Drawing Labs without an order

[umnurs]

I work in a Level 1 trauma center in NYC. I only started a few months ago. We generally have anywhere from 4-12 patients at a time, so as soon as I get a new patient I try and line and lab them to expedite things (as do my coworkers). We recently heard a story from management that at another nearby hospital 3 nurses were suspended for "inserting an IV and drawing labs without a MD order." This was related to a lawsuit from a patient who ended up not needing an IV, but was "lined and lab'd" by the RN and went home to develop a staph infection at the site resulting in hospitalizattion, IV abx, and an I&D. The other 2 nurses were suspended when management did an "investigation" and found that they had done the same thing (as i'm sure EVERY nurse in that ED does). I dont know all the details or the "full story"...

So we were reminded that inserting an IV and drawing labs are "not in an RN''s scope of practice". We dont have standing protocols except for true "emergencies". i make the judgement call every day regarding which patients I out Iv's in and which one's i wait for the MD to see first. But sometimes it can take HOURS for a MD or resident to see a pt., and if i feel that the pt will need an IV and labs or may go bad-- i do it.

Anyone ever heard of this happening? What do you guys do in your hospital?

(and yes i know the ratio is bad but thats how it is everywhere in this crazy city!!)

[umnurs]

by "true emergencies" i mean the obvious MI's, strokes, GI bleeds, traumas etc. But we get plenty of "tooth pain", "i need my prescription refilled","i have a rash down there", abd pain for "a few years" , blah blah. most of whom dont even need labs (and shouldnt have come in at all!) But other pts arent so clearcut-- they may have minor complaints but have an extensive hx.

I think the prob is we have no extensive nursing protocols-- which puts us at potential risk like the BS that happend at that other hospital.... maybe ill have to start a commitee or something!!

[ThrowEdNurse, BSN, RN]

I know this isn't an exact analogy but this dilemma reminds me of triage. You know, how it is out of the scope of an RN to diagnose, but really what are you doing in triage? You assess, diagnose, and prioritize. Yeah, out of my scope, but try to triage without it. Try to nurse in the ED without being able to guess who may need an IV and who doesn't. Emergency medicine just has a long way to go.

[mmutk, BSN, RN, EMT-I]

Yes I would have to agree with some of the previous posters, if I think you need a line and labs you're gonna get it and that's just the start. Often I have ordered xrays or CTs and ABGs and sometimes given meds before the doc even gets to them.

If we didn't do that the wait in the waiting room would be over 5 hours I'm sure.

[ThrowEdNurse, BSN, RN]

Yes I would have to agree with some of the previous posters, if I think you need a line and labs you're gonna get it and that's just the start. Often I have ordered xrays or CTs and ABGs and sometimes given meds before the doc even gets to them.

If we didn't do that the wait in the waiting room would be over 5 hours I'm sure.

Not only that, but many pts would become sicker waiting for an MD exam. And isn't delaying pt care a big no-no? Like if a pt is actively seizing, do you actually wander around the ED searching for a Dr. to give you an ativan order or do you just give Ativan? Knowing what is going to be done diagnostically for each pt and getting those diagnostics going is a major nurse intervention in the ED. Often after waiting hours for the MD exam, everything is done. The only pending items are interventions. As long as you are conservative with your orders, the Dr's are okay with this. I like it when the techs take initiative and get things done on my pts without my asking, what's the difference?

In as far as a hospital coming after ED nurses for this common practice, they are digging themselves a hole. This trend will weed intelligent, strong nurses out of the ED and leave behind the ones who need orders to do everything. See how much the ED MDs will like that....

[edmia, BSN, RN]

I switched hospitals and the new place has protocols set up for drawing labs and putting in IV's and it gives nurses the opportunity to use our knowledge, brains, and clinical skills to figure out if a patient needs a work up or not. It is a wonderful place to practice in because of it. Lawsuit wouldn't fly here.

This was not the case at a different hospital I used to work at and it was always a call that had to be made based on the acuity of the patient and mainly based on the MD in charge... Some would expect a work up and others would chew your head off if you did anything without an order. This was a ridiculous way to practice.

I think protocols should be in place so the rules are clear and patients are safe.

[KNARE]

We have a physician in Triage for 12 hrs. daily during our busiest times. This has cut down the number of times we need to line and lab. We also have protocols and order sets. I sure hope our physicians would back us up. We save them enough!!!!

[emtb2rn, BSN, RN, EMT-B]

My ER has standing protocols developed by our ER medical director and our NM that allow RNs to initiate orders for certain critical situations, i.e., acute abd pain, code/MI, stroke, etc. This way, when we get a hot pt in, we're able to not only start a line and draw labs but get those labs on their way. Saves time and we use nursing judgement to determine when to fire off the orders. I've only been there 3 months but have yet to hear about anyone having a problem with an RN initiating orders.

[Jennifer, RN]

My ER also has protocols, and lots of them. They come in handy, but of course, many patients don't fit neatly into the protocols. So, we still end up ordering labs and xrays that aren't part of the protocol. I never order CTs or meds though, without a doctors verbal order and I make sure that any verbal orders I do get are documented as such in the chart.

[Hilinenursegrl]

I work in a very small, rual ED. All of our charting is done on the computer, except for the huge traumas;for those there is a trauma flow sheet, anyway, When we see the pts we usually throw a line in if we think thats needed and draw labs. Then we will come tell the doc, I did this and ordered this, what else? We will add on what he wants, order it per VO on the computer and this sends it to him to sign off on. We haven't had a problem yet.

[mannurse65]

I am currently attempting to get a clear answer from Joint Commission, but their latest attempt to screw up ED practice is that a protocol is fine as long as it is signed off on by the patient's MD. So, every IV you start, med you give, under the protection of a protocol is medicine without a license unless the patient's doctor approves. This includes ACLS. Do you want to bet your license on which doctor you get for that patient, that day? I will continue to do what is best for the patient, within the scope of my training, but I know the risks, and many nurses out there do not.

[nghtfltguy, BSN, RN]

yeah...

my hospital has certain protocols...

depending on the chief complaint.... i just automatically start a saline lock * and yes i can finally call it that instead of a hep-lock* took me 2 years to call it that... anyway... i just automatically draw blood and have it available.. if i want to send it i can put in the order myself and tube it up to the lab... i have never got in trouble for sending labs that were not ordred... nor have i got in trouble for ordering labs... i just put in the order and send em so if they have to wait in the waiting room for a couple of hours.. their labs and x-rays are already done....

i can't order a ct or an mri....

only things they won't let me do....

[Footballnut]

Sorry to hear about this. I am sure the other hospital was on a witch hunt of some sort. They had to pay for an IV infection which might have happened with or without a direct order. As many have already said, the real story would be helpful.

Our hospital has decided to have carepaths for us. This is because our docs and administration are committed to keeping turnaround times as fast as possible. The MDs spent time deciding exactly what they wanted to be done if they were too busy to jump in at that time. The preprinted carepaths are individualized by just adding the sheet with the pt name to the chart and the doc signs them. No big deal, the orders were things the docs had already decided on some time ago. Before we had these protocols nurses did line and lab patients but now we are covered legally as well.

The carepaths are fairly comprehensive and cover a wide range of presentations. Occasionally something pops up outside of the parameters. If I want to do something outside of the carepaths I find a doc and ask them what they want to do. Most of the time they are happy to get things going. If they want to wait it's fine with me unless the patient is in extreme pain or will be compromised.

Interestingly enough the carepaths are used a small percentage of the time since our docs are in to see the patients so quickly. Our door to doc times average around 20 minutes or so. Most of the time I am in the room with the doc (or right behind) when I am ready to make a decision about what I want to do anyway. I don't know what administration did to motivate these guys but things are working pretty well.