Can I bolus this patient? A legal / practice question about sedatives and narcotics - page 3

by simvee

18,887 Visits | 77 Comments

Hi, I'm a new RN in a trauma ICU. We use a LOT of pain drips and sedative drips. Typical patient has Versed and fentanyl on pumps with orders to titrate as needed to maintain sedation (MAAS score of 2-3). Sometimes they use... Read More


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    We have this problem in our SICU. Our order sets have a bolus dose for Ativan and Versed. There is a drip order and a PRN order. For example Agitation bolus ativan 1 mg and increase ativan drip xx per hour. The problem that we have is with Fentanyl and other drips. Some of the nurses would rather bolus from the pump by running it at 999 for the dose. The problem with this is that it creates a discrepancy on the MAR. When the nurse goes to get a refill on the drip it doesn't match. Since these are controlled substances this creates a whole load of hate and discontent resulting in up to and including corrective action. The bottom line is that if you are bolusing you should have an order (and it should be part of the order set). If you are bolusing from the drip then there should be a way to chart it otherwise the bolus needs to be taken from the pixis.

    On the other hand in a true emergency I have ordered bolus from the pump (patient eviscerated and bleeding when both the surgeon and I had our hands in the wound trying to stop the bleeding). In that case I put in an order, wrote a communication order and documented the order for the bolus so that the nurse was protected.

    David Carpenter, PA-C
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    1. op, your colleagues sound like a scary bunch.

    2. if you haven't already, get yourself some nsg insurance.
    i promise you, at some point, you are going to need legal protection.

    leslie
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    I'm no ICU nurse, but I have cared for patients after tramatic surgery (ie: cut fingers off etc). We titrate up after the Drs do their rounds and can see the patient's pain score. I have never titrated a patient down before. Bolusing is different as far as I know. Nothing should be done/given unless it is written down by the treating Dr - you can't just up someone's medication or titrate it down without a written order as far as I know - you would be leaving yourself and the hospital open to litigation. In other words, if there is no written record, it didn't happen/med wasn't given, whatever. How do you keep track of how much pain medication the patient has had?
    You sound like you don't want to be the one responsible for reporting this. Do you have a number like we do here in Aus to call anonymously for incident reporting? We don't have to say where we are calling from etc. If not, write a letter or type a letter, to your NM or Director of the Medical Staff maybe.
    And not charting what you are giving - in relation to ANYTHING not just meds - is a big no, no. I would refuse to do it. I have actually started my own charts on a shift to document things, to cover myself and I would also be writing in the nursing notes what I have done.
    Demand an order to be written up for specific titration variation doses. The Drs have to do this. EVERY medication a patient takes in hospital whether it is a narcotic, mulitvitamin or even simple saline eye drops has to be charted, except for RN initiated PRN meds, and they are written on a separate chart by the RN.
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    I didn't realize this post would cause so much drama. Or animosity.

    To clarify: we certainly do have orders to bolus. The trauma surgeons would be angry if we didn't bolus as needed, or if we called them every time we needed to. The problem is that in our electronic MAR (by Cerner Corp) there is no easy way to enter this order, or to document it. In other words:

    1. MD says start patient on fentanyl and Versed, titrate and bolus as needed. There are no starting or bolusing parameters. This is totally up to the RN. I am fine with this because the RN who has been there for 12 hours typically knows better than the MD who can only evaluate the patient for five minutes.

    2. Whoever enters the order into the eMAR can only select "titrate for sedation". So this makes it appear only titration, and not boluses, are covered. They also have to pick some random dose, say 1 mg/hr, so then when the RN charts that he or she started at 4 mg/hr it pulls up an alert box that says YOU'RE NOT STARTING AT THE ORDERED DOSE! ARE YOU SURE? So stupid.

    3. When the RN charts the ongoing titration, THERE IS NOWHERE TO CHART A BOLUS. The software has nowhere to put it, even if the MD managed to enter "bolus as needed" in the order. You can chart volume boluses, say 5 ml. You cannot chart a 5 mg bolus of Versed. Also stupid.

    4. Therefore, THERE IS CONFUSION AMONG THE RNs whether boluses are something we can and should chart. Considering you technically can't chart them with the stupid charting software, it's a gray area. I chart them as volume boluses, which accounts for the dose but looks confusing.

    5. But rest assured that any RN who got pulled aside and asked on whose orders they were bolusing the patient would have the full backing of the trauma surgery team.

    So like I said, what should I do? I guess I could ask the pharmacy and the practice council. They're not going to be able to change the software, though.

    The only problem I have with "reporting" this problem is that any possible solution involves removing the freedom the ICU RN needs to operate. What will probably happen is this: the Versed bolus will be entered separately in the eMAR from the titratable drip. We'll have to open that separately to chart those boluses. And the bolus will need parameters, simply to satisfy the computer, even though the MDs never dictate parameters (appropriately so). What will probably happen is that false parameters will be entered by the pharmacy.

    Does that make anything more clear?
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    If you have to bolus more than once during your shift that is an indicator to me that the patient is not being adequately sedated.

    Perhaps this is a separate issue, but I think this is a bad idea. If you have to bolus more than once in 12 hours, that's bad? Our ideal sedation score or MAAS score is 2-3. If you maintain someone at a 3, which is more awake and certainly more conducive to extubation, then you're going to have to bolus sometimes.

    Keeping someone snowed to the point that they never need to be bolused is just going to lead to a trach and a PEG, I'd say.

    Chris
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    I guess I should clarify what kind of patients we work for. We're dealing with trauma patients who are typically young and healthy prior to their trauma; also many of them are very opiate tolerant from drug use. Someone posted they have a Versed max of 20 mg/hr, but we've had people up to 45 mg/hr. Not often, but it happens.

    So we have to balance on the one hand their huge pain issues, disorientation, confusion, and fall risks, and on the other hand the goal to extubate and rehabilitate them instead of traching and pegging them.
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    Your IT department needs to work with Cerner to build this in. I'm pretty sure (though I'm going to have to go back and look now!) that our cerner-built program has the ability to chart boluses.
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    Quote from ithryn
    I didn't realize this post would cause so much drama. Or animosity.

    To clarify: we certainly do have orders to bolus. The trauma surgeons would be angry if we didn't bolus as needed, or if we called them every time we needed to. (WHO CARES IF THEY GET ****** MAYBE THEY WILL STOP BEING LAZY AND GIVE PROPER ORDERS) The problem is that in our electronic MAR (by Cerner Corp) there is no easy way to enter this order, or to document it. In other words:

    1. MD says start patient on fentanyl and Versed, titrate and bolus as needed. There are no starting or bolusing parameters. This is totally up to the RN. I am fine with this because the RN who has been there for 12 hours typically knows better than the MD who can only evaluate the patient for five minutes.

    Titrate: How much? how often? What max?
    Bolus: How much? How often? How much? What max?
    There are no starting/bolusing parameters: WHAT???? It legally cannot be left up to the RN. Is your facility JACHO accredited? How's your insurance reimbursment for drugs you are giving but cannot prove have been given?
    The RN typically knows better than the MD..........What are you thinking?? I get it you are at the bedside and can judge the patient's response but really.............Where is this hospital so I don't go there or let a loved one go there. You really can't think this is ok....do you?

    2. Whoever enters the order into the eMAR can only select "titrate for sedation". So this makes it appear only titration, and not boluses, are covered. They also have to pick some random dose, say 1 mg/hr, so then when the RN charts that he or she started at 4 mg/hr it pulls up an alert box that says YOU'RE NOT STARTING AT THE ORDERED DOSE! ARE YOU SURE? So stupid.

    Is the ordered dose 1mg by the real orders? Maybe you better check! Someone better get a better system before anyone audits (ie: the DEA) or get new IT guys.......I know you are not realizing that this is a big problem.....but it is HUGE!!!!!!!!!! Sounds to me there are many people being lazy!!!!! Call your BON.....ask a random question to them see what they have to say.......I won't be suprised ..................but I think you will be!

    3. When the RN charts the ongoing titration, THERE IS NOWHERE TO CHART A BOLUS. The software has nowhere to put it, even if the MD managed to enter "bolus as needed" in the order. You can chart volume boluses, say 5 ml. You cannot chart a 5 mg bolus of Versed. Also stupid.

    Where do you chart any of your titrated gtts.........If you can chart 5ml given you can chart how many mg's..........DO THE MATH!!!!! If your gtt is 0.5 mg per cc then a 5mg bolus is HOW MANY CC'S ARE GIVEN FOR 5mgOF DRUG???????

    4. Therefore, THERE IS CONFUSION AMONG THE RNs whether boluses are something we can and should chart. Considering you technically can't chart them with the stupid charting software, it's a gray area. I chart them as volume boluses, which accounts for the dose but looks confusing.

    You SHOULD and you need to find a way......At least you are accounting for the drugs used and it is not stupid............it's what is right! Who care how stupid it looks.

    5. But rest assured that any RN who got pulled aside and asked on whose orders they were bolusing the patient would have the full backing of the trauma surgery team.

    If the DEA or JACHO ( Joint Commision) wants someone's head on the platter...........Don't bet on it..........those doc's will sell you down the river so fast your head will spin!


    So like I said, what should I do? I guess I could ask the pharmacy and the practice council. They're not going to be able to change the software, though.

    It is a start...........here's a thought..............maybe they will.......... what if they are unaware there is a problem!:redpinkhe

    The only problem I have with "reporting" this problem is that any possible solution involves removing the freedom the ICU RN needs to operate.

    I fell like I have entered the twilight zone. YOU are taking a huge risk!!!!!! If you don't have orders....you can't do it !!!!!!!!!! If you don't have orders and you don't chart it.............WHERE ARE THE DRUGS????? You can't possibly believe what you are saying, go ahead .... keep your freedom........lose your license you'll have all the freedom in the world!

    What will probably happen is this: the Versed bolus will be entered separately in the eMAR from the titratable drip. We'll have to open that separately to chart those boluses.

    BOO HOO!!!!! Then you will just have to chart in two places...........beats losing your license.

    And the bolus will need parameters, simply to satisfy the computer, even though the MDs never dictate parameters (appropriately so). What will probably happen is that false parameters will be entered by the pharmacy.

    Unbelievable.............false parameters! Of course you need parameters! How do you know when too much is too much???? Are you kidding me?????? And don't tell me common sense because nothing is common in this post and nothing is making sense! That is blatant malpractice. It is not to satisfy the computer. It is to keep your license. If it isn't documented it isn't done or hasn't been given. If it is given without an order that is practicing medicine without a license. Narcotics are no joke. Many nurses have fallen to doing whatever everybody else does,got audited, got fired, and lost their license. The MD's are really putting you in a bad position....willingly or not......through being vague and lazy. If they are vague they don't get phone calls and because you do it and don't make them behave......if anything happends it's your fault because you should have known better!!!! Improper/inconsistant documentation/administration of a controlled substance. Look at your state board website. PLEASE CALL THEM with a hypothetical situation if you don't believe me, maybe you'll believe them!
    .
    Does that make anything more clear?

    CRYSTAL...........what hospital is this?

    By the way.......................the answer is 10cc is equal to 5mg's.
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    Ok it sounded harsh...............but I really mean this from the bottom and top of my heart........this practice is not good......please call you BON and ask that rhetorical question...........thanks
    leslie :-D likes this.
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    Emse12, are you an ICU nurse? Have you ever initiated or maintained a Versed drip? I don't know how you could be going so over the top about this.

    We work with Level 1 trauma surgeons, intensivists, general surgeons, thoracic surgeons, internal meds, and critical care pulmonologists. I cannot for the life of me imagine asking them something so basic as how to start and titrate and bolus intravenous Versed. Are they psychic? Can they foretell that my patient will need 3 mg to start with and then have to go up to 5 by the morning? No. If I asked them where to start, they'd ask me where to start, based on the patient's agitation, body weight, prior drug history, etc. If you think this is illegal can you show me any laws or precedent that indicates this? Because the physician is ordering it.

    If I say that fake parameters are sometimes entered, that is the case. It's the fault of the software, not the ordering entities. I'm not an idiot, and I'm not neglecting to check orders. If the order in the computer reads "titrate fentanyl to maintain pain control" and it starts at 0 mcg/hr, I should double check because the physician might really want 0 mcg/hr? I don't think you're getting what I'm talking about at all.

    When I said that you can only chart volume boluses, I meant you can only chart volume boluses. You click "bolus" and there is an entry box only for volume (ml). I'm not sure how to explain it any further to you.

    If you've worked with narcotic drips before, you'd know that the amount of fluid in the IV bags are not exactly easy to track. It's easy to do a narc count and see that a Versed injection is missing. It's not easy to see that 1 ml of a 250 ml bag of Versed is missing. Unfortunately this is the way it works. If you want a more restrictive scenario where every ml of fluid is accounted for, where we pour out IV bags into graduated cylinders so we can verify the amount left, you can feel free to create one. Me, I just want to be able to chart that I did it. I don't see that it's my fault that the computer charting was not designed for this, probably because it had no nursing or even physician input.

    And thanks, I know how to calculate.
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