Nurse initiated SVE

[canoehead]

I've been working in the ER of a small hospital (no OB services for about 40 miles) for two years, before that I was an OB nurse. Recently we had a PPROM come in at 33 weeks, and the doctor did a digital SVE as part of the assessment. I took her aside afterwards and explained that a speculum exam was the preferred method in that situation, and I printed up some articles for her afterwards that went throught the usual care for PPROM.

She was less than receptive and said "I've delivered hundreds of babies and I know how to assess a pregnant woman. How else would I find out if she was dilated or not?" So I dropped the subject and a note to our NM and included the articles about standard of care.

I have an appt with my NM to discuss the situation next week and he has already spoken with the doc. The nurse I was working with the night the pregnant woman came in was working the day they had their meeting. The doc told my NM that I had done the SVE first. (!!) I can easily prove that didn't happen via nurse's notes, and my nurse partner's recollection. However the other rumor is that she is campaigning to forbid nursing SVE's without an MD order. I need some help in referencing articles that say early and appropriate SVE's are important to guide care decisions.

I'm the only OB trained nurse in the hospital, so I need help. FYI the doc said this primip was 2 cm dilated, but the baby was crowning by the time they got to the OB facility. Was she really 2 cm? Another doc sent me on an OB transfer with a 23 weeker, and about 5 min out from our hospital the cord was hanging out of her lady parts. When he did the SVE, what was the presenting part? He said he wasn't sure when I asked him later. So clearly I'm not going on any transfers without doing my own SVE from now on, but what about women who come in, are triaged appropriately, but still wait 30-60 minutes to see the doc. A nursing SVE would be important IMO to detect problems.

This doc has already insisted that nurses wait for an order before we start an IV in the ER (crazy) and now wants SVE's to require an order. I want to be well prepared for the meeting with my NM, and proof that early assessment is important. I want to treat patients, but we are required to salve this doc's ego instead. Can anyone help me out?

Thanks guys.

[canoehead, BSN, RN]

Interesting, I didn't know RN's could be considered medical personnel. Even when I worked OB the docs had to come in and do an assessment if they were going to transfer anyone. I'll check it out.

[MemphisOBRNC, BSN, RN]

transferring a patient opens a new can of worms. ematal rules should be the same nation wide, unless your state or hospital has rules that preclude them. besides mds, ob and psych. nurses are considered qmps but your hospital by-laws must include them.

http://www.medlaw.com/healthlaw/emtala/guidelines/interpretive-guidelines.shtml below is information taken from the medlaw link (which is a great site):

hospital resources and staff available to inpatients at the hospital for emergency services must likewise be available to individuals coming to the hospital for examination and treatment of an emc because these resources are within the capability of the hospital. for example, a woman in labor who presents at a hospital providing obstetrical services must be treated with the resources available whether or not the hospital normally provides unassigned emergency obstetrical services. the mse must be conducted by an individual(s) who is determined qualified by hospital by-laws or rules and regulations and who meets the requirements of 482.55 concerning

emergency services personnel and direction. the designation of the qualified medical personnel (qmp) should be set forth in a document approved by the governing body of the hospital. if the rules and regulations of the hospital are approved by the board of trustees or other governing body, those personnel qualified to perform the medical screening examinations may be set forth in the rules and regulations, or the hospital by-laws. it is not acceptable for the hospital to allow informal personnel appointments that could frequently change.

if a qmp other than the physician (registered nurse, physician assistant, etc.) determines a woman is in false labor; a physician must certify the diagnosis. how the physician certifies (telephone consultation, or actually examines the patient) the diagnosis of false labor is determined by the hospital and its medical staff. the hospital should have policies and procedures in place providing guidance to their qmp on how to meet this requirement. if telephone consultation is the means utilized to satisfy

this requirement, documentation within the patient charts must be in accordance with the hospital cop at 42 cfr 482.24©(1).

[beckinben, CNM]

If a QMP other than the physician (Registered Nurse, Physician Assistant, etc.) determines a woman is in false labor; a physician must certify the diagnosis.

This is not true anymore. CMS changed the EMTALA rules last fall to allow CNMs and others to certify false labor. The wording now is:

"a woman experiencing contractions is in true labor unless a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certifies that, after a reasonable time of observation, the woman is in false labor." (489.24(b))

Becki

[NPinWCH]

Interesting, I didn't know RN's could be considered medical personnel. Even when I worked OB the docs had to come in and do an assessment if they were going to transfer anyone. I'll check it out.

Where I work all RNs, who have been through orientation and have met our minimum clinical guidlines, are then "credentialed" by the hospital to provide a labor assessment/screening exam. We still have to receive telephone orders from the doc, but we are qualified to make the assessment. Credentialling actually requires us to have preformed a certain # of each procedure and to have been observed doing them by the OB Chief.

Anytime we have to transfer, the doc must come in and actually do his own assessment, this was OUR decision. We felt that if a pt is active enough/sick enough...they should actually be seen by the doc. This policy change hacked off 5 of the 6 delivering docs since they lived 30 min out. Same policy stands for newborn transfers. We still have docs try to pull the "Give me OSU's # or give me the # for childrens and I'll call them..." :nono:but they KNOW they have to come in.

[Dayray, RN]

Maybe im passive agressive but with a doc like this I would give them what they want. It seems he wants complete control so give it to him. allow him to do all the assessment. when he gives orders request that they be written rather then verbal. wake him up to clairafy orders on tylenol etc etc...

Doctors have the political and legal power over nurses. Our leverage is that we can make their lives so easy if they show us a littel courtesey. trust me after a few weeks of "getting what he is asking for" his strugle to assert his supremacy over nurses will end

[crysobrn]

At our hospital which is smaller with now only 2 OBs we are not only asked but expected to know what tests to perform and actually get them done before calling. So, we would be expected to do our own spec exam, ferning, and sve if we had a pretermer come in with those complaints. If in fact she were to be transferred I'd say that they come in 99%of the time.

On the subject of the 18 wker I've had the same thing happen. The person came in with uti symptoms and I had her completely assessed and discharged before ER could have even seen her! Plus they tend to get really nervous the second someone says they are pregnant. Whether or not they have any pregnancy related complaint. They often are generous with dates, or they encourage the pt to c/o abd pain or bleeding so they can get the pt up to us rather than dealing with them down there... No lie I had a pt come in one day that was "20 wks" and her complaint was and I quote "I need my ears cleaned out" she was a real piece of work!! I called the OB cause there was nothing that I could really do for the ears LOL and she was mad that they even brought her upstairs.

[SueBee RN-BSN]

If this doctor is so great at what she does, she could have U/S the cervix via the abdomen. A sterile spec exam is always the best care. (microbiology 101)

[crysobrn]

Oh and I'd be very hesitant to trust the dr that you explained at first. If I am the one going on the transfer I'd like to get a baseline sve before I get into an ambulance with the woman and her preterm baby (or babies as is often the case) and a ems worker that does not know nrp.