ACLS requires a doctor's order?

[BUNightingale]

My facility is telling us that we must have a physician's order to start pushing ACLS drugs. They are telling us that it is a violation of the Nurse Practice Act to start ACLS without an order and that we are operating outside of our scope of practice because we are administering meds without an MD order. We have, in the past, just paged the MDs and started ACLS with high quality CPR, pushing whatever meds the patient's condition called for, following the algorithm. I work in a large teaching facility so there is always an MD somewhere close by so this problem isn't really that important specifically to me but what do smaller hospitals do when there isn't a doctor handy? Has anyone else ever heard of this? What do we need certification for if we can't do it without an order? Wouldn't any RN be able to administer these drugs with a physician present?

[puravidaLV]

I'd probably ask for the written protocol before taking someones word about this.

[Perpetual Student]

Our policy has language stating to follow the appropriate ACLS/PALS algorithm unless otherwise ordered. I cannot comprehend not being able to intervene immediately in an emergency. I hope they don't expect you to withhold defibrillation until specifically ordered if it's indicated.

[turnforthenurse, MSN, NP]

We are expected to begin CPR/start the ACLS algorithm if a patient codes. Sometimes the hospitalist doesn't respond in a "timely" manner but the ER physician and the rest of the code team usually arrives within minutes and by that time, they are usually the ones directing the code and telling us what to push. If not, it's usually the charge nurse or the nursing supervisor running the code until either the ER physician or on-call physician arrives. Afterwards, the physician(s) sign the code blue sheet, which is your order.

[Babs0512]

I guess it would depend upon the hosptal's policy and procedures. When I worked the ER, one of us was assigned to in hosptial codes. So was a member of ICU. Both being ACLS certified. When I responded to hospital codes, I would usually "take over" the code and bark out orders (trying to get it organized). We are certifed to run a code without the physician present. Yes, when the MD is present, we would defer to MD (sometimes - you'd be surprised how many have no clue). We aren't going to lose the chance at saving a patient when you have several ACLS certified nurses in the room, RT would manage the airway and intubate, we would monitor the EKG, give epi, atropine, ... per ACLS protocol. If they were a diabetic, we would get a finger stick and if BS was low, and amp of D50 would go in. Well, you get the picture. I won't belabor the point.

Usually, it wasn't an issue, the ER doc would come with me to the code - however, if he/she was already attending a code in the ER or a fresh MI and couldn't break away, it was up to the nurses to run the code.

[Dazglue, ADN, BSN, MSN, RN]

At our hospital it's a standing order for all MD's. It's even in our policy & procedures. As long as you're certified you are to start algorithms until the MD/code team shows up, which will only be like a half of minute (certain code teams are assigned to certain floors to make it easier). Usually the person who finds the pt unresponsive pushes the code button and starts compressions. Someone else will bring the crash cart and by that time the code team is there to take over. But what's odd is our MD's are not required to be ACLS certified so during a code, they always ask, what's next? Any suggestions? The code team literally does everything. I guess the MD is just there for liabilty issues. lol

Every facility is different. This is something I would get a clear understanding of.

[Babs0512]

I agree with you. Many of our MD's weren't ACLS certified. I took ACLS classes and recerts with MD's, and boy was it an eye opening experience for me! Talk about dumber than a box of rocks! Mostly, the code team ran the code, even with the MD present - for the reason you stated.

[PMFB-RN, RN]

I agree with you. Many of our MD's weren't ACLS certified. I took ACLS classes and recerts with MD's, and boy was it an eye opening experience for me! Talk about dumber than a box of rocks! Mostly, the code team ran the code, even with the MD present - for the reason you stated.

*** At my hospital we have residents who always show up at the codes. Usually too many of them and they are a real nuisance. However they are there to learn, not run the code. We usually allow them to "run" the code with the rapid response nurse or ICU nurse giving them directions when they need it, or if that particular resident of too clueless we don't even allow them to pretend they are running the code. They are handy for pronouncing death when needed.

I am an ACLS instructor and frequently have physicians on our classes. It was an eye opener for me as well. With interns and young residents nobody expects them to know much and it's OK if they are clueless. What is shocking to me is how little attending physicians and senior residents know about ACLS r taking care of sick people. Of course the ER, anesthesia and intensivists docs are superstars but the radiologists, internal med, and surgeons are shockingly helpless.

[NurseGreta]

I am an ACLS Instructor and you must have a doctors order to push any meds, no matter your certification. However, as has been alluded to most hospitals have an Emergency Treatment Protocol that covers you but not all floors opt to use it, more often medical floors. Especially if their nurses are mostly new or a certain percentage are not ACLS certified. So check your protocols to make sure you are covered. Think about it this way if you are on the street and happen to have epi, atropine, an ET tube, manual defibrillator...etc, and someone codes, can you use them? No cuz you don't have an order. Same is true in the hospital.

[canchaser, BSN, RN]

Wow, I am taking ACLS this week, and will bring this up? Its at my PRN job, I want to know the policy and orders. Good timing for me.:)

[mags73]

That is not true. You do need an official code status established by the patient & signed within 24 hours of admission. That is a joint commission standard. Its gross negligence not to start ACLS if your certified of course. There should be one RN on the floor that is ACLS & of course there is a code team who responds even in rural hospitals there has to be a MD usually the ER doc who can manage the patient.

[BlueBug]

I have never heard of anything like that before! Start checking with some outside sources, Nursing board, Joint Commission, American Heart Association, ACLS instructors.

Have you talked to your director about this, or is it a rumor on the grapevine?

[qaqueen]

Wow, it is amazing that there are so many diverse responses to what should be a straight forward answer. I have learned over the years that there are several things that provide opportunities for discussion like this.

I work for an organization that runs several hospitals. Our docs have the option to use caresets for admission orders. These caresets include orders for rapid response and emergency response activities. Basically standing orders for ACLS. Most docs automatically order both of these on admission.

That being said, I am the only RN on my M/S unit that is ACLS certified. There is no requirement in my facility that there be an ACLS certified nurse on M/S floors. When I interviewed for my position, no one cared a bit that I was certified. I pursued the certification because in my previous positon, rapids and codes were pretty regular in M/S, and because I hope to move into a higher acuity area in the near future.

If I did not have the emergency response orders, the only thing I can do is BLS. Without orders, even following the algorithms is outside of my scope.