On Call Tips

FY1s are usually most apprehensive about being on call, but it is also the shift you will usually learn the most. Predominantly as an FY1 you will be doing ward cover shifts and so that is what we will focus on below, with templates to improve your documentation.

A brief overview of the types of on calls

  • Ward shift – bleeped by teams to support ward patients
    • This is the majority of your on-call commitments
  • Clerking shift – clerking new patients that are referred to the team
  • Discharge ward round (in some hospitals) – you go round the hospital usually with a consultant discharging patients
    • Ensure you complete the medication list early as usually the pharmacy will close early in the day. Prioritise patients with a blister pack
    • Call wards beforehand to ask them to make a list of patients to potentially discharge

On-Call Duties & Handover
Usually, the on-call starts with either a formal handover in a meeting or you responding to bleeps where people handover patients. During the shift, you will receive further bleeps and will act on these by prioritising. You also attend all cardiac arrest or peri-arrest calls (but you are usually the first to be sent away if there’s no need as we appreciate you’re usually the busiest!).

Handover usually occurs every morning and night & there’s a weekend handover on a Friday afternoon for the weekend team. It is attended by at least the clerking & ward cover doctors, but the site manager and others may attend. The purpose is for everyone to be aware of unwell patients at risk of deterioration, to handover outstanding jobs & patients to review. Read more about tips on handover here.

General tips

  • There’s plenty of https://mindthebleep.com/2019/08/essential-apps.html
  • Exchange phone numbers/bleeps with the on-call team
  • Wear warm and comfortable clothes
  • Wear quiet shoes! (extra jobs appear if people hear you!!)
  • Bring snacks (you’re entitled to at least 30-minute breaks for every 5h, more if you’re working the night)
  • Travel mug – hot drinks
  • Water
  • Equipment (Clipboard, Pockets/bag, Spare pen)

Keeping organised is essential
People have many different ways they like to organise their list. Some have a different page by ward, others list by priority or have symbols or colours to help differentiate. Go with whatever works for you!

Download the handover sheet template – a list you could use for your first on-call & adapt to your needs.

Prioritisation is key, but this comes with experience. If a nurse is worried, they have a massive change in their observations/early warning score or newly scoring a “3” should prompt urgent review. Read more about prioritising jobs

Pre-set documentation – having this saved can ensure you review patients thoroughly, with prompts to ensure you don’t forget anything.

An hour before the end of your shift, aim to sort through your list to be able to handover succinctly & thoroughly. This includes making sure you have reviewed any investigations you sent & putting out reviews and bloods for anyone that might need them the next day.

Answering the bleep – triage
Sit in front of a computer if you can before ringing back. Say who you are and find out which ward they’re ringing from and, assuming you have electronic documentation, look at the patient’s notes whilst on the phone. Look over obs, recent documentation and other relevant information depending on the nurse’s request. A lot of calls can be dealt with whilst on the phone as a lot of answers to their questions are in the notes.

How to see patients
If the nurse is worried/high EWS, quickly eyeball the patient just to make sure they don’t need immediate help. If they look unwell consider a (peri) arrest call! If you’re thinking “should I put a peri-arrest call out” then put one out! No one will mind if they get called and aren’t needed. They will mind if you didn’t put a call out when you should have.

Review the notes, blood results, observations etc. If you think that they will require bloods, take equipment & labels with you. If you think they will need a cannula (for IV fluids, antibiotics or treatment), take one with you to avoid multiple stabs. Always consider a VBG as it gives you immediate information.

Take a history from the patient. Do an A-E. Think of any investigations you want and order them. Call up radiographer if you have ordered imaging overnight to let them know. Read more about managing a deteriorating patient

'Asked To See Patient' Template

Download Template

[Name] FY1

ATSP for:

Issues
1)

Relevant Background
1)

Discussion

Examination

Airway –

Breathing –

Circulation –

Disabilities –

Exposure –

Investigations

Impression:

Plan
1)

[Name] FY1

Bleep

Always talk stuff through with senior
Asking questions makes them confident that if you’re unsure you will ask rather than try and take it on yourself. If you’re not talking to them or asking questions they will be worried about what you’re doing as they know that you don’t know everything yet. The seniors have overall responsibility of supervising you & of the patients and so they will want to know early if there are any issues.
When you have seen patients, make a plan and start it. Talk this through with the senior afterwards. They will appreciate that you’ve come up with your own plan and can change it as they see necessary. It’s the best way to learn!

Most Common Calls

Temperature Spike
  • Is this new? Are the other obs normal or could they be septic?
  • Are they already on antibiotics? Were these changed or escalated recently? Were blood cultures performed?
  • Where is the source of infection? Always do a thorough review!
    • Chest & UTI are the most common therefore have a low threshold to perform a chest x-ray & MSU
    • Don’t miss pressure sores/wounds, intra-abdominal infections (especially surgical patients) or meningitis if they have a headache
  • Perform a full septic screen each time (FBC, U&Es, CRP, VBG, cultures, chest x-ray, MSU). Remember to check the results!
  • Read more about managing sepsis
Cannula
  • Why do they need it?
    • Frequently patients medications can be switched to oral: e.g. paracetamol, pabrinex (vitamin B co strong, thiamine). For antibiotics discuss with seniors.
    • Intravenous fluids aren’t always necessary. Humans don’t drink from midnight to the morning normally, therefore being nil by mouth for a scan isn’t an indication. If they are dehydrated or losing fluids (e.g. diarrhoea/vomiting) then that is different. Check their observations to see if they are hypotensive or tachycardic.
  • Has anyone else tried to attempt it? It should be escalated to the nurse in charge and often the site manager as well – particularly if you are busy with an unwell patient and the cannula is urgent.
  • When do they need it for?
High EWS Score
  • Is it newly high? If there is a new large increase in score, see urgently. Always consider sepsis – temperature spikes don’t always occur. See “temperature spike” & managing a deteriorating patient above
  • If the score has been high for a while check if anything has changed. Low saturations and/or home oxygen may be normal in a patient with COPD for example. Low blood pressure might be normal for the young or elderly patient. They may not need to be seen but have a very low threshold to review them
  • Easy to do it quickly whilst on the phone if you have electronic prescribing
  • Prescribe analgesia before fully reviewing patients if possible. It is kinder & easier to review a patient that isn’t in agony
  • If prescribing fluids, check they don’t have heart failure. Check their potassium to see if it needs replacing. If on a sliding scale (variable-rate insulin infusion) make sure you prescribe both 5% glucose and sodium chloride so the nurses can change what they use based on the patient’s CBG. Review local guidelines as it varies.
Arrest & Emergency Calls
  • Attended by the medical team (SpR, SHO and FY1), outreach teams and often ITU team
  • Your role will usually be allocated, but frequently includes
    • Presenting the patient and/or results of recent investigations
    • Arranging ECGs/medication
    • Venous access with VBG/ABG and bloods
    • Helping with the ABCDE assessment
  • Cardiac arrest: scribing and notifying the team every 2 minutes for rhythm check or chest compressions

Written by Dr Ben Dow FY1 & Dr C O’Doherty FY2
Edits by Dr Akash Doshi CT2

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