ED staff not checking blood sugars

  1. 0 I was just wondering, if a patient comes to your hospital and part of their history is diabetes but that is not part of their primary diagnosis, do you still check their fingerstick? I just found out that this is not protocol at my hospital (I don't work in the ED, but a close friend does). She said that they will sometimes look at the blood glucose level when a blood panel is drawn, but unless the patient is admitted for something diabetes related they don't check fingersticks. Well this caused a problem for me the other day. I had a patient admitted for PNA who was also diabetic. While in the ED, he had a sandwich and a few snacks (he's generally well controlled at home, knows his diet). No one ever bothered to check his fingerstick, so when I checked it at night it was 426!! At home he takes a large amount of NPH BID, but had not had any that day. Of course in the ED you can't just waltz in with your own meds and start giving yourself insulin, so this guy just went ahead and ate not knowing his fingerstick since no one checked. (I know he could have asked someone, but when your starving and can't get anyones attention, you can't help it) So, in addition to trying to get his blood sugar back to a normal level, I was also going back and forth with the docs because they had the orders all wrong for his insulin compared to what he takes at home. Anyone else experience situations like this in their hospital? Thanks for the input!!
  2. Visit  ChocoholicRN profile page

    About ChocoholicRN

    ChocoholicRN has '4' year(s) of experience and specializes in 'Med-Surg'. Joined Feb '06; Posts: 231; Likes: 136.

    17 Comments so far...

  3. Visit  Blee O'Myacin profile page
    0
    We fingerstick. In triage and every few hours while a patient is waiting for a bed. If the house doc does the admission and the patient is being held, then they have to be the ones the write the orders.

    But to answer your question, if the patient is diabetic and in one of my beds, I check blood sugar and act upon the results.

    To be honest though, if I have a code or something else big and bad, the repeat bs on an AAOx3 patient will just have to wait. Sometimes they get taken to the floor first. The ED staff is not doing this intentionally to make more work for the floor staff. We can't control how many people are in the waiting room nor the flow of ambulances.

    Blee
  4. Visit  mpccrn profile page
    0
    as unprofessional as it sounds, our ED nurses insist they are "not allowed" to do ANYTHING no specifically ordered by their docs.....not allowed to asses, not allowed to think, not allowed to troubleshoot. reports from them is a nightmare and frankly it's easier not asking questions because you know they won't know the answers. this has been a continuing fight between icu/sdu and the ED for as long as i've been here (5 years). the ED in not required to do anything that might be written on the admitting orders including hanging IV's even if the patient is down there for several hours because there is no bed available. i don't get it....don't understand how they hold onto their licenses, how they sleep at night, how they can go into work everyday and leave their brains and ethics at home. i couldn't do it.
  5. Visit  Quickbeam profile page
    0
    I investigate motor vehicle accidents for my state that relate to a health issue. I see thousands/tens of thousands of ER reports every year. You'd be amazed at how many ERs do not check blood glucose. I live in a state where almost 1 out of 3 adults probably have diabetes....yet this seems to get missed all the time.
  6. Visit  nursejennie76 profile page
    6
    Quote from mpccrn
    as unprofessional as it sounds, our ED nurses insist they are "not allowed" to do ANYTHING no specifically ordered by their docs.....not allowed to asses, not allowed to think, not allowed to troubleshoot. reports from them is a nightmare and frankly it's easier not asking questions because you know they won't know the answers. this has been a continuing fight between icu/sdu and the ED for as long as i've been here (5 years). the ED in not required to do anything that might be written on the admitting orders including hanging IV's even if the patient is down there for several hours because there is no bed available. i don't get it....don't understand how they hold onto their licenses, how they sleep at night, how they can go into work everyday and leave their brains and ethics at home. i couldn't do it.
    I dont know where you work, but I am a great ER nurse, and I work with great ER nurses, and I will hang meds on the admitting orders, I assess my patients, and know more about them then the ER doc does!! So please dont bash all ER nurses!!! By the way I sleep well at night, and will have no problem holding my license.
    Last edit by rn/writer on Oct 8, '08 : Reason: Removed unnecessary comment.
    ERnewbieRN, Blee O'Myacin, MissERN, and 3 others like this.
  7. Visit  CHATSDALE profile page
    0
    i would think that is one of the first things that an admitting doctor would ask for when advised of patients advmission
    most ers have a protocal on patients presentind with certain complains and dx so that an assessment can be completed [triage?] even before the doc comes to see patient
    a nurse should have some autonomy or you might as well hire a robot
  8. Visit  lunden profile page
    0
    in mpccrn's defense she did say "our Nurses" not every er nurse.:wink2:
  9. Visit  MAISY, RN-ER profile page
    2
    We have a very busy hospital ER. Anyone complaining of syncope, weakness, cp, stroke, ams or anything else that may related to BG levels has blood done in triage. Most patients like this have an ISTAT run-so no finger stick.

    The problem I see here is priorities. Fingersticks are not a priority in an emergency room UNLESS they have to do with the problem and outcome. Obviously if someone's blood glucose is elevated it is treated.

    Unlike some of the others, we have standing orders. If I smell ketotic breath, the patient requests, or I feel the need I can perform a fingerstick and do. Most of the time it is my judgement. And yes, people fall through the cracks-I find them all of the time. But that is the nature of the ER, we are not supposed to be holding, we are supposed to be patching, saving and sending. Unfortunately staffing on the floors doesn't always allow it.

    Again, I see another us and them situation. We are workup, emergent and sometimes maitenance. Everyone else is maitenance and sometimes emergent. A huge difference. The shame of it is, we all need each other. Look how to fix it, understand why it happens, and offer suggestions to make it better. Like better ER staffing with ancillary staff.

    JMHO

    Maisy
  10. Visit  cheshirecat profile page
    0
    I am a bit confused. Why do you need a doctors order to do a blood sugar?

    Surely it is part of the job of treating the whole person? Does it require a docs order to do ob?
  11. Visit  Roy Fokker profile page
    3
    I echo Maisy.

    I check sugars on all those who I think needs 'em. If they are a diabetic but appear to be hemodynamically stable, then I usually wait for the BMP to come back. If the sugar is over 180-ish or so and if the ED Doc doesn't make an issue out of it, I usually ask again just to be sure we're on the same page. Mostly I don't have to as our ED physicians (save for a couple) are totally kick ass competent

    All our admitting docs ask if pt. is a diabetic and if they don't ask, I remind 'em about it and they're pretty good about ordering coverage.


    And with all that being said - here in the ED we don't tend to lose sleep over a sugar of ... say... 150 or so. Same with certain other lab levels (like a K of 3.3 or some such). It's not because we are lazy or because we don't care - but these patients are stable and there is always a more emergent issue to attend to.

    Quote from cheshirecat
    I am a bit confused. Why do you need a doctors order to do a blood sugar?
    Technically, any and all tests have to be ordered by a physician.

    However, most ED's usually have "standing orders" or "protocols"; and by and large ED physicians would rather have more testing done and have results on hand than the other way around.

    Where I work, I don't ever ask a Doc to test someone for sugars. Or for a dozen other things - our Docs trust and rely on us to get the work ups started and we're more than happy to do so. Usually, they'll add on labs or tests - but we get the ball rolling initially. And in a busy ED like ours, we have to or the Docs would never get caught up!


    cheers,
  12. Visit  kmoonshine profile page
    2
    We do stat fingersticks on diabetics with symptoms (such as dizzy, increased urination, etc). If we get a pt who is confused, has a decreased level of consciousness, is having seizures, etc - then we get a stat fingerstick too. If the pt is at the ED for a med refill, their blood glucose may not be checked. This may sound sad, but some ED docs hate it when we go "fishing" because if the pt's fingerstick is way off, then the doc has to treat it (and I'm not saying that that's the right thing to do, either).

    If we have a pt being admitted with a history of diabetes, we definately get a baseling blood glucose. If their admission is unrelated to diabetes, we may or may not recheck their blood sugar before they go up to the floor (depends on the length of time they're in the ED). Most often, our ED docs will permit a pt to eat but won't start giving them insulin because they don't want to be chasing low blood sugars on a pt with a bed waiting upstairs and an admitting doc already writing orders for the floor.

    The only time we give insulin is if the person is in DKA or if their blood glucose is way too high (or if the pt's potassium is sky high, but that's a whole different story).

    Things can change so fast in the ED; one minute you have time to check a blood sugar, and the next minute you have the hall beds full with a PNB 5 minutes out. Increased blood sugar after eating is not a priority at that point in a pt who is asymptomatic.

    We truly do some amazing things each day in the ED. It seems like ICU and floor nurses hate the way we do things in the ED - but truly, we start with a blank slate and work our way up and do our best to patch the pt up before transfering them to a different department. The other night, I was treated like dirt by some ICU nurses after transfering a head bleed pt; he was very hypertensive, confused; I was 1:1 with him and went to CT with him, worked on managing his BP and educating the family, I got his old records faxed from a different hospital, gathered his med list to the best of my ability, placed another IV, removed a different IV that he had pulled out, prepared for intubation, placed a third IV, labeled my IV lines - and when I brought him to ICU and passed his copied chart to the nurse, I said "I've also included his records from xyz hospital" - I was ignored and they slammed the door in my face. So, I turned around and ran back to the ED to see how my other 4 pts were doing, only to be placed with another head bleed ready to go to the OR...
    Blee O'Myacin and gonzo1 like this.
  13. Visit  BrnEyedGirl profile page
    2
    The protocol in our ER is to do an accu check on all DM pts at triage.
    Now,..if there are 20 more pts waiting to be triaged and the pts c/o is not related to mental status change, weakness etc, they might not get an accu check at triage. That is part of prioritizing care, I'm not real concerned about a glucose of 300 if I have two chest pains, pt with L facial droop and someone bleeding all over the floor that I haven't even triaged yet.

    If a pt is being admitted and has orders that say it's okay for him to eat,.most of the time that pt will get an accu check,.especially if he/she is on insulin,..but again,.priorities here,.if we are full of traumas and MI's, in all honesty, it might not get done. That's the frustrating part of the ER,.we have no control over when our pt's show up, and can't ever say we are full no more. It isn't uncommon for us to have pt's in the hallways and EMS calls with two more traumas,.we just have to put more in the hallway and do the best we can. If we have to make a choice of getting an accu check on bed 7, and getting bed 8 to cath lab,.bed 12 to the scanner and hanging blood on bed 5,.the accu check often has to wait.
    Blee O'Myacin and MAISY, RN-ER like this.
  14. Visit  mpccrn profile page
    1
    Quote from nursejennie76
    I dont know where you work, but I am a great ER nurse, and I work with great ER nurses, and I will hang meds on the admitting orders, I assess my patients, and know more about them then the ER doc does!! So please dont bash all ER nurses!!! By the way I sleep well at night, and will have no problem holding my license, you probably could not handle 2 hours in a busy ER!!!!!!!!!!!!!!!!!!!!!!!!!!!!
    thanks for your attention to detail! i specifically said "our ED nurses", not ALL. i also specifically said "when a bed was unavailable for hours". i would enjoy getting report from you. it would be a pleasure to get report from someone that actually assesses their patient in the ED. perhaps you could give our ED staff some tips. we haven't been able to get them to understand a baseline assessment of the system the patient is being admitted for is extremely important i.e. the neuro statis of a patient being admitted for a cva. don't get so defensive next time. it wasn't a bash to all ED nurses. the faster we understand that team work transcends floors and departments, the better off our patients will be.

    oh, by the way, been there, done that... i worked a trauma center ED and held my own rather nicely.
    canoehead likes this.


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