Overnight Crosscover

Who is responsible for Cross Cover Duty

The Following Shifts are responsible for overnight cross cover of the ED Observation Unit

• 4:00 PM - 12:00 PM

• 11:00 PM - 6:00 AM

• 6:00 AM - 8:00 AM

At the beginning of your shift please arrange to get signout from the daytime ED observation physician or preceding crosscover physician.  The signout process is detailed here. 

Which patients are you responsible for

While on ED Observation cross-cover you are responsible for the care of any patients on the ED Observation service. This does not include patients expected to stay in the main ED Zone for sober-reevaluations or behavioral health evaluation and clearance.   While acting as cross cover you are expected to be assigned as the attending to these patients.   If a patient was placed on the ED Observation service by another physician after you received initial sign-out, it is the responsibility of the physician who placed the new patient in ED obs to communicate to you about the admission, at which point you should assign yourself as the attending on the patient.   If an issue arises with a patient during cross cover hours and the provider who placed the patient in ED obs is still working, it is appropriate (but not required) for the cross cover physician to defer these issues to the original provider. 

What are you responsible for

• Notes - You are not expected to write a note on patients unless your care is involved in medical decision making.  If you order Tylenol, you don't have to write a note, however if there is a meaningful test result or a consultant provides an opinion or the patient's status changes you need to document this. Please use the ED Obs Progress note template (.edobsprogressnote) to document this. 

• Orders - If a nurse requests an order for a patient, please do your best to accommodate as you feel appropriate. If this order is for something more than a typical PRN, then please write a brief update note.  Nurses will be encouraged to use Epic Chat to communicate these needs unless they are time critical. 

• Emergencies - If a patient decompensates or becomes unstable during cross cover, you are responsible for their resuscitation and disposition. You are free to pull the patient over to the main zone or to leave them in ED observation as you feel is appropriate for their condition. Please write an update note, and arrange for admission when this occurs.

• Your Own ED Obs Admissions - If you would like to place one of your patients in ED observation, you are responsible for their admission including notes, orders and medication reconciliation. 

• Direct to ED Obs Admissions - Direct to ED Obs is only available service when we have a dedicated ED Obs Doc.  If a patient arrives after 1700, they will be triaged to the appropriate ED zone according to their acuity and nursing needs, and if the primary MD from the ED feels they are a good patient for ED Obs, then they can admit the patient to ED obs after their main ED evaluation.  If you are asked to see a patient for "Direct to ED Obs", please tell nursing to triage the patient as they would any other patient checking into the ED.  

• Late Discharges - If a patient is expected to be appropriate for discharge home after 6:00 PM, it is appropriate for the previous physician to ask you to change this patients' status to "discharged" based on pre-discussed criteria (E.g. their blood transfusion is completed).  However, you should not be asked to complete a new ED Observation Summary note, write prescriptions, arrange followup or write discharge instructions on such a patient unless something about their plan or discharge has changed from expected.   In this situation these things should already be done at the time of signout, and the cross cover physician should be responsible only for changing their disposition status to "Discharged". 

What you are NOT responsible for

• New Admissions from other ED physicians - If another physician in the ED would like to place a patient in ED obs during cross cover hours, it is their responsibility to write the orders, note and med rec for such patients.  While the physician remains working in the ED it is also appropriate for them to followup on any patient care issues that arise after they are placed on ED observation status.    However, these admissions should be communicated to you, and your name should be assigned as the attending before the primary ED physician leaves.

• Family Conversations - unless a patient becomes critically ill, dies, or has a major change in status, it is not your job to update the family on their care.  If a family calls asking for an update, it is appropriate to ask the nurse to document the call and the call back number and defer until the daytime ED Observation provider is available. 

If you have any major issues with cross-cover, or would like to communicate feedback to another provider regarding issues left for cross cover please contact Daniel.v.zeccola@kp.org