Anesthesia incident on OR Nursing Record?

jwk · Jun 15, 2008

If a patient comes into the OR with a block but it's discovered that the block isn't working (after the incision is made) and then GA has to be quickly administered (w/o preoxygenation), do I need to document this in the record if there are no other complications?

If you feel the need, you can document the change from regional to general, but that would be it. Not sure why you think "w/o preoxygenation" is an issue or would be worthy of your concern as far as the OR nursing notes.

One of my pet peeves is redundancy in record-keeping and charting. If I do something or give something, I CHART IT. If YOU do something or give something, YOU CHART IT, simple as that. Examples:

The majority of the time, I give the antibiotics - just me. That's how we control having antibiotics given within 30 minutes of the incision time. Yet frequently, the pre-op nurse will chart that she hung them (not started them, just literally hung the bag), and the OR nurse wants to know what I gave and when. Why? I gave it, I charted it, it's documented on MY record. That should be enough.

The OR nurse applies and manages the tourniquet for extremity cases. It has nothing to do with the anesthetic. Why would I need to chart the tourniquet times and pressures? The OR nurse has charted it in her OR notes. That should be enough.

Annony RN · Jun 15, 2008

LOL, I refuse to chart pre-op (or intra op for that matter) antibiotics. I'm not hanging them, why am I charting them?? I don't chart how much propofol was used or if vec was given. I used that check that yes, abx were given, until I started getting my charts back (another pet peeve, why are people reviewing and correcting... "grading"?? my documentation?) they wanted me to specify what and how much. Sorry, I didn't hang it, the person who did charted it adequately. That includes them wanting to chart abx given in holding. If I happen to speed things up by starting the IV and abx in holding, or giving Versed then yes, I'm going to chart it... on the holding record only.

Anyway, to the original question. No, I don't chart specifics of a complication. I would chart that it was under block, then under GA since we have a section for type, but nothing more specific. What if I misunderstand/ misinterpret something that happened or was done? I won't put my CRNA in the situation of standing in court explaining why his charting says one thing and mine says another. Frequently, our TIVA pts desat temporarily... would you chart that? Would you chart oral airway placed, etc? I have enough to chart on my own, thanks.

riv_nurse · Jun 15, 2008

If you feel the need, you can document the change from regional to general, but that would be it. Not sure why you think "w/o preoxygenation" is an issue or would be worthy of your concern as far as the OR nursing notes.
One of my pet peeves is redundancy in record-keeping and charting. If I do something or give something, I CHART IT. If YOU do something or give something, YOU CHART IT, simple as that. Examples:
The majority of the time, I give the antibiotics - just me. That's how we control having antibiotics given within 30 minutes of the incision time. Yet frequently, the pre-op nurse will chart that she hung them (not started them, just literally hung the bag), and the OR nurse wants to know what I gave and when. Why? I gave it, I charted it, it's documented on MY record. That should be enough.
The OR nurse applies and manages the tourniquet for extremity cases. It has nothing to do with the anesthetic. Why would I need to chart the tourniquet times and pressures? The OR nurse has charted it in her OR notes. That should be enough.

Thanks jwk,

Well I am new in the OR (just over 6 months) and this is the first time that anything remotely scary happened. This patient came in with the regional, very relaxed etc. She literally jumped when the surgeon made the incision and said she could feel it. He made the decision to quickly put her under and she literally tried to get off the table. I had originally charted the regional and I made a note in the chart about the conversion but another more experienced nurse later told me I did not need to and should remove the note and modify the anesthesia type to GA so I did but now I feel guilty about it and am worried that I did something wrong.

As for the preox... it has always been done in all the surgeries I've been in on. This is the first case I've been on where there seems like there were so many lapses in patient safety.

The patient is fine - she had some bp issues in the PACU - so I guess it shouldn't matter but I just feel like the chart doesn't reflect what actually occurred and that I may get in trouble.

core0 · Jun 15, 2008

If you feel the need, you can document the change from regional to general, but that would be it. Not sure why you think "w/o preoxygenation" is an issue or would be worthy of your concern as far as the OR nursing notes.
One of my pet peeves is redundancy in record-keeping and charting. If I do something or give something, I CHART IT. If YOU do something or give something, YOU CHART IT, simple as that. Examples:
The majority of the time, I give the antibiotics - just me. That's how we control having antibiotics given within 30 minutes of the incision time. Yet frequently, the pre-op nurse will chart that she hung them (not started them, just literally hung the bag), and the OR nurse wants to know what I gave and when. Why? I gave it, I charted it, it's documented on MY record. That should be enough.
The OR nurse applies and manages the tourniquet for extremity cases. It has nothing to do with the anesthetic. Why would I need to chart the tourniquet times and pressures? The OR nurse has charted it in her OR notes. That should be enough.

I guess I have to disagree a little bit. At least here the anesthesia record is still a paper chart and the nursing OR record is computerized. If you are doing QI its a lot easier to go through 200 computerized charts than 200 paper charts (if you can find all the charts) if you are looking at antibiotic times for example.

When we do a transplant both anesthesia and nursing document the clamp times. These are fairly important times and duplication goes a long ways towards making sure that someone documented the time. Not sure about tourniquets but I would think that it might be better to have them documented on the anesthesia record for medical legal purposes if there were big VS swings or blood loss when they took it down.

David Carpenter, PA-C

amiandjim · Jun 15, 2008

I understand that it might have been scary for you that the patient had to be converted to a general, but I would not call "no pre-oxygenation" a lapse in safety. The anesthesia provider was likely trying to get the patient to sleep ASAP and didn't have time to pre-oxygenate. Yes, pre-oxygenation buys you more time for apnea if you have airway difficulty, but it isn't a lapse in safety if it doesn't occur.

riv_nurse · Jun 15, 2008

Yes, pre-oxygenation buys you more time for apnea if you have airway difficulty, but it isn't a lapse in safety if it doesn't occur.

So if there had been airway difficulty, it would have been a lapse in safety but since there wasn't, it was okay. I guess that doesn't make sense to me but as long as I don't have to chart it, I'm okay with it.

I guess what really freaked me out about this whole experience from a safety point of view is that apparently no one did a sensory or motor check on the patient before the surgery started either. She clearly felt pain and was able to move her arm when she tried to get off the table. After the patient was out the surgeon basically tore the CRNA a new one about it.

I guess I feel bad for the patient - somehow I let her down. She was really scared and now the chart doesn't even reflect what she went through. I guess I'm being too soft. I suppose after a few months I will get over it.

Thanks for the responses.

core0 · Jun 15, 2008

Yes, pre-oxygenation buys you more time for apnea if you have airway difficulty, but it isn't a lapse in safety if it doesn't occur.
So if there had been airway difficulty, it would have been a lapse in safety but since there wasn't, it was okay. I guess that doesn't make sense to me but as long as I don't have to chart it, I'm okay with it.
I guess what really freaked me out about this whole experience from a safety point of view is that apparently no one did a sensory or motor check on the patient before the surgery started either. She clearly felt pain and was able to move her arm when she tried to get off the table. After the patient was out the surgeon basically tore the CRNA a new one about it.
I guess I feel bad for the patient - somehow I let her down. She was really scared and now the chart doesn't even reflect what she went through. I guess I'm being too soft. I suppose after a few months I will get over it.
Thanks for the responses.

Its OK to feel bad for the patient, but its not your fault. It goes back to your original question. At least in our hospital nursing is not responsible for things that they cannot control. For example if the patient had fallen off the bed then yes an incident report would be necessary. However, you had conversion from regional anesthesia to general. There is no involvement here. This is essentially an anesthesia or surgery/anesthesia decision and ultimately they are responsible for the outcomes. Even if there had been an airway difficulty, it would have been up to the CRNA to document it.

You only let people down if there was something that you could have done differently. Short of taking over anesthesia there is nothing you could have done here.

David Carpenter, PA-C

justjenny · Jun 24, 2008

Iand the OR nurse wants to know what I gave and when. Why? I gave it, I charted it, it's documented on MY record. That should be enough.
The OR nurse applies and manages the tourniquet for extremity cases. It has nothing to do with the anesthetic. Why would I need to chart the tourniquet times and pressures? The OR nurse has charted it in her OR notes. That should be enough.

It is part of our keystone briefing to have the circulator verify what ABX are given and when...not only is it a safety check, but it is now a reimbursement issue...if meds are not documented within an hour of incision payment can be withheld....

As far as the tourniquet, while I agree with you...the machine is usually right next to the CRNA and it is easiest for them to put it "up" and "down" for us, and yes, we chart it...but it is a courtesy to announce the tourniquet times (and a part of keystone)

Jenny

jwk · Jun 25, 2008

It is part of our keystone briefing to have the circulator verify what ABX are given and when...not only is it a safety check, but it is now a reimbursement issue...if meds are not documented within an hour of incision payment can be withheld....
As far as the tourniquet, while I agree with you...the machine is usually right next to the CRNA and it is easiest for them to put it "up" and "down" for us, and yes, we chart it...but it is a courtesy to announce the tourniquet times (and a part of keystone)
Jenny

It's a reimbursement issue, but there's no need to document it multiple times by multiple people.