In need of ED RN

Tweety, BSN, RN · May 13, 2009

Insulin drips should have an established protocol of q1h or q2h accuchecks. Or so I thought.

Tiffofc · May 13, 2009

While in the ED, every hour is both of my hospital's policy. Your situation... totally unsafe. May I suggest http://www.nso.org for nursing insurance if your facility is willing to put your license at risk so much! :eek:

Medic/Nurse, BSN, RN · May 13, 2009

An insulin gtt should run at 10-15 units/hr until the FSBG is 250 or less.

Prudent practice indicates that FSBG is checked hourly until this 250 or less threshold is achieved - or until the insulin gtt is d/c'ed.

3 hours is a long time to go between checks - now if the level was still over 500 or so, that could explain the interval in some messed up quasi-logical manner. Fact is, I don't know.

But YES - the interval and practice of NOT doing 1 hour checks in the early DKA management/insulin gtt patient is NOT standard practice and is RISKY at best.

oramar · May 13, 2009

I work in an ICU at a community hospital. I recently got a DKA from the ED on an insulin gtt. When I asked the pt nurse, who brought the pt up, when the last accu check was she kind of shrugged her shoulders and said it's been awhile. Her 'awhile' was over 3hrs by POC test and nearly 3hr by lab result.
Is this normal?
What do other EDs do?
Trust me I know that it's a different world down there...just frustrated because it seems to be pt safety was compromised.

My reaction when I read this is, "OMG".

jlcole45 · May 13, 2009

I don't think that is ED policy but the results of either an inexperienced, incompetent, and / or uncaring nurse. Please don't let that color your opinions of all ED nurses. I would definitely report that to your supervisor so that the nurse can be either educated or counseled because

that was NOT the right thing to do or the right attitude to take.

Medic09, BSN, RN, EMT-P · May 13, 2009

Hourly checks until under 250 or so seems pretty standard.

So, was the sugar much higher, combined with an overwhelmed ED, so maybe the nurse figured it would be safe to leave it for a while? Was she called away to a trauma or cardiac, and somebody else was supposed to track BGL in the meantime?

I agree this wasn't good, but it is a little too simple to indict the nurse as "inexperienced, incompetent, and / or uncaring". The description of shrugging the shoulders and answering 'it's been a while' could be an exhausted, embarrassed nurse who doesn't know what else to say just now.

Now, given that this is a risky way to do things, what professional channel did you all employ to follow up? Is this a charge-to-charge query, or manager-to-manager? Something not-too-drastic to clarify what really happened and how it needs to be addressed.

Ultimately it is the nurse's responsibility, but did a tech get assigned to track this and let her down while s/he was overwhelmed with more actively sick/injured patients? I've screwed up plenty over the last couple of years; but on one recent occasion I got chewed out by a doc for labs that didn't get sent off for cardiac ruleout over an hour before. I drew them, and the tech was supposed to send them off pronto. Well, I just told him 'yes, I screwed up' and got embarrassed; but I did not mention that the tech had the bloods and was supposed to send them. I knew the tech now knew the problem, and there was no point in making their night worse, too. They learned, and so did I, and we move on.

So, what really happened with this nurse? We don't know. Until then, I'll avoid marking her as 'incompetent' or worse.

MassED, BSN, RN · May 13, 2009

I work in an ICU at a community hospital. I recently got a DKA from the ED on an insulin gtt. When I asked the pt nurse, who brought the pt up, when the last accu check was she kind of shrugged her shoulders and said it's been awhile. Her 'awhile' was over 3hrs by POC test and nearly 3hr by lab result.
Is this normal?
What do other EDs do?
Trust me I know that it's a different world down there...just frustrated because it seems to be pt safety was compromised.

nope. usually hourly accuchecks in the ER. I'd have an issue with that too.

MassED, BSN, RN · May 13, 2009

Hourly checks until under 250 or so seems pretty standard.
So, was the sugar much higher, combined with an overwhelmed ED, so maybe the nurse figured it would be safe to leave it for a while? Was she called away to a trauma or cardiac, and somebody else was supposed to track BGL in the meantime?
I agree this wasn't good, but it is a little too simple to indict the nurse as "inexperienced, incompetent, and / or uncaring". The description of shrugging the shoulders and answering 'it's been a while' could be an exhausted, embarrassed nurse who doesn't know what else to say just now.
Now, given that this is a risky way to do things, what professional channel did you all employ to follow up? Is this a charge-to-charge query, or manager-to-manager? Something not-too-drastic to clarify what really happened and how it needs to be addressed.
Ultimately it is the nurse's responsibility, but did a tech get assigned to track this and let her down while s/he was overwhelmed with more actively sick/injured patients? I've screwed up plenty over the last couple of years; but on one recent occasion I got chewed out by a doc for labs that didn't get sent off for cardiac ruleout over an hour before. I drew them, and the tech was supposed to send them off pronto. Well, I just told him 'yes, I screwed up' and got embarrassed; but I did not mention that the tech had the bloods and was supposed to send them. I knew the tech now knew the problem, and there was no point in making their night worse, too. They learned, and so did I, and we move on.
So, what really happened with this nurse? We don't know. Until then, I'll avoid marking her as 'incompetent' or worse.

even with a trauma or other critically ill patients, a CNA, or another person can check the BS prior to the patient being brought to the floor. I'd never deliver my ER patient to the floor without a recent BS. Nope, no way. I can't imagine an ER nurse that wouldn't. I'm sure there are some out there, obviously, as you experienced. This is not the norm. I don't believe the OP was writing that all ER nurses are like this - as she knows, ER nurses are, most of the time, spot on and don't need to be corrected or reminded on how to treat their acutely ill patients.

Editorial Team / Moderator · May 13, 2009

I'd never deliver my ER patient to the floor without a recent BS. Nope, no way.

I was thinking the same thing, and I thought that was common sense. (The older I get, the more I realize how uncommon sense really is. )

APNgonnabe · May 13, 2009

Thanks all. I do not know what was going on in the ED at the time as some have pointed out. I discussed this with our CNS so I'm sure she'll handle it appropriately. And no I don't have a clouded view of most all ED RN because of this.

Medic09, BSN, RN, EMT-P · May 13, 2009

Well, again I am not validating what was done, but...

I've had those times when my patient got held in the ER just because I was called off to something evolving - trauma, MI, etc. When I got back to the patient, ICU just wanted that patient in their hands and bed. So, off we go with less than ideal prep. Stuff happens.

Of course I agree that the original posted incident wasn't good. We just don't know what brought it about. I agree with the standards noted here; they're the same for us. I just objected to so facilely labeling this nurse as incompetent or worse. I would need a whole lot more clear information before jumping to those kinds of labels. If my charge or manager judged me that way, I would have been fired several small incidents ago. All we actually know is this wasn't done in the manner normally accepted. We have no idea what brought this about.

Then again, maybe I'm the only ED nurse who ever gets overwhelmed and is just glad to get the patient safely and stable to where they need to be next.