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!!)

[Displaced]

The best thing I have ever heard from one of our docs when ordering something out of protocol is, "Be prepared to explain why." She was helping one of the new nurses who had questions about what to order and why when she said this. Basically, what the entire conversation revolved around was order things for a reason. I don't think I am doing the conversation justice, I am probably leaving some things out. It was very enlightening. Even some of our more experienced techs order things (for the obvious stuff, chest pains, etc.) We have never had a problem.

Anyway, I registered just to post this, so, hello everyone.

[SDS_RN, RN]

We line & lab also. We've never has a problem w/ our docs not backing us up. We do have certain SO w/ what labs/xrays ect to get started. A lot of the times the doc will get xrays/labs done before seeing the pt. As said before if we had to wait for them to get in there sometimes it would be hours before and tx was initiated.

[mannurse65]

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.

So, if you have to have the MD sign them, then do you wait to start care? How do you handle the critical patient that needs immediate intervention? What happens if the physician refuses to sign the paper? We all get along with our docs until there is a problem, like the patient complaining, or suffers one of the risks associated with IV starts. It will happen, It has happened in our department several times in the 12 years I have work there. If there is no protocol, there is no protection. I still take care of the patient first, but I know I am at risk.

[Footballnut]

"So, if you have to have the MD sign them, then do you wait to start care? How do you handle the critical patient that needs immediate intervention? What happens if the physician refuses to sign the paper? We all get along with our docs until there is a problem, like the patient complaining, or suffers one of the risks associated with IV starts. It will happen, It has happened in our department several times in the 12 years I have work there. If there is no protocol, there is no protection. I still take care of the patient first, but I know I am at risk."

Thanks for the questions. No, we do not wait for the MD to sign them. They agreed that they would want these orders initiated for the presentations that are listed for us. They sign them along with the chart when they are ready. We have a strong history of the docs wanting what is best for the patient. I don't see any doctor stepping out and refusing. I am sure the medical director would deal with anyone that did not sign. The algorithims are fairly straightforward and we have at least 20 different things to choose from.

We are pretty sure where to start with almost all of our patients. Anything high risk or high pay procedure is cleared with the MDs but the carepaths are clear about where to go. And a copy of the carepaths are included with each chart that is generated. We are actively encouraged to use them. For example, our patients that walk through our door (a bigger time challenge than the ambulance patients who are partially packaged) that need to go to cath lab have everything done and ready to go in less than 15 minutes on the average. The carepaths help us identify and treat these patients quickly. Part of the suspected cardiac carepath is to get the physician immediately if a STEMI is found. We do not wait for initial orders on EKGS, labs or lines for these patients.

True, if you step outside of the carepaths you are at risk. But we have so many carepaths there is almost nothing that we would need an IV for that we are not covered. A lot depends on your docs and how willing they are to take responsibility for what they want and for maintaining a good working relationship with the nursing staff.

[mannurse65]

A lot depends on your docs and how willing they are to take responsibility for what they want and for maintaining a good working relationship with the nursing staff.

So, I'm guessing you have never had a doctor denie that they gave a verbal order, or change

a written order or the time of an order? How about writing "I did not order this!" on a protocol

order? It only takes one patient complaining to the right person to leave you high and dry.

I am suprised that no one has had a personal experience with the frailty of Doctor - Nurse Trust.

[nuangel1, BSN, RN]

it comes down to your confidence level in yourself the protocols and the mds .we too use them and the dr signs em .i have been a nurse 22 yr and only 1x with a resident in the icu claim he didn't order something .but it was never me in trouble .the chief surgeon who's pt it was believed me not the resident .because i helped to stabilize the pt .its always about the pt.

[rjflyn, ASN, RN]

I was going to say like Jennifer mentioned we have a nice folder of protocols but everyone doesn't always neatly fit in to one protocol. Fortunately our doctors one understand this and two want us to use the one that fits best. Being Florida we get hit with pt loads this time of year that can cause waits to see a doctor of several hours. Having the labs done more often speeds things up. We also have a Flow Coordinator nurse who not only floats but chases down those labs and studies that should have been done hours ago or will order protocols if the nurse caring for the pt hasnt. This leaves the charge nurse to run the dept.

[Looking4Seaglass]

We recently had that decision to start an IV and draw labs taken away from us as well. This really ticked the nurses off as we know when one is needed, just as the docs do. One thing we do now........since we can trust our docs is say....... "Hey, I went ahead and started the IV and drew labs, cultures, they had to pee too, dipped that, and checked a BS since they are diabetic, etc....., can I write that as a verbal order?" Each and everytime they role their eyes and say....of course, thanks"

[sissiesmama, ASN, RN]

We do it all the time. Obviously we do it on critical patients but we also do it on anyone we know will need one. Anyone with Chest Pain, ect...

I'm not exactly sure what our policy says about it or the exact criteria but I do know we have a standing order. Also our Physicians will always back us with an order. They are very good about that!

Me too! We don't just do protocol bloodwork or that type of thing, but also concerning resp dx that are not so much "critical" at that time, but if it is a patient we know we will need one.

I do hate to read about what happened to that patient in question, but I have worked in quite a few facilities and was always done.

Anne, RNC

[sissiesmama, ASN, 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.

I have worked a lot of my time as a nurse in the ER, and had to go into the facility for an interview with stated reviewers r/t a patient complaint starting from a medicaid (I think!) patient who after I triaged them, the PA sent them to their PCP, which goes along with our policies. I was glad I had documented the things I did, I covered myself, thank goodness.

Anne, RNC

[Footballnut]

So, I'm guessing you have never had a doctor denie that they gave a verbal order, or change

a written order or the time of an order? How about writing "I did not order this!" on a protocol

order? It only takes one patient complaining to the right person to leave you high and dry.

I am suprised that no one has had a personal experience with the frailty of Doctor - Nurse Trust.

This seems to be a different subject. The carepaths have never been an issue. The medical staff was in the forefront of making them the way they wanted and they back them up. They even ask the nurses for suggestions about the carepaths to be sure they are doing what the nurses and the doctors want. What I'm saying is that it is working pretty well. I have a fair amount of independence in being able to make reasonable decisions.

I hate to sound Pollyanna about this but our ED docs are really good to work with. I have to watch my back side a whole lot more with practitioners and specialists from outside the ED group. I've had outside docs try to totally screw me because they would be in a whole lot more trouble if the pt went after them. Never went anywhere because I'm careful about what I do. In addition, if they mess with my patients they had better be worrying themselves.

And, our place would never tolerate and "I did not order this!" written anywhere. Whatever was wrong would be addressed off the legal record. In addition our risk manager is one of our former ED nurses. He does a good job addressing patient complaints but does not cave to nonsense. Everyone from the top administrator down punts patient complaints to him. I've had patients that keep trying to get another person higher in the organization and the same risk manager keeps showing up. I am aware that one day some real complaint could threaten my job so I keep my practice as sound as I can.

If you want to start a "doc said, nurse said" thread that's a whole different subject . . .

[rjflyn, ASN, RN]

What really helped us was for the longest time was that our nurse manager and the medical director (MD) are husband and wife. He's still there she's moved on but our protocols are as strong as ever. In fact we are looking at improving things.

Rj