Appendix and Acknowledgements Summary

Appendix and
Acknowledgements
Appendix A: Formulas
Electrolytes
+
Na (corrected for hyperglycemia):

Corrected Na+ = measured Na+ + [(glucose 100) x 0.024]
Ca2+ (corrected for hypoalbuminemia):
Corrected Ca2+ = [(4 serum albumin) x 0.8] + measured Ca2+
Free Water Deficit:
Water deficit = wt (kg) x k x [(plasma Na+ / 140) 1]; where k = 0.5 for males and 0.4 for females
Osmolality:
Calculated Osm = (2 x Na+) + (glucose / 18) + (BUN / 2.8) + (EtOH / 4.6)
normal: 270290
Osm gap = measured Osm calculated Osm {normal < 10}
>10 is abnormal: caused by renal failure, methanol, ethylene glycol, sorbitol, mannitol, isopropanol,
radiocontrast dye
Anion Gaps:
Serum AG = [Na+] [Cl-] [HCO3] {normal 10-14}
Corrected AG (for hypoalbuminemia)
Corrected AG = serum AG + [(4 serum albumin) x 2.5]
AG = (AG 12) + HCO3 {normal 2330}.
AG >30: concomitant metabolic alkalosis (excessively high HCO3).
AG <23: concomitant non-AG metabolic acidosis (excessively low HCO3).
Urine AG = U[Na+] + U[K+] U[Cl-]
NH4+ is the major unmeasured cation, so a strongly negative UAG suggests high urine NH4+.
Urine AG <0: GI HCO3 loss.
Urine AG >0: Renal HCO3loss (RTA).
Body Fluid / IV Fluids
Body fluid composition:
Total Body Water = 0.6 x wt (kg) for males 0.5 x wt (kg) for females
Extracellular fluid (ECF) = 0.2 x wt (kg)
Intravascular: 1/3 ECF
Interstitial: 2/3 ECF
Intracellular fluid (ICF) = 0.4 x wt (kg)
IVF and tonicity:
Fluid
Na+ (mEq/
L)
K+ (mEq/
L)
Cl- (mE
q/L)
HCO3 (mEq/
L)
Other
(mEq/L
)
Osmolalit
y
(mOsm/L
)
Plasm
a
142
104
27
29
306
NS
154
154
308
D5W
278
D5
12NS
77
77
421
1 amp
NaHC
O3
50
50
100
20 mEq
KCl
20
20
40
e.g. 14NS + 20 mEq KCl + 12 amp NaHCO3 = (308/4) + 40 + (100/2) = 167 mOsm/L, or roughly
equivalent in tonicity to 12NS
IVF effect on plasma Na:
Na per liter IVF given = [NaIVF(mEq/l) + KIVF(mEq/l) Naserum (mmol/l)] / [Total Body Water + 1]
Renal
Creatinine Clearance:
Estimated CrCl (Cockcroft-Gault Equation)* = [(140 age) x (wt in kg)] / [serum Cr x 72]
*multiply by 0.85 for females
{normal 100125 ml/min (M) or 85105 ml/min (F)}
Measured CrCl = [urine Cr x urine volume (ml/24hr)] / [serum Cr x 1440 (min/24hr)]
Fraction Na excretion:
FENa = [(urine Na+ / serum Na+) x 100] / [(urine Cr / serum Cr)]
<1% suggests pre-renal
FENa interpretable only in oliguric states (UOP < 400 cc/day)
Transtubular Potassium Gradient:
TTKG = (urine K+ / serum K+) / (urine Osm / serum Osm)
With hyperkalemia:
< 7 suggestive decreased aldosterone activity.
> 7 suggestive effective volume depletion with normal aldosterone activity.
Hemodynamics
Cardiac Output:
CO = HR x stroke volume
CI = CO / BSA (in m2); where BSA= ([ht (cm) x wt (kg)] / 3600)
Fick Technique: CO = estimated O2 consumption or VO2 (ml/min)* / arteriovenous O2 difference**
Resistance:
SVR = [(MAP CVP) / CO] x 80
{normal 7001600 dynes*s/cm5}
PVR = [(MPAP PCWP) / CO] x 80
{normal 20120 dynes*s/cm5}
Pressure:
Pulse Pressure = SBP DBP
MAP = [SBP + (DBP x 2)] / 3
Pulmonary
Alveolar-arterial O2 gradient:
Aa O2 gradient = [FiO2 x (pAtm pH2O)] (pCO2 / R) pO2

o
= [FiO2 x (760 47)] (pCO2 / 0.8) pO2
= 150 (pCO2 / 0.8) pO2
{normal 525 or age/3} *at sea level on RA
Statistics
Disease (+)
Disease ()
Test (+)
A
True Positive
B
False Positive
Test ()
C
False Negative
D
True Negative
Sensitivity = A / (A + C)
Specificity = D / (D + B)
Positive Predictive Value = A/ (A + B)
Negative Predictive Value = D / (C + D)
Positive Likelihood Ratio = sensitivity / (1 specificity)
Negative Likelihood Ratio = (1 sensitivity) / specificity
Number needed to treat (NNT) = 1 / (absolute risk reduction)
References
Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction factor for hyperglycemia. Am J
Med. 1999 Apr;106(4):399-403.
Appendix B: Abbreviations
ACE - Angiotensin
converting enzyme
A
A-a - Arterial-alveolar
AAA - Abdominal aortic
aneurysm
ABC - Airway, breathing,
circulation
ABG - Arterial blood gas
ABX - Antibiotics
AC - Assist-control
ventilation
ACA - Anterior cerebral
artery
ACC - American College
of Cardiology
ACE-I -Angiotensin
converting enzyme inhibitor
ACLS - Advanced
cardiac life support
AF - Atrial fibrillation
AFB - Acid-fast bacilli
A-fib - Atrial fibrillation
AG - Anion gap
ACS - Acute coronary

syndrome
ACTH
- Adrenocorticotropic
hormone
AHA - American Heart

Association
AI - Aortic insufficiency
ACV - Assist-control
ventilation
ADC - AIDS dementia
complex
ADH - Anti-diuretic
hormone
AI - Adrenal insufficiency
AICD - Automated
implantable cardiac
defibrillator
AIDS - Acquired
immunodeficiency syndrome
ASA - American Society

of Anesthesiologists
BMJ - British Medical

Journal
AIN - Acute interstitial

nephritis
ASA - Aspirin
BMT - Bone marrow

transplant
ALL - Acute lymphoblastic

leukemia
ALS - Amyotrophic
lateral sclerosis
ALT - Alanine
aminotransferase
AML - Acute myeloblastic
leukemia
AMS - Altered mental

status
ANA - Anti-nuclear
antibody
ANCA - Anti-nuclear
cytoplasmic antibody
APACHE - Acute
physiology and chronic health
evaluation
APC - Activated protein C
ARB - Angiotensin
receptor blocker
AST - Aspartate
aminotransferase
AT - Atrial tachycardia
A-thal - Alpha
thalassemia
BNP - B-natriuretic
peptide
BP - Blood pressure
BPM - Beats per minute
BRBPR - Bright red blood
per rectum
ATN - Acute tubular

necrosis
BSA - Body surface area
ATP - Adenosine
triphosphate
BUN - Blood urea

nitrogen
AV - Atrioventricular
BZD - Benzodiazepine
C
C&S - Culture and
specificity
AV - Arteriovenous
AVM - Arteriovenous
malformation
AVNRT - AV nodal
reentrant tachycardia
AVRT - AV reentrant
tachycardia
B
BAL - Bronchoalveolar
lavage
Ca - Calcium
CA - Cancer
CABG - Coronary artery
bypass grafting
CaCl2 - Calcium chloride
CaCO3 - Calcium
carbonate
BCx - Blood culture
ARDS - Acute respiratory

distress syndrome
BG - Blood glucose
CAD - Coronary artery

disease
ARF - Acute renal failure
BID - Twice a day
CaO2 - Oxygen content
ARRD - Acute reversible

renal dysfunction
BiPAP - Bi-level positive

airway pressure
CAPD - Continuous
ambulatory peritoneal dialysis
AS - Aortic stenosis
BMI - Body mass index
CCB - Calcium-channel
blocker
CCPD - Continuous
cycling peritoneal dialysis
CCU - Coronary care unit
CFU - Colony-forming
unit
CHF - Congestive heart
failure
COPD - Chronic
obstructive pulmonary
disease
CP - Chest pain
CPAP - Continuous
positive airway pressure
CPK - Creatine kinase
CVVHDF - Continuous
venovenous
hemodiafiltration
Cx - Culture
CXR - Chest x-ray
D
DBP - Diastolic blood
pressure
CPP - Cerebral perfusion

pressure
DDAVP - Vasopressin
CPPD - Calcium
pyrophosphate dihydrate
DDx - Differential
diagnosis
CK - Creatine kinase
CPR - Cardiopulmonary
resuscitation
DI - Diabetes insipidus
CKD - Chronic kidney

disease
Cr - Creatinine
CI - Cardiac index
CIWA - Clinical institute
withdrawal assessment
CK-MB - Creatine kinase

(myocardial fraction)
CLL - Chronic
lymphocytic leukemia
CML - Chronic myelocytic
leukemia
CMV - Cytomegalovirus
CN - Contrast
nephropathy
CNS - Central nervous
system
CO - Carbon monoxide
CO - Cardiac output
CO2 - Carbon dioxide
Cocci
- Coccidioidomycosis
CrAg - Cryptococcal
antigen
CrCl - Creatinine
clearance
CRRT - Continuous renal
replacement therapy
Crypto - Cryptococcosis
CSF - Cerebrospinal fluid
CT - Computed
tomography
CVA- Cerebrovascular
accident
CVP - Central venous
pressure
CVVH - Continuous
venovenous hemofiltration
CVVHD - Continuous
venovenous hemodialysis
DIC - Disseminated
intravascular coagulation
Diff - Differential
DKA - Diabetic
ketoacidosis
DLCO - Diffusing
capacity of carbon monoxide
DM - Diabetes mellitus
DM - Dermatomyositis
DMV - Department of
motor vehicles
DOT - Directly observed
therapy
DS - Double strength
DT - Delirium tremens
DTR - Deep tendon
reflex
DVT - Deep venous
thrombosis
Dz - Disease
E
EBV - Epstein-Barr virus
ECASA - Enteric-coated
aspirin
ECG - Electrocardiogram
ED - Emergency
department
EEG
- Electroencephalogram
EGD
- Esophogastroduodenosco
py
EKG - Electrocardiogram
ELISA - Enzyme-linked
immunosorbent assay
EMG - Electromyogram
ER - Emergency room
ERCP - Endoscopic
retrograde
cholangiopancreatography
ESR - Erythrocyte
sedimentation rate
ESRD - End-stage renal
disease
ESWL - Extracorporeal
shock-wave lithotripsy
EtOH - Alcohol
ETT - Exercise treadmill
test
F
FENa - Fractional
excretion of sodium
FEV1 - Forced expiratory

capacity in one second
FFP - Fresh frozen
plasma
FH - Family history
FIO2 - Fractional inspired
oxygen
FNA - Fine needle biopsy
FQ - Fluoroquinolone
GU - Genitourinary
GVHD - Graft versus
host disease
H
H&P - History and
physical
HA - Headache
HAART - Highly active
antiretroviral therapy
HAV - Hepatitis Avirus
FRC - Functional residual

capacity
HBV - Hepatitis B virus
FSGS - Focal segmental

glomerulosclerosis
HCG - Human chorionic

gonadotropin
FUO - Fever of unknown

origin
HCO3 - Bicarbonate
FVC - Forced vital

capacity
G
GBM - Glomerular
basement membrane
Hct - Hematocrit
HCTZ
- Hydrochlorothiazide
HCV - Hepatitis C virus
GCA - Giant cell arteritis

HD - Hemodialysis
GCS - Glasgow coma
scale
GERD
- Gastroesophageal reflux
disease
GFR - Glomerular
filtration rate
GI - Gastrointestinal
GIB - Gastrointestinal
bleed
HDL - High-density
lipoprotein
He - Helium
Hgb - Hemoglobin
HgbA1c - Hemoglobin
A1c
Histo - Histoplasmosis
GN - Glomerulonephritis
HIT - Heparin-induced
thrombocytopenia
GSH - Glutathione
HIV - Human
immunodeficiency virus
INR - International
normalized ratio
LDL - Low-density
lipoprotein
HOB - Head of bed
IPAP - Inspiratory positive

airway pressure
LDUH - Low-dose
unfractionated heparin
HOCM - Hypertrophic
obstructive cardiomyopathy
IR - Interventional
radiology
LFTs - Liver function tests
HONKC - Hyperosmolar
non-ketotic coma
IV - Intravenous
LGIB - Lower
gastrointestinal bleed
IVC - Inferior vena cava
LLQ - Left lower quadrant
IVDU - Intravenous drug

use
LMWH - Low molecular

weight heparin
IVF - Intravenous fluids
LP - Lumbar puncture
IVP - Intravenous push

J
JAMA - Journal of the
American Medical
Association
LR - Lactated Ringers
HME - Heat moisture

exchanger
HPF - High powered field

HR - Heart rate
HSP - Henoch-Schonlein
purpura
HSV - Herpes simplex
virus
HTN - Hypertension
HUS - Hemolytic-uremic
syndrome
I
IBD - Inflammatory bowel
disease
IBW - Ideal body weight
ICP - Intracranial
pressure
ICU - Intensive care unit
IE - Infective endocarditis
JVP - Jugular venous

pulsation
K
K - Potassium
KCl - Potassium chloride
KI - Potassium iodide
IMI - Inferior myocardial

infraction
INH - Isoniazid
LTRA - Leukotriene
receptor antagonist
LUQ - Left upper
quadrant
LV - Left ventricle
LVEDP - Left ventricular
end-diastolic pressure
KS - Kaposi sarcoma
KUB - Kidneys ureters
bladder (abdominal film)
L
LAD - Left anterior
descending artery
IJ - Internal jugular
IM - Intramuscular
LR - Likelihood ratio
LBBB - Left bundle

branch block
LVEF - Left ventricular

ejection fraction
LVH - Left ventricular
hypertrophy
M
MAC - Mycobacterium
avium complex
Mag - Magnesium
LCx - Left circumflex

artery
LDH - Lactate
dehydrogenase
MAHA - Microangiopathic
hemolytic anemia
MAO - Monoamine
oxidase
resistant staph epidermis
MAP - Mean arterial

pressure
MS - Mental status
MAR - Medication
administration record
MCA - Middle cerebral
artery
MCP
- Metacarpophalangeal
MCV - Mean corpuscular
volume
MDI - Metered dose
inhaler
MELD - Model for Endstage Liver Disease
Mg - Magnesium
MgSO4 - Magnesium
sulfate
MI - Myocardial infarction
MIF - Maximal inspiratory
force
MOM - Milk of magnesia
MPO - Myeloperoxidase
MR - Mitral regurgitation
MRA - Magnetic
resonance angiography
MRI - Magnetic
resonance imaging
MRSA - Methicillinresistant staph aureus
MRSE - Methicillin-
NG - Nasogastric
NH4+ - Ammonium
NIPPV - Noninvasive
positive pressure ventilation
Nl - Normal
MS - Mitral stenosis
MTX - Methotrexate
NNT - Number needed to

treat
NPO - Nothing per mouth
NQWMI - Non-Q-wave
myocardial infarction
NRB - Non-rebreather
NS - Normal saline
NSAIDs - Non-steroidal
anti-inflammatory drugs
NSTEMI - Non-ST
elevation myocardial
infarction
NTE - Not to exceed
NTG - Nitroglycerin
O
OA - Osteoarthritis
OR - Operating room
Osm - Osmolality
OTC - Over the counter
P
PAline - Pulmonary artery
catheter
PAN - Polyarteritis
nodosa
PAP - Pulmonary artery
pressure
MUGA - Multiple gated

acquisition
PBS - Peripheral blood

smear
MVI - Multivitamin
PCI - Percutaneous
coronary intervention
MS - Multiple sclerosis
MSH - Melanocyte
stimulating hormone
MSSA - Methicillinsensitive staph aureus
MSSE - Methicillinsensitive staph epidermis
MTHFR
- Methylenetetrahydrofolate
Reductase
MTP
- Metatarsophalangeal
MVP - Mitral valve

prolapse
N
N/V - Nausea/vomiting
N/V/D
- Nausea/vomiting/diarrhea
PCKD - Polycystic kidney

disease
pCO2 - Partial pressure
of carbon dioxide
PCP - Pneumocystis
pneumonia
Na - Sodium
PCR - Polymerase chain

reaction
NaHCO3 - Sodium
bicarbonate
PCV - Pressure control

ventilation
Nebs - Nebulizers
PCW - Pulmonary
capillary wedge
NEJM - New England

Journal of Medicine
PCWP - Pulmonary
capillary wedge pressure
PD - Peritoneal dialysis
PE - Pulmonary
embolism
PEA - Pulseless electrical
activity
PEEP - Positive endexpiratory pressure
PEG tube
- Percutaneous endoscopic
gastrostomy tube
PEX - Physical exam
PF - Peak flow
PICC - Peripherally
inserted central catheter
PID - Pelvic inflammatory
disease
PIP joint - Proximal
interphalangeal joint
PLT - Platelets
PM - Polymyositis
PMH - Past medical
history
P-MIBI - Persantine-MIBI
PML - Progressive
multifocal
leukoencephalopathy
PMNs - Neutrophils
PMR - Polymyalgia
rheumatica
PNA - Pneumonia
PNH - Paroxysmal
nocturnal hemoglobinuria
PO - By mouth
pO2 - Partial pressure of
oxygen
PO4 - Phosphorous
PPL - Plateau pressure
PR - Per rectum
PRBC - Packed red
blood cells
PRN - As needed
PRSP - Penicillinresistant streptococcus
pneumoniae
PS - Pressure support
PSVT -Paroxysmal
supraventricular tachycardia
PT - Physical therapy
PT - Prothrombin time
Pt. - Patient
PTCA -Percutaneous
transluminal coronary
angioplasty
PTH - Parathyroid
hormone
P-Thal - Persantine
thallium
PTHrP -Parathyroid
related protein
PTT - Partial
thromboplastin time
glomerulonephritis
RR - Respiratory rate
RSI - Rapid sequence
intubation
PTX - Pneumothorax
RT - Respiratory therapy
PUD - Peptic ulcer
disease
PVR - Post-void residual
Q
QD - Once a day
QHS - Once a night
QID - Four times a day
QOD - Once every other
day
QTc - Corrected QT
interval
R
R/O MI- Rule out
RA - Rheumatoid arthritis
RA - Right atrium
RBBB - Right bundle
branch block
RBC - Red blood cell
RCA - Right coronary
artery
RCT - Randomized
controlled trial
RDW - Red cell
distribution width
RTA- Renal tubular

acidosis
RUQ - Right upper
quadrant
RV - Right ventricle
RVH - Right ventricular
hypertrophy
RVMI - Right ventricular
S
S/P - Status-post
SAH - Subarachnoid
hemorrhage
SaO2 - Oxygen
saturation
SBE - Subacute bacterial
endocarditis
SBP - Spontaneous
bacterial peritonitis
RF - Risk factor
SBP - Systolic blood

pressure
RI - Reticulocyte index
SC - Subcutaneous
RLQ - Right lower

quadrant
SCD - Sequential
compression devices
ROS - Review of
systems
ScvO2 - Central venous

oxygen saturation
RPGN - Rapidly
progressive
SES - Sick euthyroid

syndrome
SFGH - San Francisco

General Hospital
SH - Social history
SIMV - Synchronized
intermittent mandatory
ventilation
SIRS - Systemic
inflammatory
response syndrome
SL - Sublingual
SLE - Systemic lupus
erythematosus
SOB - Shortness of
breath
Sosm - Serum osmolality
SPEP - Serum protein
electrophoresis
SQ - Subcutaneous
SSRI - Selective
serotonin reuptake inhibitor
STEMI - ST segment
elevation myocardial
infarction
SV - Stroke volume
SVC - Superior vena
cava
SVR - Systemic vascular
resistance
SVT - Supraventricular
tachycardia
T
T.bili - Total bilirubin
TB - Tuberculosis
TBW - Total body water

TCA - Tricyclic
antidepressant
TEE - Transesophageal
echocardiogram
TFT - Thyroid function
tests
TTE - Transthoracic
echocardiogram
TTP - Thrombotic
thrombocytopenic purpura
TV - Tidal volume
U
UA - Urinalysis
UAG - Urine anion gap
TIA - Transient ischemic

attack
UCl - Urine chloride
TIBC - Total iron binding

capacity
UGIB - Upper
gastrointestinal bleed
TID - Three times a day
UK - Urine potassium
TLC - Triple lumen

catheter
UNa - Urine sodium
TLSO
- Thoracolumbosacral
orthotic
UO - Urine output
UOP - Urine output
TM - Tympanic
membrane
UPEP - Urine protein

electrophoresis
TMP/SMX
- Trimethoprimsulfamethoxazole
UTI - Urinary tract

infection
Toxo - Toxoplasmosis
t-PA- Tissue
plasminogen activator
TPN - Total parenteral
nutrition
TRALI - Transfusion
related acute lung injury
TSH - Thyroid
stimulating hormone
TSI - Thyroid stimulating
immunoglobulin
Utox - Urine toxicology

screen
V
V/Q - Ventilation/perfusion
scan
VC - Vital capacity
VDRL - Venereal disease
research laboratory
VF - Ventricular fibrillation
VRE - Vancomycinresistant enterococcus
VT - Ventricular
tachycardia
VZV - Varicella zoster
virus
W
WBC - White blood cells
WPW - Wolff-ParkinsonWhitesyndrome
Appendix C: Sliding Scales

Heparin
Bolus and initial maintenance rate are determined by underlying disease state (higher initial bolus for pulmonary embolism
than acute coronary syndrome). Always check with your local hospital pharmacy for correct initial bolus and maintenance
rate.
Acute coronary syndrome: initial bolus = 60 U/kg, initial maintenance rate = 12 U/kg/hr.
Pulmonary embolism: initial bolus = 80 U/kg, initial maintenance rate = 18 U/kg/hr

Check PTT and adjust infusion at 6, 12, and 24 hours after the initiation of heparin and QD thereafter. Check PTT 4 to 6
hours after any dose adjustment.
PTT (sec)
Change
IV infusion
< 35
70 U/kg bolus
Increase by 3 U/kg/hr
35 49
35 U/kg bolus
Increase by 2 U/kg/hr
50 70
no change
no change
71 90
no change
Decrease by 2 U/kg/hr
> 90
Hold infusion for 30 minutes
Decrease by 3 U/kg/hr
Insulin
For updated insulin sliding scales and regimens that take into account differences between
type 1 and type 2 diabetics, see Endocrine: Insulin sliding scale. Included here is the more traditional
sliding scale (most hospitals are transitioning toward pre-printed insulin sliding scale order
sheets and away from arbitrary insulin sliding scales):
FBS
Action
< 50
1 amp D50 IV and call MD
51 80
Give juice and repeat in 12 hour
81 200
No coverage
201 250
3 U regular insulin SQ
251 300
301 350
351 400
> 400
12 U regular insulin SQ, call MD
Nitropaste
Apply to chest wall q 6 hours according to sliding scale and after 24 hours, wipe off nightly from 12
a.m. to 6 a.m. to avoid development of tolerance.
SBP
Action
< 100
wipe off
100120
121140
>140
Potassium
Caution in renal failure or ESRD. Always check the creatinine prior to replacing potassium.
Serum K+
KCl (mEq) to give IV or PO
3.7 3.8
20
3.5 3.6
40
3.3 3.4
60
3.1 3.2
80
3.0
100
Magnesium
Caution in renal failure or ESRD. Always check the creatinine prior to replacing magnesium.
Serum Mg2+
MgSO4 (g) to give IV
1.8 1.9
1.6 1.7
1.4 1.5
1.2 1.3
< 1.2
References
Becker RC, et al. A randomized, multicenter trial of weight-adjusted intravenous heparin dose titration
and point-of-care coagulation monitoring in hospitalized patients with active thromboembolic disease.
Am Heart J. 1999;137:59-71.
Handbook Editors
Editors
Somnath Mookherjee, MD
Cindy Lai, MD
Stephanie Rennke, MD
Chapter Editors
1.
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Hospitalist 101
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Elizabeth Le, MD, Karimi Gituma, MD
o
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Night Calls
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Dandan Liu, MD, Erika Mak, MD
o
Faculty: Stephanie Rennke, MD
Palliative Care
o
Sunita Puri, MD, MS, Kristen Adams, MD
o
Faculty: Meredith Heller, MD, Matt Gonzales, MD
ACLS
o
Ravi Garg, MD, Elizabeth Hardin, MD
o
Faculty: Catherine Lau, MD
Preface and Acknowledgements

The Hospitalist Handbook represents the culmination of several years of effort on behalf of the
Internal Medicine housestaff at the University of California, San Francisco to make a thorough, yet
concise, bedside guide to inpatient clinical medicine. The Hospitalist Handbook began as the
Housestaff Handbook several years ago and has served as both an educational tool for its authors as
well as a valuable resource for students, housestaff, and attending physicians.
The fourth edition of the Hospitalist Handbook continues in the process of updating the handbook to
reflect the most recent advances in hospital medicine. We hope that with the fourth edition, anyone
engaged in inpatient medicinemedical students, residents of all specialties, hospitalist physicians,
nurse practioners, physician assistants, and otherswill continue to find the handbook easy to read
and practical in its approach to common problems in inpatient medicine.
We are indebted to the UCSF staff who have assisted with this book, especially Sue Sheehan.
As stated earlier, the Hospitalist Handbook is a result of the efforts of many past and present
housestaff in the Department of Medicine at UCSF. The following physicians have all been past
contributors to the handbook: Lexmi Acharya, Susan Alt, Garth Beinart, Anna Bloxham, Carolyn
Calfee, Paul Campbell, Ethan Canin, Larry Chang, Sumitra Chari, Tom Chen, Victor Cheng, Peter
Chin-Hong, Molly Conroy, Sarah Cooley, Ethan Corcoran, Ian de Boer, Fiona Dulbecco, Darryl
Elmouchi, Sara Erickson, Monica Gandhi, Anil Gehi, Leslie Gillum, Andrei Goga, Antonio Gomez,
Nathan Gunn, Samir Gupta, Jennifer Guy, Steve Harr, Mary Beth Humphrey, Jimee Hwang, Andy
Josephson, Todd Kim, Ajay Kirtane, Kiran Khush, Drew Klein, Katy Lease, Natalie Lee, Sei Lee, Josh
Lehrer-Graiwer, Adam Lauring, Amy Levin, Debbie Lindes, Pam Ling, Raymond Liu, Taylor Liu, Annie
Luetkemeyer, Kamyar Madani, David McManus, Denise Marciano, Deepu Nair, Anisa Nayeem, Justin
Ortiz, Daniel Perlov, Samantha Pitts, Josefa Rangel, Mike Ren, Anne Rosenthal, Kiki Rutkowski,
Urmimala Sarkar, Sanjiv Shah, Brad Sharpe, Robin Shaw, Mike Shiloh, Eddie Siew, Jacek
Skarbinski, Michael Steinman, Jack Tsao, Elizabeth Turner, Jim Uyeki, Doug White, Ed Vasilevskis,
and Roni Zeiger.
The Hospitalist Handbook is a continual work in progress. We are always looking for ways to
improve the handbooks content in order to make it more accurate, practical, and coherent, as
well as concise. If you have any comments, suggestions, or corrections, please email ssheehan@medicine.ucsf.edu so that we can continue to enhance the value of this
resource.
HOSPITALIST 101
The Hospitalist
Definition
First described in the 1990s, the term hospitalist describes a physician who assumes the generalized care of a hospitalized
patient, and transfers care of the patient back to a primary care physician at discharge.
Context
Advantages to the hospitalist model of medicine include greater inpatient physician availability, increased emphasis on
hospital-wide safety and quality improvements, and potential increased participation in medical training and education.
Studies have shown increasing differences between hospitalist and non-hospitalist-driven patient care, including length of
stay, cost of hospitalization and performance with respect to certain quality of care measures.
Common communication issues
Who is my doctor?
o
Patients may not understand the hospitalist model or who is responsible for their medical
care.
o
Explain to patients the hospitalist model of care, especially the role of the team, primary care
provider (PCP) and specialists in decision-making.
o
Inform the patient that their PCP will be contacted and made aware of major
decisions/results.
The Voltage Drop.

o
The concept that there may be a loss of information as a patient is transferred from one
provider to another.
o
Contact PCPs when their patient is admitted (preferably within 24 hours). PCPs are
invaluable resources for background information on patients and can help make major
decisions, including decisions regarding code status and transitions to higher levels of care.
o
Contact the PCP and inform them of an impending discharge. Important things to relay are
a discharge summary with follow-up, pending tests and changes in medications.
Hospitalist vs. PCP

o
Though the hospitalist should be recognized as the expert on inpatient care, disagreements
may arise with the PCP concerning a variety of issues.
o
Collegiality is essential. The PCP and hospitalist should communicate openly and provide
a consistent message to the patient, which they consider to be in the patients best
interests.
Acknowledgements to Cason Pierce, MD and Amy Clouse, MS4 for their contributions to this chapter.
References
Alpers A. Key legal principles for hospitalists. Am J Med 2001;111:5S-9S.

Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AA. Outcomes of Care
by Hospitalists, General Internists, and Family Physicians 2007; 357: 2589-2600.
Vasilevskis EE, Knebel RJ, Dudley RA, Wachter RM, Auerbach AD. Cross-sectional Analysis of Hospitalist
Prevalence and Quality of Care in California 2010; 5: 200-207.
Wachter RM and Goldman L. The Emerging Role of Hospitalists in the American Health Care System. N
Engl J Med 1996; 335: 514-517.
Admission Checklist
Contact family for all patients, but especially for those who are altered or demented.
o
Obtain pertinent phone numbers for contacts, and establish a decision maker within the family.
Contact the patients primary care provider.
o
Contact with PCPs has been shown to decrease rates of urgent readmissions.
o
All PCPs should be contacted, preferably within 24 hours of admission.
Medication reconciliation.
o
Use the resources around you: past discharge summaries, computerized medications, patient pill
bottles, and a patients pharmacy.
o
Check in with the patient:
Make sure he or she is taking the listed meds.
Regarding allergies and the specific reaction to each listed medication.
Ask about any supplements, herbal medications, or over the counter medication
use.
Limits on all blood pressure meds, opiates, and laxatives.
o
For example Hold for BP < 100, HR < 60 or Hold for Sedation, RR < 8.
IV Access.
o
Consider whether your patient needs an IV, how many and what sizes. Remember that for
resuscitation, several large bore (16 and 18 gauge) IVs are superior to a triple lumen catheter.
o
Order PICCs early for patients who will need long term IV antibiotics. If a patient may need future
dialysis, check-in with Renal consultant before ordering a PICC.
o
For patients with difficult access, attempt EJs or deep brachial IVs instead of central lines.
Pneumovax.
o
Not everyone needs a pneumovax. The guidelines for pneumovax are as follows:
Immunocompetent patients > 65 years of age. If pneumovax was given

previously, revaccinate only if the last dose was > 5 years ago AND the patient
was < 65 years old at the time of previous vaccination.
Immunocompetent patients aged 19-64 with chronic cardiovascular, pulmonary,

renal or liver disease, alcoholism, cochlear implants or CSF leaks/shunts, as
well as patients aged 19-64 who are living in chronic care facilities should get
vaccinated once.
Immunocompromised patients > 19, including patients with HIV, malignancy,

chronic renal disease, nephrotic syndrome, asplenia (including sickle cell disease),
post-transplant patients or those on chronic immunosuppression.
Influenza shot in appropriate seasons.
Indications for gastric ulcer prophylaxis.
o
Not all patients admitted to the hospital need a proton pump inhibitor. Patients who should be
considered for ulcer prophylaxis include:
Patients in the ICU with: mechanical ventilation > 48hrs, coagulopathy, shock,
sepsis, burns, head trauma, hepatic failure, renal failure, organ transplant
recipients, spinal cord injury.
Patients with 2+ of the following: in the ICU > 1 week, occult bleed > 5 days, on
steroids.
Patients with previous history of PUD or UGIB within one year of hospital
admission.
Relative indications: patients on high dose or chronic steroids. Contraindications:

use of atazanavir.
Foley vs. condom catheter vs. urinal. Keep track of which patients have a foley catheter and remove
ASAP.
o
Accepted indications for long-term catheterization include: uncorrectable bladder outlet obstruction,
intractable skin breakdown due to urinary incontinence, neurogenic bladder, and palliative care.
o
Short-term catheterization is acceptable in patients undergoing urologic surgery, critically ill patients
requiring accurate urine output, patients receiving high dose diuretics and for acute urinary retention.
o
Condom catheters can be useful for those who have difficulty using a urinal, or cannot tolerate foley
catheters, but keep in mind the infection risk is similar to that of foley catheters.
Smoking cessation counseling. Assess patient readiness to quit and provide appropriate
counseling. Respiratory therapy provides counseling and education for smoking cessation.
Involve PT/OT, social work and case management early (see discharge planning).
Check final reads of all studies.

o
Many initial or overnight reads change upon attending physicians read. As these studies may have
been done while the patient was in the emergency department, radiologists may not know who to
contact for final reads.
Establish patients surrogate decision-maker, and goals of care for resuscitation in the case of an
emergency.
Discharge Planning
Context: The transition immediately following a hospitalization is a vulnerable period for patients, often resulting in adverse
events and subsequent readmissions.
Risk factors for hospital readmission include:
Depression: 73% increase in hospital utilization (ED or readmission) within 30 days post-discharge.
Lack of post-discharge PCP follow-up.
Lack of hospital based discharge teaching.
Errors in medications.
Discharge Planning Checklist
1. At the time of admission (things to get rolling early)
Social work: discuss socially complicated patients with your social worker. Consider
that the patient may already have a caseworker who should be notified of the
admission.
Home vs. placement: consider the stability of the patients living situation. Is he or she
likely able to return home after this hospital admission? Consider referral to acute
rehab, skilled nursing facility, board and care or permanent placement. Discuss patients
who will have home needs with case management early. Start the Patient Discharge
Plan (PDP) early case managers cannot refer patients for any services until the PDP
is completed.
Physical therapy/occupational therapy: involve physical therapy and occupational

therapy early. Early rehabilitation can prevent need for placement.
High utilizer: if the patient is an ED high utilizer, consider coordinating with an ED

representative, the patient, and PMD on a developing care plan to guide future ED,
home, and inpatient care.
Conservatorship: if your patient is not felt to be competent to make medical decisions,

consider medical conservatorship. If your patient already has a conservator, contact
them early in the discharge. (See Decision Making Capacity and Involuntary Holds)
2. Preparing for discharge (24-48 hours before discharge)
Home safety: consider a home social worker evaluation and a home safety evaluation,
even for patients who have family members caring for them at home.
Home health: consider a referral to home services. Available services include: skilled
nursing needs (BP monitoring, medication education, insulin education), home safety
evaluation, social services, occupational/physical therapy, rehabilitation services,
speech therapy, infusion therapy.
Preparing meds: consider new medications, oxygen, and equipment patient will need
on discharge. Contact your social worker or case manager to ascertain the tests or
consults a patient needs to qualify for service (e.g., some insurance companies require
an ABG for home O2, others require a room air oxygen saturation < 88%).
Arrange follow-up: obtain dates and times of all follow up appointments your patient
will need following discharge. Many patients do not have a stable address, and will not
receive mail/telephone reminders. For patients who do not have a primary care
physician, consider appointments in Bridge Clinic (SFGH), Screening and Acute Care
Center (UCSF), referrals to MP Clinic (VAMC) or a referral to Healthy San Francisco for
follow up care.
Remove foley
3. 12-24 Hours Before Discharge
Patient education:
o
Use patient-friendly language and avoid medical jargon.
Closing the Loop or use the Teach-back Method: Confirm

comprehension, for example, by asking patients in a nonjudgmental
way: I want to make sure Im being clear. Could you explain to me how
youre going to take your medications? Invite questions from patients and
their families by asking, What questions do you have? rather than Do
you have any questions? which may prompt a No response.
Have the pharmacists or nurse educators see your patient. Many

hospitals have diabetes, COPD, and CHF educators who can see the
patient and discuss medication changes.
Check on pending tests: Follow up on tests ordered during the admission that may
still be pending to avoid last minute surprises. Any outstanding tests should be
conveyed to the PCP.
Contact the PCP: Phone or email the PCP about new diagnoses, medication changes,
pending tests and appointment dates. Follow up appts with PCPs should be made
within 2-3 wks.
Order medications early: For hospitals that provide discharge meds, preparation of
these medications can delay discharges by hours. Have the medication list prepared
the day prior to discharge, so small changes can easily be made on the day of d/c.
Transport: Ensure that the patient has a ride home by bus if appropriate, by taxi
voucher or family member. Make sure patients have keys to their living facilities when
appropriate.
4. Discharge Summary
Should be completed within 24-48hrs of discharge
Should include:
o
Diagnoses, abnormal physical findings, diet, activity level, important test

results, discharge medications, follow-up arrangements and appointments
that still need to be made, counseling provided to patient and family and
tests still pending at discharge.
Make sure to highlight changes in discharge medications which are

often the main cause of adverse events following hospital discharge.
5. Discharge Checklist - Summary
Follow up appointment requested
Medication reconciliation completed

o
Includes: phone call or email with communication of key elements of

discharge summary (as above) securely send actual discharge summary
if possible.
Communication with multi-disciplinary team completed

o
Includes: ensuring patients understand their hospital findings, discharge

diagnoses and follow up plans/tests
Communication with PCP completed

o
Includes: principal diagnosis, concise hospital course by problem,

discharge meds and doses, follow-up plan and appt date(s), pending
tests
Discharge discussion/education with patient completed

o
Also includes: assess how pts will pick up their medications on discharge
and pharmacy consult for high risk meds.
Discharge summary completed

o
Includes: appointment within two weeks for routine home discharge, four
weeks for SNF discharge.
Includes: discussion of discharge plan (as applicable) with SW, CM, PT,
OT, Pharmacy for high risk meds, and ancillary services.
Discharge timeout completed

o
Includes: Face-to-face conversation with the nurse about: Discharge

diagnosis Follow up plans RN teaching to patient (e.g. ostomy care,
lovenox injections) Home care or equipment (e.g. home 02) ordered
Review key med changes (meds started/stopped)
References
Balaban R, Williams M. Improving Care Transitions: Hospitalists Partnering with

Primary Care. J Hosp Med 2010; 5: 375-377.
Kripalani S, Jackson A, Schnipper J, Coleman E. Promoting Effective Transitions of

Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital
Medicine 2010; 2: 314-320.
Van Walraven C, Taljaard M, Etchells E, Bell CM, Stiell IG, Zarnke K, Forster AJ. The
independent association of provider and information continuity on outcomes after
hospital discharge: implications for hospitalists. J Hosp Med 2010; 7:398-405.
Care of Vulnerable Patients

Definition: Medically vulnerable populations are those at specific risk for poor health status as a result of social forces.
Immigrants
Communicable diseases (TB, parasitic illnesses, rheumatic heart disease, malaria, hepatitis, HIV), elevated
lead levels among children and pregnant women, violence and trauma exposure (particularly among
refugees).
Application:
o
Obtain history about immigration status (country of origin, reasons for immigration,
hardships endured, length of time in the U.S., social/family situation).
o
Consider screening for medical conditions listed above.
o
Review vaccination history; remember to provide appropriate prophylaxis if patient plans to
visit country of origin.
o
Conduct culturally competent patient education.
Limited English proficiency patients (LEP)
All hospitals are federally regulated to provide language services through CMS regulations.
Receive lower quality of care than those who speak English fluently; using interpreters has been shown to
narrow this gap (both in-person and telephonic interpreters).
Application: Use trained interpreters, either in person or by video monitor (preferred over telephone
interpreters).
o
Trained interpreters translate words, but also provide cultural interpretation and are
preferable to ad hoc (or untrained) interpreters.
o
Ad hoc (untrained) interpreters (e.g., non-trained staff, family, friends):
Except in emergencies, children should never be used as interpreters.
Remind ad hoc interpreters: Thank you for your help. Please try to
translate our conversation word for word, and even when you know the
answer to the questions I ask, please tell me what she says. If you have
something to say, we can talk separately.
o
Bilingual physicians: If you have doubts about your language ability, it is probably best to
call for an interpreter. Physicians often overestimate their own language skills.
Persons with limited health literacy
25% of American adults have limited functional health literacy (FHL). At public hospitals, as many as 50% of
patients have been estimated to have low FHL.
These Americans can have higher rates of hospitalization, fewer preventive services, increased risk of
poorly controlled chronic disease.
Application:
o
Assess patient understanding of and beliefs about their illnesses.
o
Be specific and avoid medical jargon.
o
Use Closing the Loop or the Teach-back method: For instance, confirm
comprehension by asking in a non-judgmental way, I want to make sure that Im being
clear here. Can you tell me how youre going to take the medicines?
Homeless persons
Increased prevalence of mental illness, both acute and chronic medical illness, communicable diseases
(TB, HIV, HBV/HCV), substance abuse, and violence exposure.
Application:
o
Obtain history of current and prior housing status at every visit. Consider screening for
medical conditions as above (i.e. yearly PPD).
o
Screen for history of physical of sexual abuse, substance abuse, mental illness, and refer to
appropriate services; address foot care; refer to dental services.
o
Coordinate care with other members of the health care team (case managers, social
workers, vocational trainers, visiting nurses).
o
Consider referral to appropriate housing: shelters, respite, board and care or other solutions
that are available in your area.
Persons with a history of incarceration:
Increased prevalence of communicable diseases (HIV, STDs, HBV/HCV, TB, Staphylococcus infection),
mental illness, substance abuse and violence exposure.
Application:
o
o
o
o
o
References
Screen for history of physical or sexual abuse, substance abuse, mental illness, gang
involvement and refer to appropriate services. Screen for medical diseases above.
Obtain an incarceration history in a non-judgmental way.
Refer to social work for assistance with housing, insurance, vocational training, reunification
with children and social support.
Harm reduction: Recently released patients are at especially high risk of mortality from:
Drug overdose
Cardiovascular disease
Violence
Suicide
Cancer
Primary care: It is essential that recently released patients be connected with primary care
physicians. Ninety percent are uninsured and high users of emergency departments.
Binswanger IA, Stern MF, Deyo RA, et al. Release from prison Ahigh risk of death for former inmates. N
Engl J Med 2007;356:157.
Chen AH, Jacobs EA. Providing Care to Patients Who Speak Limited English. In: King TE and Wheeler
MB, eds. Medical Management of Vulnerable and Underserved Populations. McGraw-Hill, New York,
2007:265-274.
Kushel M, Jain S. Care of the Homeless Patient. In: King TE and Wheeler MB, eds. Medical Management
of Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:245-254.
Morales S. Immigrant Health Issues. In: King TE and Wheeler MB, eds. Medical Management of
Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:255-264.
Paasche-Orlow MK, Parker RM. Improving the Effectiveness of Patient Education: A Focus on Limited
Health Literacy. In: King TE and Wheeler MB, eds. Medical Management of Vulnerable and Underserved
Populations. McGraw-Hill, New York, 2007:101-110.
Wang EA, Tulsky JP, White MC. Clinical Care for Persons with a History of Incarceration. In: King TE and
Wheeler MB, eds. Medical Management of Vulnerable and Underserved Populations. McGraw-Hill, New
York, 2007:235-244.
Decision Making Capacity

Definitions
1.
2.
Competency: A legal term regarding an individuals ability to make their own decisions. Assessment of
competence requires a judge and hearing (but in practice is determined de facto by physicians).
Decision-making capacity: A medical assessment by health care providers regarding the ability of a
patient to make informed decisions.
o
Decision-making capacity is both decision and time specific. Patients may have
capacity for certain decisions but not others, and this may fluctuate over time.
o
Psychiatric evaluation is not always necessary but can be helpful in making and
documenting this determination.
Context
Assessment of a patients decision-making capacity frequently takes place during the routine
patient-physician interaction, often without either party aware. However, whenever a patients
decision-making capacity is disputed, thorough assessment and potentially surrogate decisionmaking are required. Most often, questions of patient decision-making ability arise in the geriatric
population with dementia or in individuals with co-morbid psychiatric disease.
Application
Assessing decision-making capacity: See algorithm below.
Surrogate decision-making: When a patient lacks decision-making capacity, look for guidance in an
advance directive, DPOA, next of kin or court ordered guardian. Informed consent applies to surrogates.
Standards for decisions include:
o
Substituted judgment: What decision would the patient make if he/she were capable?
o
Best interests: What decision is in the best interests of the patient?
Medical Probate:
o
If there is no surrogate decision-maker available and a patient lacks capacity, a court may
order a medical probate for authorizing treatment. If a patient regains capacity to give
informed consent, this court order becomes invalid.
o
Until a probate is in place, the patient can be held against their will until treatment can be
provided.
Medical Conservatorship:
o
A conservator is a court-appointed surrogate who is responsible for consent for medical
treatment in patients with sustained loss of capacity to give informed consent. Informed
consent still applies, and the conservator is obliged to act in the patients best interests,
taking into account patient preferences.
o
A temporary conservatorship, or T-Con, may be granted for 30 days upon the
recommendation of a conservatorship investigator to expedite this process
(see Involuntary Holds).
For information regarding psychiatric loss of decision making capacity, see Involuntary Holds
Approach to Determining Decision Making Capacity
References
Lo B. Resolving Ethical Dilemmas: A Guide for Clinician, 2nd Editions. Lippincott Williams & Wilkins,
2000:80-93.
Critchfield JM, Williams MV. Care of Ill Socially Complicated Patients in the Hospital Medical Management of
Vulnerable and Underserved Populations. McGraw-Hill, New York, 2007:407-418.
Informed Consent and Refusal
Definition
Informed consent is a shared decision-making process between the patient and physician. It is
required for invasive or complex procedures and for treatments with significant risk. On the medical
ward, this includes blood transfusion or any procedure, including paracentesis, thoracentesis, or
lumbar puncture.
Context
Informed consent is a legal and ethical responsibility that protects patient safety and autonomy. In
situations in which it is difficult to obtain informed consent (emergencies, low health literacy) or
informed refusal (pts leaving AMA, refusing procedures), thorough assessments of capacity,
multidisciplinary assistance and clear documentation are key.
Application
Critical steps of informed consent:
Assess patients capacity for decision-making and communication.
o
Use professional interpreters as available. Document use of interpreters.
o
Patients with low health literacy, limited English proficiency, or significant illness have more
documented difficulties with informed consent.
Explain intervention and risks and benefits. Use plain language and concrete details.
Discuss reasonable alternatives (as well as no intervention), along with their risks & benefits.
Assess patient understanding. Have the patient teach-back to you their understanding.
Patient consent and documentation:
o
Ask patient to sign a consent form, but consent can be verbal if documented.
o
Remember, simply obtaining a patients signature on a consent form does not equate to the
patient having given informed consent.
o
Document informed consent in the procedure note. Below is an example:
Date
Procedure Note
Mr./Ms. ______ was explained the major risks and benefits associated with ______
procedure, and I answered his/her questions. I obtained informed consent directly
from the patient in his/her language/through a professional interpreter/through
nurse/staff/family member as interpreter. The patient signed a consent form. The
patient was then prepped in the usual manner. A time-out check was performed.
Signature
Emergency consent
Consent may be presumed in emergencies. However, if the situation permits, it is better to take the time to
obtain informed consent, collect collaborative information or use a surrogate decision-maker (see Decision
Making Capacity). These circumstances must be documented.
Informed consent may be obtained by phone. These telephone discussions should be witnessed by a
hospital employee and well documented.
Informed refusal
Informed refusal is often as important as informed consent, particularly with patients who may be leaving
AMA or placing themselves at danger. Assess capacity to make decisions (see Decision Making
Capacity) and go through the usual steps of obtaining informed consent.
Patients may refuse information if they so choose. Documentation of this event is advisable.
Exceptions to informed refusal may include communicable diseases, pregnancy or attempted suicide
during hospitalization.
Leaving against medical advice (AMA)
These patients often have a high rate of readmission, longer subsequent hospitalizations and worse
overall outcomes. Use the following checklist below to assess patients requesting to leave AMA
(adapted from Berger et al):
Capacity: Does the patient have decision-making capacity? (see Decision Making Capacity) Consider a
STAT psychiatry consult if you are unsure. Does the patient understand the risks?
Voluntariness: Assess for physical, social, emotional, psychiatric or cultural controlling influences. What are
the patients reasons for leaving (e.g. withdrawal? family or social issues?)
Mitigation: Attempt multidisciplinary efforts to mitigate controlling influences (e.g. social work, case
management, community partners).
Treatment alternatives: Assess medically appropriate outpatient treatment alternatives.
Aftercare: Encourage and facilitate aftercare and harm reduction strategies (e.g. schedule follow up,
prescribe medications).
Documentation: Ask the patient to sign an AMA form when possible. Clearly document the event and the
AMA discussion with the patient.
References
Applebaum PS, Grisso T.Assessing patients capacities to consent to treatment. N Engl J M
1988;319:1635-1638.
Berger JT. Discharge against medical advice: ethical considerations and professional obligations. J Hosp
Med 2008; 5: 403-408.
Cassileth BR, Zupkis RV, Sutton-Smith K, et al. Informed consent why are its goals imperfectly realized? N
Engl J M 1980;302:896-900.
National Quality Forum. Implementing a national voluntary consensus standard for informed consent. 2005.
Meise A, Kuczewski M. Legal and ethical myths about informed consent. Arch Int Med 1996;156:25212526.
Rajput V, Bekes CE. Ethical issues in hospitalist medicine. Med Clin N Am 2002;86:869-886.
San Francisco General Hospital Medical Center, Policy and Procedures. Consent to Medical and Surgical
Procedures. Section 3.9. 2006.
Sudore RL, Landefeld CS, Williams BA, et al. Use of a modified informed consent process among
vulnerable patients: a descriptive study. J Gen Intern Med 2006;21:867-73.
Involuntary Holds
Context
References
Patients admitted for psychiatric reasons often require further medical attention prior to initiating inpatient
psychiatric care.
Application
The Medical Hold: Officially, this entity does not exist. If there is a medical emergency, a patient can be
held with appropriate documentation if he or she lacks decision making capacity.
o
Call psychiatry to help clarify and corroborate the incident. (see Decision Making
Capacity)
For non-emergencies, seek out surrogate decision makers or medical probate conservatorship. Aprobate
conservatorship is a court proceeding wherein a judge appoints a responsible person (conservator) to make
decisions on behalf of an adult for cannot care for themselves or their finances.72-hour hold (e.g., in
California termed a 5150):
o
Involuntary hold for one of the following three reasons.
Danger to self.
Danger to others.
Grave disability (unable to provide food, clothing, shelter).

o
Usually done by police or mental health professionals. Patients with Alzheimers, brain
injuries, or other organic brain disorders or intoxication may be held under a psychiatric hold
(5150). However, it does not confer permission for medical interventions in which case you
must consult a surrogate decision maker or seek conservatorship. The exception to this is
in cases of medical emergency.
14-day hold (e.g., in California 5250): Involuntary hold for 14 days after a 5150. This extends a 72 hour
hold if the patient still requires treatment for the above reasons (see 72-hour hold). Requires a judicial
hearing and one of the same three criteria must be met.
Temporary Conservatorship (T-Con): A temporary 30-day psychiatric conservatorship for patients who
remain gravely disabled and require additional treatment after the initiation of a 5150 and 5250.
o
Placed by Psychiatry.
o
Does not allow for the involuntary administration of psychotropic medications, except in
urgent situations.
o
Riese hearings are the process by which a judge determines if the patient is able to provide
informed consent or refuse medications.
LPS (Lanterman Petris Short) Conservatorship: A conservator is appointed, via a court process, to
make decisions in the best interest of a mentally ill adult, such as consent to mental health treatment,
placement in a facility and financial decisions (e.g. paying bills, collecting income).
o
The most common illnesses for which LPS conservatorship is pursued include
schizophrenia, bipolar disorder, schizoaffective disorder, clinical depression and obsessive
compulsive disorder.
o
LPS conservatorship does not apply to patients with organic brain disorders, brain trauma,
addiction, developmental delay or dementia unless there is also a con-current DSM
psychiatric disorder.
When in doubt, consult with psychiatry, ethics committee, or risk management.
Felker B, Yazel JJ, Short D: Mortality and medical comorbidity among psychiatric patients: a review.
Psychiatr Serv 1996; 47:1356-1363.
USCF Psychiatry Residents. Psychiatry Resident Handbook. 2010-2011 Version.
Approach to Inpatient Death

Context
As an inpatient physician, you will be called to pronounce a patients death. It is important to make sure that
there is notification to the appropriate parties and clear documentation.
Application
Things to think about before entering the room:
o
Was the death expected or unexpected.
o
Are there unusual family dynamics that you should address with the attending prior to
entering the room.
o
If the family is present, inform them of what you are doing and ask if they would like to be
present for the examination.
o
Ask the family if they would like to request or decline an autopsy.
How to pronounce a death:
o
Identify the patient by ID tag.
o
Assess for response to tactile or verbal stimuli (avoid overtly painful stimuli, particularly in the
presence of family).
o
Listen for absence of heart sounds and feel for the absence of a carotid pulse for a
minimum of 60 seconds.
o
Look and listen for the absence of spontaneous respirations for a minimum of 30 seconds.
o
Record the position of the pupils and the absence of a pupillary light reflex.
Who to notify: the phone numbers and appropriate forms for the Organ Donor Network and Medical
Examiner are part of the death packet to be filled for each patient.
o
The attending physician
o
Organ Donor Network
o
Medical Examiner
A death note must be documented in the chart. Below is a sample of information that should be included:
Called at _____ by _____ to pronounce _____. On exam, no heart sounds or breath
sounds were noted after 1 minute of auscultation. Pupils were fixed and dilated
without pupillary light reflex. Patient was pronounced dead on --/--/---- at --:--.
Attending Dr._____ was notified. Family _____ was present/notified by phone and
condolences were offered. The organ donor network was notified and the case was
accepted/declined. The case was/was not reportable to medical examiner. Autopsy
was requested/declined.
References
Marchand LR, Kushner KP. Death Pronouncement: survival tips for residents. American Family Physician.
July 1998.
Marshall SA, Ruedy J. On Call: Principles and protocols. 4th Ed. Philadelphia, PA: Saunders; 2004.
Patient Safety and Errors

Definitions
Medical error: An act or omission that leads to an unanticipated, undesirable outcome or to substantial
potential for such an outcome
Adverse event: An undesirable clinical outcome related to diagnosis or therapy while in the hospital, which
may or may not result from a medical error
Context
Creating a culture of safety to reduce errors includes embracing the following ideas:
Moving from the paradigm of errors as individual failures to system failures
Moving from a punitive environment to a just culture
Trading secrecy for transparency
Moving care from being provider-centered to patient-centered
Moving from models reliant on individual performance to collaborative teamwork
Embracing the idea that accountability is universal and reciprocal

Application
Reporting of medical errors: Many hospitals use online Incident Reporting to alert the appropriate people
of systems that have broken down, and to promote change without individual blame.
o
Reporting medical errors is essential to optimal patient care and promoting positive change.
o
If you believe a medical error occurred, check online for your institutions Incident Reporting
mechanism. If you are unclear about what needs to be reported or how to report an
incident, consider involving your attending or even risk management.
o
Even a close call i.e. when no adverse event resulted from the error, should be reported.
o
Write down and report errors ASAP as often errors or their details are forgotten.
Disclosure of medical errors: There is generally a large discrepancy in the percentage of patients
desiring error disclosure and the percentage of physicians actually disclosing error. Disclosure of a medical
error is not only an ethical obligation to the patient, but can also provide a cathartic and educational benefit to
the health care providers involved.
o
Involve your attending physician and consider involving risk management prior to
discussion with the patient.
o
Keys to disclosure of medical error include:
Disclosure: full and immediate disclosure to the patient. Less than full
disclosure can often lead to patient mistrust of the care provider. However,
if unsure about the reason behind the error, it is acceptable to immediately
disclose that an error occurred and that we will be looking into what
happened. Reassure the patient that the team will continue to openly
discuss the issue as more information is discovered.
Repentance: apology with sincere remorse and discussion of what will

be done to prevent future errors (systems changes, root cause analysis,
etc). This often allows patients a sense that recognition of their error can
help other patients avoid error.
Forgiveness: in addition to seeking forgiveness from the patient, the

physician must be able to forgive him or herself in order to learn from the
incident and start healing.
Tips: choose an appropriate setting (private, interruption-free), give the

patient the option to have support present, use laymans terms, allow for
silent moments, have time for questions.
o
Reducing medical errors: The reduction of medical errors involves defining and
implementing Patient Safety Practices, processes meant to reduce the probability of
adverse events resulting from exposure to the health care system. Common patient safety
practices include, but are not limited to:
Adverse drug events: computerized order entry, protocols for high-risk

drugs.
Infection control: hand washing practices, prevention of catheter

associated infections and nosocomial UTIs, contact precautions for C.
difficile.
Perioperativemedicine: cardiac risk stratification, perioperative glycemic

control.
Geriatricmedicine: fall precautions, delirium prevention.
Nosocomialcomplications: GI bleed, DVTs, contrast nephropathy,
References
pressure ulcers.
Pain control.
Procedural safety: ultrasound guidance of central line placement or
procedures.
Increased patient participation: promoting hand hygiene to their care
workers, medication familiarity.
Berlinger N, Wu AW. Subtracting insult from injury: addressing cultural expectations in the disclosure of
medical error. J Med Ethics 2005;32: 106-108.
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug event: a
problem for quality improvement. Comm J Qual Improv 1995;21:541 548.
Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC:
National Academic Press. 2000.
Leap LL, Berwick DM. Five years after to err Is human: what have we learned? JAMA.2005;293:23842390.
Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge
and applicability to patient safety 2010. Mayo Clin Proc; 85:53-62.
Rosner F, Berger JT, Kark P, Potash K, Bennett AJ. Disclosure and prevention of medical errors. Committee
on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med 2000; 160: 20892092.
Shojania KG, Duncan BW, McDonald KM, et al, eds. Making Health Care Safer: A Critical Analysis of
Patient Safety Practices. evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-e058;
July 2001.
Patient Handoffs
Definition
A patient handoff is generally defined as the exchange of information during transfer of primary medical responsibility from
one provider to another provider.
Context
On average, 15 handoffs occur per patient during a 5 day hospitalization and interns are involved in approximately
300 handoffs per month.
Increasing handoffs have been associated with poor communication leading to adverse events, medication
errors, and worsened educational outcomes for medical students.
Safely done handoffs provide opportunity for increased volume of exposure to clinical cases and
management styles, an opportunity for error-correction, (double checking medication lists, problems lists,
clinical reasoning) and opportunities to improve communication skills.
Application
Information technology: Electronic Medical Records (EMR) with standardized electronic sign-out
templates carry the benefits of improved legibility, reduction in omissions, decreased chance of missed
patients on rounds and reduction in time spent pre-rounding or performing handoffs.
Individual practices: Several mnemonics exist to describe key features of high quality handoffs
o
SBAR:
Situation: describe the patients current situation and location
Background: provide background information on the patient including

reason for admission
Anticipated Problems: provide a list of likely anticipated problems
Recommendations: provide recommendations or contingency plans for

any anticipated problems
o
SIGNOUT?: (closer to the practice at UCSF)
Sick/DNR: prioritize patients who are most sick and clearly identify code
status
Identifying data: provide basic demographics as well as up-to-date patient

location
General hospital course: summarize major events of patients hospital

course
New events: identify any new events in the last 24-48h including
procedures, changes in clinical status
Overall health status/clinical condition: summarize current clinical status,

trend (improving, worsening, stable), and provide baseline for vitals, mental
status and pertinent physical exam findings
Up-coming possibilities with plan/rationale: provide a concise and thorough

list of the most-likely anticipated problems with contingency plan for each
Tasks to complete overnight: clearly identify and keep up-to-date any

tasks that need to be performed by the covering physician
?: Time for questions and clarification: provide the recipient time for
questions, clarifications. Request the recipient to teach back any critical
information or to-dos
Commonly observed mistakes in sign-out:

o
Lack of clarity in plan for broadening antibiotics.
o
Missing baseline mental status, abdominal exam, joint exam, etc.
o
Patient location is not up-to-date.
o
Medication list is not up-to-date.
o
Nothing-to-do or NTD listed on the sign-out but patient has to-dos.
o
Poor feedback by all parties about quality (or lack of quality) surrounding patient handoffs.
Tips:
o
Make sure one designated person is responsible for updating sign-out (resident vs. intern).
o
Sign out in a quiet location with minimal interruptions, this should occur in the same location
and at the same time every day.
o
Both parties should have access to the electronic version of the handoff document.
o
Exchange of information should be face-to-face.
o
Prioritize the sickest patients first.
References
Arora, V., Kao, J., Lovinger, D., Seiden, S. C., & Meltzer, D. (2007). Medication discrepancies in resident
sign-outs and their potential to harm. Journal of General Internal Medicine, 22(12), 1751-1755.
Cohen, M. D., & Hilligoss, P. B. (2010). The published literature on handoffs in hospitals: Deficiencies
identified in an extensive review. Quality & Safety in Health Care, doi:10.1136/qshc.2009.033480
Bernstein, J., MacCourt, D. C., Jacob, D. M., & Mehta, S. (2010). Utilizing information technology to mitigate
the handoff risks caused by resident work hour restrictions. Clinical Orthopaedics and Related Research,
468(10), 2627-2632.
Petersen, L. A., Brennan, T.A., ONeil, A. C., Cook, E. F., & Lee, T. H. (1994). Does housestaff discontinuity of
care increase the risk for preventable adverse events? Annals of Internal Medicine, 121(11), 866-872.
Sarkar, U., Carter, J. T., Omachi, T.A., Vidyarthi, A. R., Cucina, R., Bokser, S., van Eaton, E., & Blum, M.
(2007). SynopSIS: Integrating physician sign-out with the electronic medical record. Journal of Hospital
Medicine : An Official Publication of the Society of Hospital Medicine, 2(5), 336-342.
Van Eaton, E. G., Horvath, K. D., Lober, W. B., & Pellegrini, C. A. (2004). Organizing the transfer of patient
care information: The development of a computerized resident sign-out system. Surgery, 136(1), 5-13.
Van Eaton, E. G., Horvath, K. D., Lober, W. B., Rossini, A. J., & Pellegrini, C. A. (2005). A randomized,
controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care
and resident work hours. Journal of the American College of Surgeons, 200(4), 538-545.
Vidyarthi, A. R., Arora, V., Schnipper, J. L., Wall, S. D., & Wachter, R. M. (2006). Managing discontinuity in
academic medical centers: Strategies for a safe and effective resident sign-out. Journal of Hospital
Medicine : An Official Publication of the Society of Hospital Medicine, 1(4), 257-266.
Health Care Quality and Improvement

Context
Quality improvement has been defined as the cumulative efforts of all parties involved in healthcare to make changes [to
systems of care] that will lead to better patient outcomes (health), better system performance (care) and better professional
development (learning) (Batalden. OSHF 2007). The quality movement has arisen from several concerning observations
and areas of research in healthcare, including:
Dramatic and often inexplicable variations in health care practices.
Disparities in health and health care.
Medical errors and the impact on patient safety.
Escalating health care costs have prioritized maximizing value and clinical efficacy.
Application
How is quality measured? The Donabedian triad categorizes clinical variables as structure, process or
outcome measures, each type with its own advantages and disadvantages.
Measure
Definition
Advantages
Disadvantages
STRUCTUR
E
How care is
organizedExamples: # of ICU
beds EMR
Easy to measure
Quantifies otherwise
complex systems
Limited description of
quality of care delivered
Often no gold standard
PROCESS
What care is
providedExamples: ASA for
ACS Influenza Vaccination
Medication Reconciliation
Often from evidence or

consensus-based
guidelines Easier to
measure and change
than outcomes Direct
measure of care
Proxy for desired outcomes

Gold standard not always
agreed upon. May draw
attention from unmeasured
clinical care
OUTCOME
What happened to
patient Examples:Inpatient
mortalityVentilator-associated
PNA Readmissions
What we really care

about
Influenced by many factors

besides clinical care Often
long-term, less common
events Comparisons
require careful case-mix
adjustment
Who measures quality? Health care organizations (hospitals quality committees, health care networks,
etc.).
o
Regulatory (e.g., Joint Commission on Accreditation of Healthcare Organizations).
o
Government (e.g., Center for Medicare and Medicaid Services, Agency for Healthcare
Quality and Research)
o
Public-private partnerships (e.g., National Quality Forum).
o
Business coalitions (e.g., Leapfrog Group).
o
Foundations (e.g., California HealthCare Foundation).
How can housestaff impact quality improvement?
o
Educational efforts: A dedicated quality improvement rotation for housestaff, participation in
Root Cause Analysis (RCA) sessions, board recertification.
o
Feedback: Outpatient report cards or provider performance data compared to
benchmarks, for example, percent of congestive heart failure patients who receive ACE-I.
o
Financial incentives/penalties: Housestaff incentive program, quality and safety initiatives
and competitions.
References
What is continuous quality improvement?

o
Involves a team of clinical and non-clinical members in a continuous cycle of change and
measurement.
What are we trying to accomplish? Set measurable and time-specific

goals.
How will we know that a change is an improvement? Select practical

quantitative measures.
What changes can we make that will result in improvement?

PDSA Cycles Plan, Do, Study, Act: Allows quality improvement teams to plan interventions, test whether
they work, and modify the intervention.
What is the Joint Commission?
o
The Joint Commission on Accreditation of Healthcare Organizations (aka Joint
Commission or JCAHO) is the primary health care standards-setting and accrediting body.
Its mission is to improve the safety and quality of care provided to the public through the
provision of health care accreditation. Current JCAHO standards for accreditation include:
Time Out: Patient identification and identification of surgical/procedure

site.
Policies surrounding verbal and telephone orders.
Do Not Use abbreviations: Avoidance of misinterpretable abbreviations.
Critical test read back and confirm procedures.
Sentinel and adverse event reporting policy.

Batalden PF, Davidoff F. What is quality improvement and how can it transform healthcare. Qual Saf
Health Care. 2007 16:2-3.
Batalden PF, Davidoff F. Teaching Quality Improvement: The Devil is in the Details. JAMA 2007: 10591061.
Berwick D, Nolan T. Physicians as leaders in improving health care: a new series in Annals of Internal
Medicine. Ann Intern Med 1998;128:289-292.
Boonyasai RT, WIndish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of teaching
quality improvement to clinicians: Asystematic review. JAMA 2007; 289: 1023-1037.
Wachter RM, Goldman L, Hollander H. Hospital Medicine, Second Edition. 2005: Chapter 12: Assessment
and Improvement of Quality and Value.
Health Care Costs

Context
Over-utilization of diagnostic tests have contributed to the increasing costs of health care. The number of
tests used per patient discharged at UCSF is higher than 15 other comparable academic hospitals
(according to University Hospital Consortium data). The following is a list of costs incurred to the patient and
healthcare system as a whole.
Costs of Commonly Ordered Diagnostic Tests at Moffitt-Long Hospital:
Service
Hospital Charge
Medicare Reimbursement
Full Metabolic Panel / Chem-7
Panel not available at Moffitt. $49$64 per individual test ($409)
$15.14
- Na (individual test)
$53.00
$6.89
- K (individual test)
$51.00
$6.58
Liver Function Tests (AST,ALT, Total

Bilirubin, Alkaline Phosphatase)
Panel not available at Moffitt. $6366 per individual test.
$11.70
CBC
$98.00
$9.27
- Hemoglobin
$30
$3.39
ABG
$260.00
$27.04
ANA
$71.00
$15.60
CRP
$167.00
$19.32
Urinalysis with Micro
$48.00
$4.43
Chest X-Ray (PA/Lateral)
$251.00
$57.00
Abdominal X-Ray (KUB)
$213.00
$57.00
CT Head (+/- contrast)
$2,551.00
$420.00
Common Laboratory Tests
Common Radiology Exams
Service
Hospital Charge
Medicare Reimbursement
CT Chest (+/- contrast)
$3,194.00
$420.00
CT Abdomen/ CT Pelvis
$3,067.00
$420.00
MRI Brain
$5,475.00
$677.00
Abdominal Ultrasound
$767.00
$125.00
Blood Culture
$270.00
$14.42
Urine Culture
$172.00
$11.28
Sputum Culture
$234.00
$12.34
EKG
$176.00
$22.96
TTE
$3,101.00
$533.71
Common Micro Tests
Common Diagnostic Procedures
Cost of One Night Stay (not including other services)
ICU
$19,755.00
Varies greatly depending on

medical condition.
Floor Bed
$6,556.00
Varies greatly depending on

medical condition.
Data obtained from UCSF billing department, 2010. Based on outpatient charges.
The UCSF Clinical Laboratories maintain an on-line laboratory manual that is constantly
updatedhttp://labmed.ucsf.edu/labman/. Contains important information regarding test availability and turnaround
time and test utilization tips.
References
Hamill, Tim (2010). Lab Test Utililization: The right, the wrong, and the overused [PowerPoint slides].
Health Care Costs

Context
Academic hospital physicians strive to balance patient care with clinical teaching and team management. Individual styles
differ, but the following are some common strategies.
Plan ahead
Most effective teaching and management does not happen spontaneously.
On Day 1: Establish expectations and priorities for medical students and housestaff, especially:
1.
Patient care priorities.
2.
Specific learning and teaching goals for individuals and the team.
3.
Process for feedback and evaluation.
4.
Clinics and days off.
5.
Call nights.
6.
Oral presentations (level of detail, length, references to current literature).
7.
Work round and attending round logistics.
Plan each day
1.
Review team priorities each day before rounds. Identify patients who need to be monitored closely,
discussed in depth, or discharged.
2.
Schedule formal teaching (i.e., attending rounds, work rounds, student presentations).
3.
Identify learning opportunities by taking time before rounds (or the night before) to review patients
and possible teaching topics.
Ward teaching
Highly rated teachers are enthusiastic, flexible and teach within clinical context.
Teaching files: It is never too early to develop or collect teaching files (e.g., pneumonia). Effective teaching
plans identify:
1.
Goals for instruction (e.g., ddx and management of shortness of breath).
2.
Key teaching points (e.g., initial workup and management of dyspnea).
3.
Teaching method (e.g., case-based vs. chalk-talk vs. bedside, etc.).
4.
Knowledge of common misconceptions and difficulties among learners (e.g., ABGs).
Bedside teaching. Can be time consuming, but almost uniformly preferred by students and models physical
examination and patient interactions.
Frequent, short, pertinent sessions are highly preferred to episodic long ones.
Teach clinical reasoning, which can be as valuable as teaching clinical content. Use clinical cases,
involvement of learners in decision making, and explicit discussion of clinical reasoning.
Turn to-dos and scut into teachable moments. Take time with learners to reflect on family meetings,
condolence cards, adverse outcomes, and even sign-out or cross-cover.
The One Minute Preceptor model focuses the teacher on involving the learner and providing
immediate feedback.
The One Minute Preceptor teaching script
Microskill #1: Get a commitment.
Ask an open-ended question about the learners thinking process about the data he/she presented.
Example: What do you think is going on? How do you plan to manage your patients shortness of
breath?
Microskill #2: Probe for supporting evidence.
Test the learners knowledge or thinking process and clinical decision-making regarding their
commitment.
Example: What factors did you consider in making that decision? What alternative diagnoses did
you consider and why?
Microskill #3: Teach general rules.
After you have assessed how much the learner knows, summarize a few teaching points that the
learner can apply to future cases. Target your teaching, such as physical findings, diagnostic workup,
treatment, or missed connections. This may be in the form of a mini-lecture or assigning reading to a
learner, with subsequent follow-up.
Microskill #4: Reinforce what was done right.
Verbally reinforce specific effective behavior.
Example: That was a terrific synopsis. It shows that youve gathered the history and performed the
physical exam in an organized, thoughtful manner, and have incorporated these findings into your
assessment.
Microskill #5: Correct mistakes.
After allowing the learner to identify his/her error, discuss the specific mistake and suggest new
behaviors for the future.
Example: I agree that the most likely cause for nausea in this patients case is gastroenteritis.
However, remember that the general rule is that we should also consider pregnancy in this young
woman, particularly since she is a day late with her period.
Feedback and Evaluation
Learners respond best if feedback is immediate (e.g., after presentations), frequent (e.g., everyday or call
cycle), and specific (i.e., more than great job).
Schedule formal feedback and evaluation.
An approach to giving effective feedback:

Step 1: Ask for self-reflection (e.g., How do you think youre doing?).
Step 2: Focus on types of behaviors, not the person.
Step 3: Reinforce positive behaviors.
Step 4: Give specific constructive feedback (sandwiched between positives & goal setting).
Step 5: Develop new goals and a plan for improvement.
References
Irby DM. Three exemplary models of case-based teaching. Acad Med 1994;69:947-953.
Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. Arandomized controlled trial. J
Gen Intern Med 2001;16:620-624.
Neher JO, Stevens NG. The one-minute preceptor: Shaping the teaching conversation. Fam Med
2003;35:391-393.
Wachter RM, Goldman L, Hollander H. Hospital Medicine, Second Edition. 2005: Chapter 11: Effective
clinical teaching in the inpatient setting.
NIGHT CALLS
Common Nighttime Calls
Intravenous access
Patients who lose IVs overnight often have poor venous access (i.e., ESRD patients or IV drug
users). First, determine whether IV access is necessary. If a patient can wait safely until the morning,
more experienced staff can place peripheral IVs or more definitive venous access like PICC lines or
other catheters. Consider whether IV medications can be given orally overnight. Some quick tips:
Lower extremities (not in diabetics) can be a good option, consider hanging the patients legs off the bed to
allow veins to fill and dilate. Warm compresses may also help.
If there is no good venous access in the extremities (or if contraindicated by cellulitis, phlebitis, etc.), then you
should consider external jugular or central venous line placement.
Ask for help/supervision for an EJ until you are comfortable doing it alone.
Hyperglycemia
Insulin sliding scales used in the inpatient setting are usually poor at maintaining tight control of blood
sugar. It is important to determine whether a patient is symptomatic from hyperglycemia and what
the patients blood sugar control has been like during the hospitalization.
Blood sugars > 200 mg/dL initiate an osmotic diuresis.
Steroids, TPN, or enteric feeding can often exacerbate hyperglycemia in the diabetic patient.
Usually, the insulin sliding scale will provide sufficient coverage for a single high blood glucose level.
However, if the patient is a risk for a hyperosmolar hyperglycemic state (admitted for this diagnosis or prior
history of it), or if the patient is symptomatic (nausea, vomiting, hypovolemia, tachypnea), then the patient
should be seen and evaluated, pay attention to the last electrolyte panel, or order a new one (i.e. increased
anion gap). See Endocrine: Diabetic Ketoacidosis and Hyperosmolar Non-Ketotic Coma.
Hypoglycemia
Defined as glucose < 50 mg/dL with symptoms.
Some patients, however, feel symptomatic with blood sugars of 51-80 mg/dL.
Frequently it is the result of excessive lowering of glucose in patients with dietary changes in the hospital
(NPO status/diabetic diet).
However, infection and sepsis should be considered in all hypoglycemic patients.
If hypoglycemia is mild and the patient is stable, give oral glucose (e.g., orange juice).
For more serious episodes of hypoglycemia, treat with 50g (1 amp) of intravenous dextrose (D50).
If no clear cause of hypoglycemia can be found, or if the patient has any other troubling signs of infection, a
full evaluation for infections is warranted.
Clarification of orders
The goal of the on-call physician should be to fix serious problems, but leave the overall patient
management plan to the primary team.
If any orders are unclear, and you do not believe they will alter the care of the patient overnight, it may be
best to wait and let the primary team clarify them.
On-Call Radiology
Commonly, on-call physicians are asked to interpret chest radiographs to assess the position of devices (e.g., central venous
catheters, nasogastric tubes) and to rule out complications of their placement (e.g., pneumothorax). If there is ever any doubt,
a radiologist should be consulted for assistance with interpretation.
Pneumothorax (PTX)
Particularly important to consider in ICU patients who are receiving positive end-expiratory pressure (PEEP). 5-15% of those
on mechanical ventilation can develop extrapulmonary air (PTX, pneumomediastinum, subpleural air).
Tips for identifying a PTX:
A small PTX in an upright patient collects at the apex. The lung apex retracts toward the hilum and the sharp
white line of the visceral pleura will be visible, separated from the chest wall by the radiolucent pleural space
which is devoid of lung markings.
If a pneumothorax is suspected but not initially apparent, an expiratory film will make it easier to see because
lung volume will be at its lowest.
A lateral decubitus film with the affected side up may reveal air along the lateral chest wall.
A deep sulcus sign [deep lateral costophrenic angle on the involved side] or a wavy heart border sign in
patients that with pneumothorax who are supine may be seen.
Depression of the hemidiaphragm is the most reliable sign for a tension PTX
Any suspicion of PTX warrants a non-contrast CT scan of chest since CXR correlates poorly with actual
size.
Endotracheal tube (ETT) placement

12-15% of patients will have malpositioning of the ETT on initial placement.
The tip of the ETT should be positioned 4-6 cm above the carina with the patients neck in a neutral position.
Flexion of the neck = movement of ETT inferiorly (towards carina) on CXR and vice versa.
Central Venous Catheter (CVC) Position and Placement
A CVC catheter tip should ideally be located at the cavoatrial junction.
A PICC line catheter tip should be located the inferior aspect of the SVC.
CXR landmarks and findings related to CVC placement
The arch of the azygous vein is a landmark for the SVC.
The right mainstem bronchus is a landmark for the junction of the SVC and the right atrium. Therefore,
inferior to the right mainstem bronchus corresponds to a position within the right atrium.
The development of a new pleural effusion after line placement should be considered pleural hematoma or
extravasation of fluid from the line until proven otherwise.
Nasogastric (NG) and feeding tubes (FT)
NG tubes are usually inserted for decompression of the stomach. Obstruction of the esophagus may occur
if the NG tube is not inserted far enough into the stomach; at least 10 cm of the tip should be within the
stomach.
Ideal placement of feeding tubes depends partly on the clinical situation. In general, a feeding tube placed in
the stomach poses no greater aspiration risk than a feeding tube placed beyond the pylorus. For patients
with high reflux risk, placement beyond the pylorus is often recommended, though supportive data is
lacking. IV metoclopramide may aid in the passage of feeding tubes beyond the pylorus.
The unintentional placement of a feeding tube into the airway is a potentially life-threatening complication
that is not always obvious. Placement is sometimes difficult to determine with a portable radiograph of a
poorly positioned patient. Merely assuring that the tip of the feeding tube is over the gastric bubble is not
adequate confirmation -- one must follow the entire course of the tube to ensure that it does not follow the
course of a bronchus. Obtain an Xray to confirm correct placement. If there is any question, do not clear the
feeding tube for use.
UCSF Medical Center small-bore feeding tube placement verification procedure for adults
o
X-ray confirmation is required before using for medication, fluids or feedings
Placement must be confirmed by a radiologist
After verification, the provider must write an order indicating that a radiologist has confirmed
placement: OK to use FT tube, placement verified by radiologist.
References
Henschke CI, Yankelevitz DF, Wand A, et al. Chest radiography in the ICU. Clin Imaging 1997;21:90-103.
Common Clinical Scenarios

Bradycardia
Definition: There is considerable variation in the resting heart rate of healthy, asymptomatic populations. Simply defined a
HR <60bpm is considered bradycardia. Common symptomatic and hemodynamic findings in bradycardia include:
syncope/pre-syncope, fatigue, weakness and hypotension.
Differential Diagnosis
Intrinsic Causes
Evaluation
Idiopathic degeneration
(aging)
Infarction or ischemia
(especially inferior MI)
Infiltrative diseases (sarcoid,
amyloid) Collagen vascular
disease (SLE, RA)
Surgical trauma (valve
replacement, heart
transplant)
Infectious diseases (Chagas
disease, endocarditis)
Extrinsic Causes
Autonomically-mediated
syndromes
Neurocardiogenic syncope
Carotid sinus hypersensitivity
vagal tone (micturition, strain, vomiting)
Cushings reflex (d/t intracranial pressure,
associated with HTN and bradycardia)
Medication-induced
Beta-blockers, calcium-channel blockers,
clonidine (reflexive), digoxin, antiarrhythmics
(amiodarone), eye drops (timolol)
Hypothyroidism (myxedema)
Hypothermia Electrolyte
abnormalities ( or K+)
Severe hypoxia
Obstructive Sleep Apnea
Conduction System Abnormalities Causing Bradycardia:

o
Sinus-node Dysfunction: sinus bradycardia, sinus arrest (pause >3sec), sinoatrial exit
block, bradycardia-tachycardia syndrome (alternating atrial tachyarrhythmia and
bradycardia).
o
AV Conduction Disturbances: 1st degree AV block, Type I and Type II 2nd degree A-V
block, 2nd degree with high grade A-V block (3:1 conduction) and 3rd degree A-V block
(complete heart block, A-V dissociation).
Determine if the patient is hemodynamically stable or unstable/symptomatic (if so, see ACLS
bradycardia).
Obtain 12-Lead ECG (for all new onset bradycardia or clinical change, have it ready or in process as you
are on your way to the bedside); be sure to compare to old ECG.
Take a history and examine the patient, pay attention to symptoms described above and vital sign
abnormalities and mental status.
Evaluate medication list and recently given medications (i.e.: -blocker, CCB) and obtain electrolyte panel
and TSH if not done recently.
Management
If symptomatic or unstable bradycardia follow ACLS protocols for temporary pacing and consult cardiology
for temporary pacing wire placement.
Medications are a common cause of bradycardia. Though be careful with abrupt discontinuation of certain
medications such as rate control agents that may result in a rebound tachycardia. Holding one dose or
decreasing the standing dose may be a good first attempt.
Assure that atropine and pacer pads are easily available (i.e. at the bedside if available per nursing protocol).
Transcutaneous pacing is uncomfortable and a transition to temporary pacing wire should be made if long
term pacing will be needed, these patients should be transferred to the ICU and cardiology should be
consulted.
Treat the underlying conditions i.e. cardiac ischemia, medication overdoses, hypothyroidism
(seeEndocrine: hypothyroidism), electrolyte abnormalities
Special Situations:
o
Beta-blocker overdose (if severe --> glucagon)
o
CCB overdose (1 amp of CaCl2, may require calcium drip)
Class I indications for pacemaker placement in asymptomatic patients:
o
3rd degree AV block with documented asystole >3sec in awake patients or escape rates
<40 bpm
o
3rd degree AV block with wide QRS escape rhythm
o
Mobitz type II 2nd degree AV block or 3rd degree AV block in patients with chronic bifasicular
or trifascular block.
o
Ventricular dysfunction
o
Bradycardia markedly inappropriate for age
Key points
Asymptomatic bradycardia in a young, athletic patient can be normal! But dont ignore the call.
It is important to identify the underlying rhythm in bradycardia as the management differs depending on the
etiology.
Medications are often the cause! Check electrolytes - pay close attention to the K!
Inferior myocardial infarctions often cause bradycardia due to increased vagal tone and require pre-load for
management of hypotension.
References
Mangrum, J.M and DiMarco, J. Management of bradycardia. N Engl J Med 2000; 342:703-709.
2005 American Heart Association Guidelines for Cardiopulmonary Resucitation and Emergency
Cardiovascular Care. Part 7.3: Management of Symptomatic bradycardia and tachycardia. Circulation
2005; IV-67-IV-77.
Narrow Complex Tachycardia

Definition: HR >100 with a QRS duration < 0.12 sec (120ms), can be regular or irregular. Given their narrow QRS duration
they originate above the ventricle and are commonly referred to as a supraventricular tachycardia (SVT). An SVT may also
have a wide QRS when there is aberrant conduction. Tachycardia is classified according to whether: regular or irregular,
narrow complex or wide complex.
Differential diagnosis
Regular
Irregular
Sinus tachycardia
Atrial Fibrillation
Atrial flutter with regular block
Atrial Flutter with variable block

Multifocal atrial tachycardia (MAT)
A-V nodal reentry (AVNRT)
Atrial tachycardia
Accessory-pathway mediated reentry

(aka: AVRT, Wolf-Parkinson-White)
Main Causes of Regular Narrow Complex Tachycardia (NCT):

o
Sinus tachycardia (ST): generally a physiologic response to a stress on the body and is
often the marker of an underlying illness. The maximum HR of a normal individual is 220
minus age. When cardiac function is compromised the cardiac output may be dependent
on the HR due to a fixed stroke volume (SV). Common etiologies in the differential
diagnosis:
Normal response to infection, sepsis, pain, hypovolemia, fever and

hypotension
Pulmonary embolism, hypoxia
Cardiac tamponade, pericarditis
Metabolic conditions: hyperthyroidism
Alcohol withdrawal
Response to sympathomimetic drugs (i.e.: vasopressors, bronchodilators,

beta agonists)
Atrial tachycardia (AT): paroxysmal in nature and is caused by a focus of enhanced

automaticity within the atria or a focus of an ectopic atrial pacemaker. Can be difficult to
diagnose.
A-V nodal reentry tachycardia (AVNRT): 60% of cases of SVT are caused by AVNRT,
caused by a dual conduction pathway within the A-V node itself, typically one that conducts
fast and one that conducts slowly. AVNRT is usually set off by a premature atrial contraction
(PAC).
ECG Findings: rate usually <250bpm, will have p-waves on rhythm strip
and may require adenosine (see below) to diagnose.
ECG Findings: p-waves are often absent. The p-waves are buried within
the QRS complex that creates S-waves in inferior leads (pseudo-S
waves) and apparent R waves in V1 (pseudo-R) though can be found.
Typically have a long RP interval which is longer than the PR interval
(RP>PR)
A-V reentry tachycardia (AVRT): an SVT that is generated by an accessory pathway

and accounts for 30% of cases of SVT.Acommon example is Wolf-Parkinson-White
(WPW) syndrome.
Have a short RP interval that is less than the PR interval and the p-wave
is discrete from the QRS complex and usually retrograde.
WPW: characterized by the presence of the delta wave, which is a

broadened up sloping of the R wave.
Atrial flutter with regular block: characterized by a classic saw-tooth p-wave which
typically has a rate of ~300 bpm. The ventricular rate is determined by the rate of
conduction block. Often flutter as a regular 2:1 block resulting in a ventricular rate of 150
bpm. If regular, 300/ventricular rate should characterize the rate of AV block.
Main Causes of Irregular Narrow Complex Tachycardia:

o
Atrial fibrillation (AF): very common in acutely ill patients, especially older individuals.
Characterized by a lack of p-waves or flutter waves in all leads and an irregularly irregular
rhythm. Please see Cardiology: Atrial Fibrillation for more detailed information on
etiologies, management.
Atrial flutter with variable AV block: will look similar to AF except with the presence of flutter
waves. Often the flutter waves will be visible in the inferior leads with a rate of ~300 bpm.
o
Multifocal atrial tachycardia (MAT):a result of multiple ectopic atrial pacemakers, which in
turn generates at least 3 morphologically distinct p-waves with differing PR intervals on
ECG.
Associated with: pulmonary disease (COPD), underlying ischemic cardiac

disease, valvular disease, hypokalemia and hypomagnesemia,
Evaluation
Obtain 12-lead ECG and full set of vital signs to determine hemodynamic stability.
For hemodynamically unstable patients or those showing signs of rate related cardiovascular compromise
(ongoing chest pain, altered mental status, hypotension or other signs of shock), follow ACLS unstable SVT
protocols.
Compare current ECG to prior 12 lead ECG, evaluate for evidence of delta waves when at a slower rate as
this will effect management.
Management
If unstable, follow ACLS protocol and do not delay synchronized cardioversion.
Confirm the absence of delta waves on prior ECG; if there is any question do not proceed with adenosine
until after this is confirmed.
Evaluate for characteristic findings on 12-lead ECG for each type of SVT during the event, which may
isolate the diagnosis or illustrate its termination.
Vagal maneuvers: Can often break SVT
Types: cough or bear down as if to have a bowel movement.
Carotid Massage: stimulates baroreceptors that trigger a reflexive increase in vagal activity
and slowing conduction through the AV node. Place firm pressure to the neck at the level of
the cricoid cartilage for 5 sec with circular motion. Prior to doing so, auscultate for carotid
bruits, if present do not perform this procedure.
The role of adenosine:

o
Adenosine functions by slowing conduction through the AV node, and can be used to treat
and diagnose the underlying rhythm if unclear.
60-80% of patients treated with a 6mg dose of adenosine will break their SVT and 90-95%
will break with a dose of 12mg.
If the rhythm doesnt break, it often will slow it enough to reveal the underlying rhythm such
as atrial flutter or sinus tachycardia.
Dosing and Administration
Peripheral IV: 6mg X1, may repeat X1 6mg dose several minutes later if
not broken, then increase to 12mg dose X1
Central Line: lower doses of 3mg with a repeat dose and then increased
dose of 6mg.
Continuous ECG monitoring during administration.
Rapid IV flush is required due to very short half-life.
Adverse Reactions: bronchospasm, ventricular fibrillation (VF, very rare),

chest pain and dyspnea (more common).
AVOID IN: severe COPD
DO NOT USE IN: Heart transplant recipients (causes prolonged asystole), wide complex
tachycardia (unless SVT with aberrancy is certain, causes VF), and WPW (causes rapid
ventricular rate and can degrade to VF, treat with procainamide if occurs), previous allergy.
Rate control agents: if the SVT doesnt break with adenosine or rapidly reoccurs, consider an IV -blocker or
IV CCB.
o
For treatment and management of atrial fibrillation, please see Cardiology: Atrial
Fibrillation.
Key points
Sinus tachycardia is usually not treated and is a signal for an underlying problem.
Synchronized cardioversion and ACLS protocol for unstable SVT should not be delayed.
Always look for delta waves or a widened QRS duration before giving adenosine.
Adenosine makes patients feel terrible, be aware.
Adenosine is both diagnostic and therapeutic; always use continuous ECG monitoring during
administration.
Atrial flutter can often be very difficult to rate control.
References
Delacretaz, E. Suprventricular Tachycardia. N Engl J Med 2006; 1039-1051
2005; IV-67-IV-77.
Ganz LI, Friedman PL. Supraventricular tachycardia. N Engl J Med 1995;332:162-173.

Appendix A: Formulas
Wide Complex Tachycardia
Definition: HR >100 with a QRS duration >0.12s (120ms). Can be classified as regular or irregular. Increased QRS
duration correlates with either aberrant intraventricular conduction of an impulse that is supraventricular in origin or that the
origin of the impulse is from the ventricular portions of the conduction system.
Regular
Monomorphic Ventricular Tachycardia

SVT with aberrancy
Pre-excitation tachycardia (antidromic
AVRT)
Irregular
Ventricular Fibrillation
Irregular SVT with aberrancy
Polymorphic Ventricular
tachycardia
Regular Wide Complex Tachycardia:

o
Monomorphic ventricular tachycardia (VT): a rhythm that originates from the ventricular
conducting system with only one QRS morphology. Most wide complex tachycardias
(WCT) can be assumed to be VT until proven otherwise. Predisposing factors include
cardiomyopathy, prior myocardial infarction and electrolyte abnormalities, particularly of
potassium and magnesium. Identification is made by diagnostic criteria illustrated
in Cardiology: Diagnosis of Wide Complex Tachycardia and ACLS: Stale/Unstable
VT Protocol.
Non-sustained VT: self terminates in <30 sec.
Sustained VT: self terminates in >30 sec or continues indefinitely.

o
SVT with aberrancy: caused by a supraventricular impulse that has aberrant
intraventricular conduction in the setting of a bundle branch block. This can be difficult to
differentiate from VT at times and has a very different management acutely and chronically.
o
Pre-excitation tachycardia: caused by an accessory pathway that conducts at a different
rate and causes a widening of the QRS complex. Considered to be antidromic AVRT and
is impossible to distinguish between this and VT.
Irregular Wide Complex Tachycardia:
o
Ventricular fibrillation: a form of pulseless arrest, unorganized ventricular rhythm and
requires immediate ACLS initiation and defibrillation. This is an ischemic rhythm.
o
Irregular SVT with aberrancy: likely related to atrial fibrillation or flutter with variable block.
o
Polymorphic ventricular tachycardia: an organized ventricular rhythm with beat-to-beat
variability in morphology that deteriorates to pulseless arrest and VF quickly and should be
treated per ACLS protocols immediately. This can represent an episode of ischemia, or
be related to a prolonged QT interval. Torsades des pointes is an example of polymorphic
VT that occurs in the setting of QT interval prolongation.
Management
1.
Quickly determine if the patient is hemodynamically stable or unstable, if unstable call for back up via
code blue and initiate ACLS unstable WCT protocol for unstable VT/VF.
2.
If stable, obtain 12 Lead ECG and electrolyte panel including magnesium and consider cardiac biomarkers.
3.
Look for precipitating cause and treat accordingly (i.e. ischemia, prolonged QT)
4.
Evaluate medication list for QT prolonging agents
5.
Stable VT: See ACLS: Stable VT section for anti-arrhythmic recommendations
Key points
A wide complex tachycardia should be treated as ventricular tachycardia until proven otherwise.
Evaluate for hemodynamic stability immediately.
Check potassium and magnesium levels treat for K >4.0 and Mg >2.0
Irregular WCT is likely a sign of ischemia or a result of prolonged QT interval.
Do not hesitate to call a Code Blue for appropriate back up and initiating ACLS protocol.
Consider electrophysiology or cardiology consult early for aid in management.
References
2005; IV-67-IV-77.
Brugada, P; Brugada, J; et al. A New Approach to the Differential Diagnosis of a regular tachycardia with a
wide QRS. Circulation 1999; 83:1649-1659.
Hypotension
Definition: Mean arterial pressure (MAP) <65. Keep in mind that a patient who is usually hypertensive can experience
hypoperfusion at higher MAPs.
Differential Diagnosis and Evaluation
Remember hypotension = death. Presence of normal mentation simply indicates that the patient still has a pulse and should
not be reassuring in itself.
Treat all episodes of hypotension very seriously; all hypotensive patients should be seen and evaluated promptly.
Use this equation to think through the differential diagnosis of hypotension:

MAP = SVR x CO = SVR x HR x SV (where Stroke volume = Preload x Contractility)
MAP - mean arterial pressure; SVR - systemic vascular resistance - HR, heart rate; SV - stroke volume.
Decreased SVR: Exam = warm extremities, sometimes flushing.

o
Sepsis: Common cause. Obtain blood cultures x 2. CXR, UA/micro/culture. Rapid

administration of IVF and antibiotics will be crucial. See Critical Care: early goal-directed
therapy for sepsis.
Medications: Look for antihypertensives, pain meds, sedatives, and possible dosage
errors; if concern for opiate overdose, give narcan.
Adrenal insufficiency: Is the patient on chronic steroids and unable to mount a stress
response? Consider stress dose steroids (See Endocrine: Adrenal Insufficiency).
Anaphylaxis: Look at medication list/diet for offending agent. Give epinephrine 0.2-0.5 ml
(0.2-0.5 mg) of 1:1000 SC/IM q20 minutes (diluted dosedifferent from code blue dose),
diphenhydramine 50 mg IV, hydrocortisone 100 mg IV.
Neurogenic: Spinal shock rare cause in an already hospitalized patient. Spinal

compression.
Abnormal heart rate: Look at the ECG for pathologic tachycardia, bradycardia. Unlikely to be primary
cause unless HR is very high or low.
Decreased preload: Exam-assess JVP, volume status.

o
Hypovolemia: GI bleed, diarrhea, third spacing, insensible losses. Get STAT CBC,
consider Central Venous Pressure (CVP) monitoring, review Ins and Outs. Unless the
patient has known ventricular dysfunction, almost never wrong to give an IVF bolus.
Pulmonary embolism: See Pulmonary: Pulmonary Embolism.
Tamponade: Get pulses, call cardiology to perform an echo and

pericardiocentesis. SeeCardiology: Tamponade.
Right ventricular infarct: Obtain right sided ECG. See Cardiology: RV Myocardial
Infarction.
Tension pneumothorax (PTX): Do not wait for a CXR. Insert a 14 or 16 gauge needle
into the second intercostal space at the midclavicular line ASAP.
Pulmonary hypertension: See Cardiology: Pulmonary Hypertension.
Decreased contractility: Exam-listen for gallop, murmurs (especially new), and rales/crackles.
Myocardial dysfunction: New infarct vs. prior ventricular dysfunction and precipitating event. Review
history of CAD/CHF and cardiac risk factors. Get STAT ECG, cycle troponins, telemetry; seeCardiology:
Rule out Myocardial Infarction, ACS, Congestive Heart Failure.
Medications: Look for -blockers and CCB.
Valvular dysfunction (AS, AI, MR): Acute worsening of known valve disease? Infarction causing papillary
muscle rupture? Endocarditis? Get STAT echo.
Aortic dissection: Any history of peripheral vascular disease? Get STAT chest CT.
Additional Points on Differential Diagnosis and initial evaluation: After using MAP = SVR x CO, consider the following:
Overlap syndromes: Get more data with a PAline or echocardiogram + CVP.

o
Sepsis + cardiogenic, sepsis + hypovolemia, cardiogenic + hypovolemia.
Consider other causes of hypotension as listed above and as follows:

o
Increased cardiac output without sepsis: ESLD or fulminant hepatic failure, severe
pancreatitis, trauma with SIRS, thyroid storm, AV fistula.
Increased CVP without LV failure: pulmonary hypertension, PE, RV infarct, tamponade.
Non-responsive hypovolemia: adrenal insufficiency, anaphylaxis, cold sepsis.
Autonomic dysfunction: review patients problem list/past medical history
Management
Always start with: Is the patient stable? and go evaluate the patient promptly:
Above all, stay calm. Crashing patients are scary. Do not try to manage shock by yourself.
Have a low threshold to transfer a hypotensive patient to the ICU for better nursing support and/or for
facilitated intubation. Call a code blue for immediate help.
If the BP is undetectable, palpate for pulses. A palpable femoral pulse indicates systolic blood pressure
(SBP) > 80 mmHg and a palpable carotid pulse indicates SBP > 60 mmHg.
Treatment is aimed at the underlying cause (see DDx and evaluation section above), but almost all cases
call for fluid resuscitation. If suspicion of CHF is low, then give rapid isotonic fluid resuscitation.
Start O2, additional large bore peripheral IVs, put patient in Trendelenberg, draw basic STAT labs (CBC,
lytes, BUN, creatinine, glucose, LFTs, blood/urine cultures), and get STAT ECG, CXR, ABG. See Critical
Care sections (e.g., Initial Choice of vasopressor in hypotension, Stepwise Approach to the ICU patient
with septic shock) for more information.
If the patient is stable, then move on to these questions:

o
Is this BP real? Measure the BP manually with the correct sized cuff. Get a repeat full set of
vitals.
Is the BP any different from prior values? If the patient usually has a BP of 80/40 mmHg,
then the acuity may be decreased somewhat.
Is there associated hypoxemia, altered mental status, or increased respiratory rate (reasons
for intubation)?
Access? Think about placing additional large bore peripheral IVs, a central line, or a PAline.
Monitoring? Arterial line placement gives real time accurate blood pressure measurements.
Foley catheter to measure urine output (renal perfusion).
Is the mean arterial pressure (MAP) <60 mmHg? MAP = (SBP + 2(DBP))/3. MAP less
than 60 mmHg = significant risk of hypoperfusion to vital organs.
Key points
The patient is mentating fine should only be as reassuring as the patient still has a pulse.
Treat all episodes of hypotension seriously. Always go to evaluate the patient.
Use the equation MAP = SVR x CO to help think through the DDx and initial management of hypotension.
See Hypotension Algorithm below for a quick review.
Hypotension Algorithm
References
Wood Lawrence D, Chapter 20. The Pathophysiology of the Circulation in Critical Illness (Chapter). Hall
JB, Schmidt GA, Wood LDH: Principles of Critical Care, 3rd edition. 200
Hypertension
Definition: BP >140/90. However, not every pt with a BP >140/90 warrants acute intervention.
Hypertensive emergency: Elevated BP is associated with end-organ damage (brain, eye, heart, and
kidney)
Hypertensive urgency: Elevated BP of >200/109 mmHg but no evidence of end-organ damage.
Consider underlying conditions that could be causing hypertension:
o
Alcohol withdrawal (tachycardia, tremor, confusion).
o
Drug overdose (cocaine, amphetamine).
o
Medication interactions (MAO inhibitors, tricyclics).
o
Medication withdrawals (-blockers, ACE inhibitors, clonidine).
o
Increased intracranial pressure (Cushings reflex).
o
ESRD, renal failure, renal artery stenosis.
o
Eclampsia, pre-eclampsia (is the patient pregnant?).
o
Coarctation of the aorta, aortic dissection (unequal BP in arms?).
o
Pheochromocytoma (episodic nature; associated with flushing, diaphoresis, tachycardia).
o
Endocrine (Cushings syndrome, thyrotoxicosis, Conns syndrome-primary
hyperaldosteronism).
o
Pain, anxiety (a diagnosis of exclusion).
o
Autonomic dysfunction
For hypertensive emergency, consider these important causes:
o
Hypertensive encephalopathy
o
Dissecting aortic aneurysm
o
Acute left ventricular failure with pulmonary edema
o
Acute myocardial infarction
o
Eclampsia
o
Acute renal failure
o
Symptomatic microangiopathic hemolytic anemia
Evaluation
High BP seldom warrants acute intervention. Your major concerns should be:
o
Whether this represents a hypertensive emergency.
o
Whether the hypertension reflects a more serious underlying process.
o
Avoid reflexively treating elevated BP since rapid lowering can be associated with significant
morbidity and death. Treatment should be initiated sooner for patients with a rapid rise in BP
and pregnant patients.
Accurate reading? Using correct sized cuff, take the BP again in BOTH arms.
Perform a chart biopsy: Note the time course of hypertension. Has it been constant since admission, or
has it developed suddenly? Does the patient have a history of renal or cardiac disease?
Physical exam: Ask about and examine:
o
Brain: headache, confusion, lethargy, stroke (Perform focused neurologic exam).
o
Eye: blurred vision (fundoscopic exam: papilledema, flame hemorrhages).
o
Heart: chest pain, dyspnea, S3, S4.
o
Kidney: low urine output, edema.
Studies
CBC with peripheral smear (look for schistocytes), ECG, urinalysis (look for proteinuria), electrolytes, BUN,
and creatinine (look for renal dysfunction) in all patients.
CXR in all patients with chest pain or dyspnea
Head CT for those with neurologic symptoms
Chest CT with contrast in patients with unequal BP in arms or widening of mediastinum on CXR.
Management
For hypertensive urgencies: The majority of patients with diastolic blood pressure >109 have no acute
end-organ damage and their blood pressure should be lowered over the next 24-48 with oral medications.
Rapid lower could cause MI or stroke in these patients. The following medications could be used:
o
Captopril 6.25-25 mg PO TID (check potassium, creatinine, allergies before); you can titrate
up after each dose if not having an adequate effect.

Metoprolol 12.5 25 mg PO BID, can start IV metoprolol 5mg x3 to assess tolerability.
Clonidine 0.1 mg PO BID.
Nitropaste is easy and can be easily removed. However, it can cause headache and is not
appropriate for long-term use; because of these issues, would generally consider other
choices for blood pressure management before using nitropaste. Also, always avoid in
patients with severe/critical AS. See Sliding Scales: Nitropaste for dosing.
o
Hydralazine 10 mg PO and titrate up q6h use with caution due to unpredictable effect.
o
Avoid short-acting nifedipine (increased mortality).
For hypertensive emergencies: Requires admission to the ICU and possible arterial line insertion if BP is
labile. Rapid titration of IV medications should be used.
o
Important to note that most patients are also volume depleted and may require isotonic IV
fluids to prevent hypotension following medication administration. (Assess CVP and be
careful in those with heart, kidney, or liver disease).
o
It is recommended that diastolic BP be reduced by only 10-15% over the first hour (within 510min. for dissecting aortic aneurysm patients). Then, reduce by 25% over next 6-12
hours. Goal BP should not be lowered to normal levels since autoregulation of blood flow to
brain, heart, kidneys has likely compensated for chronic hypertension.
o
Rapid declines in BP can lead to stroke, MI, or renal failure.
Use the following medications to get patients out of hypertensive emergencies then transition to PO
medications.
o
Esmolol: 0.5mg /kg loading dose, followed by starting infusion of 50g/kg/min up to
200g/kg/min. Good for post-operative hypertension and myocardial infarction patients.
Depending on dose, esmolol ends up being large volume infusion; if volume overload/CHF,
consider another medication.
o
Labetalol: 20 mg IV initial, followed by 20-80mg IV q10 minutes until BP falls; alternatively,
infusion dosed at 0.5-3.0 mg/min. Good for pregnant patient since little placental transfer.
o
Nicardipine: Initial infusion of 5mg/hour, increasing by 2.5mg/hour every 5 minutes to a
maximum dose of 30mg/hour.
o
Nitroprusside: 0.3 mcg/kg/min-4g/kg/min (levels between 4-10 associated with cyanide
toxicity). Difficult medication to use. Shown to cause increase mortality in post-MI patients.
Infusions >24 hours not recommended.
o
Nitroglycerin: 5g/min-60g/min IV Use for heart disease patients. Usually used with
another med.
o
AVOID hydralazine or nitropaste (unpredictable effects) and nifedipine (associated with
increased mortality).
Special situations:
o
Ischemic stroke: hypertension in these patients is compensatory and helps preserve
cerebral perfusion. Treatment should be reserved for when diastolic BP exceeds 120-130
and systolic BP >210. Avoid nitroprusside, fenoldopam, and nitroglycerin, since these
medications can increase intracranial BP (see Neurology chapter).
o
Pheochromocytoma: use an -blocker such as phenoxybenzamine or phentolamine.
Avoid -blockers for fear of precipitating a hypertensive crisis (unopposed alpha).
o
Pregnancy: use labetalol.
o
Cocaine: consider labetalol.
o
Scleroderma renal crisis: use an ACE inhibitor.
Key Points
Hypertension seldom requires aggressive acute intervention, unless concern for hypertensive
urgency/emergency.
For hypertensive emergency, always admit patients to ICU for close monitoring, and avoid lowering blood
pressure too rapidly (see above for more details).
Go see any patients who you are worried may have hypertensive urgency/emergency and all patients who
are symptomatic.
References
o
o
o
Varon J, Marik PE. Clinical review: The management of hypertensive crises. Crit Care Med 2003;7:374-384.

Appendix and Acknowledgements Summary

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Appendix and

Na (corrected for hyperglycemia):

Aa O2 gradient = [FiO2 x (pAtm pH2O)] (pCO2 / R) pO2

= 150 (pCO2 / 0.8) pO2

{normal 525 or age/3} *at sea level on RA

ACS - Acute coronary

AHA - American Heart

ASA - American Society

BMJ - British Medical

AIN - Acute interstitial

BMT - Bone marrow

ALL - Acute lymphoblastic

AMS - Altered mental

ATN - Acute tubular

BSA - Body surface area

BUN - Blood urea

BCx - Blood culture

ARDS - Acute respiratory

CAD - Coronary artery

ARF - Acute renal failure

BID - Twice a day

CaO2 - Oxygen content

ARRD - Acute reversible

BiPAP - Bi-level positive

BMI - Body mass index

CPP - Cerebral perfusion

CKD - Chronic kidney

CK-MB - Creatine kinase

FEV1 - Forced expiratory

FRC - Functional residual

HBV - Hepatitis B virus

FSGS - Focal segmental

HCG - Human chorionic

FUO - Fever of unknown

FVC - Forced vital

GCA - Giant cell arteritis

HOB - Head of bed

IPAP - Inspiratory positive

LFTs - Liver function tests

IVC - Inferior vena cava

LLQ - Left lower quadrant

IVDU - Intravenous drug

LMWH - Low molecular

IVF - Intravenous fluids

IVP - Intravenous push

HME - Heat moisture

HPF - High powered field

JVP - Jugular venous

IMI - Inferior myocardial

LBBB - Left bundle

LVEF - Left ventricular

LCx - Left circumflex

resistant staph epidermis

MAP - Mean arterial

NNT - Number needed to

MUGA - Multiple gated

PBS - Peripheral blood

MVP - Mitral valve

PCKD - Polycystic kidney

PCR - Polymerase chain

PCV - Pressure control

NEJM - New England

RTA- Renal tubular