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

The John H. Stroger, Jr.
Hospital Intern Survival
Guide
2012—2013
JOHN H. STROGER, JR.
HOSPITAL
OF COOK COUNTY
CHICAGO, ILLINOIS
1

Topic Page
Responsibilities 3
Documentation 3
Admit orders 4
Common ward orders 5
-Transfusion orders 6
-Discharge orders 6
-Procedure orders 8
Cermak Patients 8
Insulin Protocols 9-10
Contrast Nephropathy Prevention Protocol 11
Helpful Topics:
Mini Mental Exam 11
DKA 12
Pharmacy Pearls 12-14
Electrolyte Replacement Guidelines 14-16
Management of Hyperphosphatemia in CKD/ESRD 16
Substance abuse 17
CIWA score 18
Alcohol abuse 17-18
Opioid dependence 19
Methadone program 20
Nicotine abuse 20
Palliative Care 20
DVT prophylaxis 22
Anticoagulation Guidelines 23-26
Clopidogrel Guidelines 26
Opioid Equianalgesic Table 27
Narcotic Prescription 28
Autopsy request 29
Phone Numbers 30-37
Outpatient Clinics 37
GMC Survival Guide 38-43
2

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 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 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.
3

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 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 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.
4

Do Not Use Potential Problem Use Instead
U (unit) Mistaken for 0 (zero),
the number 4, or “cc”
IU (international
unit)
Q.D., QD, q.d., qd
(daily)
Q.O.D., QOD,
q.o.d. (every other
day)
Do not use trailing
zero
(5.0 mg should be
5 mg)
Always use a
leading zero
(.5mg should be
0.5mg)
MS
MSO4, MgSO4
Mistaken for “IV”
(intravenous) or the
number 10
Mistaken for each
other.
The period after Q
mistaken for I, the O
mistaken for I
Write “unit”
Write
“international
unit”
Write “daily”
Write “every
other day”
Decimal point is missed Write Xmg
May mean morphine
sulfate or magnesium
sulfate
Write 0.Xmg
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 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 (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 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
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
8

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
• ▪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

TPN 1 • 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 Basal dose
adjustment
If FBS is < 70 mg/dl or
hypoglycemic episodes
Decrease dose by 20%
If FBS is 70-100 mg/dl May decrease dose by
10%
If FBS is >140mg/dl and < Increase dose by 10%
200 mg/dl and no
hypoglycemic episodes
of the previous dose
If FBS is > 200 mg/dl and Increase dose by 20%
250 mg/dl and Increase dose by 30%
no hypoglycemic episodes 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.
10

PREVENTION OF CONTRAST INDUCED NEPHROPATHY (CIN)
At risk patients:
• Creat> 1.1
• GFR

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 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

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 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

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 Replace with
< 1 mg/dL 8 – 12 g IVPB**
1 – 1.4 mg/dL 4 – 8 g IVPB**
1.5 – 1.8 mg/dL 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
1.8 – 2.5
mg/dL
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
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 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 of 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
Treatment
Goals:
Management of Hyperphosphatemia for Patients with Advanced CKD or ESRD
SERUM PHOSPHORUS LEVELS

Step 3:
Notes:
If phosphorus
still >5.5 mg
/dL
↓
Add noncalcium
based
binder
e.g.
Sevelamer
along with
calcium if
necessary
If phosphorus still >5.5 mg /dL
↓
Add Aluminum Hydroxide 5-10 ml tid with meals if
necessary (only up to 1-2 weeks)
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
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.
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
CIWA SCORE
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)
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
4 Disoriented for place &/or person
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 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 6-
7 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.
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 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 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.
4 Adapted from Teno JM and Lynn J. Putting Advance-Care Planning into Action. Journal of Clinical
Ethics;7;No.3;Fall 1996:205-213.
5 Adapted from Hospice Care: A Physician’s Guide by Illinois Sate Hospice Organization.
21

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

INR
Bleeding
present
INR >
No
therapeutic
significant
range but
bleeding
10
No
significant
bleeding
Any INR with serious
or life-threatening
bleeding
Recommended action
Lower or omit warfarin dose and monitor INR more frequently
Resume warfarin at a lower dose when INR is in therapeutic range
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
a lower dose when INR is in therapeutic range
Vitamin K NOT recommended (grade 2B) per 2012 ACCP Antithrombosis guidelines
Hold warfarin and administer 2.5 to 5mg ORAL vitamin K (grade 2C, ACCP 2012). INR likely
to reduce in 24 to 48 hours. Monitor INR more frequently and administer more vitamin K as
needed. Resume warfarin at a lower dose when INR is in therapeutic range
Hold warfarin and administer 10 mg vitamin K by slow IV infusion (may repeat q12h);
supplement vitamin K infusion with FFP. Monitor and repeat as needed.
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
CrCl less than
30ml/min
Unfractionated
Heparin (UFH)
RECOMMENDE
D
CrCl 30-60ml/min RECOMMENDE
D: No
adjustment
needed
Hospitalized
medical, nonsurgical
patients
Enoxaparin
(Lovenox)
AVOID—requires factor Xa
monitoring
Preferred
product for patients
requiring > 10 days duration
Prophylactic Dose
Fondaparinux
(Arixtra)
Contraindicated
AVOID
LIMIT
TREATMENT TO 7-10 DAYS
UFH Enoxaparin Fondaparinux
5000 units SC
q8h
23

Surgery—general,
laparoscopic,
vascular
Gynecologic
surgery
5000 units SC
q8h
5000 units SC
q8h
Thoracic surgery 5000 units SC
q8h
Coronary bypass
surgery
5000 units SC
q8h
Abdominal surgery 5000 units SC
q8h
Knee arthroplasty
with additional risk
factors
Knee replacement
surgery
Hip replacement
surgery
Hip fracture
surgery with
additional risk
factors
Spine surgery with
additional risk
factors
Neurosurgery 5000 units SC
q8h
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h OR 40mg SC q24h up
to 14 days
2.5mg SC q24h*
2.5mg SC q24h AND intermittent
pneumatic compression 1*
2.5mg SC q24h*
40mg SC q24h 2.5mg SC q24h*
40mg SC q24h 2.5mg SC q24h
UFH Enoxaparin Fondaparinux
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h OR 40mg SC q24h up
to 14 days
30mg SC q12h
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
2.5mg SC q24h*
2.5mg SC q24h
2.5mg SC q24h
2.5mg SC q24h
24

Heparin induced
thrombocytopenia
(HIT)
CONTRAINDICA
TED
CONTRAINDICATED * 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
Unfractionated
Heparin (UFH)
CrCl 30-60ml/min RECOMMENDED:
No adjustment
needed
Unstable
Angina/NSTEMI
Enoxaparin
(Lovenox)
RECOMMENDED CrCl 15-30ml/min—1mg/kg SC q24h
CrCl less than 15ml/min: AVOID—
requires factor Xa monitoring
Preferred
product for patients
requiring long-term treatment
Treatment Dose
Fondaparinux
(Arixtra)
Contraindicated
AVOID
LIMIT
TREATMENT TO 7-10 DAYS
UFH Enoxaparin Fondaparinux
Heparin infusion—
see intranet
STEMI Heparin infusion—
see intranet
Atrial
Fibrillation (bridge
to
warfarin)
Mechanical Heart
Valve (bridge to
warfarin)
Cardioembolic
Stroke
Thromboembolic
Events in
Pregnancy
DVT/PE
Treatment
Heparin infusion—
see intranet
Heparin
infusion—see
intranet
Heparin
infusion—see
intranet
Heparin
infusion—see
intranet
Heparin
infusion—see
intranet
1 mg/kg SC q12h 2.5 mg SC q24h
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
1 mg/kg SC q12h Limited data
100kg—10mg SC q24h
1.5 mg/kg SC q24h (preferred) OR 1
mg/kg SC q12h
Limited data
100kg—10mg SC q24h
1 mg/kg SC q12h Limited data
100kg—10mg SC q24h
1.5 mg/kg SC q24h (preferred) OR 1
mg/kg SC q12h
100 Kg
10mg SC q24hr
25

DVT/PE
Treatment in
Patients with
Cancer
Heparin Induced
Thrombocytopenia
(HIT)
Heparin
infusion—see
intranet
Contraindicated
AVOID
1.5 mg/kg SC q24h 100kg—10mg SC q24h
Contraindicated
AVOID
Call for heme
consult
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
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
ACS/MI Bare Metal Stent (BMS) 300-600 mg load* / 75 mg po
daily
ACS/MI with DES or other off-label 300-600 mg load* / 75 mg po
use of DES
daily
DES patients who have sustained 300-600 mg load* / 75-150
stent thrombosis
†
mg po daily
Recommended duration of therapy
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
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 5 th 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) PARENTERAL DURATION OF
(mg)
ACTION
Morphine 30 10 3-4 hrs
Hydromorp
hone
7.5 1.5 3-4 hrs
Oxycodone 20 - 3-4 hrs
Fentanyl Transdermal (TD)
0.1-0.1 5-10 min, iv
25 mcg/hr =
50 mg/day of morphine
48-72 hrs TD
Methadone 20 10 6-8 hrs
Meperidine Not recommended 75-100 2-3 hrs
Codeine 30
mg + Acet
325 mg
(Tylenol #3)
Hydrocodo
ne 5 mg +
Acet 325
mg (Norco)
Oxycodone
5 mg +
Acet 325
mg
(Percocet)
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”
PT’s Address
Strength,
Dose,
Frequency
DEA #
Sample Narcotic Prescription
Quantity (Numeric and Spelled)
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 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 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: Consult in Cerner
-CCU on call 333-1922
-Echo lab 43424
-Echo scheduling 43404
-Echo reading room 43430
-Catheterization lab 43404, 06, 55
-Heart failure clinic 43437
-Carol Turner (Heart failure) 760-0615
-Clinic appt (Barbara Bradford) 43402
-ECG 43432, pager 333 1687
Critical care (MICU): 333-1735
Dermatology 1st no. 760-0696, alt: 740-8087
Endocrinology Fellow 740-2369
Gastroenterology Consult in Cerner
-GI fellow 514-2591
-Endoscopy 43250, 43252
Hematology/ Oncology Place consults in Cerner under hematology or medical
oncology.
-Appointments (Gloria) 47250.
-Fellow on call 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 Consult in Cerner.
-Fellow on call 760-0526.
-Antibiotic approval before 4 pm 333-1704. After 4pm, call fellow on call
Nephrology Consult in Cerner.
-Fellow on call 740-4371
-Resident on call (After 5 pm) 740-5450
-Dialysis 43900– 43919
-Renal biopsy results 44600
Neurology Consult in Cerner.
-Attending on call (no fellow) 46519
-NCV/EMG/EEG Clinic U – fill the required form
Neuropsychiatry 689-2585
(Dr Klingerman)
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: 333-1913 – person on call, 333 1932
CT surgery: Fellow 839-8382
Colorectal surgery Consult in Cerner but
also must call fellow
Dental office 47948
-Clinic D 47723
Dietary Consult in Cerner
ENT call 46519
General surgery 333-1759
GU surgery 46519
31

Neurosurgery 839-2436
OB/GYN 400-5257
Oak Forest 708 687 7200
Ophthalmology 46519
Orthopedics 46519
Pain 689-5664
Plastic surgery 46519
Podiatry 333-1847, office 45372
Psychiatry 48001.
-On call pager 333-1918.
PT/OT Both Consults in Cerner
Rehabilitation medicine 43642
(Dr. Dysico)
Speech and language 43600
Vascular surgery 46519
-Vascular lab 43640
General Medicine Clinic (GMC)
Scheduling 48682
IRIS Lookup 312 864 6415
IL BCCSP 1 888 522 1282
USEFUL NUMBERS
Administration 45500
Admission office 42508
Anticoagulation clinic 46327 refer pt through IRIS
Admitting /cross cover
Firm A 740-4815/ 839-2949
Firm B 333-4375/ 740-5751
Firm C 740-5161/ 400-7514
Family Practice 689-1477
Amputee clinic 47910
Bed control 41700
Blood bank 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 43439
-CCU 43002
32

Central sterile supply 42070
Cermak
-ER 773 674 5628
-Pharmacy 773 674 5623
Chief medical resident on call 400-8254
Communications 41220
Computer problems 44357
Conference room scheduling 47780
Core center 5724500
Dialysis 43920,43919
DOT 47891, pager 333-1684
ECG 43432, pager 333-1673
ER
Admitting 41577- charge attending
Red 41390
Green 41344
Blue 41437
HIS 48055
Interpreter service 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 40506
Mammography 43800
33

Medicine Department
-Michele Novak 47215
-Queenie Mendonca 47223
-Aida Calderon 47229
-John Varghese 47218
-Harsha Patel 47233
-Jackie Sappington 47358
Medical examiner 666-0200
Medical records 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
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 45520
Transportation home 41083
Transportation inpatient 42450
Transportation in charge 4000522
Ultrasound 43780
Unit control 46835
Utilization Review 46766
Vascular lab/blood flow 43639
WARDS:
6W: 45600 6S: 45650 6E: 45634
7W: 45700 7S: 45751 7E: 45734
8W: 45800 8S: 45851 8E: 45834
OBS east: 41450 OBS west: 41510
MUSE system sign on-previous cardiology work up
1019
407567
01
35

PHARMACY CONTACT INFO Pager/Ext.
CLINICAL PHARMACISTS
Pontikes, Pamala - Manager 312-333-1909
Ambulatory Care
Farias, Sol B. 312-839-3043
Gutierrez, Patricia 312-390-2001
Critical Care
Plewa, Angela - SICU, Neuro ICU 312-390-1424
Stevkovic, Natasa - Trauma ICU, Burn
ICU 312-606-6732
Xamplas, Renee - MICU 312-903-0625
Emergency Medicine
Witsil, Joanne 312-740-6423
Infectious Disease
Glowacki, Robert 312-839-0019
Itozaku, Gail 312-333-1685
Max, Blake—CORE Center 312-556-9970
Vibhakar, Sonia—CORE Center
Internal Medicine
Antonopoulos, Pete - Firm C, CCU 312-760-0800
Ibrahim, Sonia - Firm B 312-333-5109
Platakis, Aura - Firm A 312-390-1998
Oncology
Yim, Barbara 312-903-8322
Pediatrics
Ojand, Nahid 312-400-5020
INPATIENT PHARMACY 864-2180
B/C PHARMACY (ER and discharge
Rx) 864-1607
STROGER PHARMACY 864-1608
FANTUS PHARMACY
864-6189, -
6191
NON-FORMULARY REQUEST PAGER 312-333-2105
ANTIBIOTIC APPROVAL PAGER 312-333-1704
36

USEFUL OUTPATIENT CLINIC INFORMATION
Asthma 2 nd Floor Fantus building
Burn H
Breast Oncology H/G
Cardiology F
Colorectal surgery E
CT surgery F
Dermatology G
Diabetes 1 st Floor Fantus building
Dialysis J
Endocrinology 1 st Floor Fantus building
ENT D
General surgery F
GI F
GU E
Gynecology 4 th Floor Fantus building
Gyne/Oncology H
Hematology H/G
ID Core Center 2020 W. Harrison
Infusion center J
Medical Consult C
Neurology E
Neurosurgery E
Oncology H/G
Oral Surgery D
Orthopedics I
Palliative G
Pain Clinic C
Plastic Surgery I
Podiatry I
Psychiatry 4 th Fourth Floor Fantus Clinic
PT/OT N
Pulmonary F
Renal F
Rheumatology I
Sleep Clinic G
Surgical Oncology H
Vascular clinic E
Vascular (vein mapping) O
Vascular ABI 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: 180.
B: BP: ≤130/80.
C: LDL 50. TGL

-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 829-
3285).
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