Care of Complex Patients

Protocols defining common circumstances requiring faculty involvement — care of complex patient, intensive care unit transfer, do-not-resuscitate or other end-of-life decision — by year and educational level.

First- and second-year residents

All decisions regarding patient care in clinic, wards, emergency room, operating room and other situations must be discussed and approved by a senior resident or attending physician. These include:

• Transfer of patient from or to ICU.
• Transfer of patient from ICU to step down or vice versa.
• Starting a patient on vasopressor drugs or significant changes in vasopressor requirement.
• Starting or changes to be made in the antibiotic regimen.
• Any changes in the management of airway such as requiring intubation, extubation, significant changes in ventilator settings or modes of ventilation.
• Plan of care discussions regarding withdrawal of care of determining code status must be undertaken only in the presence of senior resident or attending physician.
• Changes in wound care or management of drainage tubes such as insertion or removal of urinary catheters, nasogastric tubes and surgically placed drains. 

Third-, fourth- and fifth-year residents

Residents in the final years of education can initiate discussion and plans in several aspects of patient care. Residents can initiate the implementation of these decisions so as to not cause delays in patient care. All these decisions must still be approved by the attending physician.

These include:

• Residents can initiate transfer of patient from or to the ICU and confirm the plan of care decision after discussing with the attending physician.
• Residents can initiate the transfer of patient from ICU to step down or vice versa and confirm the plan of care decision after discussing with the attending physician.
• Residents can initiate changes in plans of treatment involving vasopressor drugs or airway management and must inform the attending physician.
• For complex patient, residents can initiate changes in the type and dosage of drugs and antibiotics which must be relayed to the attending physician for approval.
• Residents can initiate discussions with patients or families regarding end-of-life decisions or code status. The final discussions and decisions on these must be undertaken by the attending physician.