Care of Complex Patients | Surgery | University of Nebraska Medical Center

Protocols defining common circumstances requiring faculty involvement:
care of complex patient, ICU transfer, DNR or other end-of-life decision (by year and educational level)

PGY I and II: 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 ICU 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.

PGY III, IV and V: 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 ICU 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.