Hopkins Intern Survival Guide.pdf

The John H. Stroger, Jr. Hospital Intern Survival Guide

2012—2013 JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY CHICAGO, ILLINOIS

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Topic

Page

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

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

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

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Palliative Care

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DVT prophylaxis Anticoagulation Guidelines Clopidogrel Guidelines Opioid Equianalgesic Table Narcotic Prescription

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Autopsy request Phone Numbers Outpatient Clinics

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GMC Survival Guide

38-43

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INTERN RESPONSIBILITIES: 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 team’s 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 call—sign outs are at 11 am For emergencies during cross-cover, contact the senior resident ASAP. If you need help, please call your Chie f 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 including allergies, family history and social 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 in “Encounter pathway” by typing typing “SOAP Note”. When you are done with your note, click ‘Sign/Submit’ ‘Sign/Submit’ to indicate indicate a completed note.

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DISCHARGE SUMMARY - written by residents in Power note under “Discharge Summary—Inpatient”, should be complete before the DC order is placed. PROCEDURE NOTE: This will be done in Clinical 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-Chart—these 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 for  3am under routine under routine lab. 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 collect  and print  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  for 8am 8am timed . If your patient requires morning labs, order everything for 8am timed so pt is not stuck twice. 3. Nurses collect collect urine and stool samples. Select Select nurse  provider collect  and  print label . Also enter  another order for “nurse “nurse collect ” and choose the specimen type. 4. Respiratory therapist collect collect sputum samples for gram stain, AFB and fungal cultures. Order for one sample in the morning and one in the afternoon.

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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 DAILY—all 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 a t 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 (CII—CV). 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 PO—have 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. Don’t 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 a ssist 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 Cytology—send 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 

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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 patient’s 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

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NPO

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Eating

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Tube Feeds1

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▪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

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TPN1

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If patient is on insulin 70/30, give 70% of da ily dose as glargine once daily (no rapid acting) If patient is on NPH/Reg, continue 100% of NPH as glargine on ce 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 ½ hour before breakfast and 1/3 of TDD ½ hour before dinner OR - With 1/2 of TDD of insulin ½ hour before breakfast and 1/2 of TDD ½ hour before dinner.

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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 • • •

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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

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DIABETIC KETOACIDOSIS (DKA) Clinical suspicion: h/o DM, Vomiting Check BMP (anion gap, K+), urine/blood ketones, ABG’s (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 lo cal laboratory) 3. Serum bicarbonate ≥18 mEq/L 4. Venous pH >7.30 Calculate SQ dose Known Diabetes: same dose as before DKA Insulin naïve: 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 Dialysis—load 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 ne eded 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

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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 Chvostek’s & Trousseau’s 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 

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Electrolyte Replacement Cont’d. (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 o f elemental calcium 1 g calcium gluconate equals 90 mg elemental calcium Bicarbonate Calculated bicarb replacement in mEq = 0.1 x (goal bicarb—actual bicarb) X weight (Kg) Given orally as citric acid/sodium citrate (Bicitra, Scholl’s 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

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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 don’t 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 pt’s 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 1 2 3 4

Oriented & can do serial additions Cannot do additions or uncertain of date Disoriented for date by <2 days Disoriented for date by > 2 days 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 DT’s; assoc. w/ head trauma , focal neurological signs, or fever. Patients with hallucinations: If pt also disoriented, treat as DT’s. 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 la st 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.

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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 Benefit 5 : §

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

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§ §

§

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 physicians—the patient’s attending physician and the hospice medical director. This is based on the physician’s clinical judgment regarding the normal course of  the individual’s illness. The patient should also meet the following criteria: The patient’s 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 Benefit 5 : 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 a ides, 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 Physician’s Guide by Illinois Sate Hospice Organization.

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DVT PROPHYLAXIS If any patient has risk for bleeding or actual bleeding, start Risk Level Low risk

Recommended therapy Early mobilization

<40 y old, minor procedure NO additional risk factors Moderate risk 40-60 years <40 with additional risk factors and minor surgery High risk

Low Dose Unfractionated Heparin (LDUH) 5000 units sc q8h

>60 years 40-60 years with additional risk factors Highest risk Surgery in patient with multiple risk factors Hip/knee arthroplasty

LDUH 5000 units sc q 8h LDUH 5000 U sc q8h + Gradual compression device,

Major trauma them on sequential compression devices (SCD’s). Please refer to the anticoagulation guidelines on the intranet for updated information.

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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 Anticoagulants—Prophylaxis Dosing Unfractionated Heparin (UFH)

Enoxaparin (Lovenox)

Fondaparinux (Arixtra)

CrCl less than 30ml/min

RECOMMENDE D

AVOID—requires 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

Surgery—general, 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

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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 Anticoagulants—Treatment Dosing

CrCl less than 30ml/min CrCl 30-60ml/min

Unfractionated Heparin (UFH)

Enoxaparin (Lovenox)

Fondaparinux (Arixtra)

RECOMMENDED

CrCl 15-30ml/min—1mg/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

Atrial Fibrillation (bridge to warfarin)

Heparin infusion— see intranet

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

Mechanical Heart Valve (bridge to warfarin)

Heparin infusion—see intranet

1 mg/kg SC q12h

Limited data <50 kg—5mg 50-100kg—7.5mg >100kg—10mg SC q24h

Cardioembolic Stroke

Heparin infusion—see intranet

1.5 mg/kg SC q24h (preferred) OR 1 mg/kg SC q12h

Limited data <50 kg—5mg 50-100kg—7.5mg >100kg—10mg SC q24h

Thromboembolic Events in Pregnancy

Heparin infusion—see intranet

1 mg/kg SC q12h

Limited data <50 kg—5mg 50-100kg—7.5mg >100kg—10mg SC q24h

DVT/PE Treatment

Heparin infusion—see intranet

1.5 mg/kg SC q24h (preferred) OR 1 mg/kg SC q12h

<50 kg—5mg SC q24h 50-100kg—7.5mg SC q24h Preferred for pts > 100 Kg 10mg SC q24hr 

25

DVT/PE Treatment in Patients with Cancer 

Heparin infusion—see intranet

1.5 mg/kg SC q24h

<50 kg—5mg SC q24h 50-100kg—7.5mg SC q24h >100kg—10mg 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 dura tion 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 a t 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 Codeine 30 mg + Acet 325 mg (Tylenol #3) Hydrocodo ne 5 mg + Acet 325 mg (Norco) Oxycodone 5 mg + Acet 325 mg (Percocet)

PARENTERAL (mg) 10 1.5

DURATION OF ACTION 3-4 hrs 3-4 hrs

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

0.1-0.1

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

10 75-100

6-8 hrs 2-3 hrs

200

--

3-4 hrs

30

--

3-4 hrs

20

--

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 patient’s follow-up appointment

For a list of available medications, please see formulary page in Micromedex, available through Cerner under “clinician links”

Sample Narcotic Prescription

PT’s 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 patient’s 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 an y 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 relative’s 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 patient’s 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 

Consult in cerner  Pulmonary -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

43250 Bronchoscopy 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 1. Main 47452 2. Add-ons 47454 3. Blood gas 47090 4. Coagulation 47432 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 CT—ER (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 45071 Social Work Department 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

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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, Blake—CORE Center Vibhakar, Sonia—CORE 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

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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 1 st Floor Fantus building D F F E 4 th 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

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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.

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-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 

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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

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