Here is a situation that happened at work today-I would appriciate any feedback! Without going in too much detail, here is what happened...
Have a pt whos been with us for approx 3 weeks (SNF)...came from Hospital, and was bedridden for aprrox 3 1/2 weeks while there,due to some medical dx and background pt thats not important-important fact is pt was bedridden for sig. amt of time. completley immobile. Anyways, pt get up OOB with PT at hospital for first time after 3 1/2 weeks-MD decides is ready for d/c shortly after...maybe 2-3 days later. pt having minimal amt of pt at time. Sent to our facility for rehab purposes, with goal of going home. Pt sent to our facility with orders for Lovenox 40mg sub q qday UNTIL pt ambulating. pt NOT ambulatory at time of comming to our facility...administrators ect were riding me about having lovenox d/c'd ASAP when pt started PT due to the cost of medicine..insurance would not pay for, facility to pay out of pocket. pt with us for 2 days and PT picks up-pt doing very well in rehab however i would not call it ambulatory. Unit manager gets on phone with MD after 2 days of PT and rec's order to d/c lovenox-MD states since pt is rec'ing PT should be fine. Ok, all is fine and dandy....I think 3 days later, asses pt, o2 sats 69% on 3LPM (COPDer), pt confused to the max, alert to self only, normally A&Ox3, flushes, inceased temp 101.5 ect....can't maintain sats, nebs ineffective blah blah, lungs diminished....MD say send to hospital...send pt out.......
pt stays at hospital about 2 1/2 days and returns to our facility-at hospital some cardiac workup was done and labs ect. pt comes back to our facility, with lovenox ordered 40mg sub q qday...this time does not specifiy when to D/C. I rec phone call from admin on my day off saying "i thought u got this taken care of, pt comming back on lovenox again, please clear with MD tomorrow, pt doesnt need to be on it, is ambulatory" I say ok will look at re-admission papers tomorrow on return to work. I do some research while im at home, I am not too familiar with lovenox, dont frequently use it. So i read some stuff about how its to prevent blood clots in immobile pt's or after surgery ect...I read about how DVT's can lead to PE's and so on....the PE part really stands out to me, im thinking "pt must be coming back on it for a reason, perhaps MD is worried about PE". I return to wrok and read the re-admission papers, still thinking about the PE. Admin still riding me about d/cing med. Unit manager talks to MD, MD states "is pt moving around", unit manager says yes. MD says ok d/c it then pt doesnt need it. The whole time my gut is telling me "pt does need it, and should have been rec'ing it for the last several days" pt is not ambulatory in my mind, some PT to the arms and the legs doesnt count I dont think. pt gets from bed to WC but a lift is used-heavy pt.
Anyways fast forward to today-I get to work 7am, another nurse is on phone with MD...same pt o2 sats drop again to 70's...cannot maintain, go through the same things as before...MD says "oh crap maybe pt has a PE she needs to go to hospital now". pt refuse to go to hospital, very upset blah blah blah, MD says ok well give pt lovenox 80mg sub q STAT and set appt for chest CTA and xray and pt needs to have that ASAP at hospital...I talk with pt and explain whats going on possible PE, importance of proceedures...pt says ok il go to hospital if you promise me that ill come back today...I say go to hospital and have tests and HOPE you will come back but cant promise....pt goes on to hospital...they call me a couple hours later say pt admitted, with dx PULMONARY EMBOLISM.
I am upset with myself because number one, I am the pt advocate first and foremost. i KNEW pt needed to stay on lovenox, i KNEW pt not considered ambulatory. I know the MD gave the order but in all honesty because the MD is only in house 1 x a week, us nurses are the eyes and ears for him. I feel terrible like I should have stood my ground and said to admin and unit manager, NO pt needs to con't on lovenox for a while longer, or something along thoes lines. I feel like this could have been prevented. I have never felt this BAD before. I feel like my judgement was not of a good nurse. I had that gut feeling, the one you shouldnt ignore. Im not sure that the lovenox would have prevented the PE altogether but my gut is telling me the outcome probablly would have been much different had I been the pt's voice and gone with MY instinct, something I knew was RIGHT. Since when did we put money before patients saftey and needs? I am so frustrated with myself. Everyone says "well the MD gave the order, all you did was follow it through" but in reality the MD was only going by what WE had to tell him...
Maybe I am over-reacting for being so upset???? Has anyone else been in a situation like this before? Thanks for letting me vent, I am just feeling crappy right now! Sorry its so long, and if there was too much info in there that anyone thinks could violote HIPAA, PLEASE let me know ASAP...this is my first time posting a scenerio like this.
I know I practice in a different system but it is so bizarre to me that a facility would weigh the cost of enoxoparin higher than the risk of a DVT.
To the OP - it sounds like you were under a lot of pressure to support ceasing the anticoagulant therapy, which was in any case the decision of the doctor. I suspect your pointing out that the physio was hardly sufficient to counter the risk factors would have made much difference. Not that this will help much, but it is always the cases like this that stick with you - if anything like this happens again you will have the experience to pick up and identify the issue right of the bat.
I know I practice in a different system but it is so bizarre to me that a facility would weigh the cost of enoxoparin higher than the risk of a DVT.
To the OP - it sounds like you were under a lot of pressure to support ceasing the anticoagulant therapy, which was in any case the decision of the doctor. I suspect your pointing out that the physio was hardly sufficient to counter the risk factors would have made much difference. Not that this will help much, but it is always the cases like this that stick with you - if anything like this happens again you will have the experience to pick up and identify the issue right of the bat.
Totally agree with this. I don't think you should beat yourself up over this. Learn from it for your future patients' sake.
Coumadin most certainly IS indicated for thromboembolism prophylaxis, be it PE or DVT, particularly in very high risk patients. In fact, that's almost all it's used for! To prevent stroke/PE in atrial fibrillation. To prevent recurrent DVT in patients with previous DVT etc.
True, but generally for medium to long term conditions rather than for the short post operative period indicated in this case because it takes so long to become therapeutic and required daily testing. For one of my patients, who was needle phobic and put on warfarin post-op was mobile and taken off it before she became therapeutic.
It sounds to me that even if you did advocate for your patient more that the hospital administration and the MD would have still discontinued the order. You did the right thing by investigating the medication more to help you make a more informed decision. I agree with an earlier post that your facility needs some education on DVT/PE prophylaxis. Lovenox has become a very common medication in the acute care and rehab setting. From your post I really feel that DVT/PE should have been a primary concern since the patient is obese, was bedridden for 3 weeks, and is beginning rehab. I would also be concerned that even if they were given Lovenox therapy they may not have been given adequate dosing. In high risk individuals I frequently see orders for Lovenox 1mg/kg q12 hrs. You said they ordered an 80mg injection stat after PE became a concern. This would be adequate for a 176lb high risk individual. BTW I read your other post too and giving two Lovenox shots at the same time is perfectly acceptable especially when dealing with higher dosages. I believe the highest dose in a syringe that my facility carries is 90 mg.
BTW your coworkers sound like a bunch of nitwits when they tell you something and have no evidence to back it up.
In fact, that's almost all it's used for! To prevent stroke/PE in atrial fibrillation. To prevent recurrent DVT in patients with previous DVT etc.
Not exactly. The most common cause of PE is venous thromboembolism, or DVT. Not A-Fib. Virchow's Triad is at work here.
The vast majority of clots that form in atrial fibrillation form in the left atrium and travel to the brain (=stroke). A-Fib is not a cause of DVT.
To equate coumadin use in people with A-Fib to DVT prophylaxis is inaccurate.
Those with confirmed DVT or PE are usually put on Coumadin until the clot has dissolved. They may or may not be on Coumadin to prevent future recurrence. Unless they are high risk, as in hypercoagulable state, they often are not.
At any rate, the patient in the OP did not need to be put on Coumadin, what they needed was to continue to receive LMWH until ambulatory. Since the facility was not getting reimbursement for the Lovenox, they pressured/deceived the physician into DCing it. This is disgusting.
OP, was the patient getting brand name Lovenox? I'm having a hard time understanding why the facility couldn't have obtained enoxaparin or even tinzaparin instead of putting the patient at risk.
Lovenox "until ambulatory" is too vague and in my opinion is a poor order on the MD part. How ambulatory is ambulatory??? A pt walking six steps to a BSC is ambulating but certainly not enough. Is walking six feet with PT enough??? I agree, you will never forget this important lesson. Remind adminstration the next time they try to interfere with your nursing judgement!
Specializes in Peds/outpatient FP,derm,allergy/private duty.
If "everyone" is saying "Well the MD gave the order, all you need to do is follow through"- "everyone" would be wrong. I seem to recall that a nurse using her judgement and questioning an order that isn't right is a requirement for us!
It's a little unclear to me who is normally responsible for communicating with the MD. They called you at home on your day off to tell you that you needed to call the MD the next day to have the order d/ced? Yet unit managers, other staff nurses, and administrators also call the doctor to request orders be changed? Thats a pretty murky chain of command!
Please don't beat yourself up anymore. As you said yourself, you can't know exactly what was going on with the guy. Now, to the question should you have spoken up about it- yes- in the sense of the doctor must have an accurate description of the patient's status before he orders or d/cs an order and frankly he was ill-served by those people and their penny pinching motives. You're not the one to decide "he should have been on lovenox" - let the MD decide that based on an accurate clinical picture.
Ideally, you speak to the doctor yourself. Having said that, I've read enough about SNF politics, I know it isn't always as simple as that! It may be you are working for people that don't have the patient's best interest at heart- and they never will. At some later time you might think about working at a place that has the same values as you do.
It is a good idea to critique ourselves in order to improve things in the future- maybe you'll be more assertive next time- but the point is this is an ongoing process for all of us!! You're doing the right thing! I believe they call that "critical thinking" You won't always be right, but you'll feel better about it the next day. Best wishes to you! :)
At any rate, the patient in the OP did not need to be put on Coumadin, what they needed was to continue to receive LMWH until ambulatory. Since the facility was not getting reimbursement for the Lovenox, they pressured/deceived the physician into DCing it. This is disgusting.
OP, was the patient getting brand name Lovenox? I'm having a hard time understanding why the facility couldn't have obtained enoxaparin or even tinzaparin instead of putting the patient at risk.
I believe that the MD was given the wrong info - at least a partial truth, of which the MD would ultimately be held accountable. The nurse is to give the MD accurate information - the OP could have called the MD and provided more detailed information, of which, I'm sure, the MD did not have from the reporting RN (or LPN). Either way, a good lesson.
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talaxandra
3,037 Posts
I know I practice in a different system but it is so bizarre to me that a facility would weigh the cost of enoxoparin higher than the risk of a DVT.
To the OP - it sounds like you were under a lot of pressure to support ceasing the anticoagulant therapy, which was in any case the decision of the doctor. I suspect your pointing out that the physio was hardly sufficient to counter the risk factors would have made much difference. Not that this will help much, but it is always the cases like this that stick with you - if anything like this happens again you will have the experience to pick up and identify the issue right of the bat.