Medicating patients you won't be watching

[F.E.R.N., BSN, RN]

How do different ERs handle meds given at times when staff will not be watching the patient afterward? For example, patient's being discharged home or sent back to waiting areas where they are not directly visualized or on camera. Our ER has no written policy, but lots of differing opinion.

I see general agreement at our facility in DC: wait 15-20 minutes after any shot before sending home, and if it's a drug that could affect patient's driving, the patient must either be walking, riding the bus or have a ride home in evidence before receiving the med. We tend to agree to wait a period of time after shots, but only a few people think we should wait after 1st time PO meds, even potential mind-affecting meds like Lortab. The only reason I've heard not to wait after PO meds the same way we do for shots is that it would take too long (which is true, but I'm not sure if it's a legally adequate reason).

What about patients who are in the middle of testing/treatment, but are in the waiting room unattended, waiting on a room, labs, exray, etc.? They've been triaged, maybe even seen by a doc; can they have a prescription med? If so, are there limits to type/route/amount? Who, if anyone, is responsible for them afterward? Are there guidelines anyone follows (e.g. level of nursing assessment done at point of med admin, patient factors, history of having the med before)?

[crb613, BSN, RN]

We wait 20 mins on all shots..no po meds are given & pt sent to waiting room unless its for fever. Most xrays, simple labs are started in triage then the doc takes it from there. When they are dced from the ER they are done...admission, transfer, or home.... We also verify transportation.

If they are given po meds teaching is done & instructed to return for any problems. We have a policy that the triage nurse is to round/or have someone round the waiting room ~ every 30 mins........

[coolpeach]

We also have a 20 min wait time after all injections. We have to make sure the patient has SOMEONE driving them home before giving narcotics of any route. When I say someone that doesn't include public transportation. I must physically see this other person prior to giving the narcotic. If the person receives the narcotic, and there is no significant other person to drive him home then he must wait 4 hours or until someone comes to get him. A nurse must wheel them out in a wheelchair, and physically help them into the passenger seat when they are discharged unless the four hours has expired, and then they are free to walk out, call a cab, ride the bus or whatever they need to do.

We really don't give med to patients in the waiting room with the exception of motrin/Tylenol for fever. Generally if a patient is severe enough to need a medication now we see it as he needs to be in a room now. If for any reason all of our rooms and hallways were completely full, the waiting room was packed, and we had really sick people stacked up in the waiting room we have a protocol for that (I have never seen it happen though). In that situation one triage nurse will continue to triage patients, and the second triage nurse will float around in the waiting room revitalizing patients, and reevaluating after meds/interventions etc.

After a patient has been triaged the triage nurse/hosptial are now responsible for that patient. The patient needs to be reevaluated on a regular basis for changes to their condition if left in the waiting room regardless of if meds were given or not.

The above are policies, but you have to use your nursing judgement. If you give any med regardless of route, and feel something could go wrong (interaction, allergic reaction, etc) you can hold the patient for 20 minutes and keep an eye on him. In the end its your license so its your call.

[morte, LPN, LVN]

We also have a 20 min wait time after all injections. We have to make sure the patient has SOMEONE driving them home before giving narcotics of any route. When I say someone that doesn't include public transportation. I must physically see this other person prior to giving the narcotic. If the person receives the narcotic, and there is no significant other person to drive him home then he must wait 4 hours or until someone comes to get him. A nurse must wheel them out in a wheelchair, and physically help them into the passenger seat when they are discharged unless the four hours has expired, and then they are free to walk out, call a cab, ride the bus or whatever they need to do.

We really don't give med to patients in the waiting room with the exception of motrin/Tylenol for fever. Generally if a patient is severe enough to need a medication now we see it as he needs to be in a room now. If for any reason all of our rooms and hallways were completely full, the waiting room was packed, and we had really sick people stacked up in the waiting room we have a protocol for that (I have never seen it happen though). In that situation one triage nurse will continue to triage patients, and the second triage nurse will float around in the waiting room revitalizing patients, and reevaluating after meds/interventions etc.

After a patient has been triaged the triage nurse/hosptial are now responsible for that patient. The patient needs to be reevaluated on a regular basis for changes to their condition if left in the waiting room regardless of if meds were given or not.

The above are policies, but you have to use your nursing judgement. If you give any med regardless of route, and feel something could go wrong (interaction, allergic reaction, etc) you can hold the patient for 20 minutes and keep an eye on him. In the end its your license so its your call.

how do you make them stay....if they want to leave, it would seem they have the legal right to do so...

[coolpeach]

They can sign an AMA, and leave against medical advice at anytime. We cannot make them stay, and the AMA releases us from any responsibility (if they fall etc). I have never had an issue with anyone demanding to leave. Usually they realize they are in no condition to walk home/ride the bus etc, and appreciate that we are not kicking them out. The usual AMA's are the pts who come in with a sore throat, and feel they have been waiting too long, or the people who come in drunk and aren't using their heads.

[F.E.R.N., BSN, RN]

After a patient has been triaged the triage nurse/hosptial are now responsible for that patient. The patient needs to be reevaluated on a regular basis for changes to their condition if left in the waiting room regardless of if meds were given or not.

I like the idea of having a nurse assigned to check on waiting room patients, although I'd hate to be the one doing it

How does you facility determine how often to check a patient? Are they all checked at the same time interval, or differntly, depending on initial triage class?