Codes: Can we administer code meds without MD present?

CHATSDALE · Jul 25, 2006

most facilities have standing orders about procedure that is done within a code situation, usually a md is within calling distance but sometimes esp at night there may be times when a code teams has to take over

and i have seen epi given via jugular by emts

suzanne4, RN · Jul 25, 2006

You did not specify where the infant was being transferred from, but there are normally standing orders for transport.

Gompers, BSN, RN · Jul 25, 2006

You did not specify where the infant was being transferred from, but there are normally standing orders for transport.

It sounds to me like the baby was already in the NICU and the MD was the one en route.

I suppose it depends on the unit. Where I am, we have at least 1 doc on the unit at all times, if not 2, so this situation doesn't come up. In the rare situation where the docs are in L&D at a delivery, if a baby starts going bad the doc is paged and is up on the unit within 2 minutes. In the meantime, we bag the baby and do chest compressions, draw up the epi, and have it ready for the second the doc gets there. If the doc gave us permission and dosages on the phone before he/she left L&D, we'd give the med, but not without a verbal order at the very least.

As long as you're bagging the baby and doing chest compressions, you are circulating blood and oxygen. The epi might get the heart beating faster on its own, but in the meantime, CPR should keep the baby oxygenated.

If it's going to take more than a few minutes for the doc to get there, then a verbal order should be given by the doc or there should be a code protocol available for the unit. I could see this in units where there are not docs on call overnight.

I, personally, wouldn't ever work in a unit without 24/7 coverage. Scares me!

NICU_Nurse, BSN, RN · Jul 25, 2006

I'm sorry- yes, I meant that the doc was en route to the unit (I have no idea, truly, where he was or what took so long- there's a chain of communication that reaches the RN last). The baby had been admitted days before. There is 24/7 coverage- this seems like an unusual situation.

What I'm thinking is that if you drew the epi and still no doc to give orders (either by phone or in person), you'd be covered by your NRP certification, considering this would be an emergency...? I mean, it seems to me that as long as you were acting in a prudent manner, it would be better to go ahead and give it than not give it...? I mean, if you didn't give it and the baby died, would you be held liable in a court of law for not giving it?

I don't know. I'll have to investigate further. :) Thank you for your quick replies!

Gompers, BSN, RN · Jul 25, 2006

I'm sorry- yes, I meant that the doc was en route to the unit (I have no idea, truly, where he was or what took so long- there's a chain of communication that reaches the RN last). The baby had been admitted days before. There is 24/7 coverage- this seems like an unusual situation.
What I'm thinking is that if you drew the epi and still no doc to give orders (either by phone or in person), you'd be covered by your NRP certification, considering this would be an emergency...? I mean, it seems to me that as long as you were acting in a prudent manner, it would be better to go ahead and give it than not give it...? I mean, if you didn't give it and the baby died, would you be held liable in a court of law for not giving it?
I don't know. I'll have to investigate further. :) Thank you for your quick replies!

I don't think that NRP certifications gives you the legal right to give medications without an MD order, so I wouldn't give it. Same thing with intubation - while we did learn it in NRP training, it is not in the nursing scope of practice to intubate, even in an emergency. (This does not include nurses specially trained for intubation, i.e. certain transport nurses.)

My point is that if you are doing adequate CPR on a baby whose heart rate is less than 50 BPM, the epi can wait. You will be pumping the blood faster than 50 BPM and by bagging with 100% oxygen, you will be circulating oxygenated blood. So I'd wait for an MD order, period, before giving the epi. If I had no idea when the neo doc would be available, I'd call for another doc - on-call pediatrician, ER doc, etc. - and at the very least get a verbal order to give epi. But again, it is not in our scope of practice to give medications without a specific MD order.

As far as legal issues go, I think the hospital would be in a lot more trouble for not having a doc there when there is a coding baby - ANY doc, in the case that the NICU doc was unavailable. As a nurse, as long as you were doing CPR and monitoring the patient, I think you'd be fine. Giving a cardiac medication without an MD order, in my opinion, would get you in a lot more trouble in court.

Editorial Team / Admin · Jul 25, 2006

You need to check with your facility and see what the policies/procedures are for emergency administration of medications and/or procedures without physician presence.

dawngloves, BSN, RN · Jul 26, 2006

Good question! 98% of the time we have a doc right at the bedside, so it hasn't even occured to me. But when I did adults I gave many a cardiac med in a code situation without an MD present. Otherwise the pt would be dead waiting for them.I can't recall what the policy was.

Gompers, BSN, RN · Jul 26, 2006

Good question! 98% of the time we have a doc right at the bedside, so it hasn't even occured to me. But when I did adults I gave many a cardiac med in a code situation without an MD present. Otherwise the pt would be dead waiting for them.I can't recall what the policy was.

I know that rules are different with adults, especially because they really need those cardiac meds. I've heard of lots of nurses being able to give code meds there without a doc, and they usually have pretty solid code protocols to follow.

But in babies, it's almost always a respiratory arrest, and we can take care of that before the doc gets there. As long as we're bagging and doing chest compressions, we're buying time. Epi is such a dangerous drug with babies, I'd be so nervous to give it without an order.

lovemyjob · Jul 26, 2006

I have seen a clinician give epi when a kid coded after hemorrhaging(sp) from a prolapsed stoma without an MD order. I am guessing we have a standing protocol. Also, and this came from an NRP instructor, I was told that we would not be instructed on intubation if we were not allowed to do it. I am sure there should be some level of competence before you try it yourself, but I think it is more my opinion than rule/law.

mpccrn, BSN, RN · Jul 7, 2008

in our ICU, we have a prn med sheet giving us orders to treat arrythmias whether a doc is present or not. the ICU prn sheet must be ordered by the physician. this gives us a clear view of what the physician expects. hope it helps. :)

preemieRNkate, RN · Jul 8, 2008

I have never been part of a situation where a baby was coding and there wasn't an LIP (either doc or NNP) there. Even back when we didn't have attending coverage 24/7, we had a fellow, resident and an NNP in house (either on the unit, in the DR or in their call rooms right down the hall). We now have an attending in house 24/7, so they are in the hospital. Before that, they were called in from home. But we still had someone there.

Like previous posters said, I would think that if you are doing chest compressions and administering PPV, you will be able to buy enough time until an LIP gets there. For us, it would be just a few minutes if we had to wait at all. I can't even think of a situation where a baby started coding and we haven't already called someone to the bedside. You usually have some warning that a baby is going downhill enough to require a full code with meds.