What to do if you disagree with the care of another nurse's pt?

[Erythropoietin]

I am a new nurse working on a medical floor. There was recently a situation at work where another nurse's patient had a sudden change in condition that seemed alarming enough to me to warrant calling a rapid response, but this was not done. I witnessed the pt's condition because I was at the pt's bedside assisting in his care while his RN paged/called the MD and did other things outside the room. I asked the pt's nurse more than once if we should just call a rapid response, but I was basically ignored.

After much delay, the pt was transferred to ICU, but I do not know the outcome after that. Had we called a rapid response, I do know the pt would have been assessed/treated by the MD and rapid response team immediately and the transfer would have occurred without delay.

I do not want to be a busybody who interferes with how other nurses care for their patients, I don't want to step on the toes of my coworkers, and I don't want to be a "know it all" that questions the actions of more experienced nurses. That said, I am very disturbed by the situation I witnessed because I honestly feel that the patient received poor care. I am also very confused about what my role is in such situations since I was not the patient's nurse.

Has anyone been in a situation like this, and if so, how do you handle it?

[solneeshka, BSN, RN]

It's posts like this one that make me glad I work at a gigantic teaching facility. The place is crawling with residents, and on the medicine floors, crawling with hospitalists, even at night. Everything (usually) moves fast; you call for help, it starts coming out of the woodwork. (Unless the team gets lost on the way to the call, because we are that huge - it happened to me on the very first code I ever called - funny in hindsight, not at the time!) We have the number for our RRT posted in patient rooms, so *anyone* can call, even a family member. It does not get overused at all. I would say there are more overhead pages for codes than for RRT. But we all know about it, it's a great ace up your sleeve.

OP, I don't remember now if you did suggest rapid response to the other nurse, but if not, there is nothing at all wrong with doing that, even if that nurse is more experienced and you are new. If it were me I would think, "Would I call RRT if this were my patient?" If so, then I would be strong with the language: "Why don't I call a rapid response for you? Here, you go back in with the patient, I'll make the call." Just because another nurse is more experienced than you are doesn't mean he or she doesn't sometimes second-guess themselves. Maybe it was on her mind and just knowing it was on your mind, too, would have been enough for her to go ahead and do it.

And yes, as some have noted there are no guarantees that calling a rapid response would have improved her outcome, but the whole point of having a rapid response program is to increase the chances of improving a patient's outcome, so probably, it would have! At least the patient would have sooner been on the radar screen of those who give a higher level of care. You were thinking along the right lines, and the next time it comes up, you'll have a better idea of how you'd like to handle it. That's called "gaining experience."

[PediLove2147, BSN, RN]

This sounds like it could have been handled by the MD but only if there was a response within minutes. You waited 30, so yeah I would have been with you on a RR. I agree with the others though and it doesn't necessarily mean he would have been transferred to the ICU any sooner. It depends what is available at that time.

Just curious, you don't get EKGs on the floor for CP? We get them automatically and don't need an order in that instance. It is part of our CP protocol so maybe that is the difference?

[Erythropoietin]

Thank you all for your replies, you've each given me a lot to think about and helped me to better clarify the situation. To answer some of your questions, we have no specific protocol for CP that I am aware of, but I will definitely look into this the next time I am at work. Also, the idea with rapid response where I work is to rapidly treat the pt so a better outcome is achieved. Thank you again for all of your replies.

[leslie :-D]

op, i appreciate the angst this situation elicited from you and it sounds like your concerns were plausible.

it sounded like a more acute situation, where immediate intervention was warranted.

if you don't/didn't feel comfortable suggesting a rr to the nurse, i might consider discussing it (confidentially) with a um/cn/nm...

as long as you clarify that you are not trying to criticize the other nurse;

only that you are seeking input as to whether there is a protocol in place, or wanting to anticipate prospective actions in the event of a next time.

i agree, it is not a matter of receiving "better" care with the rrt; it's a matter of receiving immediate care.

to me, you sound rightly concerned...

and also respectful of the potential conflict it may cause.

it sounds like you're doing well in your new position.

keep it going.

leslie

[NurseOnAMotorcycle, ASN, RN]

While I agree that approaching with respect is important here I do not agree that a patient winding up in ICU is a failure on the nurses part in general. ICU happens.[/quote']

I thought about this and re-read the original post. The MD must have been called because they came to the floor after 30 min, which as we know is about the norm for a "please check this guy out" call. And the floors don't have standing orders like the ER does. So in this case, putting on O2 and monitoring is really all they could have done without orders. RR really should have been called, but if the nurse was unsure, they did the next best thing.

I apologize for assuming. We all know what that does.

[wooh, BSN, RN]

While I agree that approaching with respect is important here, I do not agree that a patient winding up in ICU is a failure on the nurses part in general. ICU happens.

To the OP: It appears you understand the severity of the situation, knew what YOU would have done, and can stand to be a valuable asset in the future to your team. I would perhaps leave this situation alone, rather than potentially alienate a co-worker. You may find, in the future, that this nurse had an off day, or really does need help, in which it is more than likely known by other staff/managers.

It might not have even been an off day. Doing something different than you would does not necessarily mean wrong.

I often don't call RR when a newer nurse would because I know that everything is being done that can be done. Having an rapid response nurse come to the room won't make what's being done have magical curative powers. If it was your patient and you called RR, great, you did good. Me not calling, it's not bad, it's just different.

[Tait, MSN, RN]

I thought about this and re-read the original post. The MD must have been called because they came to the floor after 30 min, which as we know is about the norm for a "please check this guy out" call. And the floors don't have standing orders like the ER does. So in this case, putting on O2 and monitoring is really all they could have done without orders. RR really should have been called, but if the nurse was unsure, they did the next best thing.

I apologize for assuming. We all know what that does.

As far as protocol I am surprised the OP said they didn't have one for CP. Our was always O2, Nitro SL X3 Q5, stat EKG, VSS monitoring, call MD, and there is morphine in there too. Most of us would call RRT if the CP wasn't resolving after the nitro, usually one or two of them, then call the doc if the third one failed and the EKG was showing changes. Part of me is wondering if there isn't a process issue here?

Thanks for rereading and understanding my point :)

Tait

[imintrouble, BSN, RN]

It might not have even been an off day. Doing something different than you would does not necessarily mean wrong.

I often don't call RR when a newer nurse would because I know that everything is being done that can be done. Having an rapid response nurse come to the room won't make what's being done have magical curative powers. If it was your patient and you called RR, great, you did good. Me not calling, it's not bad, it's just different.

I like this answer.

It seems to me to be a matter of trust. I know the nurses I work with. I trust their judgement. I admire most of them. Each of us respond to situations differently, and as wooh said, different doesn't mean wrong.

I generally err on the side of caution. I'll sound an alarm well before anybody else, and sometimes waiting would have been the more prudent choice. Doesn't mean I'm wrong. Other nurses implement the interventions we are allowed, then monitor and wait. Doesn't mean they're wrong. I trust their judgement, and respect the decisions they make.

MDs do not respond to RR where I work. The pt would not have been transferred any faster.

[WhereIsMyCallBell]

We all have our own nursing styles for sure. Did you have all the info the primary nurse had? Vitals stable? Primary dx? secondary to? DNR? full code??? So many factors. Some nurses go into calm mode and have good judgement and instinct. Others are alarmists. Lots to consider without ALL the facts.

[WhereIsMyCallBell]

The primary nurse very well may have had a plan in place to stabilize this pt. with MD VO's. Wouldn't hurt to ask the other nurse at a later date what their rationale was for not calling a RR. Again soooo many things to take into consideration. Might learn from it =)

[Tait, MSN, RN]

It might not have even been an off day. Doing something different than you would does not necessarily mean wrong.

I often don't call RR when a newer nurse would because I know that everything is being done that can be done. Having an rapid response nurse come to the room won't make what's being done have magical curative powers. If it was your patient and you called RR, great, you did good. Me not calling, it's not bad, it's just different.

And I did note that in another post I made where I said my floor generally relied on each other and not RRT when a patient was questionable :)

My point was basically not to confront her about the situation, but to be aware. I did wind up being the nurse who "was talked to" because I was unwilling to ask for help and would call RRT before looking to my colleagues. I learned a valuable lesson from those conversations which made me a much stronger team mate, but no one jumped on me the first time they saw it happen, it was gradual.

[anotherone, BSN, RN]

If you really thought a rrt needed to be called then you should have called it. In some places a dr does not come to an rrt. Also we have called rrts and had a dr write for icu stat and guess what ? no beds so now we have to wait up to hrs for a bed. Some times a rrt becomes more of an unneeded side show depending on who shows up to them in your facility. I also work at a teaching hospital and we can overhead stat page a medical/ surgical team to the bedside .