I don't know what to think about this?

[Janlynn]

I work as an LPN doing Fast Track in our local ED. I just graduated in June and this is my first job as an LPN, I think I'm doing well and catching on fast, I haven't had a problem thus far--I do seek help if I'm not sure about something and my fellow nurses have always been kind and helped me. I get along with everyone there with the exception of last night.

I usually work 5p-1a, however since we're a NP short they've been leaving at 9p and I've been staying and just working with the doc's. Well last night I was leaving at 9p since I had a meeting first thing this am--I had pre-approved this with our Nurse Manager. When I get in last night we had a few pt's and I was informed that our NP was moving really slow. The ED was extremely busy and they started using some of our rooms which left us with 3 rooms--no biggie, it happens. Well the 3 rooms we do have open included one pt that was there before I got there and two that I had just checked in. The two I checked in took forever for her to assess, and they sat there for a good 2 hours, after I discharged two of those pt's I called another two more back. In the meantime the WR was filling up with our pt's. The other pt that was there when I got there was still there--it was a questionable fx--I put in orders for at least 5 x-rays. I called in two more pts one was a repeater that had just been there a couple of weeks before for the same thing. Anyway our NP sat on these three pt's the whole time, she was ordering test after test.

As she was sitting on these pt's the WR had at least 11 of our pt's out there with some waiting 4 hours in the WR. She asked if I could set up a pelvic on the one pt that was just there a couple of weeks ago--at which time she had a pelvic done--when I questioned her about it, she then stated to me "this may sound bad but I'm going to keep these pt's here until I leave" she didn't want to see any new pt's. I didn't know what to think.

I said something to one of the RN's about how long our pts had been there, I made no mention of what the NP had told me as I have always gotten along with her in the past I didn't want to come off as a snitch or something. I was getting really frustrated each time I looked to see the people in the waiting room waiting to be tx and there was nothing I could do about it.

Well lo and behold at around 9p she discharged the two pt's ,one that was there with a questionable break she finally called the ortho resident in and he immediatly said it's not a break. The other repeat pt was given the same meds as she's gotten in the past and sent home and the other pt was still there. I decided to wait until the last pt left before leaving as I didn't want to have to turn her over to someone else--everyone was so busy, I felt bad enough just leaving all of our pt's for them to p-up anyway. So 9:30 rolls around and she hands me orders for the one pt with the discharge papers attached. It's for a strong antibiotic given in two separate IM injections-this is a 5 yo who I had to hold down previously for a lab draw. I asked if there was any alternative and she said no. I told her I would need help holding the pt while giving the IM's and she told me to find someone to help me. It was for 1 gm of Rocephin which hurts going in. I was not very happy but was going to do it. I asked one of the RN's about it and she went in with me to talk to the mom and we determined that putting in an IV and hanging it would be less traumatic than two IM's. During this time the NP comes over the room with yet another order to call lab and order another lab test.

I finally said, I'm doing this now--I was supposed to leave at 9 and here it is almost 10, as I was saying this she said in a snippy way "Can I finish please" and I said yeah, go ahead. So she wanted me to call lab. OK. Why she couldn't do it--I don't know? Why couldn't she help me with the IM's when I help her with procedures? She was leaving, it was her last pt. She got upset when she saw that we were going to infuse the Rocephin insted of giving it IM and huffed as she walked away. She left.

I finally left a little after 10, the dept was still busy and there were a ton of our pt's still waiting to be seen 5 hours after walking through the door--not a very fast--fast track. I felt like crying on the way home. The other two NP's that I work with have never done this--they get them right in and right out--this is what our area is for. I usually feel like I do something good for these pts--except for last night I felt like I did nothing.

Do you think I may get in trouble for being defiant with her at the end of the night--do you think I should say something about what happened? I just don't know what to do. I feel like I don't even want to go back there. I don't know what to do? I'm really discouraged right now.

[Katnip, RN]

No, you probably won't get in trouble.

Yes, you should say something to somebody about it, your NM, your charge, whoever. They can then take it up with the head of the service that hires this NP.

Fast track is just that. Fast track. The goal in ours is to get most of them treated and out in less than 90 minutes. Admitting to holding patients just to keep from getting new ones is wrong. Your administration will be watching that sort of thing. THEIR goal is customer satisfaction and that means quick treatment.

[babynurselsa, RN]

Did you get an order to change the route on the rocephin? If she was upset you changed the route she is not going to cover you on that.

[Janlynn]

Did you get an order to change the route on the rocephin? If she was upset you changed the route she is not going to cover you on that.

You know things were happening so fast at that point. After me and the other RN went in to talk to the mother and the mother decided to do the IV instead of the two shots the RN was already putting in the line before the NP walked up there and started giving more orders. I didn't even think about getting the order changed. I'll just have to explain the situation and see where it lands me?

[JBudd, MSN]

Well, she tacitly consented when you told her you were doing IV instead of IM, but still, you are hanging out there unless you have a written protocol that you can change route on Rocephin at parent request. We always mix Rocephin with 1% Lidocaine rather than saline.

And yes, I would tell your manager about the holding onto patients comment.

Good luck and remember, this was just one shift. As you said, you get along well with all the rest of it; don't let her "win" by driving you away. We are the patient advocates, defending their right not to be held for convenience is part of what we do. Welcome to the world of ER!:kiss

[JBudd, MSN]

Meant to say we mix Rocephin with lido for IMs!

[Janlynn]

Well, she tacitly consented when you told her you were doing IV instead of IM, but still, you are hanging out there unless you have a written protocol that you can change route on Rocephin at parent request. We always mix Rocephin with 1% Lidocaine rather than saline.

And yes, I would tell your manager about the holding onto patients comment.

Good luck and remember, this was just one shift. As you said, you get along well with all the rest of it; don't let her "win" by driving you away. We are the patient advocates, defending their right not to be held for convenience is part of what we do. Welcome to the world of ER!:kiss

Thanks JBudd for your words of encouragement. I was going to use the Lido, I actually had it in my hand as I walked over to the pt's room. This little girl was deathly afraid of needles and her mom was like "there's no way that's going to happen". Luckily the RN that went in with me talked the mom into doing just one stick with the line--she was really good with the pt and got it started with no problem.

I have no idea what the protocol is--so if there is none what does that mean? Will it be a med error? What will happen to me? Will I be disiplined in any way? Like I said I'm new to all of this. I think I will just have to explain the situation the best I can and go from there. The RN knew the order was for IM and she's been there much longer than I have--so maybe there is some sort of protocol? I sure hope so.

[babynurselsa, RN]

I have never worked in a facility that a nurse may change the route without an actual change in the order.

This would be considered an error.

It may be that this RN knows how much latitude is allowed by this practitioner. It may be that she soes her own thing regardless of orders. If this is the case this would not be a good thing. If the NP was angry that you changed the route she may complain. I do not agree that just because she saw you doing it she tacitly agreed. At that point all she really could have done is make a scene in front of the mother which would have raised more red flags.

Is your manager approachable to discuss the original issue with? It is not proper procedure to sit all night on patients to keep the rooms filled.

[mommatrauma, RN]

If we have to split the shot for two sites, we get enough people to do both shots at the same time...one in each leg...that way the child only really feels the sticks once...and its done in 5 seconds and they are on their way...I think an IV may have been more traumatic than the two shots...and the lido would have burned for a second, but the site would be numb in a few minutes...My theory is you would have had to hold her down either way...I would have stuck with the IMs, but that's just me...

[Janlynn]

Please see my post above--the mother wasn't agreeing on the shots. I even asked her if her daughter had ever been immunized because that's what it would be like--she was still upset and shaking her head about it, the RN then asked about putting the line in of which she agreed to. It worked the pt got the antibiotic. It's obvious that the NP didn't even go in and talk to the mother and the pt before writing the order--the mother had no idea what we were coming in for until we told her.

I just think I'll have to talk to someone about the whole situation that night. I just want to make sure something like this never happens again.

[JBudd, MSN]

You're welcome Janlynn. Unfortunately, yes, it is a med error because you are responsible for following orders as to route. Can't tell you what the RN was thinking, but she should know better. You have to run changes past the one who wrote the orders, its outside of our scope to give anything by another route. The NP should have pulled you out of the room (or you her!) to discuss it.

End of the world? NOT at all. I totally agree with your decision to talk to someone, preferably your manager. Its very unlikely that a policy exists that lets you change routes, (and I personally wouldn't trust it anyway, BONs take dim views of working outside your scope), that said, again NOT the end of the world. :icon_hug:

[BBFRN, BSN, PhD]

I used to work in our ER fast track, where we also had a NP who like to sand bag the beds. She'll probably get found out by management, or called out by the other providers for doing so. We had a monthly print out that showed how many patients each provider had seen, and it was apparent and on paper what this NP was doing. She also got on the bad side of the ER attendings, who caught on to this and wanted to know why she was ordering so many tests on people. This was a big problem where I work, because we have so many uninsured patients.

At any rate, you might want to mention the problem to your manager, but she's probably hanging herself in the end anyway.