NS at 125 ml/hr is not an ER order

Specialties Emergency

Published

Pet peeve.

Tolerating PO, maintenence rates of ns are just silly in the ER. Anything under 500 ml/hr is silly. If you really think they need 125 ml an hour, I'll be happy to bring them an 8 ounce glass of water every couple of hours.

I am not refering to the dehydrated LOL with CHF. I am talking about the garden varity pt who is going to get a bunch of pointless tests and then get sent home with an ambiguous dx.

OK, I feel better.

Specializes in Med/surg, Quality & Risk.

All well and good, if they're actually paying for their care

This is why the cost of medical care is skyrocketing because of lame orders like that. :nurse:

Specializes in Emergency, Case Management, Informatics.
This is why the cost of medical care is skyrocketing because of lame orders like that. :nurse:

I can assure you that normal saline is not making the cost of healthcare skyrocket.

Defensive medicine in response to our litigious society is what's driving up the cost of healthcare. Physicians defensively ordering CT's on every single headache that comes into the ED is driving up healthcare. Physicians defensively ordering CT's on every single belly pain that comes into the ED is driving up healthcare. Physicians defensively ordering a full cardiac workup on a 21-year-old with no medical history who's coming in for chest pain that's actually an adverse reaction to Taco Bell is driving up healthcare.

Yes, some of these workups are necessary. In the majority of cases, they are not, and would not be ordered if there wasn't that one in a million case where a physician was sued for something that couldn't have been predicted.

Case in point - another ED in my hospital system had a 60-year-old woman come in with elbow pain. No other complaint. Just elbow pain. She had an extensive history of bursitis, but no other significant medical history. MD did an XR of the elbow, discharged her with instructions for bursitis. She was brought in dead by EMS 4 hours later for a massive MI. The family is suing the MD and hospital.

Should the MD have done a cardiac workup on this patient? She had absolutely no sx/sx of cardiac problems. No SOB, non-diaphoretic, no pain other than elbow pain. No cardiac history. Yes, women with MI's present differently. However, there was no evidence to suggest that this could have been an MI, especially with the patient's history of bursitis. We cannot do a full cardiac workup for every musculoskeletal complaint. But, because of cases like this, any MD who is familiar with the case will now do a full cardiac workup on any 60-year-old woman with elbow pain.

A bag of normal saline is pretty darned low on that list of the increasing costs of healthcare.

Specializes in Emergency Nursing.

The chief of emergency medicine at my facility said it best when he stated, "In the ED, orders are more like 'suggestions' ."

Some of you people are very uptight. In my facility, we NEVER get specified rates for fluids. Many of us initiate fluids prior to anyone being seen by a provider. Where I'm at, were trusted with knowing if someone is renal/chf. We generally have an istat to get a good feel for BUN/Cr and electrolytes.

Anywho, on a side note: I had to laugh the other day. I had a woman with an ectopic (who was very stable). I get a call from her OB/gyn that he will be there to save the day. He tells me he wants rapid fluid resuscitation and writes an order for ns @ 125/hr. We had a good laugh over that one.

And the 0.5 of dilaudid. (Again, maybe we are rebels where I work.) I wouldve immediately gone to the MD and asked the rationale/ made a joke about giving an elephant a baby aspirin. I Would have also suggested morphine at this point.

If you work in a place where you can't question orders, well Jesus, I pity you.

Specializes in Pediatrics, ER.

You would've gotten a kick out of the orders the admitting doctor wrote for a stable new onset afib patient the other night. NS @ 60ml/hour....pt eating and drinking fine. I asked him if it was necessary and he said "yes, I find that they're always behind and I like to keep my patients well-hydrated." I stood there staring at him waiting for the punch line, but he was completely serious. Ok doc, that 2 oz of fluid an hour is going to tank him up really well.

Specializes in Pediatrics, ER.
If you work in a place where you can't question orders, well Jesus, I pity you.

Where I work, some of the doctors will specifically order something other than what you ask for just to **** you off. The other night I asked for Zofran and morphine for my chole patient, and I got Reglan and Stadol.....STADOL! When I asked the doctor to teach me why that was a good chance for a chole pt the doc told me "Stadol is a great choice in general." Alrighty then...the pt had a terrible reaction to it and the physician vehemently refused to order anything for her saying "she's fine" even though she was pale, diaphoretic, and extremely anxious. It was only after we quit bugging this doc that they ordered Zofran an hour of dry heaving later...

Specializes in Emergency Nursing.

There again, I just wouldn't give it. I'd then take it to my charge rn and up the chain. Playing with orders just to be an ass is a bit unprofessional. I will say we don't have that issue where I work.

I'll add that im sorry providers react that way to you when you ask for something. :(

Specializes in Pediatrics, ER.

Unprofessional is just the tip of the iceberg. Everyone has trouble with this particular doctor. He berates nursing in general as a "private conversation" to other doctors out loud in front of the nurses. He has also threatened me and various other nursing staff for bringing patients back when he has a few ahead to see, but will continue sitting in front of the computer taking his sweet time eating dinner. I think a lot of it is burn out, but that's not my problem. My responsibility is to the patient.

There again, I just wouldn't give it. I'd then take it to my charge rn and up the chain. Playing with orders just to be an ass is a bit unprofessional. I will say we don't have that issue where I work.

I'll add that im sorry providers react that way to you when you ask for something. :(

In many places, that chain is very short. Or goes nowhere.

Certainly trends should be reported, but the likelyhood of being able to affect a change in orders for an acute pt is unikely.

The best you can do is document:

"EDMD infored that calling him a moron would be an insult to morons. No new orders given."

Specializes in ICU, ER.
In many places, that chain is very short. Or goes nowhere.

Certainly trends should be reported, but the likelyhood of being able to affect a change in orders for an acute pt is unikely.

The best you can do is document:

"EDMD infored that calling him a moron would be an insult to morons. No new orders given."

:yeah:

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.
I can assure you that normal saline is not making the cost of healthcare skyrocket.

A bag of normal saline is pretty darned low on that list of the increasing costs of healthcare.

I agree that defensive medicine is the biggest culprit but at least at my institution it's not the ACTUAL bag of saline that's the problem. A patient with an IV gets bumped up two levels on the visit charge scale not because of the saline but because a higher level of nursing assessment is required, a higher level of physician assessment is required and overall it lengthens their stay. So yes, that bag of saline does cost me, as a taxpayer and insurance holder a whole lot more than an Ibuprofen, pat on the head and discharge papers would.

Specializes in Spinal Cord injuries, Emergency+EMS.
Who cares what was written? You're not the doctor...

Want a change? Go be a provider and write your own orders.

an extremely hostile response

also a response that questions your credibility as a Nurses, if indeed you are one....

siting an IV when the patient has no clinical need is done for one thing and one thing only - to increase billing possibilities arguably it is a battery if it is not clinically indicated.

siting an unnecessary IV has significant risks of iatrogenic harm , here's a couple off the top of my head

- Infection

- Mechanical irritation

- risk of Nerve damage if injudiciuously sited

Nurses have an important role in acting as a patient advocate , and this includes challenging inappropriate medical intervention

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