In what instances would you use your chain of command

I can only offer two instances that both happened to me.

One time I needed the physician to come to the hospital to evaluate the patient following a C section who was bleeding into the fascia of her incision. She completely soaked the ABD dressing from the OR, I let him know, replaced the ABD with another, she soaked it again in less than 1 hour. The skin surrounding the incision was hard as a rock, bluish, lumpy and very painful to the pt. I knew she had to go back to the OR due to the bleeder. I called the doc again and asked him to come in now. He said "no" he understood my concern but he wasn't going to come back to the hospital and take her back to the OR. He said the bleeding would stop. So I initiated the chain of command. He finally showed up, opened up the wound, tried to use pressure to stop the bleeding(HELLO, i already tried that!), and guess what, went back to the OR with the pt to caulderize the bleeder he left.

Second time, I just had an outpatient triage pt and absolutely could not get a hold of the doctor on call. I'm at a small rural facility now, so I had to climb the chain of command to figure out what to do. I had to call the cheif of staff at 3am who knows nothin bout birthin babies. But I got my orders and was able to send the pt home.

Hope it helps.

In both cases, regarding staffing and physician issues. I have called upon and carried situations up chain of command when staffing was dangerously low AND when a physician was behaving and/or acting in a way that I felt jeopardized safety and/or wellbeing of patients.

One time we had to use it up the nursing chain due to the fact that the MD in question was our chief of OB! We had a level 1 nursery only and he wanted to induce a 34 weeker for PIH--she had intermittantly slightly elevated BPs and normal labs at that point and her cervix was fingertip. Basically, if he felt such a strong need to induce her, she was stable enough to send to another facility who could properly handle a 34 weeker. He called a ped who agreed to take the baby at our hospital, but there were no nurses who were going to agree to following the orders. Our manager was called in the middle of the night and backed us up in this. So, because the MD and the MD ped had no intention of camping out at the hospital all night to do the work themselves, the pt was transfered.

Used it twice recently...

Anaesthesiologist was not happy to be called to the bedside and then sent away when the pt decided not to have an epidural at the last moment and told the team leader RN that if the fetus should "crash" during the epidural placement that anaesthesia would NOT perform an emergency c/s (440 lb pt)

4th year resident wrote an order for 1 on 1 nursing care for an acutely ill pt who really needed an ICU bed for DIC and refused to call a consult from whoever could have admitted her to the ICU. She insisted that we needed to care for her here because ICU RN's would not know how to deal with a postpartum pt.