Drawing Labs without an order

[umnurs]

I work in a Level 1 trauma center in NYC. I only started a few months ago. We generally have anywhere from 4-12 patients at a time, so as soon as I get a new patient I try and line and lab them to expedite things (as do my coworkers). We recently heard a story from management that at another nearby hospital 3 nurses were suspended for "inserting an IV and drawing labs without a MD order." This was related to a lawsuit from a patient who ended up not needing an IV, but was "lined and lab'd" by the RN and went home to develop a staph infection at the site resulting in hospitalizattion, IV abx, and an I&D. The other 2 nurses were suspended when management did an "investigation" and found that they had done the same thing (as i'm sure EVERY nurse in that ED does). I dont know all the details or the "full story"...

So we were reminded that inserting an IV and drawing labs are "not in an RN''s scope of practice". We dont have standing protocols except for true "emergencies". i make the judgement call every day regarding which patients I out Iv's in and which one's i wait for the MD to see first. But sometimes it can take HOURS for a MD or resident to see a pt., and if i feel that the pt will need an IV and labs or may go bad-- i do it.

Anyone ever heard of this happening? What do you guys do in your hospital?

(and yes i know the ratio is bad but thats how it is everywhere in this crazy city!!)

[SteveNNP, MSN, NP]

The 80 bed ER I used to work in had protocols for nearly every chief complaint. 90% of them required labs and/or an IV.

We just did it. IMHO if the nurse had prepped the skin properly to begin with, that pt wouldn't have developed an infection. Unfortunately, when the poo hits the fan, the nurse is the one who gets the wrist slapped.

[Iam46yearsold]

There is absolutely nothing wrong, and everything is right in assessing a pt. then starting a line and ordering anticipated labs. This is just teamwork between the ER MD and the staff.Its in the pts best interest.

[neko11111]

If we waited for the doc to see each pt and order each lab/line - could you even IMAGINE how bad the 'stink eye' you'd be getting from the pt's because of how bad the ER would be backed up and how long the wait times would be???? ICK!?!?! Don't want to even think about that one! It's bad enough as it is!

[rjflyn, ASN, RN]

The 80 bed ER I used to work in had protocols for nearly every chief complaint. 90% of them required labs and/or an IV.

We just did it. IMHO if the nurse had prepped the skin properly to begin with, that pt wouldn't have developed an infection. Unfortunately, when the poo hits the fan, the nurse is the one who gets the wrist slapped.

Or just bad luck I personally start anywhere from 2000-3000 a year, I am not sure what the nation infection rate is but I can guess one or two are going to go bad. My next question would be is are they having a higher rate of infection? If so then why and are they fixing that problem as well.

RJ

[mannurse65]

I too, was involved in creating the Pre-printed Orders and Practice Guidelines, with our physician group. The intention is the same as protocols except that a protocol allows the nurse to initiate care regardless of what the doctor decides after the fact. The protocol should be considered a direct doctors order, or it is non-binding and you are not protected. I use the trust issue because I think it is foolish to base your future on the hope that, if it all goes to hell, your physician will choose to protect your licence over her/his own. Even if you had such an angel, doesn't anyone feel like this is a big step backwards?

Mother may I?

[edmia, BSN, RN]

Or just bad luck I personally start anywhere from 2000-3000 a yearRJ

I've been trying to figure out where you work! that's an average of 13 to 20 IV starts per shift? I'm basing the calculation on a regular 13 shift/month kind of thing.

That seems like an extremely busy practice.

Anyway, the number just stood out to me. I figure I start an average of 3 or 4 lines per shift - somedays more, some none and I'm in a pretty busy urban ED.

[Mr Ian]

Stripping this down - the OP is asking about protection for nurses who perform commonplace duties without docs orders.

Since the administration has seen fit to address this in one hospital - I'd say take it to the adminstration at your hospital and ask them directly - preferably in writing - then get their answer in writing - then take it to the nursing team to decide if they feel covered or not. This is what your union should do for you to protect your anonimity as a 'stirrer' - because you are right to question the practice.

If admin is not prepared to cover nurses or to set pathways or protocols - then down tools and do not continue doing what they aren't prepare to defend you for.

Footballnut seems to have a place where it is all done correctly, as well as a couple of others.

Doing what has to be done - but not with the backing of the admin - is another martyrdom of nursing.

And many martyrs are made.

The only way to stop adminstration throwing you under the bus is to stop putting yourself on the kerb side.

[Iam46yearsold]

I've been trying to figure out where you work! that's an average of 13 to 20 IV starts per shift? I'm basing the calculation on a regular 13 shift/month kind of thing.

That seems like an extremely busy practice.

Anyway, the number just stood out to me. I figure I start an average of 3 or 4 lines per shift - somedays more, some none and I'm in a pretty busy urban ED.

Well just 3 or 4 starts of IV would be considered a very slow day. Its more likely no less than a dozen IV accesses a day for us.

[Triage24]

We have standing protocols for starting IV's and drawing labs. If chest pain, critical or we know we are going to need one, we line and lab them.