DHH taking away our ability to practice and use critical thinking skills

[guestnurse]

Recently the DHH has stepped in to our hospital and now tells us ICU nurses can not titrate drips to keep systolic blood pressure greater than 90, that is practicing outside our scope of practice. We can only change the drips per the new written protocol. if the protocol says increase drip by 2 mcg every 15 minutes then that's all you can do. If your patient's pressure is going down the drain you can't dare go up on your drip anymore than what is stated in the protocol. You must call the physician and get an order to increase the drip sooner than 15 minutes etc....So at 2am when you have a blood pressure that is plummeting, and you are on the phone trying to page and get in touch with a physician so you can go up on your drip, good luck. Our administration has said if we DARE deviate from the written protocol we will be fired immediately, and reported to the state board of nursing. All this says to me is they are taking away our ability to think, and use critical thinking skills. All we can do now is follow directions, we have no judgement of our own, we merely follow what the physicians tell us to do. We can't go up by 2mcg if after 5 minutes your patient's blood pressure is still falling, you can't go up after 12 minutes if your patient's blood pressure is still falling. We better hope our physicians are quick to answer our pages at 3am. We have no physicians here in the ICU unit at night, we are strictly at the mercy of paging physicians through answering systems. Are other states doing this? Other hospitals?

[jadelpn, LPN, EMT-B]

Can each patient have a standing order that addresses this? For instance, each patient has a standing order that if the systolic BP were to drop below 90 before the 15 minute time frame, one is to increase dose to ____________ or whatever it is that you were doing before.

I get that in ICU, the nurses do think critically, and increase/decrease based on years of experience. With that being said, when ya'll start employing new nurses who don't really know how to eyeball critical drips, it does need to be specific.

In order to do that, I would ask for a specific order set. Even if it has to say "after 10 minutes, if systolic BP is less than 90, increase by 1 mcg. Assess at 11 minutes. If no change, increase by......all the way to "if systolic falls at or below 70, call MD"

It could be part of every ICU patient's order set going forward.

[nrsang97, BSN, RN]

Most ICU have orders like the ones in the OP. We have always had orders that state start neosynepherine if SBP MAP

I would definitely be wanting out of where you're working. What is DHH? Department of Health and Human Services? Or is that something different.

You better bet if my patient is tanking I am going to titrate the drip and get the order retrospectively.

[blondenurse12, MSN, NP]

That sounds literally insane. Does your ICU have an intensivist or ICU resident on 24/7? Even then, it's cumbersome and very dangerous for the patient. If you have a patient who is very intravascularly dry, they can have extremely labile blood pressures. Just a short delay can cause major problems. Because realistically, sometimes it takes a doc 15-20 minutes to call back. Sometimes you have to page 2-3 times before you get a response. So what? You're just going to sit there and watch your patient's BP tank and wait for them to code? It seems like there is going to be one of two things that happen: a Sentinel event or the physicians get so frustrated by the constant barrage of pages over drip titrations that something will have to give.

[Caffeine_IV]

That's nuts IMO.

Titrating drips is not practicing outside of your scope. You are titrating per the physician order and per the protocol. When I oriented in ICU, the orders were very specific ex: titrate by 2.5mcg/kg/min every 10 minutes for a goal of ____

It also had a max rate and weaning guideline.

[tyvin, BSN, RN]

Have the docs write standing orders...

[MunoRN, RN]

State surveyors aren't always the brightest bulbs and every once in a while we have one who makes this claim even though it doesn't appear to be an actual requirement in any state. Our standard response is to ask how specific the parameters have to be, at which point they try to find out, only to discover that it's not actually a requirement to begin with.

[RNperdiem, RN]

This only works if you have an ICU doc or covering NP/PA on the unit at all times.

[Ruby Vee, BSN]

What is the DHH and how do they have a say?

[CraigB-RN, MSN, RN]

Unfortunatly I've seen to many nurses titirating away, without having a solid enough understanding of the underlying pathophysiology and pharmokinetics. I've worked with attornies of nurses who got turned into their BON's for things like that.

My first thought is you need to get knowledgable nurses on the right commitee. Protocols need to be sepcific and comprehensive. But they can't cover everything, or else we wouldn't need nurses and doctors, just people who can read a cook book.

My second thought is maybe this is the motivation for you to go back to school and become an NP. Although you will find that as you move farther up the food chain, you still have to deal with stupid stuff like that.

I do defintitly agree that sometimes surveyors (more ofthen than we like to belive) INTERPRET guidlines with their own predjudices. I've seen some pretty stupid interpritations. i.e I can't push the etomidate, but I can push the paralytic. The etomidate is labled an anasthetic and I'm not a CRNA. Or I can pull a PA catheter, but I can't take the stitches holding the introducer in.