MD not present for code??

[shhhh]

My husband is a nurse who works at a different hospital than I do, and he been there a few years. We're just biding our time until he can find a job at a different place. The stories he tells me about what he has to put up with makes my hair curl. I would love to tell you a few nightmares that stick out in my head just to feel better from venting about them, but I really wish for advice or perceptions from any experienced nurses and anyone in nursing administration on this one incident that recently occured.

A patient (not my husband's) unfortunately coded early in the AM on NOC shift and this patient did not survive. This was a major shock to everyone involved; this patient, even though in their 60's, was rock stable, and was awaiting to go to surgery to have a lap chole. The protocol at his facility is that the ED physician comes to the unit to run the code, but the hospitalist (who's the patient's PCP during night shift) needs to be present to help recount patient's history, work through H's and T's, etc. The hospitalist on shift is notorious for being sub-par (writing the most ridiculous orders, taking forever to call back when paged, etc.) and did not arrive when paged for this code. This was no surprise to my husband, because he overheard this particular doctor say once, "Oh, it's silly for me to go to my patient's codes, because the ED docs always run the codes anyway."

The ED doc asked my husband to page them again. He did, and when they called back, the hospitalist said to my husband, "I'll be there in 20 minutes (!!!)... mumble...mumble."

He said, "I didn't hear what you said." And after some more coaxing, they finally said, "I said, 'I'll be there in 20 minutes (again... can you believe that crap!?). I left the hospital to get a cup of coffee." My husband relayed that to the ED doc and, of course, the ED doc went nuts. Apparently, leaving the hospital while on duty is typical for this particular hospitalist, but this ED doc only had heard rumors until now. He wanted the whole incident written up, and rightly so, because from what my husband understood, there was no way anyone could have foreseen this patient dying.

The charge nurse (who was this patient's nurse) encouraged my husband to document the phone conversation in the patient's chart, and as a result, all of the hospitalists are mad at him now for documenting it. His nurse manager has just given him a warning, and I think this is just another incident that's going to make him look harder for a job elsewhere.

I'm just baffled and I don't know what to tell him. I work at a large university hospital, and I usually have to kick doctors out of codes for just being in the way and gawking, so being told about there being not enough doctors at a code is foreign to me!

My biggest question is this: Do you think it was wrong for my husband to document the phone conversation? I feel like all objective data should be documented, and that this doctor has been playing with fire for a while now and should pay the price for their negligence. Even if their presence probably wouldn't improve the outcome, I still feel that they should have been there. I also feel that since the hospitalists are employed by the hospital, they should NOT leave the hospital for any reason whatsoever, and certainly should notify another MD to sign out to them if they absolutely have to. I can understand how it can be viewed at "tattling" by the hospitalist team, as well, but hearing about this "'good ol' boy mentality" among the hospitalist team ticks me off. What do you think of this situation? What's protocol at your hospital? Thanks everyone!

[tokmom, BSN, RN]

Our hospitalists will leave the hospital for their lunch break, not uncommon for them to do so. If there was a code, they would hurry back and I know it wouldn't take 20 min!

I think I would have asked Risk management if I should put the time frame down in the charting. My gut says No.

[himilayaneyes]

I feel sorry for your husband. It sounds like that's a rough facility to work in. The hospitalists sounds like he could care less about his patients. I definitely agree that the incident should be written up. However, as a nurse to another nurse,...as one who knows the mess that management loves to pull...if the ER doc wanted the incident written up..he should have done it himself. At the end of the day, the hospital is going to back the doctor b/c they bring in the business...not the nurses. I don't know how exactly your husband documented, but the best thing is to keep it short and simple. "Notified MD of pt condition at this time"," not "Spoke with MD. He left for coffee. Will come in 20 minutes." Plus, it should have been written up as part of an incident report and not on the pt's medical record. It doesn't just show negligence on part of the physician, but increases hospital liability. Did your husband use the hospital's internal system of reporting incidents or chart the phone conversation on part of the patients permanent medical record?It's a fine line we nurses have to walk. I encourage your husband to look for work elsewhere.

[xtxrn, ASN, RN]

I would have documented the conversation in the chart- just the facts- and covered my own butt just by being in the same city with this jerky doc.

I've documented when docs haven't returned my calls, and all I had left to do was call the consult doc (apologizing, but not knowing who else to call).

I've documented how many days I'd been trying to get a return call from faxes and calls to the office (as well as the individual calls and faxes).

I don't advocating "emotional" words... just "dr x notified of code, which started at __;__ am/pm, states he will be here in 20 minutes".... then in 20 minutes, chart "dr x is/is not present in room as code continues".

Risk management is not looking out for my butt- they look after the hospital.

[LouisVRN, RN]

The conversation and the fact that he left for coffee and would be back in 20 minutes should be documented in the incident report. The fact that the doctor was notified should be noted in the patient's medical record.

[xtxrn, ASN, RN]

The conversation and the fact that he left for coffee and would be back in 20 minutes should be documented in the incident report. The fact that the doctor was notified should be noted in the patient's medical record.

And follow up when he doesn't show- trust me- if it ends up in court, they will hammer it until you cry purple tears why there was nothing about where the doc was, did the nurse call again, etc. It needs to be in the chart since the IR doesn't go in the notes.

[shhhh]

And follow up when he doesn't show- trust me- if it ends up in court, they will hammer it until you cry purple tears why there was nothing about where the doc was, did the nurse call again, etc. It needs to be in the chart since the IR doesn't go in the notes.

Thanks, everybody! All your comments really contribute.

To clarify, DH documented something along the lines of, "Hospitalist paged a second time per Code Team/ED doctor's request. Hospitalist called unit approximately 5 minutes later, stating over phone to this nurse, 'I'll be there in 20 minutes. I left the hospital to get a cup of coffee.' Message relayed immediately to ED doctor."

And with regards to what xtxrn mentioned above, I suspect my husband's charge told him to document it in the patient's chart because there's probably very few nurses at this hospital who really trust that an incident report will actually be filed. I think it's easier to "lose" an incident report that incriminates a doctor than it would be to "lose" a piece of a patient's chart.

[evolvingrn, BSN, RN]

I would get in trouble for charting that ..........., i think an incident report would be protocol.........since incident reports leave less liablity risks.....but still report the problem

[xtxrn, ASN, RN]

I would get in trouble for charting that ..........., i think an incident report would be protocol.........since incident reports leave less liablity risks.....but still report the problem

The whole thing with charting it is to show that the nurse on that shift DID something to try and find this skanky doc, and find out where his butt was :) If you get in trouble for standing up for patients, RUN :) An incident report is not a substitute for accurate, COMPLETE charting.

The liability risk is when the family sues and their lawyer has someone go through the chart to see if anybody tried to get the hospitalist there- especially since he was the patient's PCP as well...if it's not charted, it wasn't done.... even if you know it was- the law will go with what's in the chart. I was grilled about something to do with charting (that had nothing to do with the cause of a patient's death- but a HUGE deal was made about it...resulted in the case being settled, and a family that never showed up or called when grandma was alive was living it up off the settlement).

[Forever Sunshine, ASN, RN]

I wouldn't have documented it in the patients chart.

I would have typed up a statement and sent it to the appropriate parties. Ex- nurse manager, nursing admistration, hospital administration, and whoever the hospitalist's supervisor is.

[wooh, BSN, RN]

I might find it annoying, but not something that really affects the care. I've never expected a hospitalist to show up at a code for anything more than courtesy. The hospitalist needs to be there for a history? For H&Ts? What's wrong with the patient's nurse?

I mean, our hospitalist covers the entire hospital, all he'd know is what's in the notes left by the daytime docs. Generally at night, the nurses know the patient a LOT better than the doc covering. (During the day too, for that matter.)

At my last facility, the hospitalist would come by to see if the ED doc needed any help, even if it wasn't a patient of the hospitalist, as a courtesy. But it was always the nurse that was supposed to know the history, know what's happened recently. Because the doc at night doesn't know the patients like the nurse does. I really don't see it making that big of a difference. As long as you've got someone capable running the code, you really don't need more cooks in the kitchen.

[MunoRN, RN]

If the hospitalist was expected to stay in house or to respond to codes then it would be appropriate to document that in an incident report. Although where I work I wouldn't expect a hospitalist to respond to a code, particularly at night when the on-call hospitalist is covering over 100 patients and is unlikely to know more about the patient than the Nurse. The primary RN should be the source of History, treatments, labs, med profile, etc. and the ED Doc or intesivist should run the code. If the patient is an open heart then I would expect the surgeon on call to show up quickly and I'd also expect a cardiologist to show up on one of their patients depending on the nature of the code, but other than that I don't see any benefit in the primary Doc or the person covering for the primary Doc being present.