Question for those who work in small and/or rural hospitals. - page 2
I work in a small rural hospital. Our hospital has about 80 beds total. The med/surg floor has about 30 beds, and there is a 4 bed ICU. Our ER is staffed 24/7 by a physician. The other doctors are... Read More
Jun 30, '02Joined: May '01; Posts: 12,079; Likes: 15,900My hospital is really, really small: about 35 beds total. But "oh-agnurse" your hospital got us beat!!!!
The E.R. doctor comes during the codes. If he's unable to come because he's coding a patient in the E.R. (believe me, this would be the ONLY reason the E.R. doctor would not come during a code), I run the codes (the ICU/CCU nurse) until a doctor comes.
When a person is more or less slowly goes down the tubes, we manage that patient with the covering physician over the phone. This is done initially until the covering physician comes to the unit. . . maybe.
We have only one part-time cardiologist . . . Mondays through Fridays 8:00 am to 6:00 pm. The rest of the admitting physicians are basically GP's.
Our RT inhouse coverage ends at 11:00 PM. There is alway some RT on call, though.
TedLast edit by Ted on Jun 30, '02
Jun 30, '02Occupation: Nurse Consultant Specialty: 24 year(s) of experience in Obstetrics, M/S, Psych ; Joined: Jun '02; Posts: 3,105; Likes: 49The ED doc in Our small rural hosptial responds to all codes when PCP is not availbable. I was suprised to see that this is not so in many of the other small hospitals. Seems there would be some legal ramifications for not responding, but obviously not. Go figure.
Jun 30, '02Occupation: Nurse Educator: love those students! Specialty: Med/Surg,ER,L&D,ICU,OR,nrs. educator ; Joined: Apr '02; Posts: 968; Likes: 41Our ER docs are our GP's (they take turns on-call and assume responsibility for all in-patients and the ER). They do not sleep in the hospital (generally) so we would have to run codes, react to a bleeder ourselves until doc shows up(mandatory 20 minute response from them). RT is done at 6pm (although someone is on call with a 30min mandatory response time) but they do not intubate anyway. It would be more likely that us RN's would insert a combitube then it would be for RT to intubate someone.
If we have contract docs covering ER (some weekends), their contract stipulates ER only....they do not have anything to do with the in-patients, although I haven't met one that wouldn't step in to help us if a 'situation' cropped up.
Jun 30, '02Occupation: Registered Nurse Joined: Aug '01; Posts: 997; Likes: 23What do other facilities do in this situation?
Jun 30, '02Occupation: RN Joined: Aug '01; Posts: 2,276; Likes: 42I like the idea of emergent transfer to ER! Our facility doesn't have a mandated time for the PCP to respond (or if we do it is not adhered to by most PCPs). We are fortunate that we have RT available 24/7 in our facility. Getting the person intubated wouldn't be a problem. Our ER docs show up for codes, unless there is one in ER at the same time. That doesn't happen often enough that is a concern to me. Maybe our facility needs at looking at policies to get the PCP there sooner. I really appreciate everyone's input on this subject. I have learned a lot about other small facilities. Maybe that could be a topic of its own: Rural/small hospital nursing.Last edit by deespoohbear on Jul 1, '02
Jul 1, '02Occupation: Deputy Ward Manager Joined: Apr '02; Posts: 523; Likes: 7When I posted my earlier reply about Blue Lighting - had been working in the Unit 1 yr not had to do it.
BUT today at shift start had a NIDDM pt who was unresponsive on sliding scale insulin.
Little Dr. unsure so sent him to ER took 10mins and they are keeping him.
SO it seem to work just fine
Best wishes to you all
Jul 1, '02Occupation: RN Joined: Apr '01; Posts: 117; Likes: 18I work in a rural hospital, 24 bed Med/surg and 4 bed ICU. ER docs will respond to code blue in these areas. All of our primary docs and internists (except one) live in close proximity to the hospital. When we need intubation it is either the CRNA or RT to do the procedure. The patient is usually already tubed by the time the doc gets there. We have great response time from everyone.
Jul 1, '02Joined: May '01; Posts: 12,079; Likes: 15,900Originally posted by WashYaHands
Hire a Nurse Practitioner
Actually . . . .
Our hospital hired a new night supervisor who was also a Nurse Practitioner. She used to work on our ICU/CCU . . . just recently received her Nurse Practitioner education and stuff. So she took the job . . . thinking that she would be to utilized her Nurse Practitioner abilities as was told she would be able to do . . . down the road. She was smart and totally dedicated to the hospital.
Well . . . the road never came. Apparently the Chief of ER . . . or whatever his title is . . . . doesn't like Nurse Practitioners.
She's now working somewhere else utilizing her talents.
. . . . ahhhhh, small hospitals. . . . got to love them . . . got to hate them.
Jul 1, '02Occupation: Deputy Ward Manager Joined: Apr '02; Posts: 523; Likes: 7Oh Shame
Same happened to us. Apparently a part of their job discription was teaching but AT NIGHT. let's be fair didn't happen due to circumstances beyond their control
Nurse Practioners are worthy they weight in gold
Jul 2, '02Joined: Mar '01; Posts: 230; Likes: 4I did not read all of the posts here, but as an ER nurse I back an ER doc not responding to anything other than a code, in a small hospital. If the surgeon was 30 minutes away he should have given you orders. Get the fluids rolling, insert the ng tube, yadda yadda. If these things didn't help and patient crashes call a code!! Sounds harsh I know but, between liability and never knowing what is going to come through the ER doors. It is safer this way.
I worked med-surg as well, at a small hospital to boot. It is frustrating not having immediate access to a doctor, one of the many reasons I love ER nursing.
Jul 2, '02Joined: Aug '01; Posts: 892; Likes: 3Is the country club/golf course/$500,000.00 homes subdivision thirty minutes AWAY from the hospital ?...These docs are fully aware of how far they are from the hospital when they purchase their homes. If they don't care, then why do you have your knickers in a knot?
That's what phones and faxes are for. do your doc's have faxes at home?? Most do. You can fax ekg's. You can type and cross, start fluids, draw stat labs and have 90 % of it done before he walks thru the door. GI bleeder, you've already got the blood in the blood bank, do stat HH, call dr. Get 2nd or 3rd iv access line going , start NS, get order to start blood and do it ! Throwing up BRB...insert ngt and start icing them down with normal saline...have someone doing vitals...You won't have time to be watching the clock...if you are carrying out verbal orders....put o2 on pt. .do stat labs, start ns, NO doc is going to criticise you for common sense nursing decisions.
Pts start trending down prior to a code, usually. I never wait til they are asystole or in resp arrest to call a code....Why would anyone do that? you can see which way they are going....
Jul 2, '02Occupation: Hospice clinical director Joined: May '02; Posts: 2,873; Likes: 26I'm not saying that this is right, but there are nurses who are not as aggressive about initiating interventions without a doc's order. I am not sure if this is from lack of experience, or institutional.
I do agree...you should not be waiting until there's a full blown crisis (not that this is the situation here). It is rare for someone to abruptly crash; if something is "niggling" at you that the pt just doesn't seem right, call the doc. Basic interventions like starting lines, getting EKG's, labs, O2...well, any doc that reams you out for that is an idiot.
But I still feel that the ED doc is there for the ED, he's not the hosp. on-call doc. Once he/she gets called to help for something other than a code, eventually is will become the expectation that he/she will continue to be available, it's just human nature.
Trust your assessment skills, do your interventions, marshall up ancillary help...then call a code IF appropriate.
Jul 2, '02Occupation: Nurse Practitioner Joined: Jan '01; Posts: 481; Likes: 36I agree with fab4fan and others....
We are going to a similar situation here. Small hosp. ER docs are refusing to go to codes or urgent situations inhouse as they will not be available 'in case' a trauma should come in the door. To compensate all ICU nurses are ACLS certified and can initiate treatment according to those guidelines (covered by standing orders). My other suggestion is to DO YOUR HOMEWORK, research guidelines for emergent situations and follow them. Have lots of resource material aroung such as the Washington Manual etc (what do you think the residents and interns use at 2AM in teaching institutions?) BE proactive, make sure you have the worst case scenario covered, such as ask the surgeon what he would like you to do if his patient were to suddenly bleed out and drop his pressure? or what if your patient goes into status epilepticus, what is the immediate treatment? Dont take 'just call me' for an answer, the docs have to be accountable too, if your not comfortable with their answers get an explanation. Get your NM or DON to support you on this. If they dont go to your state Board of Nursing and find out just what you can and cannot do in this situation. When I worked in NC as a transport nurse we were able to get special permission from the BON to intubate. There are ways to get your patients the care they need and deserve and you are probably it!