Doctors That Give you "Band-Aids"

[Caffeine_IV]

How do you deal with doctors that basically give you just enough to get a patient through until the next shift but won't get really aggressive or better yet transfer a patient during the night?

I have had a couple occasions where I or a coworker had a patient starting to go bad and they really needed a higher level of care but the MD would just order 2-3 boluses, labs and medicine that would JUST hold the patient above the water.

And when I return for the next shift, I find out that the patient went to critical care (one really stands out to me because she had a wound evisceration the morning I left and later died)

[classicdame, MSN, EdD]

Chain of command

Rapid response team

[Orange Tree]

They may have "suggested" restrictions if not hard guidelines that they must follow. I've had an MD order a patient moved to a higher level of care only to have the house officer block the move pending negotiations. The house officer wanted to make SURE that the patient couldn't be stabilized and stay put. They didn't want to lose a higher acuity bed if they didn't have to.

[pers]

If it's the end of the shift, I worry less as the oncoming shift (we work 12's) is going to be dealing with a new doctor and have not only my assessment and old orders but their new assessment as well (and we'll assess the patient together depending on what's going on so they can ask questions about possible changes).

When it's earlier in my shift, I do the best I can and document my butt off. I use our rapid response team when appropriate but outside of a code situation only the doctor can order a transfer to a higher level of care. If there is a spare nurse floating around, sometimes the supervisor will bring them to our unit so we can keep a closer watch on the patient.

*edit to add* I would also look for consults to call that may be appropriate. Of if I start with a consult and don't feel what they are offering is adequate I'd call the primary, even just to recommend a transfer to higher care.

[linearthinker, DNP, RN]

I am the higher level of care, and we used to get many inappropriate CCU admits. Now we have specific criteria, thank god, and if pts don't meet criteria, they stay put- where they belong. Sometimes a bolus is all they need. However, if you really work in a place where physicians and house officers are not able to accurately assess a patients condition, I'd go work someplace else. My guess is more often than not, the band aids work and they do fine.

[RNperdiem, RN]

If you work nights, your patient will likely be under the care of the "cross-covering" doctor who is covering patients from several different services.

Yes, they will band-aid the patients as long as possible since cross-covers are discouraged from making big patient care decisions without consent of the primary doctors.

A rapid response would be a good idea.

Now that I work only days, getting the docs and resources is no longer a problem.

[cardiacmadeline, RN]

I am the higher level of care, and we used to get many inappropriate CCU admits. Now we have specific criteria, thank god, and if pts don't meet criteria, they stay put- where they belong. Sometimes a bolus is all they need. However, if you really work in a place where physicians and house officers are not able to accurately assess a patients condition, I'd go work someplace else. My guess is more often than not, the band aids work and they do fine.

I work on a stepdown unit and am curious what your criteria are. I know we have sent patients that we could take care of on our floor, but sometimes if they are one on one care it makes it difficult to take care of your 3-4 other patients. I love it when we send a patient to the ICU for low/high blood pressures that we have been trying to treat for half our shift and then once they hit they ICU, they are fine! Makes us look like idiots.

[wooh, BSN, RN]

I love it when we send a patient to the ICU for low/high blood pressures that we have been trying to treat for half our shift and then once they hit they ICU, they are fine! Makes us look like idiots.

Yep, that's annoying. You've been fighting for hours to get the patient stable, and then finally when all those interventions start to kick in and work, THAT is when you're finally able to transfer them.

We had a patient that kept coming out to the floor, would have an episode, we'd send him back to the unit, he'd be fine. So they'd send him back out, he'd have an episode, we'd send him back, he'd be fine.

FINALLY, he had one of his episodes while he was still back in the unit. Died. He wasn't going to have any kind of quality of life, so the death was for the best. Sounds horrible, but I really found satisfaction in the fact that the unit kept acting like we were incompetent sending this patient back over and over again. But hey, at least when had an episode with us, we were able to get him through it. Considering how "stable" the unit kept telling us he was, seems like he shouldn't have died in their care if they were so right about him.

[canoehead, BSN, RN]

Ask for what you want, if he gives you Bandaids suggest what you think will really work.

Specifically ask for a transfer out. Document.

Specifically ask for the MD to come in and assess the patient. Document.

Call with any change in condition that concerns you, even if you told them it would happen already, tell them that it DID happen.

Have another nurse do an assessment and call the doc too. Have the supervisor do an assessment and call the doc too. Document.

State what you see that is very concerning, and ask for teaching from the doc regarding what makes them feel reassured. If the patient is sick you may uncover some miscommunication somewhere that will change his or your mind.

Go over their head. Go up the doc chain of command, and up the nurse chain.

[Caffeine_IV]

I just had a couple of past cases on my mind and sometimes when the outcome is not what you hoped...you wonder if you missed something OR if I'm not painting the picture accurately enough of what is going on with the patient.

[msjellybean]

We work with one doc specifically who always band-aids his patients. Never any large scale interventions. A couple weeks ago, one of our new grads had one of his patients & was fighting her rising BP for the better half of the shift. At 0600, when her pressure was two-teens/one-teens (after about 4 interventions that only seem to have made her BP rise) & she called him about it and he was like, "yeah, not doing anything about it." You can bet a rapid response code was called.

I had her the next night & she converted to new afib & his interventions were to, "leave her alone & let her sleep" and to turn the alarms on the tele up to 160.

[Mona77]

In our Acute Care facility it depends on ICU bed capacity if a patient is transfered to a Critical Care Unit

Our doc's try to stabilize critical patients as long as possible at the ward - which leads beyond doubt to dangerous situations - not only for the critical patient, but also for all the other assigned patients which are neglected because of changed priorities.

I had several disagreements with my docs - and the only way to secure yourself is to document, document and once again document.

After such a shift I feel disappointed not to have provided the best possible care, feared that the critical patient will have a bad outcome.