Need to Vent

[KerrylynnBSN]

I work on a busy medsurg floor with many great hospitalists and ARNPs. Most of the physicians who have privileges to our facility our also usually pretty easy to work with. However, we have the "terrible three" that every nurse dreads working with. One of them is an ID doctor, another is a Cardiologist and the other has no speciality, however, these doctors are constantly being given medical patients to manage when they are clearly incapable or just don't care. Our hospital utilizes a paging system to contact our doctors for us. In this scenario, I had a patient who had been admitted for bilateral DVTs in his upper extremities. The attending doctor (cardiologist), decided to send this man back to the nursing facility he came from and put discharge orders in without ever seeing the patient. There was an order for a PT/INR, so I paged the MD to make sure he didn't want the lab drawn before discharge. He replied that he did not require the lab to be drawn but requested that I change his "mistake" on the discharge paper work .. he left the Lasix IV but meant for it to be PO. Well, our hospital has also rolled out a new policy that the MD MUST go in to the system and physically change the incorrect order so that it prints out correctly on the discharge paper work. This way there is no scribbling out of orders and hand written corrections, which can be very dangerous. I covered my butt on my end by doing a reconciliation but told the MD he must change this himself on the paperwork per policy. When I mentioned this, he flipped a lid and said he was not aware of such a policy and that I should "JUST LEAVE IT IV!" *click*. Ok fine. I'll do the right thing; policy calls for me to call the "higher up" and let them know of the situation, which I did. I did this because I have never, EVER sent a pt to a rehab facility with an IV unless there is specific orders for antibiotics. This pt is already at risk having peripheral IVs (he had an EJ while hospitalized) and they also do not give IV lasix in most rehab facilities. A simple change to PO could fix the issue. The higher up calls me back and tells me we are going to have PICC place a perhiperal IV in the patients hand. By this time my mind is baffled. I reply to the higher up that we don't typically send people to facilities with IVs for lasix and he replies "oh YES you do." Ok. I do what I'm used to and call the facility to give report. They laugh when I tell them he has an IV for lasix because they don't give it. By this time, I'm done. I get my supervisor and ask him to page the MD to make him aware of all of this. The MD has such a BIG ego that he ordered the whole order for lasix to be removed completely and to have the admitting nurse at the facility call him for an order. Also claims I misunderstood him, he never asked me to change it, and I was simply questioning his order. Damn right. Any good nurse who saw that would have called and said uhhhh are ya sure?!?. I just still can't believe this happened and was all brushed under the rug. Discourages this nurse from doing the right thing again. But I advocated for my patient like I should. Anyone have an opinion? Just venting.

[JKL33]

I'm going to be painfully honest here. I've been through the type of wringer you're talking about and at this point in my career I'd have only one question, and that is what are the ramifications for ME if I send him out with the IV lasix order knowing they can't do it IV. If no one is coming back to me 2 weeks later and "dinging" me for it - - it's not worth the time. The facility who can't give it IV will call this guy and he'll get away with giving them a phone order instead of having to muddle through changing the one in your EMR system. No harm to the patient in this particular case (and that is the key decision-making point).

If my reply seems not ideal - - no, it's not. But I can't fix everything and what I do know is that other patient care is not happening while I'm messing with buffoonery like this. So, in reply to your situation, what I likely would've done is called him, let him say to leave it like that, and I would've left it and documented the call.

[KerrylynnBSN]

Your reply makes absolute sense. I will never use this policy again and just make sure I fully document everything on my end. It's just frustrating and unfortunate that they spend time and resources to come up with these policies and they're not implemented properly. I was encouraged by my supervisor to make the call. I did make an incident report as well. I just needed to vent. You're right, your reply may not seem ideal but in the world of nursing, there's real and ideal... real is more common. Thanks for your thoughtful reply.

[JKL33]

You're welcome - and I just feel like I should say that obvious - - don't go shirking policies because of what some unknown nurse online says! If/when I decide to let something go it's because it's small potatoes...and because I've been doing this long enough to be confident about my judgment of the situation and the likely responses to my actions. And my overall personal MO is to do excellent work and fly under the radar as much as possible.

Also, for the record, you did not do anything wrong. With lots of experience you will come to see situations for what they are and then will be able to make wise choices about how to handle them - - but that's not to say that going strictly by policy is the wrong thing. It's technically the right thing, of course!

[Glycerine82, LPN]

Wow, what a dink!

Not sure if this helps, but at my facility we get new orders from our medical director when getting a new rehab patient. If something is written IV we simply re-order it PO. (we actually do give IV therapy, but not if there's an alternative).