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

[simvee]

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 propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.

The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!

The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.

What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.

[simvee]

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

[simvee]

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.

[BluegrassRN]

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.

[Esme12, ASN, BSN, RN]

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!!!!! :crying2: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.

[Esme12, ASN, BSN, RN]

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

[simvee]

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.

[simvee]

David Carpenter (core0) - bolus injections are not easily available from the electronic med cabinet when your patient is on a drip. In fact I think the software tries to prevent people on drips from being double-ordered injections of the same med, but I'm not sure.

At any rate, don't you think that's a waste of time and resources? Why should I waste the time it takes to get a bottle, draw it up, inject, and then throw away all the garbage generated by this, when our pumps are DESIGNED to give boluses? They're designed with the medications, dose per volume, drip rates and bolus injections pre-set.

[Flying ICU RN]

At any rate, don't you think that's a waste of time and resources? Why should I waste the time it takes to get a bottle, draw it up, inject, and then throw away all the garbage generated by this, when our pumps are DESIGNED to give boluses?

Yes it most certainly is a waste of time and resources.

However, one good multidisciplinary (Pharmacy Service, Nursing management, Hospital Administration, D.E.A.) narcotics investigation due to an abusing co-worker, will cure you of seeing it as a hardship.

[Esme12, ASN, BSN, RN]

What facility did you say you worked at again?????

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.

ithryn, read my bio........31 years of critical care medicine. All but 8 months of my entire career.... Open heart, transplant, trauma, peditrauma,neuro,cath lab..................all ICU critical care. I have all my certifications.......BCEN,CCRN, CFRN and CRNI to name a few. In all specialties....adult,pedi,neonate. I went over the top out of concern for you......my error.

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.

YOU should be a valued member of the team.......not the only member. I don't think asking my opinion is illegal but writing orders or medicating the patient without an MD is malpractice and you as a "new to trauma" nurse cannot be so wise to the ways of all patients and wiser that the MD's. My opinion was always valued and followed but never shoved down someones throat (except when they deserved 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.

Yes you should clarify the busy doctor's or incompetent residents orders........yes.

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.

So if you bolus x cc's you can account for x amt of mg's right? no explanation necessary.

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.

Suggestion........use a buritrol or a micro dripper as is used for exact dosage in the neonatal/pediactric medicine administration/ and yes there is always some missing cc at the end but really not if you are bolusing thru the pump and clearing the pump every....let's say 4 hours....you can get pretty close....that is unless there is a problem. You know some of these new fangled pumps actually will infuse medicine from a syringe.......Oh and one more thing.............. that graduated cylinder ...........is called a med cup.

And thanks, I know how to calculate.

You're right........I am way over the top..................no skin off my nose when you lose your license. Don't believe me?????? Call your BON.........by the way.....you do have malpractice insurance....you may need it some day. You asked a question......I thought you wanted an honest answer and I gave you an expert, qualified,honest one..........from an honest place....my heart.....Take it or leave it your choice.

[Esme12, ASN, BSN, RN]

David Carpenter (core0) - bolus injections are not easily available from the electronic med cabinet when your patient is on a drip. In fact I think the software tries to prevent people on drips from being double-ordered injections of the same med, but I'm not sure.

At any rate, don't you think that's a waste of time and resources? Why should I waste the time it takes to get a bottle, draw it up, inject, and then throw away all the garbage generated by this, when our pumps are DESIGNED to give boluses? They're designed with the medications, dose per volume, drip rates and bolus injections pre-set.

Then why are they not documented!!???

[simvee]

Flying ICU RN - I still fail to follow you. How exactly are my coworkers going to abuse a drug that's confined to IV drip bags and the tubing running to the patient? I suppose if you were creative you could angiocath yourself and attach yourself in the patient's room, or you could bolus the line into a paper cup and drink it...? Anyway, a properly programmed pump that is properly cleared and accounted for does the same work without the extra syringes and easily stolen glass bottles. Isn't it more likely that you would remove a glass bottle of a narcotic and take it home but simply chart you gave it to the patient? It's harder to make the pump lie than it is to falsify charting.

emse - I don't recall saying I was wiser than the physicians. I don't see how that could be construed when it's the physicians writing the orders. This is how the orders are universally written. I've seen this at a few different hospitals. Maybe it's different in your state? It certainly could be.

For instance, in our hospital, the physician orders a paralytic agent. We start it using hospital guidelines. We adjust it using hospital guidelines based on our assessment findings. The physician almost never dictates a dose, titration, or bolus. In fact, it's generally assumed (i.e. a head pharmacist said this) that we know more about the intricacies of dosing than the physician does. Which is no shame on him or her at all! But regardless of who you think is in charge in this situation, all of our actions are legally covered by (in fact obligated by) the physician's order. There's no such thing as a nurse giving or titrating a paralytic agent without an order.

Our use of analgesics and sedatives are governed exactly the same way. The only problem I have is that the hospital guidelines are a bit hazier, i.e. there's no "Go up by X amount if the patient is acting Y or Z." like there is with paralytics or pressors or antihypertensive drips. And my original question was whether boluses are covered by this, and that's what I wanted input on. I didn't expect the entire concept of RN-led titration would be called into question and that people would call for my license to be revoked!

I admit that our charting software is not ideal. In fact, we've had to recently hound some physicians for getting lax about adding the "titrate to sedation" part in the computer. So maybe I will bring up the difficulty of charting boluses and the confusion the RNs have over whether boluses are technically covered under that order any longer. Maybe it will be fixed? Like I said, I chart them as volume boluses, but that doesn't feature as prominently in the charting flowsheet as the dosage titrations do.

Anyway. I do thank you for your concern. I just didn't realize there were so many people who have apparently never heard of RNs being delegated (with hospital guidelines and protocols) the titration of medications.

Chris

[Flying ICU RN]

Flying ICU RN - I still fail to follow you. How exactly are my coworkers going to abuse a drug that's confined to IV drip bags and the tubing running to the patient?

Because a drug abuser gets quite creative in ways that you cannot imagine until it is revealed. Aside from that, when one of these "Witch Hunts" gets initiated, everyone's in the cross hairs and considered guilty until proven otherwise. What happens is a review (at the molecular level) of everything you've done for months, if not further.

In my case, as part of the collateral damage caused by the abuser, I was questioned on why a PCA had run dry a few hours earlier than it should have. The reason; undocumented bolus's from the prior shift.