EPIC and carrying out orders?

[JKL33]

Googlenurse said:

The ED at the hospital has a habit if sending patients up with orders that should have been done in the ED.

Because that is not how the ED works. The overarching goal there is to safely dispo patients, meaning get them out of the ED. They are either staying or going. In the case of staying, as soon as that is decided the goal is to make it happen so that the bed can be freed up for the next patient. Whatever is in progress at that time is continued in the next place. There are plenty of situations where ED patients have orders for things that might be necessary but do not need to get done in order to figure out whether the patient is staying or going, and/or do not facilitate them getting there. So they are lower priority.

Googlenurse said:

I was told in orientation that if you acknowledge an order, you are responsible for carrying them out. 

I would guess that what was said was more like, "responsible for seeing that they are (or have been) carried out appropriately." There is no way one nurse can personally carry out every single order.

With that said, I agree with your general concern on this one.

There is a reason that an RN needs to sign their name to something. Acknowledging an order is the same as taking nursing responsibility to see that it gets done or has been done. Though employers might like to make us feel like "acknowledging" is just a box-checking type of formality, nah, it's taking responsibility. In my opinion the responsibility for acknowledging should fall to the person who had a fair likelihood of having the opportunity to at least do basic double-checking and see that things are in order.

ETA: You could facilitate a discussion about this by just asking "so when we are acknowledging orders, what is the purpose of that? What are we attesting to? That we "saw" the orders? That they are appropriate for the patient? That they got done? That we carried them out ourselves?" Get an answer then you can decide how to handle. You should decide how to handle based on the answers you get; not on whether someone on the previous or next shift is going to huff and puff about it.

[chare]

Googlenurse said:

[...]

If the patient came to the floors at say 4pm, but an EKG was ordered at 1pm, but the ER nurse never acknowledged it, who has to do it?

The nurses on the floor are saying since the order was written while the pt was in the ER during that time, the ER nurse should do. 

[...]

I agree with your coworkers that the ED nurse should have done it.  However, it wasn't, and since the patient is now on your unit someone needs to complete the ECG.

Googlenurse said:

[...]

Another disagreement happens during shift change. Our doctors will round and write order between 0630 and 0700. My shift ends at 0645. I do not acknowledge orders because then I would have to carry them out, right? I would also be responsible if an order is wrong or inappropriate. 

I've gotten into a few arguments about this with day shift nurses. They are saying since it occurred when I was there, I should acknowledge them. 

[...]

I'm not sure I follow your reasoning that you would "be responsible if an order is wrong  or inappropriate."

Acknowledging an order doesn't mean that you are responsible for implementing it.  It means that you have seen and reviewed them, and addressed any issues or concerns that you encountered.

As for as not acknowleging orders at or near your shift end time.  In my opinion too many nurses seem to believe that this is some magical time at which your responsibility to provide care for the patient; it doesn't. All this does is provide more fuel for the shift wars 

Googlenurse said:

[...]

Who is right in these situations? 

Again, in my opinion, neither of you are "right."  When shifts tif over whose responsibility a task is, rather than just doing it, the patients are the ones that end up paying the price.

Best wishes.

[Been there,done that, ASN, RN]

Most units have a policy regarding end of shift orders. Most frequently, I saw that if  orders were  written less than an hour until the end of shift.. it was the oncoming shifts responsibility. This is to reduce overtime. Of course, if it is a stat order... things are different.

 

[sideshowstarlet, BSN, RN]

I'd probably say acknowledge it, and, as far as actually implementing orders written close to shift change, do what you can. If the next shift gives you flack about you not having time to implement every single order written on your shift, have them fill out the form to approve overtime. 

[Tweety, BSN, RN]

Been there,done that said:

Most units have a policy regarding end of shift orders. Most frequently, I saw that if  orders were  written less than an hour until the end of shift.. it was the oncoming shifts responsibility. This is to reduce overtime. Of course, if it is a stat order... things are different.

I've never heard of such a policy.  Basically where I work it's a "work it out amongst yourselves".  But I agree if there's an hour left in my shift it's my responsibility.    I've had to pass on shift change orders especially since we get a lot of shift change admissions.  But if it's an order I have time for, I get it done.  

[NRSKarenRN, BSN, RN]

JKL33 said:

Because that is not how the ED works. The overarching goal there is to safely dispo patients, meaning get them out of the ED. They are either staying or going. In the case of staying, as soon as that is decided the goal is to make it happen so that the bed can be freed up for the next patient. Whatever is in progress at that time is continued in the next place. There are plenty of situations where ED patients have orders for things that might be necessary but do not need to get done in order to figure out whether the patient is staying or going, and/or do not facilitate them getting there. So they are lower priority.

I would guess that what was said was more like, "responsible for seeing that they are (or have been) carried out appropriately." There is no way one nurse can personally carry out every single order.

With that said, I agree with your general concern on this one.

There is a reason that an RN needs to sign their name to something. Acknowledging an order is the same as taking nursing responsibility to see that it gets done or has been done. Though employers might like to make us feel like "acknowledging" is just a box-checking type of formality, nah, it's taking responsibility. In my opinion the responsibility for acknowledging should fall to the person who had a fair likelihood of having the opportunity to at least do basic double-checking and see that things are in order.

ETA: You could facilitate a discussion about this by just asking "so when we are acknowledging orders, what is the purpose of that? What are we attesting to? That we "saw" the orders? That they are appropriate for the patient? That they got done? That we carried them out ourselves?" Get an answer then you can decide how to handle. You should decide how to handle based on the answers you get; not on whether someone on the previous or next shift is going to huff and puff about it.

EXCELLENT advice as always! 

Review facility policy and respond based on that and seriousness of patient condition:  STAT should be signed off as acknowledged but CAN be passed on to next shift to follow-through with order when prudent e.g. awaiting med from pharmacy, need to get special lab tubes or central supply equipment, 

[JKL33]

And I wouldn't even entertain malarkey about shift change orders. If they are written within 15-30 min of shift change or so then the bellyaching about it is just ridiculous. Life has trade-offs. If people don't like it that doctors round and write orders near the time their day shift starts, then they are welcome to join the dark side where you get to try to run your life on two separate sleep-wake cycles, freeze your *** off and have dried donut crumbs lunch ?

[mmc51264, BSN, MSN, RN]

Sorry, but just acknowledge that darn orders! They can be discussed in report. Unless it is something that needs to be done STAT, it doesn't matter who acknowledges them.  alot of times, there are orders for urine tests in the ED, but the pt doesn't void, it has to continue to the floor. If a pt needs an EKG, acknowledge the order and then the techs can find the pt. 

Not sure why this is an issue. 

[mmc51264, BSN, MSN, RN]

JKL33 said:

What is the purpose of this action called acknowledging? If there's no purpose to it then it should be completely eliminated.

No, it's to signify that someone has seen, read, and, well, acknowledged the order (s). If it is not something that can be completed during one's shift, it carries over to the next shift. 

In EPIC, the worklist will have the items like urine tests, etc that are under nursing purview. Others, like an EKG, will go to electronically to that department. Same with xrays, CT, MRI etc. 

[mtmkjr, BSN]

Acknowledge and complete assuming you have time. 

Acknowledge and begin to carry it out, the next nurse will complete if you don't have time. 

Acknowledge and communicate the order if you aren't able to complete it.

Ask the next nurse if they want you to acknowledge. If yes then expect that they will be looking at active orders and ensuring everything gets done until the cycle starts over at the end of their shift.

They may say no, leave it for them to acknowledge. 

All the above would be correct.

Acknowledging an order just means you are aware that the order exists.  The responsibility is either to complete it or relay to the next shift, whatever is appropriate, assuming you put your best effort into completing what can reasonably be done.

[LovingLife123]

I acknowledge the orders so epic then puts my orders in their proper place.  I don't do floor orders.  I'm just acknowledging that I'm seeing them and I sort through what may or may not apply to me in pacu.  

Some physicians don't grasp the whole signed and held orders.  They make everything active.  Also, some physicians like to throw every post op order in no phase of care.  It's annoying.

As far as shift change orders, on my old unit, I didn't do any order after 1845.  I left those for night shift.  I had one nurse try to give me crap about my 1900 admission and some labs one night.  I looked her dead in the eye and said you're lucky I bathed them.  

[Googlenurse, ASN, BSN, RN]

I was told in orientation that if you acknowledge an order, you are responsible for carrying them out. 

The ED at the hospital has a habit if sending patients up with orders that should have been done in the ED.