On-Call Resources

Weeknight and Weekend call fellow must be signed in to EPIC for the GI consult/ Hepatology consult/ DHS/ Nutrition teams from 1700-0700

VCU Weeknight Call

• One fellow is on call each evening from 5:00PM until 7:00AM (cover only VCU hospital)

• Call fellow covers new GI consults, Hepatology consults. 

• DHS admissions are to be screened by the MAA and DHS fellow will receive a page only when MAA accepts a patient to DHS. 

• If the ED pages on-call fellow for "Request for Admission" you should direct ED to call the MAA  

• If the MAA accepts pt to DHS, MAA will page the DHS resident and the overnight fellow. 

  • The DHS resident is then responsible to see the patient, place admission orders, and update on-call fellow if questions on management or changes in clinical status. 

  • The on-call fellow should remotely access EPIC to review the case and either page basic recommendations to DHS resident, or page resident to discuss via phone call. 

    • Known admissions from clinic or known outside transfers, do not require this if a plan is set prior to admission. The on-call fellow does not have to physically see the patient, write a note (unless a special circumstance needing documentation), or staff with attending overnight (unless any questions the fellow would like to discuss).  

• Most evening consults can be triaged to be seen by the GI or Hepatology consult fellow in the AM (such as stable patients admitted to the general medicine service). The overnight fellow must remotely access EPIC to review chart and call back consults to discuss further details and provide preliminary recommendations.  

  • Remote EPIC access is through https://connect.vcuhealth.org

• ICU consults for the reasons listed below should be seen overnight, staffed with the attending over phone, and consult note signed in the chart:

  • Unstable GI bleeds going to the ICU (not patients with other ICU admission criteria with minor bleeding)

  • Food impactions: Check if patient is able to keep secretions. If unable, then will need overnight endoscopy.

  • Foreign body ingestion: What type of foreign body? How far is the foreign body in the intestine? See ASGE guidelines.

  • Acute liver failure (must have encephalopathy, not just severe acute liver injury)

• Overnight consults that fellow typically does not have to come in for:

  • Acute on chronic anemia without overt GI bleeding

  • Bleeds not going to the ICU (if patient is stable for floor, no endoscopy can be done overnight)

  • Hepatic encephalopathy or other non ALF liver issues

  • If called about a PEG tube issue- can have ER place a Foley in gastrostomy site (only if site is mature) and either have patient come to endoscopy next day or keep patient in CDU for morning GI consult evaluation.

• For after-hours ICU endoscopy cases (bleeding, food impaction, high risk foreign bodies):

  • • Receive the page from the ICU team -> Review chart and call ICU team to discuss -> If it sounds like patient may need endoscopy, go evaluate the patient, present to the attending and write a consult note -> if agreed to overnight endoscopy, page GI tech on call at Pager 6055 or call directly -> Perform the procedure and tell the ICU team and family the results in person or by phone-> Complete the Provation note -> If attending is not signing the Provation note overnight, write a brief addendum or short note in EPIC with recs -> Drive home safely and go back to sleep until the next page. 

• Any patient calls or abnormal results to the GI division will be forwarded to the on-call fellow

  • Calling patients back: use Doximity Dialer App on smartphone or call VCU operator from personal phone and have them call the outside line

  • Document discussion with patient in EPIC and send a message to the patient's primary GI or Hepatology physician

    • All phone calls about VCU outpatients (includes patient calls, critical lab results, calls from outside providers/hospitals) require a note that is sent to the appropriate GI/Hep provider. Document a brief SOAP note including the plan. If the patient contacts you via telepage but has never been seen by GI/Hep as in inpatient or outpatient, then advise to followup with PCP as we cannot provide advise to those without an established relationship.

• Discuss case with outside physician and whether appropriate for transfer. Even if DHS is full, if patient is appropriate for VCU, the patient can be admitted to medicine with GI or Hepatology consult. 

• Never "ACCEPT" a patient for transfer; tactfully say you believe that the person is a good candidate for transfer, but the requesting physician must call the Transfer Center at 804-828-2638 to discuss transfer approval as you do not have that power. Even if your attending "ACCEPTS" a transfer, the outside hospital must call the Transfer Center and MAA must be notified of acceptance to DHS. If you or your attending thinks the patient is best served on DHS then discuss with DHS fellow regarding space, and notify the MAA that you would like the person admitted to DHS.  

• Refrain from providing official recommendations for outside hospital calls asking about "phone consult." If this is an issue, fellow can discuss with the on-call attending.  You must call the outside hospital doctor back (you cannot just ignore their request), but you should say that our program has a policy of not providing specific medical recommendations due to medico-legal reasons regarding patients you have not evaluated and not in your facility. You can also offer the option of patient transfer if they need clinical assistance, but they must call Transfer Center at 828-2638 to discuss transfer approval.

VCU Weekend (Downtown) Call

• Weekend call fellow covers the GI consult, Hepatology consult, GI/Nutrition, and DHS pager from 5:00 PM Friday until 7:00 AM Monday

• Fellow should be present for DHS rounds if desired by the on-call attending at 8AM-10AM -- after 2 hours of rounding with DHS (even if rounds are going over), on-call fellow should attend to consult duties. 

• Endoscopy unit is not open on the weekends - endoscopy is performed in the ICU or OR if urgent. ICU and OR scopes are to be done by the Scope call fellow (see below).  All other patients on consult lists (and DHS list) are posted by the on-call fellow in endoscopy to be done on Monday or Tuesday (see GI inpatient section). If there are several add ons, can try and space them out between Monday and Tuesday as appropriate.

• For new scope consults between 7AM to 5PM that require endoscopy, the VCU downtown fellow should evaluate the patient, discuss with the downtown attending, and write the consult note. If urgent endoscopy is recommended, the downtown call fellow will notify the scope call fellow and post the case via calling the anesthesia coordinator (804-663-4305) and the 5-OR Main Desk (804-628-6850) if the OR is needed. The on call fellow has the option of notifying the scope call attending; however, it is the responsibility of the scope call fellow to do so. The scope call fellow will contact the tech on call (via page first), write pre-procedure H&P, perform the endoscopy, and write Provation endoscopy note. 

• For new scope consults from 5PM to 7AM, the VCU weekend fellow reviews the case with the primary team, and if overnight endoscopy may be needed, (ex: patient going to ICU for bleeding), then the on-call fellow must contact the scope call fellow to evaluate the patient in person.  

Scope Call

• Weekend Scope Call fellow covers all consults from the VA and any urgent endoscopy or patient's that need to be seen overnight at VCU and VA between 5PM Friday and 7:00 AM Monday

• Scope call fellow rounds at the VA to see follow-up consults and new consults on Saturday and until 5PM Sunday. 

  • New GI/ hep consults and follow-up patients can be discussed with the VA GI or Hepatology attending who was covering VA consults that week. 

  • New GI consults with potential for scope or overnight for ALF can be discussed with the Scope Call attending and new Hepatology consults with the Hepatology VA attending who was covering consults that week. 

• Ensure that you have the physical keys to access the endoscopy suite (it will be locked on the weekend) and lock the door again when you leave. 

  • VA Cases: Fellow is to evaluate need for endoscopy via case discussion from referring team, chart review, and bedside evaluation. Then they are to call the Scope Call attending to determine if and when to scope. If moving forward with endoscopy then the fellow is to contact the tech (and anesthesia if needed), place procedural orders, and write consult note. To post a case to the OR, open a "Out of OR anesthesia" note from the Notes tab in CPRS and fill out the required information. Once you call anesthesia to confirm timing of the procedure based on their availability, call the VA operator to speak to the nursing supervisor. The nursing supervisor is responsible for calling the on call OR nurse (Please ask for PACU nurse and OR nurse). Cases have to be done in OR 2-7. Call the endoscopy techs once timing of procedure is finalized.

Following procedural completion, the tech will upload procedure and images into Endosoft. The fellow will complete documentation in Endosoft and write an endoscopy consult/comment in CPRS. The attending (VA or VCU attending) should sign Endosoft before leaving. If VCU attending does not have CPRS access, then add the VA GI consult attending for that month as an additional signer so that the VA attending is aware AND can co-sign the endoscopy comment note. In the note the fellow is to specify that VA GI consult attending is being added for administrative purposes.

• • VCU Cases: VCU Call fellow will get primary page from VCU and can initially triage the call. 

    • Between 7AM-5PM: VCU fellow will see in person and discuss with their attending before notifying Scope Call fellow.

      • VCU fellow will also complete the consult note, notify the anesthesia coordinator, and post via 5-OR Main Desk. 

      • "Case Request Operating Room" is the EPIC Order to post cases to OR.

      • The scope call fellow must help the downtown call fellow coordinate the time of the procedure with their scope attending, GI techs, and ICU if needed (example: when to give erythromycin/azithromycin etc). The scope call fellow is also responsible for completing the EPIC pre-procedure H&P note, the procedural consent, Provation note, and a brief procedure findings note in EPIC. The Provation note must be completed by the fellow before leaving the hospital.

    • After 5PM: the VCU fellow reviews the case with the primary team and if overnight endoscopy may be needed (ex: patient going to ICU for bleeding), then VCU they must contact the scope call fellow. The scope call fellow will then have to evaluate the case including need to visit the patient at bedside, write the consult note and call the scope call attending. If overnight endoscopy is recommended, then scope fellow must also obtain consent, contact tech, complete the EPIC pre-procedure H&P note, Provation note, and a brief procedure findings note in EPIC. The Provation note must be completed by the fellow before leaving the hospital.

    • The advanced fellow is not on-call or responsible for any of the above steps. If there is an advanced endo case over the weekend, then the fellow writing the consult may text advanced fellow to notify of the pending scope. Same rules apply as above on who writes the consult note, obtains consent etc. If the advanced fellow is willing to participate then he/she may write the pre-procedure and Provation note; however, it is the Scope call fellow's responsibility to coordinate the procedure, ensure all necessary steps are completed, and participate in the scope. 

Short Call

• Every Friday from 11AM-5PM any new GI or Hepatology consults or ICU procedures is handled by the short call fellow at both VCU (for VCU clinic fellows) and the VA (for VA clinic fellows).  

• Short Call fellow is not expected to call back follow-up questions about patients seen previously (that morning or earlier in week) as they have no or limited knowledge of these patients; these questions should be answered by the fellow that was on the respective consult service (exception is change in clinical status that would indicate same-day endoscopy or in-person evaluation).

• Short call fellows at the VA will have a reduced clinic patient load to allow for these responsibilities to be performed 

• GI and Hepatology consult fellows should e-mail sign-out to weekend fellow and short call fellow, and the short call fellow should add any new patients to the sign out and send to the weekend call fellow.