Is there a Doctor in the house? Working a code without one in an LTAC

suzanne4, RN · May 27, 2007

If a patient codes in a physician's office, trust me the first thing that they are going to do is call 911 and get some help.

And if you take the time to think about it, most of the doctors that cover LTAC, are family practice physicians , or internal medicine that do not have a hospital practice, and are not used to running codes in the first place. How can they be giving you orders of what to do; when they are not there to assess the patient?

Long term care facilities of any type do not have the equipment to run a full code. Most of the staff there is not trained in ACLS, nor are they able to always read strips in the first place. Nor is their usually any of the equipment available, that is why 911 should always be called. That is what they are there for. Even if the LTAC is across the parking lot from a hospital, they need to be called.

I would also follow up what is written in the policy and procedure manual of the facility, and follow that. Not the order to phone the physician for orders. Many times you are the only nurse there, so if you are speaking with the physician, who in the world is running the code?

suzanne4, RN · May 27, 2007

Thanks...we had a neighbor about 6 years ago that died. She had a heart attack at home, they called 911, and when first responders finally got there, we found out they had to go and "pick up" the only guy that was working that night that was certified to use one of those machines. Of course, because it took them 24 minutes to repond, she was dead when they got there.
What irritated the woman's husband the most was that the first question they asked when they walked in the door was if she had a DNR order. He didn't even know what that was, and he couldn't even believe that was a priority when they walked in.

In six years, alot has changed.

The defibrillators out there now do not require cerification, they are very user friendly. Even many police cars have them.

As for the DNR question, many times family members have called 911 when a no code arrests, and the responders are only asking the appropriate question that they were trained to do. Once they intubate a patient, even if they are a no-code, then there are other issues that come up. They cannot just pull the tube once they have placed it.

jen123321 · May 27, 2007

how can someone say it doesn't make sense to call EMS? Are you going to throw the pt in the back of your car and take them to the ER? When someone is coding, there's a reason for it. Mainly, interventions to save this persons life cannot happen in a LTC facility...

AnnieOaklyRN, BSN, RN, EMT-P · May 27, 2007

Hopefull2009: I am a paramedic and just to educate you a bit.... Like the other poster said usually EMS wise a tiered response is dispatched. In other words a fire truck with BLS equipement or ambulance with BLS equipement will be sent followed by an ALS truck with people like me who will provide ACLS to the pateint. They are dispatched at the same time, but fire trucks are usually closer since they are more spread out.

The recomendation for initiation of ACLS is within eight minutes and BLS within 4 or 5 minutes... In most communities this is met, but not all. I beleive the OP did also say teh facility IS ABLE TO INITIATE ACLS, so the paramedics would just be continuing it and adding intubation to it as well, and possibly IO..

Also AHA is acutally stressing the importance of GOOD CPR over everything else INCLUDING ACLS...

I am not trying to pick on you, but just feel I needed to provide some information.

Swtooth

TrudyRN · May 27, 2007

What is an LTAC?

I agree with the others. This sounds very wrong and very dangerous.

Perhaps an anonymous call to CMS, JCAHO, the newspapers will bring forth change. First, though, are you absolutely certain that you are not supposed to call EMS?

Quietly get and keep for your records, a copy of the written policies on this matter.

In the meantime, call 911 and let the chips fall where they may. You might lose your job but you will know you did the right thing and you will keep your license.

firstaiddave907 · May 27, 2007

how can someone say it doesn't make sense to call EMS? Are you going to throw the pt in the back of your car and take them to the ER? When someone is coding, there's a reason for it. Mainly, interventions to save this persons life cannot happen in a LTC facility...

thats a good point.

rgroyer1RNBSN, BSN, RN · May 27, 2007

Oh hell no way! Uh huh! Believe me if I was the charge nurse ems would be called, and Like the paramedic said they come in a tiered response, to a full code first should be the Bls unit who can initiate cpr, and aed defib, then the Als unit should intervene intubate, push acls drugs, and manuel defib.

MrsWampthang, BSN, RN · May 28, 2007

To clarify, an LTAC is an long term acute care facility, which is a facility between the hospital and a ECF. We do have the equipment and medications to handle a code, and at the charge nurse is always ACLS certified as well at the RTs so we can get a good running start on running any code. A lot of our patients are trach/vent patients also, so an airway is already established in a lot of cases. We have a doctor in the facility from 8pm to 6am, however, the last two codes we had were during that time when there were no docs in house at the time. Both already had airways, and on vents, so that was done ahead of the game. Fortunately I am a charge nurse on nights so the chances of having a code when a doc isn't there are slim, but again, the last code I worked was right at shift change, doc wasn't due for about 45 minutes and we had too many cooks in the kitchen so it turned out to be one of those rodeo codes. Our night doc showed up in time to help work the last 30 minutes of this code and eventually called it because it was a no win situation from the start anyway. We did have a doc on the phone but he wasn't much help. The ACLS nurses did better at handling the code without orders from him. As I said, it was a rodeo. Anyway, thanks for your input. I need to bring this up at the next PCC meeting.

Pam

vamedic4, EMT-P · May 28, 2007

I work in a freestanding LTAC and there are times when we have no doctor present. In the case of a patient coding, we are supposed to call the doctor on call for that patient's group, and take orders from him/her over the phone for working the code. Until the doctor calls we just follow ACLS protocols. We're not supposed to call EMS to come and take the patient out either. Does anyone else work places that do this? I have to admit, I'm not really comfortable with this. I guess I'm not very trusting because what if we get a doctor on the phone who won't give orders or, in the case of a bad outcome, refuses to call the code over the phone, or doesn't admit to giving orders, or never even calls back, etc. What do you all do in your LTACs? Thanks for any and all input. Sorry if I sound paranoid.
Pam

Runnnn, Forrest , Ruuunnnn!!!

If you work in a facility like that and a code happens...call EMS. You're not "supposed" to?? What the hell ever. Write me up then...and make sure you spell my name correctly. And if you really want to get them there ASAP tell the dispatcher / 911 operator what's going on, make sure to tell her CPR IS IN PROGRESS, PATIENT UNRESPONSIVE/NOT BREATHING. This will ensure you get the CORRECT response from the city or agency coming to help. There's really little sense in sending out a BLS crew when ALS is needed. Yes, good CPR is a must, but the advanced care has to be there...intubation/defibrillation and drug therapy...all of these combined have been shown to have the greatest positive outcome for the patients you describe. And of course, you all can initiate this - but they're going to need a higher level of care than many LTACs are capable of - so best to call EMS and err on the side of the patient.

Good luck, Pam. Let us know if things get better for you all.

vamedic4

Will the rain ever stop?? My kids want to swim!

TheCommuter, BSN, RN · May 28, 2007

I work on a long term acute care (rehab) unit, and have participated in many codes. Since there's no physician on site, physicians never participate in our codes.

Anyhow, we're allowed to call EMS without notifying the physician.

BrnEyedGirl, BSN, MSN, RN, APRN · May 28, 2007

Guess I'm confused,...doesn't a post code always to to ICU? ie a call to EMS?,.and if you work nights do you really always have a DR around,..spent 8 years on a tele/step down unit NOC's almost never ran a code with a DR,.if you have the meds and equipment and ACLS then do it!!!

arual56 · May 28, 2007

I work in a freestanding LTAC and there are times when we have no doctor present. In the case of a patient coding, we are supposed to call the doctor on call for that patient's group, and take orders from him/her over the phone for working the code. Until the doctor calls we just follow ACLS protocols. We're not supposed to call EMS to come and take the patient out either. Does anyone else work places that do this? I have to admit, I'm not really comfortable with this. I guess I'm not very trusting because what if we get a doctor on the phone who won't give orders or, in the case of a bad outcome, refuses to call the code over the phone, or doesn't admit to giving orders, or never even calls back, etc. What do you all do in your LTACs? Thanks for any and all input. Sorry if I sound paranoid.
Pam

If you want to remain a nurse, and keep your house, car, etc. run (do not walk) away from that facility. That is just down right scary!