Emergency Titration Protocol ?

Sounds like a code. 44/20 with a HR = PEA (not guessing you could've found a pulse with that, especially on ECMO) You didn't say A-V or VV, but it doesn't really matter. Should have something on hand to show them for patients on ECMO.

All that aside, they are idiots and if they think you guys were "practicing medicine without a license" you should insist that they fulfill their obligation and responsibility to formally complain to your state board of medicine on behalf of the patient as well as the state attorney general for criminal investigation. Knowingly withholding information about criminal activity is a crime and they could be held culpable.

Morons throwing around stupid and incendiary accusations like that need to be taken to task. Guessing they'd back down pretty quickly.

Thank you! I appreciate your fire!

Btw.. it was A-V.

I will let you know how this unfolds. We have 3 of our pts on ECMO right now in the unit. I will chat this up with my Nurse buddies.

Since there is nothing standard about an ECMO patient I don't think any of that should apply! So annoying that people can't see that if you didn't do that you would just be enacted acls and be giving meds that way. I'm guessing the hospital can fix this by adding this to the standard Ecmo protocol order set. Maybe something along the lines of, in the setting of impending code, may increase pressors and notify physician immediately. í ½í¹„ So annoying that this is even an issue, so sorry, totally would've done the same thing. I mean when you have really sick patients you don't always have time for the doc to call you back to give fluid or increase gtts.

I don't want to sound rude or unprofessional but you can tell them to stick to their check lists and office work. This is the big leagues not some Doctor's office or school nursing office. Bring it to their attention that we could have either

A) Do what we needed to keep the patient alive

B) Followed "protocol" and have had our selves a fresh corpse

You could have gently reminded them why we work in a Critical Care setting by saying "I realize that there was no written order for me to save the patients life, but I did it with the patient's best interest in mind. Please speak to my Resident/Fellow/Attending to see if my actions were prudent for a patient in such critical condition. I could have left the patient to search for an MD but then I would have been cited for abandoning my patient in a time of need which would have led to their death and would have also gotten my Nursing License taken away. At least I still have a Nursing License and we still have a living patient to talk about right?"

Some people (JCAHO) are so far removed from the things we do, so out of touch with the reality of true Critical Care nursing, and have to deal with concepts that go completely over their heads that they stick to what they know.

I don't want to sound rude or unprofessional but you can tell them to stick to their check lists and office work. This is the big leagues not some Doctor's office or school nursing office. Bring it to their attention that we could have either

A) Do what we needed to do to keep the patient alive

B) Followed "protocol" and have had our selves a fresh corpse

You could have gently reminded them why we work in a Critical Care setting by saying "I realize that there was no written order for me to save the patients life, but I did it with the patient's best interest in mind. Please speak to my Resident/Fellow/Attending to see if my actions were prudent for a patient in such critical condition. I could have left the patient to search for an MD but then I would have been cited for abandoning my patient in a time of need which would have led to their death and would have also gotten my Nursing License taken away. At least I still have a Nursing License and we still have a living patient to talk about right?"

Some people (JCAHO) are so far removed from the things we do, so out of touch with the reality of true Critical Care nursing, and have to deal with concepts that go completely over their heads that they stick to what they know.

It's time to get rid off those clowns!

Those who CAN'T DO.. CARRY A CLIPBOARD!

I would have loved to have seen how they would have reacted to my actions if it was THEIR family member in that bed!

We are notorious for "practicing medicine" on nights. We have a LOT of autonomy on our units on nights because the drs and surgeons trust us to do what's best for their patients. They know we have the skills and brains. They do NOT let green nurses, newbies, or idiots take care of their patients. They will literally say, when wheeling the patient out from the CVOR, "DO NOT let, ***** take care of my patient!"

We are currently re-writing our ECMO protocols right now w/ one of our Intensivists and CT Surgeons. This is a process.. but I'm very optimistic on where it's going. Our CM highly encouraged the "CLIPBOARD NURSES" to attend as well.

Out of curiosity, what protocol would they want you to follow? I don't know nothin' 'bout no ECMO (we shipped them off to CV from the MICU!) but if there was a titration protocol, I didn't know of it. I mean, you kinda did what your preceptors did and then got to know the individual patient's response.

I would *love* to see these clowns hovering around a code.

Our hospital got called out by The Joint Commission before and accused us of "practicing medicine" (they like to use that term) when our electrolyte protocols weren't "tight" enough. They didn't like that our protocol allowed us to continue to replace after subsequent labs have been drawn after the initial replacement. They insisted we call the physician after the first lab draw if the electrolytes still needed replacing. Do you have titration parameters in place? EX: "Levophed drip to tritrate for MAP >65. Maximum dose of 20mcg/min"? That was another issue with TJC. They said nurses were "practicing medicine" if the exact parameters were not ordered. So we played along and changed our protocols but in reality it did not change our clinical practice at all.

They are always looking for something to justify their own existence. If they don't find problems, they don't have a job. Too bad they can't actually go do some good in the world instead of hanging out in the hospital terrorizing nurses and complaining about things they don't understand.

Kudos for doing what was right to keep the patient alive! My hospital more recently has worked to address this same issue; we also got cited for practicing outside of scope for drip titration. What was implemented into the eMAR order sets was the condition that any deviation from the ordered titration parameters requires a physician/ service note. Luckily for us, there is an almost full staff of providers at night, minus attending/ surgeon. We will inform the team and they will write a quick note justifying why titration was deviated from the order set for that event. We will see how we do on the next survey.

Also, I thought out of curtesy for the nurses JCAHO usually does not get involved during a code like situation? As in they will step aside to allow the nurses to work? Did they audit you right after? Or during?

When I worked ICU I do not ever recall an emergent protocol. If they tanked and the med was on the profile we began or increased the drip and you notify the physician. The alternative is to call, wait and then you are coding the patient - so WTF.

The goal is to save the patient and prevent code. If you are starting a med without an order then...maybe, but most orders provide a starting rate and titrate for BP of xx/xx or MAP of XX