Scene: LTC/SNF

Day 1 - INR comes back, cannot get in contact with primary for new warfarin orders to start the next day.

Day 2 Part one - Other MRP now on-call for primary, complains that primary doesn't help him out enough, doesn't feel he should help him with his patients, takes info regarding patient then states he doesn't know enough about patient to write a new order (patient stable with known chronic conditions and long-term warfarin use).

Day 2 Part Two - Finally get in touch with back-up residential care physician late PM because he had his phone off all day and res get new warfarin orders.

Obviously totally serious question - who deserves a smack, and who deserves a boot in the rectum?

More serious question - is this sort of behavior worth following up by registering a complaint? The patient could have been at risk because physicians were either unavailable when they were supposed to be available, or because one has bad feelings about the other. I understand that the physicians in this region have a massive workload due to the shortage of HCPs. No doubt many are burnt out by the demand - particularly coming from our sector who need a lot more attention, more quickly than clinic patients. But besides the obvious impact on patient care, it impacts nursing's ability to perform good patient care by having to make repeated call outs for one single routine order that takes five minutes to calculate and deliver.

When I've really, REEEEEALLY needed the MD and I couldn't reach him/her, I would call the facility's Medical Director (only problem might be if it was the Med Dir who wasn't calling back in the first place!!!). And if it's something critical, your DON should know immed. Sometimes, a phone call from the DON brings results when regular staff's calls didn't.

Important that DON and Admin know about the problem and get the Med Dir involved. The errant PMP may need to have facility privileges curtailed or terminated.

Some physicians like the NH practice - usually pts become 'routinized' into a pattern and the NH nsg staff usually 'run interference'. So for some, it's minimal effort for a decent chunk of income.

So, to your question, YES, the 'higher uppers' at your place need to know and to address the issue. Not my job to do it except to follow the chain of command. That's what they get paid the bigger bucks for.

We don't have a medical director - DOC and GM are both RNs with experience and higher education in geriatric care. They are great, but obviously can't help with writing orders. Our home runs a bit differently from the ones you're experienced with - for example, we can't just revoke facility privileges. Although many residents are covered by one physician, quite a few are followed by the GPs they've had for years prior to admission. The physicians decide whether to continue to follow or not on admission, and it's their responsibility to ensure timely response, on-call coverage, and the (very) occasional in-house visit. Many join rotating on-call groups to ensure full coverage with no-one having to to shoulder full-time responsibility of after hours calls.

I will write up a brief on what happened and pass it on to our admin. At least if it becomes an ongoing issue there will be documentation to support a formal complaint.

A very good reason to have a Coumadin protocol for stable patients

I'm confused about your facility. Is it really LTC or more Assisted Living? Continuing Care? What is a DOC and GM = General Manager?

A very good reason to have a Coumadin protocol for stable patients

With an order (for stable patients) to extend orders x1 day if MD cannot be contacted.

Scene: LTC/SNF

Day 1 - INR comes back, cannot get in contact with primary for new warfarin orders to start the next day.

Day 2 Part one - Other MRP now on-call for primary, complains that primary doesn't help him out enough, doesn't feel he should help him with his patients, takes info regarding patient then states he doesn't know enough about patient to write a new order (patient stable with known chronic conditions and long-term warfarin use).

Day 2 Part Two - Finally get in touch with back-up residential care physician late PM because he had his phone off all day and res get new warfarin orders.

Obviously totally serious question - who deserves a smack, and who deserves a boot in the rectum?

More serious question - is this sort of behavior worth following up by registering a complaint? The patient could have been at risk because physicians were either unavailable when they were supposed to be available, or because one has bad feelings about the other. I understand that the physicians in this region have a massive workload due to the shortage of HCPs. No doubt many are burnt out by the demand - particularly coming from our sector who need a lot more attention, more quickly than clinic patients. But besides the obvious impact on patient care, it impacts nursing's ability to perform good patient care by having to make repeated call outs for one single routine order that takes five minutes to calculate and deliver.

While this behavior is annoying, neither a smack or a boot in the rear is appropriate. I have been known to page one of the two and hand the phone to the other when the first calls back.

I once watched a pulmonologist hit a nurse in the face with a chart in a metal chart cover -- lac to her nose. The pulmonologist said he was sorry it happened, but he wasn't trying to hit her -- he was trying to hit the surgeon with whom he had a longstanding dispute.

I once walked passed an OR when the door burst open and two men in scrubs rolled out (literally, rolling on the floor with their hands around each other's throats). One was a surgeon; the other an anesthesiologist. They'd been having a disagreement about the correct method of doing cardiac outputs.

While I was at lunch, the cardiologist and the cardiac surgeon got into a screaming match across my patient's bed. The patient's wife fired them both. The nurse who was relieving me described the situation in such colorful terms I was sorry to have missed it. One of them was sent to Anger Management (again) and the other was invited not to renew his contract again.

I work Cardiology and a wonky INR can be dangerous!!

I have no qualms about 3am phone calls to attendings... i say be more persistent and chart everything you did. You never know...

At night calls to the DON..

Akin to 3am calls to an Attending or the

AOD in the hospital.

If MDs cant handle stuff..not my problem.