CCU Probs (centralized monitoring and MD notification)

[nursebairee]

Hey everyone!

I'm a new-ish nurse working in a cardiac PCU at a pretty large hospital. I have a lot to write but I'll try not to give you all a novel to read.

#1: Centralized monitoring

Long story short: we used to have monitor techs watching the monitors on our floor, and budget cuts caused them to be cut. Now, we have centralized monitoring in a different location of the hospital. The monitor techs are to call us on our Ascom (phone we have to carry around) for any rhythm changes.

Now... this scares me for a ton of reasons. Reason #1 being that even if the best monitor tech in the world is watching the monitors and observes a rhythm change, they still have to pick up the phone and call the nurse. Ideally, we are able to answer our phones and respond quickly.

There are problems with this, but a big problem is that we aren't getting called for important things--such as pauses, v-tach, etc. Last week a patient awaiting a CABG scheduled for the next morning coded and died. Turned out that this patient had been having a STEMI that was missed.

It's super scary, especially as a new nurse. I'm already talking to my management about it and have expressed my concern.

#2: MD notification

The second topic that I wanted to bring up is... when do we call the doctor?

I realize that I went to nursing school to obtain critical thinking skills. This is very important and I am in no way attempting to get out of critically thinking about things. However, I realize that there are many new RN's on my floor including myself. I emailed my manager about having some type of protocol for calling MD's, especially after hours. Does anyone know of any protocols/guidelines used at other hospitals? Especially at night when it can be difficult to discern what is worthy of notifying an MD and what could wait until morning. I realize that each individual patient is different, every case is different, and every baseline is different.

An example of current critical thinking would be... a patient has a potassium of 3.3, which is low but not necessarily emergent. However if that patient was having multiple new onset PVC's, the nurse should let the doctor know so that the potassium could be replaced early if the MD deemed necessary. This is part of critical thinking; however, it would be nice to have a protocol that could include something like this.

Another idea would be to have standing orders for situations that tend to repeat themselves, such as a low potassium.

The reason I'm asking all of this is because during the code I previously talked about, that RN got reamed by the MD for not calling him because the pt was having chest pain. OBVIOUSLY chest pain is a really big deal. However, the pt had chest pain at baseline AND was getting a CABG in the morning AND was already on heparin and nitro... personally I feel that if the had called the doctor, he wouldn't have cared. Obviously in retrospect she should have called to CYA but it leaves me feeling confused about what to do. Because I know for a fact that a lot of nurses on my unit would not have called for that.

Anyone have any thoughts? She asked me to work on a protocol and I'd really like some input because I'm so new.

Sorry this was so lengthy!! I hope some people actually read through it...

[MinoritySN]

Hi there,

I Well first I want to say if the pt was on Nitro had the nurse administered 3 nitro with unrelieved chest pain? or was this pt on a nitro drip? If so this does call for her to notify the MD. Also had the nurse used MONA (Morphine, oxygen, nitro, and Aspirin? secondly electrolyte protocols are used in the ICU so if this pt was in the CCU there should have been standing orders to replace the K+ if the pt was not in renal failure. Also I would not call the MD for PVC's unless there are 3-5 in a row and sustained (lasting more than 30 seconds) if sustained this is considered a run of V-tach and the pt might have needed their Magnesium checked. Magnesium is also given in codes especially with Torsades de Pointes which caused by Magnesium.

I hope this helped!!

[brillohead, ADN, RN]

My hospital recently started using a nurse-initiated electrolyte replacement protocol. We have one for ICU and another for med-surg, and it's an order set in Epic.

If the attending has ordered the protocol to be in place for that patient, then the nurse can start it whenever labs hit a certain number, and it covers how much of the electrolyte to give over what time frame, whether to administer PO or IV, and what labs have to be redrawn when.

If the protocol has not already been ordered, the nurse has to call the doc with lab results and get orders at that time. Or, do what I did -- call the doc with the lab results, ask the doc if he wants the protocol initiated, then enter the order for the protocol for the doc (because he didn't know how to order it because it's something new) and then he can sign off on it after the fact.