Nurse Lynwood here. Forgive me if this question has been asked before, I am new to the forums.
I work 11-7 at a LTC facility. I get a call from my unit manager today saying it is urgent that I come up to the nursing home (LTC facility) where I work and write an order for Friday night (the last day I worked). That was a really chaotic night. To make a very long story short...I had to call 911 because a resident was a full code, (usually A&Ox3) and became unresponsive on me. And was hypotensive BP 80/40. I immediately called 911 to have him transported to the ER. The situation was critical and I didn't feel there was time to call the doc, and wait an hour for the on call doc to give me the order to "send to ER for eval and tx" (it was 3am). So I get a call today (Monday morning, I was off all weekend) and my unit manager says "you must come up here immediately and write the order for sending Mr. X to the ER for Friday night". Huh? I never got any such order or talked to any doc. I straight 911'd him out because the situation was so critical. In my years of experience, I have never had to write an order to "Send to ER for eval" unless I got that order straight from the doc before sending the patient out. As I understand it, if you "911 em out" you don't need an order from the doc to send them. Correct?
I think she just wants me up there because "the administrators" are in the building and they are short staffed & she is using this phoney excuse to get me up there so she can put me to work (they are short staffed today) and once I clock in (to write a 30 second order), they'd hold me there for a 16 hour shift and call it "abandonment" if I left. Yeah, that's they way they roll. I'm getting ready to quit this place because they've done nothing but abuse me with situations like this over the past 10 months.
So, my question is, YOU DO NOT NEED AN ORDER FROM THE MD TO SEND SOMEONE OUT TO THE ER if you used 911 to send them out in an emergency, CORRECT?
Thanks in advance for your time and response. I have already asked another nurse who works with me and they were unsure?
If I send a patient anywhere, I have to have an order -- transfer to Med/surg, transfer to telemetry, transfer to Hospital A, B or C. We have to have a COBRA package before we can send them out of the building, and that is our "order" to transport.
Heavy ... talk about covering all of your bases.
mazy's answer was a succinct explanation of how I would have answered the OP ... well put and to the point. I would include that a late entry can be made at the nurse's next scheduled work day. That is of course unless your facilities p&p dictates something different such us nerdtonurse's facility.
Yes...you still need an order. Why didn't you just write one after you talked to the doc in the am?
"Hey Dr so and so...I just sent Mr X to the hospital for xyz...he was a full code and going bad fast. Can I write that order to transfer to the hospital now?"
There is no way in heck that I'm going to wait for a order to send someone to the ER in an emergent situation. I've worked many a shift where this was the case...never got in trouble for it ever. Just write the order after the fact put a note in the chart indicating such.
In LTC you must have an order, and like the others said, you could probably get it later, or the nurse who takes your call could probably just give you the on-calls name and give the okay for him/her. Assisted Living facilities do not need orders and you may call 911. In my experience, I usually just call the ambulance phone number and tell them to come, since its a direct line.
What is the point of writing an order after the fact...what if the MD disagrees with the sendout and refuses to sign? If the order is that important, it should be obtained before the patient is sent out..
At my LTC there is ALWAYS at least 2 RN's in the building. Once anything happens I always call them- if i have a resident who has a change in mental status ect. If there is a cod like in your case and a pt is unresponsive I immediatly call "STAT" on our PA system and call 911 and every nurse in the building LPNS included run and we all help out in CPR. Once the pt is out the do with EMS we call the DR to let them know what happen and get an order. Cover Your ASS!!!
We have had several stats aka codes in the past month and each time it has worked out efficiently
Specializes in ED, Long-term care, MDS, doctor's office.
If your supervisor wants an order, tell her she can write it since you did not get the order...In the good old days, an order was needed for every transfer (and often obtained after the patient was taken care of & sent out); however, technically, even though the doctor is informed of the patient's condition and transfer to the hospital, obtaining the order after the fact is really inappropriate and possibly could be considered practicing out of your scope...An order is an order...You can't give someone extra insulin coverage & then get the order...you can't give someone a 1 time dose of a medication such as phenergan & then call & get the order..So I don't see why it is necessary to get the order after the fact in this case of transfer to the hospital...Anyone can call 911: the patient, family, a visitor, or another staff member...Many years ago, I called 911 for a patient in distress at a LTC facility...The EMTs arrived and was tending to the patient, when the physician returned my call & did not want him sent out. The physician wanted to do labs, try an extra breathing treatment, etc. (this patient needed to go and wanted to go to the ER)...I went in to tell the EMTs that the physician denied the request for an order for the transfer.The EMTs then told me that they have a patient who wants to go & is in distress & they don't need any order from anybody. Then they scooped and ran with him...I didn't get in any trouble & I don't worry about it anymore...If I can get the order I write it, if not I just document the circumstances, that 911 was called, report was called to the ED, and the physician and family notified of the transfer....
Do you seriously need an order in LTC to call 911? Any reasonable layperson should have been able to recognize that the resident was suffering an acute medical emergency. So a trained, licensed nurse does not have the authority to do the same? What if the family was with the resident when the episode occurred? Do they need an order? If it were my family member I would most definitely activate the EMS.
In a true emergency no, I wont call an on-call and wait for an order while endangering a person, however, ASAP I would call the MD and update them on what was going on. The MD has to be notified of ANY change of condition, esp. such a drastic one. Then I'd write the order for the pt to be sent out. Even if you technically got the "order" after the pt was gone, it still has to be written and the documentation needs to show the MD was updated. The family also has to be notified and report has to be called to the ER.
It's like someone above said, it's a just a documentation issue. Yes, the order does have to be in the chart, but of course we send them out before obtaining the order in an emergency.
Any doctor I have ever worked at in LTC understands this and isn't going say, "no, I don't agree with sending that patient out, I wont sign that order". When you call as soon as possible during or after the event (if you have help they can make the phone call during) explain what happened and what you did of course they say "ok" of the order to send out. They want to keep their medical licenses too and they understand how LTC works. But yes, to satisfy the documentation that telephone order does have to be written.
What is the point of writing an order after the fact...what if the MD disagrees with the sendout and refuses to sign? If the order is that important, it should be obtained before the patient is sent out..
As an ICU nurse you should know when a patient is going south.. act fast. In LTC same rules apply. There is no doctor in the facility. There is no PA. There is no NP. Its just licensed nurses(LPN/RN) and a handful of CNAs. Unless you have a direct number to the doctor's home or cell phone(which we did and would call her first before sending a patient out 911 as we know she would answer right away..but that doctor is not with us anymore).. you call the doctor and you get a service which pages the doctor and sends them your message and the doctor calls back. Can take anywhere from 5 minutes to 3 hours or more to get a response from the doctor.
If you are sending the patient out 911. Its an emergency. If a full-code is going south, crappy vitals, unresponsive or altered mental status, are you going to wait for the doctor to call you back? Not really.
If the resident is a DNR. But is having signs of lets say a CVA. Then I would call the doctor first and then get an order.
I would have called for an order and then called 911 pre the call back. For an arrest, no question. 911, AED, MD called last. But yeah, you need an order even for the arrest.
nerdtonurse?, BSN, RN
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