In my outpatient clinic I am trying to verify policies and procedures.
My new manager is making many changes, one of which is getting rid of the monitor and moving to using an AED and CPR (BLS) only. We still have to remain ACLS cert to recognize heart rhythms.
That said, when I pulled the outpatient clinics policy it says that for cardiac arrest the RN, in the absence of a physician (there never is one on site and sometimes we flex down to 2 staff in clinic) MAY institute the appropriate ACLS algorithm.
Basically we totally got rid of all IV's, code cart, drugs, etc. All we have is AED/call EMS. He is even trying to get away with no longer doing blood sugars even though policy clearly states what to do if BS under 70 or over 300. ???? Of course, as the RN, I am concerned about this from a safety standpoint since these patients are exercising.
I can't go to who is above him with this question because I am not sure she can answer me right (none of these people are RN's so seem disinterested in the whole following policy thing).
As a nurse though, would I still be following policies and procedures if I was taken to court or do the changes my manager is making have to be reflected on paper for it to be a safe place to work? Maybe I am worried for no reason but I'm paranoid.
Last edit by Curious1alwys on May 8, '17
May 8, '17
I can't really speak from a legal standpoint, but as an employee, you can only work with what you have. It's not your responsibility to keep the outpatient clinic stocked with the appropriate emergency supplies. It is within your scope of practice to initiate ACLS protocols whether it's written down or not, and as an ACLS certified nurse, I imagine you're more likely to be held liable for not initiating ACLS- even if the policy states BLS only- than you would for initiating it in violation of a policy.
However, if you're in a code situation and you have no emergency equipment or drugs, you can't implement an ACLS algorithm whether you're certified or not, regardless of what the policy states. So you would perform BLS and call 911- just like you would if you came across a person in cardiac arrest on the street corner. From a liability standpoint, it will fall on the owners and managers of the facility to justify why the necessary emergency equipment wasn't provided to their staff.
May 8, '17
From a liability standpoint, it will fall on the owners and managers of the facility to justify why the necessary emergency equipment wasn't provided to their staff.
Thank you. Ok so this is what I've been trying to figure out. But years later, if the patient sues, won't they look back at P&P? If I say my manager did not have any equipment around, will that be good enough?
May 8, '17
Policies should reflect actual expectations and vice versa. Otherwise they are utterly useless in that they protect no one and can't be used as a resource either.
You write as though your new manager has rejected the idea of updating the policies but didn't actually say that, so I must ask - has he indeed refused to consider the issue of the policies that need to be updated? If not, you could casually/neutrally bring it up. "When will the new policies be in effect? I'd like to make sure I familiarize myself with them" or "Anything I can do to help you make sure our policies reflect the new expectations?" Sadly, this could be an issue that simply hasn't crossed his mind. Perhaps it seems like a technicality (as pointed out above, it would be hard to hold you liable when the appropriate supplies were not available), but OTOH we're talking about policies related to patients who may be trying to die! It's a little different than changing a practice such as "we will no longer be calling in prescriptions". If you're expected to institute BLS and manage the proper use of the AED, and call 911, the policies should state that and not mention advanced interventions that you have zero capability to perform due to lack of proper equipment and supplies.
May 8, '17
Speaking as someone who does risk management for ambulatory care, the trend nowadays is to get away from the classic full crash cart/ACLS protocol in your typical medical clinic. The drugs expire, the training goes stale and the LifePaks are expensive. Depending on your location, patient demographics and the ability of ACLS via the Medic One unit, ditching the ACLS cart can make a lot of sense. In the majority of my clinics, I have a basic crash cart and an AED. I expect my staff to initiate BLS and call 911.
I would work to have the policy changed to get rid of the language about starting the ACLS algorithm. I would change it instead to something along the lines of calling 911, initiating BLS and applying the AED as necessary.
May 8, '17
I will echo RM. I worked for 4 years as a charge nurse/supervisor of an ambulatory clinic. We did ONLY BLS. We had an AED on site, and would call EMS for any transports.
May 9, '17
Moved to Ambulatory Care Clinic
May 9, '17
You aren't responsible for making your setting a safe place to work. You are responsible for practicing safely within your scope of practice. Look at it this way: If somebody codes and you try to initiate a protocol that you don't have tools to effectively deliver, you are more at risk than if you just delivered BLS and called 911. The court tends to default to what would a reasonable person do, and a reasonable person doesn't try to fly without wings, but rather gets another form of transport. The written policies which are inconsistent with the tools available are the facility's issue, and do expose them to liability. As a courtesy and as an additional CYA, an email to the person responsible along the lines of what JKL33 suggested would be helpful.
Ditto with the blood glucose. As a professional if you have a symptomatic patient and you know they have a history of diabetes, you have an obligation to do what you can to get them assessed and treated, which would mean 911 if you have a policy but don't have a glucometer - or an order - and the patient doesn't either. Just as if you were, say, a nurse at an outpatient mental health unit. But again I would think as a courtesy and a CYA you would let someone know that the policy doesn't reflect what's available. That's a different deal, really, not checking a BG doesn't have the potential for immediate threat to life as not initiating some form of life support - ACLS or BLS - does, which is why the policy says you may start ACLS in the absence of an MD. Also note MAY and not WILL or MUST - if your policy says you may start it, not having the tools is a perfectly defensible reason for not starting it.
Remember, anybody can sue for anything, and in medical situations the plaintiff goes after every pocket that has promise. But that doesn't mean they will necessarily prevail against you.
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