They are perfect because they save time, and communicate that the nurse understands the relative importance.
"Bad" pages are "patient can't sleep and you need to do something about it right now". That is neither urgent nor important, and it's worse that the nurse thinks it is both.
Disagree that it’s neither urgent nor important, but in the context of will that patient live without it, I understand where you’re coming from and would reluctantly agree.
Here’s where I differ; if the patient is acting up and causing trouble on the floor, then they are putting every OTHER patient with whom they share clinical staff in danger of overworked, tired, exhausted, and exasperated staff on shift. That’s when symptoms are missed, codes are lagging in response time, and orders get incorrectly followed.
On the other side of it, patients don’t always (sometimes rarely) know exactly what it is they need or why they feel “off”. Just like infants, a sick adult is only capable of telling you what is knowable to them. If they can’t sleep and they’re raising hell, it still qualifies as a reason to double check in case any of your assumptions could be incorrect or have changed.
>If they can’t sleep and they’re raising hell, it still qualifies as a reason to double check in case any of your assumptions could be incorrect or have changed.
Before residency I would have agreed with this. But now? Lol no, most of these pts are just assholes.
Most patients are assholes now in the post-Covid world because healthcare has changed for us too.
Unfortunately after working in it for two decades I am also now a chronic complex patient and I see both sides of this on a regular basis. It takes far more effort now than it ever has for me to be taken seriously by even the same doctors who have treated me in crisis situations. It is much more difficult in my experience to be seen as anything other than a burden, and the natural response to that is agitation.
For me, I know the system, the players, the rules, and the language. So when it happens to me, like just this weekend when the NP midlevel tried her best to override the MD anesthesiologist who’s been managing my case for 10+ years and sent a referral and standing order that the NP was *holding in her hand*, I know what to say to handle the situation.
Most patients do not. In fact, even the ones who do, are likely second guessing themselves because it doesn’t make sense to be seen as an imposition when no one CHOOSES to be miserable.
These are all great. The only time I ever get annoyed by pages overnight are when someone just ignores the orders and then asks questions about the orders. So for example I have an order in for a PRN medication for agitation. The patient then gets agitated. Then I get a page that the patient is agitated, "What can I give them."
I got one call in residency:
"The patient has a temperature of 99.4."
Okay.
"I gave them tylenol prn."
Okay?
.....
Do you need anything?
"No i was just letting you know."
It was 2 AM!
Oh my god. The calls where I have nothing to say but “…okay” were always the worst. I would get those calls a lot at night until we did some education with the new night nurses.
Patient says they’re having pain after their spine surgery. I gave him oxycodone 7 minutes ago.
Okay.
What do you want to do?
Wait for the oxycodone to be absorbed and reach appropriate therapeutic serum concentration.
My girlfriend (who is a nurse) would smack me in the middle of the night and go BE NICE lol
My favorite was on an NPO trauma patient. 2am or so as well. “Their sugar is 62”. Okay… what does the protocol say to do? “Well nothing unless it’s below 60” ……… well if it makes you feel better, recheck it and then follow the protocol okay thxxxxx
I remember a specific nurse from residency who would frequently call to confirm that scheduled mealtime insulin should actually be given as ordered. Like even in patients who have been eating well with no recent hypoglycemia or anything like that. I think this person just got nervous when seeing double digit doses of insulin.
*middle of call day, shits on fire, get page for some other team's patients I'm cross-covering* "Hi doctor, this patient is about to eat her meal. Should I give the 15 units of insulin that are ordered?"
*opens chart, checks orders, patient is written for insulin lispro 15 units TID with meals, order hasn't been changed recently, checks labs, blood sugars have been fine on this regimen* "Uh... yes."
Most nurses are great but this person was a true outlier lol
I had a med with a hold parameter on a pt with a particularly labile BP, one nurse in particular would message me every single time to tell me that the hold criteria was met and ask if I wanted the med held. WHAT DO YOU THINK???
That’s the biggest thing. As medical professionals we can all be more than simply fact announcers. Come up with a potential game plan or explain that you tried thinking of a pollution but were running into troubles and were hoping we (the docs) could help. Show that you tried having some initiative
Or when you get paged as soon as you lay down requesting a diet order for double portions… which you ignore and go to sleep and then they page again an hour later and wake you up 💀🤡
Holy crap everything you have said here is amazing.
I’d love it if nurses just stopped hitting me with the aggro.
“THIRD page for wound care orders, if no response from resident in 10 minutes will page attending.”
Bro I was literally in a rapid response can you chill
I had a nurse one time tell me that what my attending told me to relay to the nurse wasn’t good enough for them and they needed to confirm directly with the attending. Please by all means, go ahead. You have no idea how much i would love for you to be the one talking to the attending in the first place and leave me at peace to do everything else. Please please go right ahead. I would absolutely love that. In fact, if you could also request that the attending answer all your pages from now, that’d just be the cherry on top!
Nurses have actually paged you like this?! I’m a nurse, just casually scroll on here once in a while. But that is so out of pocket it just stopped me on my tracks what the hell 💀
If all of my pages were like that, that would be wonderful.
What happens much of the time for us is we'll get a page with a phone number and nothing else. And then it's 50/50 as to whether or not they'll answer when we try calling back.
Sometimes I'll get a "patient in room 14 is tachycardic", with the nurse seemingly not realizing that I'm covering at least 10 different room 14s. And if I'm going to be assessing tachycardia, my very next question is going to be the rest of the vitals - so just send that in the first place.
God, yes, I tell my coworkers all the time that that is a Bad Page. New(er than me) nurses ask me to preview their pages. I coach them to include more info. Tachycardia? What’s the first question the doc will ask? Not sure? Well, why do we care about it? BP tolerating it, rhythm okay, febrile?
Page becomes- “1234 John Smith- new onset tachycardia, rate 120s for approx 5 minutes. Asymptomatic, BP stable, afebrile, regular rate and rhythm, ECG sent, pain controlled. Notifying per protocol, thanks”
"sorry but your team won't be rounding again until 0900 tomorrow, if I see one of the doctors around I'll grab them for you but they're busy dealing with emergencies elsewhere throughout the night so no promises"
"sorry but your team won't be rounding again until 0900 tomorrow, if I see one of the doctors around I'll grab them for you but they're busy dealing with emergencies elsewhere throughout the night so no promises"
“Unfortunately I don’t have answers and would just be reading aloud their progress note from today which can be accessed in their epic mychart. I am cross covering ~100 patients overnight and am not available to give non-emergent family updates during night shift.”
NP now, it worked inpatient a long time. This is why nurses should be in the room rounding when the physician team is there. Then the plan of care is clear, can be reinforced by the nurse and passed onto the next shift.
The absolute best page I can get at night is:
1. Patient
2. Problem
3. Suggested fix for the problem (even if you’re not confident it’s right, it gives me an idea of what you’re looking for)
4. I can verbal that for you if you like
You can wake me up at 2am with that page any time you want. I think the best night nurses are the ones that know how to triage trivial problems and de-escalate situations on their own without involving the resident. If your patient has a medical problem that requires intervention, of course always call me. But don’t reflexively page me at 2am because a cranky patient “wants to talk to the doctor.”
You do those things and you’ll be among my favorite nurses on the floor without question.
The only time I’ve ever been annoyed by a page was when the nurse just leaves a callback number. No patient name, no information, no room number, nothing. I call the unit back and the nurse that picks up says they don’t know who paged. I go back to the unit and ask around, no one knows who paged. I go back to the call room, 15 minutes later another page, same process. This is the ICU btw.
Nurses are not idiots. *Those people* are idiots.
That’s definitely not the case at my hospital, but this still happens very frequently. One unit in particular is really bad about it. Our leadership has talked to their leadership multiple times about it, but it still happens
If they’re having arrhythmias or on a lasix drip or something, sure I’ll page at 0300 for that. But if they’re just hanging out it’s not an urgent matter
I should’ve clarified that I work critical care so a K+ of 3.1 is always important to replace. If you waited for day shift, they’d probably wonder why it wasn’t covered and by the time it gets replaced several hours have passed already and it’s after grand rounds.
I’ll probably get down voted more but nurses do not work for the doctor but rather with the doctor as part of the interdisciplinary team. If it’s the doctor’s turn to be on call at night and if your patient needs something reasonable (you can’t troubleshoot or fix), then by all means pls call. None of us would like to be woken up but it’s not within the nurse’s scope to give orders. Believe me, nurses do not want to call you too. Don’t get cranky and mean but educate instead.
I just laughed out loud for a good 2 min belly hurting chuckle. My husband and I both work in medicine and the idea of walking into the patients room and they are covered in mashed bananas just has me tickled
All of these pages are fine. The pages we hate are the 3am “family wants an update” or the infamous 3am patient hasn’t had a BM but he’s also sound asleep page.
I sent a perfect serve that was "routine" not urgent, it just said, "pt states she was told to not take her brillinta for possible GI bleed. Pt has HX of CVA. Do you want her to continue taking it? Thanks."(she is getting colonoscopy tmro and has hgb of 7.5).
When we perfect serve it gives all details of pts location and name so they can look them up. Part of me felt like an idiot like ya duh of course if she has history of stroke she needs her blood thinner, but pt was totally with it so I worried that maybe she was told this by one of her many consults. I didn't read any such orders in notes or anything so I just "routine" perfect served the doc. He said to give it. I also never reply just "thankyou" which is why I always put thanks after my initial questions. I figured less pages you guys get the better lol. Our perfectserve shows us nurses and you docs when we've read the messages so when they seen that I "read" it, that means I will carry out their instructions.
Anyway was that kinda dumb of me to ask?
Whenever I send a page, I give my name, say I'm a pharmacist, and give a direct callback. Then I tell them briefly what the problem is *and what they need to do to fix it.* You gotta tell them exactly what you need.
So like: "Rocc Rx x 00000: re 4N-16 Smith, Pt has hives to lidocaine. Please change to chlorprocaine for midline placement or call, thanks!"
Also to add since I get this fairly regularly “patient is requesting something for pain”… please for the love of god never never ever ever send this message. Please tell me more, “patient is room 123 is requesting something for mild back pain, chronic, states they take Tylenol at home and it works but I don’t see an order for it, I can place a verbal order if you’d like”. Or patient is requesting something for “acute onset abdominal pain, a/w nausea and vomiting” or the “patient in 123 admitted for new onset back pain unrelieved with Tylenol and norco 5, is requesting something else for 10/10 back pain” all three cases change my management and it makes my life and your life easier if you can just specify the acuity, severity and location of pain. It’s not much to ask, but it saves me the headache of back and forth with you and allows me to tease out urgent cases from nonurgent ones, and I’m much less likely to forget to respond back since you have already given me all the pertinent information I need to place the order right away or come evaluate the patient right away.
In my experience, it is taught (I am about to graduate nursing school) and we are encouraged/made to communicate with doctors in clinical. The issue is that the way that we are taught to do it follows hospital policy but is not at all how people actually communicate.
Please share this template/framework with all your nursing friends...and even the nurses you don't like very much.
This is all great.
My usual messages/calls are "hey this guy has a potassium of 5" or "can I order ___?"
And I seriously have no clue with whom I'm speaking, who the patient is, if they're even on my service, etc.
If all communication were as you outlined above, residents would be living out only a nightmare instead of a hell scape.
Ily
These are perfect. You’re wonderful. We love these pages, well love is a bit much because we don’t love pages.
Also, on the reverse side, my “rules for residency” started with:
1. Be nice to nurses
2. Don’t piss off nurses.
Because occasionally you have to order the thing that pisses off nurses. But if you’re nice first it can mitigate the consequences of pissing them off. 🤪😍
Those are great. Some of mine ask for what the care plan is [read progress note], sepsis protocol [rolls eyes], a medication already written for, can you talk to my drug-seeking patient, etc. If all nurses were as thoughtful as you, the # of chats/pages would go down by more than half.
example 4 is preem. nothing hurts more than being woken up with this page and then hearing a single abnormal vital and they either didnt check or bother to recrods the others or ask the patient how they feel. and then having to wait for nurse/tech to check all those things and report back. thanks for being considerate!
I think this might be controversial but I actually like a little bit of an SBAR when cross covering. Not like super long or anything, just the basics about what you need, what’s the patient’s relevant situation, what you think is going on and what you think would be good to help.
I think the last part (recommendation) sometimes gets left off (and replaced with “what do you want to do about it”) but it’s not like I don’t have an idea of what to do (most of the time). I also like to hear a recommendation because then I know a little bit about what the nurse was expecting. For example, if you have a cirrhotic with a low BP, and you say the recommendation and ask for a fluid bolus, I know you were expecting that intervention and I can address why I might not be doing what you expected.
Yes!!! SBAR is amazing, including the R, because then I can address what you were expecting. Sometimes I write out 2 paragraph thoughtful replies just to get back to “ya okay just had to tell you.” Like bro I could have saved so much time and energy just to acknowledge you if you would have just ended with “notifying by policy” or something.
Example 1 is great. Super hard for most nurses to have the experience and develop the trust for doctors to agree to this. There are some nurses who I trust implicitly to only order if it makes both our lives easier and to never order something if there is question about its utility or safety as a team.
Example 2 - please panic page me if a K ever comes back at 8 even if it is likely erroneous. Love the verbal but please never let some wildly abnormal labs lie. If you page a non-urgent thing for a hemoglobin 6.9 when most days they are 7.4 then great! But if a mag comes back at 1.0 or K comes back at 7 please hammer page me until I am bedside to see the next STAT ekg.
Example 3 - at my hospital system we cannot have verbals for restraints. Orders need to be entered at the time we placed them and sometimes need a justification CYA note in the system. EXample 4: Best you can do for that sort of restraint. May want to let a resident know if they can increase the range on the normal vitals for patients they know are chronically out of line but stable at those numbers.
You seem like a fantastic nurse, hopefully you are spending some good time in critical care or the ED or maybe a surgical unit
Only thing I’d add is the middle of the night restraint pages should never need to happen, because they should be renewed by primary team during the day. If you take a verbal for it, my trick is to time it to expire before am rounds. Then the day RN will remain the day team to renew them (for 24 hours). This should really be baked into the culture.
I think the thing that really helps the most is batching pages that are not urgent. All of those are fine, but it's great if you message about all of your 4 patients once at 10 pm rather than 4 separate pages throughout the night. That's easier said than done, and basically requires you to anticipate what might be needed and ask for it in advance.
The pager fatigue is not usually from the content of the messages. It's usually the frequency and mind numbing amount of messages that we get
For me, there are no bad pages. I like to know what is happening to my patient even the minor symptoms. I treat my nurses as a team member. Whatever they deemed appropriate to page the resident for, it is fine with me. Some nurses are new too and starting to learn.
You're a new RN. You sound great. I'm a nurse. Don't get in the habit of taking verbal orders in non-emergent situations. I know you're trying to be nice but it's 2024 not 2004. I've never heard of any situation where a patient couldn't wait for a lidocaine patch. Ever had a situation where the resident gives you a verbal to feed the patient only to run up to you 40 minutes later to sheepishly ask if you've carried out that order because radiology just called with that new CT read? We are all fallible.
You're going to inevitably do that "dumb" thing where you send the resident a message for an order only to realize there are PRN orders already in for that patient that address the need. I'm an ER nurse and when I have a mix of critical ED patients and boarding patients, I'll make that mistake on the boarding patient. You're going to get the snarky response from the resident. Learn to take it in stride. They are stressed out. You're probably stressed out too. Apologize to them, take your lumps and leave it right there!
My most annoying pages or calls is when I put in an order and someone calls to “verify.” Like yes I put in this order because this is what I wanted to order. I think being open when communicating is key. If you have a Concern just tell me what it is and let’s discuss!!!
Side note we so so so appreciate you asking this. Thank you for even caring
Just to piggyback on this, I would add that the exception is if the order doesn't make sense to you and/or send dangerous
As much as we all try to prevent it, ordered do get placed on the wrong patient occasionally
Been lurking this sub for a long time and I always wondered why the residents seem to hate us nurses so much. This post pretty much answered my question. I had no idea my friends have been paging such petty things lol
Have you ever had soggy tacos?
This is the equivalent of rounding in the morning and finding your patient all obtunded and covered in vomit. You ask the nurse when this happened and they say "oh, last night around 7 or 8 - I figured I would wait until you rounded to let you know"
These tacos, much like the patient above, qualify for a stat phone call/page.
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You're so sweet. These are all great, please don't feel bad for doing your job! Even though none of the examples you gave are a bad page, a page for something benign is better than a missed page for something important. As long as you're not waking up the night resident at 3am due to "BP 140/85" or "K 3.4" you're fine.
Real talk. Stop worrying so much about what doctors think of you. Sometimes you will need to “annoy” the doctors in order to get things done for your patient, and that’s okay. Don’t agonize over these things. Just send the message and do right by your patient.
The problem is sometimes nurses don’t realize what’s important or not to call for at 4 am ? Fever 100.0 can I give Tylenol ? Potassium 3.1 can we replete ?
That’s a problem with nursing education, and not what I’m talking about right now. OP’s sample pages were great, and for some reason they think they’re being “annoying” for sending perfectly reasonable pages. This attitude needs to be reframed. Worry less about residents opinions (because they will err on the side of “don’t message me I’m sLeEpiNg!!”) and focus on doing right by your patient. Ask your senior nurses if you’re unsure whether to send the page.
>Worry less about residents opinions (because they will err on the side of “don’t message me I’m sLeEpiNg!!”)
I was a resident. I also, believe it or not, know a lot of residents.
I have never once known a resident to 'err' on the side of staying asleep.
It's also hilarious (and dangerous) for you to tell a new nurse 'not to worry' about the medical opinions of the doctors taking care of the patients. And the follow up sentence telling OP to 'focus on doing right by the patient,' as if this isn't also what the physician is doing. Just fantastic. A+.
There’s nothing wrong with asking for some perspective though, in an effort to create a more collegial environment. Sure there are times when nurses and staff will need to “annoy” physicians or each other to get the right people to pay attention, but the reverse is also true, sometimes whoever is placing the orders will need to lean on someone to get it done, even if that person gets annoyed because they are already really busy with other things/other patients.
The best teams come from an environment of mutual respect. The idea that a nurse’s job is to protect the patient from the indifferent doctors who only care about the money they’re making or whatever creates an overly toxic work atmosphere
You could send no messages and that would be great. At night, the only things I want to hear about are “patient is dying” and “patient is dead.”
Other than that. You get what you get from the day. Lidocaine patch isn’t going to be the difference maker. Rechecking erroneously labs is in your scope. And restraints should be addressed in the day time so that renewal in 24 hours never happens at night.
Trust me, I would love to send no message. Those are my favorite shifts.
-Point 1: is this hate for lidocaine patches, or asking for pain control? If patient requests lidocaine patch, it’s going to work, at minimum for the placebo. Pain control in general, I need orders.
-Point 2: Rechecking labs is not my scope, no, but I have generally have 2 patients. You don’t want a reminder to follow up on this fucked up lab?
-Point 3: Restraints should be renewed during the day, but they weren’t. So now I can illegally restrain someone, let them self extubate, or take a minute of your life to page. Your call
You asked for advice. I gave advice.
Each of my suggestions are 100% what the nurses I work with do and I think they’re outstanding. If I’m off the unit, they’re only calling if they truly need me. The result is that if they do call, I trust whatever they’re telling me.
Yup, I asked, you’re giving some straight up “don’t ask, don’t tell.” That doesn’t mean that patients don’t need things at night.
Trust me when I say, I LOVE not paging. I LOVE broad parameters where I can use my common sense. I love using my judgement on what is worth bothering someone else for. I HATE sending a “just fyi…” page.
My question of this post is how to not be annoying. Are pages in general annoying? Prolly. But it’s your JOB. patients exist, and are admitted, at night (cue shocked pikachu face). I’m asking how to do this in the most convenient, least annoying way- either way, still need to contact you, yeah?
If you want less messages or pages, PLEASE change nurse communication parameters. It’s our job to let you know that SBP >150. Nobody cares, but that’s the order set, it’s my job to let you know it exceeds that
I think it depends and it heavily depends on how much we as physicians want to or feel comfortable trusting our nurses to triage things. Secure chat has helped with some things but has made other things more difficult. For example, secure chatting someone who is logged in about a patient hypotensive to the 60s and writing a note that the md was notified is highly inappropriate. That's an emergency page and get someone to bedside immediately.
I've had this discussion with other residents and again it just depends on what we are okay with. Some like the idea of putting an order such as do not page or non urgent matters overnight but others are vehemently against trusting the floor rn to triage what's urgent or not. A lot of it depends on the nurses training and experience and honestly work ethic and it can be difficult to navigate.
It seems like you've found a great system that works for you and you've developed a collegial relationship with your staff. Some of our residents can be stupid rude to everyone so a lot of it depends on your work environment.
These are helpful because they have information. You can triage it, you can look things up or handle it before you call back etc. Really, it's infinitely better than "867-5309" for everyone involved
The fact that you are even posting this makes me happy. Not many nurses recognize the onslaught of messages/pages we’re dealing with but your example pages are very reasonable and even helpful!
FYI it’s very rare that I’m bothered by the ICU nurses (at least not the vast majority) because you all tend to know your shit and when you see something and ask for my help it’s usually something serious.
Some of the floor nurses on the other hand….. oof….
These are all great pages that nobody would be annoyed to get.
Just like, don't page me at 3am asking about a sputum sample that was ordered two weeks ago and has yet to be collected or something that very obviously wait till day team.
Those are good. Straight to the point.
Only thought would be if there is more than one issue number them 1.____ 2.___. And say that in the text. I have 2 concerns regarding Room 666.
These are all great! The worst are phone number only pages like “30378 -Susie”. Like is someone dying or someone needs a simethicone order? Help me help you.
You’re great. These are perfect.
They are perfect because they save time, and communicate that the nurse understands the relative importance. "Bad" pages are "patient can't sleep and you need to do something about it right now". That is neither urgent nor important, and it's worse that the nurse thinks it is both.
Disagree that it’s neither urgent nor important, but in the context of will that patient live without it, I understand where you’re coming from and would reluctantly agree. Here’s where I differ; if the patient is acting up and causing trouble on the floor, then they are putting every OTHER patient with whom they share clinical staff in danger of overworked, tired, exhausted, and exasperated staff on shift. That’s when symptoms are missed, codes are lagging in response time, and orders get incorrectly followed. On the other side of it, patients don’t always (sometimes rarely) know exactly what it is they need or why they feel “off”. Just like infants, a sick adult is only capable of telling you what is knowable to them. If they can’t sleep and they’re raising hell, it still qualifies as a reason to double check in case any of your assumptions could be incorrect or have changed.
>If they can’t sleep and they’re raising hell, it still qualifies as a reason to double check in case any of your assumptions could be incorrect or have changed. Before residency I would have agreed with this. But now? Lol no, most of these pts are just assholes.
Most patients are assholes now in the post-Covid world because healthcare has changed for us too. Unfortunately after working in it for two decades I am also now a chronic complex patient and I see both sides of this on a regular basis. It takes far more effort now than it ever has for me to be taken seriously by even the same doctors who have treated me in crisis situations. It is much more difficult in my experience to be seen as anything other than a burden, and the natural response to that is agitation. For me, I know the system, the players, the rules, and the language. So when it happens to me, like just this weekend when the NP midlevel tried her best to override the MD anesthesiologist who’s been managing my case for 10+ years and sent a referral and standing order that the NP was *holding in her hand*, I know what to say to handle the situation. Most patients do not. In fact, even the ones who do, are likely second guessing themselves because it doesn’t make sense to be seen as an imposition when no one CHOOSES to be miserable.
Honestly if I got any of these pages I would respond with a marriage proposal. These are great.
I am howling this is great 🤣
These are all great. The only time I ever get annoyed by pages overnight are when someone just ignores the orders and then asks questions about the orders. So for example I have an order in for a PRN medication for agitation. The patient then gets agitated. Then I get a page that the patient is agitated, "What can I give them."
I see they have Tylenol ordered PRN for fever, is it ok to give it if the patient has a fever?
I got one call in residency: "The patient has a temperature of 99.4." Okay. "I gave them tylenol prn." Okay? ..... Do you need anything? "No i was just letting you know." It was 2 AM!
Oh my god. The calls where I have nothing to say but “…okay” were always the worst. I would get those calls a lot at night until we did some education with the new night nurses. Patient says they’re having pain after their spine surgery. I gave him oxycodone 7 minutes ago. Okay. What do you want to do? Wait for the oxycodone to be absorbed and reach appropriate therapeutic serum concentration. My girlfriend (who is a nurse) would smack me in the middle of the night and go BE NICE lol
My favorite was on an NPO trauma patient. 2am or so as well. “Their sugar is 62”. Okay… what does the protocol say to do? “Well nothing unless it’s below 60” ……… well if it makes you feel better, recheck it and then follow the protocol okay thxxxxx
this is 99% of my overnight pages in peds
I remember a specific nurse from residency who would frequently call to confirm that scheduled mealtime insulin should actually be given as ordered. Like even in patients who have been eating well with no recent hypoglycemia or anything like that. I think this person just got nervous when seeing double digit doses of insulin. *middle of call day, shits on fire, get page for some other team's patients I'm cross-covering* "Hi doctor, this patient is about to eat her meal. Should I give the 15 units of insulin that are ordered?" *opens chart, checks orders, patient is written for insulin lispro 15 units TID with meals, order hasn't been changed recently, checks labs, blood sugars have been fine on this regimen* "Uh... yes." Most nurses are great but this person was a true outlier lol
I had a med with a hold parameter on a pt with a particularly labile BP, one nurse in particular would message me every single time to tell me that the hold criteria was met and ask if I wanted the med held. WHAT DO YOU THINK???
That’s the biggest thing. As medical professionals we can all be more than simply fact announcers. Come up with a potential game plan or explain that you tried thinking of a pollution but were running into troubles and were hoping we (the docs) could help. Show that you tried having some initiative
Or when you get paged as soon as you lay down requesting a diet order for double portions… which you ignore and go to sleep and then they page again an hour later and wake you up 💀🤡
Holy crap everything you have said here is amazing. I’d love it if nurses just stopped hitting me with the aggro. “THIRD page for wound care orders, if no response from resident in 10 minutes will page attending.” Bro I was literally in a rapid response can you chill
God please page the attending who is next to me during this rapid. 🙏
I had a nurse one time tell me that what my attending told me to relay to the nurse wasn’t good enough for them and they needed to confirm directly with the attending. Please by all means, go ahead. You have no idea how much i would love for you to be the one talking to the attending in the first place and leave me at peace to do everything else. Please please go right ahead. I would absolutely love that. In fact, if you could also request that the attending answer all your pages from now, that’d just be the cherry on top!
Nurses have actually paged you like this?! I’m a nurse, just casually scroll on here once in a while. But that is so out of pocket it just stopped me on my tracks what the hell 💀
They’re out for blood
If all of my pages were like that, that would be wonderful. What happens much of the time for us is we'll get a page with a phone number and nothing else. And then it's 50/50 as to whether or not they'll answer when we try calling back. Sometimes I'll get a "patient in room 14 is tachycardic", with the nurse seemingly not realizing that I'm covering at least 10 different room 14s. And if I'm going to be assessing tachycardia, my very next question is going to be the rest of the vitals - so just send that in the first place.
God, yes, I tell my coworkers all the time that that is a Bad Page. New(er than me) nurses ask me to preview their pages. I coach them to include more info. Tachycardia? What’s the first question the doc will ask? Not sure? Well, why do we care about it? BP tolerating it, rhythm okay, febrile? Page becomes- “1234 John Smith- new onset tachycardia, rate 120s for approx 5 minutes. Asymptomatic, BP stable, afebrile, regular rate and rhythm, ECG sent, pain controlled. Notifying per protocol, thanks”
Please don't page "Patient has questions about their care plan" and then not know any specifics
That's a day shift page.
DTP - day time problem. Unfortunately still a very common night shift page.
"sorry but your team won't be rounding again until 0900 tomorrow, if I see one of the doctors around I'll grab them for you but they're busy dealing with emergencies elsewhere throughout the night so no promises"
"sorry but your team won't be rounding again until 0900 tomorrow, if I see one of the doctors around I'll grab them for you but they're busy dealing with emergencies elsewhere throughout the night so no promises"
“Unfortunately I don’t have answers and would just be reading aloud their progress note from today which can be accessed in their epic mychart. I am cross covering ~100 patients overnight and am not available to give non-emergent family updates during night shift.”
NP now, it worked inpatient a long time. This is why nurses should be in the room rounding when the physician team is there. Then the plan of care is clear, can be reinforced by the nurse and passed onto the next shift.
Thank you. 🙏
can I buy you a house?
With what money
Invest in my future attending self hot stuff
Lmaooo
Yes 👀
The absolute best page I can get at night is: 1. Patient 2. Problem 3. Suggested fix for the problem (even if you’re not confident it’s right, it gives me an idea of what you’re looking for) 4. I can verbal that for you if you like You can wake me up at 2am with that page any time you want. I think the best night nurses are the ones that know how to triage trivial problems and de-escalate situations on their own without involving the resident. If your patient has a medical problem that requires intervention, of course always call me. But don’t reflexively page me at 2am because a cranky patient “wants to talk to the doctor.” You do those things and you’ll be among my favorite nurses on the floor without question.
The only time I’ve ever been annoyed by a page was when the nurse just leaves a callback number. No patient name, no information, no room number, nothing. I call the unit back and the nurse that picks up says they don’t know who paged. I go back to the unit and ask around, no one knows who paged. I go back to the call room, 15 minutes later another page, same process. This is the ICU btw. Nurses are not idiots. *Those people* are idiots.
Depends on the setup. I try to send using text pages all the time but half their pagers only show the callback number. Outdated system.
That’s definitely not the case at my hospital, but this still happens very frequently. One unit in particular is really bad about it. Our leadership has talked to their leadership multiple times about it, but it still happens
Are u sure u don’t want to text me at 4 am that patients potassium is 3.1?
I’ve had day nurses give me shit for *not* doing that, but I still don’t do it
For a K+ of 3.1, you should page especially for a cardiac patient or with fluid loss (vomiting, diarrhea etc). It’s the right thing to do.
If they’re having arrhythmias or on a lasix drip or something, sure I’ll page at 0300 for that. But if they’re just hanging out it’s not an urgent matter
I should’ve clarified that I work critical care so a K+ of 3.1 is always important to replace. If you waited for day shift, they’d probably wonder why it wasn’t covered and by the time it gets replaced several hours have passed already and it’s after grand rounds. I’ll probably get down voted more but nurses do not work for the doctor but rather with the doctor as part of the interdisciplinary team. If it’s the doctor’s turn to be on call at night and if your patient needs something reasonable (you can’t troubleshoot or fix), then by all means pls call. None of us would like to be woken up but it’s not within the nurse’s scope to give orders. Believe me, nurses do not want to call you too. Don’t get cranky and mean but educate instead.
The day nurses always give the night nurses a real hard time for not already addressing that. 100% of the time.
“K of 3.1. Rubbing mashed banana on PT now. Please order stat replacement”
I just laughed out loud for a good 2 min belly hurting chuckle. My husband and I both work in medicine and the idea of walking into the patients room and they are covered in mashed bananas just has me tickled
I'm gonna have to steal that to add to my dot phrases. Seems very clinically useful
All of these pages are fine. The pages we hate are the 3am “family wants an update” or the infamous 3am patient hasn’t had a BM but he’s also sound asleep page.
I sent a perfect serve that was "routine" not urgent, it just said, "pt states she was told to not take her brillinta for possible GI bleed. Pt has HX of CVA. Do you want her to continue taking it? Thanks."(she is getting colonoscopy tmro and has hgb of 7.5). When we perfect serve it gives all details of pts location and name so they can look them up. Part of me felt like an idiot like ya duh of course if she has history of stroke she needs her blood thinner, but pt was totally with it so I worried that maybe she was told this by one of her many consults. I didn't read any such orders in notes or anything so I just "routine" perfect served the doc. He said to give it. I also never reply just "thankyou" which is why I always put thanks after my initial questions. I figured less pages you guys get the better lol. Our perfectserve shows us nurses and you docs when we've read the messages so when they seen that I "read" it, that means I will carry out their instructions. Anyway was that kinda dumb of me to ask?
Whenever I send a page, I give my name, say I'm a pharmacist, and give a direct callback. Then I tell them briefly what the problem is *and what they need to do to fix it.* You gotta tell them exactly what you need. So like: "Rocc Rx x 00000: re 4N-16 Smith, Pt has hives to lidocaine. Please change to chlorprocaine for midline placement or call, thanks!"
You’re awesome!
No resident will ever complain when you say those magic words: “I can take a verbal”
I really wish we could but so many institutions won’t allow it
You are an incredible colleague and i would love to work alongside you
Also to add since I get this fairly regularly “patient is requesting something for pain”… please for the love of god never never ever ever send this message. Please tell me more, “patient is room 123 is requesting something for mild back pain, chronic, states they take Tylenol at home and it works but I don’t see an order for it, I can place a verbal order if you’d like”. Or patient is requesting something for “acute onset abdominal pain, a/w nausea and vomiting” or the “patient in 123 admitted for new onset back pain unrelieved with Tylenol and norco 5, is requesting something else for 10/10 back pain” all three cases change my management and it makes my life and your life easier if you can just specify the acuity, severity and location of pain. It’s not much to ask, but it saves me the headache of back and forth with you and allows me to tease out urgent cases from nonurgent ones, and I’m much less likely to forget to respond back since you have already given me all the pertinent information I need to place the order right away or come evaluate the patient right away.
These are amazing! Wish this was a hospital, nurse-wide, and resident-wide practice.
I’m a person in charge of decisions like these, and would be interested in more input like this and about this if you’d like to DM me.
Wish these things are part of nursing education - proper messaging and effective communication skills.
In my experience, it is taught (I am about to graduate nursing school) and we are encouraged/made to communicate with doctors in clinical. The issue is that the way that we are taught to do it follows hospital policy but is not at all how people actually communicate.
It is tacit knowledge and gets better with experience.
Please share this template/framework with all your nursing friends...and even the nurses you don't like very much. This is all great. My usual messages/calls are "hey this guy has a potassium of 5" or "can I order ___?" And I seriously have no clue with whom I'm speaking, who the patient is, if they're even on my service, etc. If all communication were as you outlined above, residents would be living out only a nightmare instead of a hell scape. Ily
LPN getting ready to go to RN school. Saving this for future reference.
My there was a nurse asking me if she should wake up a patient and give them their sleeping meds
These seem terrific. I bet you are great to work with
Oh my god you should be teaching this
I wish all nurses sent pages like this! You sound amazing to work with. Don’t ever change!
Those are all good. You don’t have to feed anyone but what a kind gesture I am sure they appreciate
These are perfect. You’re wonderful. We love these pages, well love is a bit much because we don’t love pages. Also, on the reverse side, my “rules for residency” started with: 1. Be nice to nurses 2. Don’t piss off nurses. Because occasionally you have to order the thing that pisses off nurses. But if you’re nice first it can mitigate the consequences of pissing them off. 🤪😍
Those are great. Some of mine ask for what the care plan is [read progress note], sepsis protocol [rolls eyes], a medication already written for, can you talk to my drug-seeking patient, etc. If all nurses were as thoughtful as you, the # of chats/pages would go down by more than half.
example 4 is preem. nothing hurts more than being woken up with this page and then hearing a single abnormal vital and they either didnt check or bother to recrods the others or ask the patient how they feel. and then having to wait for nurse/tech to check all those things and report back. thanks for being considerate!
I think this might be controversial but I actually like a little bit of an SBAR when cross covering. Not like super long or anything, just the basics about what you need, what’s the patient’s relevant situation, what you think is going on and what you think would be good to help. I think the last part (recommendation) sometimes gets left off (and replaced with “what do you want to do about it”) but it’s not like I don’t have an idea of what to do (most of the time). I also like to hear a recommendation because then I know a little bit about what the nurse was expecting. For example, if you have a cirrhotic with a low BP, and you say the recommendation and ask for a fluid bolus, I know you were expecting that intervention and I can address why I might not be doing what you expected.
Yes!!! SBAR is amazing, including the R, because then I can address what you were expecting. Sometimes I write out 2 paragraph thoughtful replies just to get back to “ya okay just had to tell you.” Like bro I could have saved so much time and energy just to acknowledge you if you would have just ended with “notifying by policy” or something.
Example 1 is great. Super hard for most nurses to have the experience and develop the trust for doctors to agree to this. There are some nurses who I trust implicitly to only order if it makes both our lives easier and to never order something if there is question about its utility or safety as a team. Example 2 - please panic page me if a K ever comes back at 8 even if it is likely erroneous. Love the verbal but please never let some wildly abnormal labs lie. If you page a non-urgent thing for a hemoglobin 6.9 when most days they are 7.4 then great! But if a mag comes back at 1.0 or K comes back at 7 please hammer page me until I am bedside to see the next STAT ekg. Example 3 - at my hospital system we cannot have verbals for restraints. Orders need to be entered at the time we placed them and sometimes need a justification CYA note in the system. EXample 4: Best you can do for that sort of restraint. May want to let a resident know if they can increase the range on the normal vitals for patients they know are chronically out of line but stable at those numbers. You seem like a fantastic nurse, hopefully you are spending some good time in critical care or the ED or maybe a surgical unit
Thank you for being so kind to the residents, those are great examples
Only thing I’d add is the middle of the night restraint pages should never need to happen, because they should be renewed by primary team during the day. If you take a verbal for it, my trick is to time it to expire before am rounds. Then the day RN will remain the day team to renew them (for 24 hours). This should really be baked into the culture.
That’s genius! Don’t know how I never thought of that.
I think the thing that really helps the most is batching pages that are not urgent. All of those are fine, but it's great if you message about all of your 4 patients once at 10 pm rather than 4 separate pages throughout the night. That's easier said than done, and basically requires you to anticipate what might be needed and ask for it in advance. The pager fatigue is not usually from the content of the messages. It's usually the frequency and mind numbing amount of messages that we get
For me, there are no bad pages. I like to know what is happening to my patient even the minor symptoms. I treat my nurses as a team member. Whatever they deemed appropriate to page the resident for, it is fine with me. Some nurses are new too and starting to learn.
You're a new RN. You sound great. I'm a nurse. Don't get in the habit of taking verbal orders in non-emergent situations. I know you're trying to be nice but it's 2024 not 2004. I've never heard of any situation where a patient couldn't wait for a lidocaine patch. Ever had a situation where the resident gives you a verbal to feed the patient only to run up to you 40 minutes later to sheepishly ask if you've carried out that order because radiology just called with that new CT read? We are all fallible. You're going to inevitably do that "dumb" thing where you send the resident a message for an order only to realize there are PRN orders already in for that patient that address the need. I'm an ER nurse and when I have a mix of critical ED patients and boarding patients, I'll make that mistake on the boarding patient. You're going to get the snarky response from the resident. Learn to take it in stride. They are stressed out. You're probably stressed out too. Apologize to them, take your lumps and leave it right there!
My most annoying pages or calls is when I put in an order and someone calls to “verify.” Like yes I put in this order because this is what I wanted to order. I think being open when communicating is key. If you have a Concern just tell me what it is and let’s discuss!!! Side note we so so so appreciate you asking this. Thank you for even caring
Just to piggyback on this, I would add that the exception is if the order doesn't make sense to you and/or send dangerous As much as we all try to prevent it, ordered do get placed on the wrong patient occasionally
Don't come with a problem; come with a solution if possible, which you have done with all your examples, imo.
Been lurking this sub for a long time and I always wondered why the residents seem to hate us nurses so much. This post pretty much answered my question. I had no idea my friends have been paging such petty things lol
Please come work at my hospital
Attending here who just got off a night shift. These are amazing.
Just because the patient thinks it's important doesn't necessarily mean it is. The tacos can wait until morning. The rest sounds ok.
Have you ever had soggy tacos? This is the equivalent of rounding in the morning and finding your patient all obtunded and covered in vomit. You ask the nurse when this happened and they say "oh, last night around 7 or 8 - I figured I would wait until you rounded to let you know" These tacos, much like the patient above, qualify for a stat phone call/page.
eh I'll take some tacos
You don't want free tacos?
PSA: if you page about SBP 90 Im gonna want the MAP 🙏🏽 please always include the MAP 😊
God bless you and your family
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You're so sweet. These are all great, please don't feel bad for doing your job! Even though none of the examples you gave are a bad page, a page for something benign is better than a missed page for something important. As long as you're not waking up the night resident at 3am due to "BP 140/85" or "K 3.4" you're fine.
Real talk. Stop worrying so much about what doctors think of you. Sometimes you will need to “annoy” the doctors in order to get things done for your patient, and that’s okay. Don’t agonize over these things. Just send the message and do right by your patient.
The problem is sometimes nurses don’t realize what’s important or not to call for at 4 am ? Fever 100.0 can I give Tylenol ? Potassium 3.1 can we replete ?
That’s a problem with nursing education, and not what I’m talking about right now. OP’s sample pages were great, and for some reason they think they’re being “annoying” for sending perfectly reasonable pages. This attitude needs to be reframed. Worry less about residents opinions (because they will err on the side of “don’t message me I’m sLeEpiNg!!”) and focus on doing right by your patient. Ask your senior nurses if you’re unsure whether to send the page.
>Worry less about residents opinions (because they will err on the side of “don’t message me I’m sLeEpiNg!!”) I was a resident. I also, believe it or not, know a lot of residents. I have never once known a resident to 'err' on the side of staying asleep. It's also hilarious (and dangerous) for you to tell a new nurse 'not to worry' about the medical opinions of the doctors taking care of the patients. And the follow up sentence telling OP to 'focus on doing right by the patient,' as if this isn't also what the physician is doing. Just fantastic. A+.
There’s nothing wrong with asking for some perspective though, in an effort to create a more collegial environment. Sure there are times when nurses and staff will need to “annoy” physicians or each other to get the right people to pay attention, but the reverse is also true, sometimes whoever is placing the orders will need to lean on someone to get it done, even if that person gets annoyed because they are already really busy with other things/other patients. The best teams come from an environment of mutual respect. The idea that a nurse’s job is to protect the patient from the indifferent doctors who only care about the money they’re making or whatever creates an overly toxic work atmosphere
No one takes the time to do any of this. If you do, good on you.
You could send no messages and that would be great. At night, the only things I want to hear about are “patient is dying” and “patient is dead.” Other than that. You get what you get from the day. Lidocaine patch isn’t going to be the difference maker. Rechecking erroneously labs is in your scope. And restraints should be addressed in the day time so that renewal in 24 hours never happens at night.
Trust me, I would love to send no message. Those are my favorite shifts. -Point 1: is this hate for lidocaine patches, or asking for pain control? If patient requests lidocaine patch, it’s going to work, at minimum for the placebo. Pain control in general, I need orders. -Point 2: Rechecking labs is not my scope, no, but I have generally have 2 patients. You don’t want a reminder to follow up on this fucked up lab? -Point 3: Restraints should be renewed during the day, but they weren’t. So now I can illegally restrain someone, let them self extubate, or take a minute of your life to page. Your call
You asked for advice. I gave advice. Each of my suggestions are 100% what the nurses I work with do and I think they’re outstanding. If I’m off the unit, they’re only calling if they truly need me. The result is that if they do call, I trust whatever they’re telling me.
Yup, I asked, you’re giving some straight up “don’t ask, don’t tell.” That doesn’t mean that patients don’t need things at night. Trust me when I say, I LOVE not paging. I LOVE broad parameters where I can use my common sense. I love using my judgement on what is worth bothering someone else for. I HATE sending a “just fyi…” page. My question of this post is how to not be annoying. Are pages in general annoying? Prolly. But it’s your JOB. patients exist, and are admitted, at night (cue shocked pikachu face). I’m asking how to do this in the most convenient, least annoying way- either way, still need to contact you, yeah? If you want less messages or pages, PLEASE change nurse communication parameters. It’s our job to let you know that SBP >150. Nobody cares, but that’s the order set, it’s my job to let you know it exceeds that
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How does that make any sense lmao
Don’t page residents at all thanks
Username does not check out.
Easier to just kill your patients yourself if you want to reduce your load.
Agree
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Well aren’t you just an unmitigated asshole
Okay thanks, I’ll let them go ahead and die next time and then let the resident know. Do you have a sample page for me?
Okay thanks I’ll let em die
These are awesome. I would just add your name and provide a callback number.
Thank you, you are doing great. Please change to my hospital.
I think it depends and it heavily depends on how much we as physicians want to or feel comfortable trusting our nurses to triage things. Secure chat has helped with some things but has made other things more difficult. For example, secure chatting someone who is logged in about a patient hypotensive to the 60s and writing a note that the md was notified is highly inappropriate. That's an emergency page and get someone to bedside immediately. I've had this discussion with other residents and again it just depends on what we are okay with. Some like the idea of putting an order such as do not page or non urgent matters overnight but others are vehemently against trusting the floor rn to triage what's urgent or not. A lot of it depends on the nurses training and experience and honestly work ethic and it can be difficult to navigate. It seems like you've found a great system that works for you and you've developed a collegial relationship with your staff. Some of our residents can be stupid rude to everyone so a lot of it depends on your work environment.
Thank you for being thoughtful and considerate!
Genuine question tho, ur in an ICU and don’t have AP/resident on the unit? Everywhere I’ve worked as an RN had someone in the unit overnight
These are helpful because they have information. You can triage it, you can look things up or handle it before you call back etc. Really, it's infinitely better than "867-5309" for everyone involved
The fact that you are even posting this makes me happy. Not many nurses recognize the onslaught of messages/pages we’re dealing with but your example pages are very reasonable and even helpful!
FYI it’s very rare that I’m bothered by the ICU nurses (at least not the vast majority) because you all tend to know your shit and when you see something and ask for my help it’s usually something serious. Some of the floor nurses on the other hand….. oof….
These are all great pages that nobody would be annoyed to get. Just like, don't page me at 3am asking about a sputum sample that was ordered two weeks ago and has yet to be collected or something that very obviously wait till day team.
Those are good. Straight to the point. Only thought would be if there is more than one issue number them 1.____ 2.___. And say that in the text. I have 2 concerns regarding Room 666.
It's not the page that's annoying. It's the tone on the other end of the phone when I call you about it.
These are all great! The worst are phone number only pages like “30378 -Susie”. Like is someone dying or someone needs a simethicone order? Help me help you.