Overnight Cross-Cover Quick Reference

Evidence-backed adult bedside triage for common overnight pages, focused on safety, evaluation, escalation, and local order-set use.

Scope and safety boundary

This page is for overnight cross-cover of adult general internal-medicine inpatients. It distills the domains in Aleisha Khan’s July 27, 2026 quick reference into an evidence-backed triage framework. It is not an order set: use the current local formulary, nursing policy, and escalation pathway for every medication, dose, concentration, route, and infusion.

Do not use this page for pediatric, obstetric, perioperative, or specialty-service protocols. Assess the patient in person, review sign-out and the current record, and escalate through the local rapid-response or emergency pathway whenever there is airway, breathing, circulation, or acute mental-status compromise.

First response to any page

Confirm the immediate problem, onset, severity, vital-sign trend, mental status, code status, and whether the patient is clinically stable.
Review the active medication administration record, allergies, renal and hepatic function, recent procedures, relevant laboratory or imaging results, and the primary team’s contingency plan before placing orders.
Look for a reversible driver, including pain, urinary retention, constipation, withdrawal, missed chronic therapy, hypoxemia, infection, or a new medication effect.
Use the lowest-risk intervention that fits the diagnosis, and communicate the assessment, action, and re-evaluation plan to the bedside nurse and covering clinician.

Common stable symptom pages

Headache, mild pain, fever, and acute non-emergent back pain

First exclude a time-sensitive diagnosis from the history, examination, and vital-sign trend before treating symptoms. For uncomplicated acute low-back pain, the ACP recommends superficial heat and other nonpharmacologic measures first; if medication is needed, an NSAID or skeletal-muscle relaxant may be considered after individual risk assessment. Routine opioid treatment is not the default approach. ACP low-back-pain guideline

For headache, pain, or fever, choose only a locally approved symptom regimen after reviewing the cause, medication exposure, renal function, hepatic function, bleeding risk, oral intake, and contraindications. Escalate for new focal neurologic findings, meningismus, hemodynamic instability, hypoxemia, severe or rapidly progressive pain, or another concerning change from baseline.

Nausea, vomiting, constipation, pruritus, and insomnia

Identify the syndrome before treating it: obstruction or ileus, gastrointestinal bleeding, medication toxicity, urinary retention, withdrawal, infection, and evolving abdominal or neurologic disease require diagnosis-specific evaluation rather than a reflex PRN medication.

For adults 65 years or older, avoid or minimize first-generation antihistamines, benzodiazepines, Z-drugs, and skeletal-muscle relaxants when a safer alternative is available because the 2023 AGS Beers Criteria identifies important anticholinergic, delirium, sedation, and fall risks. 2023 AGS Beers Criteria

Start with low-risk nonpharmacologic measures when appropriate, such as adjusting the care environment for insomnia or supporting mobility and bowel function for constipation. If medication is necessary, select it from the local protocol after reviewing age, cognition, QT-risk medications, bowel function, renal and hepatic function, and route safety.

Agitation and delirium

Treat new agitation or delirium as an acute change in condition. Assess oxygenation, glucose, pain, urinary retention, constipation, withdrawal, infection, medication effects, and neurologic change; provide reorientation, sensory aids, sleep support, and a calm environment when safe to do so.

Haloperidol and ziprasidone did not shorten delirium or coma in the MIND-USA ICU trial, so antipsychotics should not be used routinely to resolve delirium. The trial was conducted in critically ill adults, which limits direct extrapolation to all ward patients. MIND-USA trial

When behavior creates an immediate safety threat, use the local emergency agitation pathway and obtain senior support. For older adults, include the Beers medication-risk review before continuing a sedating or anticholinergic agent. 2023 AGS Beers Criteria

Time-sensitive cross-cover pages

Elevated blood pressure without obvious target-organ injury

The AHA distinguishes asymptomatic elevated blood pressure in acute care from elevated blood pressure with new or worsening target-organ damage. Confirm an accurate repeat measurement, assess symptoms and end-organ findings, and address reversible contributors before changing therapy. The evidence base for treating asymptomatic inpatient blood-pressure elevations is limited, and the statement favors a practical, patient-centered approach over reflex IV or as-needed treatment. AHA acute-care BP statement

If symptoms or findings suggest acute target-organ injury, activate the local hypertensive-emergency pathway rather than applying this stable-patient framework. Do not turn a number alone into an IV medication order.

Hyperglycemia and hypoglycemia

For noncritically ill adults, the ADA recommends initiating or intensifying treatment for persistent glucose at or above 180 mg/dL and generally targeting 100 to 180 mg/dL when this can be achieved without significant hypoglycemia. A basal-based regimen is preferred for most hospitalized adults; correction-only insulin is discouraged except in selected mild cases. Use the local insulin protocol and reassess oral intake, renal function, steroid exposure, and recent hypoglycemia before changing insulin. ADA inpatient standards 2026

For an alert adult with glucose at or below 70 mg/dL who can swallow safely, give 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. Patients unable to take oral carbohydrate need the local emergency hypoglycemia pathway, such as glucagon or IV dextrose, with prompt reassessment. ADA hypoglycemia standards 2026

Urinary retention

Evaluate symptoms, abdominal examination, medication contributors, and the need for a bladder scan. When catheterization is clinically required, favor the least invasive effective approach, document the indication, and reassess an indwelling catheter daily. The SHEA/IDSA acute-care update emphasizes avoiding unnecessary indwelling urinary catheters and removing them as soon as they are no longer needed. CAUTI prevention update

Use institution-specific bladder-volume thresholds, catheter-selection guidance, and urologic escalation criteria. Do not attempt urethral instrumentation when injury is suspected without urgent senior or specialty input.

Alcohol withdrawal

Use a validated withdrawal assessment and the local symptom-triggered alcohol-withdrawal protocol. Benzodiazepines are first-line pharmacotherapy; phenobarbital, alpha-2 agonists, and ICU sedative infusions require the setting, monitoring, and clinician experience described in the local pathway. Assess for seizures, delirium, marked autonomic instability, concurrent sedatives or opioids, hepatic disease, and Wernicke risk, then escalate early when severe or complicated withdrawal is suspected. ASAM alcohol-withdrawal guideline

Use the local protocol for thiamine, electrolytes, fluid, medication selection, dosing, and level-of-care decisions. Do not rely on a CIWA-Ar score alone when the patient cannot participate reliably in the assessment.

Chest pain

New acute chest pain requires in-person assessment and a local acute-chest-pain pathway. The 2021 AHA/ACC guideline recommends obtaining a 12-lead ECG within 10 minutes of arrival in an acute-care setting and using serial cardiac troponin testing, with high-sensitivity assays preferred when available. AHA/ACC chest-pain guideline

If acute coronary syndrome is suspected, initiate the local ACS or STEMI pathway and involve the appropriate emergency or cardiology team. Antiplatelet, anticoagulant, anti-ischemic, and reperfusion decisions require diagnosis, bleeding-risk, hemodynamic, drug-interaction, and procedural context. 2025 ACC/AHA ACS guideline

Do not label chest pain as benign solely from a remote history or a single unrevealing test. Escalate immediately for ischemic ECG changes, rising troponin, hemodynamic instability, hypoxemia, syncope, or ongoing severe symptoms.

Handoff and documentation

Document the trigger, bedside assessment, stability, differential, interventions, response, escalation, and plan for reassessment. Ensure the primary team receives unresolved diagnostic questions and any change that may alter daytime management.

Hypertension for background reference material. Acute-care decisions must follow the current local emergency pathway.
Pain Management for background reference material. Avoid using conversion tables as direct cross-cover orders.
DKA and HHS for a separate hyperglycemic-crisis pathway.
Acute Intoxication, Withdrawal, and Overdose for related emergency concepts. Use current local protocols for all medication orders.