Question for those who work in small and/or rural hospitals.

Nurses General Nursing

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I work in a small rural hospital. Our hospital has about 80 beds total. The med/surg floor has about 30 beds, and there is a 4 bed ICU. Our ER is staffed 24/7 by a physician. The other doctors are family practice who usually round just once a day. Here is the question. A couple of the ER docs basically refuse to come to our unit if there is an emergent situation and the family doc can't get to the hospital in a reasonable amount of time. We very rarely call for the ER doc to come, but when we do we mean business. Some of the family practice guys are 20 to 30 minutes away from our facility. The ER docs say their won't cover them outside of the ER, therefore they don't want to get involved. Our DON supports the ER docs on their position. She says 30 minutes is a reasonable amount of time for us to wait for the family doc.:( :eek: She says the ER physicians number one priority is the ER. The ER docs are suppose to respond in a code blue situation on our unit, provided they are available. I think the DON's idea stinks. She has no idea what it is like to be in a situation with a crashing patient and no physician available. What do other facilities do in this situation? If the ER doc is the only physician in the house and an emergent situation arises, is he or she expected to respond? Or do you just wait until the patient's regular physician or on call doc arrives? I would really like to know. I need to know how to present this to my DON. Thanks.

I'm not saying that this is right, but there are nurses who are not as aggressive about initiating interventions without a doc's order. I am not sure if this is from lack of experience, or institutional.

I do agree...you should not be waiting until there's a full blown crisis (not that this is the situation here). It is rare for someone to abruptly crash; if something is "niggling" at you that the pt just doesn't seem right, call the doc. Basic interventions like starting lines, getting EKG's, labs, O2...well, any doc that reams you out for that is an idiot.

But I still feel that the ED doc is there for the ED, he's not the hosp. on-call doc. Once he/she gets called to help for something other than a code, eventually is will become the expectation that he/she will continue to be available, it's just human nature.

Trust your assessment skills, do your interventions, marshall up ancillary help...then call a code IF appropriate.

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I agree with fab4fan and others....

We are going to a similar situation here. Small hosp. ER docs are refusing to go to codes or urgent situations inhouse as they will not be available 'in case' a trauma should come in the door. To compensate all ICU nurses are ACLS certified and can initiate treatment according to those guidelines (covered by standing orders). My other suggestion is to DO YOUR HOMEWORK, research guidelines for emergent situations and follow them. Have lots of resource material aroung such as the Washington Manual etc (what do you think the residents and interns use at 2AM in teaching institutions?) BE proactive, make sure you have the worst case scenario covered, such as ask the surgeon what he would like you to do if his patient were to suddenly bleed out and drop his pressure? or what if your patient goes into status epilepticus, what is the immediate treatment? Dont take 'just call me' for an answer, the docs have to be accountable too, if your not comfortable with their answers get an explanation. Get your NM or DON to support you on this. If they dont go to your state Board of Nursing and find out just what you can and cannot do in this situation. When I worked in NC as a transport nurse we were able to get special permission from the BON to intubate. There are ways to get your patients the care they need and deserve and you are probably it!

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Specializes in ICU/CCU (PCCN); Heme/Onc/BMT.
Originally posted by Y2KRN

I did not read all of the posts here, but as an ER nurse I back an ER doc not responding to anything other than a code, in a small hospital. If the surgeon was 30 minutes away he should have given you orders. Get the fluids rolling, insert the ng tube, yadda yadda. If these things didn't help and patient crashes call a code!! Sounds harsh I know but, between liability and never knowing what is going to come through the ER doors. It is safer this way.

I worked med-surg as well, at a small hospital to boot. It is frustrating not having immediate access to a doctor, one of the many reasons I love ER nursing.

Y2KRN

I agree with you. But some of the posts here tell stories of ER doctor not even responding to codes on the floor. The originator of this thread tells a story of the ER doctor not responding to a patient who is "crashing". Maybe I'm mis-reading his post, but to me a person who is "crashing" is a person who is "coding" and needs immediate medical attention. If this is the case, this scenerio is scary . . . especially if the DON, as told by the originator of this thread, is supporting the ER doctor!!! :eek: :eek:

Ted

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In response to a previous post. No, the doctor doesn't live 30 minutes away, it just took that flippin' long for him to come to the hospital. Unlike ER's med/surg DOES NOT have standing orders for every situation. ER nurses have a lot more automony that med/surg nurses in most places. If all the ER nurses are ACLS and PALS certified, then what is the complaint about not being covered in emergent/code situations??:confused: I am ACLS certified, have floated to ER and have been involved in emergent and/or code blues before. I wasn't even involved in the situation I described in my original post. It happened to one of my co-workers. My intent of this post was not to get anyone upset, I am genuinely seeking information about what other small facilities do in situations like this. I would like to be able to present to our DON some possible solutions to a situation that will most likely come up again at some point. I figured this board was a good place to start for information, but maybe I was wrong. I have found out one thing though through this thread. That is that most people who work ER really think their unit is the only unit in a facility and to heck with the rest of us people in the hospital.

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I work in a small rural hospital,56 beds, 4 icu beds. If i have patient "crashing", our ed docs will come,if i have been unable to reach the primary doc, and IF they are not up to their ears in the ed.Also can "grab" any doc who happens to be in house,except for the ones who are feuding......Our docs seem to actually listen to us,usually, ....i know, miracles do happen.......lol.....And in the rare instance that us nurses feel that the patient isn`t being appropriately cared for we can call our icu medical director to interveen......but that isn`t very often.......And the med surg unit can move a patient to icu, if bed available, if things are going downhill...........they come crashing through those doors....lol....too bad they aren`t as efficient at getting folks moved the other way......but that`s another subject

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I'm sorry you didn't get the responses you wanted; I don't think anyone was trying to criticize you. Several people gave you some suggestions on things to do when a pt is deteriorating while you wait for the doctor to arrive.

My understanding of ACLS is that ED/ICU nurses learn this so they know the appropriate interventions during a code, not for them to be running codes indep. (although that can happen, but that should only happen in an unusual situation).

I really think a lot of this has to do with malpractice/liability, not matter of ED staff not caring about other floors (if that were true, why would we be agreeable to help out the floor if they have an IV they can't get...ED nurse could say, "sorry, can't help you," but we don't...at least in my hospital).

It's not about being selfish/uncooperative; presenting it in that way just fuels contention between floors.

:stone

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Specializes in Clinical Risk Management.

I worked in a 50-bed (incl. med-surg, ICU, OB & nursery) hospital for 1 year before coming to my current position 2 years ago. I had at least one episode where I had a patient who needed immediate medical attention. ED doc wasn't contacted. I contacted the Primary Care doc. & asked for orders, giving suggestions based on my experience taking care of patients in similar situations in a teaching hospital. I acted on those orders until the doc arrived. Another doc called me from his car using his cell phone & gave me orders while in transit.

I'm wondering...why didn't the primary care doc get there sooner if, as you said deespoohbear, he didn't live 30 minutes away but took that long to get to the hospital? Is there a written policy in medical affairs that give any guidelines for repsonding to calls about their patients, especially ones who deteriorate? If not, then why not? The patients are the customers of both the hospital & the physician. Isn't it good customer service to have docs who respond promptly?

Just my 2 cents worth, such as it is.

Peace ya'll,

Joy

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