doctor thinks I should administer med based on "telephone game"

[lincoln77, RN]

So I work in a prison, was giving meds in the infirmary. One inmate was on IV cefepime.  The order simply says, give 1 gram every 12 hours. Fluid type or volume was not included, and it did not say the time it should be given in.   I asked for clarification from the doctor, and her first response was "what did the nurse who gave you report tell you?" She finally gave me clarification.  (I did not see it in any records) Isn't this really unsafe?  for months the doctor has writing IV medication orders like this. I was kind of miffed that she gave such an arrogant response, and even wanted to educate me that this inmate has CHF and we can't give to many fluids.  I was thinking...yeah I know IV meds can be dangerous so I want really clear orders.  I was going to go to the nursing director to tell her we need better orders, but am re-thinking this before I do it. What do you all think? I really have not worked in the hospital....I assume that its pharmacy that specifies how much fluid and over how long...maybe this doctor wasn't sure about the answer to my question.

[londonflo]

In the hospital, a Doctor's order only states the time interval. The pharmacist and the nurse (that's you) decide the time -- considering factors such as meal times, sleep times and shift change times. 12PM and then 12AM The whole schedule takes into account the daily life of the patient and the nurse. The goal, after all is to make things run smoothly and effectively

With regards to dilution in a piggy back bag, the pharmacist literature should specify this.

[lincoln77, RN]

thanks for your response. My main question was really on dilution.  During my school clinicals, that was always specified in the hospital ie "1 gram cefepime q 12 hours in 100cc NS over 30min".  Here the order says "1 gram cefepime q 12 hours".  So are you saying its the nurse's responsibility to determine the dilution?  

And just because it may be relevant to discussion, are you a nurse in the USA? just asking because your name says londonflo. Could be that things work differently in different places. 

[Rose_Queen, BSN, MSN, RN]

I have never seen meds that required reconstitution that weren’t packaged by pharmacy/the manufacturer. Most orders will not include “in xx mL of saline” because the physician will default to whatever the pharmacy has in stock (which can change daily in times of shortages). Pharmacy has many of their own protocols and formularies that are approved by an interdisciplinary team including medical staff. 

[londonflo]

47 minutes ago, Rose_Queen said:

I have never seen meds that required reconstitution that weren’t packaged by pharmacy/the manufacturer.

The pharmacy should supply the diluent or have it available. In some settings the 50cc or 100cc bags of saline or D5W are available separately in a pharmacy stock room (hospital) but the Medication Administration Record (provided by pharmacy) should specify the specific solution and volume. If that information is not provided you will need to contact the pharmacy supplying your agency with the RX. The choice of saline or dextrose depends on what dilutes best for the specific RX. For many years the piggybacks came reconstituted 'ready to run' but that decreases the shelf life of the RX and caused a lot of waste and $loss if not given.

MDs have nothing to do with the solutions IV antibiotics run in except sometimes they will ask if the medicine can be given with something other than dextrose because of a patient's blood sugar situation or if there is a concern of total IV fluid volume but this is not common. 

6 hours ago, lincoln77 said:

are you a nurse in the USA? just asking because your name says londonflo.

No, I am based in the US but love the London Nightingale Museum. 

6 hours ago, lincoln77 said:

During my school clinicals, that was always specified in the hospital ie "1 gram cefepime q 12 hours in 100cc NS over 30min". 

I wonder if this was in connection to a drug calculation problem in school?  You do need to know volume to calculate a drip rate or set a pump. 

 

[MunoRN, RN]

15 hours ago, lincoln77 said:

thanks for your response. My main question was really on dilution.  During my school clinicals, that was always specified in the hospital ie "1 gram cefepime q 12 hours in 100cc NS over 30min".  Here the order says "1 gram cefepime q 12 hours".  So are you saying its the nurse's responsibility to determine the dilution?  

And just because it may be relevant to discussion, are you a nurse in the USA? just asking because your name says londonflo. Could be that things work differently in different places. 

I've never seen a Physician order state how to properly prepare the ordered medication, nor would I want them to try, that could only create confusion.

All medications have publically available FDA labelling (even if you're not in the US this info is still available).  This includes proper preparation and administration instructions (what to dilute it with and how much) and what timeframe to administer it over.  

[JKL33]

On 12/16/2020 at 7:31 AM, lincoln77 said:

thanks for your response. My main question was really on dilution.  During my school clinicals, that was always specified in the hospital ie "1 gram cefepime q 12 hours in 100cc NS over 30min".  Here the order says "1 gram cefepime q 12 hours".  So are you saying its the nurse's responsibility to determine the dilution?  

And just because it may be relevant to discussion, are you a nurse in the USA? just asking because your name says londonflo. Could be that things work differently in different places. 

In general, the specification of all of this within the order has been relatively recent, and directly associated with widespread CPOE. With CPOE they click a box that includes the pharmacy-related specifications in addition to the med/dose/frequency/route. And that is why that is now what you see when you are looking at an EMR/EMAR, which is what it sounds like your training involved.

No it has not always been that the doctor needed write all of this out as part of ordering a medication itself. That is because the labeling (I.e. package insert) has included this information and if it was not known to staff then it was available to the pharmacist.

 

[TheMoonisMyLantern, ADN, LPN, RN]

Typically vials of IV medication come in a small individual box that has an insert that will tell you what fluid to use to reconstitute the medication. Usually the choice comes down to a 50mL bag or a 100mL bag of either saline or dextrose whatever your employer orders.

[lincoln77, RN]

12 hours ago, JKL33 said:

In general, the specification of all of this within the order has been relatively recent, and directly associated with widespread CPOE. With CPOE they click a box that includes the pharmacy-related specifications in addition to the med/dose/frequency/route. And that is why that is now what you see when you are looking at an EMR/EMAR, which is what it sounds like your training involved.

No it has not always been that the doctor needed write all of this out as part of ordering a medication itself. That is because the labeling (I.e. package insert) has included this information and if it was not known to staff then it was available to the pharmacist.

 

Thanks for this response. This is what I suspected but wasn't sure.