another dilemma.. when do i ever learn???

[cebuana_nurse]

I had a resident which was admitted for altered mental status a week ago. Last night, she was extremely confused, verbally and physically abusive, exit-seeking, and verbalized that she will kill herself if we wouldn't let her go home. MD was called and got an order for stat p.o Haldol (which didn't help at all). Got a call from Behavioral Unit stating that they were contacted by MD about a possible admission. Now, MD wants a direct admit to Behavioral Health, Behavioral Health on the other hand doesn't want to admit said resident pending papers that needs to be signed by POA and its already 10PM. They wanted me to send resident to ER while awaiting for POA to come in and sign the said paperwork. Resident was sent to ER at 2230. I wote a V.O to send resident to ER for eval.

To make the story short, my ass is getting burned today about the said resident. MD didn't want the resident to be sent to the ER but I sent her instead. Behavioral Health told me so. My fault for not making MD aware of Behavioral Health's conditions. Though before I left my 16hour work for the day, I made sure my nurse's note was well documented. Plus there's a red flag because it's a NO-NO to administer Haldol prior to leaving facility since the MD prescribing it is not a psychiatrist. Since when anti-hypnotics limited to psychiatrists only??

Now, did I made the wrong call?

[cebuana_nurse]

With the Haldol order, I got a telephone order from the MD. But why am I being flamed with this when in fact the MD did prescribed it? I have two elderlys that are on Haloperidol but was prescribed by a psychiatrist. Unfortunately, these are straight orders.

[CoffeeRTC, BSN, RN]

Oh yes, let's dump these patients on the ER because it's well known that they have nothing better to do than babysit difficult patients when nobody else wants to deal with them!

So...I agree with you, the ER is over loaded with people that shouldn't be there in the first place, but isn't the ER kinda like a gateway to the hospital after hours?

Picture my LTC..50 residents with 2 nurses and if we are lucky 4 CNAs on the 3-11 shift. (goes down to 1 nurse and 2 cnas on the 11-7)

I have a massive amount of meds to do and more often than not I have at least 3-7 sub acute or med surg appropriate patients along with the 20 or so.

The ER isn't the most appropriate place, but if you have doctors on staff, meds at hand and security in the building..its a lot better than my place where I have frail elderly, no emergent meds or only a dose or two (po meds too) no security and no staff to deal with them.

What should happen is that they should never be sent to the LTC.

[mazy]

A couple of things were pointed out that are on target:

it was a system cluster**** for sure and is something that should be addressed within management to clarify protocols so such things don't continue to happen

It is also true that facilities are now admitting more behaviorial patients and it is bad practice to bring patients like that into a facility that does not have the resources to handle them. It's not fair to the other patients and can tie staff up dealing with disruptive psych issues that end up pulling them away from providing good medical care to other patients.

But it's all about the money these days

Haldol is an anti-psychotic, not an anti-hypnotic,and is dangerous to use in the elderly and most places are not allowing it to be used anymore. Seroquel is also an anti-psychotic and is also not a good choice but it can sometimes have a very sedating effect. Both meds do require a time period to build up so not a great choice as a PRN unless you are going to use large doses, which is just bad practice for a medically frail patient

Ativan, which is a benzo, is a much safer and more effective choice

You do need a verbal order from the MD to send the patient to the ER and that was a bad call on your part but I can see that if you were new to this it would have been confusing at the time. Rule of thumb is that any decision involving a patient, no matter how small or large, you need to notify the doc directly.

If this was a p****ing contest between him and the BX unit, he should have battled it out with them personally and that would have also freed you up to do your job.

Also, next time something like this happens, get management involved, even if you have to call them at home, if only just to CYA. Believe me, a few calls like that and they'll be coming in and having meetings to clarify these issues so they can be free to enjoy their time off.

[evolvingrn, BSN, RN]

Wow, im not sure what the huge deal is with LTC and haldol. Haldol is in my facilities standing orders iv/sq or po i can give it without calling for any pt (unless its specifically d/c by md) Just and FYI for 'suggestions' when calling for an order when a pt is agitated/agressive ask for the SQ route right away. I have observed it to be much more effective in those instances. Sorry about your rough day.

And to the PP we use Haldol prn , and its very effective. we also use it off lable for nausea prn (its of course written in our standing to be used for both agitation and nausea) and that is also effective.

[CapeCodMermaid, RN]

Wow, im not sure what the huge deal is with LTC and haldol. Haldol is in my facilities standing orders iv/sq or po i can give it without calling for any pt (unless its specifically d/c by md) Just and FYI for 'suggestions' when calling for an order when a pt is agitated/agressive ask for the SQ route right away. I have observed it to be much more effective in those instances. Sorry about your rough day.

And to the PP we use Haldol prn , and its very effective. we also use it off lable for nausea prn (its of course written in our standing to be used for both agitation and nausea) and that is also effective.

In LTC, at least in Massachusetts, we CAN NOT use a PRN anti psychotic unless the patient already has a scheduled order. NEVER would we give Haldol IV. Are you going to wrestle the psychotic resident to the floor to start an IV and then give them Haldol? Not in my building. I've sent people out many times without waiting for the doc to call back. The regs (again can only speak for my state) allow someone with 'the necessary knowledge to determine it is an emergency" to send someone out.

Too bad if the ER doesn't like it....let THEM load the resident up with IM Haldol until we can get them into an appropriate facility.

[evolvingrn, BSN, RN]

In LTC, at least in Massachusetts, we CAN NOT use a PRN anti psychotic unless the patient already has a scheduled order. NEVER would we give Haldol IV. Are you going to wrestle the psychotic resident to the floor to start an IV and then give them Haldol? Not in my building. I've sent people out many times without waiting for the doc to call back. The regs (again can only speak for my state) allow someone with 'the necessary knowledge to determine it is an emergency" to send someone out.

Too bad if the ER doesn't like it....let THEM load the resident up with IM Haldol until we can get them into an appropriate facility.

I think my point , if you read my post was SQ is a more effective method and if they had an iv / iv would be as well. I don't do ltc but we end up getting a lot of ltc pts when they get 'sent' out because they can't be effectively managed by LTC faclities, which is too bad because honestly most of the time Haldol will do the trick. i was simply trying to suggest starting with SQ as the route when a pt is agitated to the point where needing to be sent out is a possiblity.

[CapeCodMermaid, RN]

We never give Haldol sc...never and I've been doing this for a really long time. So sorry we have to send them out, but as long as we are bound by the old LTC rules and have to take care of younger and sicker and crazier people we will send them out until the rules change and we can safely manage them. I'd much rather keep my patients in my facility where they are known.

[cebuana_nurse]

I guess we'll see what happens when I come in to work tomorrow. Hope this doesn't get in my record. My transfer papers to L&D is a few days away..

[TakeOne]

I think my point , if you read my post was SQ is a more effective method and if they had an iv / iv would be as well. I don't do ltc but we end up getting a lot of ltc pts when they get 'sent' out because they can't be effectively managed by LTC faclities, which is too bad because honestly most of the time Haldol will do the trick. i was simply trying to suggest starting with SQ as the route when a pt is agitated to the point where needing to be sent out is a possiblity.

You didn't have to tell us that you don't do LTC. Those of us who DO already knew it

Regulations stipulate how and when we can use psychotropics in LTC.

Beyond that, though, Haldol is notoriously ineffective in the geriatric population due to paradoxical effect, so it rarely does "the trick." Ativan is far more reliable but takes a while to take hold.

[Schmoo1022]

At my facility, if a patient is threatening harm to themselves or others...they are taking a little ride. We can send immediately, then get an order. We are not allowed PRN Haldol.

We have had times when a resident refused to go to the hospital and the ambulance drivers wouldn't take them because they said no. That is when we have big problems. Either the police are called or pysch has to come in and sign for them. We are having these issues more and more.

[cebuana_nurse]

UPDATE: So far my day after that crazy 16hours of work was good. I wasn't called to the director's office. The said resident came back to the unit after 2 days and seem pretty alert and oriented. The MD got flamed too for prescribing a PRN Haldol instead of an Ativan. Lesson learned. Thanks to all for giving your inputs.

[Forever Sunshine, ASN, RN]

UPDATE: So far my day after that crazy 16hours of work was good. I wasn't called to the director's office. The said resident came back to the unit after 2 days and seem pretty alert and oriented. The MD got flamed too for prescribing a PRN Haldol instead of an Ativan. Lesson learned. Thanks to all for giving your inputs.

Lesson learned is right.. move on.

As for the haldol. My facility uses IM Haldol. I've seen different responses. One it didn't even touch. Another it worked fine. And another it kicked it a few hours after it was given.