Question for those who work in small and/or rural hospitals.

  1. 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 family practice who usually round just once a day. Here is the question. A couple of the ER docs basically refuse to come to our unit if there is an emergent situation and the family doc can't get to the hospital in a reasonable amount of time. We very rarely call for the ER doc to come, but when we do we mean business. Some of the family practice guys are 20 to 30 minutes away from our facility. The ER docs say their malpractice insurance won't cover them outside of the ER, therefore they don't want to get involved. Our DON supports the ER docs on their position. She says 30 minutes is a reasonable amount of time for us to wait for the family doc. She says the ER physicians number one priority is the ER. The ER docs are suppose to respond in a code blue situation on our unit, provided they are available. I think the DON's idea stinks. She has no idea what it is like to be in a situation with a crashing patient and no physician available. What do other facilities do in this situation? If the ER doc is the only physician in the house and an emergent situation arises, is he or she expected to respond? Or do you just wait until the patient's regular physician or on call doc arrives? I would really like to know. I need to know how to present this to my DON. Thanks.
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    Joined: Aug '01; Posts: 2,276; Likes: 42


  3. by   fab4fan
    I work in a small hospital, too, in the ED. Our docs will only go to the floors if there is a code. I think it may be related to their malpractice. There could also be a "political" component, too.

    Personally, I support them in this. You never know when someone could come through the doors and need immediate attention; if the doc is off the floor attending to something other than a code, he could be in for a world of trouble, legally.
    Also, and I'm not saying you guys would do this, I think there could be the tendency for people to start to expect this of the ED doc, not just from the staff, but from attendings as well.

    It's really just not appropriate for the ED doc to be the "fall back guy" unless it's a code, IMO. :spin:
  4. by   BadBird
    I remember working in a small hospital like that. I am used to a large teaching hospital now with residents always in the unit 24/7 and I can't imagine waiting 30 minutes to intubate if needed. You are working in a very scary situation I suggest you document to cover your rear. Any chance of working somewhere else? I would seriously consider this. Good luck
  5. by   fab4fan
    PS: I know it's unnerving to be with a crashing pt, waiting for the attending to arrive...I didn't want to sound unsympathetic; it's not unusual, however, for people to come staggering into the ED in anaphylactic shock, heroin OD's being "dropped off" by their buddies, acute chest pains walking in, etc., you get the idea.

    If the ED doc is off the floor for anything other than a code and something like this happened...WOW...trouble, big time.
  6. by   fab4fan again. You can always get RT to "tube" if needed, so you shouldn't have to wait for that...but like I said, it can be scary, and I've been there.
  7. by   deespoohbear
    The situation I am referring to is a GI bleeder (actively bleeding)!, with no palpable B/P. The surgeon on call took 30 minutes to arrive at the hospital. So, what do the nurses do in that situation? In the eight years I have been at our facility, I can only remember the ER docs being called to the floor for a non-code situation maybe 5 times. To me, that isn't over using the ER doc. I am not one to call for immediate physician assistance, but by George, if I say I need a doc, I mean it!! Our ER has standing orders for every imaginable scenario. The nurses start ordering labs and such before the doc even sees the patient 90% of the time. I don't believe in calling a code unless the patient has actually arrested or is near arrest. Our DON suggested that maybe we ought to call a code if we can't get the doc up there any other way. I think that is a lousy idea. I think that situation would just be setting up for abuse! To me, 30 minutes is a long time to be waiting for a doctor when someone is bleeding out as fast as you can pump the stuff in. I wouldn't want to be that patient or that patient's family.
  8. by   canoehead
    In our hospital the ED MD responds to codes, but will come to the floor prn at the request of the supervisor- they assume that if it is bad enough for them to leave the ER that the sup is involved. We call the FMD first and get orders, but if a code is imminent, or something changes during their ride in to see the pt the ER MD is available. They do not fully assess or start their own treatment plan, they merely stand by to provide needed stat orders. Sometimes the FMD will call the ER and ask them himself to go up and assess the pt.

    Even though they don't DO a lot is feels much better to have someone available to intervene in a hurry, intubate, head off a code etc. Nursing draws labs, gets an EKG etc and gets the orders once the doc gets there. I think that if there was an MD in house and he/she wasn't called when immediate care is needed the nursing staff would be negligent. However if you call and he refuses to come it is on his head. So can you all agree to do that- you'll call, they refuse, and you chart it? Or can you get in writing the policy that the ERMD is NOT to be called unless heart or breathing stops? Put the responsibility on the instuitution to fix the problem.

    Of course no one could blame you for calling them anyway and be damned the policy. Good luck.
  9. by   deespoohbear
    Thanks for the replies. Canoehead-You can bet it will be in writing that the ER doc "declined" to come to the floor! All the times and phone calls would be documented. I would cover my backside so well if that situation arises, they would never find it! I always call the family doc first if I need orders. I only use the ER as a last resort. I also agree with you Canoehead that if the ER doctor was asked to come and help with an emergent situation and refused to do so there could be some serious legal problems. Especially if the patient had a negative outcome. RT is always available to intubate, so that doesn't worry me. What concerns me the most is if you have a patient that is going down the tubes and you can't get some doctor to get up there to give just basic orders until the family practice doc arrives. I hope our facility can find a solution soon, before someone suffers serious consequences.
  10. by   fab4fan
    In your situation, I would say, "call the code" if the pt truly had no BP; there are things I would just go ahead and do if it would be an ED pt, but I don't know if you'd be able to get away with it on a M/S floor. But get as many ancillary personnel you can, eg RT, supervisor. Could someone have gotten phone orders from the doc that was in transit?

    If you think about your situation, though, can you see how it could turn out to be very messy, tying up the ED doc and taking him away from where he is assigned. I really believe that there are liability issues driving this.
  11. by   st4304
    I work in a rural hospital (around 325 beds with 16-bed ICU) and our ER docs only respond to codes. But I'm not complaining. That's just one of the many responsibilities of working nights --- we have to stay on top of our game and know the early signs of trouble so we can be talking to the patient's MD from the get-go. Sometimes that's not possible, I know, but we just deal with it until the MD shows up or the patient crashes (THEN we can call a code).

    We once called a code on a young girl (22yrs old) in our ICU who stopped breathing during a seizure. (We also had 12 patients to 3 RNs that night! -- but that's another post!) We got in an oral airway and started bagging her. When the ER doc arrived and saw she had a heart rate (160s to 180s), he asked if her doc was on his way in. I responded 'yes, he'll be here in about 20 min.', his response was, 'call me if her heart stops. Otherwise, just do what you're doing.' He turned around and left. Her seizure lasted 55 min, she ended up intubated when her doc finally showed up, but she made it.

    Also, if you are needing to 'tube' a patient, that's a code in my book. Call it.

    Nightshift Nurses Rule!

    Your pal,

  12. by   jevans
    Hi All

    Things are the same here. If we have a situation like this we need to BLUE LIGHT the patient to ER.
  13. by   canoehead
    There's a thought emergent transfer to the ER!

    If the ER MD is unavailable because of his ER duties the supervisor runs the code until another MD can make it in.
  14. by   oh-agnurse
    I work in a small rural hospital (22 bed M/S and 4 CCU beds), besides in a large teaching hospital. In the small hospital (I work in the CCU), if we call a code we are it ! The ER docs don't come, and to cut cost RT leaves the hosp. at 7:30 pm nitely. If I have 1 to 2 pats. then I'm on my own ---I'm screwed!!! The RT and the PMD have to be able to get to the hosp. in 20 mins. !! I like the code teams of the large hospitals!!!