Docs making stupid decisions

  1. Quick background: I work in a small hospital birth center in a rural area. We serve patients from up to 75+ miles away. Two dedicated L&D rooms, 5 PP rooms, 2 antepartum/PP rooms and one multipurpose room (AP, triage, PP, and L&D if needed). Biggest baby boom ever was in August with 59 births.

    Typical staffing: Days 3RNs, 1RN/LPN, and 1 CNA; PMS 2RNs, 1RN/LPN, 1CNA; and nocs 2RNs and 1 CNA with 1RN/LPN on call. These nurses cover L&D, AP, PP and nursery.

    Anesthesia is on call at home with a 20 minute get here time, same for entire surgical crew, after hours and on weekends. We only have a single crew on call during off hours.

    So, here's the issue. OB schedules 2 inductions on Saturday. One a prime and one a VBAC that lost twins after emergency c-section late 2nd trimester/early 3rd trimester - last year. Already have 3 mom's and two babes. Of course, both inductions go to he** in a hand basket at the same time. Called a C-section on one for non-reassuring FHTs, then walks into the other room with fetal brady and tells the nurses, never mind, this one goes first and get the other one ready to go downstairs to the other OR.

    Reason for induction: patients didn't know why they were being induced, MD just asked if they wanted to come in on Saturday, when he was on call, and have the baby - and not yet 39 weeks

    We have OBs that will insist on AROM on a latent labor pt. even when we are doubling up patients in private rooms and giving them the desk telephone number because there is only one call light in each room. And have two others in active labor

    The question: is there some sort of mechanism for the RNs to report or have these decisions reviewed by a higher authority? Do you have authority to tell a doctor that he/she cannot induce a 38 week VBAC on a weekend? Can you tell a doc not to AROM or pit augment a GBS+ mom before getting her 2nd dose of ABX?

    Any thoughts would be greatly appreciated. Thanks for letting me rant. You folks are great.
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  2. 19 Comments

  3. by   BSNtobe2009
    I had a couple of friends whose OB's scheduled them to be induced when they were not due and with no medical reason to do so.

    If he doesn't have a medical reason, I think it's unethical to do medical procedures like this for convenience.

    It's a crying shame.
  4. by   SmilingBluEyes
    OMG this all sounds like you have a huge problem, mainly growing numbers of patients, and insufficient staff and rooms/facilities, as well as unnecessary inductions for convenience (which is not just a problem where you practice, believe me).

    However, It's not just the doctors being "stupid" but a system that is failing to keep up "with the numbers". What does your manager have to say about all this? And are you receiving a lot of complaints from patients about their care and/or room accomodations?

    And most importantly, what is management doing about the UNSAFE way things are going down?

    Just wondering. More questions than answers, I am sorry.
    Last edit by SmilingBluEyes on Oct 3, '06
  5. by   meownsmile
    Sorry to say but i think this lies in the "designer baby" category. Although doctors will induce and do sections to accomodate their own scedules, whether it be office or vacation, i think sometimes the patients like the idea of scheduling procedures when their famiy can get in on the weekend, or dad has the weekend off and wont have to be out of town maybe when nature takes its course. I dont know about your situations, just a couple points that have occurred to me over the years, including in my own situation when the doctor asked me for the preceding 5 weeks prior to due date if i wanted him to induce this weekend so i could have the baby before he left town for vacation. Sure put that in my lap, when the doc didnt want to lose the income by maybe having a doc he signed out to deliver and get the fees.

    I think maybe a call to your risk management office, or maybe the medical director at your facility may be the first course of action. At least they would be aware of the concerns and can look at the flow of patients over a period of time. If they see a pattern growing they will usually question any unusual patterns and/or concerns that may be involved.
  6. by   SmilingBluEyes
    as far as authority:

    No, you really do not have much authority to tell a dr. when he/she can or cannot induce a patient. Medical diagnoses are not our call to make. HOWEVER, you CAN tackle this from a staffing standpoint, stating staffing cannot support unnecessary inductions on given days. Also don't neglect to bring repeat problem situations to your Risk mgt office for their information and action.

    We limit the number of scheduled procedures in our unit, for this very reason. In order to TRY and stay on top of the acuity and workloads in any given shift, you have to do this. The trick is, no one can predict when the "labor bus" will pull up and throw all plans to the winds. You are hard-pressed to staff for "what may be's". This is true in any OB unit. You have very little control over your acuity and census numbers, clearly. But if a given physician is being unsafe, you do have redress, again, noting this in an occurence report and/or notifying your Risk Management personnel.

    Also, AROMing GSB positive patients prior to sufficient ABX tx, unsafe. Again, this is something you have to take up with your charge nurses, manager and perhaps, your OB committee. Anytime you feel a procedure is unsafe or ill-advised, it's your obligation to "elevate it up the chain" for resolution.

    I wish you well. A lot of real, lasting change really will depend on how strong your management is---that means just about everything in situations like this. And, as always, document, document, document.
    Last edit by SmilingBluEyes on Oct 3, '06
  7. by   babynurse2001
    Wow! We have a similar setup as you but not quite as busy (if we do over 30 in a month we almost keel over).

    It has been our long standing practice as a unit to regulate inductions to some degree. Unless the doc has a really serious medical reason (PIH, etc.) they don't get to do inductions if we're already busy. We'll schedule them if they want but the doc and the pt know that they will be "bumped" if we're too busy to care for them safely. There is no way tose inductions would have both proceeded here with the example you gave. We also never schedule more than 1 thing per day unless we really have to then we get someone to work extra to back it up.

    Do you have a dedicated OB manager? If so they probably need to take this one an and write some clear policy and then have the *&^% to back it up when the docs get pissed off. It will be a difficult transition but the patients will be safer for it in the long run.

    As far as the other stuff goes - things like doing an AROM on someone that could wait when the rest of the floor is busy that's a litttle more sticky. Are your docs open to suggestions at all? If you can talk to them and explain your rationalle will they listen? That is how I have handled that one in the past but then again we have fabulous docs that are very reasonable.

    Good luck.
  8. by   htrn
    In answer to Deb's questions:

    The growing number of deliveries is a fairly new thing, we added an OB doc a couple of years ago and her practice is growing by leaps and bounds - which may be why some of the other docs are scheduling 'their' patients when they are on call. More and more of the smaller hospitals in the area no longer deliver babies, and those that do are not willing to do VBACs any more.

    It is also becoming evident that the unit itself is too small for this new pace. But, building a bigger unit is something that is years in the making.

    Our current manager is retiring in December - don't know who the new manager is or how he/she will deal with this situation. Telling a doctor 'no' is really not a part of the culture in my unit - that may have to change.

    We have a 'Shared Governance' model at our hospital - staff nurses on councils that are supposed to have decision making abilities - I have approached a member of the managment council about the need to have questionable practices of MDs submitted by staff nurses for review. I am also going to take it to the Practice Council (I'm on that one) and ask them if they would like to take it up as well.

    We really do get very few complaints from patients. When we do have to double up, we will let the pts know they will probably be getting a room mate as soon as we can. Many of them will then decide that they really didn't want to stay a second or third night if they had to share the room with someone else. It seems like the ones that may get a room mate are often good candidates for early discharge anyway .

    It is really hard on the staff to be this busy as we have always been able to spoil our patients - we pride ourselves on spoiling patients when we can. We even had one ask, after her 5th baby with us, if she could just come for a two day vacation once a year or did she have to keep having babies to come spend time with us.

    But, there are still several nights a month, sometimes 2-3 in a row, where we can be completely empty - and then have to float or get called off. Those nights make it hard to justify staffing up permanently. The other thing is we really do try not to call our call person in on nights unless it is absolutely impossible to keep up with safe patient care. I will go an entire shift without charting much of anything, give report in the am, then start charting. That practice will be changing tho, I am tired of doing that.

    One more thing, it is amazing the c-secion rates we have with certain docs that do lots of inductions - think there may be a correlation there???
  9. by   htrn
    Answers to more questions:

    We do limit the number of inductions we schedule to two a day. We may add a C-section for that day or a cervidil for that night, if we can staff for it - or more likely if the doc can bully the poor nurse that answers the phone into putting it on the calander.

    Two inductions will tie up both of our labor rooms and two nurses - leaving the 'back up room' for who ever walks in the door. And try to cancel an induction if we get a bunch of true labor patients during the night - not gonna happen. I have to say that we do have one and sometimes 2 docs that can be reasonable about rescheduling inductions, but it is rare.

    The MDs solution to 'we don't have the staff' - well then find someone to come in.
  10. by   Jolie
    I agree with involving your nurse manager and risk manager. Taking on elective inductions without adequate staff, too high a census, and only on-call access to OR and anesthesia places patients at unnecessary risk, and creates unnecessary liability.

    Do you have morbidity and mortality review within your OB/GYN service? We had a group of docs with a reputation for convenience inductions, and statistics showed that their patients had a higher rate of emergent C/S and other serious complications (maternal infections, PROM, babies with r/o sepsis, etc.) Every "complication" was reviewed during morbidity and mortality conferences, basically putting the physicians on notice that they were being scrutinized by their peers and the department chair who made decisions regarding practice privileges. It helped. I highly recommend the process.
  11. by   q12RN


    The increase in the number of inductions irks me to no end! Drs think for some reason that you can start induction at 6am and the baby will be born before their office closes at 5pm. Just simply for convenience! I am so against this. I mean if youre 42 weeks or the baby isnt being sustained by the placenta it fine. But in all the other cases just because youre "tired of being preggo" just doesnt cut it with me.
    Surely you can make a complaint with your upper management or someone on the board. Sounds like youre terribly understaffed wiht the amount of inductions you have going on.
  12. by   CEG
    I am still a student so no experience from a nursing standpoint. But with my first baby I was scheduled for post-dates induction at 42 w1 d. When I called the hospital I was told I had been bumped because they were too busy. I would like to think I had a legitimate, if not so much urgent, reason for induction, but they obviously had some sort of triage and were able to refuse something that was scheduled. Good luck to you!
  13. by   JaneyW
    I am currently taking an ethics course in my MSN program and have discovered a label for the feelings you are describing--feelings that nurses in all areas feel way too often. It is called 'moral distress' and has been studied a lot recently. It has to do with knowing what the right thing to do is and not having the authority to do it. As nurses we are so often put in this position as we serve as the moral agent or advocate for our patient but very often have little control over their plan of care. Even when we should and do disagree we still have to work with those docs the next day! We are somehow expected to be back stage negotiators while we are providing care and do all of this at the same time with the highest of moral standards. I wish I had a good answer, but rest assured that you are not alone!!
  14. by   Jolie
    Quote from JaneyW
    I am currently taking an ethics course in my MSN program and have discovered a label for the feelings you are describing--feelings that nurses in all areas feel way too often. It is called 'moral distress' and has been studied a lot recently. It has to do with knowing what the right thing to do is and not having the authority to do it. As nurses we are so often put in this position as we serve as the moral agent or advocate for our patient but very often have little control over their plan of care. Even when we should and do disagree we still have to work with those docs the next day! We are somehow expected to be back stage negotiators while we are providing care and do all of this at the same time with the highest of moral standards. I wish I had a good answer, but rest assured that you are not alone!!

    Wow! You have summed up in a very concise paragraph the very reason why I chose to get out of nursing management.

    Like many (similarly naive) new managers, I accepted a position with the idea that I would be able to impact the quality of care for all patients on my unit (a neonatal ICU). How wrong I was! In reality, I think I had even LESS ability to influence care than I did as a staff nurse, because I was spending less time at the bedside. I quickly found that policies were difficult to enforce, some nurses practiced sub-standard care (that I was ultimately answerable for), and that the granting of physician practice privileges in our unit had more to do with hospital politics than medical competence.

    To sum it up, I had 24 hour RESPONSIBILITY AND ACCOUNTABILITY for what happened on our unit, but very little AUTHORITY to do anything to influence the quality of care. I had no hiring or firing authority. I could only evaluate employees (which meant nothing since raises were accross the board), or write them up (which likewise meant nothing since there were never any consequences). I had no means of recognizing nursing excellence either, other than a hearty handshake and pat on the back. I also had no control over the medical practice on our unit, which included pediatricians with no NICU experience who refused to relinquish the care of their private-paying patients to the neonatologists on staff.

    When I could no longer reconcile the tremendous responsibility I carried 24 hours per day with my utter lack of authority, I resigned. I will never do management again, and will never be responsible for the care delivered by anyone other than myself.

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