Sending residents to the ER without a doctor's order.

  1. I can usually get the doctor to return my call on night shift. However, last night the Dr. was out of town. I called his answering service and she said a different Dr. was on call for this doctor. When I called that doctor I didn't get a real human on the phone. I just got an answering machine that said "Leave a message and we'll get back to you the next day. Anyway, after 30 minutes and no doctor available I had her sent to the ER. It turned out she had gone into congestive heart failure. Anyway, how about you? Do you ever send out residents to the ER without a doctor's order? Thanks
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  2. 28 Comments

  3. by   nckdl
    I had a friend who actually got fired for sending a pt to the hospital without a doctors order. At my facility the answering service pages the on call dr. until she talks to him and then they call us back. And if we don't hear from them within 15 minutes we call back. I can feel how helpless you would be knowing that your pt is in serious trouble. I hope your pt is okay.
  4. by   z's playa
    But why? If you're at home and your loved one is in obvious distress..you'd call an ambulance to take them to the ER. In the LTC facility you let them die? WTH? Doesn't LTC stand for Long Term CARE?

    Z
  5. by   VivaLasViejas
    This is where so many people, medical people included, forget that DNR does NOT mean Do Not Treat. When I worked LTC I sent many residents to the hospital without a doctor's order, although I always attempted to obtain one before I sent them out. Most docs are lousy at calling back promptly when it's a nursing home patient, and when you've got someone deteriorating rapidly you're not going to be sitting by the phone waiting for the MD to call.

    The way I see it, unless there is a specific order on a resident's chart that states they are not to be hospitalized for any reason, it's up to me to make the call when a resident's condition appears serious enough to require ER evaluation.........and unless the resident or family refuses transport--OR the doctor calls me back right away and tells me not to send them---they're going to the hospital. :stone
  6. by   leslie :-D
    i've sent a few pts out w/o an md order.this is after my inability to contact them.
    to me, if it's emergent, i am using nsg judgement and send them out accordingly, of course that is, if they're not a dnh.

    leslie
  7. by   AlixCoastRN
    I have no problem with sending someone to the ER without the MD order - I will attempt to call the MD as a courtesy to let him or her know what has been going on. If there is any question at all, no matter the code status, I will ask the resident ( if cognitively aware enough and able to make that decision) if they want to go to the ER or not. I will also call the family, no matter what time it is. I think its ridiculous to 'ask' a doc for an order to send someone out to the ER if, as a nurse, it is medically necessary and/or the res wants to go.
  8. by   Bird2
    You could contact your Medical Director or I've had to call families so I could chart that famliy wanted the resident sent to the E.R.
  9. by   CapeCodMermaid
    When in doubt, ship 'em out. We have one doc who doesn't like to send people to the ER because the "hospital gets mad if they show up at night". Puhleeeze...that's why there are staff members there 24 hours a day. If I think it's an emergency, I call 911 and then call the doc to inform them that I've called rescue and will be sending the patient out to the hospital.
  10. by   Antikigirl
    Yep...got my degree to know when and where to send a patient who is in trouble, so I send them by my own clinical judgement and the judgement of the paramedics who come as well. I have yet to be wrong!

    I mean, if you have someone who is not breathing but has a pulse, you would call 9-11 right away (even with DNR, DNR requires pulseless and apnec..both!!!). So why wouldn't you send someone out that is on their way to being pulseless or apnec? Same rule applies and it is within my scope of practice to make that choice .

    I have even had times when I have sent in hospice patients for injuries unrealted to their illness.

    I had one lady who was on hospice for cancer and got up and fell and hit her head badly on the nightstand and had a large laceration, and complaints of an aching back and hip! I called the hospice nurse and luckily was able to get a return call within a minute! She said "HECK YES!"..and I said "good..they are already on their way...LOL!" It had nothing to do with a natural death by cancer, it was everything to do with the comfort of my patient while this natural death occured...and yes, broken lumbar 2 verts...broken hip...and sutures in the head. They did nothing for the breaks...but we did increase implementitions for pain management so she could die without the added pain from the breaks! That was worth it to me and to my patient who did request to go to the ER (can't deny her that)!

    IF you think you must send, then you send. And don't think that it is all your responsiblity, the Paramedic in charge also has medical judgement and will send if they feel it is valid as well .

    OHHHHHH and always always document your reasons and when you called the MD or answering service! That shows you did try and had to make a clincal judgement on your own!!! That has kept my rear out of one ringer once...I called 9 times and the DOC didn't switch the phones to the answering service and so I had to make my own call...I recorded EVERYTHING I did...and now they don't forget to switch the phone lines! LOL!
    Last edit by Antikigirl on May 4, '05
  11. by   dbsn00
    Quote from AlixCoastRN
    I have no problem with sending someone to the ER without the MD order - I will attempt to call the MD as a courtesy to let him or her know what has been going on. If there is any question at all, no matter the code status, I will ask the resident ( if cognitively aware enough and able to make that decision) if they want to go to the ER or not. I will also call the family, no matter what time it is. I think its ridiculous to 'ask' a doc for an order to send someone out to the ER if, as a nurse, it is medically necessary and/or the res wants to go.
    I totally agree with you...this is how we do it at my facility also.
  12. by   RoxanRN
    Quote from TriageRN_34
    IF you think you must send, then you send. And don't think that it is all your responsiblity, the Paramedic in charge also has medical judgement and will send if they feel it is valid as well
    Not quite true. In most (about 99%) ambulance systems, it is "you call, we haul." Not because the medics want to, but because of the bosses. It's not cheap to turn a non-productive wheel. And the service doesn't get paid for refusal/no transport calls.

    Roxan
    EMICT, RN
  13. by   TracyB,RN
    I've sent out many residents to ER without an order, sometimes the patient doesn't have time to wait around for the doc to call back, but I document all the steps taken...no problems with that method, so far...
  14. by   steff_rn1
    At our LTC, we often call the medical director if we can not reach one of the doctors. If we can't get the doctor, we also send them if needed, and continue to try to contact the doctor. Never had any problems with calling the ambulance before the doctor is notified.

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