Nurses thrown under the bus

[GM1928]

I'm an RN on an ortho unit at a large hospital. We recently admitted a patient with a chest tube. Several days went by without the dressing being changed. I cared for the patient on the 7th and 8th days after admission. The general surgeon, who was the admitting, did not include any orders for dressing changes. Pt's family got very upset, especially after I paged the MD for change orders, and he didn't call back. Because we're an ortho unit, we don't see a lot of chest tubes, but apparently on the respiratory unit, it is common knowledge that this MD likes daily dressing changes on chest tube pts, so he never puts in orders for changes. Family contacted the director of med/surg for the hospital about this, and the director contacted shift supervisor, who then contacted me. I did page the MD, and I also left a note in the electronic chart for him indicating that the family wanted to speak with him about care, and included a phone number. He didn't contact them until he found out that they were upset. He didn't respond to my page (he's notorious for this). I feel like I did my best, but this matter has gone all the way to the chief medical officer, my unit supervisor, and the med/surg director. In an email, it was stated that our ortho staff needs education on chest tube dressing changes. I feel like we're being thrown under the bus. The MD should have put in dressing change orders. The MD should have responded to my page. The patient shouldn't have been on an ortho unit for over a week when he could have been transferred to the respiratory floor. As I said, I cared for him on the 7th and 8th days after admission. Maybe one of our nurses who cared for him much earlier in the week should have asked the MD about change orders. As it turns out, the MD is pissed off at me, the family is pissed off at me, and administration is pissed off too. Sometimes, you do your best and it still doesn't work out.

[xoemmylouox, ASN, RN]

Well it wouldn't hurt to get staff some education in regards to this, if you are going to be expected to care for patients with chest tubes. It is definately not just your fault. Everyone who cared for that patient should also be questioned. The MD should also be provided education on the importance of placing orders and not just expecting staff to know what they want. It appears they are lacking that basic concept. Often if a family is upset someone will get thrown under the bus. Hopefully you documented that you attempted to reach the MD without response. This will help cover yourself. Good luck with this mess.

[chivon101]

I've been an ER nurse for almost 8 years and never have worked in any other department, so our docs are at our beck in call. I feel nurses in the ED tend to have a great rapport with the majority of the docs. My question is, if the dressing looked soiled, you couldn't just change it without an order. I'm just curious and not being funny at all. In my department we would just change it, if it looks nasty.

[GM1928]

Because it was a chest tube, I deferred changing it until we got actual instructions from the MD. If I'd changed it without an order, and something had gone wrong, I'd have been on the hook for doing something without an order. I discussed this very issue with shift supervisor and she agreed that we needed orders before changing it. She talked to the MD and got the orders for daily changes; he insisted that he'd put them in on admission, but shift supervisor and I both checked the order history and he had NOT put change orders in.

[Been there,done that, ASN, RN]

You should not have to be under the bus alone. Every nurse that took care of this patient should be included.

Is not the email correct in stating the ortho staff needs education on this?

I do not see this as "doing your best" How grody was that dressing on day 7?

[Ruby Vee, BSN]

Because it was a chest tube, I deferred changing it until we got actual instructions from the MD. If I'd changed it without an order, and something had gone wrong, I'd have been on the hook for doing something without an order. I discussed this very issue with shift supervisor and she agreed that we needed orders before changing it. She talked to the MD and got the orders for daily changes; he insisted that he'd put them in on admission, but shift supervisor and I both checked the order history and he had NOT put change orders in.

Most hospitals have their policy and procedure manuals online these days. You could have looked up the policy for chest tube care and the procedure for changing the dressing. If the policy says dressings are changed every other day, there's your order. You're following the hospital policy. The procedure should tell you how to do it.

I'm concerned that if you (the collective you, not just you personally) weren't changing the dressing "because it was a chest tube." Were you also assessing the drainage, looking for possible air leaks, making sure the chest tube was patent, listening for lung sounds and looking for subcutaneous air? How many other chest tube assessments were you doing (or not doing) appropriately?

[Pepper The Cat, BSN, RN]

Why didn't anyone connect with the resp floor and ask one of the nurses there to come over and show the ortho nurses how to change the drsg?

[HouTx, BSN, MSN, EdD]

Hey, surgeons can be picky about their chest tube dressings, especially if they are on a trauma patient. Some - especially in teaching hospitals - want to do the initial change themselves & thereafter will only allow residents to do it. But I do agree that there needs to be some sort of clarification. If there is indeed a facility standard for daily chest tube dressing changes, it needs to be in writing & nurses need to be aware of it.

[KatieMI, BSN, MSN, RN]

While it is unfair for you to be thrown under the bus alone, I wonder why the question was not brought up at the time of admission. You got a human being with something sticking out of his body, with no idea what to do with it. Even if your unit's policy book may not contain anything about chest tubes (quite possible, since you are not dealing with them, and may not even have necessary supplies), then your charge had to call any unit dealing with such patients and with that particular surgeon regularly, ask them and maybe even ask one of their nurses to come and show the proper technique. The whole thing shows just a failure to communicate, more of your leadership than your own, and results of politics of "we never do it here".

[Dranger]

Honestly, I feel like it got ignored because none of the nurses were familiar with it. This is where you ask for help. Call the ICU and ask. You shouldn't need orders after day 7 to change a dressing.

Combination of laziness and lack of education with everyone involved, to be honest.

I have googled/YouTubed mid shift if our policy wasn't clear on how to do something. There was SOMETHING besides paging you could have done.

[flyersfan88]

No one checked policy? We don't need orders for ours unless the team for whatever reason WOULDN'T want the dressing changed....which is pretty much never. Our policy is for them to be changed every 48 hours, so it just gets done. I find it hard to believe that everyone waited over a week for 1 doctor and absolutely no one checked policy....or even asked a unit that sees them all the time.

[Anna Flaxis, BSN, RN]

They're giving your unit education on chest tube dressing changes, and this is being thrown under the bus? I don't think "being thrown under the bus" means what you think it means.

It's true that the physician bears some culpability here, but the failure of the floor staff to implement P&P for over a week is not something that should be overlooked, and I think providing education in order to prevent this from happening in the future is quite generous. I would be thanking them.