I Need Advice - MD Not Signing Order

[Andrew, RN]

Hey everyone. I'm a RN working in a PACU. At my facility, CRNAs do the cases and there is one float MD that is there as a resource. We have "protocols" to give meds for pain/nausea without needing to call the doctor. The doctor then signs the order some time later, often not seeing the patient ever.

Here's my problem. I had a patient that just had a very painful ankle surgery. The surgeon wrote for a dilaudid PCA. I called the pain nurse to come and set it up. In the mean time, the patient was hurting at a "12 out of 10" and their vital signs/facial expressions reflected this. The pain nurse told me it would take her a while to get there and that I could give the patient some dilaudid IVP. Nothing wrong with that, we do it all the time. Basically, we are giving the patient their loading dose that the pain service nurse would be giving anyway once they get the PCA set up.

So, I give her 1mg IVP. Waited 5 minutes, gave another 1mg. The patient's pain went down and I left it at that. I wrote my order for it. The patient had a good outcome and had pain relief. This was earlier in the week.

Fastforward to today. I get called into my charge RN's office. The anesthesiologist is refusing to sign this order. I got sent home and they are going to talk to the pain service nurse later today when she comes in at 3 pm. I'm not sure if I'm going to have a job and it's up to "how far" the doctor wants to take this.

Basically, I was going by our protocols and giving the patient a medication in a manner consistent with its guidelines. I don't know what to do.

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

This sucks. =(

[pricklypear]

Hi Andrew - I really, really feel your frustration. Things like this - the gray areas - are the reason I left the hospital setting. I decided long ago to NEVER trust doctors to sign ANYTHING. And I don't trust co-workers who say things like, "It's fine! We do it all the time!!" I had a surgeon tell me once to "just give some norcuron next time your 3 hour post-op open heart freaks out on the vent. You don't need to call me, you're a "critical care nurse", right?" Uhh, yeah, I don't think so. It might be fine the first time, but what happens when he decides NOT to back me up? I've seen too many excellent nurses get thrown to the wolves over things like this. It's always going to boil down the the technicallity of the situation. Not the fact that the outcome was good. You'd THINK that would be taken into consideration, but it doesn't seem to be a deciding factor for nurses who are taken to court, or accused of doing something "out of their scope."

Don't give up on nursing. You went to all the work to earn a degree, don't throw it away. Find something else. Even if it's boring (like office nursing), it will allow you to relax and feel out your options. Luckily, the nursing field has many options. I left the hospital to do chronic dialysis. Luckily, I work with some really great people - this doesn't seem to be the norm in the dialysis world. I don't know if the dialysis field is where I want to stay forever, but at least my license isn't on the line every day.

Anyway, I really hope things work out for you...hang in there!

[RNKPCE]

Protocol or standing orders have to be somewhere in writing/computer. We have standard orders in our PACU and the doctors check what they want and can add things not pre-printed. Basically in this case one RN told another RN what to do. A doctor was never involved in the decision process unless you can find this protocol in writing.

I have also seen orders for PCA and a separate order that reads. Dilaudid 0.5mg IV q10min if PCA unavailable.

Like others have said we can't take doses with ranges on the floors where I work. PACU may be different though.

[3boysmom3]

It will pass, Andrew. All you can do is explain your side. I doubt your manager particularly blames you- it's usually more about having to soothe the doctor's ego. Maybe after this they will write a policy so that it can be clear in the future. Even if you get reprimanded or disciplined in some way, the main thing to remember is that the patient was not harmed in any way- so the worst case scenario did NOT happen. Don't quit over it. You know, JCAHO is trying to crack down on verbal orders, not only because of errors, but also because there are instances occasionally where a doctor will refuse to sign, saying "that's not what I said." You can never predict what one of those folks (docs) are going to do unless you know them pretty well. Hang in there.

[VICEDRN, BSN, RN]

Dear Andrew-

I will let the other comments from experienced nurses stand without further comment because I am student.

I actually thought it might help though if I let you know that nursing is not the only profession where this kind of stuff goes on. I am a former paralegal and I gotta good story for you.

An associate attorney asked me to prep some subpoenas for trial. I ordered the subpoenas, filled them out and served them according to the directions he had given me which I had written down as we spoke. When the partner was preparing the boxes for packing for trial, he asked the associate where was the subpoena for such and such entity. The associate didn't have one and he blamed me for the entire incident.

I almost lost my job. No matter what happened, I refused to back down but it didn't matter. After that, I told the associate that he would need to communicate to me all requests in writing via email so that we wouldn't "miscommunicate" again. Of course, he didn't want to do this, called me stupid in so many words and etc. I could on and on with similar stories. I have been threatened with my job sooo many times over stuff like this. Trust me on this!

Inside, I was boiling that I had to use the politically correct speak "miscommunicated." Inside, I couldn't wait to leave work as a paralegal. The only thing I can say is that since then I have learned to go inward with it. I learned that I know what I know, that I just need to accept that his lies are his problem and his ego is not my problem but also that I am not in control of what happens to me in these situations. Maybe it rides out like someone else already said or maybe it doesn't. I have learned to over-communicate and smile when people act like I am stupid for doing so.

Leaving nursing isn't the answer because it happens everywhere. Good luck.

[wtbcrna, MSN, DNP, CRNA]

Some of this advice is helpful, some of it isn't. Thanks anyway for those who have commented.

Here's some facts. The hospital is not JCAHO so their standards don't apply here.

The pain nurse is a RN, not AP. They write orders all the time that later get signed by the anesthesiologist, just like I do, only they write much more... PO opioids, sleep aids, toradol, etc etc.

In the given situation, I have done nothing wrong. The patient had pain, I treated it using a drug that they were prescribed to get. It's a gray area I am in. Perhaps if I had given fentanyl (a drug the anesthesiologist seems to be more comfortable with) instead I would not be in this mess and the doctor would have signed the order, but I gave dilaudid because that is the drug the patient was to receive via PCA.

The pain nurses often times when setting up the PCAs will give a loading dose starting with 2mg and redose 1-2mg at a time. I've seen them give 4-6 before. Every patient is different and requires a different dose for dilaudid. To the person that says "OMG it's 8 times more potent than morphine blah blah blah"... It's 2-8 times more potent, depending on the patient.

I gave 1mg, repeated it, then stopped. There was no harm done to the patient. Nothing bad happened. They're just singling me out. I gave a normal loading dose that the pain service nurse would have given. She was sitting around in the breakroom instead of being at the bedside treating the patient's pain. So I did.

This is what I hate about nursing. Infinite responsibility and no real power to do anything.

You know your post really worries me that you think there is nothing wrong with your dosing of this patient. Here is dosage recommendation from Lexi-Comp's Drug Guide (which is used by the American Pharmacists Association): Dilaudid-IV: Initial: 0.2-0.6mg every 2-3hrs for opiate naive patients. Now from the Anesthesia Drugs Handbook by Sota Omoigui (which is still one of the most popular drug references for anesthesia providers) recommends: Slow IV: 0.5mg-2mg (0.01-0.04mg/kg) every 4-6hrs. I am not sure how you can justify giving a dosage that goes against pretty much all drug references and think it is ok....mistakes happen and we learn from them, but thinking it is ok to dose patients like this without realizing that these are high doses of opioid doses stacked one on top of each other before even maximum respiratory depressant effect has set in is bad judgement in the very least.

All this other stuff that your talking about is extraneous information. The simple fact with your current state of denial thinking that this type of dosing is ok to use on patients just because they are in pain is going to cause a patient serious harm or death.

I could care less what another nurse does, and neither should you when it comes to something like this. This is you doing something that is not recommended and you can't defend it. By the way Dilaudid is 5-8x more potent than morphine depending on the reference. Do I need provide those references also? Try anything by Stoelting to start....

To start why don't you put aside the scapegoat attitude and set up meeting with the anesthesiologist and have him/her explain to you their aversion to signing your order, because if I am so wrong then why is MDA not willing to sign the order?

[litbitblack, ASN, RN]

Well Im sorry I disagree with some of you. If you have an order for a pca dilaudid and you give a loading dose it is still part of the original pca dose. WHY is it any different. The pt is getting pain med as ordered he is just getting his loading dose before the actual pca is started. Now if there are standing pca dilaudid orders that do not have an ordered loading dose then there would be a problem. I probably would have ordered per pca orders to the order that you wrote. The doc is being like that because he knows he can. I would personally talk to him and explain your thinking. Maybe he is thinking totally off the wall about the whole thing. And if hes not then I would call him about everything lol. Even tylenol unless there is a standing to cover you. We had some ortho docs who wanted us to handle stuff before we called them. When i first started working on that unit i had to get to know who wanted what. WEll after awhile this particular doc wouldn't even cover an order for an h&h on a post op that had a low bp (which is what we normally did). He flat out refused to sign this other nurses order for lab. He wanted to be the decision maker. LOL....which is totally fine with me if you don't trust my nursing judgement...i will call you 30 times a day if required lol. Hang in there. If there was a pca standing order for that bolus then I think you did nothing wrong. And to save yourself and your license then I would call him for everything you don't have a sig for and if you have a question about anything. Its your license and they get paid the big bucks so CAll HIM!!!! let us know what happens.

[Virgo_RN, BSN, RN]

You know your post really worries me that you think there is nothing wrong with your dosing of this patient. Here is dosage recommendation from Lexi-Comp's Drug Guide (which is used by the American Pharmacists Association): Dilaudid-IV: Initial: 0.2-0.6mg every 2-3hrs for opiate naive patients. Now from the Anesthesia Drugs Handbook by Sota Omoigui (which is still one of the most popular drug references for anesthesia providers) recommends: Slow IV: 0.5mg-2mg (0.01-0.04mg/kg) every 4-6hrs. I am not sure how you can justify giving a dosage that goes against pretty much all drug references and think it is ok....mistakes happen and we learn from them, but thinking it is ok to dose patients like this without realizing that these are high doses of opioid doses stacked one on top of each other before even maximum respiratory depressant effect has set in is bad judgement in the very least.

"IV Medications" by Gahart states:

"0.5 to 1 mg every 3 hours as needed. May increase up to 4 mg every 4-6 hours if pain is severe."

The OP gave the patient 2mg for 12/10 pain. This falls within the guidelines published by both Gahart and Omoigui.

[BradleyRN]

I wrote the order as "Hydromorphone 0.5-1mg IVP q 5-7 minutes MAX of 4mg" and I only gave 2mg.

I would not have given more than 1mg in your situation, as the pt's ability to tolerate the drug must first be assessed. I do not believe that you made a "huge mistake" by giving 2mg though. The error i find is in an order that could potentially allow 4mg over 20 minutes. If i had given 1mg twice 5 minutes apart, then i would have just written: Dilaudid 2mg X 1 dose now. Since you only gave 2mg, what was the point in writing for more than that? Offer to rewrite the order to a dosage a little more fitting for a pt who may have never received the drug previously. Explain that 2mg would have been the loading dose anyway, and acknowledge that you should have written "MAX of 2mg" instead of 4.

[wtbcrna, MSN, DNP, CRNA]

I am trying to teach you something since I write PACU orders everyday and you don't!

1. You have not stated the body habitus of your patient, and along those lines if they were obese would you even know if they had Pickwickian syndrome. Would you even be able to recognize it? Do you even know what that is, because I you probably have had patients with it...

2. The reference I stated was based on mg/kg. Did you take that into account? You gave no indictation that you did. Did volume of distribution even come into your mind? Those doses are over several hours and meant to be worked in with maximum respiratory depressant effect set in and then another dose given.

3. You have not stated the exact type of surgery, the ASA level of your patient, what opioids were given during surgery, if any blocks/local were given or not. Did you consider that extreme pain after ankle surgery might be early signs that something is wrong?

4. Was this an opioid naive patient or a chronic pain patient, if it is chronic pain patient then you are probably actually quite right in your dosing execpt for the time between dosing. Again you gave no indication that this wasn't an opioid naive patient.

5. Did you send this patient to a unit that has constant pulse oximetry monitoring? Did you consider that respiratory effects might increase later after the pain decreased? Does the patient have OSA diagnosed or undiagnosed? Were they snoring in the PACU (that could give you indication)?

6. How about since you came up with this plan on your own based on what you normally see in your PACU did you consider that there might have better alternatives? How about Toradol, an alpha-2 agonist, a rescue lower ext. block (which may or may not be done very often at your institute), and then just the normal nursing measures repositioning etc (which I assumed that you had already done).

7. Now getting back to this 12 out of 10 pain.....That is not an objective scale. Patients can rate their pain like that and be comforted with two motrin or 160mg Oxycontin TID plus breakthrough oxy IR 10-15mg every 4hr prn (that was my personal highest dose opioid dependent patient) and have had the same procedure.

8. Instead of considering me a troll you may want to think about all these questions that I just posted and if you can reasonably justify all your answers then I think most reasonable MDAs would probably sign your order or they might still be a jerk no matter what you do.

Again I am telling you this as someone that provides anesthesia everyday, and I would have problem with my PACU nurses giving that much narcotic over such a short period of time without consulting with me.

The other thing with this if you give such large doses of narcotics up front you have no idea what kind of doses the patient actually needs to make them comfortable (it should be the smallest dose possible to eliminate as many side effects as you can), and then you take a patient like this the start out on large doses of opioids continue them through the post op stay and the surgeon thinks they need large doses of opioids to go home on. Then these patients go home on large doses of narcotics. These patients then have up-regulation of their opioid receptors and develop opioid induced hyperalgesia.

You obviously care about your patients or you wouldn't have went out of your way to make them comfortable, but there is a lot of other things that come into play.

I have made errors in nursing, and I learned from them and moved on. I also hated many of the things that you are talking about and decided being an APN was the best route for me. Throw away your career in nursing or learn from it and move on it is totally up to you.

[madwife2002, BSN, RN]

I suggest you ask what management feels you have done wrong and what can you do to rectify the mistake or problem!!! Go with cap in hand because how you handle this could make or break your career.

You feel you have done nothing wrong but obviously somebody does, so you want to difuse the situation not aggrevate.

Listen to what they have to say, try to keep emotion out of it, then present the facts. Try not to be defensive

[netglow, ASN, RN]

"IV Medications" by Gahart states:

"0.5 to 1 mg every 3 hours as needed. May increase up to 4 mg every 4-6 hours if pain is severe."

The OP gave the patient 2mg for 12/10 pain. This falls within the guidelines published by both Gahart and Omoigui.

This is correct.

Follow Vito's direction... this is the best way to organize your mind. You are a fighter, like me :heartbeat. Blow off some steam... prepare, but don't let anyone get an idea of where you see fault, no more discussing. When you formally meet this is your deal, if things look like you are going to be thrown under the bus, you question the doc, the pain nurse, your boss on the lack of protocol (have your documentation typed and dated, but don't let it leave your hands). You control the direction of that meeting. It means being calm, cold and calculated, clear, and concise in your questioning/response.

[Virgo_RN, BSN, RN]

wtbcrna, it's not that you aren't raising valid points. The issue here is one of context. This is a new nurse who is working in a facility in which nurses writing these types of orders without an MD's order is the norm, and Andrew, RN, is taking the fall for it. This is something that has become an unofficial "protocol" where he works, and the new nurse who is doing what he has been trained to do by the experienced nurses who have come before him is the one being hung out to dry. Of course the anesthesiologist's concerns are valid (that he does not want to sign an order he did not give), but what we're really looking at here is a problem brought on by the facility's lack of written protocols, and Andrew, RN, the newbie, is caught in the crossfire. I agree it's a dangerous practice and needs to stop, but I don't agree that Andrew, RN, should bear this responsibility on his shoulders when this is a practice that has been in place and has been allowed to continue long before he ever set foot in that place.