Acute Dialysis patients arriving to unit with no orders

[Dialysis101]

So I'm an experienced acute dialysis nurse that just started at a new hospital. This place is a step up for me, a major trauma center doing maybe 45 runs a day. I love the place, the staff are just wonderful, and I'm learning new things. But I have this issue over how they handle chronic patients arriving to the unit with no orders.

Basically, the nephrologists are bad at remembering to write orders for the chronic patients staying in the hospital, plain awful really. Probably 2/3 of the patients arriving for dialysis have no order written for treatment. The nurses are instructed to just copy the previous treatment orders, fabricate a telephone order, and change whatever they need to. For instance, "The weekend is coming up and he likes his orange juice, so I think he needs to run on a 2K bath today even though his potassium is 3.2", or "she clotted last time, let's change her to a revaclear dialyzer this time and start her on some heparin too", etc. The nephrologists come by later to blindly sign off the telephone orders, usually the treatment is already over. That would never have been tolerated where I worked before, as we always called for any little thing and would never bring a patient to the room without orders.

I've talked to the charge nurse about this on some instances, and she won't let us call the doctor. If they come without orders she will say to "just write a telephone order, we don't have any choice, we would be here until 3 in the morning if we called each time that happens". For instance I received a pt. that had just been admitted overnight and scheduled for a cardiac cath and an order for "consult nephrology". The charge nurse said just write a telephone order for whatever treatment and bath he runs on in the outpatient clinic since this is his day, continue the heparin if he needs it, decide how much you need to pull, decide if you need to draw any labs, and nephrology will sign it all when they receive the consultation. I'm like, "this pt. could be unstable, the nephrologist doesn't even know he's in the hospital yet, do we have a standing order to run patients on outpatient parameters when they come in?" She said "there are no standing orders for anything we do, that's just the way it's always been done and the nephrologists support our decisions". I also talked to the manager about it and she said the same thing, that it can be nerve wracking to write false telephone orders at first, but she expects her nurses to be independent thinkers and not always be automatons following orders.

Is this the way most acute units run and my old unit was just the exception? The telephone orders situation is causing stress in a lot of the newer nurses here, but the established nurses don't seem to have any problem with it, maybe because they've been working there so long. I feel like these "independent decisions" they force on us could lead to some serious trouble if something ever happened on the machine and the doctor was never spoken to and didn't agree with our decisions. Do nurses have a legal leg to stand on if they run a patient "because it's their day" before a nephrologist has written the official orders? Can the hospital legally fire you for refusing to write a telephone order until you actually speak with the doctor? Just wondering.

[westieluv]

Wellll...I'm fairly new to acutes, so take that for what it's worth, but we get orders for each and every treatment. Some nephrologists prefer to give orders before we start the tx, and some prefer that we start and then call for orders and adjust the tx if need be. Honestly, with doing it the way that you're describing, do they take into consideration that patients who are acutely ill in the hospital do not necessarily call for the same exact tx that they get when they are at the outpatient clinic and relatively well? So the guy "loves his orange juice", but what if he ends up vomiting all weekend instead and his K+ drops because he was run on an inappropriately low bath based on what he "normally" does? "She clotted last time, let's start her on some Heparin,"...is anyone checking her PTT?

It sounds pretty scary to me, and I would honestly fear for my license, because if a patient were given a tx with a bath that was inappropriate for their acute issues and had an adverse reaction, I can't imagine even the nicest nephrologist saying, "I'll stand in your corner. I wanted you to run that tx without calling me first for orders and I will take all consequences that come as a result", more like, "What the $*## were you thinking, running that patient without calling for orders? Are you a nephrologist? I didn't order that!" and then there goes your license.

But then...I'm fairly new...

[NurseRies, BSN, RN]

I have been to about a dozen or more hospitals as an acute dialysis nurse with traveling. Often times, we operate off "standing orders", so when the doc writes in the chart for MWF dialysis with details, that's what we follow. It may not make much sense, but that's the bare minimum I would take as orders. If they write for a 2K bath and then labs come back at 3.2 potassium, I would call the Doc and switch the bath. Honestly though, sometimes these docs don't call back for hours, so most acute nurses I know would just switch the bath, tell the doc what happened and then write an order. That's what the doctor would have wanted you to and would be mad if you didn't.

It's kinda how the ER operates from what I understand. Sometimes we just simply can't wait for orders to do what we know is right, there's too much going on. Any ER nurse I've ever talked to says they act now and then the doc signs off later, can you imagine what would happen if they waited?

I'm not saying dialysis is like that but where do we draw the line? I agree with you that this is scary. Why doesn't the hospital operate under some kind of standard protocol like the clinic does. In the clinic you have your prn Benadryl and acetaminophen, nitroglycerin, oxygen etc. In the protocol, you should also have if potassium is less then 4.5, change to 2 K bath. If patient is MWF in clinic, dialyze patient per outpatient orders, or just standard dialysis orders. No one should lose their license because of this. The problem is that many hospitals do not have a good operator system and they don't hold doctors accountable. Then again, imagine being a doc and nurses are calling you at 6 am for orders when you are covering 10 hospitals that day and you simply didn't get to it. If we didn't start some of these chronic patients that have been there for weeks, we would be working 18 hour days. I think big hospital programs like the one you are talking about should have in house PAs or NPs that could get there when you do and write orders on all these in limbo ESRD patients.

Bottom line- you are right, almost everywhere I've worked has stood firmly by the rules. And if you're not comfortable, then don't do it. These docs will not improve if we don't hold them accountable for not writing orders.

[Chisca, RN]

Always act as if you would have to testify in court to explain your actions because if something goes wrong guess who they will hang? A jury will not have any sympathy for the nurse that fabricated orders. And a charge nurse that won't let you call the doctor? She is placing productivity of the unit over safety of the patients. I would at least try to talk with the medical director and get clear guidance to have some kind of standing orders in those situations where the doctor can't be reached. If it is a right to work state they can fire you but you will still have a license to practice with. I have little sympathy for MD's who like the money from having so many patients but are too cheap to even hire a nurse practioner let alone acquire another partner to share the load. You are in a tough spot.

[TEXASWAG, MSN, RN]

You're putting your license at risk. Say you write that verbal order without speaking to the nephrologist. What if the nephrologist later says that he/she did not give you the order. What if something bad happens to the patient....your ass will be grass with your board of nursing being the lawn mower.