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MODULE 27: AFTER-HOURS, NIGHTS & ON-CALL REALITIES
Section 27.2: “Do I Wake the On-Call?” The Decision Ladder
A Step-by-Step Framework for High-Stakes Communication When You Are the First Line of Defense.
SECTION 27.2
“Do I Wake the On-Call?” Decision Ladder
Building the confidence and the competence to make the most stressful call of the night shift.
27.2.1 The “Why”: The Stewardship of Attention
At 03:00, a page to the on-call resident is not a simple request for information. It is a powerful clinical intervention with significant consequences. You are pulling a clinician from a state of rest—a resource that is in critically short supply—and forcing them to engage in high-stakes decision-making while cognitively impaired from sleep. This act must never be taken lightly. The decision to wake an on-call provider is a careful balancing act between two of your most sacred professional duties: your duty to protect your patient from harm, and your duty to be a responsible steward of the healthcare team’s limited resources, which includes their sleep, time, and attention.
Waking a provider for a trivial or avoidable reason is not a minor faux pas; it is a significant withdrawal from your professional bank of trust. It can lead to “pager fatigue” for the provider, making them less responsive to future alerts, and it damages your credibility. Conversely, failing to make a necessary call for fear of “bothering” someone is a catastrophic, and potentially career-ending, error. The anxiety surrounding this decision is immense for new hospital pharmacists. The purpose of this section is to eliminate that anxiety by replacing it with a clear, logical, and defensible decision-making framework. This “Decision Ladder” will give you the confidence to know not only when to make the call, but how to make it perfectly.
27.2.2 The Analogy: From Calling Your Manager to Launching the Rescue Helicopter
A Deep Dive into the Analogy
In your retail practice, when you face a problem you can’t solve—a major system outage, a security concern—you call your pharmacy manager or supervisor. This is like calling for your shift supervisor. The barrier to making the call is relatively low. It may be inconvenient for your manager, but it is an expected part of their job to provide operational support, and the situation is rarely life-or-death.
As the after-hours pharmacist, you are the lone park ranger deep in a vast, remote wilderness. You have a powerful satellite radio, but it connects directly to the pilot of a rescue helicopter who is off-duty and asleep. The act of waking them is not a simple request; it is the decision to launch the rescue helicopter. Launching the helicopter is a massive use of resources and it carries its own risks. Before you ever touch that radio, you must perform a rapid but thorough assessment of the situation:
- Assess the Victim: Is the hiker you’ve found simply lost with a twisted ankle? Or do they have a life-threatening injury? (This is Rung 1: The Imminent Harm Question).
- Use Your Own Tools: Can you provide first aid, splint the ankle, and stabilize the hiker with your own equipment until morning? (This is Rung 2: The Pharmacist Intervention Question).
- Prepare Your Report: If you do need to call, are you prepared to give the pilot the exact GPS coordinates, the patient’s status, and the nature of the terrain for landing? (This is Rung 3: The Information Sufficiency Question).
You don’t launch the helicopter for a sprained ankle. But you absolutely do for a severe injury. Your judgment is all that stands between a wasted resource and a preventable death. This Decision Ladder is your field protocol for making that critical launch decision.
Masterclass Part 1: The Decision Ladder Framework
This is a sequential, four-question framework. You must proceed from Rung 1 to Rung 4 in order. If you get a “YES” on Rung 1, you do not need to proceed. If you get a “YES” on Rung 2, you have found your answer. This structured approach prevents panic and ensures your decisions are logical and defensible.
Rung 1: The Imminent Harm Question
The Question: “Is there a risk of imminent, significant, and irreversible patient harm in the next 1-2 hours if I do nothing and wait until the morning team arrives?”
The Rule: If the answer is YES, you do not climb further. YOU ALWAYS CALL. This is the prime directive. Fear of bothering someone is never an excuse to allow patient harm.
The “Always Call” Scenario List:
If your situation falls into any of these categories, you have an ethical and professional obligation to call.
| Scenario | Rationale for Calling |
|---|---|
| Code Blue / Rapid Response / Code Stroke | These are active, life-threatening emergencies. Your expertise is required immediately. |
| Critical Lab Values | A lab value that signals immediate danger (e.g., K+ > 6.0, Glucose < 50, INR > 8, a critically high drug level). A delay in treatment could lead to arrhythmia, seizure, or major hemorrhage. |
| STAT order for a Life-Sustaining Medication that is Incorrect or Ambiguous | A STAT order for a vasopressor drip with no titration parameters, a STAT insulin order that appears to be a 10-fold overdose. The order is for an emergency, but is itself unsafe. You must clarify before dispensing. |
| Sudden, Acute Change in Patient Status Related to a Medication | A nurse calls to report a patient’s blood pressure is 70/40 after receiving a new antihypertensive, or a patient has a sudden drop in respiratory rate after a dose of an opioid. |
| Absolute Contraindication Identified | You discover a new order for a medication to which the patient has a documented anaphylactic allergy, or an order for a teratogenic drug in a newly-pregnant patient. |
Rung 2: The Pharmacist Intervention Question
The Question: “If the answer to Rung 1 is NO, is there a temporary, safe, pharmacist-driven action I can take to stabilize the situation and bridge the patient safely until morning?”
The Rule: If the answer is YES, you should take the independent action, document it clearly, and add it to your morning handoff. This demonstrates your autonomy and respects the on-call provider’s time.
Your “Default Safe Moves” Playbook:
These are common, professionally acceptable interventions you can often perform without an immediate physician order (always follow your institution’s specific policies).
| Scenario | Your “Default Safe Move” & Documentation |
|---|---|
| A patient’s blood pressure is soft (e.g., 95/55) and their next dose of a routine antihypertensive is due. | Action: Hold the dose. Documentation: “Held 22:00 dose of lisinopril due to SBP in the 90s. Will notify primary team in AM to re-evaluate need for dose adjustment. Patient stable.” |
| A patient on a heparin drip has a moderately elevated aPTT that, per protocol, requires a dose hold or rate decrease. | Action: Instruct the nurse to take the action specified in the protocol. Documentation: “Per heparin protocol, instructed RN to decrease rate to 10 units/kg/hr for aPTT of 125. Will recommend new rate to primary team in AM.” |
| A TPN or other critical infusion is due to run out at 04:00 and there is no replacement bag. | Action: Hang a bag of a “safety” solution to prevent a metabolic crisis (e.g., D10W at the same rate for a TPN). Documentation: “Patient’s TPN bag expired at 04:00. Hung D10W at 80 mL/hr to prevent hypoglycemia pending new TPN from morning shift. Notified RN.” |
| A non-urgent order is incomplete (e.g., PRN Tylenol missing a frequency). | Action: Park the order. Documentation: “Order parked pending clarification of frequency. Will add to morning handoff for day shift to follow up with provider.” |
Rung 3: The Information Sufficiency Question
The Question: “If I cannot act independently and must make the call, have I gathered all the necessary information to present a clear, concise case and a specific recommendation?”
The Rule: If the answer is NO, you are not ready to call. Waking a provider only to be unable to answer their first follow-up question is a major credibility killer. You must prepare your “briefing packet” before you page.
Your Pre-Call Briefing Packet Checklist
Before you page, have the answers to these questions open in the chart or written on your worksheet:
- Patient ID: Full Name, MRN, and Room Number.
- The Core Problem (SBAR format):
- S: “The patient’s potassium is 5.9.”
- B: “He has CKD stage 4 and was just started on lisinopril yesterday.”
- A: “This is significant hyperkalemia, likely from the new ACE inhibitor.”
- R: “I recommend we give one dose of Kayexalate and hold the lisinopril.”
- Key Data: The full set of recent vital signs, the full BMP/CBC, and the patient’s code status.
- What You’ve Already Done: “I’ve already checked the MAR to ensure no extra doses were given.”
Rung 4: The “Who to Call” Question
The Question: “Have I identified the correct provider to call, following the chain of command?”
The Rule: Unless it is a code situation, you ALWAYS start with the most junior member of the primary team covering the patient—typically the intern or resident. Bypassing them and calling their attending or a specialist directly is a major breach of etiquette that undermines the team structure.
The On-Call Escalation Path:
- Start with the Primary Service Resident on Call. They are your first and primary contact for 99% of issues.
- If the issue is beyond their scope OR they ask you to, call the Specialist Fellow on Call (e.g., for a complex ID or Cards question).
- If the Resident is unresponsive after multiple pages OR if you have a profound safety disagreement with them, escalate to the Attending Physician on Call. This is your safety net and should be used judiciously (see Section 24.5 on escalation).
Masterclass Part 2: Executing the Perfect On-Call Page and Conversation
You have climbed the ladder and made the decision to call. Now, the execution must be flawless. Your goal is to be so prepared, concise, and professional that the provider hangs up the phone feeling grateful you called, not annoyed you woke them up.
The Perfect On-Call Page Script
Your page should contain just enough information for them to understand the urgency and topic before they even call you back.
[Your Name], night RPh x1234. URGENT re: John Smith, Rm 314. Critical K+ of 6.8. Please call to discuss management.
The Perfect On-Call Phone Conversation Script
When they call you back (often groggy and disoriented), you must take immediate control of the conversation and guide them efficiently.
Provider: “This is Dr. Davis, I was paged.”
You: “Dr. Davis, thank you for the quick call back. This is [Your Name], the overnight pharmacist. I’m sorry to wake you, but I’m calling about an urgent lab value for your patient, John Smith in room 314.”
(Deliver your prepared SBAR)
S: “His potassium just resulted at 6.8.”
B: “As you know, he has CKD stage 4 and was started on lisinopril yesterday. His vitals are stable.”
A: “My assessment is that this is critical hyperkalemia requiring immediate treatment.”
R: “My recommendation is for one dose of Kayexalate 15g PO, and for us to hold his lisinopril in the morning. Would you like me to enter those orders for you?”
(Listen to their response, answer any follow-up questions from your prepared data packet)
(Read back any verbal orders)
“Okay, just to confirm, I will enter an order for Kayexalate 15g PO x1 now, and I will discontinue the lisinopril. Is that correct?”
(Close professionally)
“Perfect. Thank you for your time. I’ll take care of it. Have a good night.”
