It’s 2:30 in the morning. You saw a patient at evening sick call for a cough and fever, and you have reassessed him twice since then. His respiratory rate is a little faster than it was earlier, and his oxygen saturation is a few points lower. He tells you he feels about the same. Nothing is dramatically abnormal, and nothing clearly meets the parameters in the protocol. The provider will be on site at 8:00. You find yourself at the desk with the phone in your hand, wondering whether this is worth a call.

Every correctional nurse knows that moment, and most of us know the reasons we hesitate. The on-call provider was short with us the last time. We don’t want to seem unable to handle things on our own. The protocol seems to cover the situation, or the patient will be seen in the morning anyway. These are real pressures, and experienced nurses feel them too. But none of them is a clinical reason to wait.

One of the most useful things I have learned is that choosing not to call is also a clinical decision. We tend to think of the call as the decision and waiting as the default. But when you decide to wait, you are judging that the patient is safe to continue without provider input for now, and that judgment needs the same reasoning as a call. What exactly are you waiting for? What finding would change your mind? When will you reassess, and what will you do if things are the same or worse? If you can answer those questions, you have made a deliberate decision, and you can document it clearly. If you can’t, it may be time to pick up the phone.

Some situations call for a call even when no single finding looks alarming. A change from the patient’s baseline is one, even a subtle one. A trend matters too: a heart rate creeping upward over several checks or an oxygen saturation drifting downward tells you more than any single number. A patient who isn’t responding to treatment as expected, or whose symptoms fall outside what the protocol was written to address, needs a provider’s input. Then there is the moment many nurses dismiss, when you sense something is wrong but can’t fully explain why.

I have learned to take that feeling seriously. Worry is often experience recognizing a pattern before the data fully catches up. It is a legitimate reason to call, and the work is to turn it into findings you can report: what you observed, what has changed, and why it concerns you. “His respiratory rate has gone from 18 to 24 since 10:00, his saturation has dropped from 97 to 93 percent, and he is working harder to breathe than he was earlier” gives the provider something to act on, even though no single number is alarming.
In the situation above, the nurse made the call. The provider asked several questions, decided the patient needed to be evaluated at the hospital, and he was treated there for pneumonia that had been progressing through the night. The nurse didn’t need certainty to call. She needed to recognize that the trend, and her own concern, were reasons enough.

Most providers I have worked with would much rather get an early call they didn’t need than a late call they did. A clear, organized call that ends with “no new orders” is not wasted. The provider has the information, and you have direction, which is exactly what belongs in your note, as we discussed in July. When you find yourself standing at the desk wondering whether it’s time to call, take that question seriously. It is often your clinical judgment telling you the answer.