amputee clinic
Bed control
Blood bank

47910
41700
47470

Bronchoscopy
43250
Note if the patient has undergone bronchoscopy call the nurse in the bronchoscopy suite and
request to send the patient to clinic M for post bronchoscopy x-ray
Cardiology
-Exercise ECG and Holter
-CCU

43439
43002
32

Central sterile supply

42070

Cermak
-ER
-Pharmacy

773 674 5628

773 674 5623

Chief medical resident on call

Communications
Computer problems
Conference room scheduling
Core center
Dialysis
DOT
ECG

400-8254
41220
44357
47780
5724500
43920,43919
47891, pager 333-1684
43432, pager 333-1673

ER
Admitting
Red
Green
Blue

41577- charge attending

41390
41344
41437

HIS
Interpreter service

48055
45225

LAB
Main
47452
1.
2.
Add-ons
47454
3.
Blood gas
47090
Coagulation
47432
4.
5.
Cytology
47494
6.
Endocrine
47409
7.
Hematology
47440,47443
8.
Immunology
47480
9.
Microbiology
47410
10.
Send out- Tony
42490
11.
Urine
47428
12.
Pathology
47500
Note: call this number for expediting. Ask for the specimen case number, talk to the responsible
pathologist. Do mention that you need the results fast.
13.Virology
47422,47414
Library
Mammography

40506
43800

33

Medicine Department
-Michele Novak
-Queenie Mendonca
-Aida Calderon
-John Varghese
-Harsha Patel
-Jackie Sappington
Medical examiner
Medical records

47215
47223
47229
47218
47233
47358
666-0200
46260

Medicine consult pager

760-0559
MICU
43001(B), 43000(A)
Morgue
47523
MRI
43828
To order MRI Fill out the radiology requisition form take it with you to the MRI suite in the
basement, talk to the MRI attending (Dr. Egiebor) if approved place the order in CERNER the
day of the test.
Nuclear medicine
43700,43701, 43678 (Ms Moore)
For scheduling stress thallium, adenosine thallium etc plus place the order in Cerner
Occupational/Env. Medicine
636-0081
Appointments Stroger
45550
Appointments UIC
413-0369
Pacemaker problems
606-6989(pager Dorothy Gore)
Pain service
689-5664, 4-3220
Pastoral service
41245
Pharmacy ADR hotline
42235
Pharmacy Antibiotic Approval
333-1704
Pharmacy inpatient
42180
Pharmacy outpatient (B/C)
41607
Pharmacy outpatient (Stroger)
41608
Pharmacy Non-Formulary
333-2105 8am- 4pm, otherwise call
inpatient pharmacy 4-2180
Phlebotomy
46147
Note: check phlebotomy book on each floor before calling to see if your patient was drawn.
Poison control
800 222 1222
Radiology, Main (Clinic M)
43744
Radiology CT
43720
Radiology CTER (11pm-7am)
41263
Radiation Therapy
43838
Radiology observation
43764
Radiology ED (Dr. Gilkey)
43739
Radiology Resident (out of hours)
43743
Interventional Radiology
43752/ 43761
Reportable disease
7473741
Respiratory therapist
42250 pager 3331902
For immediate concerns call - otherwise the nurse will call
34

Rush paging:
312 942 6000
Rush Information:
312 942 5000
Risk management
839-3745
SBIRT
4-4448
Social Work Department
45071
6 East -> Bernadette Cornejo
400 4241
6 South-> rooms 11-25 Bernadette Cornejo
400 4241
rooms 31-44 Daniel Jimenez
400 6597
6 West-> Daniel Jimenez
400 6597
7 East-> Greg Osbeck
400 5596
7 South-> rooms 11-25 Greg Osbeck
400 5596
rooms 31-44 Deborah McGowan
400 6742
7 West-> Deborah McGowan
400 6742
8 East-> Sheila Gailey-Craig
400 6756
8 South-> rooms 11-25 Sheila Gailey-Craig
400 6756
rooms 31-44 Michael McLoughlin
606 6086
8 West-> Michael McLoughlin
606 6086
MICU/ CCU/ BICU-> Jonathan Platt
689 2982
ER
(Wed Sun)-> Borislava Pashova
333 1728
(3pm -11pm)-> Sylvia White
333 1728
NICU-> Gladys William
839 3253
Ped's/Ped's ICU/ OB-> Brenda Chandler
750 0276
TICU/NI CU/SICU-> Margaret Creedon
400 6461
For off hours call ER SW 3331728, cell phone 41593, voice mail 41230
GMC Social Worker-> 41427. Room R36.
Toxicology
Transportation home
Transportation inpatient
Transportation in charge
Ultrasound
Unit control
Utilization Review
Vascular lab/blood flow
WARDS:
6W: 45600
6S: 45650
7W: 45700
7S: 45751
8W: 45800
8S: 45851
OBS east: 41450
OBS west: 41510

45520
41083
42450
4000522
43780
46835
46766
43639
6E: 45634
7E: 45734
8E: 45834

MUSE system sign on-previous cardiology work up

1019
407567
01

35

PHARMACY CONTACT INFO

CLINICAL PHARMACISTS
Pontikes, Pamala - Manager
Ambulatory Care
Farias, Sol B.
Gutierrez, Patricia
Critical Care
Plewa, Angela - SICU, Neuro ICU
Stevkovic, Natasa - Trauma ICU, Burn
ICU
Xamplas, Renee - MICU
Emergency Medicine
Witsil, Joanne
Infectious Disease
Glowacki, Robert
Itozaku, Gail
Max, BlakeCORE Center
Vibhakar, SoniaCORE Center
Internal Medicine
Antonopoulos, Pete - Firm C, CCU
Ibrahim, Sonia - Firm B
Platakis, Aura - Firm A
Oncology
Yim, Barbara
Pediatrics
Ojand, Nahid
INPATIENT PHARMACY
B/C PHARMACY (ER and discharge
Rx)
STROGER PHARMACY
FANTUS PHARMACY
NON-FORMULARY REQUEST PAGER
ANTIBIOTIC APPROVAL PAGER

Pager/Ext.
312-333-1909
312-839-3043
312-390-2001
312-390-1424
312-606-6732
312-903-0625
312-740-6423
312-839-0019
312-333-1685
312-556-9970

312-760-0800
312-333-5109
312-390-1998
312-903-8322
312-400-5020
864-2180
864-1607
864-1608
864-6189, 6191
312-333-2105
312-333-1704

36

USEFUL OUTPATIENT CLINIC INFORMATION

Asthma
Burn
Breast Oncology
Cardiology
Colorectal surgery
CT surgery
Dermatology
Diabetes
Dialysis
Endocrinology
ENT
General surgery
GI
GU
Gynecology
Gyne/Oncology
Hematology
ID
Infusion center
Medical Consult
Neurology
Neurosurgery
Oncology
Oral Surgery
Orthopedics
Palliative
Pain Clinic
Plastic Surgery
Podiatry
Psychiatry
PT/OT
Pulmonary
Renal
Rheumatology
Sleep Clinic
Surgical Oncology
Vascular clinic
Vascular (vein mapping)
Vascular ABI

2nd Floor Fantus building

H
H/G
F
E
F
G
1st Floor Fantus building
J
1st Floor Fantus building
D
F
F
E
4th Floor Fantus building
H
H/G
Core Center 2020 W. Harrison
J
C
E
E
H/G
D
I
G
C
I
I
4th Fourth Floor Fantus Clinic
N
F
F
I
G
H
E
O
U

37

GMC SURVIVAL GUIDE

Disclaimer: The intention of this document is to provide easy access to answers for frequent
questions and situations encountered in GMC, as well also to provide guidance in management
of common cases.
The present document does not substitute the judgment and responsibility of the user.
Basic Rules
-During a session, reassignments for busy residents are done by the charge attending only
before 16:30. Acceptance of a reassignment is not optional.
-Intern on call: Interns who are on call will see only 2 patients and can leave early at 3 PM once
done.
inform charge attending immediately after arriving to the clinic. Reassignments will be done if
needed.
-For patient follow up interval, use your professional and clinical judgment. You can always
overbook by writing your initials on the right top corner of the appointment slip.
-All notes will be documented under General Medicine Outpatient using power notes and all
prescriptions should be made electronically.
Policies for Post Hospital Follow Ups
I. Patients without: GMC doctors:
1. Residents take all their night admissions and all patients admitted by a sub-intern or a
rotating resident into their GMC.
2. Interns take SOME of their day admissions into their GMC:
-Intern should have no more than 2 post hospital follow ups on any given GMC day.
-If the intern's post hospital slots are filled, the resident will take the patient into their clinic AND
keep the patient as part of their PCP panel. The exception is when intern will be on vacation or
in MICU immediately after the ward month. In those cases, the resident can identify up to eight
patients who they will see for the post hospital follow up, and then return to the intern for primary
care.
-If a patient has an upcoming GMC appointment with an MD he/she has never
seen in the clinic (either post hospital from prior admission or with new provider), post hospital
care and further GMC care should be provided by the admitting team.
II. Patients with a PCP Attending:
-The attending should be called when the patient is admitted.
-At the time of discharge, the resident should obtain a post hospital date from the
attending.
-The attending can not refuse the patient if he/she saw the patient at least once in the GMC
within the past 2 years
-If the attending is not able to see the patient in a timely fashion, the resident will
see the patient in his/her GMC for a post hospital FU.
-If you primary team is not able to reach PCP, at least one time follow up should be provided
38

with the discharging team residents. Any exception to this rule should be approved by
discharging team attending.
III. Patients with PCP Residents:
-The resident should be called when the patient is admitted.
-At the time of discharge, the patient can be scheduled for a post hospital visit with the PCP
resident, and he/she should be notified.
-If the PCP resident will not be in GMC (lCU or vacation), the discharging resident will see the
patient for |his/her post hospital FU.
IV. Exceptional Post Ward Rotations:
-When two or more members of the team will be out of clinic on the month following wards, you
may use the walk in provider to see some of the post hospital follow up patients.
-Patients should be given 2 appointments at discharge: one with a walk in provider and a latter
appointment with the resident or intern who will become the PCP.
-When you are scheduling patient for a walk in provider, please notify your GMC preceptor that
the patient will be coming. (If you are not able to reach your preceptor, you should notify the
educational coordinator for your clinic day).

HOW TO:
Admission to JSH from GMC:
-Elective admission:
Provide preadmission package (green folder, same as used on inpatient wards)
1. Ask RN for a pre-admission package and fill it out. Patient is to be admitted to your firm
2. Go to Start button on your computer -> Programs -> ED Databases -> Medicine assignments
-> obtain medicine assignment -> manual assignment to your own firm
3. Page on-call resident and endorse the patient (see plan of the day for pager number)
4. Have your patient present to the admission office next to the gift shop in the hospital. Room
1673
If patient is to be admitted the following day, still admit to your own firm and endorse to the team
that will be on call that day. Admitting resident will then enter the patient in the database when
patient gets bed.
-Admission to ER:
If patient condition requires:
1. Fill out the Physician Consultation Form and inform GMC nurse.
2. Call the ED at 4-1534 and ask to speak with charge nurse: endorse the patient
Anticoagulation Clinic referal:
Refer through IRIS. Waiting time can exceed one month, until then, provide your patient close
follow ups, sufficient lab slips for INR checkups, do not let you patient run out of medication,
obtain a valid phone number to contact your patient after every INR check.
39

Colonoscopy referal:
-For screening colonoscopy, ask your nurse to direct the patient to the Health Educator. (Office
location changes frequently). Provide several stickers.
-Diagnostic colonoscopy:
a. Place referral through IRIS, prepare patient as below.
b. Urgent cases: Call GI Clinic (43250 or 43252) for appointment.
All cases:
Instruct your patient for correct preparation and print a copy of the instructions that appear after
placing the referral or access them by clicking on View/print patient instructions on IRIS.
2. Prescribe: Bisacodyl 10mg 2 tabs (to be taken at noon 1 day prior to the procedure), golytely
1 gallon (to be drank at 5 PM 1 day prior to admission, preferably within 2-3 hours) and Fleet
enema (to be used at 5AM in the morning prior the colonoscopy)
Diabetic patients:
-Diabetic Group Visits:
Write Diabetes GMC group visit on top of an appointment slip. Write patient info. Place sticker.
Spanish groups are available, specify.
-Insulin education:
Ask your nurse to instruct the patient.
-If your patient needs a glucometer: complete a discharge form requesting that the patient
receive a glucometer (they are distributed in the clinic), and teaching if necessary (orders for
glucometers should not be written on a prescription nor submitted electronically to pharmacy).
Place the discharge form in the discharge basket in the respective firm.
-Dietician:
Write Refer to dietician on the top of a new appointment slip. Write pt info, place sticker.
-Goals:
Provide all you patients the ABC of Diabetes from your form rack.
A : HgA1c: <7%, Glucose before meals 90-130, no >180.
B: BP: 130/80.
C: LDL <100 (<70 if CAD), HDL m: > 40, f: >50. TGL <150.
-Ophthalmology exam: DM1 start 2-5 years after dx and in patient older than 10. DM2 start
screening at dx and once a year then after.
-Feet examination: Every visit. Complete exam for neuropathy including monofilament at least
once a year.
-Each visit: assess frequency of hypo/hyperglycemia, self monitored blood sugars, results,
regimen adjustment/adherence problems, tobacco and alcohol use, diet,
symptoms/complications.
Labs: Annually electrolytes, BUN, creatinine, lipids, microalbumin.
HgA1c: At least twice a year. Not at goal: every 3 months. At goal: every 6 months.
-Aspirin, statins, ACE inhibitor. Consider in all patients starting if appropriate.
-Pneumovax once prior to age 65yo, then repeat once after age 65yo
-If your patient is initiated on Insulin ask your nurse for education.
40

-Familiarize yourself with de Diabetes Guidelines in the Intranet.

EKG:
Ask your RN.
Geriatrics:
Senior Assessment Clinic (SAC). If you need extra help with patients 65+. Examples: memory
impairment, falls, incontinence, malnutrition, depression, etc.
Fill out SAC form and send your patient to the appointment desk with the completed form. Or
place referral through IRIS.
GMC plus:
Provide to your patient the GMC plus information slip located in each office. Patient can call
46912 with questions, advice, appointments, and refills.
Health educator:
Asthma/COPD inhalator technique, smoking cessation strategies.
Back hall of firm B clinic. Am only.
Afternoon: ask your nurse for inhalator and peak flow techniques or have your patient come any
am with health educator.
IRIS:
Interns: Access IRIS trough the intranet. Refer for tests and subspecialty consults. You may
choose to place your referral after your clinic session but be aware that some test require
immediate action. (i.e x-rays require giving your pt. a copy), other tests like colonoscopy require
instructing, providing printed information and prescribing meds for adequate preparation.
Ordering hand x-rays before a rheumatology consult for RA or PFTs before a pulmonary
consult for COPD, are examples of required action before placing a subspecialty consult.
-Residents may request the nurse to place IRIS referral for you (clerks do not place referrals in
IRIS): complete the discharge form requesting referral and reason for referral, write patient's
phone number on the top of the discharge form, place the discharge form in the discharge
basket in the respective firm. Make sure all pre-testing has been completed or ordered.
Lifestyle Center:
For healthy eating and exercising. Place referral through IRIS; provide a copy to your patient.
Mammogram:
a. Uninsured patients: provide IBCCP phone number 1-888-522-1282 and instruct the patient
to call.
(Of note: if patient is referred to BCCSP-RN clinic or GMC-BCCSP clinic (Dr Pamela Smith) for
pap and breast exam, they will get a breast exam, but they will NOT get a mammogram referral)
b. Insured patients: Fill out the Universal Order Form for Mammogram located in each office.
Instruct the patient to go to the medical center of her preference.
-If form is not available obtain it through IRIS -> Miscellaneous Functions (at the bottom of the
first screen) -> View/print patient instructions -> Forms for offsite services -> Universal order

41

form for mammogram at any outside institution. Print this form and fill it out, then give it to the
patient
Palliative:
For patients who 1. Are terminally ill, 2. Have advanced medical illness (cancer, COPD< CHF,
etc), 3. Need assistance with symptom management, 4. In need of establishing goal of care.
Refer through IRIS. Urgent cases call pager on Plan of the Day. Dr. Dearmant (pager 8293285).
Bereavement Counselor: Call Jacqueline Linko 4-4431
PAP:
-Write on top of the appointments slip GMC-BCCSP CLINIC. Write patient info. Place sticker.
-Alternatively can place referral through IRIS to BCCSP-RN clinic: go to Breast clinics ->
choose Breast and/or Cervical Cancer Screening option.
Smoking cessation:
For motivated patients only. Health educators are available in the back hall of firm B clinic in
the am clinic only. Afternoon: Refer trough IRIS.
Social worker:
-Refer for home visiting, physical therapy, food services, etc. Refer also patients who need
Durable Medical Equipment (wheelchair, O2 tanks, etc.)
-Room 36 firm C. Talk to Social Worker directly, bring stickers.
-Afterhours: Fill out a Physician Consultation Form; include patient phone number and your
name and pager. Dispose form in the basket at room 36 firm C.
-Urgent cases: Call 46138, 41247.
Scheduling:
-Centralized scheduling: 312-864-0200 for making, rescheduling and retrieving information
about appointments.
-Rescheduling missed appointments, call 46610.
Subspecialties, All:
Refer through IRIS. Urgent cases call pager on Plan of the Day.
SCREENING:
Discuss with preceptor, guidelines change frequently.
-Cervical cancer (PAP): Start at age 21. Every 1-3 years depending on risk factors. Make sure
patient has uterus, and if s/p hysterectomy you need to document with path report or records
that it was due to benign reasons, otherwise will need further pap smears.
-Breast Ca (Mammogram): Yearly starting at age 40 years. May decide to start at age 50yo or
do mammograms every other year AFTER discussion of risks vs. benefits with patient.
-Colon Ca: All > 50 years old. High risk at age 40 or 10 years before the youngest affected
family member.
Colonoscopy every 10 years, or FOBT annually, or FOBT every 3 years

42

All equally effective. Stop at age 75 or if life expectancy <10 years.

Other:
Cholesterolknow your goal

Risk category

LDLcholesterol
goal

Coronary
heart <100 mg/dL
disease (CHD) or
CHD risk equivalent
2 or more risk 130 mg/dL
factors (10-year risk
20 percent)
0 to 1 risk factor
160 mg/dL

LDL-cholesterol
level at which to
initiate therapeutic
lifestyle changes
100 mg/dL

LDL-cholesterol level at
which to consider drug
therapy

130 mg/dL

160 mg/dL

160 mg/dL

190 mg/dL

130 mg/dL

USEFUL NUMBERS:
Admission Office: 42508
Anticoagulation clinic: 46327
ASC: 46500
Centralized Scheduling: 312 864-0200
ER: when endorsing a patient 41534, Nurse in charge 41300, Triage 41317, Charge attending
41576.
Interpreter: 45225
Lab: 47400
Medical Records: 46260
Pager numbers: 46519
Pharmacy, Fantus: 46189
Rescheduling missed appointments: 46610
Police: 48097

Disclaimer

The intern survival guide serves as a guide not as a policy. Each decision must be based on the
individual clinical situation and the judgment of the physicians on the team.

43