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 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.
This is one of those lessons you learn. ADM will try to get you go do many things...you are the nurse..they are the paper pushers. Do your own research next time. Call the pharm and ask them to explain the drug next time, call the doc and explain the full situation...educate the ADM next time too. I've been in situations like this before, but not exactly pressured to d/c a certain med. Sometimes cheaper meds will work just the same as more expensive meds and docs will make changes if they are asked and know the whole picture.
Don been yourself up about this one...move on and learn from them.
No offense taken. The article backs up my assertion. It states that platelet aggregation inhibitors, such as aspirin (Plavix is not mentioned, but is also in this class), are ineffective in preventing PE. As far as Coumadin, sure I can see it being used in high risk patients, but it is not first line therapy for DVT prophylaxis.
Exactly. First line defense is typically initiated in the hospital. What goes on once they transfer to a rehab or LTC is different. Coumadin does take a long time to become therapeutic, which why my docs would often use the lovenox concurrently with coumadin and d/c the Lovenox once the INR was therapeutic.
I do have to admit that many of my patients on Coumadin did have multiple risk factors- often taking up an entire page when I would list their dx's.
This was an option that could've been suggested to the doc, so administration would be happy.(having a d/c date possible.) Not that it is her job, but as an advocate for my patients I've been known to say what about trying x therapy. In LTC/rehab we run into these situations all the time - insurance won't pay, facility won't pay, so we find out what they will pay for and get them on that. I don't know for sure, but something about this patient suggests that they could've fallen in the higher risk category.
Arixtra seems to be the best option out there right now, but it's newer and I'm sure that translates into more expensive - which explains why I have given it to exactly 2 patients.
I agree with some prior posts in that the MD was shortchanged information which ultimately led to poor care for the patient. Who is responsible? Why did your supervisor go over your head and call the MD? It is your license on the line, I would think that even if you weren't to call the MD per policy then you should've at least had a concensus on what to say if he/she was called. I'd consider it a lesson learned for later. I don't think you should beat yourself up, you tried to be an advocate and you lost this battle. You live to fight another day though and next time you will know.
Also, I wonder about the appropriate level of care for this patient being your facility. Perhaps a LTAC would be more in line with this patient's acuity.
And coumadin is not the first line of defense in PE, neither is LMW Heparin/lovenox, not that I've seen. Its straight IV Heparin along with coumadin until coumadin is therapuetic. I really rarely see people sent home on injections, and this may be due to the cost of them plus higher level of noncompliance.
Note to OP---- You provided waaay too much detail. This could be construed as a HIPAA Violation! I am sure you have absolutely the best intentions - to get feedback and learn from others, but remember to always be very general if you are referring to any patient car situation.
Please be careful - I don't want to see a conscientious nurse caught in the HIPAA web.
And coumadin is not the first line of defense in PE, neither is LMW Heparin/lovenox, not that I've seen. Its straight IV Heparin along with coumadin until coumadin is therapuetic. I really rarely see people sent home on injections, and this may be due to the cost of them plus higher level of noncompliance.
The hospitalized patient will be on a heparin gtt while the INR becomes therapeutic, but I've frequently seen patients DCd on an anticoagulation bridging protocol, which involves daily trips to the anticoagulation clinic for injections of LMWH and doses of warfarin until therapeutic.
Also, our hips and knees are frequently sent home with a 7-10 day supply of enoxaparin for DVT prophylaxis.
Note to OP---- You provided waaay too much detail. This could be construed as a HIPAA Violation! I am sure you have absolutely the best intentions - to get feedback and learn from others, but remember to always be very general if you are referring to any patient car situation.
Please be careful - I don't want to see a conscientious nurse caught in the HIPAA web.
Thank you for spelling "HIPAA" correctly. Spelling it "HIPPA" is one of my absolute pet peeves. Like nails on a blackboard.
What is prescibed depends on the practioner and institutional practices. I'm just pointing out that there are cheaper alternatives that are in use even though they aren't "first line of defense" or even the best or more appropriate therapy available. And if nobody will pay, and my patient's hx seems to indicate a need for an anticoagulant, then I'm going to at the very least suggest that we try an alternative.
It happens all the time. For some reason, hospitals are allowed to use meds that will get denied in rehab/LTC It's very frustrating. They may fill it initially but then fax a slip saying they need to switch A med to B med. We fax the docs for them to sign off on the request and then sometimes they will get ticked off and say no. They won't d/c it the pharmacy won't send it and the patient gets nothing and the nurse in the middle gets cited for a med error. (that's when my nurse's notes gets very specific about what is going on to protect myself.) BTW you don't give Heparin IV in this type of setting. (At least not yet - we never did TPN but that is becoming more common. )
Note to OP---- You provided waaay too much detail. This could be construed as a HIPAA Violation! I am sure you have absolutely the best intentions - to get feedback and learn from others, but remember to always be very general if you are referring to any patient car situation.
Please be careful - I don't want to see a conscientious nurse caught in the HIPAA web.
How so? I don't see any identifying info here. I can't access the OP's profile to identify a location, and there was no disclosure of pt's age, race, name/initials, or other identifying information.
I already stated that it is indicated in high risk patients. It is not first line therapy for DVT prophylaxis in low to moderate risk patients.
I didn't suggest it is, nor do I require a tutorial on the cause of PEs or the mechanism of DVT. I am pretty clear on that. I was merely responding to your verbatim quote that stated:
Originally Posted by Virgo_RNCoumadin, Plavix, and ASA are not indicated for DVT prophylaxis
I currently have a father on coumadin for stroke phophylaxis due to AF, a brother on coumadin for DVT recurrence prevention after a large DVT earlier this year, and a mother on coumadin for PE recurrence prevention after a PE earlier this year.
Thanks to all who relied. I am feeling a little better about the situation today. Heard that my pt is doing fairly well in hospital so that makes me a little happy! Some answers to the replies-No, there was no dx of PE when the pt return from hospital. That def would have red-flagged me to keep the lovenox. No CXR done in hospital either. Could have been for a multitude of reasons, who knows what they are! Not sure why facility didnt want to switch to a generic brand, and i certinaly didnt think of that. I think from the get go they were so concerned with the $$ that they just wanted it gone ASAP. Pt allergic to coumadin so that not an option. In regards the low o2..a mask was placed on pt and o2 bumped up, but was ineffective. the highest it would go was 84 and then drop right back. Also im a firm believer that simply "pushing o2" does not solve the problem. o2 sats drop due to an underlying cause generally, and if breathing tx are ineffective and whatever else MD may order are ineffective then i certianly dont want to just keep pushing o2. EMT's came in one time and said "oh you called for low o2 sats but my machine is reading 93%" This was AFTER the bagged pt and put o2 up to 15 liters-OF COURSE ITS GOING TO READ HIGH NOW!!. My co-workers, while most of them are very helpful and very educated-there are thoes few who act like "know it alls" and feel like the have to belittle thoes of us who may not know as much as they do, or they THINK they do. I cant stand it. I may not know everything, but I pride myself on the fact that I ALWAYS try to seek learning opportunities and I never am afraid to ask questions.
To NurseL156-Yes, they called me at home, on my day off from work to ask me about this pt. I was very irritated I said to the person who called me "please look in the chart and you will see where I d/c'ed the order on such and such date". They then proceeded to say "when you come to work tomorrow i need you to page the MD and get it d/c'ed again". My response was-its 12:00 noon and there is a perfectlly capable nurse in the building right now who can page the MD and get this taken care of right now, if thats what neccessary, please dont call me on my day off unless its an emergency". So when i return to work, they tell me "oh we paged the MD like 5 or 6 times and he never called back". While that is belivable sometimes, i doubt it was this time. I get sooo frustrated because things like that happen all the time. And EVERYONE Talks to the MD, like the DON, the ADON, the unit manager, nurses who work on different halls...but like when the unit manger takes orders, she will only write the order and not sign it, and not take it off in the chart. Us floor nurses have to rec the order, send to pharm, note in chart, talk with family ect. And then half of the time weeks later, someone else will question the order and because i signed it, i have to take all responsiblity. It sucks and i have brough it to mgmt's attention thousands of times, that when nurse's write orders they need to SIGN THEM THEMSELVES so they can take the accountibility. Its helpful to have the unit manger to talk to the MD and rec orders, but its not helpful when the unit manager doesnt know the patients like us floor nurses do, and then all hell breaks loose when you question why they got an order for something...i guess thats why they hole that oh so important "title". Hmmmm...sorry for the mini vent.
As for my post being a violation of HIPAA....maybe I should take it down????
Note to OP---- You provided waaay too much detail. This could be construed as a HIPAA Violation! I am sure you have absolutely the best intentions - to get feedback and learn from others, but remember to always be very general if you are referring to any patient car situation.
Please be careful - I don't want to see a conscientious nurse caught in the HIPAA web.
how did she provide too much detail? Do we have a location, or name of facility? I think she has been pretty general...
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CoffeeRTC, BSN, RN
3,734 Posts
This is one of those lessons you learn. ADM will try to get you go do many things...you are the nurse..they are the paper pushers. Do your own research next time. Call the pharm and ask them to explain the drug next time, call the doc and explain the full situation...educate the ADM next time too. I've been in situations like this before, but not exactly pressured to d/c a certain med. Sometimes cheaper meds will work just the same as more expensive meds and docs will make changes if they are asked and know the whole picture.
Don been yourself up about this one...move on and learn from them.